How Our Genomes Shape Psychiatric Symptoms

Robert A. Berezin, MD


November 09, 2018

We talk often about the role of genetics in shaping our character. Because as always, what it is to be human involves both nature and nurture. I have already addressed the nurture part in "Psychotherapy Is 'The' Biological Treatment." Here is the nature part: the role that genetic temperament plays as to how specific symptoms are created.

First, let's remember that in the play of consciousness, memory is continuous. We owe this knowledge to famed neuroscientist Eric Kandel, whose lab discovered that a prion-like protein in the brain allows for permanent memory. Our salient emotional realities are permanently mapped by the memory protein in the amygdala and limbic system of the brain. When memory tracts of sadomasochistic aggression and loveless emotional deprivation are present —that is, when one has experienced abuse —they become the foundational elements of the basic story of the play. And likewise, later traumas generate darker, engrained plays.

As I discuss in my book, Psychotherapy of Character: The Play of Consciousness in the Theater of the Brain,[1] one theory holds that there are four pairs of genetically determined temperamental elements: internalizer- externalizer, introversion-extroversion, active-passive, and participant-observer. I'll go over each of them to show how an abusive and/or depriving environment creates the range of psychiatric symptoms.

In addition, any one or the other of each pair may be predominant, or balanced. Any one of the four may have a more pronounced effect and may be more powerful than the others. By temperament, no two people are alike; by digesting our specific nurture, we all are as unique as our fingerprints. None of these positions are pathological. It is only in the context of abusive nurture that psychiatric symptoms develop.


The internalizer or externalizer position determines the "depressive" position of character. With trauma, an internalizer feels abuse taking place internally, which can manifest as self-hate: "This is my fault; I'm bad; I'm inadequate; I'm stupid; I'm ugly." Internalizers feel ashamed in the face of trauma. This defines the depressive position in the play of consciousness.

An externalizer in the same situation generates a very different scenario. Because an externalizer projects abuse onto other people, he is genetically predisposed to identify abuse, hatred, or criticism as coming from an external source. His orientation is that of a paranoid blamer. He believes people are out to get him.


Introverts operate from the point of view of oneself, whereas extroverts operate from those of other people. Introversion literally means "to turn inward." In the context of a loving enough environment, the introvert will be naturally oriented to his own internal endeavors and creative imagination. In the context of abusive nurture, the introvert will be a narcissist. He will be purely self-involved and easily injured, leading with an exposed nerve.

This is all spelled out in the in the Narcissus-Echo myth. Echo is a nymph who longs for Narcissus's love and attention. Unfortunately for her, he is completely self-absorbed, admiring his reflection in a pool of water. Echo desperately hopes and yearns for Narcissus to love her, but to no avail. In his pure self-involvement, he doesn't notice her at all. Eventually, as she waits and waits and pines for him, she loses all form. She remains only as an echo, an echo of other people, reflecting their voices back to them.

Extroverts, on the other hand, are "other-oriented." In the setting of abuse, they focus on their attacker's view of them, rather than inhabiting their own view of themselves. The extrovert takes in the other person's projection of him as lacking and defective, and identifies with it. He agrees with the injured narcissist and believes that he deserves to be attacked. His default position is one of guilt.


An individual with an active temperament naturally operates as the possessor of aggression and primarily identifies as a protector. An individual with a passive temperament does not operate as the possessor of aggression and primarily identifies as one in need of protection.

Active children sit and walk and climb early in childhood. They take off at the beach and don't look back.

One can readily tell whether a child is active or passive. Active children sit and walk and climb early in childhood. They take off at the beach and don't look back. The active child is naturally physical, physically expressive, and action-oriented. In the context of enough loving, the active child operates as a take-charge doer.

The passive child is not oriented by such an eagerness to thrive and charge into the world. In basic orientation, he is more absorbed elsewhere. He tends to be off daydreaming. He locates the protector strength and capacity outside of himself. The passive child depends more on someone else to provide shelter from the storm. He identifies as the recipient of action rather than as a doer.

A passive temperament with abuse leads to anticipating external attacks, with no possibility of protection. This generates anxiety. As the recipient of abuse, he is inclined towards masochism.

If one were active rather than passive in the context of abuse, he would generate an opposite scenario. He would have identified with the active position of dishing it out, with the potential for sadism. He would have been predisposed to become a bully and make someone else anxious, someone else the unprotected object of attack.


A participant is naturally oriented to be immersed in and emotionally involved in the "play" of consciousness; he naturally engages with the world. The natural orientation of an observer, however, is to process the world at a distance. An observer tends toward thinking, caution, circumspection, reticence —he tends toward wanting to figure things out.

For example, let's say a participant is diagnosed with lung cancer. From his emotional orientation, he plunges into pain and fear, sadness, despair, and anger. He wells up with tears, cries, and screams that his life is over. An observer type, in the same situation, removes himself to "understand" why this is happening. He distances himself from the situation and analyzes it. On what is the diagnosis based? What are the survival rates? What are the treatment options? What are the protocols, and what are the side effects of the drugs? "Understand" literally means to "stand under" and evaluate, rather than be immersed in. In that sense, one stands outside of the scenario.

We are all participants and observers in our plays. Our primary orientation is just a matter of where on the axis we fall.

In the context of abuse, a participant tends toward over emotionalism, impulsivity, loss of control, and boundary- blurring with others. This can lead to borderline personality symptoms. An extreme participant might do well to be more like an observer and pull back and have some perspective.

In contrast, an observer, in the context of abuse, tends toward distancing himself, removal, emotional withdrawal, and obsessing. This leads to schizoid-like symptoms. In fact, in the extreme, when he separates himself from feeling his anger, he is literally beside himself (with anger).

We are all participants and observers in our plays. Our primary orientation is just a matter of where on the axis we fall.

I have mentioned some of the major symptoms that are generated by our specific genetically determined temperaments. Different combinations of temperament and trauma create the entire fabric of psychiatric nosology: obsessive, compulsive, anxiety, depression, paranoia, panics, phobias, and delusions. People have character behaviors that get them into trouble—drinking, drugs, gambling, eating (anorexia, bulimia, overeating, bingeing), sexual perversions, impulsivity, rages, emotional isolation, narcissism, echoism, sadism, masochism, low self-esteem, and psychotic and manic states. They may have crises in their lives—divorce, death, loss, illness, rejections, failures, disappointments, traumas of all kinds, and posttraumas.

Human suffering does not exist in a vacuum. It flows from our damaged plays of consciousness. Because there are built-in fault lines to every problematic play, the way we break down follows along those fault lines. The way a person breaks down reflects the way he is constructed. All psychiatric suffering is the manifestation of something having gone wrong in one's internal play.

The Biology of Suffering

I will close with an essential word about synaptic neurotransmitters. The very important function of neurotransmitters is to connect the axons and dendrites of neurons in the brain. Neurotransmitters are but a part of the chain of the millions of neurons that map of the brain. When a sufficient number of neurons are connected together, it produces symbolic form. It is how human experience is present in our imagination on every level, and connects our inner and outer realities. We are constantly mapping our experience.

The issue for psychiatry is about the brain mappings that write our top- down cortical play of consciousness. Neurotransmitters are not just some stand-alone thing. Problematic plays come from sadomasochism mapped by serotonin and other transmitters in the limbic system. The synaptic mappings reflect the darkness of the play. It is the prions that keep the story intact.

The explanation as to how psychiatric symptoms appear or disappear is not about neurotransmitters themselves. It is about the overall mappings of sadomasochistic plays. Psychotherapy works by deactivating these problematic limbic mappings in the chain of memory. When a problematic mapping is deactivated, these neurotransmitters are no longer operative. And new, more positive, memory mappings take their place.

What changes our play of consciousness is mourning a problematic memory in psychotherapy, and allowing for real brain change. This happens no matter which symptoms are generated by our different genetic temperaments. This constitutes a unified field theory of psychiatry.


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