This is the fourth in our series on schizoaffective disorder. The discussion so far has focused on psychosis and it’s relationship to affective states. We may experience psychosis in bipolar mania, but in schizoaffective our clinicians are looking for (or at least supposed to be looking for) evidence of “free-floating” psychosis unconnected to mania.

In real life, the quest amounts to “diagnosis impossible.” Seriously, clinicians barely have enough time to learn how to spell our names right, let along do the investigative groundwork. 

There is another twist: think of schizoaffective as “schizophrenia lite.” In schizophrenia, psychiatry is notorious for over-focusing on psychosis as the defining feature. So much so that I have attended lectures where experts have had to remind the psychiatrists in the audience that in fact psychosis may not be the main event. What psychiatry really needs to be addressing is disorganized thinking.

This is a hot research topic. Last year, at a NAMI California conference, I heard Cameron Carter of UC Davis talk about how “cognitive deficits” compromise our ability to control our own thinking and behavior.

Brain imaging studies reveal losses in gray matter volume in different areas of the brain, though this is not the same as what occurs in Alzheimer's. All the cells are there, but there appears to be a loss in connectivity. The different regions of the brain, in effect, are out of sync. Thinking gets disrupted.

In a series of web lectures on human behavioral biology, Robert Sapolsky of Stanford provided one example of disorganized thinking that may occur in schizophrenia. Just about all of us, for instance, would know that what bananas, oranges, and apples have in common is that they are all fruits. Someone whose thinking is impaired, however, might not make the connection, might respond instead that all three words have the letter “A” in them.

Ah, you say. That is definitely not you. Okay, then. Let’s consider how stress may disrupt thinking. Last year, at the 9th International Conference on Bipolar Disorder, I heard Steven Strakowski of the University of Cincinnati give the equivalent of a master’s class on the topic. His research points to the fact that on simple brain tasks we the bipolar may keep up with those who are “normal,” but we have to work our brains harder.

We have an unfortunate tendency to get stressed easily, even when euthymic. When the tasks grew more difficult (demanding near-instant responses), the “normals” exhibited an ability to slow down just long enough to recruit the thinking areas of the brain. The bipolars failed in applying the brakes. They plowed straight ahead, without cognitive support.

One of these tasks is called the “counting Stroop.” The word, “blue,” for instance may appear in green text. Your brain needs to sort out the dissonance fast.