SOCIALIZATION FACTOR (PART 5)

SEEKING AN UNDERSTANDING OF THE SOCIALIZATION FACTOR AND ITS RELATIONSHIP TO CLINICAL PSYCHIATRY.

5-A) ROLE OF INHIBITION OF THE SOCIALIZING FACTOR IN MENTAL ILLNESS.

A large volume of material has been presented in order to provide convincing evidence that the inhibition of the socialization factor plays a major role in a number of mental disorders. Below is a preliminary attempt to provide improved understanding to this material.

5-A1) Inhibited socialization is seen in many disorders – such as Autism, Schizophrenia, Social Phobia. It is much more present in other conditions than has been recognized.

5-A2) The socialization factor seems to be present in all brains—but is
poorly operative in many conditions such as autism and schizophrenia.

5-A3) Treating inhibited social interaction may improve in response to various treatments—including various behavioral programs, atypical antipsychotics, glycine-serine agonists, mecamylamine/ Inversine and occasionally to various dietary changed, food supplements, and to many other seemingly unrelated treatments.

5-A4) The timing of improvement varies widely. Changes can be instantaneous or gradual. The effect can last permanently, last for an extended time or last only as long as the treatment is in progress. In many cases the change is so rapid that it seems necessary to assume that the mental processes that emerge had already been present but were unexpressed.

5-A5) This is different type of behavioral phenomenon—The number treatments which have pro-socialization effects, the number of neuroreceptor pathways that seem to be involved, the nearly bizarre variations in dosages of medications, and the persistence of response after treatment ends seem to point to a different type of treatment effect than is normally encountered. The socialization factor in the brain does not seem to be due to a simple balance or imbalance of one particular chemical—or to one connection of a particular nerve pathway. It seems to be a factor of basic brain function. The exact nature of this factor is uncertain, but there are certain clues available.

5-B) Clues to the nature of the socialization factor and its treatment.
Even though therapy to affect inhibited socialization is so unpredictable, there are some clues that do help the understanding its nature. The clues presented come from incomplete observations in different spheres of psychiatric knowledge; therefore they cannot yet be integrated into one well-defined concept.

5-B1 Clue 1) The “two primitive selves” concept of Margaret Mahler.

5-B1.a) The concept of there being a socializing brain function and a distinct non-socializing brain function. This concept seems to be reinforced by the work of a mid-20th century child psychiatrist named Margaret Mahler. In her book, The Psychological Birth of the Human Infant, she states that early in the development, the child has two primitive personality phases.

5-B1.a1) The first is the “autistic phase”. It lives within an internalized world blocking out external stimuli.
" The child with predominantly autistic defenses seems to treat the 'mother in the flesh' as nonexistent." ® 3
5-B1.a2) The second is the “symbiotic phase”. This is a state in which a child is so enmeshed in reacting to external stimulation that it may perceive that it is not a separate individual from its adult caregiver.
" On the other hand, the child with a predominantly symbiotic organization seems to treat the mother as if she were part of the self, that is, as not [being] separate from the self but rather fused with it." ® 3
Dr. Mahler demonstrated the activity of these two “functioning selves” exist in the course of development of normal children. It is very easy to extend this concept to the extreme and believe that autistic individuals become totally trapped in their autistic self and close down most of the inter-personal dependency of the symbiotic function of their brain.
® 3 The Psychological Birth of the Human Infant. Margaret S. Mahler et al. pp. 7. HarperCollins Publishers 1975
5-B1.b) The retention of the influence of the primitive autistic phases.
Dr. Mahler dedicates much of her book dealing with the integration of the early phases of brain function—the autistic and the symbiotic. Her next stated phase, “the Separation-Individualization phase,” is supposed to replace the first two phases; but it seems more likely that these early stages are suppressed or covered over to provide the shaky foundation on which later patterns are built. Autism, schizophrenia and other non-socializing conditions represent the continued activity of the unsuppressed autistic phase of the brain, mania may be a product of the unsuppressed symbiotic phase.
5-B1.c) Childhood Degenerative Disorder. This concept would clarify the phenomenon of Childhood Degenerative Disorder in which a seemingly normal child older than 3 years may regress into a non-verbal autistic child. Or as stated in the DSM-IV. “the child has a clinically significant loss of previously acquired skills in – expressive or receptive language, social skills or adaptive behavior—” For various reasons, the individualization process ceases to be dominant in its function and the child reverts to its irrational inner world reactivity. Parents of such children naturally assume that some external event is always the cause of the regression, and in some cases it may be. (This is the contention of those who attribute autism to the mercury preservative in the MMR vaccine) But with or without an obvious external cause, the pattern of regression is a failure based on the way the brain is put together. If this is true, then there is reason to believe that the socialization factor is still present but suppressed—and may be recoverable.

However, the concept that these two early phases can fail to integrate points to another phenomenon which offers a somewhat different clue concerning the socialization factor – that is the phenomenon of dissociation.

5-B1.2)
Clue 2) Dissociation – the possible mechanism by which the blocking of the socialization factor occurs.
5-B1.2a) Atypical reactions: The events seen with the blockage of the socialization drive are not typical of the events seen in standard treatment experiences—especially in three ways:

5-B1.2a\1) Sudden change: The ability to show a sudden change from one behavioral state to a different one.
5-B1.2a\2) Persistence: The persistence of that change for prolonged periods – even without the medication.
5-B1.2a\3) Multiple neurotransmitters: The seemingly numberless chemical mechanisms which can influence the process.

5-B1.2a\3) Reactions seen in dissociation. However, such behavioral changes are consistent with phenomena seen in dissociation. It is a fairly common experience for someone who had a long-term symptom such as paralysis due to dissociation to suddenly be permanently cured in an unusual way – for example during a visit by a favorite aunt from North Dakota. In situations involving dissociation, there can be prolonged periods of one pattern of behavior changing to another pattern for an indefinite length of time. Furthermore, there has never been any demonstration of a specific chemical transmitter associated exclusively with the process of dissociation; so it might be complex process influenced by many different neurotransmitters.

5-B1.2b) What is Dissociation?
Dissociation is a poorly explained, poorly understood, and poorly publicized function of the mind.
5-B1.2b\1) It is defined in the DSM-IV as a “disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment.” (DSM IV: The American Psychiatric Association Press, Washington, 1994, Page 477).
5-B1.2b\2) A definition written for laymen defines it as, “The segregation or separation of a group of mental processes so that their normal relationship to the rest of the personality is lost. This generally results in the almost independent functioning of the isolated processes.” Baker Encyclopedia of Psychology David G. Benner editor Baker Book House, Grand Rapids, 1985 page 318.
5-B1.2c) “Multiple Personality” an example of dissociation
Multiple personality, now called Personality Identity Disorder, is the one phenomenon involving dissociation that is generally known by the public. The idea of there being two differently expressed personalities in the same person holds a fascination for the rest of mankind. However, multiple personality is a small part of the various ways that dissociation presents itself in the various activities of mankind.

5-B1.2d) Dissociation is common in some societies.
The dissociative phenomenon is the basis for many of the traditional rituals and ceremonies in which the participants do atypical behaviors—especially go into trances and perform difficult and painful acts. In our modern educated society, dissociation is generally considered a disordered behavior; but in the lives of many individuals in mankind’s struggle to reconcile mental function with life’s problems, dissociation has been a necessary mechanism of life survival. Consider the wife in labor sent out alone to deliver her child. It is fortunate that a dissociative mechanism which blanks out the memory exists to wipe out the hours of frightened, lonely suffering.
5-B1.2e) Dissociation and the developmentally disabled.
The large number of developmentally disabled (DD) individuals whose speech was improved by mecamylamine /Inversine therapy was surprising, but the presence of dissociative-like phenomena in this population was not. Over the years of caring for DD individuals, this clinic has been increasingly aware of the frequency of dissociative behaviors. A large number of DD have a mental fantasy world in which they live on an intermittent basis. Frequently these fantasies involve dissociation and may even become psychotic. They might identify themselves as being other personalities, adopt a fictional character such as the Incredible Hulk as an alter ego identity, talk in multiple voices, etc. These behaviors come and go and are MOST often diagnosed as “Psychosis Not Otherwise Specified”.

5-B1.2f) Case history –chronic dissociative disorder.
The case history presented below demonstrates commonly seen behavior, which seems best understood as being dissociative in nature.
{Case 28} This severely mentally retarded 32-year-old female originally presented over five years ago demonstrating violence towards others, responding to hallucinatory voices and talking to herself using various voices. She could speak in four word sentences but rarely talked except to answer or make a request. She was diagnosed as having Dissociative Disorder NOS with psychosis, and her symptoms were controlled somewhat with antipsychotics and a low dose serotonin antidepressant. Because she continued to have episodes of impulsive aggression, she was placed on mecamylamine/ Inversine 1.25 mg/ day. Two months later she was reported to have less impulsive yelling at imaginary people, less social isolation, and increased appropriate laughing. Over the next months her dissociative and aggressive behavior waxed and waned and Seroquel/ quetiapine was gradually raised to 400mg a day. Then the mecamylamine/ Inversine was discontinued because of the possibility that it was causing over-activation. Within two months she was demonstrating a marked increase in angry confrontations using her dissociative voices. She was placed again on mecamylamine/ Inversine 1.25mg /day. This time she responded by stopping the angry tone of her dissociative voices and becoming much more conversational with others. For example, during a recent visit, she rang the bell that she loves to carry then looked at me and said in a confident, conversational tone, “Did you hear my bell?” Before that she simply would have listened to the bell while being socially out of touch with those in the room.
5-B1.2g) Treatment of dissociation. This clinic has found that such dissociative symptoms have responded fairly consistently but often incompletely to treatment with atypical antipsychotics. Mecamylamine/ Inversine seems to provide a stronger therapeutic benefit. It seems possible that mecamylamine/ Inversine and other prosocialization treatments have an effect on a “switch mechanism” which allows for the expression of behavioral drives that were previously hidden in a dissociative state.

5-B1.2h) Release of maladaptive primitive dissociations.
The concept of mecamylamine/ Inversine therapy allowing for expression of dissociative states might explain the wild, aggressive responses seen in some patients. In them, the early emerging dissociative impulses for socialization would be for aggressive domination rather than for mutual social interaction. (This problem will be dealt with more thoroughly in the next section.)
5-B1.2i)The large number of individuals affected and treatment response would imply the following principles.
[32] A large percentage of the DD population had dissociatively repressed behavior patterns.
[33] It appears that the communication barrier in autism is at least in part from a psychological (dissociative) block and is not exclusively caused by a neurological deficit.
[34] Unexpectedly, It seems that the communication blocks found in autistic individuals are similar to those in non-autistic DD individuals.

5-B1.3)
CLUE 3) --THE POSSIBILITY OF DISSOCIATION BEING A FUNCTION OF THE MNDA (GLUTAMINE/GLYCINE) RECEPTOR MECHANISM.
When explaining dissociation, I stated that dissociation has not been directly linked to one particular neurotransmitter as some other behavioral phenomena are. However, all information passed from one nerve cell to another is done so by means of chemical signals. It is possible that there is some undiscovered relationship between the dissociation process and the MNDA glutamate receptor. The following are various factors suggesting such a relationship.
Glutamate receptors (NMDA and others) are abundant in the brain. They interact with many neurotransmitter systems including dopamine and nicotine receptors. It is possible that dissociation is related directly to the glutamate system and indirectly by other agents; but until that is demonstrated, it seems easier to consider the process of dissociation as being attributable to complex circuitry with many neurotransmitters involved. The shift from one association to another seems to involve a gate-like mechanism, which may open and close quickly—or stay open, or stay closed for an extended time providing prolonged effects. However, not all prosocialization medication have demonstrated the prolonged effects that were seen with glycine-serine agonists and mecamylamine/ Inversine

5-B1.3a\1) Persistence of response with glycine agonists. This unusual phenomenon has already been mentioned concerning the treatment of socialization factor block with the glycine-serine agonists. It was dramatically demonstrated in the double blind study giving l-glycine to schizophrenic patients. When the responders were switched off the active drug they retained their improvement for a considerable time. (Remember, however, that the same reaction was seen with Mecamylamine/ Inversine and possibly Secretin.)

5-B1.3a\2) Persistence of the effects of the hallucinogenic drugs.
PCP and some other hallucinogenic drugs of abuse create hallucinations by being strong blockers of the NMDA glutamate receptor mechanism. Since the beginning of PCP’s use, it has been known that sometimes the psychosis that is precipitated by PCP will last for months. There is a question exactly whether this long-lasting effect is due to persistence of the PCP in the body or some other mechanism.

5-B1.3b\1) Memantine/ Namenda is an NMDA blocking medication, which does not cause hallucinations – presumably because it is weakly binding. It is effective to treat memory loss in Alzheimer’s disease, but also it seems to be able to stimulate increased socialization and conversation in those receiving it.

5-B1.3b\1a Successful treatment of catatonia with memantine/ Namenda.
{ CASE 28A} A report of the successful treatment of extremely socially withdrawn patient with catatonia is slated for publication in 2004 or 2005. The patient improved within a day of being put on the dose of 5 mg. The dose was raised to 20 mg of memantine/ Namenda with 300 mg clozapine/ Clozaril daily. When the memantine/ Namenda was temporarily stopped the symptoms of catatonia briefly reappeared.

(communication from Brendon Carroll, Chillicothe, OH Veterans Hospital.)
5-B1.3b\1b. Transient change of social function in individual with senile dementia
{CASE 28B} 88-year-old woman with dementia and significant psychotic paranoia and delusions. Over two years these were treated with increasing doses of exceptionally high doses of anti-psychotics—and these symptoms were somewhat stable on loxapine/ Loxitane 5mg, olanzepine/ Zyprexa 10 mg, quetiapine/ Seroquel 100mg at night plus varying anti-anxiety and antidepressant agents. She remained very negative, uncooperative, cursing and complained at staff interactions.
Her social demeanor did not improve after a trial of 2.5 mg aripiprazole/ Abilify a day. She was then given memantine/ Nemenda 2.5mg a day and aripiprazole/ Abilify stopped. Within two days she became friendly, told care workers that she loved them, and enquired about calling a relative in another state. This state lasted for about a week.
5-B1.3b\2) amantadine/ Symmetral. This medication is a relative of memantine/ Namenda. It has been used for years for its dopamine stimulation properties. However, it also has NMDA blocking properties. There as also a reported case of catatonia improved by amantadine/ Symmetral, presumably through NMDA effect.
(communication from Brendon Carroll, Chillicothe, OH Veterans Hospital.)

(5-B1.3b\3) The cough suppressant Dextromethorphan (which is the “D” in Robitussin D) is also an NMDA blocking agent. It normally is changed in the body to a morphine-like substance for cough control, but in some situations the original compound persists. If there is too much in the system, the individual can have a drug “high” similar to PCP’s. At more modest doses, dextromethorphan can have positive psychiatric benefits.

(5-B1.3b\3a
{case 28C} There is a literature report about one mentally retarded male who stopped self-abusive behavior when put on Delsym, a pure dextromethorphan preparation. After the medicine was stopped, the self-abuse returned. ® (1) Occasionally, this clinic has given two teaspoons of Delsym at bedtime to dementia patients and stopped much of their nighttime agitation.

® (1): The treatment of a chronic organic mental disorder with dextromethorphan in a man with severe mental retardation L Welch and R Sovner, The British Journal of Psychiatry 161: 118-120 (1992)

(5-B1.3b\4 acamprosate/ Campral

c) Glutamate receptors (NMDA and others) are abundant in the brain. They interact with many neurotransmitter systems including dopamine and nicotine receptors. It is possible that dissociation is related directly to the glutamate system and indirectly by other agents; but until that is demonstrated, it seems easier to consider the process of dissociation as being attributable to complex circuitry with many neurotransmitters involved. The shift from one association to another seems to involve a gate-like mechanism, which may open and close quickly—or stay open, or stay closed for an extended time providing prolonged effects. However, not all prosocialization medication have demonstrated the prolonged effects that were seen with glycine-serine agonists and mecamylamine/ Inversine.