Refractive anisometropia | schizo-binoc.de

 Refractive anisometropia  - 
a risk for schizophrenia?

A

In schizophrenia
 a decrease of accommodation and accommodative vergence of the same eye diverts the binocular axis.

Abstract 
Introduction


The case

Optical correction of the deficiency

Discussion 

Psychiatric consequences  of the transformation

Diagnosis and therapy

Conclusion


References

 

img1


Hildegard Korn
licenciée ès lettres,  Sorbonne


 The interpersonal 
component

B

Truth and trust in 
chronic schizophrenia


Summary

Introduction
 
Biographical Facts

Conclusion

References


Test-Forms:


Tests of Symmetric  Convergence-
Aniseikonia-
Stereopsis


 

 

Last revision 14.08.2019

Please send your results and/or comments to hi.korn@gmx.de

Keywords: accommodation, aniseikonia, anisometropia, binocular vision, contact lens  corneal surgery, egocentric/oculocentric disparity, eye movement, fixation,fixation disparityfovea, fusion, horopter, schizophrenia, selective attentionstereopsisstrabismus, vergence

Abstract

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 – aniseikonic – patients a reduced accommodation of the more myopic eye is accompanied by a reduced convergence of the same eye instead – as normal – of the other – hyperopic – eye, thus dissociating the binocular axis from the vestibular axis of self-perception and misguiding foveal fixation of the target of selective attention – the mediator between peripherally discovered targets of cognitive interest and their emotional assessment in the amygdala and memory storage in the hippocampus – to an object without interest for the patient.

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 and exercises of convergence, 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. By correcting the resulting anisometropia with a contact lens on the hyperopic right eye instead of spectacles – which had caused an aniseikonia binocular convergence and fixation of the target of selective attention was established and the patient's psychotic problems disappeared.
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) and can only be corrrected by a contact lens, by corneal surgery or in the course of cataract operations.
One question is, why the anisometropia was not corrected by a stronger accommodation of the hyperopic right eye – induced by the parasympathetic autonomous nervous system – but by a disaccommodation of the myopic left eye– induced by the sympathetic nervous system via Brücke's muscle which is much weaker and less precise than the accommodating Müller's muscle. The answer is given in biographical Part B, showing that the patient had grown up with continuously changing personal relations, favouring the development of the sympathetic system.
The other question, why the disaccommodating eye is stimulated to diverge from the binocular axis instead of the other eye is explained by an exchange of stimuli (or the stimulated nerves) of accommodative vergence in the vegetative oculomotor nuclei of the two eyes - lying very near to each other in the mesencephalon – constituting the specific component of schizophrenia.

Introduction

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, does not describe strabismus 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, 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/or a negative stereopsis test. Without these tests we may assume that the object fused bifoveally before covering one eye was not the object intended for fixation by selective attention  – which was fixated with the non-covered eye by the described movement when fusion was prevented – but the result of an abnormal unilateral divergence of the disaccommodating dominant eye.

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 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). 

img2

Legend figure 1: Horopter

grey area: part of horopter right visual field

Fo  fovea

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.

A disorder 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 cohort.   
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 targetOtherwise it would not have been possible to measure an angle between the pupil and the reflection of the penlight. 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,  or has it annulled an accommodative divergence of the disaccommodating eye?

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 case

The above findings correspond to what the author has hypothesized to be the somatic component of schizophrenia, namely a dissociation of the peripherically perceived target 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. 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). 

 

 Symmetric Convergence Test developed by the author (Korn 1999a): 
The distant target consisted of the mirrored rear of the near target. It  had initially been considered to be aligned behind the fixated near target on the visual binocular axis, when it appeared at the same distance from the near target for each eye in binocular or monocular vision. 

However, only in binocular vision the same distance proves that the near target is actually fixated, whereas in monocular  vision 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 .

img3

 Legend figure 2: 
 Symmetric Convergence Test:
 pathological result

▲ near target 

סּ  mirrored target

Fo  left fovea

F▲ right fovea

 -----  binocular axis

 _ _ _head axis


◄-►movement of right eye  between monocular fixation of near target and binocular fusion with left eye

 

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). 

In all stereopsis tests, however, the patient displayed spatial vision, excluding heterotropia.

img4

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[3] 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 ZEISS Pola-Test indicated almost no need any more for horizontal prismatic correction (base 0 or 180).

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 – an an-is-eikonia – of the images of the two eyes, the anisometropia of which, by reactivating the left accommodation, had been increased from 0,75 to 1,75 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 [5] 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.

When lateron, the eyes had to be operated for cataract, the artificial lens of the myopic left eye was reduced – and of the hyperopic right eye was increased – by 0,75D, which made the contact lens dispensable.

Discussion

From the course of the reactivation – which can be followed on the list of spectacles made for the patient between 1992 and 2016 – we can conclude to what had occurred before: The difference of magnitude of the two images had been compensated by reducing the accommodation of the myopic left eye, accompanied by an abnormal reduction of convergence of the same eye.

 

 

 

Left eye hyperopic
lacking convergence

Right eye
hyperopic

Date
Producer

Spectacles

Sphere

Cylin

Axe

Add

Prism

Base

Sphere 

Cylin

Axe

Add

Prism

Base

04.08.92 Wagner

varifocals

+0,5

+0,5  

90

2,0

 

 

1.25

+0,5

22

2,0

 

 

06.95 Schwabe
"Hypo left"

bifo

+1,25

 

 

 

1,0

90

+2,0

-0,5

 

 

1.0

270

08.95 Dickmann

near

+3,0

 

 

 

1,0

90

+3,75

-0,5

 

 

1,0

270

10.6.96Burg  "Hypo-Exo "

varifocals

+1,25

-0,25  

10

2.0

1,25

90

+2,25

-0,75

105

2.0

1,52

279

25.6.96 do.

near

+3,25

-0,25

10

 

1,25

90

+4,25

-0,75

105

 

1,52

279

9.8.96 do.

near

+3,25

-0,25

10

 

2,69

111

+4,25

-0,75

105

 

1,52

279

21.8.96 do.

far

+1,25

-0,25

10

--

2,69

111

+2,25

-0,75

105

--

1,52

279

6.97 Wulf/ Sellmeyer  "Hyper-Fareso OD"

varifocals

+1,0

 

 

2,25

1,6

38

+1,75

-0,25

103

2,25

1,45

210

29.9.97  do.

varifocals

+1,0

 

 

2,25

2.5

36

+1,75

-0,25

103

2,25

2,50

216

30.12.97 do

varifocals

+1,0

-0,25

0,00

2,25

2,92

19

+1,75

-0,25

104

2,25

2,23

206

19.3.98 do.

bifo

+1,0

-0,25

180

2,25

2,75

1,25

1,0

0,5

00

90

00

90

+1,75

-0,25

104

2,25

2.25

1.0

1,0

0,75

180

270

180

270


+3,25

Divergence excess

 

 

near part

nearpart

26.6.98 Witt

bifo

+1,0

-0,25

108

2,25

2,75
1

0
90

+1.75

-0,5

104

2,25

2.0
1,0

180    270

1.9.98 Witt

PC

+3,25

-0,25

108

 

1,75

 

00

90

+4,0

-0,5

104

 

1,5

1

180

270

13.2.99 Witt

bifo

+1,0

-0,25

180

2,25

2,0

1

00

90

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.3.00 Witt

bifo

+1,25

-0,25

180

2,25

1,75

1

00

90

+2,0

-0,5

104

2,25

2

1

180   

270

 

 

 

 

 

 

 

 

 

7.4.00 Witt Rodenstock

bifo

+1,0

-0,25

180

2,25

2,5

90

+1.75

-0,5

106

2.25

3,5

a/u

5.5.00 Witt

bifo

+1,0

-0,25

180

2,25

--

 

+1.75

-0,5

106

2.25

 

 

23.5.00 Witt

bifo

+0,75

--

 

2,25

1,87

1

00

90

+1.75

-0,5

85

2.25

1,87

1

180

270

 

 

 

 

 

 

 

 

 

17.11.00 Witt

bifo

+1,0

-0,25

180

2,25

1,75

1

00

90

+1.75

-0,5

104

2.25

1,75

1

180   

270

 

 

 

 

 

 

 

 

 

24.02.01 Witt

bifo

+1,0

-0,25

180

2,25

1,75

1

00

90

+1.75

-0,5

104

2.25

1,75

1

180

270

 

 

 

 

 

 

 

 

 

03.01 Hegener

bifo

+1,25

--

--

2,25

4,12

14

+1.75

--

--

2.25

4,12

194

2.5.01 Witt

bifo

+1,0

-0,25

180

2,25

?

 

+1.75

-0,5

 

2.25

?

 

31.5.01 Witt

near

+3,25

-0,25

180

 

1

90

+4,0

-0,5

104

 

1

270

22.6.01 Witt

bifo

+1,0

-0,25

180

2.0

1

90

+2,0

-0,5

104

2.0

1

270

2.2.02 Witt

near

+3,5

-0,25

180

 

1

90

+4,25

-0,5

104

 

1

270

9.7.02 Witt

bifo

+1,25

-0,25

180

2,25

1

90

+2,0

-0,5

104

2,25

1

270

17.1.05 Wit

bifo

+1,25

-0,25

180

2,25

1

90

+2,0

-0,5

104

2.25

1

270

1.2.05 Wit

PC

+3,25

-0,25

180

 

1

90

+4,0

-0,5

104

 

1

270

From here:                           left eye almost emmetropic  -   almost symmetrical convergence of both eyes

25.9.06 Witt

bifo

+0,25

 

 

 

2,0

90

+1.75

-0,5

90

2.25

 

 

25.9.06 Witt

near

+2,25

 

 

 

2,0

90

+3,75

-0,5

90

 

 

 

8.2.07 Witt

bifo

+0,25

 

 

2,25

 

 

+2,0

-0,75

75

2.25

2.5

270

9.2.07 Witt

near

+2.25

 

 

 

 

 

+4,0

-0,75

75

 

2.5

270

1.3.07 Witt

near

+2.25

 

 

 

1,0

90

+4,0

-0,75

85

 

2,88

?

1.3.07 Witt

bifo

+0,25

 

 

2,25

1,0

90

+2,0

-0,75

85

2.25

2,88

200

16.5. 07 Witt

bifo

 

 

 

 

 

 

+2,0

-0,5

104

2.25

1

270

19.7. 07 Witt

bifo

+0,25

 

 

2,25

1,5

90

 

 

 

 

 

 

17.8.07 Witt

near

+2.25

 

 

 

1,5

90

 

 

 

 

 

 

 From here                                                       aniseikonia                                      Right eye contact lens +1,5 D                             

1.9. 07 Witt

bifo

 

 

 

 

 

 

+0,5

-0,5

105

2,25

 

 

26.9.07 Witt

nah

 

 

 

 

 

 

+2,5

-0,5

104

 

1

270

26.9.07 Witt

bifo

 

 

 

 

 

 

+0,5

-0,5

104

2,25

1

270

13.6.08 Witt

near

+1,5

 

 

 

0,5

90

1,75

-0,5

104

 

0,5

270

31.10. 07

bifo

0,00

 

 

2,25

1

90

 

 

 

 

 

 

14.12. 07

near

+1,75

 

 

 

0,5

90

+2,0

-0,5

104

(1,5)

0,5

270

11.1.08 Witt

bifo

0

 

 

2.0

0,5

90

0

 

 

2,0

0,5

270

31.3.08 Hau

PC

+1,5

 

 

 

 

 

+1,5

 

 

 

 

 

11.4.08 do.

PC

 

 

 

 

 

 

+1,75

-0,5

86

(1,5)

 

 

6.08.08 do.

bifo

00

 

 

1,75

 

 

+0,25

-0,5

86

(1,5)

 

 

from here                            left eye myopic     symmetrical convergence!      Right eye contact lens +1,75

26.8.08 Witt

bifo

-0,5

-0,25

120

2,0

0,5

90

plan

-0,75

100

2,0

0,5

270

15.10.08 do

near

+1,25

-0,25

 

 

0,5

90

+1,75

-0,75

86

 

0,5

270

30.01.09 do

PC

+0,75

-0,25

120

 

0,5

90

+1,50

-0,75

97

 

0,5

270

20.05.09

Far

-1,0

-0,5

125

--

--

--

plan

-1,00

86

--

--

--

05.06.09

near

+0,5

-0,5

125

 

-

-

+1,50

-1,50

86

 

--

--

22.06.09

bifo

-1,00

-0,5

125

2,0

0,5

90

plan

-1,00

86

2,0

0,5

270

23.07.09

near

+0,75

-0,25

120

 

0,5

90

 

 

 

 

 

 

   02.10             Cataract-OP left eye: – 0,75 D = 21 D                                        Right eye contact lens +1,5 D                           

13.07.10

near

+1,75

-0,5

 50

 

1.0

90

+3.5

-0,75

104

o.Kl.

--

--

17.08.10

bifo

-0,25

-0,5

 50

2,0

0,5

90

plan

-0,75

104

2,0

0,5

270

     08.10 ?

near

+1,75

-0,5

 50

 

1.0

90

+1,75

-0,5

105

 

1,0

270

                                                                                                                               without contact lens      

19.01.11

bifo

 

 

 

 

 

 

+1,5

-0,75

104

2,0

0,5

270

10.02.12

near

 

 

 

 

 

 

+3,0

-0,75

104

 

0,5

270

22.03.12

bifo

 

 

 

 

 

 

+1,25

-0,75

104

1.75

1,0

270

13.12.13

near

 

 

 

 

 

 

+2,25

-0,75

 80

 

0,5

270

13.12.13 Mayerhofer

bifo

-0,25

-0,5

50

2,00

 

 

+0,25

-0,75

 80

2,00

1,5

270

28.03.14

near

+1,75

-0,75

60

 

-

 

 

 

 

 

 

 

28.03.14

bifo

-0,25

-0,75

60

2,00

-

 

 

 

 

 

 

 

09.07.14

bifo

0

-0,25

50

2,00

 

 

+0.5

-0,5

 83

2.00

1,0

270

15.06.15Witt

near

 

 

 

 

 

 

+1,75

-1,25

90

 

1,0

270

19.06.15 do.

bifo

 

 

 

 

 

 

0.00

-1,25

90

1,75

1.0

270

01.07.15 Mayerhofer

bifo

-0,25

-0,25

63

2,00

 

 

+0,5

-1,0

80

2,00

1,5

270

11. 07.16                                           Cataract-OP  right eye: +0,75 = 20,5D:     No anisometropia 

30.4.19 Matt

bifo

+0,25

-0,25

50

1,75

 

 

+0,5

-0,75

90

1,75


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 disaccommodation and divergence of the myopic left eye instead of a stronger accommodation of the hyperopic right eye combined with a movement of convergence of the left eye. The ability of the human eye to disaccommodate depends on Brücke's intraocular muscle which receives a relatively weak and unprecise stimulation from the the sympathetic vegetative nervous system lying at some distance from its executive organs. It becomes active only, when the parasympathetic system – which stimulates accommodation and convergence to the near range by special nuclei of the oculomotor nerve has not been sufficiently developed in early childhood by trustworthy (motherly) relations (cf. Schmidt ME 2018).  We shall see in Part B that this had probably occurred in our patient. Her exercises of landscape painting accommodating her eyes – and her body – from the far model to the near painted picture had disactivated in 2006 the sympathetic stimulation of disaccommodation and abnormal divergence – thus allowing binocular fixation of the near target of attention and correspondence of the visual axis with the self-perceptive body-axis.
This possibility is little known among opticians and even orthopticians. This is why the abnormal divergence was misinterpreted as a hyper-exotropia of the left or a hypo-esotropia of the right eye and corrected prismatically. The effect of horizontal prisms, however, remains unchanged by the distance of the target – which influences accommodative vergence stimulated by the vegetative system, as shown by the differing prismatic results in the near range the
19.03.98. That is why the dizziness of the patient could not be overcome by various modifications of horizontal prismatic correction.

Another question is, why the disaccommodation of the left eye had stimulated accommodative divergence of the disaccommodating eye itself,  instead of the other eye, as normal in accommodation vergence according to Alpern (1972 p. 318): "The increase of accommodation of one eye is invariably accompanied by an inward rotation of the other (occluded) eye", i.e. the adaptation of one  eye to the depth of the target stimulates the other  eye to horizontal adaptation to the target.img5

 "In binocular vision", however, "accommodative vergence movements are nulled, and egocentric disparity is not changed" (Alpern 1957b). This nullification of vergence might be attached to the accommodating Müller's muscle, activated by the parasympathetic autonomous nervous system, but not to the disaccommodating Brücke's muscle, activated by the sympathetic autonomous nervous system stimulating divergence. As shown in the Conclusion of Part B, the activation of the parasympathetic nervous system by trustworthy familiar relations can overcome aniseikonia by accommodation of the more hyperopic eye without abnormal vergence.

The list of spectacles made for the patient between 1992 and 2016 shows, that the sudden decrease of disaccommodation in 2006 goes along with the decrease of divergence of the disaccommodating left eye itself, which means that  the unvoluntary accommodative divergence is determined by the same nervous system as the unilateral disaccommodation. The abnormal ipsilateral divergence can therefore be explained by an interchange of oculocentric disparities of the two eyes stimulating accommodative vergence in the vegetative nuclei of the oculomotor nerve lying very near to each other in the center of the mesencephalon, even nearer than the motor nuclei of the same nerve which stimulate volontary eye-movements - or of the nerves leaving the mesencephalon (Beske F, 1970, vol. I, p. 456). The interchange not only stimulates the divergence of the disaccommodating eye but also deprives the other eye of its stimulus of divergence, so that the two eyes make a common version to the left (cf. Bolding B below: -15). 7

img6

As long as there is no an-is-eikonia between the two eyes requiring correction by unequal accommodation for binocular fusion, this exchange of stimuli is without importance for the fixation of the target of interest, because accommodative vergence is the same for both eyes – which can explain the normality of siblings of schizophrenic patients. In case of a difference of eikonia however, foveal fixation of the target of interest and correspondence of binocular and self-perceptive vestibular axis - following interchanged stimuli of accommodative vergence – are sacrificed to reducing egocentric disparity of the two eyes by disaccommodation with erraneous accommodative divergence of the same eye.    

The unilateral accommodative divergence has been documented by an experiment developed by Bolding et al (2014) comparing the binocular eye-movements following a target moved forward and backward on the midline between the eyes in schizophrenic patients and normal controls. While in the controls, the vergence movements corresponded precisely to the movements of the target, the movements of the patients were full of diverging disturbances, which was explained by a defective gain of convergence-velocity. What the authors omitted in their interpretation, however, was the obvious difference between the two eyes: While the right eye reached the target up to its nearest point (-18) and even further with some excursions, the left eye remained at a certain distance from the approaching target even in the far range, with sudden larger excursions in the divergent direction at the nearest position of the target, i.e. the convergence insufficiency was clearly unilateral and based on diverging movements of the left eye – caused by Brücke's intraocular muscle which receives a relatively weak and unprecise stimulation from the abnormal vegetative nervous system – disturbing the movements following the target stimulated by the motor nervous system.

img7

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 orientationvisual 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. 

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. misguided foveal fixation and inferotemporal processsing away from the parietally localized target 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). 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. 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.

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 scanning'". 
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."     

Psychiatric consequences of the transformation

1.  The dissociation of the binocular axis from the vestibular 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 foveally perceived objects in the centers of emotion and memory amygdala and hippocampus (cf. Kaas 1986, p. 317) intended for the 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 diverging 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.

Diagnosis and therapy

Binocular fusion and foveal fixation are both spontaneous reflexes of the visual plant aiming on the one hand at stereoptic perception and orientation, on the other hand at detailed cognition and relation with 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 accommodation and accommodative convergence of the same 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 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 acommodative (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. 

img8

Aniseikonia Screening Test: A rough comparison can be obtained by presenting to the patient two large identic letters (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). 

img9

__________________________



img10

A longstanding deviation of the binocular axis is difficult to correct because perceptive and motor habits have developed according to the dissociated axes. Before the first correction of any anisometropia with spectacles, an aniseikonia test ought therefore to be made prophylactically with the Aniseikonia Inspector. 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, 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).  

Conclusion 

The unilateral convergence insufficiency found in schizophrenic patients can be explained by a refractive aniseikonia compensated by a disaccommodation of the more myopic eye combined with an abnormal accommodative divergence of the same 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 somatic basis of schizophrenia is a scission of attention between the object selected for fixation via the dorsal stream – perceived clearly in the parietal cortex by voluntary 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 autonomous accommodation vergence correcting (refractive) aniseikonia. 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). 

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: " If your right eye causes you to stumble, gouge it out and throw it away. It is better for you to lose one part of your body than for your whole body to be thrown into hell." ) 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 than 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. Clip-on eyeglass shield EP 1077388 B1) – the easiest and most effective solution to longstanding psychotic problems? After all this would correspond to the suppression of the image of the non-dominant eye achieved normally by art or by nature in case of incorrigibly differing images of the two eyes.  Also the adaptation of the eye-lenses to each other by cataract-operation(s) - as in my patient - corresponds to the advice of Christ "to gouge out your right eye and throw it away if it causes you to stumble."

References

Achiron LR, Witkin N, Primo S, Broocker D. Contemporary management of aniseikonia. Surv Ophthalmol 1997; 41 (4): 322-330.

Alpern M, Arbor A. Eye movements. In: Handbook of Sensory Physiology VII/4. Visual Psychophysics.  Berlin: Springer 1972.

Barton JJ, Pandita M, Thakkar K, Goff DC, Manoach DS. The relation between antisaccade errors, fixation stability and prosaccade errors in schizophrenia. Exp Brain Res 2008; 186: 273-282.

Bennett AG, Francis J. Ametropia and its correction. In: Davson H (ed).The eye. New York: Academic Press 1962: 174-176. 

Beske F. Lehrbuch für Krankenschwestern und Krankenpfleger, Band I, Thieme 1970: 456.

Bogerts B. Die Bedeutung hirnmorphologischer Befunde für die Schizophrenieforschung. In: Heinrich K, Bogerts B (eds). Pathophysiologische und pathomorphologische Befunde bei schizophrenen Psychosen. Stuttgart: Schattauer 1990: 27-44. 

Bolding MS, Lahti AC, White D, Moore C, Gurler D, Gawne TJ, Gamlin PD.

Vergence eye movements in patients with schizophrenia. Vision Research 2014: 64-70.

De Wit CG. Evalutation of a direct-comparison aniseikonia test. Binocul Vis Strabismus Q. 2003; 18:87-94. 

Colbourn CJ, Lishman WA. Lateralization of function and psychotic illness: a left hemisphere deficit? In: JH Gruzelier, P Flor-Henry (eds), Hemisphere asymmetries of function in psychopathology. Amsterdam: Elsevier 1984: 539-559.

Connolly JF, Manchanda R, Gruzelier JH, Hirsch SR. Pathway and hemispheric differences in the event-related potential (ERP) to monaural stimulation: a comparison of schizophrenic patients with normal controls. Biol Psychiatry 1985; 20 (3): 293-303. 

Desimone R, Duncan J. Neural mechanisms of selective visual attention. Annu Rev Neurosci, 1995; 18: 193-222. 

Falkai P, Bogerts B, Greve B, Haupts H, Lammerts J, Wurthmann C. Neuere neuropathologische Untersuchungen an schizophrenen Patienten. In: Heinrich K, Bogerts B (eds). Pathophysiologische und pathomorphologische Befunde bei schizophrenen Psychosen. Stuttgart: Schattauer 1990: 17-26.

Flach F, Kaplan M. Visual perceptual dysfunction in psychiatric patients. Compr Psychiatry 1983; 24 (4): 304-311.

Flach F, Kaplan M, Bengelsdorf H, Orlowski B, Friedenthal S, Weisbard J, Carmody D. Visual perceptual dysfunction in patients with schizophrenic and affective disorders versus control subjects. Journal of Neuropsychiatry 1992; (4): 422-427.

Foxe JJ, Yeap S, Leavitt VM. Brief monocular deprivation as an assay of short-term visual sensory plasticity in schizophrenia – "the binocular effect". Front Psychiatry 2013; 4:164. doi: 10.3389/fpsyt.2013.00164.

Gaebel W. Okulomotorische Befunden bei schizophrenen Kranken. In: Heinrich K, Bogerts B (eds).Pathophysiologische und pathomorphologische Befunde bei schizophrenen Psychosen. Stuttgart: Schattauer 1990: 133-148.

Green MF, Leitman DI. Social cognition in schizophrenia. Schizophr Bull 2008; 34 (4): 670-672.

Grosh ES, Docherty MN, Wexler BE. Abnormal laterality in schizophrenics and their parents. Schizophr Res 1995; 14 (2): 155-60.

Gruzelier JH, Jutai JW, Connolly JF, Hirsch SR. Cerebral asymmetries and stimulus intensity relationships in EEG Sprectra of VEPs in unmedicated schizophrenic patients: relationships with Active and Withdrawn syndromes. Int J Psychophysiol 1993; 15: 239-246.  

Haase HJ. Zur Fixationsdisparation. Heidelberg: Verlag Optische Fachveröffentlichungen GmbH 1995

Hegener H. Pupillen-Distanz-Messungen sind ungenau: Deshalb gibt es Probleme mit Gleitsichtanpassungen. Deutsche Optiker Zeitschrift  1999; 2: 22-27.

Howard IP, Rogers BJ. Binocular vision and stereopsisNew York: Oxford University Press 1995.

Hugonnier R, Magnard P. Schielen. In: François J, Hollwich F, eds.: Augenheilkunde in Klinik und PraxisThieme, Stuttgart 1986:1.2-1.180.

Kaas JH. The structural basis for information processing in the primate visual system. Vis Neurosci 1986; 21: 315‑340.

Katsumi O, Tanino T, Hirose T. Effect of aniseikonia on binocular function. Invest Ophthalmol Vis Sci 1986; 27: 601-604. 

Koh KGWW, Yeo BKL. Self-enucleation in a young schizophrenic patient – a case report. Singapore Med J 2002; 43 (3): 159-160.

Kolb B, Whishaw IQ. Neuropsychologie. Heidelberg: Spectrum Akademischer Verlag 1996.

Korn H. The somatic component of schizophrenia: a dissociation of the goals of visual attention and bifoveal fixation? Med Hypotheses 1999a; 52 (2): 163-171. 

Korn H. The biographical component of schizophrenia: a two‑faced definition of relationship? Med Hypotheses l999b; 6: 539-544. 

Korn H. Schizophrenic vulnerability: a deficiency of the correlation between foveal perception and oculomotor proprioception? Med Hypotheses 2000; 55 (3): 245-252.

Korn H. Further evidence for a reversed crossing of foveal projections in schizophrenic vulnerability. Med Hypotheses 2002; 58 (4): 305-311. 

Korn H. Schizophrenia and eye movement – a new diagnostic and therapeutic conceptMed Hypotheses 2004; 62: 29-34. 

Kovelmann JA, Scheibel AB. A neurohistologic correlate of Schizophrenia. Biol Psychiatry 1984; 19: 1601-1621.

Krakauer EL, Goldstein LE, Sernyak MD, Scott WW. Schizophrenia and Strabismus. J Nerv Men Dis 1995; 183 (10): 662-3. 

Lancelot C, Ahad P, Noulhiane M, Hasboun D, Baulac M, Samson S. Spatial and non-spatial auditory short-term memory in patients with temporal-lobe lesion. Neuroreport 2003; 14 (17): 2203-7.

Ndlovu D, Nhleko S, Pillay Y, Tsiako T, Yusuf N, Hansraj R. The prevalence of strabismus in schizophrenic patients in Durban, KwaZulu Natal. S Afr Optom 2011; 76 (3): 101-108.

Otto J. Amblyopie. In: François J, Hollwich F (eds). Augenheilkunde in Klinik und Praxis. Stuttgart: Thieme 1986: 3.1-3.56.    

References for Refractive Surgery for Children: Laser, Implants, Current Results and Future Directions. Expert Rev Ophthalmol 2008; 3(6): 635-643.

Rockland KS, Van Hoewen GW. Some temporal and parietal cortical connections converge in CA1 of the primate hippocampus. Cereb Cortex 1999; 9 (3): 232-237.    

Rolls ET, Aggelopoulos NC, Zheng F. The receptive fields of inferior temporal cortex neurons in natural scenes. J Neurosci 2003; 23(1): 339-348 . 

Schechter I, Butler PD, Jalbrzikowski M, Pasternak R, Saperstein AM, Javitt DC. A new dimension of sensory dysfunction: Stereopsis deficits in schizophrenia. Biol Psychiatry 2006; 60: 1282-1284.

Schiffman J, Maeda JA, Hayashi K, Michelsen N, Sorensen HJ, Ekstrom M, Abe KA, Chronicle EP, Mednick SA. Premorbid childhood ocular alignment abnormalities and adult schizophrenia-spectrum disorder.  Schiz Res 2006; 81: 253-260. 

Schmidt ME. Bindungsserie. Die Tagespost 2018/19.

Schneider  F. Brain-behaviour relation of emotion in schizophrenia. Euro Arch Psychiatry Clin Neurosci 2011; 261 Supplement 1: 24.

Silverstein SM, Wang Y, Roche MW. Base rates, blindness, and schizophrenia.  Front Psychol 2013; 4: 157.

Spaemann R, Löw R. Natürliche Ziele. Klett-Cotta, Stuttgart 2005.

Toyota T, Yoshitsugu K, Ebihara M, Yamada K, Hisako O, Fukasawa M et al. Association between schizophrenia with ocular misalignment and polyalanine length variation in PMX2B. Hum Mol Gen 2004; 13(5): 551-561.

Trappenberg TP, Rolls ET, Stringer SM. Effective size of receptive fields of inferior temporal visual cortex neurons in natural scenes. 2002 University of Oxford, Centre for Computational Neuroscience, Department of Experimental Psychology, South Parks Road, Oxford OX1 3UD, U

Waters F, Rock D, Dragovic M, Jablensky A . "Social dysmetria" in first-episode psychosis patients. Acta psychiatr Scand 2011; 123 (6): 475-484.

Wölwer W, Gaebel W. Impaired visuomotor integration in acute schizophrenia.  World J Biol Psychiatry 2003a; 4 (3): 124-128).

 

Formularbeginn

Tests of Convergence, Aniseikonia and Stereopsis 

For stereoptic fixation of the object of your attention the images of both eyes must be combined. When their information is too different concerning form or location, fixation or stereopsis can be impaired. You can check this with the following tests. Wearers of spectacles should undergo the tests with their correction to begin with.The fields behind the slashes are to be filled in later without spectacles. 

1) Symmetric ConvergenceTest: Place yourself at arm's length or more before a well illuminated mirror and turn your face straight ahead parallel to the mirror, so that both ears are equally perceived. Place your thumbs under your chin and fold up both hands vertically on the back of your nose. Advance your folded hands half-way towards the mirror and fixate them with both eyes. You should now see the mirrored image of your hands on both sides of your fixated thumbs. Or do you see it only on one side? 
I see the mirrored image  on both sides, nearer on the  left, on the  right side. 
I see my folded hands twice and the mirrored image between them   .

2) Difference of magnitude: Sometimes the image of one eye is larger than the other one. 
Adjust the Zoom of your display at 500 and place two letters I . I
(Times New Roman) in the center. 
Now keep your hand vertically – with the thumb towards your face – between the display and your nose so that you see the right letter only with the right eye and the left letter only with the left eye. 
Does one of the letters appear  larger
The  R ight or the  L eft one? Or are they  E qual?

>

With magnification 72 / 48 / 36 / 24 /

3) Stereopsis Test: For this test you must ask your optician or your ophthalmologist for the 
necessary device. Put on the test spectacles – above your own spectacles if necessary.
a) Do you now see in the upper part of the test an animal standing before the background?
    Describe it! 

b) In the lowest part do you see one sign nearer than the other three? Which one (1, 2, 3, 4)?
    In line A  /     In line B  /      In line C  / 

c) In which of the 10 fields of the central part one of the cercles appears to be nearer?
    Which one? (the left, right, upper, lower)
    In field 1 /    2  /   3  /   4  /    5  / 
               6 /    7  /   8  /   9  /  10  / 

If you wear spectacles, do the tests now without your spectacles and put the answers down behind the slashes.

4) Additional questions, to answer without spectacles

Perhaps one of your eyes is better in the near range and the other in the far range.
With which of your eyes you are better at reading   the right or the left? 
With which are you better at recognizing people from a distance  the right or the left?

Do you have your lens specifications? Please write them down !
Right eye    Left eye 

Are any eye deficiencies known to you

Name (or initials)    Year of birth               

Diagnosis               Date and hour of test 

Drugs (with dosis)  Date of last dosis       

Thank you for your cooperation! 

Formularende

 

 

 

 

B

Truth and trust in chronic schizophrenia

     Summary       

     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 

INTRODUCTION 

     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. 

BIOGRAPHICAL FACTS

     1. Childhood
     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. 

    2. Adolescence 

    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 an 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 Marocco 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'Ss 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. Autonomous Nervous System, 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. When lateron, the eyes had to be operated for cataract, the artificial lens on the myopic left eye was reduced – and of the hyperopic right eye was increased – by 0,75D, which made the contact lens dispensable. 

CONCLUSION

    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 an unrecognized refractive anisometropia – producing aniseikonia by correction with spectacles - compensated by disaccommodation and abnormal divergence of the more myopic eye, dissociating the binocular from the vestibular body axis and 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. The lack of (early) trustworthy familiar relations may have promoted disaccommodation to the far range together with abnormal divergence of the same – myopic – eye, stimulated by sympathetic vegetative impulses, while in "healthy" families, aniseikonia was overcome by accommodation of the hyperopic eye stimulated by parasympathetic impulses (cf. Schmid ME 2018/19)

REFERENCES

Hegener H (1999) Pupillen-Distanz-Messungen sind ungenau: Deshalb gibt es Probleme mit  Gleitsichtanpassungen. DOZ 2: 22-27. 

Korn H (1999a) The somatic component of schizophrenia: a dissociation of the goals of visual attention and bifoveal fixation? Med Hypotheses 2: 163-171.

Korn H (1999b) The biographical component of schizophrenia: a two-faced definition of relationship? Med Hypotheses 6: 539-544.

Pateman T, Laing RD (1972) On Sanity, Madness and the Problem of Knowledge. Radical Philosophy 1. 

Scheurer H (1981) Kognitive Dissonanz und Schizophrenie. Basel: Beltz.

Schmidt ME. Bindungsserie. Die Tagespost 2018/19

Tienari P et al (1989) Die finnische Adoptionsfamilienstudie über Schizophrenie. In: Böker W, Brenner H (eds) Schizophrenie als systemische Störung. Bern: Huber.

Tournier P (1959) Echtes und falsches Schuldgefühl. Zürich: Rascher Verlag.

Watzlawick P & Beavin J (1990) Einige formale Aspekte der Kommunikation. In: P Watzlawick, JH Weakland (eds) Interaktion. München: Piper 95-110.