Brief Lecture Notes for Unit 9
This unit covers the cognitive disorders, which involve serious disturbances in thought processes (usually involving chronic loss of reality contact) as a primary symptom. Note that there are at least a few other (non-cognitive) disorders that involve loss of reality contact (e.g., bipolar affective disorder, perhaps dissociative identity disorder), but only on an acute, not a chronic, basis.
Symptoms of the cognitive disorders
A key distinction in the cognitive disorders has to do with the distinction between so-called positive versus negative symptoms. Positive symptoms are not "positive" in the sense that they are pleasant or enjoyable! What is meant by "positive" is that something (i.e., something maladaptive or undesirable) is added to normal functioning. In contrast, with negative symptoms, something (i.e., something functional or desirable) is subtracted from normal functioning. As we'll see below, positive symptoms are usually cognitive in nature, while negative symptoms are affective, somatic, or behavioral in nature.
Characteristic positive symptoms include:
1. Overinclusive thinking -- an inability to keep one's mind "on track" and to stop the flow of free associations that can be voluntarily inhibited by normal individuals
Here is an example of what overinclusive narrative sounds like:
There exists a playing of the great things: a frank, unique, out-in-the open acknowledgment of the telepathic interface. This idea has the potential to transmute the cosmos: but only when the present alienation of the egalitarian asynchrony has been alleviated. I have nothing to say and I am saying it: and this is the secret of the universe. In 1993, I changed into two men. President Clinton was judge at my trial. I was convicted and hung. My brother and I were given back our normal bodies five years ago, and I became a policewoman. I have thoughts, these fidgeting habits. Well, yes, see, it’s been happening. I have enigmatic selfhood, but you used to know me as Franklin D. Roosevelt. The balance of forces is on my side, but there exists an asynchrony, and I am a Transformer.
2. Ideas of reference, in which events that normal individuals would call unimportant, random, meaningless, or insignificant are invested with extreme personal significance
3. Delusions, or ideas that are not supported by observation or objective reasoning, but which are deeply held (and not part of a consensual subculture)
4. Hallucinations, or sensory experiences in the absence of an external stimulus
In the spirit of the notion, emphasized throughout the course, that there is no clear-cut dividing line between normality and abnormality, we can think of each of these symptoms as pathological exaggerations of normal personality variants. It's easy to do so with the first two, at least. Certainly some of us find it easier than others to keep our mind "on track" or to keep it from "wandering" (E- O+ C- types find it hardest to focus their thinking in a linear way, and tend to be daydreamy types who chase the mental rabbit where it runs... which is why it's no surprise that most academics have this personality configuration), and taken to extremes, this becomes overinclusive thinking (uncontrolled nonlinearity and rumination). Similarly, some of us (probably O+ A+ types especially) tend to "overpersonalize" situations, or to invest them with "deep meaning" or "hidden significance", more than others; some of us "read between the lines" (which to some extent simply represents a greater propensity to what psychodynamicists would call projection and introjection) more than others, and our more solid and stolid, O- A- friends probably accuse us of "seeing things that aren't there". Taken to extremes this becomes ideas of reference. Delusions are harder to link to normal cognition, yet if you consider that some of us have viewpoints that are less likely to be accepted by the cultural majority -- are more discrepant from the prevailing Zeitgeist, are more "on the fringe" -- then you can see that ideas that are still more radically different from conventional understandings of reality might be viewed as delusional from a consensual standpoint. As for hallucinations, while these don't form part of everyday cognition for most of us, we all hallucinate every night -- we just call it dreaming -- and some of us have more vivid daydreams (sometimes taking on a pseudo-hallucinatory quality) than others as well.
In contrast, characteristic negative symptoms include:
1. Flat (or inappropriate) affect - the person seems to have no emotional capabilities, or they are expressed in ways that do not fit the outward context
2. Sizothymia - extreme levels of social withdrawal (not just shyness or introversion, but an apparent lack of any normal interest in even the most routine of social interactions)
3. Lack of behavioral flexibility which, in the most extreme cases, can become literal catatonia
Again, we don't have to look too hard to find normal variants of all of the above. Some of us are more "emotional" than others; E- A- N- types, specifically, have "flatter" affect (a more restricted emotional life) than others, and also probably show less interest in social interactivity, which is like a subclinical form of mild sizothymia. (Note that E- alone does not tend to sizoythmia; an E- A+ person, for instance, craves human interaction but probably struggles with shyness -- akin to the social phobias, but nothing at all like sizothymia. The sizothymic, remember, has no apparent desire or need for human contact.) As for catatonia, most of us aren't quite this sluggish, but it's harder to light a fire under some people than others! And some people are extremely deliberate and ritualistic in their activities (most notably E- O- C+ types).
Sidebar: Based on the above, some clinicians believe that E- (and especially E- O+ A-) types are more prone to the cognitive disorders (in terms of statistical risk), while E+ (and especially E+ O- A+) types are more prone to the affective disorders. There is, in fact, some evidence that schizophrenia (particularly the sizothymic varieties, which involve flattened affect) and bipolar affective disorder (which has the opposite or "affectothymic" characteristics, that is, wild affective swings) are negatively, not positively, correlated. If single-subject anecdotal evidence impresses you, it's perhaps of interest that John Nash, whose life story is told (with dubious accuracy, but that's another matter) in the haunting and compelling movie A Beautiful Mind, was without doubt E- O+ A-... and just as obviously cognitively disordered. An accident? Or the diathesis-stress model in action?
(On that same topic, the question of possible links between genius and mental disorder, particularly the cognitive disorders, will briefly be considered later in this unit. Stay tuned.)
Types of cognitive disorders
The schizophrenias are the major (but not the only) type of cognitive disorders. Note that while the word "schizophrenia" literally means "split mind", contrary to popular stereotypes, there is not a multiple sense of self in schizophrenia (we've already encountered that condition, in our discussion of the dissociative disorders). Rather, the "split" is between the self and the world, as the person feels increasingly "split off" from, or out of touch with, normal or conventional reality.
Based on the distinctions above, in the classic scheme of diagnosis there are four major types of schizophrenia. (see in-class flowchart also) The first two involve primarily positive symptoms, the last two primarily negative symptoms.
1. Paranoid schizophrenia in which a strong pattern of delusional thinking (often, delusions of persecution) are the major, but not the only, defined symptom; cognitions are focused and (if one accepts the underlying premises) rational or at least internally consistent
2. Disorganized or hebephrenic schizophrenia in which the other positive symptoms (particularly overinclusive thinking) predominate; delusions, if they are present, are usually not so tightly centered around ideas of persecution; cognitions are scattered and show few signs of rationality or consistency
3. Catatonic schizophrenia, in which the negative symptoms generally predominate (often but not always including literal catatonia or extremely decreased behavioral responsiveness)
4. A fourth, undifferentiated type is used when a clear diagnosis among the other three types cannot reliably be made. Usually, negative rather than positive symptoms are at least slightly more pronounced; or there is a totally mixed picture.
Paranoia (as opposed to paranoid schizophrenia) is a term sometimes used to refer to a condition in which delusional thinking is the only symptom, with no other evidences of cognitive distortion. In practice, it is difficult to distinguish from paranoid schizophrenia, above. However, the formal test is the presence of any significant symptoms other than delusional thinking. If such exist, a diagnosis of paranoid schizophrenia (versus paranoia pure and simple) is generally made.
Schizoaffective disorder is a term used to distinguish conditions in which both schizophrenic symptoms and extreme mood swings (such as might be characteristic of manic depression) are present. In this syndrome, the usual flat affect of the schizophrenias is markedly absent. Loss of reality contact is central and far more profound than the brief cognitive symptoms sometimes associated with the extremes of the manic states in bipolar affective disorder. Mood swings are more erratic and less obviously cyclic. This pattern somewhat straddles the categories of the cognitive and the affective disorders and is a difficult diagnosis to make. Note that the sizothymia-affectothymia argument above suggests that this would be a rare disorder since there is an inherent oppositional quality to the symptoms of this disorder. However, it does exist, though it may be used mostly in situations where it is difficult to determine whether the loss of reality contact in cyclic manic phases is more acute or more chronic.
Etiology of the cognitive disorders
Not surprisingly, the different schools of thought provide sharply differing perspectives on the causes (and probable cures) of the cognitive disorders. We will be examining three lines of thought in detail, one (relating to neurotransmitter imbalances) clearly drawn from the biomedical school, the other two (family systems influences and general sociocultural influences) that, while having some links to the psychodynamic and the phenomenological schools respectively, are somewhat more self-contained and somewhat divergent from the usual logic of the schools of thought that underlie them.
Biochemical influences: The most long-standing biochemical model involves imbalance in a neurotransmitter chemical known as dopamine. Evidence for this point of view includes the fact that most known antipsychotic drugs block the production of dopamine in some way (act as dopamine agonists) even though this fact was generally not known at the time the drugs were (often more or less by accident) discovered. Also, the fact that use of drugs that increase dopamine levels (often used to treat Parkinson's disease and related syndromes) can have side effects that mimic or mirror the symptoms of schizophrenia. However, at this point, little is known about the specific biochemistry of schizophrenia, other than intriguing bits of evidence related to the heritability of the illness, and related to abnormal brain structures in schizophrenics, suggest an as-yet not well understood mechanism that may involve deficits in the ability to suppress overinclusive mental associations. Dopamine may act as an endogenous hallucinogen in extreme doses, also producing some of the positive symptoms noted above.
Microcultural influences: By far the most historically controversial question has to do with the possible existence of so-called schizophrenogenic or "crazymaking" families: family structures or family constellations that produce (or increase the probability of) schizophrenia in children. The once shrill debate over this set of issues has somewhat settled down in recent decades, but there is still some likelihood that families that use frequent double bind communication patterns are more likely to produce a sense of confusion about emotionality and about external reality in children. A "double bind" is a situation in which a person is presented with inherently incompatible emotional responses or demands, as when a mother complains about her son's lack of affection yet becomes more distant or hostile when he does attempt to behave affectionately.
One influential model of family dynamics is Virginia Satir's model of congruence in communication. Communication is said to be congruent when all the elements -- words, emotions (as expressed primarily by nonverbals such as facial expressions and tone of voice), and actions all "line up" or express the same thing. When different elements do not align -- as when a person who is obviously visibly angry says "I'm not upset" -- communication is incongruent. There is good evidence that chronic incongruence in family communication patterns leads to various kinds of pathology, and may especially lead to the cognitive disorders because the child may not know which "channel" (words, nonverbals, actions) to "trust as being real" -- thus, there is a more tenuous grasp on reality, lower levels of trust (= paranoia or delusionality), and so forth.
Satir's model suggests that there are two major, and independent, dimensions along which family systems can be classified. One, the blaming vs. placating dimension, has to do with who is at fault for problems and conflicts. The other, the over-rational vs. under-rational dimensions, has to do with the primacy of analysis (the "head") versus expressivity (the "heart"), or with the primacy of serious-intellective versus playful-emotive modes of responding. Typically, people who are habitually incongruent in one way will tend to be attracted to (e.g., marry) people who have an opposite tendency (blamers marry placators, over-rationals marry under-rationals). Satir does not specifically address the question of whether one type of familial incongruence is more associated with cognitive symptoms in children specifically.
Macrocultural influences: It has long been known that there is a strong and significant negative correlation between schizophrenia and social class, but it's much less clear why this correlation occurs. One can imagine chains of cause-and-effect in both directions: is there something about the stresses of being at the bottom of the socioeconomic ladder that produces a heightened risk of schizophrenia, or is it simply that cognitively disordered individuals, because of their inability to function in normal life contexts, end up on the bottom economic rung as a result? The former is known as the social causation hypothesis, the latter as the social drift or social selection hypothesis. A third possibility is that eccentricities of various sorts are simply better tolerated among those on higher rungs of the ladder, or that different attributions are made about them (hence there are higher rates of undiagnosed cognitive disorders at higher rungs); this is the social perception hypothesis. In addition, the fact that some cultures show much higher rates of cognitive disorders than others suggest that there may be, in some as yet poorly understood way, "crazymaking" cultures. More "developed" nations (like the U.S.) tend to fare worse; can you think of why this might be so?
Cognitive disorders and intellectance?
As indicated on page 430, Box 10-1, of your text, one reason that the cognitive disorders may persist genetically despite their obvious maladaptiveness is that lesser forms of these conditions are associated with positive mental traits such as creativity and intellectuality. For instance, Karlsson (1991) notes that genetic carriers of schizophrenia (who do not themselves have the disorder, but who pass it on to their offspring) often have striking mental abilities including "a superior capacity for associative thinking". He suggests that society depends on "subclinical" schizophrenia for scientific, artistic, and cultural progress. (If this makes you think of some members of the UWMC faculty or instructional academic staff, please keep those thoughts to yourself.) Whether this model is true or not, it is now increasingly clear that many mental illnesses represent an extreme (hence pathological variant) of normal personality which, in an attenuated form, conveys definable advantages.
Study Guide
1. Explain the difference between positive and negative symptoms. Give specific examples of each kind of symptom.
2. Discuss some possible links between clinical symptoms of the cognitive disorders and normal behavioral or personality variants.
3. Be able to make specific diagnoses of cognitive disorders based on case study data, using the flowchart provided in class.
4. Discuss three major models of the etiology of cognitive disorders.
5. Discuss possible links between cognitive disorders and intellectance, as well as their implications.