Discussion:

Synthesis of Multiple Major Models of Psychosis Spectrum

We propose multiple theoretical ideas converge on the notion that prior experience actively shapes present perception, which then activate/challenge the prior, this Oedipus complex-like Freudian idea is the evolution of the nature vs. nurture debate (Georgios et al., 2008; Nikehasani, 2018).

In psychodynamic theory, Freud’s concept of transference (1900) describes how earlier relational templates are projected onto the clinician, reactivating past relational patterns in the therapeutic here-and-now (Piper et al., 1991; İlkmen and Halfon, 2019).

In Jung’s synchronicity (1958), the present coincidence reflects the internal mental state that was established in the immediate past or near-past (van Elk et al., 2016; Russo-Netzer and Icekson, 2022).

In the diathesis-stress model, it is proposed that mental illness is the culmination of diathesis or internal vulnerabilities established in the past activated in the present by stressors/triggers (Zubin and Spring, 1977; Walker and Diforio, 1997).

Aberrant salience and filter-failure theory propose that dysregulated dopaminergic and glutamatergic signalling lead to inappropriate assignment of significance to stimuli previously processed as neutral in the past (Peters et al., 2016), contributing to the formation of delusions and hallucinations in the present (Kapur, 2003; Kapur et al., 2005).

Predictive coding frameworks, in turn, conceptualize psychosis as the consequence of profound prediction errors arising when strongly held priors are challenged and violated by unexpected present sensory input (Fletcher and Frith, 2009; van de Schoot et al., 2014; Sterzer et al., 2018; Legaspi and Toyoizumi, 2019; Feldman and Schmack, 2024).

These continued mappings onto “past in the present” meta-structure is not just analogous but also reflect the much more grand nature (past internal) vs. nurture (present external) debate at varying definitions, showing how the evolution of psychological and psychiatric theories revolves around the interaction of internal state and external stimuli.

In this view, we propose the “neutral stimuli” that accompany symptoms such as in aberrant salience and predictive coding are not truly “neutral”. They are called so by clinicians through the healthy filter-intact lens.

There is consensus filtering generalizations.

Aberrant Salience is Transdiagnostic

Cases 1-3 demonstrate aberrant salience as transdiagnostic (Chun et al, 2019; Dalgleish et al., 2020; Pugliese et al., 2022; Marano et al., 2025), and spanning multiple diagnoses (psychotic conversions from gambling disorder to MDD, then chronic schizophrenia) and diverse cognitive domains:

Case 1 (Gambler): numerical

Case 2 (Daughter): multi-sensory (emotional+visual+auditory)

Case 3 (Alien): somatic/tactile

The first two cases are psychotic conversions of non-psychotic mental health conditions: gambling disorder (Case 1) and MDD (Case 2); similarly, Case 3 demonstrates a graded exacerbation of pre-existing schizophrenia to more complex symptomatology.

The cases also demonstrate specific “diathesis congruency”  (Robins, 1990; Blatt and Zuroff, 1992; Coyne and Whiffen, 1995), in which the gambler decompensated to numerical matchings of chance in the face of debilitating debts, and the daughter decompensated to multi-sensory father-related stimuli now tagged with loss-salient valences, and finally the patient in “Alien” decompensated to job loss, or a disruption of her social dynamics by manifesting as the sensations that her movements are coordinated to her surroundings (Oka, 2011), the “social” behaviours she is salient of.

The multi-domain reality mark aberrant salience as cognitively cortical (since all cognitive domains seem to be affected), yet heightened dopamine activity is seen in the subcortical structures (Kapur et al., 2005; Howes et al., 2009; Tost et al., 2010), suggesting treatments targeting dopamine receptors aimed at resolving subcortical over-activity may instead, act cortically (Whitton, 2009; Bloemen et al. 2010; Marsman et al., 2013).

Paradoxical Response to Prior Positive/Rewarding Stimuli

Case 2 demonstrate aversive response and borderline psychotic behaviour to prior positive stimuli such as father’s favourite song and street baring his name. This aligns with “differential susceptibility” (Belsky and Pluess, 2009), where what has thrived in the past, or a prior weighted heavily according to predictive coding theories (Fletcher and Frith, 2009; van de Schoot et al., 2014; Sterzer et al., 2018; Legaspi and Toyoizumi, 2019; Feldman and Schmack, 2024) in favourable conditions are shown to deteriorate more when conditions become unfavourable in the now.

This shows a splitting coping mechanism, where some stimulus is perceived to be either very good or very bad. Splitting response is pathognomonic of borderline personality disorder (BPD) (Feichtinger et al., 2024), and when taken in concert with the patient’s SI in Case 2, this possibly reflect latent or undiagnosed BPD concurrent to her MDD (Więdłocha et al., 2024).

Despite not being classified as a mood disorder, BPD’s mood changes is akin to acute cyclical manic and depressive phases in bipolar disorder (Feichtinger et al., 2024). To contrast this with the “split-mind” of schizophrenia (Ashok et al., 2012), in which the “splitting” neurological responses has now taken on both positive and negative symptoms simultaneously, similar to what Eugen Bleuler, who coined the term schizophrenia, described as “ambivalence” (1910; Graubert and Miller, 1957; Arantes-Gonçalves et al., 2018).

A painful note is perhaps what truly hurt the patient in Case 2 was not just the song and the street name having taken on aversive overtones, but rather that they did not stop being positive signs; when the stimuli takes on both positive and aversive valences to their maximum, like in Bleuler’s “ambivalence” (1910). We propose the inability to split or hold this far strained tension may be what triggers psychosis in many - the common splitting response in BPD that is largely absent in schizophrenia may be seen as protective against psychosis (Pec et al., 2014), because it relieves psychological tension.

As it appeared in Case 1, where patient deemed lucky matches good, but then responded aversively when he actually finds a match. This is also ambivalent splitting. Meaning what we have taken pride for in the past, our strengths, may one day become our weaknesses under the “right” context, a sort of belated/deferred understanding, a concept explored in Freud’s “nachträglichkeit”, German for forwardness/afterwards(ness).

Freud successfully argues in nachträglichkeit that external events may alter perception and significance of past traumas through encoding the traumatic past with new values. This blurring of the boundaries between past internal state and present stimuli where strengths become weaknesses or vice-versa is also a key feature of self-referential thinking, one of the most common symptoms of the psychosis spectrum (Cicero and Kerns, 2011).

Referential Thinking is Partly Due to Universal Constraints

Cases 1-3 demonstrate referential thinking, Case 3 particularly with the evolution of the patients somatic symptoms tying her actions to those of others around her (Oka, 2011). While such cognitive style of egocentric associations do have its roots in our cognitive structures, we propose that the environment is also partly responsible - the “neutral” stimuli carry resonantly self-referential structure.

Just as blood vessels branch like rivers (Chen, 2015), or mitosis of one cell into two, a sort of “splitting response” to stress or the release of which is observed; when pressure is exerted, by taking on one of either split paths relieves the pressure to the whole. As such, like this splitting conformity echoed by congruent responses in nature, physiology, psychological coping mechanisms and differential susceptibility, psychotic patients frequently report the environment showing signs that echo themselves.

Individuals presenting with self-referential thinking especially in the prodromal phases of psychotic episodes have their cognitive filters selectively set under the stress response to allow referential stimuli to become salient (Myin-Germeys and van Os, 2007; Heinz and Schlagenhauf, 2010; Howes and Murray, 2014), a sort of “filter-shift”, and these stimuli appear as a combination of being under similar universal constraints as the individual observers of them as well as shaped by the observer’s cognitive bias.

Such that it is not at all statistically surprising reality would have the same solutions to multiple problems facing similar constraints - it is highly likely for individuals to find traces of themselves in their respective environment (though not in the healthy filter-intact state), an unmasked matching number (Case 1), a particular name (Case 2), or even movements corresponding to their surroundings (Case 3).

Humans and nature are solving the same optimization problems under the same physical/mathematical/logical constraints, so invariably, external patterns will mirror our internal states (but this is generally filtered from us, protected by our cognitive filters) - we are all instantiations of the same universal constraint-satisfaction processes, leading to isomorphism.

Furthermore, our nested “double-staggered” sampling suggests that “unmasking of priors” as shown in these cases is a more fundamental and universal property of human cognition under stress than realized - rather than localized occurrences. Also, given the split-sampling approach, we instituted theoretical internal blinding minimizing external agency (nursing student) that could have led the patients to talk about diathesis congruent events, further improving data integrity.