the concept of affect logic: an integrative psycho...

The Concept of Affect Logic: An IntegrativePsycho-Socio-Biological Approach to

Understanding and Treatment ofSchizophrenia

Luc Ciompi

IN THIS ARTICLE, the psycho-socio-biologically integrative concept of af-fect-logic, and its relevance for a comprehensive understanding and therapy ofschizophrenia, is briefly presented. This concept has been developed by the au-thor over the past 20 years, on the basis of the literature, of clinical experienceand his own research into long-term evolution, rehabilitation, effects of milieu-therapy. and nonlinear evolutionary dynamics of the illness. It postulates, basi-cally, that fundamental affective states (or emotions, feelings, moods) are con-tinuously and inseparably linked to all cognitive functioning (or "thinking" and"logic" in a broad sense), and that affects have essential organizing and integrat-ing effects on cognition. Schizophrenia is understood as an altered mode ofaffective-cognitive interaction based, possibly, on disturbed (loosened) affec-tive-cognitive connections. This hypothesis leads to: 1) an integrative psycho-socio-biological model of long-term evolution of the illness; 2) a new under-standing of psychopathological core phenomena such as ambivalence,incoherence, and emotional flattening; 3) an innovative therapeutic approachbased on an emotion-relaxing milieu and style of care; and 4) the hypothesisthat schizophrenia could basically be an affective (and not a cognitive) disease,of another kind than mania or melancholia, however.

Since the classical descriptions byKraepelin (1896) and Bleuler (1911) of thepsychotic condition we now call schizo-phrenia. this enigmatic disorder contin-ues to represent one of the most puzzlingunsolved problems in the whole field ofmedicine. Even though many biological,social, and psychological factors which in-fluence its etiology and course have beendetected during the last decades — among

them genetic, perinatal, and biochemicalfactors, disturbed rearing conditions andconfusing familial communication pat-terns, high expressed emotions, socio-economic and cultural conditions (refer-ences see below) —no predominant single"cause" of the multitude of psychotic phe-nomena has so far been identified, norhas an adequate theoretical frameworkemerged which would convincingly link

Luc Ciompi, MD, is Professor of Psychiatry and former Director of the Social-Psychiatric UniversityClinic of Berne, Switzerland. He has won several international scientific awards, among them the Stanley R.Dean Award of the American College of Psychiatry, 1986. Address correspondence to Luc Ciompi, M.D.,Prof. Em. of Psychiatry, Cita 6, La Cour, CH-1092 Belmont-sur Lausanne, Switzerland.

This paper is based on a lecture at the X Ith International Symposium for the Psychotherapy of Schizo-phrenia, Washington DC, June 12-16, 1994

158 PSYCHIATRY, Vol. 60, Summer 1997

AFFECT LOGIC AND SCHIZOPHRENIA

the scattered pieces of biological and psy-chosocial knowledge together.

A certain progress was made, however,when George Engel (1977) proposed his bi-ological-psychosocial model of humanfunctioning. Other models specificallyadapted to schizophrenia promoted an in-tegration of biological and psychosocialapproaches – among them the informa-tion processing model (Chapman andChapman 1973), the stimulus-windowmodel (Wing 1975), the vulnerabilitymodel (Zubin and Spring 1977), and thestress-diathesis-model (Gottesman andShields 1978). Remaining mostly too gen-eral or partial, and additive or summativerather than truly integrative, in the senseof explaining how specific psychodynam-ical, sociodynamical, and biological fac-tors actually interact, none of themgained general recognition, with the ex-ception, perhaps, of Zubin's and Spring'svulnerability model, which will be ad-dressed below.

During the last 10 to 15 years, the basicknowledge on psychosocial-biologicalinteractions has remarkably increased,however. At least three fundamental phe-nomena, or mechanisms, functioning as"psychosocial-biological mediators" (Ci-ompi 1989) have been described. First isthe mechanism of neuroplasticity (the factthat activated synaptic connections areneurophysiologically reinforced and den-dritic growth is stimulated by repeatedaction, whereas inactivated connectionsare weakened – a mechanism which is theneurophysiological basis of all learningand memory, and provides a crucial com-mon point of impact for both biologicaland psychosocial influences, cf. Haracz1984, Changeux and Konishi 1987). Sec-ond is the notion of stress, with its simul-taneously biological, intrapersonal, andinterpersonal aspects (Seyle 1946, Levi1973). Third is the notion of affects, withits simultaneous intrapersonal-subj ec-tive, social and biological points of im-pact, and its crucial organizing and integ-rating effects on cognitive functions thatare explained below (Zajonc 1980, 1984;Ciompi 1982/1988, 1991a; Lazarus 1982,1991; Leventhal and Scherer 1987; Izard1977, 1993a).

In the concept of affect-logic which is tobe presented in this paper, these three bio-logical-psychosocial mediators and theirinteractions play a central role. Inte-grated into a comprehensive psycho-socio-biological model of the psyche, with spe-cial relevance to schizophrenia, theyprovide an empirically grounded theoreti-cal link between a wide range of phenom-ena on all three levels mentioned. The con-cept of affect logic was first proposed bythis author in a book written in German(Ciompi 1982, English translation 1988)and further developed since (Ciompi 1986,1991a, b, 1994). It is based on empirical re-search in long-term evolution, psycho-pathology, and rehabilitation of schizo-phrenia (Bleuler 1978; Tsuang, Woolson,and Fleming 1979; Ciompi, Dauwalder,and Ague 1979; Ciompi 1980, 1988b;Huber, Gross, and Schuttler 1980; Har-ding et al. 1987a, 1987b; McGlashan 1988;Marneros et al. 1988), in therapeutic ef-fects of an emotionally relaxing therapeu-tic setting and style of care (Mosher andMenn 1978; Ciompi et al. 1992a, b, 1993a,b), and on a theoretical approach focusedon affective-cognitive interactions, whichintegrates central elements of Piaget's ge-netic epistemiology (Piaget 1977a, b) withcurrent psychoanalytical (Kernberg 1976,1980, 1990), psychological (Zajonc 1980,1984; Lazarus 1982, 1991; Izard 1977,1993a, b) and biological (Derryberry andTucker 1992; McNeal 1993; Davis 1994)findings. The overall theoretical frame-work is system theoretic (Bertalanffy 1950;Miller 1975), including current notions onself organization and nonlinear (chaostheo-retical) dynamics of complex systems farfrom equilibrium (Prigogine et al. 1983; Ha-ken 1982, 1990; Ciompi 1996; Tschacher etal. 1992, 1996; Ciompi 1996).

In the following paper, the basic no-tions of the concept of affect-logic willfirst be briefly presented. Secondly, its re-lations to schizophrenia will be outlined.Thirdly, some of its main practical impli-cations will be summarized.

BASIC ELEMENTS OF AFFECT-LOGIC

The term "affect-logic" is a not entirelysatisfactory transposition into English of

PSYCHIATRY, Vol. 60, Summer 1997 159

LUC CIOMPI

an appropriate German neologism mean-ing, simultaneously and with equalweight, "the logic of affectivity" and "theaffectivity of logic." It points to the – cer-tainly not new but, we believe, in its far-reaching consequences not yet adequatelyunderstood – central postulate that af-fects (or feelings and emotions) on oneside, and cognitive functions (or thinkingand logic) on the other side, are continu-ally and systematically interacting in allnormal and in most pathologic mentalfunctions. Affects are operationally de-fined as global psychosomatic states ofvariable duration and degree of conscious-ness, with corresponding psychomotorand (perhaps) expressive behavior. Aseven indifference, apathy, or the more re-laxed "neutral" mood of everyday behav-ior correspond to a specific emotional"tuning" of body and mind, it is impossiblenot to be in a certain affective state. Cog-nitions, on the other side, are defined asthe perception and further elaboration ofsensory differences. And "logic," finally, isunderstood in the general sense of "theway cognitive elements are linked to-gether" – a broad definition which con-duces to the notion of different kinds oflogics, or modes of cognitive functioning,in different affective states (see below).

According to the concept of affect logic,the enormous variety of normal andpathological mental phenomena can beunderstood, on a formal level, as the resultof specific patterns of complementary in-teractions between two fundamentallydifferent but obligatorily linked biologicalsystems. The first is a cognitive and ulti-mately quantifying one, which is primar-ily based on perception and on further pro-cessing of sensory informations (that isdifferences). The second is an affectiveand qualifying one which provides thesecognitions (and the relations betweenthem) with specific emotional connota-tions, by linking them with different af-fective states. Corresponding affective,cognitive, and behavioral elements aresystematically connected through repeti-tive actions and experiences; they are in-tegrated into functional "programs for

feeling, thinking and behaving" (or "affec-tive-cognitive-behavioral systems of ref-erence"), which eventually form the essen-tial "building blocks" of the psyche, bothon elementary and on complex levels. Asimple example is an acquired reflex of thetype "burnt children fear the fire" (aGerman proverb), a complex one is atransference reaction pattern in the psy-choanalytical sense (e.g. an anxious-ag-gressive behaviour against all fatherfigures). Self-representations and object-representations, as described by psycho-analysts such as Jacobson (1965), Mahler(1968), and Kernberg (1976, 1980), canthus be understood as complex supra-ordinated "feeling-thinking-behaving-pro-grams" generated through action (whichmainly corresponds, here, to interper-sonal communication). Actually, thewhole psyche (or the "psychic apparatus",as Freud preferred to say) appears as acomplex hierarchy of functionally inte-grated affective-cognitive behavioral"programs," which represent a condensa-tion of past action, and provide, simulta-neously, the relevant basis for all futureperception and action in similar contexts.

The conceptualization of affect logic isstrongly supported by basic neuroana-tomical and neurophysiological research.Recently detected rich ascending and de-scending connections between limbic andparalimbic structures, which generateand regulate emotions on the one hand,and, neocortex, thalamus, and hypothala-mus on the other hand, provide the neu-ronal basis for continuous interactionsbetween emotions, cognitions, sensori-motor activity, and hormonal tuning ofthe whole body (Panksepp 1982, 1991;Gainotti 1989; Derryberry and Tucker1992; Le Doux 1993; McNeal 1993; Schore1994). Of particular interest is the discov-ery of direct connections between thala-mus and amygdalae, allowing for emo-tional emergency reactions to sensoryinputs without previous high-level cogni-tive processing (LeDoux 1989, 1993). Dif-ferent genetically rooted affect-organizedneuronal systems, with operationally in-tegrated cognitive, affective, sensori-



motor, and hormonal-vegetative compo-nents, have been identified, or are on theway to being identified, during the last10-15 years; among them a so-called re-ward-system characterized by pleasantfeelings (Routtenberg 1978), an anger-aggression system, a fear-anxiety system,and a panic system (Panksepp 1982, 1991;Ploog 1989, 1992). These systems haveprivileged relations to certain neurotrans-mitters: the so-called reward-system toendorphine, the anxiety-panic system todopamine, the anger-aggressivity systemto noradrenaline, and the sadness-depres-sion system to serotonine (Ploog 1989).The well known projections of the rele-vant neurotransmitter systems towarddistant brain areas provide a functionalbasis for the postulated far-reaching ef-fects of emotions. By the already de-scribed phenomenon of neuronal plastic-ity, complex context-specific functionalcircuits (or "programs") based on action –that is, experience–are generated through-out life. Here, too, all the available evi-dence (especially conditioned reflexes andother learning phenomena) speaks for theassumption that relevant emotional com-ponents (and corresponding humoral reac-tions) are functionally associated withcontext-specific cognitive and behavioralpatterns. Other biological findings con-cerning emotion-dependent informationprocessing, learning, and memory, will bepresented below. Furthermore, an ex-tended body of evidence shows that endor-phines, related to positive emotions be-tween mother and child during earlychildhood, contribute to the maturation oflimbo-frontal connections that are eventu-ally of paramount importance for bindingpatterns and social communication ingeneral (Schore 1994). These findings alsosupport the idea, developed elsewhere (Ci-ompi 1991a), that the hypothesis of anobligatory "emotional imprint" in cogni-tive structures would furnish an explana-tion of practically all affective-cognitiveinteractions postulated by affect logic.Among these are the systematic organiz-ing and integrating effects of emotions oncognitions, presented in the next para-

graph. In addition, as cognitive informa-tion processing and affective componentsbecome increasingly observable (e.g. byneuro-imaging or by spectralelectroence-phalographic methods – see below), thefollowing seven hypotheses of increasingspecificity may be proposed for furtherneurobiological and neuropsychologicalresearch (Ciompi 1991a).

• affective processes are always coupledwith cognitive processes, and vice versa

• different affective states correspond todifferent functional states of the brain,characterised by different modes of in-formation processing

• specific affects tend to be related to spe-cific cognitive contents, and vice versa,forming functional affective-cognitivesystems

• affects and their respective neurophysi-ological equivalents are involved in thestorage of cognitive information

• affects and their respective neurophysi-ological equivalents are involved in themobilization of stored cognitive infor-mation

• in specific affective states, specific cog-nitive contents tend to be mobilized

• affects and their respective neurophysi-ological equivalents are capable of in-tegrating extended neuronal systemsinto operational entities which regulatecontext-specific feelings, thoughts, andbehaviour.

Affect-logic, furthermore, postulatesthat affects have not only major energiz-ing, that is, motivating and mobilizing, ef-fects on cognitions, as claimed by Piaget(1981) and other authors, but also funda-mental organizing and integrating func-tions mediated through, at least, the fol-lowing five mechanisms (Ciompi 1989,1991a; quite similar theses have recentlybeen advanced by Izard 1993b).

Firstly, the focus of attention is contin-uously conditioned by specific emotionalstates. These have a decisive influence onselection and linkage of cognitive stimuli.Affective-specific types of thinking and


LUC CIOMPI

"logic" in the above mentioned sense aretherefore generated by different emo-tional states. In addition to conventionalforms of logic, which are linked to an aver-age state of relaxation, there also exists aspecific "fear-logic", "anger-logic", "sad-ness-logic", "happiness-logic", etc.

Secondly, storage and remobilization ofcognitive material is state-dependent forthe same reasons. This is already obvious(and largely exploited in advertising) ineveryday experience. Cognitive informa-tion without a specific emotional connota-tion is hardly noticed nor stored, andstate-specific memories are remobilized incorresponding moods. State-dependentlearning and memory has actually beendetected by spectral electroencephalo-graphic research showing, for example,significantly different types of informa-tion processing in the state of wake, sleep,dream, psychosis, trance, and drug-induced states (Koukkou et al. 1983,1986). Five different global cerebralstates, corresponding to five so-called ba-sic emotions (interest, fear, aggressivity,sadness, and joy), have been made out bythe same method (Machleidt et al. 1989;Machleidt 1992). Affect-specific memori-zation with integrative functions of af-fects has also been demonstrated by ex-perimental work with drug-induced orhypnosis-induced emotions. Cognitivelyvery heterogenous events scattered overthe whole life, but characterized by com-mon affective connotations (such asshame, rage, or pleasure) were remem-bered "en bloc" in corresponding emo-tional states (Grof 1975).

Thirdly, an affect-specific cognitive hi-erarchy is generated by activating affect-congruent cognitions and suppressingnon-specific ones. In a fearful situationcaused by a fire, for instance, all other cog-nitive stimuli and preoccupations, exceptthose directed on salvation, are elimi-nated. It is obvious that this mechanismhas a high survival value. More subtlemechanisms of the same type are, how-ever, also at work in less dramatic situa-tions. Even in scientific work, for in-stance, focalization of attention, as well as

mobilization and storage of memory mate-rial, are continually directed and condi-tioned by specific underlying states withclear emotional connotations, e.g. inter-est, ambition, or competition. In all kindsof defense mechanisms in the psychoana-lytic sense, too, affect specific organ-izational effects (selection, repression,negation, projection, particular ways ofconnecting cognitions, etc.) are at work.

Fourth, coherence and continuity ofcognitive experience are created, bothcross-sectionally (synchronically) andover time (diachronically), by connectingcognitive material having common affec-tive qualities. This mechanism, too, hashigh survival value, because it increasesthe probability of activating context-appropriate cognitions and behaviors, andeliminating inappropriate ones.

Fifth, emotional factors also play an im-portant role in reorganizing cognitive ma-terial on higher levels of abstraction, ac-cording to the concept of affect logic. InPiaget's (1977a, b) phenomenon of "major-izing equilibration," as he calls this pro-cess, it is obvious (although neglected byPiaget himself) that unpleasant feelingscaused by contradictions or inconsistenc-ies furnish the needed energy for lookingfor new solutions (a term with clear emo-tional connotations) which, when found,are immediately linked with pleasant feel-ings. More adequate (easier going, moreeconomical) thinking is pleasant becauseit is tension-reducing. Eventually, differ-ent cognitive elements characterized bysimilar pleasant feelings are linked to-gether, and combined into cognitive struc-tures of progressively higher orders ofabstraction (e.g. a new sequence of reason-ing, a new theory, or overall hypothesis).

Thus, common pleasant and unpleasantfeelings literally guide and connect rele-vant cognitive elements and disconnect ir-relevant ones, and these initially intenseand quite conscious feelings (which arestored together with the correspondingcognitions) will eventually continue tomanifest themselves in what Freud hascalled "pleasure of function"– an oftenhardly conscious positive mood which ac-



companies all easy going mental (and alsopsycho-motor) activities. On the otherhand, strongly unpleasant feelings (anger,aggressiveness, sadness, or fear) are im-mediately activated when automatizedcognitive paradigm are suddenly ques-tioned and disturbed by contradictory evi-dence.

All these affective-cognitive interac-tions may be mutually reinforcing, i.e. cir-cular. They are by no means observedonly on the individual level, but also onthe collective level. Affects are highly con-tagious, and thus create common globalpatterns of feeling-thinking-behaving incouples, groups, and even in whole na-tions. Extreme examples are collectivehysteria, panic, aggressiveness, or enthu-siasm. Goal-directed common actions with-out common feelings are practicallyimpossible, and a common emotional "tun-ing" is the most important preconditionfor cognitively successful communication.Affects thus create coherence and conti-nuity of cognitive experience, not only onthe individual level, but also on the sociallevel. Collective storage and mobilizationof mnemonic material is also highly influ-enced by basic emotions, as demonstratedby the reactivation of emotionally loadedcollective memories (e.g. of injustices ortriumphs) by nationalistic groups in ap-propriate emotional states. Both on the in-dividual and on the social level, affectshave hence very similar mobilizing, ener-gizing, organizing, and integrating effectson cognitive material. A somewhat simi-lar thesis has already been advanced byCollins (1981).

PSYCHOPATHOLOGIC IMPLICATIONS

Affect-logic has implications in severaldomains of psychopathology. Only thoseconcerning schizophrenia shall be high-lighted here. They include, mainly, the fol-lowing four domains. Firstly, affect-logicleads to a psycho-socio-biologically integ-rative model of long-term evolution ofschizophrenia in three phases which iscentered on a modified version of the

vulnerability hypothesis. Secondly, itdeepens the understanding of psycho-pathologic core-phenomena such as am-bivalence, incoherence, or emotional flat-tening. Thirdly, it generates new hypoth-eses concerning the role of nonlinear dy-namics in short-term and long-term evolu-tion of the illness. And finally, it leads toinnovative therapeutic approaches.

The psycho-socio-biological model oflong-term evolution of schizophrenia inthree phases (Ciompi 1982/1988a, 1988b)(cf. Fig. 1) integrates basic notions of af-fect logic (especially the concept of inte-grated feeling-thinking-behaving programs,generated through experience, but alsoaffected by genetic and other biologicalfactors, as basic "building-blocks" of thepsyche) with essential findings of the re-search in schizophrenia, especially withthe discovery of a great diversity oflong-term courses by recent longitudinalstudies (among them our own), and of nu-merous biological, psychosocial, and ther-apeutic or rehabilitative factors which areinfluencing these courses (see below).

During a first premorbid phase, whichlasts from conception until the outbreakof psychosis, interacting biological andpsychosocial factors known for increasingthe statistical risk of psychosis (heredity,perinatal traumata – cf. Gottesman andShields 1978; Kringlen 1986; Shapiro1993; severe developmental discontinu-ities – cf. Mednick, Schulsinger, andSchulsinger 1975; Parnas, Teasdale, andSchulsinger 1985; confusing communica-tion patterns or other family-related fac-tors – see Singer et al. 1978; Tienari et al.1985) create a specific vulnerability(Zubin and Spring 1977; Ciompi 1982/1988; Nuechterlein and Dawson 1984). Byneural plasticity, all these influences arebiologically encoded in the complex hier-archy of feeling-thinking-behaving pro-grams mentioned above. Biologically root-ed neuropsychological deficiencies, as wellas severe interpersonal-relational discon-tinuities and conflicting or confusing com-munications, obviously result in a lack ofclarity and operational stability/flexibil-ity – and hence in reduced functional per-


LUC CIOMPI

Biologicalinfluences

Psychosocialinfluences

Phase 1

premorbid vulnerability(Information processing disorder)

Phase 2

Phase 3

1

severe chronicityresidual states

complete remission

Figure 1Three-phase-model of schizophrenia (Ciompi 1982/1988)

formances –in important affective-cog-nitive connections, such as those linkingspecific affects to parental images andself-image (object-representations andself-representations in the psychoanalyti-cal sense), to relevant peer-images, or tothe representations of important environ-ments, activities, and technical objects.As will be further discussed below, themain characteristic of the schizophreno-genic vulnerability may therefore consistof a particular lability in affective-cogni-tive connections, which crucially reducesinformation processing capacity, or stresstolerance, with particularly negative con-sequences in the vital domains mentionedabove.

During the second phase, which corre-

sponds to acute psychotic decompensa-tion, increasing emotional tensions cre-ated by additional non-specific biologicaland/or psychosocial stressors (e.g. hor-monal changings, drug abuse, or leavinghome, mating, child-birth, etc.) graduallyovertax this vulnerable coping system.At a critical point of tension (which corre-sponds to a typical bifurcation in chaos-theoretical terms, see below), overall pat-terns of affective-cognitive functioningare, more or less suddenly, forced into aradically different global regime, (e.g. aparanoid, hebephreniform, or catatoni-form pattern) corresponding to psychosis.

During the third phase, long-term evo-lution – which is much more variable thantraditionally assumed – strikingly con-



gruent affective, cognitive, and behav-ioral changes toward restriction and othernegative symptoms take place (whichspeak again for the postulated affective-cognitive integration and will be analysedin the next paragraph). According to ourmodel, the great diversity of possible evo-lutions observed between recurrent acuterelapses, continuous evolutions, and mildor severe, stable or unstable residualstates, is mainly determined by variableinteractions between a great number of bi-ological and psychosocial factors whichhave been identified for influencing long-term course. Among these are interactinggenetic and environmental factors deter-mining premorbid social adaptation, per-sonality structure, and vulnerability (Tie-nari et al. 1985; Kringlen 1986; Ciompi etal. 1979; Ciompi 1980, 1988b; McGlashan19881. familial communication patterns(Singer et al. 1978) and "expressed emo-tions . ' (Leff et al. 1982; Kavanagh 1992),socio-economical and cultural conditions(WHO 1979; Sartorius et al. 1987), institu-tional milieu and care system (Wing andBrown 1970), and therapeutic and preven-tive interventions. The concept of affect-logic provides the theoretical frameworkfor integrating all these seemingly hetero-geneous influences under one common de-nominator: they all have their point ofimpact on the described feeling-thinking-behaving programs, and therefore theirneuronal substratum is modified, labi-lized. or stabilized by the various influenc-ing factors.

Turning now to specific psychopatho-logic manifestations, these organizingand integrating functions of affects oncognition contribute to explain the strik-ing parallelism which exists between af-fective and cognitive aspects in schizo-phrenic core-phenomena like ambivalence,incoherence, or emotional flattening. Inambivalence, for instance, both feelingsand thoughts (and behavior as well) be-come highly unstable and finally discon-tinuous. In chronic residual states charac-terized by negative symptoms such asretreat, apathy, and emotional flattening,both affectivity and cognition are, in con-

trast, highly restricted and leveled. Eventhese apparently stable states–whichmay be understood as biological and/orpsychological counterregulations againstthe painful lability of the acute phases–can, however, slowly change (intensify orvanish) in the long run. But recurrentacute reactivations show that an underly-ing emotional-cognitive lability and over-sensitivity remains present.

On the basis of these clinical observa-tions, and the notion of organizing and in-tegrating effects of underlying affectivestates, the hypothesis arises that the typi-cally schizophrenic thinking disorderscould be related to a primarily affectivedisorder, with secondary effects on cogni-tive functions, namely to the alreadymentioned lability, or inconsistency, of af-fective-cognitive connections in acute con-ditions, and a counterregulatory oversta-bility in chronic conditions. In otherwords, not only melancholia and mania,but schizophrenia as well, may actually bea basically affective rather than a cogni-tive disease. This idea is also supportedby recent EEG-research focused on therole of emotions in schizophrenia, whichshows the predominant role played by un-derlying conscious or unconscious anxiety(Machleidt, 1989, 1992), and by increasingevidence for anatomical and functional de-fects in the limbic and paralimbic areas ofschizophrenics (Bogerts 1985; Buchs-baum 1990; Shapiro 1993; Davis 1994).Additional clinical evidence, such as cog-nitive-emotional lability, parathymia, andincoherence, manifesting itself mainlyduring the initial phases of the illness,speaks for the same hypothesis. Already,Eugen Bleuler (1911) emphasized a partic-ular loosening of affective-cognitive con-nections in schizophrenia, and this phe-nomenon could well represent a centralelement of the still enigmatic schizophren-ogenic vulnerability. Simultaneously, spe-cific differences between mania, depres-sion, and schizophrenia thus becomeevident. In mania and melancholia, affec-tive-cognitive connections are not tooloose and unstable, but, on the contrary(at least temporarily), too rigid and unilat-


era! in opposite directions. In mania, allcognitive functions are rigidly connectedto euphoric affects, and in melancholia todepressed ones. Again, thinking and be-havior are also globally distorted in thesame direction.

Finally, the proposed notion of the ener-gizing, organizing, and integrating func-tions of affects on cognitions, and theirimportance in the generation of opera-tional affective-cognitive systems of ref-erence, leads to an innovative chaostheo-retical interpretation of the short-termand long-term dynamics of schizophrenia.Chaos theory (and also its more recent de-velopment, complexity theory) offers newexplanations for sudden nonlinear phasetransitions, irregular short-term andlong-term evolutions, and big effects trig-gered by minimal causes (the so called"butterfly-effects") appearing under criti-cal conditions in dynamic systems thatare driven far from equilibrium by a con-tinuous input of energy. At a criticalpoint, a globally changed pattern of en-ergy distribution may emerge (a new "at-tractor", or "dissipative structure" in thesense of Prigogine and Stengers 1983). Ifaffects, with their energizing and simulta-neously organizing and integrating ef-fects on cognitive components, are consid-ered as major energy vectors in mentaland neuronal systems, then psychotic pat-terns of functioning can be understood asglobally modified patterns of energy dis-tribution – that is, affect distribution andaffect organization – among available cog-nitions, appearing at critical bifurcationpoints under the influence of gradualovertaxation (Ciompi 1982/1988, 1991b,1996). Such phase transitions are fa-voured, according to the chaostheoreticalconcept of synergetics proposed by Ha-ken (1982, 1990), by critical modificationsof so-called control parameters (basic con-ditions). Clinically, as well as theoreti-cally, it seems very likely that unspecificemotional tensions (such as those createdin a vulnerable individual, e.g. by "highexpressed emotions", or by other psycho-social or biological stressors) function inmental systems as relevant control pa-rameters which, when modified to a criti-

uc c '01\1131

cal point, are capable of provoking a non-linear shift to psychosis. Furthermore, atthis unstable point of transition, formerlyperipherical cognitive elements (e.g. sub- a

liminal thoughts and perceptions, or occa- S

sional delusional phantasies) may beginto act as so-called order parameters (for-merly marginal structural elements which z

can suddenly become dominant) that aeventually "enslave" (as Haken calls it) theoverall dynamics of the evolving dynamicsystem.

Clinical phenomena at the beginning ofpsychotic decompensations actually showclose analogies to nonlinear processes, asdescribed by chaos theory. Particularlystriking is the sudden switching of theoverall feeling-thinking-behaving pat-terns toward a new global regime that wecall psychosis. The final switch to it mayoccur under the influence of a minimal butcritical input (e.g. a critical word, aglimpse, a colored spot, a particular idea),which eventually "enslaves" the wholefield of mental functioning. Rapid ("am-bivalent") changes between opposite waysof feeling, thinking, and behaving maycorrespond to typical so-called fluctua-tions, preceding bifurcations in chaosthe-oretical terms. Other phenomena support-ing a chaos-theoretical interpretation arethe unforseeable ("chaotic") dynamicalpatterns of short-term and long-term evo-lutions, reflecting psychotic exacerba-tions and remissions. Quite similar ideashave also been advanced by Globus et al.(1993), closely similar evolutionary dy-namics to our observed long-term evolu-tion have been produced by an appropriatecomputer-model (Schiepek and Schoppek1992), and the first empirical and mathe-matical evidence for typically chaotic dy-namics in psychotic evolutions has beendetected by our research group (Ambuhl,Diinki, and Ciompi 1992; Tschacher et al.1997; Ciompi 1996).

THERAPEUTIC CONSEQUENCES

Details on a major practical applicationof the proposed concepts, namely our now13-year-long pilot-project, "Soteria Berne,"


kFFECT LOGIC AND SCHIZOPHRENIA

nave already been presented at the lasttwo International Symposia on the Psy-chotherapy of Schizophrenia (Ciompi etal_ 1992b. 1993a). Therefore, only somesummarizing information concerning thisproject will be given here. One importantconsequence of the proposed hypothesesconcerning the fundamental organizingand integrating functions of affects oncognition is a new emphasis on the basicemotional atmosphere of therapeutic set-tings. interpersonal approaches, andtreatment methods in general. Partly rep-licating — and also partly modifying— afirst Soteria-House experience realized onocher conceptual bases by Mosher andMean 11978) in San Francisco, we were ac-tually able to show that, in a therapeuticsetting and style of care especially fo-cused on anxiety reduction, emotionalreiaxation. interpersonal support, andprotection from affective-cognitive over-stimulation, psychotic symptoms can dis-appear within weeks, with no or only mini-mal neuroleptic medication. Comparabletwo-year results concerning psychopath-ology. relapse rate, working, and housingsituation were obtained with three to fivetimes lower global doses of neurolepticsthan in a carefully matched control popu-lation treated with conventional methodsCiompi et al. 1993b). The significantlymore relaxed and supportive emotional at-mosphere of the therapeutic environmentand style las measured by a German ver-sion of the Ward Atmosphere Scale byMoos. 1974) was interpreted as a crucialcontrol parameter in the above mentionedsense. favouring return to normal cogni-tive functioning and respectively decreas-ing the probability of psychotic function-ing in vulnerable individuals, thanks tothe favorable organizing and integratingeffects of feelings of confidence, accep-tance, and security which were systemati-cally built up and stabilized over weeksand months.

The similarity of the therapeutic effectsof neuroleptics and of a therapeutic set-ting especially designed for emotional re-laxation is an additional argument infavor of the hypothesis, based on the con-cept of affect logic, that schizophrenia

may basically be an affective disease of aparticular kind, and that the primary im-pact of neuroleptics may be on the emo-tion-regulating limbic-paralimbic system,with only secondary effects on cognitivefunctioning. This interpretation is furthersupported by a controlled study by Hodeland Brenner (1996), where the basic emo-tional atmosphere turned out to be moreimportant for improving the cognitivefunctions of schizophrenics than the spe-cific cognitive training methods.

CONCLUSIONS

In summary, in affect-logic theory, thepsyche is understood as a complex hierar-chy of functionally integrated affective-cognitive systems of reference (or feeling-thinking-behaving programs), generatedthrough action, which store in their struc-ture relevant past experiences — amongthem important interpersonal relations.Their neurophysiological substratum arecorresponding neuronal pathways, mod-eled by neuronal plasticity. These "pro-grams" function as a matrix for all furtherinformation processing and coping. Si-multaneously, they are the essential pointof impact for both biological and environ-mental influences of all kind. As affectsplay a primary role in mobilizing, organiz-ing, and integrating cognitive functions,both in normal and in pathologic condi-tions, schizophrenic thought disorganiza-tion, in particular, could be a secondaryeffect of primary affective (limbic, para-limbic, or limbo-frontal) disorders and ten-sions. The emotional quality of therapeu-tic settings and proceedings may thereforebe an essential, but so far rather ne-glected, therapeutic variable.

By establishing a theoretical link be-tween a wide range of psychopathologic,psychodynamic, and neurobiologic phe-nomena relevant for schizophrenia whichhave not been sufficiently connected sofar, the concept of affect logic leads to aninteractive psycho-socio-biological evolu-tionary model of schizophrenia in threephases, to a new interpretation of the cen-tral but still enigmatic notion of schizo-

tty

nr-h.te

,fVS

V

7

tI


phrenic vulnerability, and to innovativetherapeutic approaches, with special em-phasis on the emotional atmosphere oftherapeutic settings and methods. Fur-thermore, it generates a chaos-theoreticalhypothesis of the underlying evolutionarydynamics of the illness that conduces to anew dynamic understanding of pathoge-netic processes with interesting therapeu-tic (and also preventive) consequences. A

LUC CIOMPI

number of testable hypotheses concern-ing its basic assumptions have been for-mulated above (Ciompi 1991a).

We conclude, finally, that the conceptsof affect logic seem capable of furnishinga useful theoretical framework for furtherresearch, both in affective-cognitive inter-actions, and in the interactions betweenbiological, psychological, and social vari-ables in schizophrenia.

REFERENCES

AMBUHL, B., DUNKI, R. M., and CIOMPI, L. Dynami-cal systems and the development of schizophrenicsymptoms. In: W. Tschacher, G. Schiepek, and E.J. Brunner, eds. Self-Organization and ClinicalPsychology. Springer, Series in Synergetics, 1992,pp. 195-203.

BERTALANFFY, L. An outline of general systemstheory. British Journal of Philosophic Science(1950) 1:134-165.

BLEULER, E. Dementia praecox oder die Gruppe derSchizophrenien. In: G. Aschaffenburg, ed., Hand-buch der Psychiatrie, specieller Teil, 4. Abt. 1.Ha lfte., Deuticke, Leibzig 1911.

BLEULER, M. The Schizophrenic Disorders. Long-Term Patient and Family Studies. Yale UniversityPress, 1978.

BOGERTS, B. Schizophrenien als Erkrankungen deslimbischen Systems. In: G. Huber, ed., Basissta-dien endogener Psychosen und das Borderline-Problem. Schattauer, Stuttgart 1985.

BUCHSBAUM, M. S. Frontal lobes, basal ganglia,temporal lobes —three sites for schizophrenia?Schizophrenia Bulletin (1990) 16:377-378.

CHANGEUX, J. P., KONISHI, M. The Neuronal andMolecular Bases of Learning. Wiley, 1987.

CHAPMAN, L. J., and CHAPMAN, J. P. DisorderedThought in Schizophrenia. Appleton-Century-Crofts, 1973.

CIOMPI, L. Catamnestic long-term studies on thecourse of life of schizophrenics. Schizophrenia Bul-letin (1980) 6:606-618.

CIOMPI, L. Affektlogik. Ueber die Struktur der Psy-che und ihre Entwicklung. EM Beitrag zur Schizo-phrenieforschung. Klett-Cotta, 1982/The Psycheand Schizophrenia. The Bond Between Affect andLogic. Harvard University Press, 1988a.

CIOMPI, L. Zur Integration von Fuhlen und Denkenim Licht der 'Affektlogik". Die Psyche als Teileines autopoietischen Systems. In: Kisker, K. P.,Lauter, H., Meyer, J.-E., Muller, C., Stromgren,E., eds., Psychiatrie der Gegenwart, Bd 1,Springer, Berlin-Heidelberg-New York-Tokyo1986, pp. 373-410.

CIOMPI, L. Learning from outcome studies. Towarda comprehensive biological-psychological under-standing of schizophrenia. Schizophrenia Re-search (1988b) 1:373-384.

CIOMPI, L. The dynamics of complex biological-

psychosocial systems. Four fundamental psycho-biological mediators in the long-term evolution ofschizophrenia. British Journal of Psychiatry(1989) 155:15-21.

CIOMPI, L. Affects as central organising and integ-rating factors. A new psychosocial/biologicalmodel of the psyche. British Journal of Psychiatry(1991a) 159:97-105.

CIOMPI, L. Affect logic and schizophrenia. In C. Eg-gers, ed., Schizophrenia and youth. Springer, 1991b.

CIOMPI, L. Affect logic: an integrative model of thepsyche and its relations to schizophrenia. BritishJournal of Psychiatry (1994) 164:51-55.

CIOMPI, L. Non-linear dynamics of complex systems:The chaos-theoretical approach to schizophrenia. InH. D. Brenner, W. Boker, and R. Genner, eds., To-wards a Comprehensive Therapy of Schizophrenia.Hoegraeve & Huber, 1996, pp 18-31.

CIOMPI, L., DAUWALDER, H. P., AGUE, C. EM For-schungsprogramm zur Rehabilitation psychischKranker. III. Langsschnittuntersuchung zum Re-habilitationserfolg und zur Prognostik., Nerve-narzt (1979) 50:366-378.

CIOMPI, L., DAUWALDER, H. P., MAIER, CH., AEBI,W., TRUTSCH, K., KUPPER, Z., and RUTISHAUSER,CH. The pilot project "Soteria Berne". Clinical ex-periences and results. British Journal of Psychia-try (1992a) 161: 145-153.

CIOMPI, L., DAUWALDER, H. P., AEBI, E., TRUTSCH,K., and KUPPER, Z. A new approach of acuteschizophrenia. Further result of the pilot-project"Soteria Berne". In: A. Werbart and J. Cullberg,eds., Psychotherapy of Schizophrenia: Facilitatingand Obstructive Factors. Scandinavian Univer-sity Press, 1992b, pp. 95-109.

CIOMPI, L., MAIER, CH., DAUWALDER, H. P., andAEBI, E. An integrative biological-psychosocialevolutionary model of schizophrenia and its thera-peutic consequences: First results of the pilot proj-ect "Soteria Berne". In: G. Benedetti and P. M.Furlan, eds., Psychotherapy of Schizophrenia. Ho-grefe & Huber Publ., 1993a, pp. 319-333.

CIOMPI, L., KUPPER, Z., AEBI, E., DAUWALDER, H.P., HUBSCHMID, T., TRUTSCH, K., and RUTIS-HAUSER, CH. The pilot project "Soteria Berne" forthe treatment of acute schizophrenics. II. Resultsof a comparative prospective study over 2 years.Der Nervenarzt (1993b) 64:440-450.


1 AFFECT LOGIC AND SCHIZOPHRENIA

1-COLLINS, R. On the microfoundations of macrosoci-

ology. American Journal of Sociolology (1981) 86:984-1014.

DAvIS, M. The role of the amygdala in emotionalS learning. International Revue of Neurobiology

(1994) 36:225-266.DERRYBERRY, D., and TUCKER, D. M. Neural mech-r

anisms of emotion. Journal of Consulting and Clin-ical Psychology (1992) 60:329-338.

a ENGEL, G. L. The need for a new medical model: a chal-[- lenge for biomedicine. Science (1977) 196:129-136.

GAINOTTI, G. Features of emotional behaviour rele-vant to neurobiology and theories of emotions. In:G. Gainotti and C. Caltagirone, eds., Emotionsand the Dual Brain. Springer, 1989, pp. 9-27.

GLOBUS, G. G., and ARPAIA, J. P. Psychiatry andthe new dynamics. Biologic Psychiatry (1994) 35:352-364.

'.;CrITESMAN, J., and SHIELDS, J. A critical review ofV recent adoption, twin, and family studies on

schizophrenia: Behavioural genetics perspectives.Schizophrenia Bulletin (1978) 2:360-398.

GROF, S. Realms of the Human Inconscious. Viking,1975.

HAKEN, H. Evolution of Order and Chaos. Springer,1982.

HAKEN, H. Synergetics. An Introduction. Springer,1990.

HARACZ, J. L. A neuronal plasticity hypothesis ofschizophrenia. Neuroscience and Biobehavior Re-vue (1984) 8: 55-71.

HARDING, C. M., BROOKS, G. W., ASHIKAGA, T.,STRAUSS, J. S., and BREIER, A. The Vermont lon-gitudinal study of persons with severe mental ill-ness. I. Methodology, study sample, and overallstatus 32 years later. American Journal of Psychi-atry (1987a) 144:716-726.

HARDING, C. M., BROOKS, G. W., ASHIKAGA, T.,STRAUSS, J. S., and BREIER, A. The Vermont lon-gitudinal study of persons with severe mentalillness. II. Long-term outcome of subjects who ret-rospectively met DSM-III criteria for schizophre-nia American Journal of Psychiatry (1987b) 144:727-737.

HODEL, B., and BRENNER, H. D. A new develop-ment in integrated psychological therapy forschizophrenic patients (IPT): First results of emo-tional management training. In: Brenner, H.-D.,Boker, W., Genner, R. eds., Toward a comprehen-sive therapy of schizophrenia. Hogrefe & Huber,1977. pp. 118-134.

HUBER. G., GROSS, G., SCHUTTLER, R. Longitudi-nal studies of schizophrenic patients. Schizophre-ma Bulletin (1980) 6:592-605.

IZARD, C. E. Human emotions. Plenum Press, 1977.IZARD, C. E. Four systems for emotion activation:

cognitive and non-cognitive processes. Psycholog-ical Revue (1993a) 100:68-90.

IZARD. C. E. Organizational and motivational func-tions of discrete emotions. In M. Lewis and J. Hav-iland, eds.. Handbook of Emotion. Guilford Press,11993b). pp. 631-641.

JAcossoN, E. The Self and the Object World. Ho-garth Press. 1965.

KAVANAGH, D. J. Recent developments in ex-pressed emotion and schizophrenia. British Jour-nal of Psychiatry (1992) 160:601-620.

KERNBERG, 0. Object Relations Theory and ClinicalPsychoanalysis. Jason Aronson, 1976.

KERNBERG, O. Internal World and External Reality.Jason Aronson, 1980.

KERNBERG, 0. New perspectives in psychoanalyticaffect theory. In: Emotion. Theory, Research, andExperience. Academic Press, 1990, pp. 115-131.

KOUKKOU, M., and LEHMANN, D. Dreaming: thefunctional state-shift hypothesis. A neuropsycho-physiological mode. British Journal of Psychiatry(1983) 142:221-231.

Kouxxou, M., and MANSKE, W. Functional statesof the brain and schizophrenic states of behaviour.In: C. Shagass, R. C. Josiassen, and R. A. Roemer,eds., Brain Electrical Potentials and Psychopath-ology. Elsevier Science Publishing, 1986, pp. 91-114.

KRAEPELIN, E. Lehrbuch der Psychiatrie. 5.Auflage, Barth, Leipzig, 1896.

KRINGLEN, E. Genetic studies of schizophrenia. In:G. D. Burrows, T. Norman, and G. Rubinstein,eds., Handbook of Studies on Schizophrenia. PartI: Epidemiology, Aetiology and Clinical Features.Elsevier, 1986, pp. 45-49.

LAZARUS, R. S. Thoughts on the relations betweenemotion and cognition. The American Psycholo-gist (1982) 37:1019-1924.

LAZARUS, R. S. Cognition and motivation in emo-tion. The American Psychologist (1991) 46:352-367.

LEDOUX, J. E. Cognitive-emotional interaction inthe brain. Cognition and Emotion (1989) 3:267-289.

LEDoux, J. E. Emotional networks in the brain. In:Lewis, M., and Haviland, J. M., eds., Handbook ofemotions. Guilford Press, 1993,109-118.

LEFF, J. P., KUIPERS, L., BERKOWITZ, R., EBER-LEIN-VRIES, R., and STURGEON, D. A controlledtrial of social intervention in the families of schizo-phrenic patients. British Journal of Psychiatry(1982) 141:121-134.

LEVENTHAL, H., and SCHERER, K. The relationshipof emotion to cognition: A functional approach toa semantic controversy. Cognition and Emotion(1987) 1:3-28.

LEVI, L. Stress and Distress in Response to Psycho-social Stimuli. Humana, 1973.

MACHLEIDT, W. Typology of functional psychosis -A new model on basic emotions. In F. P. Ferrero,A. E. Haynal, and N. Sartorius, eds., Schizophre-nia and Affective Psychoses. Nosology in Contem-porary Psychiatry. John Libbey CIC, 1992, pp.97-104.

MACHLEIDT, W., GUTJAHR, L., and MUGEE, A.Grundgefuhle. Phanomenologie PsychodynamikEEG-Spektralanalytik. Springer, 1989.

MAHLER, M. S. On Human Symbiosis and the Vicis-situdes of Individuation. Vol I: Infantile Psycho-sis. International Universities Press, 1968.

MARNEROS, A., DEISTER, A., ROHDE, A., JUNE-MANN, H., and FIMMERS, R. Long-term course of


LUC CIOMPI

schizoaffective disorders. Psychiatric and Neuro-logic Sciences (1988) 237:264-290.

MCGLASHAN, T. H. A selective review of recentNorth American long-term followup studies ofschizophrenia. Schizophrenia Bulletin (1988) 14:515-542.

MCNEAL, P. Cerebral evolution of emotion. In M.Levine and J. M. Haviland, eds., Handbook ofEmotions. Guilford Press, 1993, pp. 67-83.

MEDNICK, S. A., SCHULSINGER, F., and SCHUL-SINGER, H. Schizophrenia in children of schizo-phrenic mothers. In W. Davis, ed., Childhood Per-sonality and Psychopathology. Current Topics.Wiley, 1975.

MILLER, J. G. General systems theory. In A. M.Freedman, H. J. Kaplan and B. J. Sadock, eds.,Comprehensive Textbook of Psychiatry. William& Wilkins, 1975.

Moos, R. Evaluating Treatment Environments. ASocial Exological Approach. Wiley, 1974.

MOSHER, L. R., and MENN, A. J. Community resi-dential treatment for schizophrenia: two-year fol-low-up data. Hospital and Community Psychiatry(1978) 29:715-723.

NUECHTERLEIN, K. H., and DAWSON, M. E. A heuris-tic vulnerability/stress model of schizophrenic epi-sodes. Schizophrenia Bulletin (1984) 10:300-312.

PANKSEPP, J. Toward a general psychobiologicaltheory of emotions. Behavioral and Brain Sciences(1982) 5:407-467.

PANKSEPP, J. Affective neuroscience: A conceptualframework for the neurobiological study of emo-tions. In K. T. Strongman, ed., International Re-view of Studies on Emotion, Vol. I., John Wiley &Sons, 1991, pp. 59-99.

PARNAS, J., TEASDALE, T. W., and SCHUI,SINGER,F. Institutional rearing and diagnostic outcome inchildren of schizophrenic mothers: A prospectivehigh risk study. Archives of General Psychiatry(1985) 42:762-769.

PIAGET, J. The Development of Thought: Equilibra-tion of Cognitive Structure. Viking Press, 1977a.

PIAGET, J. The Essential Piaget. H. von Gruber andJ. Voneche, eds., Basic Books, 1977b.

PIAGET, J. Intelligence and affectivity. Their rela-tionship during child development. In T. A. Brownand C. E. Kaegi, eds., Annual Review Monograph.University of California Press, 1981.

PLOOG, D. Human neuroethology of emotion. Prog-ress of Neurology, Psychopharmacology, and Bio-logical Psychiatry (1989) 13:15-22.

PLOOG, D. Ethological foundation of biological psy-chiatry. In H. M. Emrich and M. Wiegand, eds.,Integrative Biological Psychiatry. Springer, 1992,pp. 3-35.

PRIGOGINE, I., and STENGERS, I. Order Out ofChaos. Heinemann, 1983.

RourrENBERG, A. The reward system of the brain.Scientific American (1978) 239:122-131.

SARTORIUS, N., JABLENSKY, A., ERNBERG, G.,

LEFF, J., KORTEN, A., and GULBINAT, W. Courseof schizophrenia in different countries: Some re-sults of a WHO international comparative 5-yearfollow-study. In: H. Hafner, W. F. Gattaz and W.Janzarik, eds., Search for the Causes of Schizo-phrenia. Springer, 1987, pp. 107-113.

SELYE, H. The general adaptation syndrome and thediseases of adaptation. Journal of Clinical Endocri-nology (1946) 6:117.

SCHIEPEK, G., and SCHOPPEK, W. Synergetik in derPsychiatrie: Simulation schizophrener Verlaufeauf der Grundlage nicht-linearer Differenzenglei-chungen. Systeme (1992) 6:22-57.

SCHORE, A. N. Affect Regulation and the Origin ofthe Self. The Neurobiology of Emotional Develop-ment. Lawrence Erlbaum Associates, Publ, 1994.

SHAPIRO, R. M. Regional neuropathology in schizo-phrenia. Where are we? Where are we going?Schizophrenia Research (1993) 10:187-239.

SINGER, M. T., WYNNE, L. C., and TOOHEY, B. A.Communication disorders in the families of schizo-phrenics. In L. C. Wynne, R. L. Cromwell, andMatthysse, S., eds., The Nature of Schizophrenia.Wiley, 1978.

TIENARI, P., SORRI, A., LATHI, I., NAURALA, M.,WAHLBERG, K. E., POHOJOLA, J., and MORING, J.Interaction of genetic and psychosocial factors inschizophrenia. Acta Psychiatrica Scandinavica(1985) 71:19-30.

TSCHACHER, W., SCHIEPEK, G., and BRUNNER, E.J. Self-Organization and Clinical Psychology. Em-pirical Approaches to Synergetics in Psychology.Springer, 1992.

TSCHACHER, W., SCHEIER, CHR., and HASHIMOTO,Y. Dynamical analysis of schizophrenia courses.Biological Psychiatry. (1997) 41:428-437.

TSUANG, M. T., WOOLSON, R. F., and FLEMING, J.A. Long-term outcome of major psychoses: I.Schizophrenia and affective disorders comparedwith psychiatrically symptom-free surgical condi-tions. Archives of General Psychiatry (1979) 39:1295-1301.

WHO. Schizophrenia: An International Follow-UpStudy. Wiley, 1979.

WING, J. K. Impairments in schizophrenia. In R.Wirt, G. Winokur, and M. Roff, eds., Life HistoryResearch in Psychopathology, Vol IV. Universityof Minnesota Press, 1975.

WING, J. K., and BROWN, G. W. Institutionalismand Schizophrenia. Cambridge University Press,1970.

ZAJONC, R. B. Feeling and thinking: preferencesneed no inferences. The American Psychologist(1980) 35:151-175.

ZAJONC, R. B. On the primacy of affect. The Ameri-can Psychologist (1984) 39: 117-124.

ZUBIN, J., and SPRING, B. Vulnerability: A new viewof schizophrenia. Journal of Abnormal Psychology(1977) 86:103-123.


the concept of affect logic: an integrative psycho...

Documents