Sezione Medicina

da Leadership Medica n. 7 del 2000

If we compare the brain to computer hardware, the states of consciousness represent its operating programs. These are no more than patterns for the processing of data, and can only work if they are compatible with a basic language which, in turn, is a code capable of organising the data supplied by the individual programs. Within the structure of consciousness, the basic language can be viewed as the ancestral memory, holding remembrances of the individual sensations or of the single basic operating schemes, based on which it has been possible to learn the language and build an "interior model of the physical world".

Although approximate, and therefore inaccurate, as are all the technological metaphors which attempt to describe biological structures, nevertheless this comparison is certainly useful to understand a subject, that is consciousness, which in the last fifty years has forcefully imposed itself on the attention of neurobiologists.

This interest can be said to have began in the forties, when Albert Hofmann, in the Roche laboratories, in Switzerland, discovered and synthesized the lysergic acid diethylamide, which subsequently became very well known by the acronym LSD. Till then, consciousness had only been a field of philosophical speculation and a subject of little interest for psychology.

LSD suddenly disclosed extraordinary connections between the neuronal hardware and the mental software, thus suggesting that consciousness is somehow a product of the activity of neurons and of chemical relations set up among them. The neuroscientific importance of consciousness, of its structure and of its modified states, had already been amply perceived during the last century by the Salpetrière clinicians, by the school of Jean Marie Charcot, by the founder of psychoanalysis, Sigmund Freud, by a number of experimental psychologists like William James and, above all, by Pierre Janet.

Somehow, with the success and the diffusion of the psychoanalytic theory, it appeared that the unconscious was more significant than consciousness, and the latter subject faded into the background. Undoubtedly, the initial interest arose because Charcot and all his followers (including Freud) used and practised hypnosis, a condition which today could be defined as the chief of many modified states of consciousness ("modified" sounds much better than "altered", as one often reads; and besides, the English word "altered" is the exact translation of the Italian word "modificati"); this is why they had been in some way forced to direct their attention to the structure of consciousness in order to understand the modifications experienced in a state of trance.

Anyhow Charcot was a clinician, essentially interested in the pathogenesis of diseases, and although he was able to reproduce the symptoms of a neurosis by putting his patients into a state of trance, he was never able to demonstrate the causal connections between the modifications of the state of consciousness and the pathogenesis of neuroses. However, the great interest for this aspect was shared by all those who attended his famous "Tuesday lectures" and, amongst all, the person who succeeded in constructing a satisfactory aetiological theory of neuroses was Freud, with his concept of "pathogenic unconscious" which, although weakened nowadays, has not yet been replaced by a more valid theory. Even though they spent the rest of their carriers working on the ideas of their master, the other followers of Charcot have either been forgotten or are now remembered for other merits.

Babinski, for instance, is known for his "sign" (extension of the hallux as a reaction to friction on the side of the foot) rather than for the fact that he (rightly) supported the idea that hysteric neurosis is a psychiatric disorder and not a neurological syndrome (as Charcot had claimed for years).

Bourneville is not known to many people even though he had attempted to demonstrate that hypnotic trance represents an interpretation model for many psychosocial manifestations, such as mediumistic states, the behaviour of crowds or even mystic ecstasies. Placed halfway as regards popularity, is Pierre Janet, remembered almost exclusively for his book "From Anguish to Ecstasy", which is still today a basic reference text for all those who have an interest in religious psychology; however this author certainly deserves today an overall revaluation, since he was the only one who passionately and enthusiastically continued to investigate consciousness and trance, leaving behind a significant bulk of writings and ideas which are now becoming topical again. For instance, it is to this aristocratic and reserved thinker that we owe the term "dissociation", an expression which is misused, but has deeply entered the psychiatric language. Janet used the word "désagregation" to indicate that mental phenomenon, both common and perfectly physiological, which enables us to do two things at the same time: while we are driving a car we can at the same time be engaged in conversation with a passenger; while we are speaking on the telephone we can at the same time doodle on a piece of paper; we can walk along the street while reading a book and our "automatic pilot" enables us to reach our destination without having to devote our whole attention to the task.

Janet believed this capacity of our mind to be the basic foundation of trance and now, after over a century, many experts share this opinion. On the other hand, the term "dèsagregation", corresponding to the English word "dissociation", has become a synonym for serious pathology, giving rise to continuous misunderstandings and communication problems. Janet also devised the concept of "mental automatism" and of "narrowing the field of consciousness", which have also been accepted in psychiatrics even though, again, they have been misused. The point is that Janet was a "physiologist" of consciousness rather than a psychopathologist, and therefore, in view of the interests of culture in his days, he was almost doomed to be forgotten. Furthermore, in the latter part of his life, he developed a greater interest for the philosophic aspects of consciousness, thus giving up the physiological and clinical side and entering a frontier territory which was only of marginal interest to clinicians and psychologists.

In fact, after the triumph of the psychoanalytical theory, with the importance it attached to dreams, the attention of neurophysiology and psychology focussed on the physiology of sleep and dreaming and, on these themes, extremely important work was started which was to lead to milestone discoveries, but was also to definitely diverge from the idea that consciousness and its altered states are, even if only functionally, related to certain disorders, or that hypnosis can be of use in psychotherapy.

The pivotal concept on which many neuroscientists have based (and continue to base) their work is that consciousness is produced by the activity of neurons and studies on sleep and dreaming seem to have demonstrated this very fact: when asleep or dreaming, the brain functions in a different way than when it is awake. Broadly speaking, this was the situation in the 1950's, at the beginning of the so-called "psychedelic era", when the high propagation of psychoactive substances started a pressing interest for chemically induced modified states of consciousness. A number of neurobiologists became enthusiastic about the idea of having at their disposal "chemical scalpels" with which they could demonstrate that consciousness has also a strong neurochemical basis.

In fact, it was (and it is) extremely surprising that a few hundred millionths of a gram, a nearly homeopathic dose of LSD, is able to completely disrupt the operating program of normal consciousness; and this discovery not only strengthened the idea that consciousness is a "secretion" of the neurons, but it seemed also to indicate that it is possible to study the neurobiology of consciousness and that neurochemistry could be the most direct way to the understanding of the pathogenesis of many psychiatric disorders. The international prohibition, requested by the United States government and undersigned by all the western governments, against the production and experimentation of the so-called psycho-dyslectic drugs, interrupted this kind of research and obliged neurobiologists to study consciousness by taking different paths and exploring other approaches.

Meanwhile, we have witnessed a great change in scientific research, which is no longer carried out by small groups of researchers confined to small geographical areas, as it happened in the times of Charcot and Freud, but is widely practised in countless laboratories scattered all over the world. The result is that we now have much essential but incomplete information about consciousness; all these pieces of information remain confined within the field of research in which they were discovered, waiting to be put together and connected in a mosaic capable of giving them the coherence of a global image, that which in Anglo-Saxon scientific language is called a "model".

In neuropsychology, for example, the studies on the different functional roles of the two cerebral hemispheres have been absolutely fundamental, and they seem to indicate that wakeful consciousness actually consists of two coexistent and collaborating consciousnesses, even though one of them, the consciousness of the left hemisphere, has a leading role. This discovery should encourage neurophysiologists to find the real basis of the phenomenon of hemispheric dominance but so far the subject does not seem to have aroused the interest it deserves. This issue becomes far more urgent when considering the fortuitous observation, made on subjects whose two hemispheres have been surgically separated (that is they have undergone commisurotomy).

These patients claim that, after undergoing the operation, they no longer have dreams: electroencephalographic tests demonstrate that in the right hemisphere the regular alternation of the REM phases takes place, whereas such phases have disappeared in the left one. On the other hand, oneirologists (and therefore experimental psychology) have demonstrated that dream activity is not confined to the REM phase, but is fully present in every phase of sleep. In this manner they have given the psychoanalytic theory a shake-up and have, at the same time, strengthened the concept that the brain is basically a data processor (a computer) and that every state of consciousness is characterised by a specific operating program. Various other observations seemed to strengthen the concept that the three basic states of consciousness, wakefulness, sleep and dreaming, are mutually exclusive, in that one can either be awake or asleep or dreaming, while other discoveries have demonstrated that it is possible to retain a consciousness of wakefulness (self-consciousness) even while dreaming: one can dream knowing that it is a dream, a phenomenon known for a long time in parapsychology with the name of "lucid dream", but considered impossible by academic psychology. From a clinical point of view, the most significant progress has resulted from experimental research into hypnosis, which has been abundantly revalued.

Hypnosis has proved to be a very useful condition of consciousness for understanding many of its modified states. Trance was no longer to be used as a concept for understanding ailing consciousness, but rather for understanding physiological consciousness, as Janet had rightly perceived. During the state of trance there would seem to be a suspension of the dominance mechanism and contemporaneous operation of right and left hemisphere consciousnesses, that of wakefulness and that of dreaming, an absolutely physiological and natural functional condition, which can only be described with the term suggested by Janet, "dissociation", as opposed to its contrary, "association". The latter, on the other hand, could be proposed to describe the cooperation which characterises ordinary consciousness when the dominance mechanism is fully active. Based on this theory of the structure of trance, and based on the discovery that in a divided brain the left hemisphere can no longer dream, there has been the suggestion that the right hemisphere might be the seat of the Freudian unconscious.

This suggestion, on the one hand, at last provides the unconscious with an exact neuronal seat, but on the other hand considerably reappraises the very concept of the unconscious: it is no longer seen as an unreachable dimension, which is remote and uncontrollable, but rather as being easily accessible by inducing a state of trance, and influenceable by means of the rationality of the left hemisphere. In short we could carry on with a list of small discoveries or important observations which are gradually leading us towards a model of consciousness, but are, at this stage, still scattered and complete in themselves. Nevertheless a number of attempts have been made in order to link these scattered data together; these have resulted in at least two models which have influenced for a few years the activity of the experts.

The first model is the one suggested by Roland Fischer who called it "map of the states of consciousness" because it should be of use both to internal navigators and to researchers to find their way in the labyrinths of consciousness. According to Fischer, having accepted the brain/computer metaphor, the state of consciousness of relaxed wakefulness corresponds to an operating state where there is a substantial balance between amount/speed of data input in the central processing unit and the related processing speed. In the metaphor, the processing unit is the cerebral cortex, the input from senses (sight, hearing, touch etc.) corresponds to the keyboard and the soma represents the peripheral units on which the processing results appear (changes in the internal chemical state, changes in the neurovegetative parameters, actions etc.). The state of consciousness of relaxed wakefulness is considered the landmark and from this, by increasing or reducing the amount of sensorial data entered in the computer, or by increasing the processing speed, it is possible to obtain/induce some changes in the state of consciousness, which are somehow proportionate to the increase or reduction in the processor's workload.

So, when we get up in the morning, we proceed from relaxed wakefulness to a "daily routine" state of consciousness, which is characterised by a moderate increase in sensorial input and mental hustle and bustle (checking the coffeepot, seeing to personal hygiene, thinking of the first things to be done at work, etc.), which however is not too far from the input/processing equilibrium found in relaxed wakefulness. When we arrive at work, the amount of data received by the processor, as well as the related processing speed, undergo a marked increase and we enter a state of consciousness called "of sensitivity".

Later on, during the day, when our job demands maximum commitment, we enter a state of consciousness defined "of creativity", characterised by the speed required to process the data, that is by the impossibility of evaluating and processing them slowly. In these conditions, the processor/cortex operates at full capacity, which means that any further increase in the amount of data and in the processing speed would result in our entering a state of consciousness defined "anxiety". This progression, which is universally experienced, is also characterised by specific, subjective experiences, such as directing attention towards the outer environment and the need to control reality in an increasingly meticulous manner, which, in terms of dynamic psychology, means a progressive increase in the Ego functions and a decrease in the presence of the Self. In practice, even though the model offers a description of the physiology of consciousness, it describes at the same time the pathogenesis of anxiety. A number of clinicians, mainly from the Cognitivist school, would recognise in this model the foundation of their viewpoint: it is not the unconscious that causes illness, but thought. Nevertheless, this progression is reversible: it is sufficient to decrease the working speed of the processing unit or reduce the input from the senses (that is calm down and return to relaxed wakefulness).

If, on the other hand, the sensorial overload persists or increases, or the external reality demands a further increase in the data processing speed, one enters a state described by Fischer as "acute schizophrenic" or also as "hyperphrenic", in an attempt, by resorting to these inappropriate terms, to describe the operating chaos produced by the excessive functional demand on the brain/computer. But, while the causes of anxiety can be traced back to an exaggerated central activation, the comparison between the state of dissociation resulting from anxiety and the mental state of the main psychiatric pathology has given rise to an insurmountable misunderstanding.

This brings to the surface the serious ambiguity inherent in the use by Janet of the word "désagregation", which in the Anglo-Saxon medical culture has become a synonym for pathologic dissociation: if, rather than denominating this condition "acute schizophrenic state", Fischer had called it "state of dissociation", in line with Janet's interpretation of the term, the model would have retained its complete reliability, by simply describing the dissociation of trance and remaining within the boundaries of physiology. But, evidently, Fischer was not familiar with hypnosis and this inaccuracy seemed to many experts a mistake serious enough to completely invalidate the model. This model, beyond the dissociative state, provides for further changes in the state of consciousness.

According to Fischer, the reaching of the processor/cortex' operating limits causes the blockage of the computer/brain and originates a state of consciousness similar to catatonia (once again a term derived from pathology is used, thus generating further confusion, while, according to Fischer, the involuntary movements which can be induced in hypnotic trance perfectly correspond to the state in which the brain has fallen).

Entry in the catatonic state is associated with the loss of sensorial contacts with external reality: the brain segregates itself, becomes deaf, dumb, insensitive to touch and loses taste and smell. This is the condition of ecstasy, a state in which the speed of the processor goes back to normal, the operating program is that of wakefulness, but the data being processed are completely hallucinatory because they no longer come from the outside but originate directly from the inside of the central nervous system itself. Fischer built this model in an experimental manner, by studying the psychophysiological and neuropsychological effects of psychoactive substances, as well as data derived from experimental literature and ethnologic and anthropologic traditions (particularly with respect to ecstasy). Consequently, even if he made mistakes in terminology or was wrong in the conceptual interpretation of the phenomenology he observed, the objective data still remain and are repeatable as are all respectable experimental results. The concept of activation of the central processor, for instance, depicts an increase of the ergotrophic activity which, in turn, becomes a progressive activation of the orthosympathetic system. This hyperactivation is objectively recognizable in the corporeal periphery in terms of heart rate, muscle tone, arterial pressure, glycemia, perspiration etc.

The states described so far constitute an unavoidable progression, a continuum. Consequently one cannot pass into the next state without first experiencing the previous one. This sequence of states of central stimulation has been called "continuum of progressive ergotrophic activation" and gives a neurobiological explanation of a number of practices developed for millenniums by the various peoples in the world in order to modify their state of consciousness. Besides using psychotropic stimulant substances (for instance psilocybin), journeys towards excitement and ecstasy are provoked by tribal dances, overloading the brain/computer with intense auditory and cenesthetic stimulations, by the dervish dances in a circle, which overload the labyrinths, by the practices of the Bacchantes with wine, drums and disorderly dances, etc.

As a matter of fact, according to Fischer, Catholic mystic ecstasy is a state reached by means of stimulating techniques (probably through intense emotional activation) and should be considered as the final stage of the ergotrophic continuum. As opposed to this sequence of states of excitement, there is a continuum constituted by a series of states of consciousness caused by a progressive decrease in the sensorial input and in the processing speed of the elaborator/cortex. This is the "continuum of trophotropic activation", that is of progressive orthosympathetic activation. The states constituting it are those of deep relaxation, of meditation, of pre-sleep, of higher meditation and, finally, of "samadhi", that is Yoga ecstasy.

The steps of this progression have also been built experimentally by means of psychoactive substances (precisely lorazepam) but, fortunately, in describing the conditions of consciousness in each step, Fischer did not make use of psychiatric terminology, although it is easy to understand that the step of this progression corresponding to anxiety in the other continuum is depression. Also the sequence of states which can be reached by the progressive extinction of the sensorial contacts with the environment or the voluntary or involuntary decrease of the processing speed of the computer/cortex gives a neurobiological explanation for various other practices developed by mankind throughout the centuries to modify states of consciousness in order to reach ecstasy: these are the Yoga techniques and those of eastern cultures in general.

Surprisingly, missing from the list of the states of progressive sedation, is the condition of hypnotic trance which, in our culture, is considered a state of relaxation and is exploited, partially, exactly for this reason. In fact also (or above all) the practices of intense concentration or of progressive self-sedation easily lead to Janet's type of dissociation, as it is convincingly demonstrated by studies on sleep, that is on the hypnagogic state: every evening, when we are about to fall asleep, without realising, we all repeat the same actions performed by meditators or by a hypnotist while inducing a state of trance. We deviate our attention from the outside reality to the mental (impoverishing or abolishing the input from the senses) and we concentrate it on imagination or thoughts with such intensity as to completely lose contact with reality.

The hypnagogic state (which is one of the possible modified states of consciousness) only lasts a few minutes and, although we all find it very pleasant, it is not incisively recorded in the list of our interior experiences. In fact, if we artificially prolong it, a rather odd phenomenology takes place, in that we easily experience hallucinations and we are under the impression that our mind has somehow split into two. That is the time when the right hemisphere gives way to its twin and, although we are still unable to explain why hallucinations should take place, this phenomenology, in a fascinating way, recalls hypnotic trance and, once again, Janet's dissociation condition. In conclusion, it appears clear that the psychophysiologic operations we carry out in order to fall asleep, which are similar to those a hypnotist prompts us to do when inducing hypnotic trance, and also similar to those performed by a meditator, produce functional dissociation between the two cerebral hemispheres which can lead to sleep, prolongation of trance or ecstasy. The Fischer model is structured on neurophysiological, psychophysiological and psychopharmacological data and it therefore is a neurobiological model, very useful for studying the behaviour of the consciousness hardware, but not as enlightening as to the events taking place from a neuropsychological and psychological point of view.

An attempt to fill this theoretical void was the second model of consciousness and of the states of consciousness referred to above. This is Charles Tart's "systemic model", according to which consciousness should be viewed as a system of functions, each of which contributes to the configuration of structural sets which are its various modified states. In other words, each state resembles a cocktail in which the various "higher nervous functions" are represented in variable proportions: when this mixture steadily persists for psychologically relevant periods of time (and therefore long enough for a recognisable subjective experience to take place), we may call this a "distinct state of consciousness".

Some of the most important basic components of these mixtures (which once used to be called "higher nervous functions") are: esteroception, enteroception, processing of incoming sensorial data (input), memory, the subconscious (by which Tart actually means the Freudian unconscious), emotions, the faculty to make assessments and decisions, the sense of time, the sense of identity and motor output, and so on. In dream, for instance, esteroception is almost entirely abolished and the sensorial input processing function also goes down to very low levels, whereas memory becomes a very important ingredient in terms of quantity.

The decision powers are blocked, and the sense of time is distorted. In conclusion, according to Tart, with the employment of quantitative scales to "measure" the importance of each ingredient, it is possible to represent each state of consciousness on a system of Cartesian coordinates, and no longer compile a single map but a whole atlas of the states of consciousness. In those days (thirty years ago) this concept had a number of followers, even though its practical applications have been very limited and very few researchers have attempted to experimentally produce the various maps of the atlas.

It has been useful for the description of the phenomenology of consciousness and to focalise certain nodal points of such phenomenology; however it may now be regarded as superseded. Many researchers have found it more productive to investigate the mental activity characterising the various states of consciousness as a computer operating system, that is by employing the information theory; this may possibly have involved the loss of the systemic perspective but on the other hand has enabled them to pursue paths which have led to the modification of various dogmas so far unassailable. For instance, the demonstration that the brain continues to process data during all the stages of sleep has reopened the whole question of the function of sleep, stressing that it is also important to establish "why" it should continue to process data, as well as "how" it does it.

Others, in an attempt to understand the machine language which acts as interface between hardware and software, have started an in-depth investigation of memory and have reached the point of stating that consciousness is the result of learning, thus reinvigorating a debate involving both neuroscience and philosophy as to how much of our mind's structure is learnt and how much is innate. In conclusion, as mentioned earlier, today scientific research proceeds so fast and diffusely, that specialists find it quite difficult to keep their colleagues' activity under control and often are not concerned with the implications that a certain observation may have in other fields of knowledge. As regards Tart's systemic model, even though the system concept has not proved very productive, full validity must be acknowledged with respect to the parts of the model which analyse and attempt to explain how the changes in states of consciousness take place.

According to Tart, each state of consciousness/system is stabilised by a "functional adhesive" which prevents any change in the relationship among its components. This adhesive is attention/awareness and it is through manipulation or self-manipulation of this function that changes in state of consciousness are produced. Generally, attention can be: 1) entirely projected into the outside environment; 2) entirely concentrated on the inside environment; 3) fluctuating between inside and outside. In the state of wakefulness, attention is continuously directed on the environment, but if we start to interiorise it and concentrate it on mental contents, we set off for the radical change called sleep. As mentioned above, self-control of attention is also the foundation of meditation practices which, as eastern cultures claim, represent the main path to getting to know the structure of our mind/consciousness and how it works.

As mentioned, a hypnotist also induces trance by controlling the attention of the subject he wishes to hypnotise: he deliberately and progressively diverts the subject's attention towards the inside environment and gets it to focus on sensations and somatic or mental perceptions until the outside environment is no longer perceived. In this way, the hypnotist applies "dissociating forces" to the original structure of the system/consciousness, and once he has dissociated it, that is he has produced a new system/consciousness (the state of trance), he applies "stabilising" forces which make the new system long-lasting.

The meditator carries out the same process on his own, without having to resort to anybody else's help. And we all follow the same process to go to sleep, with the only difference that, contrary to what happens with hypnosis or meditation, at a certain point we lose control over the situation, having triggered a series of automatic mechanisms which make us fall asleep. Meditators may also lose control over the situation and enter an ecstatic state, but, at this stage, we do not yet know why. Fischer's and Tart's state of consciousness models where, in many respects, complementary. Time has demonstrated their incompleteness and, in some respects, also their superficiality. However, we should not forget that these are physiological models, which proves there has been a significant change in the manner consciousness and its states are viewed, compared to the Salpetrière clinicians: before we look for physiopathological explanations, it is wise to investigate normal consciousness in depth, and today we are prepared to do so. In neurophysiology, psychiatry, psychology and neuropsychology manuals it has become proper to include or add a chapter covering states of consciousness, but each of these subjects can only describe these phenomenologies in part: sleep and dream, the modifications of consciousness induced by psychoactive substances, the bipolarity of the conscious and the unconscious, the functional attributes of the cerebral hemispheres, and so on.

A culture laboriously distilled and carefully sieved through experimental liturgy, which proceeds slowly. There will probably be great progress when we start to harmonise western scientific knowledge and eastern psychological understanding.

According to the eastern cultures which, by tradition, have always devoted much more energy than the western culture to self-study, there is only one model of the structure of consciousness: the one which says that reality is an illusion and a product of the mind. Countless writings attempt to explain this strong statement and, to this end, meticulously analyse the structure of thought and how the mind works. Even though this knowledge was codified centuries ago, here in the west it has so far remained unused, since it is expressed in a metaphoric language or as an unreliable account of subjective experiences. So far, we have only had minor appropriations or loans: Carl Gustav Jung became very fond of "The Tibetan Book of the Dead" which relates NDE's (Near Death Experiences), that is a phenomenology which western science has only acknowledged a few decades ago and which, in any case, it considers illusory.

Dream Yoga, a technique which teaches how to "lucid dream", is about two thousand years old, whereas the possibility of dreaming with the awareness of dreaming has only recently been accepted, thanks to Stephen La Berge's stubbornness. Regarding the possibility of lucid dreaming, Tibetans have constructed a model of consciousness and a theory of dream which are a masterpiece of simplicity, even though still unacceptable for our experimental science. However, this is a path to take in the future and we now await a brave genius who, in the same way as Sigmund Freud, may be able to construct a theory of consciousness capable of satisfying both the eastern and the western cultures.

Marco Margnelli
Medico e Psicoterapeuta