“LE MOI EST UNE CO-ORDINATION”
EVIDENCE PRESENTED in the previous chapter suggested that the core of BPD is a constellation of features that can broadly be subsumed under the banner of self. In exploring the nature of disturbances of the self in BPD, Wilkinson-Ryan and Westen (2000) found that “painful incoherence” is its central characteristic. This is in accord with Heinz Kohut’s clinical appraisal of the central pathology of BPD. He saw it as a failure of the development of a “cohesive self” leading to “fragmentation of the body–mind–self and of the self-object” (Kohut, 1971, pp. 31–32). Fragmentation is not unlike the identity diffusion of Kernberg (1967), nor is it dissimilar to the broken-up, shifting states of being described by Janet.
The observations of Wilkinson-Ryan and Westen (2000) suggest that in order to discover the basis of BPD, we must find the cause, or causes, of “painful incoherence.” Such an investigation demands a more extended concept of self than has so far been given, as well as an understanding of its development. The theories of Hughlings Jackson are helpful in these respects. His definition of self is clear. He also makes a proposal about the way an experience arises in terms of brain function. His proposal is sufficiently precise for a hypothesis concerning the basis of fragmentation to be formulated and tested. Chapter 5 reports on the outcome of such a test. This chapter gives the background to the hypothesis, beginning with an outline of Jackson’s concept of self, interwoven with Jamesian ideas. James fully subscribed to Jackson’s hierarchical model of mind (James, 1890, I, p. 29; II, pp. 125–126), and his psychological descriptions are complementary to Jackson’s evolutionary and neurological approach.
John Hughlings Jackson (1835–1911) is often spoken of as “the father of British neurology,” yet he once considered a career in philosophy (Taylor, 1925). His abiding interest in notions of mind, or “self,” led him to explore the problem of mental illness. His writings on this subject make up much of his opus but remain largely neglected in the fields of psychiatry and psychology. His main theory, derived from meticulous observation of the smallest changes in the mental and neurological functioning of patients with aphasia and epilepsy, and organized by evolutionary ideas, is “particularly modern—so much so, in fact, that his ideas are receiving more serious consideration today than they did in his own time” (Kolb & Whishaw, 1990, p. 338).
Jackson’s colleagues considered him a genius. He pioneered the concept of the lateralization of hemispheric function (Jackson, 1958, II, pp. 129–145), anticipated the notion of the triune brain (Jackson, 1958, II, pp. 41–42, 45–75; MacLean, 1990), and suggested that sensory data are integrated during sleep (Jackson, 1958, p. 71). Jacksonian theory provides a preliminary framework for understanding the ongoing state of mind in patients with BPD and also for the syndrome of dissociation that is a central feature of BPD.
Jackson’s approach to mental illness was highly logical. He understood it to be a manifestation of a disruption of mind, or self. This being so, it was necessary to begin a study of mental illness with a definition of what self might be. He believed himself to be the first person in the medical literature to use this term. He was certainly the first to develop a plausible neural model of self, preceding, and in certain fundamental aspects, compatible with, the important and influential account of Damasio (1996, 1999), formulated over 100 years later.
Jackson’s definition of self is condensed, deceptively simple, but philosophically sophisticated. He considered that self is identified by, but not the same as, a reflective consciousness of inner events, which he called “object consciousness.” By this he meant that seeing an object such as a brick is not unlike thinking of a brick. “My assertion is that both the seeing and the thinking of are states of object consciousness, that they are but different (compound) degrees of objectification” (Jackson, 1958, II, p. 92).
Self, although a unified state, is double when conceived in an abstract way. Jackson wrote: “It is impossible to speak of objective states without implying subject consciousness. In every proposition, subject and object consciousness are indicated.” In his examples of “I see a brick” and “I think of a brick,” “subject consciousness is symbolized by ‘I,’ and objective consciousness by ‘brick.’ Each by itself is nothing; each ‘is only half itself.’ ” Jackson notes that this duality is expressed in popular psychology with statements such as “Ideas come into consciousness.” In his view the correct statement is “ideas come out of subject consciousness and then constitute object consciousness” (Jackson, 1958, II, p. 93). This concept is important and discussed in more detail in the following chapters. On the basis of his observations, Jackson inferred that the state of mind he labeled self is the outcome of evolutionary history, which is reflected in a hierarchical organization of the brain. He conceived the course of evolution laying down successive levels of neural structure, which he termed “lowest, middle and highest” (p. 41), noting that the terms were figurative, a “simplification,” since all so-called levels work together.
Jackson built up his model from what he considered the smallest elements of the central nervous system. They are reflexive, simple sensorimotor units. Each unit has a representing function; that is, it has a memory of some kind. This proposal was made before Sherrington introduced the term synapse in 1895 and well before Kandel’s (1976) demonstration that the synapse has a kind of memory.
The earliest level of the system consists of the basic units operating relatively independently. Movements from an earlier to a later state of evolution come about not through the introduction of any new form of neural tissue but as a consequence of an increased coordination between units of neural function. “The whole nervous system,” he wrote, “is a sensori-motor mechanism, a co-ordinating system from top to bottom” (Jackson, 1958, II, p. 41). The highest level of the brain–mind system, which gives rise to the experience of self, is achieved through greater coordination between brain elements brought about by the evolutionary elaboration of existing structures, most importantly the prefrontal cortex (p. 399). As Jackson put it, quoting his follower Ribot, “Le moi est une co-ordination” (Jackson, 1958, II, p. 82). The significance of prefrontal functions, particularly the orbitofrontal cortex in the creation of the experience of self, is a main feature of Damasio’s (1996) thesis.
Each stage of enhanced coordination between the elements of the central nervous system (CNS) brings with it states of mind and function that show an increased complexity that is allied to a multiplicity of representation. More recent levels of evolution do not involve the introduction of new representations. Rather, there is re-representation, then re-re-representation. In addition, evolution brings greater voluntary control over the contents of consciousness and systems of response. This control includes enhanced inhibition of earlier evolved “levels.”
In essence, Jackson proposed a hierarchy of consciousness. Hierarchy is a basic feature of the structure of biological systems (Smith, 1978) but not in the sense of a unidirectional system of dominance, a command tree found, for example, in military organization. Rather, the coordination of which Jackson speaks is not only across “levels” but also between them. Each level is coordinated with other levels and depends upon them. Switching between levels is related to adaptive needs and environmental circumstances. Fight and flight are dominant and adaptive states of mind in specific situations. The highest level is not a single level but comes into being through a coordination of lower levels, which creates a larger system that now “contains” all levels.
This hierarchical organization can be illustrated by the development of memory in an individual life. Early memory systems are sensory and motor. The first sensorimotor memory system involves simple recognition of fragments of the sensory environment; for example, the baby perceives eyes rather than a face. This form of memory, “perceptual representation,” is atomized, inflexible, and very accurate (Tulving & Schacter, 1990). Memory for motor repertoires—called procedural memory—also emerges early. Tulving calls these early memory systems “anoetic,” a neologism derived from the Greek noesis, meaning mind.
The second “level” of memorial capacity is achieved when the child has the capacity to recall facts of its sensory environment. This achievement, which comes toward the end of the first year of life (Nelson, 1992), heralds the onset of what Tulving (1972, 1983) called “semantic memory.” It is “noetic.”
The third level of memory comes considerably later, at about 4 years of age (Nelson, 1992), when the experience of self is discovered. This discovery comes with the child’s new sense of an awareness of inner events, shown by the attainment of the concept of secrecy (Meares & Orlay, 1988). This new memory is an aspect of the capacity for introspection. It is autonoetic. Tulving called it “episodic” (1972, 1983). The child is now able to conjure up, as if in “the mind’s eye,” episodes from its past. This form of awareness was once called insight (Oxford English Dictionary, 1971). It is accompanied by the capacity for some kind of insight into the world of others, a realization that, just as one has a private and unique personal reality, so others have wishes, feelings, imaginings, and so forth, which are their own and different from those of oneself. The child at this stage moves beyond the capacity for sympathy and gains, in addition, the faculty of empathy. This is an important point in the development of the so-called “theory of mind.”
Remote episodic memory is now generally termed autobiographical. Tulving called the reflective form of consciousness, of which autobiographical memory is an essential part, “autonoetic.” This state of mind is larger than earlier states. The individual is now able, figuratively, to roam around in the mind through scenes brought up at will in memory and imagination in a process Tulving likes to call “mental time travel” (Tulving, 2001, 2005; Wheeler, Stuss, & Tulving, 1997).
Although Jackson’s hierarchy is described in terms of consciousness, it implies a more extended hierarchy. Consciousness is not a single, isolated phenomenon. It necessarily arises from a brain state determined by the interplay between the sensory environment and the brain–mind system that is constantly taking place. In terms of self, the interplay, or forms of relatedness, with the social world, whether outer or inner, is particularly important. It is mediated by conversation and always accompanied by emotion.
Seen in this way, a hierarchy of consciousness necessarily comprises forms of relatedness, language, and emotion, in addition to forms of consciousness. Forms of consciousness are made up of characteristics including cohesion, continuity, value, and the senses of time, space, ownership, and boundedness. Jackson (1958) did not attempt to enlarge his sketch of the hierarchy, although he did point out that mentation involves emotion and that the highest emotions are compounded out of the lower. All aspects of the highest level of the hierarchy are disturbed in BPD, which is seen here as a manifestation of the failure of development of self, an overarching concept that includes all the features of higher-order consciousness (Armstrong, 1981). How this failure might come about is suggested by a consideration of Jackson’s concept of “dissolution,” which in turn gives us a way of understanding “fragmentation.”
DISSOLUTION AND A FAILURE OF COHERENCE
Dissolution is a reversal of the trajectory of the brain’s evolution. An insult to the brain–mind system causes a retreat down a hierarchy of function, which evolution decreed and development followed. Since it is the functions that emerged last in evolution that are affected first, the initial “level” of disturbance is particularly in the fine-tuning and voluntary control of brain mechanisms underpinning those aspects of attention, memory, and affect that together contribute to the experience of self.
Jackson did not include psychological traumata in his list of possible insults. His proposal, however, suggests that this may be the case. He believed that “dissolution” followed excessive excitation of neuronal tissue, which resulted in its exhaustion, or “fatigue,” a word repeatedly used by Janet as a synonym of psychological trauma. Temporary failure of function was seen as a consequence not of the excitation but of the exhaustion. Jackson gave an example of dissolution as manifest in memory:
One of Jackson’s patients, a doctor, reported an occasion when he was called to see a patient with a respiratory complaint. While beginning to examine him, the doctor became aware that he was going to have a slight fit and he turned away from the people in the room so they would not notice. “Coming to” some time later, he found himself writing out the diagnosis of pneumonia of the left base. The patient was no longer in the room and had presumably been sent to bed. Nobody seemed to have noticed anything strange about the doctor’s behavior. Feeling the need to check his diagnosis, he re-examined his patient. He found, as he wrote, “that my conscious diagnosis was the same as my unconscious” (Meares, 1999a, summarizing Jackson, 1958, I, p. 405)
The doctor was behaving in a manner that nobody saw as strange. He was conscious and working in a very sophisticated way, using a memory of the facts of his medical training. However, he was unable to remember anything of what he had done; no memory of the event remained. Episodic memory was lost. He was operating at the level of noetic consciousness. In diagnostic terms, he was dissociated. Dissolution is a model of dissociation (see Chapter 7).
In this state there are no imaginings, no memories of past events, and no narrative. The experience is one of the immediate present, in which there is a constriction of consciousness. Jackson’s hypothesis predicts that “self” will be lost under noxious circumstances, resulting in a diminution in the sense of “me-ness” and a feeling of personal estrangement. A story from the British writer Rebecca West (1971) suggests that this state will involve a sense of personal disintegration, presumably mirroring a disconnectedness among brain elements, and a disturbance of the normal inhibitory activity necessary to selective inattention.
Holidaying in a remote village in Cornwall, in the era before antibiotics, Rebecca West became ill with “blood poisoning.” In the following days she fell into a “curious state,” in which a failure to select out redundant sensory data and modify the intensity of sensory input seemed to be related to discontinuity of psychic life. She wrote:
I lost my power of suppressing irrelevant impressions and co-ordinating those that remained. I felt obliged to watch the trees outside my window and their behaviour in the sunshine and the wind, to note the characteristics of every person who spoke to me, with a quite disagreeable intensity, and I was so fatigued by this constant effort of apprehension that there was no continuity in the working of my brain. Every moment of consciousness was distinct and unrelated to every other moment. Instead of being a stream my mental life was a string of disparate beads. (1971, p. 52)
The disturbance in the continuity of mental life continued for some days even after her temperature had fallen to normal. Just before her discharge from the nursing home, she was allowed to take a walk beyond the grounds. She chose to climb a small hill from which she had heard there was a fine view. When she got there, as she said:
I could not see the view. I could see it in bits, but not as a whole. It was like trying to take a photograph with a non panoramic camera. And what I saw seemed like meaningless painting on glass. The patchwork of colours carried no suggestion of textures and contours. I had to work hard to interpret it; to see, for example, that that spattered rhomboidal patch was a cornfield. (West, 1971, pp. 52–53)
The disconnectedness of psychic life was accompanied, as it had been earlier in her convalescence, by an unpleasant sense of intrusion into consciousness of the stimuli of the internal world. Two miners and their dogs also came to look at the view. Even though she knew that it was unreasonable, that her “mechanism was hopelessly out of gear,” “she felt irritable and uncomfortable,” as if being “jostled by a dense crowd” (West, 1971, p. 53).
Rebecca West’s state of “fragmentation” and failure of adequate inhibitory control over sensory input was extreme. Her description may illustrate what those with BPD experience, in a minor and subtle way, as an ongoing state of existing.
Jackson’s “dissolution” hypothesis suggests that the typical childhood of people with BPD, involving multiple and cumulative traumata that excite high levels of arousal associated with negative affects that produce repeated “fatigues,” will constantly demolish emergent states of “higher-order consciousness,” so impeding its maturation. This idea, not developed by Jackson, was put forward by Janet (1911, pp. 531–532).
Maturation might also be impeded in a second way. The “facilitatory environment” which the mother and other caregivers normally create may not be provided. Jackson did not contemplate such matters, although he did intimate that achievement of psychic maturation is not inevitable. He wrote: “We develop as we must, that is, according to what we are by inheritance; and also as we can, that is, according to external conditions” (Jackson, 1958, p. 71). The unsuitable “external conditions,” beyond active trauma, experienced by the typical patient with BPD, are touched upon in later chapters.
P3, REENTRANT PROCESSING, AND SELF
A neo-Jacksonian hypothesis concerning the brain basis of BPD can be tested by studying a major component of the event-related potential (ERP), the P3 or P300.
A typical activation task used to elicit P3 in human subjects is the “oddball” paradigm, in which task-related oddball (or target) stimuli occur randomly among other “background” (or nontarget) stimuli. Using light and sound stimuli, Sutton and his colleagues (1965) first observed that a positive ERP component arises about 300 milliseconds (ms) after the presentation of the oddball stimulus. By contrast to the earlier components, which relate closely to the physical parameters of the stimulus, the appearance of P3 is determined more by the subject’s expectancy concerning an event and the information provided by the event, than by the physical characteristics of the stimulus that signals the event.
In the years that followed the research by Sutton et al., P300 has demonstrated considerable utility as an assessment of human mental function in basic and clinical studies. Although P3 appears in average ERPs as a large, monophasic waveform, as if it were the product of a single source, there is general agreement that P3 is not a unitary brain potential but is the result of activity from widely distributed areas in the brain (Johnson, 1993). There is also a generally accepted distinction between an earlier positive potential, called P3a, and the later P3b peak (Squires et al., 1975). The P3a reflects novelty detection (Soltani & Knight, 2000) and orienting (Barcelo et al., 2002), whereas the P3b (classical P300) is less clearly understood. Verleger and his colleagues (2005) suggest that it is akin to a response set. Soltani and Knight (2000) propose that P3a is an automatic response whereas P3b is a more volitional response. Dissolution theory predicts that the coordination between the neural generators will fail relatively, following an insult to the CNS, so that a monophasic wave will be replaced by a biphasic one.
In a very interesting paper, Rolf Verleger and his colleagues (2005) suggest that the P3 represents more than stimulus processing, which is the way in which it is traditionally portrayed as an aspect of attentional function (reviews by Donchin & Coles, 1988; Verleger, 1988). On the basis of their studies, the Verleger group considers P3 to be a measure of response processing. Most importantly, they see it as a manifestation of some aspect of cooperation between brain areas, integrating stimulus and response. They assume that this binding together of stimulus and response takes place in subcortical regions and in the frontal cortex.
In addition to the proposal that P3 is the outcome of integrating stimulus and response, Verleger and colleagues speculatively link it to the notion of reentrant processing. This concept is based on studies, of which Libet is a pioneer (Libet et al., 1983), which demonstrate that a stimulus has to be processed more than once by the CNS for it to be consciously perceived. This idea is supported by more recent work (Di Lollo, Enns, & Rensink, 2000). Libet’s observations suggested that the primary processing occurs earlier than 150 ms. At this stage there is sensory detection resembling “blindsight” (Libet et al., 1991). Blindsight is the phenomenon in which an individual, blinded by damage to the visual cortex, is able to locate objects in the environment when asked to guess their position (Weiskrantz, 1986). The concept of reentry has been extended to propose that relevant stimuli will undergo several passes of processing, involving multiple brain areas, before the stimuli can be perceived (Olson, Chun, & Allison, 2001; Woldorff et al., 2002). Verleger and colleagues speculate that this secondary processing triggers P3.
The linking of reentrant interactions to the generation of P3 is intriguing. Edelman (1992) has put forward the view that higher-order consciousness, which involves self, as defined by William James, is brought into being through the reentrant activity of the brain. Bringing the speculations of Verleger and Edelman together, we find that P3, in some way, becomes a reflection of self.
Reentrant interactions as the basis for the necessary integration of self are consistent with the view of the generation of self that is briefly touched upon in Chapter 16 and outlined in more detail elsewhere (Meares, 2000, 2004b, 2005). It depends upon an “analogical relatedness” (Meares & Jones, 2009) between the child and the caregiver in which the response of the latter shows the “shape” of the baby’s experience in her face and voice. An analogue, in its original meaning, is something that has a similar shape to another thing. This particular kind of mother–child relationship, then, might be seen as an interplay of patternings, each one resembling the next, but without replication, as if reentrant activity were going on in the world. It is tempting to suppose that this may be another example of the Janet–Baldwin proposal, taken up by Vygotsky, that those functions we sense as “inner” in adult life had their first forms in the outer world as activities (van der Veer & Valsiner, 1988), particularly between people.
Edelman considers that the reentrant activity of the brain brings forth “analogical abilities” necessary to pattern recognition (2004, p.147). With his colleague Giulio Tononi, Edelman demonstrated how reentry “can account for our ability to discern a shape in a display of moving dots, based on interactions between brain areas for visual movement and shape” (Edelman & Tononi, 2000, p. 86). This capacity for the discernment of pattern and shape is a manifestation of one of the two main modes of thought that are available to us, and which are evident in language, as Vygotsky (1962) pointed out. Edelman calls this mode of thought, which I term analogical, “selectionism (or pattern recognition).” The other mode is logic.
Reentry is to be distinguished from feedback. Negative feedback is productive of homeostasis. Reentry has a very different outcome. The difference between the two mechanisms is emphasized by Edelman and Tononi (2000):
It is important to emphasize that reentry is not feedback. Feedback occurs along a single fixed loop made of reciprocal connections using previous instructionally derived information for control and correction, such as an error signal. In contrast, reentry occurs in selectional systems across multiple parallel paths where information is not prespecified. . . . A key anatomical pre-condition for reentry is the remarkable massively parallel reciprocal connectivity of brain areas. (p. 85)
Reciprocal is a crucial term. Reentry refers to a dynamic interplay between reciprocally connected areas of the brain that “lead to the synchronization of the activity of neuronal groups in different brain maps binding them into circuits capable of temporarily coherent output. Reentry is thus the central mechanism by which the spatiotemporal co-ordination of diverse sensory and motor events takes place” (Edelman & Tononi, 2000, p. 85). Reentry, then, may be the means by which the coordination occurs that is necessary, in the Jacksonian thesis, for the experience of self to arise.
Verleger (2002) suggests that the temporoparietal junction (TPJ) is critically involved in reentrant processing. This proposal is a plausible one in view of the strategic location of the TPJ, particularly at the angular gyrus. The angular gyrus is situated where the borders of the occipital, parietal, and temporal lobes meet each other, facilitating linkages that would allow (1) coordination between visual and auditory inputs and (2) functions involving language and the “shaping” of sensory data.
Since such coordination is necessary to the moment-to-moment experience of self, it would be anticipated that disruption of a main aspect of the coordinating system would lead to a disturbance of self, at least in some way. This disturbance is manifest in disruptions of the function relating to the TPJ, for example, in epilepsy. The coordination and integration of various aspects of the bodily component of self-experience are apparently lost, leading to an out-of-body experience (Blanke et al., 2004). A growing literature on the role of the TPJ in the creation of the neural network underpinning self is briefly considered in Chapter 6.
It would also be predicted that disruption of the TPJ area would result in disturbance of P3, since this waveform is the outcome of coordination between different sites of neural activity. Verleger remarks that “re-entrant processing is precisely what is damaged in patients with lesions to the temporoparietal junction” (2002, p. 23). This observation is supported by reports that those with lesions in the TPJ area have more severe reductions of P3 than patients with other cortical lesions (Knight et al., 1989; Yamaguchi & Knight, 1991; Verleger et al., 1994; Hagoort, Brown, & Swaab, 1996).
Finally, these various arguments lead to the view that self is the outcome of a coordination between brain areas that is the result of reentrant processes. P3 is the product of the same process as that involved in the generation of self. Seen in this way, P3 is a neural marker of a fundamental feature of self, making it a suitable focus of a neo-Jacksonian hypothesis concerning the brain basis of the ongoing sense of personal being. An outline of a study designed to test this hypothesis is presented in the next chapter.