Schizoaffective: The Thinking Connection

Patient Expert

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.

Translate this to the real world, say to a crowded room at a family gathering. Our brains may lack the means to filter out a lot of the sensory input. We hear too many conversations going on at once. We hear background noise. On and on. We get overwhelmed very quickly. We get stressed. You're doing your best to carry on with your silly Aunt Tilly when Evil Sister barges in ...

Now add this complication: You may know that bananas, oranges, and apples are all fruits, but it may take you a bit longer than most people to make the connection. Your microprocessor, in certain situations, may be slow. So here you are, in a stressful social situation, your brain already in overdrive, suddenly having to contend with Evil Sister. Now, more than ever, you need a fast microprocessor.

In other words, if the response calls for banana, you better not be saying orange. Almost like the Stroop in being able to distinguish blue from green on the spot.

Of course, everyone knows the difference between a banana and an orange, blue from green. But factor in a faulty neural circuit or two, throw stress into the equation, and your behavior is guaranteed to come out looking odd and inappropriate, if not totally disordered.

You may be on the short list for a Nobel Prize, but if you are out of your element, unable to adapt to novel situations where you need to think fast, then you are the one wearing the dunce cap. Exhibit A: John Nash who received the Nobel in Economics but who was considered a social oddball, even in a profession (mathematics) known for its eccentrics.

Let's bring psychosis back into the discussion. According to Dr. Carter, cognitive challenges may anticipate psychosis. First, we see changes in the cortical areas dealing with "thinking". Later we see changes in the subcortical areas having to do with psychosis.

Now trace John Nash's life: Brilliance mixed with oddball behavior in his early-mid twenties giving way soon after to devastating psychosis and a major vacation from reality.

There are no easy answers here. "Thinking" is one of the greatest challenges to brain science and psychiatry, not to mention our own recovery. Whether, "normal," bipolar, schizophrenic, or schizoaffective, we all have major challenges of some sort. But that hardly means the situation is hopeless.

Much more to come ...

Previous Schizoaffective posts:

The Schizoaffective Psychosis Distinction

The Schizoaffective Conundrum

Diagnosis Impossible