(Refractive) anisometropia -
In schizophrenia requirements
Optical correction of the deficiency
Statistics (in preparation)
Challenges to the above theory
Psychiatric consequences of
Diagnosis and therapy
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Description for the Internet: In genetically vulnerable persons schizophrenia can be prevented by detecting and correcting a difference in magnitude of the binocular images before it is overcome by a unilateral reversal of foveal disparity stimulation of convergence dissociating the binocular from the head axis and misguiding fixation away from the object of selective attention.
Keywords: accommodation, aniseikonia, anisometropia, asymmetric convergence, binocular vision, contact lens, Hirschberg-test, Chiasma opticum, corneal surgery, Corpus callosum, eye movement, fixation, fixation disparity, fovea, Hering’s Law, horopter, sensory and motor fusion, schizophrenia, selective attention, stereopsis, strabismus, vulnerability
Several recent investigations have reported in schizophrenic patients disorders of fixation, interpreted on the one hand as exotropia, on the other hand as fixation instability due to saccadic disinhibition. The phenomena put forward for both interpretations can be explained by the thesis of the present paper that in these patients bifoveal fixation of the near target of selective attention is mislead by requirements of binocular fusion of dissimilar images, thus reducing the attentional support of fixation and dissociating emotional from cognitive attention. Starting point is the case of an unmedicated hyperopic patient with chronic schizophrenia in whom an inability had been found to deliberately converge with the left eye from a distant to a near target in a test developed by the author – despite evidence of stereopsis. After prismatic correction of a vertical fixation-disparity, the deficiency was suddenly overcome when working with a laser display, which was accompanied by the transformation of that eye’s hyperopia into an emmetropia and finally into a myopia of the same degree. By correcting the resulting anisometropia with a contact lens instead of spectacles – which had caused an aniseikonia - binocular fixation of the near target of selective attention was established and the patient’s psychotic problems disappeared.
Two hypotheses are discussed concerning the causes of the abnormal compensation of the aniseikonia by reducing convergence and accommodation of the more myopic eye. It is attributed to an inversion of the left foveal temporal disparity stimulus transforming the foveally stimulated share of convergence and accommodation of that eye into divergence and negative accommodation. The genetic vulnerability for the inversion of the stimulus direction is imputed to the crossing of temporal instead of nasal foveal projections in the Chiasma Opticum which is not, however, as in unaffected relatives, entirely corrected via the Corpus Callosum, being partially required for binocular fusion of dissimilar images.
When anisometropia is caused by differing axial lengths of the eyeballs - as in most cases - an optical aniseikonia is present without correction and disappears with spectacle correction. When, however, it is caused by a differing refractive power of the eye-lenses, aniseikonia is produced by spectacle correction (Howard & Rogers 1996).
In vulnerable persons, aniseikonia can be overcome by maintaining the inversion of the temporal foveal stimulus of convergence and accommodation in the more myopic eye - at the cost of dissociating the binocular from the vestibular axis and misguiding bifoveal fixation, the mediator between peripherally discovered targets of cognitive interest and their emotional assessment in the amygdala and memory storage in the hippocampus. The resulting mental splitting can be overcome by detecting the misguided fixation with the Symmetric Convergence Test, confirmed by a combination of the Hirschberg and the Cover Test revealing the dominant eye to diverge from the target of attention, and by allowing the other eye to fixate the target by excluding the dominant eye from vision. It can be prevented in young vulnerable persons by thoroughly correcting anisometropias due to differing lengths of the eyeballs with spectacles, and refractive anisometropias with contact lenses or by corneal surgery.
In their investigation on “Premorbid childhood ocular alignment abnormalities and adult schizophrenia-spectrum disorder“ Schiffman et al (2006) have found in “children who later developed a schizophrenia-spectrum disorder significantly higher eye examination and strabismus scales scores relative to children who did not develop a mental illness”. In one of their tests “the observer covered one eye” of the fixating subject, thus “preventing binocular fusion, and observed the other eye for movement. Movement of the non-occluded eye occurs when that eye takes up fixation originally held by the occluded eye, indicating the presence of heterotropia.” This statement, however, is contradictory in itself, because, according to Howard & Rogers (1995, p.634), “people with strabismus” – heterotropia – “do not fuse corresponding images”, and in the test of latent strabismus permitting fusion – heterophoria – the deviating covered eye moves when being uncovered (Hugonnier & Magnard 1986, p.1.36). The diagnosis "heterotropia" would require the additional observation of an opposite parallel movement of both eyes when the leading eye is uncovered again in the alternating cover-test, proving a constant dissociation of the two eyes excluding fusion (Hugonnier & Magnard 1986, p.1.37) - and a negative stereopsis test. Without these tests we may assume that the object fused in the horopter before covering one eye is not the object intended for fixation by selective attention - fixated with the non-covered eye by the described movement when fusion is prevented - because of a unilateral insufficiency of convergence.
|Footnote 1:The horopter is the spatial layer whose points
are represented on corresponding loci of the two retinae, i.e. loci having
equal direction and disparity from both foveolae, on the temporal half
in the contralateral eye and on the nasal half in the ipsilateral eye, and
which are therefore perceived stereoptically.
Equal horizontal disparities with opposite directions – i.e. in both eyes on the temporal halves for nearer and on the nasal halves for remoter points - are interpreted in spontaneous binocular vision as indicating the location in depth of an object with reference to the fixated point.
The opposite nasal representation of a remoter object on each retina can be made conscious, however, by observing the background while fixating a slim near target. The same background is then perceived ipsilaterally at equal distance on both sides of the near target, thus proving its binocular fixation (Symmetric Convergence Test SCT).
Legend figure 1: Horopter
grey area: part of horopter right visual field
סּ fixated point
■ point with equal direction and disparity: stimulates version
▲ point with opposite direction and equal (temporal) disparity: stimulates (con)vergence
- - - binocular and head axis
A Japanese investigation by Toyota et al (2004) reports an extremely high score of “constant exotropia” in a schizophrenic cohort (p = 0.00000000906), diagnosed with an alternating cover test and the Hirschberg test. A deficient stereopsis, however - which would prove heterotropia - was not mentioned and strabismus was defined as an “ocular misalignment in which both eyes are not directed to the object of regard”. The definition is ambivalent: If the object of negation is "both" (i.e. only one eye is aligned) it means strabismus, if it is "the object of regard" it means a disorder of fixation. As deficient stereopsis is a criterion for exclusion in other schizophrenia tests and heterophoria - as a cause of stereopsis - was excluded here by cover-uncover tests we may assume a disorder of fixation.
of fixation is also suggested by a test performed by Ndlovu et al
(2011) measuring the pupillary deviation from the corneal reflection of a penlight
held in the midline at 50 cm from the subject. Here again, stereopsis was not tested. "The position of the corneal reflection of the light in each eye was observed by the examiner while the other eye was covered.
The examiner determined which eye was the deviating eye and placed
appropriate prisms in front of this eye
until normal alignment (0,5 mm
nasal from the centre of the pupil) was achieved" - which resulted in a
"mean exotropia" of 9.22 prism diopters (pd = cm deviation per m distance) in 62.16 % of a schizophrenic
If this deviation had been strabismic, however, to cover the other eye would have resulted in a movement of the deviating eye aligning the pupil with the penlight (= unilateral Cover Test). In the original "modified Krimsky test" - a modification of the Hirschberg-test which the authors pretend to replicate - both eyes remain uncovered during the whole test and "the prism to reposition the corneal reflex is placed over the fixating eye" - inducing it to turn to the penlight - until binocular symmetry of corneal reflexes is achieved. If in the test of Ndlovu et al the prism is placed over the deviating eye - and that eye does not move when the other eye is covered - this proves that the fixating eye is deviating from the target. Otherwise it would not have been possible to measure an angle between the pupil and the reflection of the penlight.
The - uncorrelated - results found by the authors in the Cover Test - indicating at 40 cm an exotropia of 10.62 pd in only 35,14 % of the patients - concern the other eye which is esophoric with reference to the point fixated by the leading eye and exotropic with reference to the presented target (cf. fig. 2).
There are no controls mentioned in this unusual test, neither of healthy nor of strabismic probands, which would be required to prove the eventual specificity of its results for schizophrenia.
Krakauer et al (1995) report a case of strong exotropia of the right eye associated with schizophrenic episodes each time the patient discontinued his phenothiazin medication. Has the drug transformed the "exotropia" into an exophoria, restoring binocular fusion - or has it annulled a unilateral divergence, caused by requirements of binocular fusion? A stereopsis test before and after taking the drug would answer the question, but it was not mentioned.
Deficiencies of binocular convergence
have also been observed by Flach & Kaplan (1983) in unmedicated
schizophrenic patients, together with a “midline shift”, a “focusing
insufficiency” and “vergence tracking without simultaneous movement”. The
authors noticed in these patients “a loss of developmental interaction between
the visual spatial orientation and the body spatial orientation” which “results
in a serious discrepancy between vision and position sense”. Another group
around Flach discovered in 1992 extensive and asymmetric deficiencies of phoria
and fusional convergence in schizophrenic patients, especially at near-distance.
These authors found extensive vergence disorders also in other persons with
psychiatric diagnoses while “subjects who lacked any psychiatric diagnosis
showed no dysfunction.”
The above findings correspond to what the author has hypothesized to be the somatic component of schizophrenia, namely a dissociation of the goal of visual attention and its actual foveal fixation (Korn 1999a). The unmedicated hyperopic patient with a syndrome of Withdrawn schizophrenia described in that paper had stereoptic vision but showed a deficiency of the left convergence - observable from behind the patient via the mirror - when requested to change fixation from the mirrored rear of a near target to the near target itself which, with spectacle correction, was perceived clearly. When asked to fixate a narrow near target and to observe the background behind it, the same background was not seen twice, i.e. on both sides of the near target - as by normal controls - but only on the left side. The patient could see the same background on the right side only when the left eye was covered, but as soon as the left eye was unconvered she saw the right image of the background moving upwards and to the left to fuse with the unmoving background image seen by the left eye – i.e. only the right eye was performing the way back of the fixation movement observed by Schiffmann. This means that the object actually fixated and perceived stereoptically was located remoter and to the left of the intended near target, the image of which - lying outside the horopter - was physiologically suppressed in the right eye in binocular vision (cf. Hugonnier & Magnard 1986, p. 1.41).
Footnote 2: Symmetric Convergence Test developed by the author (Korn 1999a):
However, only in binocular vision, the same distance proves that the near target is actually fixated whereas in monocular vision (fig. 2), the distance perceived
between the mirrored and the near target gives no information on whether the
“same distance” is perceived with the nasal or the temporal half of the viewing
eye, i.e. whether the near or the mirrored target is actually fixated. If
the dominant (left) eye perceives the distance with the temporal retinal
half, the binocular axis is shifted to its side relative to the
head-axis while in the right eye the image of the near target is suppressed .
▲ near target
סּ mirrored target
Fo left fovea
F▲ right fovea
----- binocular axis
_ _ _head
In the RODENSTOCK Near-Vision Test (no longer available) the contralaterally represented lower rods were not fused, in contrast to the ipsilaterally represented upper rods, indicating a convergence insufficiency with stereoptic perception - i.e. without strabismus.
The patient also had defective results in tests of convergent fusional reserve, i.e. of fusion of prismatically dissociated bitemporal images while maintaining constant accommodation. (cf. Wesson 1982).
A deficiency of fusional convergence has also been proved by the author with a fixation test excluding accommodative convergence by pin-holes (Korn 2002). In all stereopsis tests, however, the patient displayed spatial vision, excluding heterotropia.
Legend figure 3:
RODENSTOCK Near-Vision Test
- Upper rods: uncrossed polarization of glasses and nasally represented signs
= remoter impression
- Fixation point
- Lower rods: crossed polarization of glasses and temporally represented signs = nearer impression
|Optical correction of the deficiency|
After her defective left convergence had been discovered in the Symmetric Convergence Test, a vertical fixation disparity of 2 pd was diagnosed in a ZEISS Pola-Test developed by Haase (1995) and prismatically corrected. When checking the result after some months, a prevalence to the left had developed which was interpreted as an exophoria (of the left eye?) by the Pola-Test optometrist. As the base-in prisms then prescribed led to dizziness, an ophthalmologist specialized on Pola-Test was consulted who diagnosed the opposite, namely an esophoria (of the right eye?) of 2,8 cm/m at far distance, the prismatic correction of which, however, was not tolerated either. With base-in and base-out prisms the deviations increased after a short period, and after several unsatisfactory attempts, the exact pupillary distance was measured using the FLA-method developed by Hegener (1999) and the patient felt best without any horizontal correction.
While, with prismatic correction, the patient displayed perfect stereopsis in the Pola-Stereo- and Stereo-turning Tests, in the RODENSTOCK Near-Vision Test only the uncrossed bars – represented on the nasal retinal halves - continued to be fused. There also remained a deficiency of convergent fusional reserve as well as the defective convergence of the left eye in the Symmetric ConvergenceTest.
To counteract the predominance of the left eye, the patient had endeavoured from the outset of prismatic correction to strengthen her right eye by shielding her eyes against diverting stimuli from the left and by occluding her left eye at times with a cover behind the spectacle glass. In addition, she conscientiously trained her convergence. When - after ten years of prismatic correction - she felt unable to defend her independence due to the deficient convergence of her left eye (details see B 9/10), she attempted to withdraw her gaze to the near range. She succeeded in this once she started to work with a TFT display with level 2 laser light. Suddenly, when wearing her usual spectacles, the patient saw with her left eye distant objects as blurred while very close objects were seen more distinctly than before. This alteration – which she took to be a spasmodic fit of accommodation – remained, so that after several days the optician stated that her left eye required for correction only +0.25 D, - after some weeks 0 D - from +1.25 -0.25 D before.
A striking change also became evident in all convergence tests. At prismatic testing of fusional reserve the ratio between convergence and divergence reserve had completely normalised at close and distant range. In the RODENSTOCK Near-Vision Test, also the temporally represented bars were now seen as perfectly fused. In the Symmetric ConvergenceTest, the mirrored target appeared on both sides of the near target in binocular vision, with a larger distance on the right than on the left side - which might be due to a larger convergence of the re-inverted left eye.
The alteration, however, was again accompanied by feelings of dizziness which could not be overcome by various modifications of the prismatic correction. After a year of experiments, the dizziness was revealed to be due to a difference of magnitude of the images of the two eyes, the anisometropia of which, by reactivating the left accommodation, had been increased from 0,75 to 2,0 D. It was overcome by correcting the hyperopia of the right eye with a contact lens of +1,75 D. Being nearer to the eye-lens, contact lenses magnify the image by only 10% of that of convex spectacle lenses (Bennett & Francis 1962).
During the following months the patient intensified her efforts to coordinate, during landscape painting, the movements of her hand with her binocular vision alternating between the near picture and the remote model. She then experienced a strong vacillating blur in her visual perception which lasted about an hour. After each of these experiences, remoter objects appeared more blurred and for sharp near vision, she needed a reduced addition in her eye-glasses. The optician finally stated a myopia of -1,0 -0.5 D in the left eye, while in the right eye the spherical correction could be reduced by 0,5 D in the far range. The addition required for sharp vision in the near range was reduced for both eyes by 0,25 D. The Aniseikonia Inspector now indicated, at a visual angle of 8°, with spectacle correction a difference of magnitude of 5,5%, while with a contact lens of +1,75 D on the hyperopic right eye the difference was only 0,5%. After a period of adaptation to the reunited binocular and head axes, the remote picture was perceived with both eyes at the same distance from the fixated near target in binocular vision, and the mental problems of the patient disappeared - as far as allowed by the social and cerebral damages produced until the age of seventy.
The statistical survey has been taken over by Prof. Jose
Gonzalez-Hernandez, Cuba, to whom the author has provided the
required Butterfly Test and Aniseikonia Inspector in November 2009.
From the course of the reactivation we can conclude to what had occurred before. The difference of magnitude of the two images had been compensated by reducing the fusional convergence and convergence-accommodation of the myopic left eye. By reducing convergence, the distance between the fused object and the eyes had become relatively smaller for the left than for the right eye, making its image larger. The reduced accommodation had assimilated the myopic left eye to the hyperopic right eye and was equally compensated by a convex spectacle lens. The reduced convergence had adapted the direction of the left eye to the right hyper(eso)tropia, at the cost of shifting the Intersection Point of Visual Lines (IPVL) to a remoter point on the left side of the target.
The question is why and how the obstacles to sensory fusion, instead of leading to diplopia or to suppression or amblyopia (Howard & Rogers 1995, p. 190; Otto 1968, p. 3.19), could be overcome by a unilateral reduction of convergence – which is an infraction to Hering’s Law of Equal Innervation of the Two Eyes concerning vergence and version separately (Howard & Rogers 1995, p. 116). The only regular asymmetric convergence known is stimulated, together with the accommodation of the contralateral eye, by contralateral blur (Alpern 1972). The present case, however, involved accommodation and convergence of the same eye. Was the convergence deficiency of the left eye due to an infraction of Hering’s Law regarding the equality of convergence – Hypothesis A-a – or regarding the direction of part of the vergence impulse – Hypothesis A-b?
assumes that the equality stated by Hering's Law depends on a condition
which is not met here. As Gauthier et al (1995) have shown, ocular muscle proprioception,
particularly from stretch sensitive palisade endings, intervenes in the
coding of eye-in-head position and motion. Investigations by
Buettner-Ennever & Horn (2002) suggest that "exact alignment and
stabilization of the eyes" require the proprioceptive feed-back of
palisade endings in the extraocular non-twitch muscles.
The question is how proprioception is able to stimulate the near trias and maintain binocular alignment. The stimulus might consist in the dilatation of the lateral recti produced by the increasing convergence at near distance. This stimulation, in fact, seems to promote the other eye: Wasicky et al (2004) found in the abducens area neurons projecting directly to the non-twitch motoneurons of the contralateral C-group responsible for the adjustment of the medial and inferior rectus achieving convergence - which they assumed to be identical with a group of vergence related neurons described by Gamlin et al (1989) near the abducens nucleus. The increasing convergence of one eye would thus stimulate the convergence of the other eye via proprioception, centering the binocular axis and anchoring it in "the near distance ... described as the biological adaptive space for individuals" (Steinmann et al 1990). In my patient, a deficiency of this contralaterally stimulating proprioception from the dilated right lateral rectus might explain why the binocular axis could be shifted to the left by the fusional demands of aniseikonia and hyper(eso)tropia (cf. Korn 2000). It would also explain the deficiencies of convergence found by the author (Korn 1999a, 2002, 2004) and by Flach et al (1983 & 1992) in schizophrenic patients.
assumes an ambivalence of nasal and temporal foveal
disparities based on a reversed
crossing of foveal projections in the Chiasma Opticum  (cf.
Korn 2000 & 2002) transmitting the nasal and temporal information to the place
in the LGN designed for the information from the other foveal half.
Having no context here, the information is immediately transferred to the other hemisphere via the Corpus Callosum (cf. Kaas 1986, p. 328 f) -
except the disparity abnormally projected from the left temporal foveal half to the right hemisphere which is employed for assimilating the images of the two eyes by transforming
the convergence-stimulated accommodation of the myopic left eye into
divergence-stimulated negative accommodation. The
inversion of the
left foveal convergence stimulus transforms binocular convergence to
the near target into version to the left, thus reducing the peripheral
left convergence stimulus and deviating the binocular axis to the
The patient’s will to withdraw her gaze to the near range, assisted by the strong parallel beams of the TFT display aligning visual and motor coordinates, transferred also the left temporal foveal disparity to the left hemisphere, from where it duly stimulated the convergence of the dominant left eye to the proposed near target.
As Buettner-Ennever et al (2001) have shown, there are two sensorimotor circuits of eye-movements with different pathways for the twitch and the non-twitch muscles including separate motoneurons. “The predominant inputs to the non-twitch motoneurons were not the fastest premotor networks generating saccades or the vestibulo-ocular reflex, but rather are driven by the networks subtending eye movements that depend on (visual) feedback circuits such as smooth pursuit, convergence and gaze-holding” – functions that are disturbed in schizophrenia (cf. Gaebel 1990).
reversed crossing of foveal projections as a vulnerability for
schizophrenia is able to explain the amplitude reductions in the
(parieto-)occipital P1 component of the visual event-related potential
80-100 ms after the event,
found not only in schizophrenic patients (Foxe et al 2001) but also in their unaffected first degree relatives (Yeats et al 2006). In the relatives, however, the reduction is compensated by "a second phase of differential activity ... where the relatives showed higher amplitude at 120-150 ms ... almost absent in the ... medicated ... probands" - which might be due to the transferred foveal component delayed by the Interhemispheric Transfer Time via the Corpus Callosum (CC) requiring 24-42 ms (Martin et al 2007).
A basic callosal
transfer of information is also suggested by an
interhemispheric hyperconnectivity in the frontocentral area of the CC found by Rehm (2007) in
Rehm assumes that the hyperconnectivity
is based on a deficient elimination of axons during the development of
the CC during the first three decades of life - an elimination which
might depend on the usefulness of each axon for the organisme,
determined here by the genetically given reversed crossing of foveal
projections in the patients and their
twins, as shown by Narr et al (2002) through the morphological
similarity of the CC in both groups. In the patients, however, the
abnormal crossing of the temporal foveal projection of the more myopic
eye, being useful for fusion of dissimilar images, is not corrected via
the CC so that the corresponding axons are eliminated and the
divergence of that eye remains when the other eye is covered, as
demonstrated by Ndlovu et al (2011).
That the hyperconnectivity is due to visual stimuli is suggested by an investigation of Wada et al (1998) comparing interhemispheric EEG coherence in never-medicated schizophrenic patients at rest and during photic stimulation: the effect of the stimulation was significantly higher in the patients than in the controls.
That the ambiguity in the direction of foveal disparity might be due to a reversed crossing of foveal projections is supported by a tachistoscopic investigation of foveal hemifields by Gur (1978) with syllabic stimuli in patients with acute schizophrenia treated with phenothiazin, i.e. probably without exotropia (cf. Krakauer above). In the left visual field the patients' positive results almost equalled the results of the controls in the right visual field, while their performance in the right visual field was worse than the controls' negative results in the left visual field. Gur gave the following explanation for this: " The present results suggest that the left hemisphere in schizophrenics analyzes visual-verbal information more accurately when it has been initially processed in the right hemisphere than when it has been initially processed in the left hemisphere." The following explanation appears more convincing: In these patients, the foveal information of the left visual field is abnormally projected to the ipsilateral left hemisphere while the bad results from the right visual field are due to their projection to the right hemisphere. This interpretation is confirmed by the second experiment made by Gur showing - by increased spontaneous eye-movements to the right - an "overactivation" of the left hemisphere, which contradicts Gur's "evident" interpretation of her first study as a "left hemisphere dysfunction".
An interchange of ipsilateral and contralateral projections as a vulnerability for schizophrenia is also suggested by auditive investigations. Here too, spatial and object perception are processed on different pathways (Lancelot et al 2003). There are two projections from each ear, one going to the ipsilateral hemisphere, the other, dominant one crossing over to the contralateral hemisphere. Contralateral dominance enables a swifter motor reaction on the side on which an attack or an opportunity is perceived, perceptive input and muscular output being controlled by the same hemisphere. That this auditive dominance is often reversed in schizophrenia was proven by Connolly et al (1985) on unmedicated schizophrenic patients: While, in the auditive ERP, the contralateral amplitudes of the control subjects were clearly greater than the ipsilateral ones this was reversed in 50% of the patients. However, dominance is also influenced by the hemispheric competence for the respective material. So there is normally a Right Ear Advantage (REA) in verbal dichotic tests. In contrast, Colbourn & Lishman (1984) found a Left Ear Advantage (LEA) in 50% of schizophrenic patients in this type of test. That a LEA also exists in a large part of the patients' first degree relatives was proven by Grosh et al (1995), pointing to a dominance of ipsilateral projections as a vulnerability for schizophrenia.
As shown by the reversal experiments of Kohler (1953), a human is able to cope with the abnormal processing of a visual hemifield in the ipsilateral hemisphere. Visual perception is integrated by motor experience and by the other sensory modi and corrected via callosal connections (Kaas 1986, p. 327) in a relatively short period. Foveal information in particular is transferred already in area 17 (2 degrees) and area 18 (8 degrees of visual angle from the midline) to the other hemisphere.
However, problems arise in intermodal networking if the foveally represented object is originally reproduced in a hemisphere other than its peripheral context. Schizophrenic patients (Rizzo 1996) as well as their first degree relatives (Myles-Worsley & Park 2002) have problems with the retrieval of information, especially concerning the position of an object, presumably because its localization is partly ambivalent for its hemispheric laterality.
Roberts et al (2012) assume in schizophrenic patients and their
first-degree relatives a defective integration of foveal with parafoveal
information, by which normal controls were enabled to larger saccades and
quicker performance when reading. Exclusion of parafoveal information by reducing the amount of visible
characters did not change the reading rate of schizophrenics whereas controls showed a significant decrease.
The hypothesis of a reversed crossing of foveal projections can also account for the saccaded Smooth pursuit found in 50-85% of schizophrenic patients and in 40-50% of their first degree relatives (Gaebel 1990) which, in the patients, has been shown by Flechtner et al (1997) to be due to catch-up saccades compensating a lower pursuit gain. Deficits in gain of Smooth pursuit eye movements were also found by Kathmann et al (2003) not only in schizophrenia and affective disorder patients but also in their unaffected relatives. The deficit was shown by Chen et al (1999) in a step-ramp task to be due to a lacking acceleration in the time window for computation of open-loop acceleration after target onset, attributed by the authors to a velocity discrimination deficit. According to their figure 5, however, the acceleration is only delayed and attains the same velocity as in the controls later. The saccade intervenes because the foveae have not reached the target in due time, which can be attributed to the detour made by the inverted foveal vergence stimulus.
The delay corresponds to the prolonged reaction-time in the Attention
Network Test (ANT) found 2011 by Breton et al in schizophrenic patients
and in their first-degree relatives, which was confirmed by Orellana et
al (2012) in first episode schizophrenia (FES) patients. In the
relatives, however, Breton did not find the deficient accuracy concerning Executive Attention of the FES patients,
who in about one of three tests (controls: one of ten) mistook the
inverted direction of the four horizontally accompanying flanker-arrows
for the direction of the target-arrow - an error which can be explained
by a unilateral inversion of the foveal convergence stimulus misguiding the
foveae - competent for "what" distinctions - to one of the flankers
instead of the central target proposed by the "where" system of
This interpretation is confirmed by the ANT-results of Gomez et al (2010) who, placing the flanker-arrows not horizontally near the target-arrow but vertically "one below and one above", found no significant difference of accuracy between schizophrenic patients and controls in this test: The horizontal deviation of the visual axis by unilateral divergence did not affect the accuracy in distinguishing the central arrow from the vertically accompanying incongruent arrows.
In contrast to the findings of Orellana et al, Lopez et al (2011) found no significant difference of accuracy in the ANT for Executive Attention between schizophrenic patients and controls. This might be due to the fact that 29 of their 32 patients received typical antipsychotics, wheras all patients of Orellana et al received only atypical antipsychotics. Typical antipsychotics are able to overcome the unilaterality of the convergence deficiency responsible for the deviation of the gaze to accompanying flanker-arrows - e.g. the above-mentioned patient of Krakauer and a patient mentioned below under "Active and withdrawn forms".
Problems of localization may also be the cause of the "impaired visuomotor integration during Trail-Making Test B performance" found by Wölwer et al (2003b) not only in schizophrenic patients but also in their first degree relatives. The dissociation of the foveal "what"- and the peripheral "where"-system due to the inverted crossing is aggravated in the patients by the dissociation of the binocular and the head-and-body axis, disabling their visual search for the target while moving the cursor with their hand.
The dysmetric saccades stated by Gaebel (1990) together with a fixation instability as a "relatively consistent finding in schizophrenic patients" may be caused by a tendency of the - foveally stimulated - postsaccadic drift to follow nasal rather than temporal stimuli - normally, postsaccadic drift is stronger in the adducting - i.e. temporally stimulated - than in the abducting eye, in order to allow binocular fusion in spite of the larger saccade of the abducting eye (Kapoula et al 1989). In the case of my patient, the postsaccadic drift would have nasally stimulated the myopic left eye to diverge and disaccommodate, instead of stimulating temporally - as normal - the hyperopic right eye to converge and accommodate to the near target.
Also the defective performance on the antisaccade task requiring the subject to inhibit a reflexive saccade to a suddenly appearing visual target and look in the opposite direction found by Nieman et al (2007) not only in schizophrenic patients but also in persons at ultra hight risk for developing psychosis may be due to a directional foveal ambiguity of the postsaccadic drift. Barton et al (2008) finding a correlation between the error rates for antisaccades and prosaccades, attributed both to a fixation instability present in these patients, but concluded "that this is not specifically concerned with inhibiting the automatic prosaccade, but a more general deficit in implementing goal-oriented" - target-guided? - "behavior".
Gonzalez-Hernandez et al (2003) found an asymmetric event-related
potential during WCST performance over occipital regions in medicated
schizophrenics, indicating a defect in early stages of visual
Also the reduced fractional anisotropy of the optic radiations found by Butler et al (2006) in schizophrenic patients confirm the hypothesis that visual processing deficits occur at the early stages of processing from where they may contribute to higher-level perceptual deficits.
Waters et al (2011) associate self-awareness deficits in schizophrenic patients with their deficits in social interactive behaviours. They report that in these patients "Functional magnetic resonance studies have demonstrated abnormalities in the neural circuitry commonly associated with self-referential processing, body awareness and social cognition, involving the medial prefrontal cortex, anterior cingulate, inferior temporal gyrus and the right parietal cortex". Now "in the posterior parietal cortex 30% of the neurons respond to visual stimuli, have large, sometimes bilateral receptive fields, usually excluding the fovea .... and exhibit enhanced responses during visual fixation. Other neurons respond during visual saccades (>10%) and visual tracking (>10%). Overall, these properties are consistent with the proposed role of the posterior parietal cortex in visual orientation, visual guidance and attention" (Kaas 1986, p.332; Desimone & Duncan 1995). In dependency of the inferior temporal cortex, on the other hand, the centers of emotion and memory, amygdala and hippocampus, process foveally centered information (Kaas 1986, p.317; Trappenberg et al 2002) and assess its emotional value before its textual meaning is understood in the frontal lobe.
As Friston & Frith (1995) have shown by comparing the eigenimages of prefrontal and temporal cortices in schizophrenic patients and controls with PET-neuroimaging, "there is a profound disruption of large-scale prefronto-temporal interactions in schizophrenia", with an increased activity of the temporal and a reduced activity of the prefrontal cortex. This imbalance of the two correlated cortices reflects the unsuccessful stimulation of eye-movements by the prefrontal cortex and the instability of the mislead fixation producing at short intervals in the temporal cortex differing images which cannot be sorted out quickly enough to form reasonable Gestalten.
That in natural scenes the receptive field of inferior temporal cortex neurons around the fovea is reduced to a mean radius of 11° was discovered by Rolls et al (2003), whereas prior investigations in an otherwise blanc visual scene had found a receptive field of 39°, which can mean a fundamental difference for the role of misguided fixation. The prefrontal cortex is in mutual relation with both the parietal and the temporal cortex allowing working memory and behavioural adaptation to the circumstances. A misguided foveal fixation and inferotemporal processsing away from the parietally localized object of attention would therfore be suitable for disturbing the temporo-parietal cooperation required for self-referential processes and social interactive behaviour. As both cortices receive visual and auditory information (Kolb & Whishew 1996, p. 225 & 242) their disturbed visual cooperation might also explain the auditory disturbances often found in schizophrenia (example see conclusion).
Active and Withdrawn forms of schizophrenia
A deviation of the binocular axis to the
right side may have occurred in a schizophrenic
patient with an active syndrome who in the Symmetric Convergence Test saw the two targets only
with the right eye in binocular vision and who had been diagnosed by her ophthalmologist to have
a convergence deficiency and an aniseikonia. The patient is unable to
distinguish the faces even of close relatives – a process which is known to be
restricted to the right hemisphere (Kolb & Whishaw 1996, p.
219). The unrecognized
faces may appear in the enlarged left visual field and be abnormally projected
to the left hemisphere. After taking her daily dosis of
Haloperidol the patient saw the near target on both sides of its mirrored rear
at the same distance, i.e. she fixated the mirrored rear and perceived the near target bitemporally. As in Krakauer's patient,
the neuroleptic medication may have overcome the shift of the binocular axis by
inhibiting foveally stimulated fusional vergence movements altogether, convergence as well
as divergence. Typical neuroleptics may be able to
overcome the dissociation of the visual and body axes without, however, enabling
fixation of the near target of selective attention by convergence.
Another - unmedicated - patient who saw the two targets only with the right eye presents a right myopia of 3 D corrected with spectacles.
Also the inattention to the - referred to the target - right hemispace found by Tomer & Flor-Henry (1989) in unmedicated acutely psychotic patients can be explained by a deviation of the binocular axis to the right side which enlarges the left hemispace. After neuroleptic medication the performance changed to "more prominent left-sided inattention": Presumably the shift of the binocular axis was annulled but the head still remained in its previous position of partial left-sided compensation of the shifted binocular axis, thus favouring now the right hemispace.
The distinction made by Gaebel (1990)
between “minimal” and “extensive” scanners corresponding to Withdrawn and Active
schizophrenic patients confirms the hypothesis of the binocular axis being
shifted to the left in the Withdrawn group and to the right in the Active group:
“In patients with ‘extensive scanning’ the horizontal coordinate of visual
focussing is shifted to the right compared to those with ‘minimal
This interpretation is consistent with the findings of Gruzelier et al (1993) investigating the visually evoked potential in unmedicated schizophrenic patients: "At occipital placements... higher power was found on the left in the Active syndrome and on the right in the Withdrawn syndrome."
|Challenges to the above
The above theory - explaining the specific vulnerability for schizophrenia by foveal, i.e. parvocellular phenomena - has been challenged by findings attributed to magnocellular deficiencies (e.g. Brandies & Yehuda 2008).
Keri et al (2004) have investigated Vernier acuity in non-medicated patients and their unaffected siblings with magnocellular and parvocellular-biased dots and bars at a distance of 9,5m, i.e. without convergence. Compared to controls, patients and their siblings required for correct answers a significantly larger interstice between the targets with M-biased than with P-biased images. These deficits are valued as reflecting “an endophenotype of schizophrenia”. They can, however, be explained by a hereditary but not schizophrenia-specific factor, namely aniseikonia. In aniseikonia there is “a rivalry between foveal and peripheral fusion. If the centers of the images are fused, the peripheral margins are not; if the peripheral margins are fused, the centers are disparately imaged” (von Noorden & Campos 2003, p. 120). As Brandies & Yehuda (2008) have shown, dopamine favours foveal perception, which in case of aniseikonia means disadvantaging, with peripheral fusion, perception of M-biased targets.
This explanation is consistent with Shuwairi et al (2002) proving the opposite in medicated patients, namely general hue discrimination errors: The anti-dopaminergic medication shifts the advantage to peripheral fusion while foveal fusion is defective. This is confirmed by Schechter et al (2006) finding in medicated patients “with corrected vision” reduced stereopsis on the Graded Circles Stereo Test. In contrast to the larger Butterfly StereoTest (diameter 80 mm) - usually part of stereo examinations (see Form for Tests of Convergence, Aniseikonia and Stereopsis) but not mentioned here - the small images (diameter 18 mm) of the GCST test foveal and not peripheral stereopsis.
Another team around Schechter had also claimed in 2003 a
"significant impairment in M pathway, but not P pathway function in
patients with schizophrenia" by visual backward masking tests with M-
and P-biased targets and masks. "In conclusion ....patients showed a
deficit relative to controls only when an M-biased mask was used." This
deficit, however, was not on the side of the M-biased mask which
efficiently suppressed the target images but on the side of the targets
which, to be identified correctly, required a longer stimulus interval - allowed by the weaker P-biased targets - as manifested also in the critical stimulus durations for unmasked
stimuli which were significantly increased for both M- and P-targets in
patients relative to controls. This requirement can be explained by an only monocular perception of the presented target, due to the remoter position of the horopter caused by the misguided fixation.
An impairment of M pathway is also assumed by Kraehenmann et al (2012) finding in medicated schizophrenic patients a larger critical spacing between two distractors and a periphal target to be required for its accurate identification, which the authors explain by an increased peripheral crowding. Also with further increased spacing, however, the accurate identification remained almost at the same level below the results of the controls, suggesting that the principal cause of the reduced identification of the target was not an increased crowding but the only monocular perception of the target - requiring more than 60 ms before appearance of the mask to be identified - the horopter being situated at a remoter distance than the target.
On the other hand, an impairment of P pathway is strongly suggested by the reduced amygdala-hippocampal volume found by Weiss et al (2004) in schizophrenic patients and by O'Driscoll et al (2001) in their first-degree relatives. The mean reduction of 9,4% in the patients corresponds to the mean reduction of 5,9% in the relatives - as genetic dispositions concern about half of them - pointing to the reduction as a marker of the vulnerability for the illness. The reduction can be explained by the detour via the Corpus Callosum, filtering foveal information which thus requires a smaller volume for its processing on the ventral pathway - but also a prolongation of RT by 0,2 s for recognition of known and novel items in the patients not only of Weiss but also of Jessen et al (2003). In the patients of Weiss, however, who made the double of false alarms compared to controls, the recognition RT for novel words was longer for the patients than for controls only in case of correct answers - a result of stress?
challenge to the above theory might be the fact that the (unilateral)
insufficiency of convergence (CI) is not detected in usual convergence
tests. In an investigation of 2012 comparing 20 medicated stereoptic patients with schizophrenia and schizoaffective disorder with 20 controls, Bolding et al defined CI by three objective criteria:
1) phoria at near of 4 prism diopters or more greater exophoria than at distance,
2) near-point convergence (NPC) greater than 5,5 cm,
3) break of near positive fusional vergence (PFV) at less than 15 prism diopters separating the two eyes, or less than twice the near phoria (Sheard's criteria).
Although the mean results in the patient group practically attained the limits of the two first criteria - 3,95 prism diopters compared to 2,35 of the controls, and 5,5cm compared to 4,4 cm in the controls - only their mean results with Sheard's criteria (p = 0,001) were significant for indicating CI. On the other hand, the subjective Convergence Insufficiency Symptom Survey (CISS) scores of the patient group were about the double of that of the control group. This incongruity between objective and subjective signs can be explained by the fact that the near-point presented peripherally to attention is not identical with the foveal Intersection Point of Visual Lines (IPVL), decisive for convergence (criterion 2), which is lying remoter in these patients than the presented point because of the transformation of the foveally stimulated share of convergence into divergence, achieved for fusion of aniseikonic images by reducing convergence-stimulated accommodation of the eye with the smaller image, a relative reduction which is independent of the distance from the model (criterion 1). (Besides, the patients with schizoaffective disorder may have further reduced the results required for diagnosing CI in schizophrenic patients.)
This reduction can also explain the instability of fixation often found in tests with schizophrenic patients and interpreted as "a proxy for saccadic disinhibition" by Benson et al 2012: The point presented for fixation on a horizontal-vertical plane cannot be simultaneously fixated with both eyes whose IPVL is lying remoter. If there is not a pronounced dominance of one eye (which may depend on the medication) the binocular gaze will jump between the diverging positions of the two visual lines on the plane, especially if a distractor or the pursuit of a target mobilizes the gaze, as in the fixation stability test and the Lissajous pursuit presented by Benson et al. The patients' restriction of gaze and longer dwelling on a limited number of features found in the same investigation may be due to a renunciation of foveal fixation after having experienced no success in trying to fixate attentionally interesting features, and contentment with peripheral over-view.
lateral inversion of foveal hemifields also interchanges the
crossedness and uncrossedness of foveal disparities, i.e. the
perception of nearness and farness. This may be the reason why in
numerous investigations with depth-inverted images (e.g. Koethe et al
2009; Schneider 2009) schizophrenic patients do not entirely restore
the model by top-down correction as controls do (Schneider et al 2002).
"Unimpaired top-down processing is only possible if knowledge or
experiences are unconsciously recalled from memory by reactivation of
their neural representations" (Passie et al 2003) - which in these patients are partially depth-inverted.
That the reduced depth inversion illusion is not a binocular phenomenon - as supposed by Schneider (2002) - but due to a substitution of nasal for temporal information in the dominant eye has been shown by Keane et al (2013) comparing the reduced illusion of schizophrenic patients and controls in stereoptic vision and in monocular vision of the dominant eye with motion parallax: "Notably the group difference arose when the analyses were restricted only to monocular viewings."
As Grosjean et al (2012) have shown, the correction of depth-inverted faces in the controls concerns not only perception but also vergence which is transformed from di-vergence to the remotest point - the nose - into a con-vergence of 14 arcmin (against 25 arcmin with convex faces), a transformation that might be achieved by projection of the foveal part of vergence stimulation to the other hemisphere, induced by the same want of experienced sensible perception which, in the patients and their relatives, stimulates the (partial) retransfer of the inverted foveal information via the Corpus Callosum. The unilateral "convergence insufficiency" found in the patients, based on an incomplete transfer of the originally inverted foveal convergence stimulus to the other hemisphere corresponds to the - complete - transfer of the divergence stimulus required by the hollow-face model in the controls. Also the RT-delay of 85 ms with reference to the convergence stimulated by convex faces found in the controls can be explained by the detour made by the disparity stimulus to the other hemisphere, corresponding to the delayed start of Smooth pursuit eye-movements in the patients and their relatives. Callosal interchange of foveal disparities seems to be a normal potentiality, useful perhaps for empathy, enabling the subject to identify with his vis-a-vis.
|Psychiatric consequences of the transformation|
1. The dissociation of the binocular axis from the head-and-body axis creates a problem of localisation of the acting self in the perceived surroundings. It prevents the automation required for immediate muscular reactions to sensory information and leads to the "Impaired visuomotor integration in acute schizophrenia" reported by Wölwer & Gaebel (2003a) and to the "Dyspraxia frequently associated with schizophrenia" (Schechter et al 2006).
2. The intensified processing of bifoveally perceived objects in the centers of emotion and memory amygdala and hippocampus (cf. Kaas 1986, p. 317) intended for the near target of selective attention is bestowed on an object in the background which has not roused the cognitive attention of the patient. Now the function of emotions and memorized associations is to identify possible relationships for a person either in a positive or in a negative sense and thus to motivate his or her planning and behaviour. If however, emotions and associations are determined not by the objects of the person’s cognitive attention but by other objects in the background, his or her spontaneous impulses will produce inappropriate signals which do do not lead to the desired relationships. The relational circuit of reception and emission of signals is thus disturbed and the person will not find his or her place in social life. (cf. Green & Leitman 2008: "Social cognitive impairment"; Waters et al 2011: "Deficits in social interactive behaviour"; Schneider 2011: "Patients tend to misinterpret feelings in others or display inappropriate emotional reactions in their everyday life"; Bogerts 1990: "Dissociation between cognition and emotion").
3. The lacking convergence of the dominant eye makes the patient look like an ennemy adjusting his weapon against his vis-à-vis. The shifted binocular axis is interpreted as a sign of insincerity evading eye contact, which weakens the patient's credibility and social position (cf. Korn 1999b and part B).
4. The transfer of the horopter from the near region to the
background disadvantages the patient's relation to his immediate
vicinity, and the depth-inversion of his foveal perception favours an excessive identification with his vis-à-vis perceived from the inside.
|Diagnosis and therapy|
Binocular fusion and foveal fixation are both spontaneous reflexes of the visual plant aiming on the one hand at stereoptic perception, on the other hand at detailed cognition of selected objects (Hugonnier & Magnard 1986, p. 1.12). In case of a conflict between the two reflexes caused by dissimilar images on corresponding loci, fixation of the object of attention normally has priority over fusion, leading to the suppression of one of the differing images or to diplopia. In schizophrenia, however, this priority is inverted, favouring in case of conflict fusion over fixation of the target of attention by a decrease of convergence and convergence-accommodation of the more myopic eye at the cost of shifting the binocular axis and misguiding bifoveal fixation. The disturbance can be detected with the Hirschberg Test, discovering in one eye the outward pupillary deviation from the corneal reflection of a centrally held penlight, followed by covering the other eye (= unilateral Cover Test). If then the pupillary deviation from the reflected central penlight is not annulled by a converging eye movement, it is not due to strabismus but to a deviated binocular fixation (cf. Introduction: Ndlovu et al).
The presence of fusion should be confirmed by a positive Stereopsis test, e.g. Butterfly Stereo Test. Random-dot stereo-tests do not refer to a particular fixation-point but to structural similarities of the two images.
The shift of the binocular axis can also be discovered by trying to fixate a slim near object while observing a picture at some distance behind it (Symmetric Convergence Test). While normally, the same remote picture is seen ipsilaterally at the same distance on both sides of the fixated near target in binocular vision, in the pathological case it is perceived single and on the side of the diverging eye. Medicated patients may see the near target contralaterally on both sides of the remote object, indicating a binocular convergence deficiency, possibly due to neuroleptic inhibition of foveally stimulated (con- and di-)vergence. In this test, patients often tend to place the near target in front of the more myopic dominant eye instead of the nose. This can be prevented by placing the near target in form of a tuning fork riding on a cord attached between the nose - where it is held by the patient - and a remoter point which ought to be seen at the same distance on both sides of the tuning fork being moved from the remoter point to the nose.
If, in addition, there is an even small anisometropia the patient should be examined for aniseikonia although, being reduced in a psychopathogenic way, the remaining rest will appear insignificant. In vulnerable persons with differing length of the eye-balls, the more myopic eye may have already adapted to the other eye by reducing its tonic convergence and accommodation before being optically tested at all, thus presenting almost normal vision apparently requiring no correction. Aniseikonia is a neglected chapter of ophthalmology (de Wit 2003; Achiron et al 1997). A method for its discovery and correction determining also its retinal extension is the Aniseikonia Inspector developed by de Wit. The magnitude of the original aniseikonia, however, is only revealed when the remote picture is perceived with both eyes at the same distance from the fixated near target in binocular vision.
Aniseikonia Screening Test: A rough comparison can be obtained by presenting to the patient two large identic letters I (Times) on a display and separating the images of the two eyes either with the vertically held window (comparison of temporally perceived contralateral letters, right figure) or by holding a stick (or a hand) between the nose and the display which covers for each eye the contralateral letter (comparison of nasally perceived ipsilateral letters, left figure).
The method can also be used with the image of a horizontal bar to discover a vertical FD or a torsion.
A longstanding deviation of the binocular axis is difficult to correct because perceptive and motor habits have developed according to the dissociated axes, eliminating during the first three decades of life the corresponding transfering axons of the CC (see above Rehm 2007). Before the first correction of any anisometropia with spectacles, an aniseikonia test ought therefore to be made prophylactically either with the Aniseikonia Inspector or with the Hook-Test, part of the ZEISS Pola-Test, also suitable for the detection of an excessive fusional reactivity of the nasal foveal halves. If the test reveals an aniseikonia of more than 3%, binocular function is significantly affected (Katsumi et al 1986) and there is a danger either of amblyopia or – in patients with the described vulnerability - of psychiatric disorders. The development of the child’s binocular vision should therefore be controlled if, in case of a decreasing anisometropia, the background is still seen at equal distance on both sides of the near target in the simplified Mirror Test and/or if in the Hirschberg Test a pupillary deviation from the reflection of the penlight remains when the other eye is covered. In this case the correction of the anisometropia should not be reduced, and in patients with refractive anisometropia the difference should be corrected with contact lens(es) instead of spectacles. When the definite metropia has developed - C-values are stabilized - the lenses should be replaced by corneal surgery (e.g. LASIK) which is apt to overcome myopias of 1 – 10 D and hyperopias of 1 – 5 D (cf. References for Refractive Surgery 2008).
The unilateral convergence insufficiency found in schizophrenic patients can be explained by an inversion of foveally stimulated fusional convergence and convergence-accommodation in the more myopic eye in order to compensate an (optical) aniseikonia and allow fusion with the (foveally) deviating other eye, at the cost of dissociating the binocular axis from the vestibular head-and-body axis and misguiding binocular fixation - i.e. intensified emotional and memory processing - to objects without cognitive interest for the patient, thus sacrificing the prior aim of mental unity to the subordinate aim of binocular unity - i.e. stereoptic vision (cf. Spaemann & Löw 2005, p. 60). In blind people there is no such competition between visual functions - which may be the reason why there has not been found a single case of schizophrenia yet who had gone blind before or during his first year of life (Silverstein et al 2013).
The vulnerability for the disorder is imputed to an inverted projection of temporal and nasal foveal information in the Chiasma Opticum, transforming the normally preferred stimulation of slow eye-movements by contralateral disparities - i.e. by nearer objects - into preferred stimulation by ipsilateral disparities - i.e. by remoter objects - favouring the development of a convergence-insufficiency. The inverted preference can be explained by a shorter circuit - favouring a quicker start, decisive especially in stress situations - between the abnormally uncrossing nasal foveal projections and the ipsilateral eye-muscle proprioception which gives the starting signal to eye-movements (Huber 1986, p. 1.11). In unaffected relatives, however, the reversed crossing is immediately and entirely repaired via the Corpus Callosum whereas in the patients, the inverted temporal information of the more myopic eye is employed for fusion of aniseikonic images.
The somatic basis of schizophrenia is a scission of attention between the near object selected for fixation via the dorsal stream - perceived clearly in the parietal cortex by blur-stimulated accommodation, but only with one eye and peripherally - and an object in the background - perceived bifoveally via the ventral stream in the temporal cortex by abnormal fusional vergence. The object chosen parietally by attention meets the actually fixated and temporally
processed differing object in the hippocampal CA3 system (Rockland
& Van Hoewen 1984; Rolls 2007) where the rivalry of the two objects
results in a disorientated breakdown of order among the normally
parallel pyramidal cells, a disorder of which Kovelmann & Scheibel
(1984) have provided histological evidence. In the long run, the
incompatible informations lead to a destruction of cells, manifested in
a reduction of the hippocampus-amygdala complex in favour of the
surrounding ventricular volume (cf. Falkai et al 1990; Bogerts 1990).
Whatever be the vulnerability that allows fixation to be misguided for the sake of fusion, it becomes effective only when there are obstacles to fusion. Prevention (and therapy) of schizophrenia ought therefore to detect and remove those obstacles, if possible before they are overcome during the first three decades of life by eliminating part of the interhemispheric axons required for correction of the reversed crossing of foveal projections - at the cost of fixation of the cognitively selected target and of the axial correspondence of outward sensory perception with vestibular self-perception.
The phenomenon of self-enucleation documented in eight schizophrenic
patients confirms that there is a problem of binocular cooperation at the
root of schizophrenia. Koh & Yeo (2002)
report that a young Chinese woman whose strong
auditive hallucinations had resisted all combinations of antipsychotic
treatment managed to gouge out her left eye despite physical and
chemical restraint, whereupon her mental state improved and she was
discharged on Clozapin. “God”, she said, “has
instructed me to do so” (cf. Mt 5,29). Her fusional
reflex being eliminated, fixation of the object selected by her
attention was restored. Even the specialists in strabismus
Hugonnier & Magnard (1986, p. 1.32), enquiring if binocular vision
is worth the sacrifices brought for it, do not hesitate to say no. The
perceptive intensity -
measured by Visually Evoked Potentials (cf. Foxe et al 2013) - is not higher in binocular
in monocular vision, probably because in binocular vision the great
majority of information lying outside the horopter is physiologically
suppressed in one eye, in the ipsilateral eye of nearer data and in the
contralateral eye of remoter data. Is the renunciation of binocular vision
– e.g. by occluding the deviating dominant eye
with an opaque contact-lens
wearing the image of the patient’s iris or with an eyepatch behind or in front of the spectacle glass (e.g.
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 In the ZEISS Pola-Test a defective local correspondence of the two foveal images - i.e. a "fixation disparity" - is made visible by presenting with opposite polarised light different but interrelated figures to each eye inside a frame perceived with both eyes. The deficiency is overcome by prisms diverting the light to bifoveally corresponding loci. For diagnosis and treatment of fixation disparities consult http://www.ivbv.org/. [back]
 In the Hook-Test, part of ZEISS Pola-Test carried out with refractive correction, a difference of magnitude manifests by a different height of the hooks, the width of one bar corresponding to 3,8% (Haase 1995, p.184). An excessive fusional reactivity of the nasal foveal halves manifests by fusion of the vertical or horizontal parts of the two hooks in the ipsilateral position (cf. Korn 2004, fig. 1b/d).[back]
 The Aniseikonia Inspector is a device accessible by Internet based on the comparison of the magnitude of the images of the two eyes separated by red-green spectacles, and offering a module to design an aniseikonia reducing prescription. .[back]
modern scientific method concluding from statistically
"significant" differences from normal controls to preceding effective causes of the difference, the present analysis is
based on the classical philosophy of Aristotle,
conceiving changes as being caused by the cooperation of
a. a structural disposition allowing the changement - a "vulnerability" (causa materialis) - here the inverted projection of foveal information
b. a performing cause - as an energetic tension (causa efficiens) - here the difference of magnitude (and location) of the two images - activated by
c. a future aim to be achieved (causa finalis) - here stereopsis abnormally displacing fixation of the target of attention. That stereopsis can act as an aim mobilizing eye-movements can be seen by heterophoria overcoming heterotropia. [back]
 In the Chiasma Opticum the projections from the nasal retinal halves - representing remoter objects - cross over to the contralateral hemisphere while those from the temporal retinal halves - representing nearer objects - go to the ipsilateral hemisphere. There are six branches of projections from each retina: four from the peripheral quadrants and two from the foveal halves (Crone & Sanjoto 1979). The assumed reversal would concern the foveal projections. [back]Tests of Convergence, Aniseikonia and Stereopsis
Truth and trust in chronic schizophrenia
Due to its formal approach, the setting of family therapy is unsuitable for penetrating the “scenes” of family interaction to gain information on concrete facts of family life. The present paper intends to fill this gap by describing in detail the circumstances of development of the persons involved (all names altered) connected with their interactions. The findings confirm the theory developed by the author since 1999 that a person vulnerable to schizophrenia by a defective eye-movement control can be pushed out of a naturally symmetrical relationsthip into the dependent position of a complementary relationship. The apparent authority acquired by her partner is abused and the patient is divested of her trustworthiness, whilst bearing the blame for the disturbed relationship. It is described how, after discovery and precise correction of asymmetrical visual defects, the patient is able to recognise the manipulations of the partner, resulting in separation and recovery.
Key-words: Schizophrenia, trust, relationship, family, eye movement
Orientation is acquired in two ways: by one's own perception and by trusting the information received from others. The organisation of perceptive data requires a system of coordinates which can be disbalanced if the central axis of perception does not correspond with the vestibular axis of self-perception and action. Fixation and normal processing of the objects of interest is then disturbed and the person becomes particularly dependent on trusting the information received from others. The essence of trust is the conviction that the partner will not conceal his true intentions in your presence nor act against your interests when you are absent. This paper wants to investigate the deficiency of truthful relationships in the development of a case of chronic schizophrenia in broad outlines and detailed spot-lights. The subject has already been examined in an earlier, more theoretical paper by the author which referred to literature on family therapy (Korn 1999b). The hypothesis was made that one of her family members played a vacant authoritative role without taking upon himself the corresponding responsabilities, thus depriving the handicapped person of her legitimate position in the family. A serious illness of the aging mother, her death and the subsequent partition of the inheritance permitted a closer examination of such a member's behaviour as well as an analysis of his motives and strategies.
When Jane, who was later to become a schizophrenic patient, was born in the small town of O. in Germany in 1935, her father had just had another bout of lung tuberculosis, which he had contracted in the First World War. Her brother Paul was 13 months old at the time and became very jealous when his little sister arrived on the scene. The mother Margret very soon entrusted a young nanny at her parents’ house in S. with the care of both children as she had to frequently attend to her sick husband at a sanatorium. During the war, the family lived in a suburb of Berlin; due to the open TB, the children were forbidden to go near the father. They were often sent to southern Germany or to Switzerland in the war which meant that they had to change school a total of 12 times during their four elementary school years.
Their father died in the fall of 1944. In the spring of 1945, the mother fled with the children to a small town in Western Germany and then went to live at her mother’s house in S. where she worked as a teacher at the same girls’ high school which Jane also attended. Jane remembers a poem that she wrote at the age of twelve about her brother: When we argued … “he runs to mummy saying: ‘She hit my leg so cruelly, no doubt she must be punished’. Thus the old villain lies, he never speaks the truth. When he steps out of the door, the children laugh at him, calling: ‘Here comes the brat with an old man’s face!’.”
Since the mother did not feel up to the task of raising her son alongside working, Paul was sent to the Jesuits in D. when he was about 13.
After the war, the children’s mother had a very low income working initially as a teacher trainee. Jane was given a pair of leather shoes from a rich school-friend because she had to trudge through the snow in wooden clogs in the winter. A friendship grew between the two girls but Jane had to give way to the daughter of a more wealthy family later. At the age of 14, a new girl joined the class who made friends with Jane. When, at the age of dancing lessons, relations to the other sex became more important for that girl and Jane moved to Switzerland, their paths separated.
In 1952, the 68-year old Swiss lawyer John having lost his first wife, the youngest sister of Margret’s mother, asked to marry the 45-year old Margret. Margret then moved to A. with both her children. She became a Swiss citizen but the children remained foreigners and were subject to restrictions concerning aliens. Tony L., the youngest son of the stepfather, who was two years older than Jane and was the only child still living at the house, had treated his 17 year-old step-sister to her favorite eucalyptus candies when the parents married in S., but paid no further attention to her in A. having become a close friend of Paul who had arrived in A. two months earlier than Jane and whose ease had fascinated Tony (as he reported later). To save losing time Jane was sent to high-school B, the high-school diploma of which did not entitle pupils to study medicine. When Jane entered that school, everyone already had partners. Jane became familiar with a girl of Italian descent who lived nearby and with whom she was able to speak standard German.
Despite their status as foreigners, the children were expected to speak Swiss dialect, which was alien to them. Linguistically talented, Jane managed to do this well quickly. But she never stopped feeling as though this was a violation of her identity. Her family’s move to Switzerland resulted in her feeling at home neither in Germany nor in Switzerland and so after graduating from high school in 1955, she went to Paris to work as an au-pair and to improve her French. After she had passed all the final exams at the Alliance Française attesting her ability to teach the french language abroad, she moved to a tiny attic and enrolled at the Sorbonne. Her step-father had declared himself willing to support her with SFr. 300 each month. After modeling a small figure in clay with a sick girl-friend in order to cheer her up, a Polish acquaintance considered that she was artistically talented. On the strength of this, Jane first visited private art academies and was finally also admitted to the Académie des Beaux-Arts. From then on, she visited the university mostly for the exams in the subject of German which she completed in 1960.
How were things to continue? Her linguistic studies did not grant her eligibility to work at schools in France, Switzerland or Germany. Nor did Jane have any connections which could have helped her to find work, for example as a translator (which she attempted) or as a publisher’s reader. Nor did her artistic talent suffice to be successful as an artist.
She only had a personal relationship to that older Polish woman in Paris who lived nearby in a somewhat larger attic. A closer relationship as brother and sister had never developed between Jane and Paul or Tony. Paul had once sent her a long letter to Paris in which he admonished her to write about her inner feelings in her letters home and not only on external incidents, although he never did anything of the kind himself with his sister.
3. Outbreak of the illness at the age of 25
In the summer of 1960, Jane traveled to Morocco with one female and two male students in a small car. She travelled home through Spain by herself, initially by hitch-hiking. She was impressed by the liveliness and warmth of the Spaniards. In the fall, she got to know the penniless young Spanish writer Robert who fascinated her. As a practicing Catholic she resisted seduction and endeavored to convince him of the existence of God, the Love when, for example, they kissed. In the following May they married under civil law and in church, and he moved into her tiny attic (about 10 sq. yd with two sloping walls, a skylight instead of a window, running water and a standing toilet in the corridor and wood-stove heating). Her family did not seem to care too much. Only Tony tried to help them to take over a book store, which, however, failed. The marriage was a disaster from the outset. Robert, who knew all the tricks of the trade when it came to sex, had obviously feigned his conversion in order to physically possess Jane. Later, he said: “J’ai voulu la détruire.” (I wanted to destroy her.) On the one hand, Jane felt obliged to give herself to him sexually because of the sacred promise she had made, but on the other hand she felt that he was abusing her. So she gave herself to him physically but without consummating this mentally. In December, she was at the end of her tether and returned home to her mother in Switzerland, desperate and unable to sleep. In the municipal psychiatric hospital, she was diagnosed as schizophrenic and received an unfavorable prognosis. At hearing this, the parents put her into a private mental clinic where she was treated with hypoglycemic and electric shocks – this was before the neuroleptic era. As she repeatedly mentioned one of her mother’s friends called Anna v. T., the physician had this woman come and entrusted the patient to her saying Jane was “emotionally at the stage of an embryo” and only had faith in her.
Having left the clinic, Jane found part-time employment at the insurance office of Anna’s husband in A. After some months, she only took the psychiatric drugs prescribed in times of crisis. Once a week she visited Anna in U. for therapeutic talks. Anna’s husband had warned his wife about taking on such a task.
In Anna’s eyes, sexuality was basically a necessary evil. The patient’s complaints about Robert triggering the illness were not taken seriously by Anna. She compared his sexual behavior with that of an irresponsible nephew and Jane dared not discuss Robert’s sexual perversions with her. Anna had no previous psychological, let alone psychiatric training. Nor did she intend to undergo training at a later stage or report to an expert on the case. She even prohibited Jane to undergo therapy simultaneously by a psychotherapist if she was to treat her. She relied completely on her intuition and saw herself as a “mouthpiece” or even a “broom in the hand of God” for Jane. For Jane, going against Anna’s wishes would have been the same as violating God’s authority. Anna was from an aristocratic family and did not have any children. When Jane complained about her difficulties at work, Anna said: “You can, but you are not willing - you cannot be willing!” (cf. motivation, part A)
Paul, Jane’s brother, had wanted to become an actor after his high-school graduation but was expelled from the German drama school after his first year on the grounds that he was not conveying anything beyond the stage. The study of German literature started afterwards was discontinued. In Switzerland, he then tried his hand as a secretary at a small business and at a boulevard press newspaper among other things. Under the influence of Anna, he had meanwhile reverted to Catholicism and, under her charge, had taken on a role as a kind of carer towards Jane which essentially consisted of two weeks of vacation together each year. He satisfied his acting passion by seeing to the lighting at a small theatre and occasionally stood in for other actors. Here he got to know Kathy, a junior high-school teacher, who got him to undergo training for her profession. However, he did not practice it for long as he had higher aims and then went to study philosophy in K. nearby. In the meantime, he had married Kathy, who had changed from the Calvinist to the Catholic faith, likewise under the charge of Anna, something which her father, a Calvinist clergyman, was never allowed to know. The family was not invited to the wedding. The couple never had any children.
After 4 years, office work had become unbearable for Jane. She was not able to study medicine at the age of 30, both for financial reasons and due to her second-rate high-school graduation. She therefore decided to train to become a doctor’s assistant. After completing this training, she found a ¾-time job at a French-speaking general practitioner’s. She fell out with him after 3 years because she refused to help to spread the anti-baby pill. She then found an interesting full-time job with a lot of vacation with an international specialist in internal medicine. But she also got trouble with this physician when she refused her approval to dismiss a colleague although she disliked her too. So, at the age of 36, she went back to school to become a medical laboratory technician and less dependent on a boss. However, she was unable to do her first job at the Electron Microscopic Institute of the University because whenever she looked through the stereomicroscope she became very giddy and felt sick. She then found part-time work at another institute and wanted to learn to play the piano in her free time. But she got a tendovaginitis in her right wrist which rendered her unable to work for months, so she was fired.
A colleague had advised her to return to Germany because her skills would be more appreciated there. She found a job as a laboratory head at a new clinic treating rheumatism through the office for Germans abroad wishing to return home and left Switzerland, her mother and Anna at 40 to move to Bad T. by herself. There she set up a laboratory with 3 other female employees and - by interiorly identifying with Anna’s authority - managed it to the entire satisfaction of her bosses for 10 years. But she was not spared even at the laboratory: the most poorly trained doctor’s assistant knew how to escape her control and set the other employees up against her. Finally, Jane told her boss that he had two alternatives: either to do something about it or let her go. As he did not give any support to her (as he had not given to the heads of other departments), Jane left the clinic. She believed that she would easily find another job with her qualifications. But she was not considered for posts because, at 50, she would not have been subject to notice and would have received high pay.
4. Second breakdown at the age of 50
She now had a second breakdown. She was especially bothered by feelings of guilt for having left work. Anna signalized to her that she could certainly have carried on, but she hadn’t been willing to. It was true that she had preferred to do pottery at home than work at the clinic. In order to rid herself of this shameful passion, she threw the last, still unbaked pots into the river. But even that did not relieve her of her feelings of guilt. At Christmas she fled to her mother who had returned to her German home town S. after the death of her second husband. She was taken to the psychiatric hospital there which she escaped from after a week. In March she went to an Evangelistic mental clinic for three months where she was at least helped to file an application for an early pension. Then somebody recommended the Landesklinik in C. to her where she was treated for 3 months with strong neuroleptic injections. (The professor in charge was sentenced later for carrying out experiments on patients without their approval.) She finally had herself referred to M. where she was treated with weaker drugs for another 3 months and was then allowed to return home, initially only on a daily basis then permanently.
She then endeavored to build herself a meaningful life without a job under the care of a psychotherapist. She tried to join the “Green Ladies” who rendered small services to the patients in a Protestant hospital. She had told her story to their head clergyman, as a result of which she was only assigned to work in the library. From then on, she kept her past a secret. In an old-people’s home she did gymnastic exercises with the residents. She also tried to help out in a music shop but had problems with her vision. She then gave people seeking asylum German lessons. Twice a week she went to the “Lebenshilfe” (Life Help) to teach two groups of mentally handicapped adults to read and write. Music meant a lot to her: she took up singing again in a good Protestant choir, took lessons in playing the recorder from the choirmaster’s wife and learnt Gregorian Chant through a correspondence course from France.
During her last years at work, she had become presbyopic and required bifocal spectacles which had contributed considerably to her problems at work as no optician was able to supply her with suitable spectacles. One day she stood in front of a mirror and attempted to fixate her thumb with both eyes. She couldn’t do it! She realised that in fact, she did not fixate her thumb but its reflection in the mirror instead and, as a cousin noted, only her right eye converged. Finally, she had discovered a starting point which might enable her to explain her problems! She attempted to interest her older friend Irma, who had recently become an anthroposophist, in her research. But to no effect – Irma only wanted to have an emotional relationship with Jane. Since they had formed an intimate friendship some time ago, a strangely irresistable, also physical attraction had developed between them. Jane was concerned that this might be of a lesbian nature. It is more likely that a symbiotic mother-child relationship had developed between Jane and the 17-years older Irma, who had lost one child after giving birth twice. In Irma, Jane would have found the motherly affection she yearned for but would have also been drawn into her anthroposophical views which would have conflicted with her ties to Anna. As she had also lost her much-loved apartment due to reconstruction measures and did not feel at home at her new apartment, she took up a friend’s suggestion to take a look at the small university town of H. to live in. She immediately decided to rent an apartment offered to her there and moved to H. in 1993. However, the people letting the apartment proved themselves to be particularly difficult – they had had 13 tenants in the apartment in 30 years, had fallen out with all the neighbors and attempted to pull Jane over to their side. As Jane resisted this, one year before her mother’s death she encountered grave difficulties which ended in the owners threatening to give her notice.
5. The spectacles
Jane had become aware that something was wrong with her sight for the first time when Robert said to her after their wedding night: “Ne me regarde pas comme ça!” (Don’t look at me like that) although this could also be interpreted as a simple reproach. From that time, she attempted to mask particularly her left eye with lachrymal fluid. When she found it impossible to work at the Electron Microscopic Institute in 1972, it became clear to her that her abnormal gaze must have somatic causes. These had now been identified in the above mentioned “Mirror test” (Korn 1999a). In 1991 she joined a self-help group of former psychiatric patients and published a questionnaire on this test in their publication. As a result she then received several confirmative responses from patients diagnosed as “schizophrenic”. One of these patients drew her attention to a visual defect, called “fixation disparity” (FD), the prismatic correction of which had improved his ability to draw boundaries. In Munich Jane found an optician of the International Association for Binocular Full Correction IVBV, who discovered a vertical FD in her vision which he corrected with prismatic bifocal spectacles. With these, however, she felt handicapped in her ability to look straight ahead. She went to an IVBV congress in Switzerland where she was recommended a different optician in R. close by. This optician diagnosed an additional exophoria which appeared to increase in further tests, without however, the patient feeling that the spectacles made were an improvement. Finally, she twice consulted the “pope” of the IVBV in Berlin, who diagnosed an additional esophoria in the far range, i.e. exactly the opposite.
Jane had coped best with a pair of near-vision glasses made by the first optician, the interocular distance of which had revealed to be too large due to a mistake made when cutting the glass, thus creating a prismatic effect with an exterior base. She now had the bridge over the nose which connected both parts of the spectacles sawn through and connected them with an electrician’s clamp enabling her to vary the distance between the centers of the lenses. After some attempts, she discovered the best distance, converted this into prism diopters and had herself suitable bifocal spectacles made. But the result still did not satisfy her.
She read that an optician in Sauerland (Hegener 1999) had found equipment to correctly determine the interocular distance of the two foveae. She consulted him, but then discovered that the spectacles prescribed by him corrected double the amount of esophoria than the physician in Berlin had, which did not solve her problems at all. But she had retained the interocular distance and with that had suitable bifocal spectacles made without any horizontal prism, but also without shifting the close parts inwards, i.e. with two glasses as for people with one eye. She managed so well with this solution that she was able to resume her artistic work.
6. The crisis in the relationship between Jane and Paul
Paul had become a teacher for “Philosophic
Didactics” at a teacher training college in E. but had
encountered problems with his students in the years before
Margret’s death in January 1998 because they increasingly
disliked his teaching and examination methods. The head of the
institute demanded from Paul that he justify his method in writing. He
was unable to submit a convincing report and was dismissed prematurely
from his post.
At this time Jane had just started with the prismatic correction of her FD. For decades, Paul had enjoyed his sister’s full confidence whom he phoned once every week. When Jane and Paul were on vacation together, he talked to his wife every evening on the phone in Swiss German dialect. On these occasions Jane hardly recognized her brother. He often complained that his wife was jealous, even of his work.
When Jane was threatened with notice in 1995, she begged her brother to come and help her find a new apartment. He refused, visiting Margret and cousin Ida in S. instead. Later he explained that Jane had only wanted him to prove his love for her. Jane then endeavored to receive an advance on the inheritance from her mother so that she could buy her own apartment. Her mother refused. After Jane had finally found a new apartment, Paul helped her to move, as he had in the past, but he insisted on renovating the old apartment so perfectly that it was not ready on the date it was supposed to be handed back to the owners. He nevertheless departed because at Easter he wanted to accompany his wife to their new second home in southern France where she used to do landscape painting. He dismissed Jane’s reproaches saying that she - no longer Kathy, with whom he had just completed partner therapy - was jealous and that she wanted to dominate him.
7. The relationship between Margret and Paul
Margret, the mother of both, had suffered from Parkinson’s
disease for several years and finally had to be moved to the nursing
care department of her old people’s home. In this period, a very
close bond developed between Margret and Paul who phoned to his mother
at great length every evening and often visited her.
About one year before her death, Jane and Paul had visited their seriously ill mother in S. after Christmas. Jane had seen her in the morning and had not found her responsive. She then phoned Paul and asked him to come so that they could both talk to the physician about whether it wouldn’t be better to stop giving her cardiac remedies and artificially prolonging her suffering. When Paul went to Margret’s bedside with Jane after lunch, Margret beamed all over her face, exclaiming “Oh, Paul...!” Paul remained with Margret for the whole afternoon and missed his meeting with cousin Ida with whom he was staying this time. She phoned Jane that evening in anger and asked why she had told Paul that they would not be meeting – which was a complete lie.
At her last visit, Jane asked her mother whether she did not yearn to be in heaven. Margret replied: “When Paul strokes my hair and gives me a kiss, that is a part of heaven”.
Margret’s room-mate: Margret only talks to her so that she will give her the phone when Paul phones up every evening.
Margret’s friend Berta reports that Paul had said to
Margret: “Mum, your skin still looks so beautiful!”
After Paul had stroked his mother’s hair, she remarked to Berta: “Just like James” (her first husband)!
After being present when his mother died, Paul said: “I am so happy!”
8. Partition of the estate
In May 1992, Margret had written a detailed will. As Jane would only receive a small pension, her mother suggested that Paul should have his inheritance reduced to the statutory share. According to his own statement, Paul had approved of this several times, probably without mentioning his consent to his wife who was noticeably unfriendly towards Jane from then on. Once Margret had been definitively transferred to the nursing care ward and her apartment had been cancelled, Paul took some of the furniture himself and handed over the bulky legacies bequeathed in the will to the legatees. This will was not to be found when the estate was divided.
Because of temporary hallucinations, Margret had then been placed under the guardianship of Helga, a sister-in-law who lived in Margret’s parents’ house and with whom both Jane and Paul stayed when visiting S.. In August 1993 she had written a second short, hardly legible will in the presence of her friend Berta (who had been very taken in by Paul) in which she changed the ratio of inheritance from 1 to 3 to the ratio of 3 to 5. At Jane’s request, this will was not handed over to Paul (who reached out for it) but given to the cousin Michel, who had been appointed executor in the first will. After Margret’s death in January 1998, Michel handed it over to Paul who took it to a notary and made a declaration in lieu of an oath that he knew of nothing that indicated that Margret had left any other testamentary dispositions. Paul defended this later by saying: “If nothing is there, nothing has been left” – a short cut skipping elegantly the possibility of embezzlement.
At Margret’s funeral, Kathy had arrived from Switzerland in order to hand over the jewelry that had been entrusted to Paul. However a pearl necklace and earrings were missing. Nor could they be found in the estate of the meanwhile deceased friend Berta, where Anna had suggested to search.
When dividing up the rest of the moveable assets, Paul publicly declared that Jane could have all of Margret’s CDs, which Jane accepted. After she had left for a moment, she noticed that 3 CDs had been removed.
Paul then suggested to Jane that they should discharge Joe, Margret’s financial administrator, without a final settlement of accounts as this would save on costs. Jane refused this, having been informed by Helga a few months before Margret’s death that with Joe’s help, Paul had obtained the reimbursement of the “out-of-pocket expenses” for his phone calls and visits from his mother’s assets. She then also had the costs of one trip reimbursed.
When, after Margret’s death, Jane asked Paul who had originally suggested the idea of reimbursing “expenses”, he maintained that Helga had suggested it to him years earlier saying that Jane had also had her expenses reimbursed. When Helga was asked about this, she stated that she knew nothing of the kind. However, Paul continued to allege that Helga had suggested it and: if she hadn’t - how could he know? (The alternative that he had lied is a priori excluded.) If Jane wanted to know the sums exactly, it had been an amount of DM 3.300 between this and that date. Jane then had the documents sent to her by the guardianship court: the payments made to Paul dated years before the one made to her, and their amount had been almost three times higher than pretended by Paul within a slightly longer period of time (DM 9,700). She notified Paul of this in writing, who failed to respond.
Jane also refused to authorise Paul to carry out the partition of the estate by himself at Margret’s savings bank. He nevertheless succeeded in carrying this out without Jane receiving any documents on the financial procedures. When she threatened the bank with legal action for the repayment of the payments made, Jane was at least sent the bank statements which showed that Joe, the financial administrator, was paid three bills totalling almost DM 10.000 after Margret’s death. These bills ought to have been submitted to Jane by the guardianship court, but this had only happened once when an official other than the usual one had signed documents. On this occasion, Jane also received the “final settlement of accounts” by Joe, a simple bank statement!
Under pressure from Jane and Anna’s husband, Paul made a list of the furniture he had taken from Margret, one item of which was a valuable baroque cupboard. The prices had allegedly been estimated by an antique dealer whose invoice was mentioned in Paul’s statement of accounts later. However, this list had neither a letterhead nor a signature.
In his statement of accounts which Paul presented to his sister some months later, Paul had also listed a donation of DM 1.000 which Margret had allegedly wanted to make to the religious association chaired by Paul, but which would have required the approval of the guardianship court in her lifetime. When Jane demanded a witness for this, she was accused of having an “abysmally low attitude”.
Jane now mustered up all her courage and demanded that Paul give her all the documents supporting his statement of account. She set him a deadline, after the expiry of which she would apply for an executor at the probate court. Despite repeated - partly gruff - reminders, Paul did not respond until the day after expiry by phoning her to say that he would send her the documents in a week. Jane replied: “I have already sent off the letter to the probate court!” However, she had initially sent the letter only to Michel, the cousin-judge, asking him whether he would accept the task of the executor now. Instead of the promised documents, Jane received notification from Paul shortly afterwards that a copy of the original will had been found by Kathy several months before when she was clearing up the cellar and he was prepared to divide the estate according to this will. Obviously Paul was afraid that the probate court might hear about the existence of the original will from Jane and prosecute him for making a false declaration in lieu of an oath. However Jane would not accept this offer and stated that she only wanted what she was legally entitled to. After the cousin Michel had declared himself willing to carry out the partition of the estate Paul agreed, not without accusing Jane in front of him of being unjust and distorting the truth. Michel ordered that both wills were to be considered valid and an average ratio was to be applied to divide the estate. The invoices of Joe, the financial administrator, had to be itemized by him. This resulted in an inexplicably large amount of time spent for the final settlement, as well as on a foundation that Paul had allegedly created, under the care of Joe, from the differing eighth part in case Jane fell on hard times later. Paul maintained that he had made a payment to this foundation at the savings bank. However, the bank’s records and the manager’s response to a personal inquiry showed that the payment had only just been paid in - to Paul’s regular account. The special account - the number of which Paul had mentioned to Michel - did not even exist.
As Paul had listed two bills from Margret’s tax consultant in his statement of account, Jane asked about the tax rebate at the tax office in S. The tax official was pleased to hear of Jane’s existence, having received instructions from Joe to transfer the money to the account of Paul, being the “son and heir”.
9. Attempts at reconciliation
The noble Anna with her paternalistic approach supported Paul now as before, also as regards the partition of the estate. She would not hear Jane’s accusation that Paul was “hypocritical” – probably because Paul and his wife Kathy were her converts and Paul was the president of an association that pursued her aims.
Now Anna was an authority for Jane. As Paul had never admitted anything, Jane did not dare to condemn him in her heart of hearts. On the other hand, it could not be denied that Paul did not have any scruples about lying to her, betraying and disparaging her. If she resumed relations with him, she would have had to put up with him continuing this behavior. Despite this, she felt guilty, particularly since she was reminded that one had to forgive those who trespassed against us every time she said the Lord’s Prayer. She was also admonished in this spirit by an uncle who got on well with Paul. But did forgiveness not require that the trespasser recognized his guilt (cf. Luke 15, 11-22, 17, 3-4; Matthew 18, 29)? Wasn't this confirmed by Pope Benedict XVI saying that "Love without truth is no true love"? Did the commandment to love one’s neighbors, yea even one’s enemies, also demand that one trusted them even when there was proof that they abused such trust?
In November 1999 she wrote to Paul and Kathy from a pilgrimage: “In
V., I prayed for a peaceful, open relationship with the two of
you.” As she had forgotten to put a stamp on the postcard, she
wrote in a letter afterwards that although she could well understand
their conduct, her sense of right and wrong could not approve it.
The response from Paul was negative: After all that she had done to them, reconciliation without “prior careful clarification of our ideas in this connection” was impossible. The openness that she requested conflicted with the “exclusiveness of marriage” about which he was not prepared to negotiate.
Some months later Jane received a call from her cousin Francis, a brother of Michel, with whom she had become friends since her move to H.: Paul and Kathy had visited him and Paul had shown him his last correspondence with Jane (the gruff parts?) and complained about how much he suffered under the discord between them. Francis then asked Paul whether he should mediate a talk between them. Paul agreed provided that Jane did not “play the moral authority nor intrude in his marriage”. Jane agreed on the condition that Paul put his cards on the table truthfully. But then Paul postponed the meeting by 4-5 months because they allegedly wanted to pass the winter in their second home in southern France – which was not at all in their usual habits and could have been postponed easily for some days - if Paul had really "suffered so much under the discord". Jane realized that true reconciliation on the basis of remembered facts and moral standards was not in the intentions of Paul and called off their meeting. The friendship with the cousin Francis - who did not want to admit that Paul had “taken him in”- was also then at an end.
After her attempt at reconciliation, Jane had received anonymous phone calls. To prevent this happening again, she had changed her telephone number and had only informed trustworthy people of the new one on the condition that they were not to pass it on. She had also informed cousin Francis of the number, but realized during a conversation with him that he had probably given it to Paul so that he could arrange the meeting they had planned. At any rate, Jane again received anonymous calls on the new number. She forbade Paul in a letter to call her who disputed that he was the caller and recommended that she had the calls traced by the post office. Jane refrained from doing this as the caller could use any phone to call her. These anonymous calls then stopped for a while. After she had sent her regards to Paul and Kathy on an embroidered card at Christmas 2001, she again received an anonymous phone call – the last one up to 2006 – at a time when, according to Helga, Paul was returning home from his annual visit to S. for Margret’s memory service.
Kathy died in May 2006. Some days before, Jane had received a letter from Paul asking her if she would agree to having her name put under Kathy’s obituary. The letter had the form of an official document making it plain that there was no personal tie between them. In her answer Jane took up the contradiction between the form and the content of Paul’s letter pointing out that this was a double-bind liable to foster her illness; she urgently requested Paul not to disturb her further before he had fundamentally put in order his relationship with truth. Some weeks later, she again received an anonymous call. When after six months this occurred three times in ten days Jane reacted furiously. Apparently, her reaction was welcomed (as a sign of weakness?) for it gave rise to another call the following day. She managed to ask quietly for the callers name as usual and wait until he hung up. Then she had her phone number changed a second time. After a fortnight, she received a letter from cousin Francis asking her if she had changed her telephone number. Being unsuccessful also in this attempt to get hold of his sister, Paul bought an appartment in S. where he could attend to Ida and to Milly, another divorced cousin who was strongly attached to the memory of her father.
10. Last stage of visuomotor correction
The intrusive behaviour of Paul after Kathy’s death had alarmed Jane for feeling unable to defend her independence at a personal meeting with Paul due to the deficient convergence of her left eye. As she also thought this gaze to be disturbing for others, she attempted to withdraw it to the near range. She actually succeeded in this once she started to work with a TFT laser display - which resulted in the reactivation of the lacking convergence and the corresponding accommodation of the left eye whose hyperopia was suddenly reduced from 1.25 to 0.25 diopters, finally to a myopia of -1,0 diopter. The ensuing reduction of the left spheric correction, however, aggravated her anisometropia, which resulted in a vertigo that could not be overcome by various changes in the prismatic correction attempted during 11 months. The vertigo was finally discovered to be caused by images of different magnitude in the two eyes when wearing spectacles; it was overcome by replacing the binocular difference of 1.5 diopters in the spectacle glasses by a contact lens on the right eye.
CHARACTERISATION OF THE PERSONS INVOLVED AND THEIR RELATIONSHIP TO JANE
According to Martin Buber (1923), the “I” develops in relation to a “you”. As the encountering of gazes is one of the main instruments of managing relationships, people who have problems with defective eye movements are particularly handicapped in the development of their identity if their persons of reference do not meet them with an attentive and reliable affection. In the case described, several persons of reference were involved:
1. The mother
Margret was an attractive, aesthetically minded, intelligent woman who captivated men’s hearts. As the oldest of seven children who grew up without any problems in a good middle-class family, she believed that children’s development proceeded on the right track by itself.
When Jane was born, her mother had been influenced by a book which advised against physical contact between mother and child. In addition to this, she was mentally distracted by the father’s illness which meant that the baby did not only fail to receive physical contact, it also lacked the mother’s emotional attention in the months following birth.
Men had priority over children for Margret. When her beloved husband was taken ill with TB, she believed it to be her primary task to take care of him and not her children. After the end of the war, she devoted her attention chiefly to her profession as a high school teacher for German, English and art history. She was popular among pupils and colleagues. When Jane’s French teacher pointed out to Margret that Jane did not appear to develop normally, Margret did not attach any importance to this. In her second marriage from 1952, she was required to look after her visually handicapped husband. This meant that Jane again did not experience the necessary warmth and safety in her family.
During her longstanding last illness, the anti-Parkinson drugs caused Margret’s dopamine level to rise which meant that her schizophrenic vulnerability broke out in hallucinations. (These stopped again after a reduction of the drugs initiated by Jane). Her confusion resulted in Paul succeeding to adopt the role of the father whom he resembled and thus to concentrate his mother’s entire love on himself.
2. The father
In contrast to the Catholic Margret, the father came from a Protestant family but was sympathetic to his wife’s religion. Due to the risk of contracting TB, physical contact with the father was not permitted. He was frequently absent in sanatoriums and, even when he was present, he remained isolated from family life and was therefore unable to play with the children, set moral standards or intervene with punishment. He died before the children reached puberty which meant that the children did not have a role model for their specific gender development (cf. Siebel, 1984). In the later years of their adolescence, the step-father – who had the age of a grandfather in relation to the children - did not want to fulfill this role. He did not intervene when there were problems: “Those are Margret’s children.” This is how Jane’s brother Paul was able to assume the father-role externally.
3. The brother
From birth, Jane’s relationship to her brother was more
strongly marked by competition than by solidarity. The happiest times
for Jane in her childhood were when she lived apart from her brother,
for example when the children were sent to different families in
southern Germany or when Paul was sent to boarding-school.
By his father falling ill again, the small boy lost the attention of both parents. This coincides with the birth of his sister, who, more perceivably for the boy, becomes the focus of motherly affection and is thus regarded as the cause of his deprivation, as a hostile intruder whom he cannot trust nor feel solidarity with. In order to obtain his mother’s attention, Paul attempts to distinguish himself by copying the outward behavior of his father which he succeeds in doing thanks to his acting talent. Being the model, the father recognizes this (“Paul is a fake”) but cannot intervene because of his illness. Paul is not able, however, to imitate his father’s character because he lacks paternal upbringing based on objective guidelines in childhood and his setting an example in puberty. His ethical aims therefore remain at the stage of subjectively pleasing his mother and other women and family members in similar functions (cf. Korn 1999b).
As Paul already uses his acting talent in his private life to his own ends, he is unable to convincingly personify another character on stage; nor does his feigned authority appear convincing to his students later. However, within the family he succeeds in playing the role of the trustworthy authority by adapting to their formal expectations, thus preventing them from verifying his statements with facts which would prevail in professional life. He also adopted a paternal role in the families of his cousins Ida and Milly who had raised their children by themselves, and towards a schizophrenic patient not related to him who committed suicide later.
After Jane had fallen ill, Paul succeeds in adopting a paternal role towards his sister with the aid of Anna. This is all the more important for Paul because his wife Kathy does not accept his leading role. After he has also lost his authoritative role at work, he attempts to regain this at his mother’s sickbed as her partner – and thus his sister’s father - at his sister’s expense. Playing such a trustworthy role, he gains the confidence of relatives, friends and public authorities and banks whom he informs that his sister is mentally incompetent (schizophrenic?) so that he has to act on her behalf. In his father-role he claims to set the standards of justice. (Paul to Jane: “You have to take what I give you”.) Although, by correcting her oculomotor deficiencies, Jane has overcome her mental handicap, Paul pretends to be her carer and even her guardian. This is why, when Jane had offered reconciliation, he first checks the tone of her voice in anonymous phone calls to find out whether she is weak and thus prepared to submit to his domination.
Paul is anxious to please and craves recognition but is afraid of confrontation where recognition could be honestly acquired. He therefore slips into the vacant role of father, but without assuming the responsibility that goes with it. The father role requires the complementary role of a child which is allocated to his sister, who, as an “intruder” in Paul’s eyes, is not accorded her own legal status in the family. He thus increases his own recognition as a paternal authority at the expense of the weakest member of the family who is unable to defend her position because of her - unrecognized and thus untreated - defective eye movements and who, diagnosed as “schizophrenic”, is pushed into isolation. He wins the recognition of his mother and her friends Anna and Berta by pretending to be pious, generously waiving part of his inheritance and sparing neither expense nor pains to support his old sick mother. He wins recognition from his wife by regaining - with the aid of Joe - the costs spent on his mother and a large part of the “denied” inheritance. (Paul to Jane: “I am not enriching myself at your expense, I am at most recouping my losses.”) He finally attempts to also please his sister by distorting the truth and withholding information which would disclose his two-facedness.
In the years when her eye-movements were corrected, Jane carried on intensive correspondence with Paul about their relationship and the partition of the estate. However, he was very skilful at being evasive. Some comments made by Paul showed
- that he considered lies to be normal behavior (“We are all liars”) - a position found to be habitual in families with schizophrenic members by Laing & Esterton (1964).
- that trust was for him “a gift of the respective moment.” On the contrary, according to Claessens (1979), trust is “the permanent expectancy that the other person will act according to the ideas which one has of a person in his position and situation”.
- that he did not recognize any obligation to be loyal to his sister (“I am not bound to be loyal to you nor to my wife”.)
- that he shifted the responsibility for his behavior either to the patient (see above) or to God (“God did not give me the grace of courage to humiliate me”.)
All these comments show that Paul’s behavior is not guided by the awareness of having a permanent, responsible identity which connects his current speech and actions with those of the past and the future. This corresponds to an actor’s awareness of his identity whose words and deeds are only binding for the duration of the actual play supported by the applause of the audience which he is careful to keep apart from other audiences. Thus Hanna was never admitted to a meal with Kathy, neither at their marriage nor at Margret's funeral, nor ever invited to their home.
4. Other persons of Jane’s own age
Owing to the frequent change of schools and homes and, later, to the change in culture it was not possible for permanent relationships to form. Due to their father’s sickness (the gravity of which had to be kept secret), the children were not allowed to invite other children home in their years of elementary school. A relationship to persons of their own age was thus unable to compensate the deficient family relations (cf. Remuss & Schmidt-Heitmann).
5. The husband
Robert initially appeared to Jane like “an angel from heaven”. But he was a fallen angel who hated God so much that he had once copulated with his girl-friend on the altar (the steps?) of the Chapel of the Pont d’Avignon during a thunderstorm. Hearing this from Robert had deeply shocked Jane. When she mentioned this to the psychiatrists, they no doubt believed it to be one of the patient’s hallucinations. Even when Jane had fled to A., Robert demanded perverse sexual practices from her during a visit. Due to her pathological disposition, she was unable to disassociate from him and identified with his conduct feeling guilty in his stead. (A frequent statement of Jane was: “The other person is closer to me than I am to myself.”) Although the marriage was annulled by the church, Jane still felt bound to him until she got rid of everything of his she had in her possession about 25 years later – including her wedding ring.
6. The carer
Due to her aristocratic upbringing and maybe also her ambitious character, Anna had a voluntaristic approach: Where there’s a will, there’s a way. She mercilessly overtaxed her own body and suffered from chronic headaches, backaches and skin rashes. Anna was intelligent but had been unable to study because her family had been in the opposition during the Nazi period. She therefore compensated her lack of education by invoking God’s authority (divine right!), tolerating no other perspective and competence alongside this allegedly superior point of view. When Jane quoted to her Thomas Aquinas saying that grace presupposes nature, she did not deal with this but quickly added: “and perfects it”. She was primarily geared to the perfection of herself and those entrusted to her care and understood the Imitation of Christ to be a “lifelong overstrain” that Jane also had to face. This is how she created deep, permanent feelings of guilt in the conscientious but disabled Jane (cf. Tournier, 1959) which stimulated her to achieve the greatest feats but could have also made her commit suicide. The thing to be avoided above all was that Jane “regressed”. Anna did not consider that Jane’s regression to the symbiotic phase with persons of reference other than her blood relatives might have been what she needed for a new beginning and development of her true identity. On the contrary, distance was maintained by using “Sie”, the German formal term of address, although Jane was addressed by her first name. When Jane once requested at a later stage to be allowed to call Anna and her husband “mother” and “father”, this was rejected almost with indignation. However, the psychiatrist’s comment about the embryonic emotionality of Jane could have certainly been understood as an indication of the lack of care given to her by her real mother. That one component of Jane’s illness might be derived from family problems was ruled out for Anna from the outset, although the uprooting of the children by transplanting them to Switzerland and the generation gap of the second marriage might have pointed to this. The commandment to honor father and mother ruled out any kind of criticism of their behavior. Anna is convinced that not only does one’s heart determine one’s outward actions, but that one’s outward actions must also change one’s heart. Together with her paternalistic view of life this allowed Paul - who was so perfect on the outside - to easily gain her affection.
7. The patient herself
Jane was talented in several areas but had a disturbed
relationship to her femininity. As a child she had seldom played with
dolls but preferred to join in the war games of the boys, who, however,
gave her the role of “nurse”. Temperament-wise she
had more courage than Paul: she quickly learned how to swim and jump by
copying the boys and her greatest wish was to be friend and comrade to
her brother, her step-brother or another boy. As she was refused this,
she hoped to find a friend in her husband, which, however, failed
After that, Jane’s self-image was dominated by the feeling that she had to hate herself because she was unable to love, to have mutual relationships with others. She felt guilty about this and that she had no right to exist; after all, love and relationships were the reason for being and God’s command.
In summary, due to the father’s illness and the mother’s tendency to give priority to her partner over her children, competition for relationships arose between Jane and Paul from the outset which was intensified by the frequent change of schools and homes and was increasingly decided in favour of Paul by the deviation of Jane’s gaze on the one hand and the acting talent of Paul on the other. While misguided fixation develops in Jane impairing her interactive abilities, Paul learns how to distinguish himself in his paternal role, inspiring confidence and winning over coalition partners against his sister. Being increasingly isolated, Jane is mentally split between her conviction of what is real by her own – disbalanced - perception and what is communicated to her as being real by trusting her family and their friends. (Cf. Watzlawick, 1990, “dilemma between content and relation”; Pateman, 1972, “unability either to state or, more radically, to know what is true and what is false in a given situation“).
The biography of Jane is an illustration of the theory of Scheurer (1981) that the schizophrenic patient is confronted in a “field” which he cannot evade with “cognitive dissonances” (conflicting experience and information) that he is unable to “reduce” because of a special disposition. This disposition consists in the compensation of binocular inequalities such as aniseikonia and/or fixation disparity by an unvoluntary dissociation of the binocular and the head axis, promoting binocular fusion of the background at the expense of bifoveal fixation - i.e. intensive emotional and memory processing - of the nearer target of cognitive attention. If, in addition, the handicapped person cannot rely on truthful relationships within the family, she will become an easy victim for manipulators of feelings and memories when reaching the age of personal choices. The resulting trauma leads to a complete loss of orientation which manifests in schizophrenic symptoms.
The importance of familial interaction for the development of schizophrenia has been proved by a prospective study tracing the development of 128 children born to schizophrenic mothers who grew up in adoptive families (Tienary et al 1989). While in families with "healthy" interaction structures only 4% of the index children were "gravely disturbed" (2% in the control group), the same degree of disturbance was found in 52% of children brought up in "gravely disturbed" families (26,5% in the control group). In "healthy" families, however, there were more healthy children in the index group than in the control group (82 : 76%), a relation that was strongly inverted in "neurotic" families (34,5 : 47%), pointing to an interactional transfer of behavioural disorders to the visually defective children.
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1: Der Horopter ist die räumliche Schicht, deren Punkte
auf der Netzhaut beider Augen auf korrespondierenden Loci abgebildet
werden, d.h. auf Loci mit gleicher Richtung und gleichem Abstand von beiden Foveolae - auf der temporalen Hälfte im kontralateralen Auge und auf der nasalen Hälfte im ipsilateralen Auge, und die daher fusioniert und stereoptisch wahrgenommen werden.
Gleiche horizontale Abstände mit entgegengesetzten Richtungen - d.h. in beiden Augen auf den temporalen Hälften für nähere und auf den nasalen Hälften für entferntere Punkte - werden im spontanen binokularen Sehen als Angabe der Tiefenlage des Objekts in Bezug auf den fixierten Punkt interpretiert.
Die entgegengesetzte nasale Repräsentation eines entfernteren Objektes kann jedoch bewusst gemacht werden, indem man den Hintergrund beobachtet, während man ein schmales nahes Ziel fixiert. Dabei wird derselbe Hintergrund ipsilateral in gleichem Abstand auf beiden Seiten des Nahziels wahrgenommen, was dessen binokulare Fixation beweist. (Symmetric Convergence Test, SCT ).
Legende Abb. 1: Horopter
grauer Bereich: Teil des Horopters im rechten Gesichtsfeld
סּ fixierter Punkt
■ Punkt mit gleicher Richtung und gleichem Abstand von der Fovea: stimuliert Versionen
▲ Punkt mit entgegengesetzter Richtung und gleichem (temporalen) Abstand: stimuliert (Kon)Vergenzen
- - - binokulare und Kopfachse
Von der Autorin entwickelter
Symmetric Convergence Test (SCT, Korn 1999a):
Das Fernziel bestand aus der gespiegelten Rückseite des Nahziels. Es war anfangs als hinter dem fixierten Nahziel auf der binokularen Achse liegend erachtet worden, wenn es beim binokularen oder monokularen Sehen von beiden Augen im selben Abstand vom Nahziel gesehen wurde.
Derselbe Abstand beweist jedoch nur im binokularen Sehen, dass das Nahziel tatsächlich fixiert wird, während der monokular gesehene Abstand zwischen dem gespiegelten und dem Nahziel nichts darüber aussagt, ob "derselbe Abstand" von der nasalen oder der temporalen Netzhauthälfte wahrgenommen wird, d.h. ob das nahe oder das gespiegelte Objekt fixiert wird. Wenn das dominante (linke) Auge den Abstand temporal wahrnimmt, so ist die binokulare Achse bezogen auf die Kopfachse zu seiner Seite hin verschoben, während im rechten Auge das Bild des Nahziels unterdrückt wird.
| Legende Abb. 2:
Symmetric Convergence Test:
סּ gespiegeltes Ziel
Fo linke Fovea
F▲ rechte Fovea
----- binokulare Achse
_ _ _Kopfachse
rechten Auges zwischen
des Nahziels und
binokularer Fusion mit
dem Bild des linken Auges
RODENSTOCK Nahsicht-Test (nicht mehr erhältlich) waren die
gekreuzt repräsentierten unteren Stäbe nicht fusioniert, im
Gegensatz zu den ungekreuzt repräsentierten oberen Stäben,
einer Konvergenzinsuffizienz mit stereoptischer Wahrnehmung entspricht,
d.h. Strabismus ausschließt.
Die Patientin hatte auch defekte Ergebnisse bei der Prüfung der konvergenten fusionalen Reserve, d.h. der Fusion von durch Prismen getrennten Bildern beider Augen unter konstant gehaltener Akkommodation (cf. Wesson 1982).
Ein Defekt der fusionalen Konvergenz wurde auch von
der Autorin nachgewiesen mit einem Fixationstest, bei dem die akkommodative Konvergenz durch Nadellöcher ausgeschlossen wurde (Korn 2002).
In allen Stereopsis Tests zeigte die Patientin jedoch räumliches Sehen, was ein Schielen ausschließt.
Legende Figur 3
- Obere Stäbe: unge-
von Augengläsern und
= entfernterer Eindruck
- Untere Stäbe: gekreuzte
Gläsern und temporal
= näherer Eindruck
Aniseikonia Screening Test:Ein grober Vergleich ist möglich, indem man dem Patienten auf einem Bildschirm zwei große Buchstaben I (Times) zeigt und die Bilder beider Augen trennt, entweder durch ein vertikal gehaltenes Fenster (Vergleich der temporal wahrgenommenen, kontralateralen Buchstaben, rechte Abb.) oder indem man zwischen die Nase und den Bildschirm einen Stock (oder eine Hand) hält, der den jeweils kontralateralen Buchstaben zudeckt (Vergleich der nasal wahrgenommenen, ipsilateralen Buchstaben, linke Abb.)
Die Methode kann auch benutzt werden mit dem Bild eines horizontalen Stabes zur Entdeckung einer vertikalen FD oder einer Torsion
ZusammenfassungÜber die Frage, welche Rolle die familiale Interaktion bei der Entstehung einer Schizophrenie spielt, gibt es theoretische Modelle, die zwar gut begründet und strukturell ausgestaltet, inhaltlich jedoch ungenügend gefüllt sind, weil das therapeutische Setting seiner Natur nach nicht geeignet ist, durch die „Kulissen“ der familialen Interaktion zu den einzelnen Fakten des Familienlebens durchzudringen. In der vorliegenden Arbeit soll diese Lücke geschlossen werden durch die detaillierte Darstellung der Umstände der Entwicklung der beteiligten Personen in Verbindung mit ihren Interaktionen. Die Befunde bestätigen die seit 1999 entwickelte Theorie der Autorin, dass eine durch eine gestörte Kontrolle ihrer Augenbewegungen für Schizophrenie vulnerable Person aus einer ihrer Natur nach symmetrischen Beziehung mit suggestiven Mitteln in die abhängige Position einer komplementären Beziehung verwiesen werden kann. Die von ihrem Partner erworbene scheinbare Autorität wird missbraucht um die Patientin ihrer Vertrauenswürdigkeit zu entkleiden und mit der Schuld für die gestörte Beziehung zu belasten. Es wird beschrieben, wie - nach Entdeckung und präziser Korrektion ihrer asymmetrischen Sehstörungen - die Patientin fähig wird, die Manipulationen ihres Partners zu durchschauen, sich von ihm zu trennen und zu gesunden.
Der Mensch orientiert sich auf zweierlei Weise: durch seine eigene Wahrnehmung und durch das
Vertrauen, das er den Mitteilungen anderer entgegenbringt. Die
Einordnung perzeptiver Daten bedarf eines Koordinatensystems, das aus
dem Gleichgewicht geraten kann, wenn die Achse der Wahrnehmung nicht
mit der vestibulären Achse der Selbstwahrnehmung und Aktion
übereinstimmt. Dadurch wird die Fixierung und Verarbeitung
der interessierenden Gegenstände gestört, und die Person wird
besonders abhängig von den im Vertrauen auf andere erhaltenen
Informationen. Das Wesen des Vertrauens besteht in der Gewissheit,
dass der Partner
in deiner Gegenwart seine wahren Absichten nicht verheimlicht und
Abwesenheit nicht gegen deine Interessen handelt. Die folgende Arbeit
möchte in großen Umrissen und einzelnen Vorkommnissen den
Mangel an vertrauensvollen Beziehungen in der Entwicklung eines als
chronisch schizophren diagnostizierten Menschen untersuchen. Das Thema
wurde von der Autorin schon in einem früheren, mehr theoretischen
Artikel unter Bezug auf familientherapeutische Literatur behandelt
(Korn 1999b). Es wurde die Hypothese aufgestellt, dass ein
Familienmitglied eine autoritative Rolle spiele, die ihm nicht zukommt,
ohne deren Verantwortung zu übernehmen, und dass hierdurch die
behinderte Person ihrer legitimen Stellung in der Familie beraubt
werde. Die schwere Erkrankung der betagten Mutter, ihr Tod und die
nachfolgende Teilung der Erbschaft ermöglichte eine genauere
Untersuchung des Verhaltens und eine Analyse der Motive und Strategien
Als die spätere Patientin Hanna 1935 geboren wurde, war bei ihrem Vater vor kurzem eine Lungentuberkulose wieder aufgebrochen, die er sich im 1. Weltkrieg zugezogen hatte. Ihr Bruder Paul war damals 13 Monate alt. Die Mutter Margret vertraute die beiden Kinder sehr bald einem jungen Kindermädchen im Hause der mütterlichen Großeltern in S. an, während sie selbst sich häufig im Sanatorium um ihren kranken Mann kümmerte. Während der Kriegsjahre lebte die Familie in einem Vorort von Berlin; wegen der offenen TB durften die Kinder sich dem Vater jedoch nicht nähern. Sie wurden während des Krieges häufig nach Süddeutschland oder in die Schweiz „kinderlandverschickt“, so dass sie in der Grundschule insgesamt 12 Mal die Schule wechseln mussten.
Der Vater starb 49jährig im
Herbst 1944. Im Frühjahr 1945 floh die Mutter mit den
Kindern in eine Kleinstadt in Westdeutschlan und
ließ sich nach Kriegsende im Haus ihrer Mutter in ihrem Geburtsort S. nieder,
wo sie als Lehrerin zunächst als Referendarin, dann als Studienassessorin am selben
Mädchengymnasium tätig wurde, das auch Hanna besuchte. Diese erinnert sich an
ein Gedicht, das sie etwa zwölfjährig über ihren Bruder verfasste: Wenn wir
Streit gehabt haben.... „so läuft zur Mutter er und sagt: ‚Sie schlug mich grausam
auf mein Bein, die Strafe muss ihr sicher sein.‘ – So lügt der alte Bösewicht,
die Wahrheit spricht er niemals nicht. – Und wenn er trat zur Tür hinaus, so
lachten ihn die Kinder aus. Sie riefen: ‚Seht, da kommt der Wicht mit seinem
Da die Mutter sich mit der Erziehung des Sohnes neben ihrer Berufstätigkeit überfordert sah, wurde Paul etwa 13jährig den Jesuiten in D. anvertraut.
Nach dem Krieg hatte die Mutter als Referendarin ein sehr geringes Einkommen. Von einer reichen Schulkameradin bekam Hanna ein PA-ar Lederschuhe geschenkt, als sie im Winter in Holzpantinen durch den Schnee stapfen musste. Es bildete sich eine Freundschaft, Hanna musste jedoch später der Tochter einer besser situierten Familie weichen. In Untertertia kam eine „Neue“ aus Hamburg in die Klasse, die sich mit der unliierten Hanna befreundete. Als im Tanzstundenalter für die Freundin die Beziehung zum andern Geschlecht in den Vordergrund trat und Hanna kurz darauf in die Schweiz übersiedelte, trennten sich ihre Wege. Sie trafen sich zwar später in Paris wieder und Hanna besuchte die Freundin nach deren Heirat mehrfach, erhielt jedoch von dieser keinen Gegenbesuch, auch nicht, nachdem ihre fünf Kinder ausgeflogen und ihr Mann verstorben war.
1952 hielt der 68-jährige Schweizer Rechtsanwalt Johann, der kurz zuvor seine erste Frau – die jüngste Schwester der Mutter von Margret – verloren hatte, um die Hand der 45-jährigen Margret an. Diese zog daraufhin mit ihren beiden Kindern nach A. Sie selbst wurde dabei Schweizerin, die Kinder blieben jedoch Ausländer und unterstanden der Schweizer Fremdenpolizei. Der jüngste Sohn des Stiefvaters Toni, der, zwei Jahre älter als Hanna, als einziger noch im Hause lebte, hatte zwar bei der Heirat der Eltern in S. seine 17jährige Stiefschwester sogleich mit den von ihr geschätzen Eukalyptusbonsbons beglückt, ihr aber in A. keine Aufmerksamkeit mehr gewidmet, sondern sich ganz an Paul angeschlossen, der zwei Monate früher als Hanna nach A. gekommen war und dessen Leichtigkeit (wie er später berichtete) ihn fasziniert hatte.Um keine Zeit zu verlieren, wurde Hanna ins Gymnasium B geschickt, dessen Abschluss jedoch nicht zum Medizinstudium berechtigte. Als Hanna dort eintrat, waren die Partnerinnen schon vergeben. Eine kameradschaftliche Beziehung ergab sich mit einem in der Nähe wohnenden Mädchen italienischen Ursprungs, mit der sie Hochdeutsch sprechen konnte.
Trotz ihres Ausländerstatus verlangte man von den Kindern, den ihnen wesensfremden Schweizer Dialekt zu sprechen, was der sprachbegabten Hanna schnell und gut gelang. Sie hörte jedoch nie auf, dies als emotionale Vergewaltigung zu empfinden. Da sie durch die Umsiedlung weder in Deutschland noch in der Schweiz zu Hause war, ging sie nach dem Abitur 1955 als au-pair-Mädchen nach Paris, um dort ihr Französisch zu perfektionieren. Nachdem sie an der Alliance Française sämtliche Abschlüsse einschließlich der Befähigung zum Französischunterricht im Ausland bestanden hatte, übersiedelte sie in ein winziges Dachzimmer und schrieb sich an der Sorbonne ein. Der Stiefvater hatte sich bereit erklärt, sie mit 300 Sfrs im Monat zu unterstützen. Als sie, um eine kranke Freundin aufzumuntern, mit dieser zusammen aus Ton eine kleine Figur modelliert hatte, fand eine polnische Bekannte, sie sei künstlerisch begabt. Daraufhin besuchte Hanna zunächst private Kunstakademien und wurde schließlich auch an der Académie des Beaux-Arts zugelassen. Die Sorbonne besuchte sie von nun an vor allem für die Examina im Fach Deutsch, die sie 1960 abschloss.
Wie sollte es nun
weitergehen? Ihr Sprachstudium berechtigte nicht zum Schuldienst, weder in
Frankreich noch in der Schweiz noch in Deutschland. Hanna hatte auch keine
Beziehungen, die ihr etwa als Übersetzerin (was sie versucht hatte) oder als
Verlagslektorin eine Stelle hätten vermitteln können. Auch ihre künstlerische
Begabung genügte nicht, um daraus einen Beruf zu machen.
Eine persönliche Beziehung hatte sie in Paris nur zu der älteren Polin, die ganz in ihrer Nähe ein etwas größeres Dachzimmer bewohnte. Zwischen Hanna und Paul oder Toni hatte sich nie eine engere geschwisterliche Beziehung entwickelt. Paul hatte ihr einmal einen langen Brief nach Paris geschrieben, in dem er sie mahnte, nicht nur äußere Ereignisse nach Hause zu berichten, sondern auch, was sie innerlich bewegte. Er selbst teilte jedoch von sich nichts dergleichen mit.
3. Ausbruch der Krankheit mit 25 Jahren
Im Sommer 1960 reiste Hanna mit zwei Studenten und einer Studentin in einem kleinen Auto nach Marokko. Den Rückweg durch Spanien machte sie allein, anfangs per Autostop. Sie war beeindruckt von der Lebendigkeit und Wärme der Spanier. Im Herbst lernte sie in Paris den mittellosen jungen spanischen Schriftsteller Robert kennen, der sie faszinierte. Als praktizierende Katholikin widerstand sie seiner Verführung und versuchte, ihn – u.a. beim Küssen – von der Existenz Gottes, der Liebe, zu überzeugen. Im Mai danach heirateten sie zivilrechtlich und kirchlich und er zog zu ihr in ihr winziges Dachzimmer (ca. 9 qm, zwei schräge Wände, statt Fenster eine Dachluke, fließendes Wasser und Steh-WC im Gang, Holzofenheizung). Ihre Familie schien das wenig zu bekümmern. Einzig Toni versuchte, ihnen behilflich zu sein bei der Übernahme einer Buchhandlung, die jedoch misslang. Die Ehe war von Anfang an eine Katastrophe. Robert, der sexuell mit allen Wassern gewaschen war, hatte offenbar eine Bekehrung fingiert, um Hanna körperlich zu besitzen. Er hat später geäußert: „J’ai voulu la détruire“. (Ich wollte sie zerstören.) Hanna fühlte sich einerseits durch das sakramentale Versprechen zur sexuellen Hingabe an ihn verpflichtet, spürte jedoch andererseits, dass er sie missbrauchte. So gab sie sich ihm zwar körperlich hin, ohne dies jedoch seelisch mitzuvollziehen. Im Dezember war sie am Ende ihrer Kräfte und kehrte in die Schweiz zu ihrer Mutter zurück, völlig schlaflos und verzweifelt. In der städtischen psychiatrischen Anstalt diagnostizierte man eine Schizophrenie mit ungünstiger Prognose. Daraufhin gaben die Eltern sie in eine private Heilanstalt, in der sie – es war noch vor der Neurolepticazeit – mit hypoglykämischen und Elektroschocks behandelt wurde. Da sie wiederholt eine Freundin ihrer Mutter namens Frau von T. erwähnte, ließ der Arzt diese kommen und vertraute ihr die Patientin an mit der Bemerkung, Hanna sei „emotional auf der Stufe eines Embryos“ und habe nur noch zu ihr Vertrauen.
Nach Verlassen der Klinik
fand Hanna eine Halbtagsarbeit im Versicherungsbüro des Ehemanns von Frau v. T.
in A. Die verordneten Psychopharmaka
nahm sie nach einigen Monaten nur noch in Krisensituationen. Einmal wöchentlich
besuchte sie Frau v. T. in U. zu therapeutischen Gesprächen. Ihr Mann hatte
seiner Frau von der Übernahme dieser Aufgabe abgeraten.
Sexualität hatte im Bewusstsein von Frau v. T. etwa den Stellenwert eines notwendigen Übels. Die Klagen der Patientin über Robert als Auslöser der Krankheit wurden von Frau v. T. nicht ernst genommen. Sie verglich dessen sexuelles Verhalten mit dem eines leichtsinnigen Neffen. Über Roberts sexuelle Perversitäten mit ihr zu sprechen, wagte Hanna nicht. Frau v. T. war in keiner Weise psychologisch oder gar psychiatrisch vorgebildet. Sie wollte dies auch weder nachholen noch sich einer fachlichen Leitung unterstellen, ja sie schloss eine gleichzeitige Behandlung durch einen Psychotherapeuten aus, wenn sie Hanna betreuen sollte. Sie verließ sich vielmehr ganz auf ihre Intuition und verstand sich als „Sprachrohr", ja als "Besen" in der Hand Gottes“ für Hanna. Eine Zuwiderhandlung gegen Frau v. T. wäre für Hanna einem Verstoß gegen die göttliche Autorität gleichgekommen. Frau v. T. war adeligen Ursprungs und kinderlos. Wenn Hanna über ihre Probleme bei der Arbeit klagte, hieß es: „Sie können wohl, aber Sie wollen nicht - Sie können nicht wollen!“ (vgl. Teil A: Motivation).
Paul, der Bruder von Hanna, hatte nach dem Abitur Schauspieler werden wollen, wurde jedoch nach dem ersten Jahr von der deutschen Schauspielschule gewiesen mit der Begründung, er bringe nichts über die Rampe. Ein daraufhin angefangenes Germanistikstudium wurde abgebrochen. Er versuchte sich dann in der Schweiz, u.a. als Sekretär bei einem kleinen Unternehmen und bei einer Boulevardzeitung. Unter dem Einfluss von Frau v. T. hatte er inzwischen zum Katholizismus zurückgefunden und unter ihrer Leitung gegenüber Hanna eine Art Betreuerrolle übernommen, die v.a. in zwei gemeinsamen jährlichen Ferienwochen bestand. Seine Schauspielpassion befriedigte er, indem er an einem kleinen Theater die Beleuchtung übernahm und gelegentlich für einen andern Schauspieler einsprang. Dort lernte er auch Kathy kennen, eine Sekundarschullehrerin, die ihn dazu brachte, sich seinerseits für diesen Beruf ausbilden zu lassen. Er übte ihn jedoch nicht lange aus, strebte vielmehr nach Höherem und studierte im nahen K. Philosophie. Inzwischen heiratete er Kathy, die vorher, ebenfalls unter der Leitung von Frau v. T., vom kalvinistischen zum katholischen Glauben übergetreten war – was ihr Vater, ein kalvinistischer Pastor, jedoch nie erfahren durfte. Die Familie wurde zur Hochzeit nicht eingeladen. Die Ehe blieb kinderlos.
Für Hanna war nach 4 Jahren die Büroarbeit unerträglich geworden. Medizin studieren konnte sie mit 30 Jahren nicht mehr, sowohl aus finanziellen Gründen als auch wegen ihrer zweitrangigen Matura. So entschloss sie sich für eine Arzthelferinnenausbildung. Nach deren Abschluss fand sie eine ¾ Stelle bei einem französischsprachigen Allgemeinpraktiker. Mit diesem überwarf sie sich nach 3 Jahren, weil sie sich weigerte, sich an der Verbreitung der Anti-Baby-Pille zu beteiligen. Eine interessante Vollzeitstelle mit viel Urlaub fand sie dann bei einem Internisten mit internationaler Klientele. Doch auch mit diesem bekam sie Schwierigkeiten, als er eine – auch ihr selbst unsympathische – Kollegin unrechtmäßig entlassen wollte. So setzte sie sich mit 36 noch einmal auf die Schulbank, um MTA – und damit unabhängiger vom Chef – zu werden. Ihre erste Stelle am elektronenmikroskopischen Institut der Universität konnte sie jedoch nicht ausfüllen: Beim Blick durch das Stereomikroskop wurde ihr völlig schwindlig und übel. Sie fand dann eine Halbtagsstelle an einem anderen Institut und wollte in ihrer Freizeit Klavier spielen lernen. Doch sie bekam eine Sehnenscheidenentzündung am rechten Handgelenk, mit der sie monatelang nicht arbeitsfähig war, so dass ihr gekündigt wurde.
Ein Kollege hatte ihr geraten, nach Deutschland zurückzukehren, dort würde man ihre Fähigkeiten besser schätzen. Über das Büro für rückkehrwillige Auslandsdeutsche fand sie eine Stellung als Laborleiterin in einer neuen Rheumaklinik und verließ mit 40 die Schweiz, ihre Mutter und Frau v. T., um allein nach Bad T. zu ziehen. Dort baute sie das Labor mit 3 Mitarbeiterinnen auf und leitete es zur vollen Zufriedenheit ihrer Chefs während 10 Jahren. Doch auch hier blieb sie nicht ungeschoren: Die am schlechtesten ausgebildete Arzthelferin verstand es, sich der Kontrolle von Hanna zu entziehen und die andern Mitarbeiterinnen gegen sie aufzuhetzen. Schließlich stellte Hanna den Chef vor die Alternative, etwas dagegen zu unternehmen oder sich von ihr zu trennen. Wie schon in den andern Abteilungen unterstützte der Chef seine Abteilungsleiterin nicht, und Hanna verließ die Klinik. Sie glaubte, bei ihren Qualifikationen leicht etwas Anderes zu finden. Doch man wies sie ab; denn sie wäre – mit 50 – unkündbar geworden und hätte zu hoch bezahlt werden müssen.
4. Zweiter Zusammenbruch mit 50 Jahren
Nun brach sie ein zweites Mal zusammen. Vor allem belastete sie das Gefühl, durch die Aufgabe der Arbeit schuldig geworden zu sein. Von Frau v. T. wurde ihr signalisiert, sie hätte durchaus weitermachen können, aber sie habe nicht gewollt. Sie hatte in der Tat lieber zu Hause getöpfert als in der Klinik zu arbeiten. Um sich von dieser schimpflichen Leidenschaft zu trennen, warf sie die letzten, noch ungebrannten Töpfereien in den Fluss. Aber auch das half nicht gegen die Schuldgefühle. An Weihnachten floh sie zu ihrer Mutter, die nach dem Tod ihres zweiten Mannes in ihre deutsche Heimatstadt S. zurückgekehrt war. Man brachte sie in die dortige Psychiatrie, der sie nach einer Woche wieder entfloh. Im März kam sie für drei Monate in einer evangelistisch orientierten psychiatrischen Anstalt unter, wo man ihr immerhin half, einen Antrag au