Ontological Adaptation in Transition to Adulthood

Abstract

In this theoretical review, the neurodevelopmental model of psychotic disorders is considered within the framework of ontological development, referring to the individual-level construction of a sense of reality regarding identity and worldview. Following Erikson's theory of development, the challenge of forging a personal and social identity is a developmental process typical of late adolescence and early adulthood. Accompanying this process is a developmentally normal increase in exploratory and risk-taking behavior, which sometimes includes challenging and defying cultural norms. Although many aspects of ontological adaptation are developmentally appropriate, we argue that psychopathology such as psychosis can be rooted in an abnormal deviation of this process, in which aberrant salience accelerates the typical drive to develop a meaningful sense of identity, leading to delusion formation. By placing psychosis onset within a broader context of normal development, this model offers a humanistic approach for understanding experiences of new onset of psychotic disorders.

Delusions are a frequent symptom in psychotic disorders and represent distortions in understanding of reality. Whereas clinical practice concerns itself with recognition and treatment of hallucinations and delusions, the phenomenological investigation of psychotic disorders such as schizophrenia has revealed that these symptoms are the sequelae of profound and pervasive abnormalities in the experience of and ability to organize reality. The literature on subjective experience is a rich mine for hypotheses on the neurobiological and developmental aspects of psychosis; but advancing these hypotheses is limited by the challenge of operationalizing the diverse and complex components of how humans experience the world. The purpose of this theoretical article is to provide direction for operationalizing phenomenological constructs in neuroscience by focusing on ontological adaptation during the transition to adulthood (i.e., during adolescence).

“Ontology” here is used to refer to the structure and contents of a sense of reality, following the proposition that “reality” is constructed at individual and group levels and that the development of an individual's ontology involves a dialectic between the individual's experiences and motivations on the one hand and social context (family, peers, social institutions) on the other (Berger and Luckmann, 1967). Importantly, this construction of reality is not simply a collection of knowledge and is not synonymous with the structure of memory or crystallized intelligence; ontology incorporates valence, values, aspirations, and its own internal logic. The generic structure of ontology is likely driven by evolutionary history to incorporate the most salient types of information for survival and reproductive success, and a broad taxonomy would likely be based on organizing information about the physical, biological, and social environment (Geary, 2005). Here, we are primarily concerned with the constructed sense of reality regarding the social environment. For the purpose of this article, we assume that there is an “objective” reality but that humans can only approximate this objective reality in both group- and individual-level understanding. We refrain from assessing the fidelity of group-level or “consensus” views of reality (rooted in religion, science, ideology, etc) to objective reality, other than to note that “consensus” ontology is ever-changing and contested. Individuals thus develop both their personal understanding of reality and an understanding of what their peers believe. Furthermore, the distinction between “normal” and “abnormal” development is a longstanding matter of debate. The authors use these and related terms within the framework of contemporary psychiatric diagnostic practices, while remaining agnostic regarding the exact boundaries between normal and abnormal.

We argue that there is a normal adolescent process that involves critical restructuring of social knowledge and values inherited from childhood for the sake of forging an adult and autonomous identity. Although the most common result of ontological adaptation is the adoption of ordinary adult roles and a worldview largely conforming to prevailing social opinion, the process can include rejection of components of consensus reality—and motivation to defy conventional expectations. We argue that this is a common and cross-cultural, if not universal, phenomenon, occurring in parallel with cognitive development and neuroplasticity. This is also a process that is sensitive to stress, deficits in neurobiological development, and other adversities, which can distort the normal process toward the psychopathology characteristic of psychotic disorders.

Adolescent Development

Adolescence is the developmental period between the ages of roughly 10 and 21 characterized by increased experience and exploration of self and the surrounding environment as well as a multitude of physical, cognitive, emotional, and sexual changes. The commonly tumultuous nature of these changes has the potential to contribute to significant anxiety for the adolescent, but it also presents opportunities for the young person to have new and diverse experiences that facilitate increased social awareness, knowledge, and skills that support their transition into adulthood. Erik Erikson, a prominent developmental theorist, described adolescence as a turning point, where the young person experiences enhanced autonomous functioning, marked by the development and demonstration of increased abilities to self-govern, make decisions, and begin to establish independence from their parental figures (Santrock, 2016).

This cognitive development is facilitated by a strong exploratory and creative drive that manifests behaviorally as risk-taking and novelty-seeking (Kelley et al., 2004). The increased motivation for exploration and novelty-seeking in adolescence may be driven by steady increases in the density of dopaminergic innervations, dopamine synthetic capacity, and levels of D1 and D2 receptors (Larsen and Luna, 2018) and is paralleled by intensification of affective processing and enhanced sensitivity to social context (Crone and Dahl, 2012). Adolescents develop a stronger sense of their own social identity and understanding of the world around them, particularly through their relationships with peers. Learning to rely on peer relationships for social and emotional support helps the adolescent develop the skills necessary to establish and maintain friendly and romantic relationships throughout their lifetime. However, peer influence is one of the strongest contributors to risky adolescent behaviors, such as reckless driving, substance use, and risky sexual behaviors (Santrock, 2016). The mere presence of peers increases activation in the neural reward processing pathway, which sensitizes adolescents to the rewarding aspects of risky behaviors (Chein et al., 2011). Poor judgment and impulsivity may result from developments in the reward system (nucleus accumbens) that outpace developments in the cognitive control (medial/ventral prefrontal cortex) and harm-avoidant systems (amygdala; Ernst et al., 2006).

Adolescence is also the developmental stage where those who develop a psychiatric condition are likely to begin exhibiting symptoms characteristic of these disorders. The 1-year prevalence of a psychiatric disorder in adolescents is common and estimates range from around 15% to 30% (Merikangas et al., 2010). A systematic review of all published literature on the (median) prevalence of psychotic symptoms during two time periods (9–12 years) and (13–18 years) reported rates of 17% and 7.5%, respectively (Kelleher et al., 2012). The co-occurrence of complex developmental changes with the emergence of psychiatric disorders during adolescence warrants exploration of how the phenomenology of psychiatric symptoms can be understood within the developmental framework of transition to adulthood. In particular, evidence from developmental psychology and neuroscience, specifically concerning ontological adaptation during adolescence, may offer insight into the processes related to the emergence of psychosis symptoms.

Ontological Adaptation

Evolutionary and developmental theories of adolescence emphasize the gradual transition from dependence on parents and other guardians to autonomous functioning. This transition requires not only physiological maturation but also the development of cognitive capacities to integrate information, construct knowledge, and achieve solutions to unique problems to guide behavior, which altogether have been termed “cognitive competence” (Sun and Hui, 2012), or “cognitive control” (Crone and Dahl, 2012). Human societies are sufficiently complex such that years of education and participation are necessary before individuals can be reasonably expected to function as full-fledged members of their society. One needs to learn the “rules of the game” before one can play. Miller et al. (2012) theorize that the prolonged maturation of neocortical white matter in humans (relative to chimpanzees) is necessary to provide more time for youth to acquire this knowledge base. Longitudinal studies of white matter structure using diffusion tensor imaging have found that development of white matter, in particular cortical association tracts, persists into adulthood, with measures of microstructure for most people peaking in the third or fourth decade of life (Lebel and Beaulieu, 2011; Lebel et al., 2012). The delayed myelination of white matter tracts suggests that aspects of brain development are genetically “programmed” for prolonged maturation, anticipating that late adolescence is the species-typical period for gaining the types of experience that should drive late maturational processes. These latter processes are “experience dependent,” in the sense that they are dictated by the environmental context that is specific to the individual (Greenough et al., 1987). Corresponding to continued white matter development during adolescence is increasing synchronization of neural activity across networks, as reflected in electrophysiological signal. This development of neural synchrony is correlated with advances in cognitive performance, but shows a nonlinear pattern of development, with a period of apparent decline and reorganization in late adolescence (Uhlhaas et al., 2009).

Cognitive control and creative drive manifest in the adolescent exploration of value/belief systems, social/political opinions, occupational aspirations, and other intellectual attire of an independent member of society. Erik Erikson described this as the developmental task of developing personal identity: “The search for a new and yet reliable identity can perhaps best be seen in the persistent adolescent endeavor to define, overdefine, and redefine themselves and each other in often ruthless comparison, while a search for reliable alignments can be recognized in the restless testing of the newest in possibilities and the oldest in values” (Erikson, 1968, p. 87). These behaviors not only allow “practice” of cognitive competence (much as social play may consolidate social skills in childhood) but also serve as a basis for the development of self-identity.

Many cultures have developed traditions that provide some structure for the experience of transition to adulthood. These can include more formal rituals and celebrations, as in rites of passage or initiation, or they can be a set of common reference points to describe and explain elements of the transition period. For most individuals, these traditions and well-established pathways to adult roles limit the potentially turbulent aspects of identity formation; rebelliousness and emotional turmoil are not as typical of adolescence as many theorists assume (Offer and Sabshin, 1974). However, there are many youths whose aspirations are uncommon or deviate from what is typical within their cultural contexts; their transition to adulthood may be less smooth compared with those who take the well-beaten paths. Consolidation of a sense of identity requires exploration and a more general capacity for cognitive control as Erikson described, but also some level of creative cognition. Individuals often seek to establish themselves as unique, and able to think for themselves, and this may require some level of divergent thinking and insight, aspects of creativity that involve generating novel ideas and solutions without specific guidance or structure. For both verbal and visual tasks, the ability to find associations between random pieces of information and integrate these data into a whole is not fully developed until late adolescence (Kleibeuker et al., 2013).

Religious conversion, especially more rapid spiritual awakenings, is a relatively well-studied example of this developmental process. Early studies described sudden religious conversion as most typically a phenomenon of adolescence, marked by a phase of doubt and anxiety upon reflecting on traditional worldview, and culminating in a transcendent experience that helps to resolve the initial tension (Bagwell, 1969). Later studies provided more empirical evidence that religious conversions in youth are often preceded by periods of heightened stress, but result in self-perceived changes in identity and self-esteem (Zinnbauer and Pargament, 1998). Similarly, many cultures contain a niche for individuals who blend medical, spiritual, and prognostic practices—a role commonly termed healer or shaman. Anthropological work in many otherwise distinct cultures note similarities in how individuals are drawn to this role; these individuals—again, often adolescents or young adults—tend to display signs of preoccupation with a narrow range of ideas, exhibit behavioral changes including sleep disturbance and social withdrawal, and soon experience subjectively profound changes in their sense of reality and self (Silverman, 1967). Among the Xhosa of South Africa, Ukuthwasa is a term used to describe the profound but sometimes distressing experience of individuals who feel the calling to become a Sangoma, or a traditional South African healer. Ukuthwasa means “to be reborn,” and it signifies the individual's transition into a Sangoma. The individual with Ukuthwasa may experience emotional lability, vivid dreams, sleep disturbance, unusual perceptual experiences (e.g., hearing the voices of ancestors), and erratic behavior (Booi, 2004). The Xhosa interpret Ukuthwasa positively because those who experience it often transition into healers and the more distressing experiences, like mood instability and sleep disturbance, resolve with the assistance of a fully matured Sangoma (Niehaus et al., 2004; van der Zeijst et al., 2021). In contrast, practitioners of Western medicine may diagnose those who experience Ukuthwasa with a brief psychotic disorder or depression given experiences that align directly with symptoms of these psychiatric disorders (Booi, 2004). Relatedly, Māori also interpret some psychotic-like experiences as evidence of a unique gift or ability (Taitimu et al., 2018), and similar experiences are sometimes reported by Balinese healers (Stephen and Suryani, 2000).

Some anthropological accounts exaggerate the extent to which formative experiences for indigenous healers resemble mental illness, but the important point for the current discussion is to recognize that healers are individuals who work at the fringe of “consensus” reality, using “autonomous imagination” to navigate uncertainties, the unknown, and the unknowable (Stephen and Suryani, 2000). In some societies, this category likely includes some artists, clergy, and scholars as well as medical workers. It is possible that the predisposition to pursue these occupations overlaps with the predisposition for delusional ideation. Consistent with this, several studies have found that healthy siblings of individuals with bipolar disorder or schizophrenia are overrepresented in creative and scholarly professions (Kyaga et al., 2011; Parnas et al., 2019), and studies using polygenic risk scores for schizophrenia have found an overlap between genetic predisposition to psychosis and having a creative occupation (Power et al., 2015). Similarly, genome-wide analyses have found a genetic relationship between risk for schizophrenia or bipolar disorder and the personality trait of openness to experience (Lo et al., 2017).

Of particular interest to the current discussion is the uncommon, but not abnormal, experience of sudden insight or revelation that often accompany advances made by individuals in creative professions. The story of Archimedes' “Eureka” moment provides a classic example: after spending some time fruitlessly thinking about how to measure the volume of a crown, he suddenly develops a solution as he settles in to take a bath. The bath was seemingly unrelated to the problem at hand, but in his contemplative mindset, he was able to draw a connection between how his body displaced water and his task. The conclusions he drew were not an established part of accepted wisdom within his culture; that is, he had developed a piece of knowledge that was beyond consensus reality. His ebullient reaction to his own discovery, running through a public street naked and shouting, speaks to the motivational and emotional valence of what was otherwise a cognitive experience and, perhaps not coincidentally, resembles behavior that is not an infrequent precipitant of an emergency psychiatric evaluation.

Thus, ontological adaptation, as a task of late adolescence, can range from a relatively uncomplicated process of adopting an accessible social role and its accompanying knowledge set, to an emotionally charged voyage of discovery that may involve defying social conventions and expectations. Cases that resemble the latter may be more unusual, but they are not inherently abnormal or pathological. However, in serious mental illness, the process of ontological adaptation appears to go awry.

Psychopathology of Ontological Adaptation

The psychopathological potential of aberrant ontological adaptation is most clear in the process of delusion formation. Psychotic disorders typically present in late adolescence and early adulthood. Even among individuals without any history of psychiatric disorder, this age may be the peak period for delusional ideation (Verdoux et al., 1998). Individuals in the very early or prodromal stages of severe mental illness commonly experience a period of preoccupation with religious, philosophical, or cultural issues; this preoccupation advances to a stage of anticipation, in which some revelation of a deeper sense of reality or meaning in life seems imminent. This uncanny feeling can be exciting, frightening, or confusing, but is above all deeply compelling. In a classic account of individuals in the early stages of schizophrenia, the German psychiatrist Klaus Conrad uses the term Trema, or “stage fright,” to describe this frame of mind (Mishara, 2010). Characteristically, patients at this stage will begin reading special importance into previously mundane details of their environment, and will begin finding connections between seemingly random bits of information. This aberrant attribution of salience and the accompanying attempts to make sense of what seems to be a puzzle can lead to crystallization of delusions, in what Conrad termed an “apophany.” The American psychiatrist Malcolm Bowers also recognized this phenomenon, describing a patient's experience “…that some momentous insight has been achieved, some realization that is life-changing and sufficient to put all the past in an understandable context… The surety with which explanation and conviction come at such moments has to be recognized as deriving from the nature of this kind of consciousness, not necessarily from its cognitive content” (Bowers, 1974, p. 101). Individuals with schizophrenia can sometimes explicitly identify experiences of this kind early in the course of their illness—“One afternoon I realized the people on the radio were talking to me, much the way one has an intuition about a geometry proof, a sudden dawning of clarity or understanding. This clarity was more compelling than reality” (Weiner, 2003).

Aberrant salience, defined as an abnormal neurobiological process of identifying motivationally relevant stimuli and ideas, is associated with dysregulated mesolimbic dopaminergic activity, a well-established pathway for symptom development in schizophrenia (Kapur, 2003; Howes and Murray, 2014). The combination of aberrant salience and cognitive processes such as negative schemas, confirmation bias, and tendency to jump to conclusions provides a basis for integrating psychological and neurobiological mechanisms for understanding delusion formation in psychosis (Garety et al., 2001; Howes and Murray, 2014). We argue here that this framework can be profitably expanded by placing it in context of normative developmental processes. Trema, aberrant salience, and apophany represent a profound detour from consensus reality, but this sequence may be a recapitulation of a normal task of late adolescence: deep contemplation on developmentally important themes (one's place in the world, morality and social justice, spirituality, sexuality, etc), the search for “clues” to provide clarity and direction on these same themes, and the eventual resolution of ambivalence and uncertainty. Delusions are built on the mechanisms for developing a compelling understanding of reality and are often accompanied by new ambitions, or sense of purpose in life. This developmental context may help explain why delusions appear “hard wired” and can return in original form even after years of apparent absence due to successful treatment with antipsychotic medications (Gitlin et al., 2001; Kapur, 2003); in many cases, delusions persist despite antipsychotic treatment (Brain et al., 2018). The abnormal ontological processes of early psychosis are likely also involved in the phenomenon of poor insight. As discussed by Henriksen and Parnas (2014), patients can be understood as having a “double ontological orientation” in which they participate in both consensus reality and their individual, psychotic worldview. The latter is experienced as “intrinsic and habitual aspects of their existence and identity” (Henriksen and Parnas, 2014, p. 4) and so cannot be reconciled with contrasting perspectives offered by peers or clinicians.

Some individuals, who have suffered fewer insults to fundamental processes of neurobiological development from prenatal stages to adolescence, have had sufficient cognitive development that they can grapple with the chaotic forces of aberrant salience and heightened perception occurring in the context of ontological adaptation, although the results of the process lead to delusional ideation. In contrast, there is likely a pathway toward schizophrenia psychopathology resulting from failure to initiate or pursue ontological adaptation. This may be likely in cases where brain development has been constrained by various developmental insults, and the enormity of the tasks of adolescence may be overwhelming to the point that ontological adaptation stalls or fails completely. Failure to develop a mature sense of self-identity and/or one's sense of place in the social world can result in a chronic aloof, amotivated state, such as is seen in patients with prominent negative symptoms. Negative symptoms could theoretically develop in the context of inadequate maturation of the mesocorticolimbic dopamine system and the associated exploratory drive. However, as few patients present with purely negative symptoms or purely positive symptoms, these developmental trajectories cannot be mutually exclusive (Ahmed et al., 2018).

In this article, we have focused on the period of late adolescence and early adulthood as the modal period for both ontological adaptation and onset of psychotic disorders. With this focus, we are unable to account for the many examples of schizophrenia or delusional disorders with onset in later adulthood, or delusional ideation as it may present in other conditions. However, it is of note that people retain the capacity to shift their perspective even on deeply held beliefs throughout the lifespan, and there is no reason to assume that ontological adaptation is limited to the period of transition to adulthood. In addition, the developmental perspective offered here does not explain the wide heterogeneity in presentation of delusions. Bizarre delusions in particular are challenging to understand within the framework presented here, and this suggests the need for further investigation of the psychological and developmental factors involved in delusion formation. Another notable limitation of this theoretical framework is that we have not attempted to account for hallucinatory experiences, owing to the distinct phenomenology and neurobiology of those symptoms.

Conclusions and Directions for Future Research

Ontological adaptation, as a function of the unique experiences, motivations, and thought processes of individuals, is likely too amorphous a construct to operationalize for the purposes of empirical research. However, it is not the content or even gestalt manifestations of ontology that are important for psychosis research, but rather the mechanisms of ontological change. The experience of sudden insight offers promise as an operationalizable phenomenon of rapid ontological change. Recent studies have studied insight experiences using behavioral paradigms based on completing puzzles that can be solved through spontaneous discovery of the solution or through methodical analysis; these paradigms allow simultaneous electroencephalography or functional magnetic resonance imaging assessments (Kounios and Beeman, 2014). The experience of solving a puzzle in these paradigms may seem trivial in comparison with the more dramatic epiphanies involved in religious conversion, scientific discovery, or artistic inspiration. However, the construct validity is supported by findings that these moments of insight are characterized by feelings of reward and certainty in the truth of the insight (Danek and Wiley, 2017). Solutions to problems attained in this manner are recalled easier than solutions found via analytic methods (Danek et al., 2013). Moreover, of key relevance to extending the construct to delusion formation, the feeling of certainty remains prominent even when the solution gained by insight is incorrect (Danek and Wiley, 2017), and this subjective feeling of truthfulness may extend to information gained around the same time as insight experience, regardless of the veracity of that information (Laukkonen et al., 2020).

One of the most meaningful uses for the construct of ontological adaptation is in advancing research on the mechanisms by which stress acts as an etiological factor in psychotic disorders. Stress, broadly understood, demands adaptation, and at a psychological level the substrate for adaptation is ontology. The “affective pathway” to psychosis is compatible with the model of abnormal ontological adaptation, in the sense that stressors can act as accelerants or retardants of developmentally appropriate ontological change (Van Os et al., 2022). The personality trait of openness to experience may be useful in further studies of this pathway. As mentioned previously, genetic predisposition to high levels of openness may overlap with genetic risk for psychotic disorders (Lo et al., 2017). Multiple studies have found an association between experience of stressful life events and higher levels of openness (Allen and Lauterbach, 2007; Chiappelli et al., 2021; Hengartner et al., 2015; Hovens et al., 2016; Rahman et al., 2017). In this context, we hypothesize that openness to experience represents motivation for ontological change that is conducive to occupations valuing creative cognition, but it also represents a risk for psychopathology.

The guiding treatment philosophy for schizophrenia is articulated in the Recovery Model, which emphasizes supporting patients in identifying and pursuing their own life goals, especially with regard to finding employment, living independently, and establishing meaningful adult relationships. The framework of ontological adaptation discussed here offers a means of integrating this treatment model with phenomenological and biological research. A humanistic narrative that “normalizes” experiences of early psychosis may facilitate understanding and acceptance of the illness by patients, their family members, and providers (Garrett et al., 2006). Embedding the development of psychosis in normative development, and recognizing the possibility that this process can represent a form of personal growth, may be more acceptable and understandable to patients than explanations of identity changes in psychotic illness that focus on biological and cognitive abnormalities (Conneely et al., 2021). Interventions aimed at symptom reduction will continue to be a mainstay of treatment for the foreseeable future, but an integrated theoretical framework could orient the development of next-generation treatments toward rectifying the aberrant process of ontological adaptation. In more concrete terms, future treatments would rekindle the processes of brain plasticity typically active in late adolescence, with psychosocial support to guide patients as they resolve the “tasks” of this life stage.