onto something…

Posted on Thursday 29 August 2013

by Kahn RS and Keefe RS.
JAMA Psychiatry. 2013 Aug 7. doi: 10.1001/jamapsychiatry.2013.155.
[Epub ahead of print]

Schizophrenia is currently classified as a psychotic disorder. This article posits that this emphasis on psychosis is a conceptual fallacy that has greatly contributed to the lack of progress in our understanding of this illness and hence has hampered the development of adequate treatments. Not only have cognitive and intellectual underperformance consistently been shown to be risk factors for schizophrenia, several studies have found that a decline in cognitive functioning precedes the onset of psychosis by almost a decade. Although the question of whether cognitive function continues to decline after psychosis onset is still debated, it is clear that cognitive function in schizophrenia is related to outcome and little influenced by antipsychotic treatment. Thus, our focus on defining [and preventing] the disorder on the basis of psychotic symptoms may be too narrow. Not only should cognition be recognized as the core component of the disorder, our diagnostic efforts should emphasize the changes in cognitive function that occur earlier in development. Putting the focus back on cognition may facilitate finding treatments for the illness before psychosis ever emerges.
Sometimes you run across something that’s just interesting in its own right. I found this piece in JAMA Psychiatry and it set me thinking. In my own speculating about schiziphrenia, over the years I’ve concluded as I’ve said here that the public marker, psychosis, doesn’t seem primary to me. In chronic patients, it seems to me that psychosis intervenes in response to things that happen in the world, situations the patient doesn’t understand in some way – not out of the blue. The better you know the patient, the easier it is to know the "triggers." That’s an opinion from my own patients, but also from seeing a lot of patients in emergency rooms or outreach situations.

My other impression from this same patient base is that the concreteness, literalness, difficulty with abstraction, whatever-you-want-to-call-it is always there – psychosis or not. So experience has primed me to find this article interesting. And I know when I read the "pre-psychotic" literature like the studies of Patrick McGorry, I often think they’re on the wrong track – looking for too many psychotic-like symptoms and not paying enough attention to concrete thinking.

This article addresses those points. They don’t talk about the qualitative aspects of schizophrenic thought so much, but stick to a quantitative fall in cognitive abilities. But it feels to me like they’re onto something important. We could certainly use some "onto something important" in schizophrenia research…
    August 29, 2013 | 11:35 PM

    That’s interesting. I have an uncle who had every right to be schizophrenic, and a cousin who became psychotic in his teens. I heard that what was hardest for my cousin was the time he became lucid after a psychotic episode and didn’t know what he had done or where he had been. I wasn’t around him then, I just heard about this; but after my experience with psychosis and medication I have to wonder if it was the medication that was responsible for the amnesia. I remember everything about my psychosis, and it all meant something.

    So, Mickey, what have you seen as far as what people remember about their psychosis and whether or not they want to talk about it, or benefit from it. I’m sure it varies from person to person, but since you say it’s a cognitive problem, I’m assuming that the same cognitive problems might interfere with interpretation or express feelings and fears in a language they understand whether they can describe it verbally or not.

    I’m sure I would have really been able to benefit from talking about it after I got some sleep. Instead, even referring to the content of it was notes as “lacking insight” in the medical notes. That’s just wrong.

    August 30, 2013 | 2:07 AM

    Well, if people start to use cognitive abilities as a diagnostic tools, I hope they also check which meds they’re using and understand how they may affect cognition. I got diagnosed as bipolar first and they gave me Abilify, Seroquel, etc. In some months also my motivation, thinking capabilities, etc, diminished very severely. I just answered their questions with “yes”, “no” or other simple sentences. Then they gave me diagnosis for schizophrenia and wrote among other crap that I have “concrete thinking”, “illogical thinking”, “inconsistent thinking”, etc, etc. I’m not saying these problems are always from neuroleptics, but I think it’s also true that often it’s quite hard to distinguish the effects of medication from other stuff. Dopamine antagonism probably isn’t the most effective nootropic out there.

    August 30, 2013 | 2:20 AM

    “Not only should cognition be recognized as the core component of the disorder, our diagnostic efforts should emphasize the changes in cognitive function that occur earlier in development.”

    That’s pretty similiar to how neurology already works.

    However “Putting the focus back on cognition may facilitate finding treatments for the illness before psychosis ever emerges.” sounds exactly the same as “it is clear that cognitive function in schizophrenia is related to outcome and little influenced by antipsychotic treatment”

    Whenever I hear that last line i cringe. Antipsychotics aren’t magical, they don’t treat symptoms without affecting cognition (by disurpting the brain itself). However it does imply whatever psychiatry uses to measure ‘cognition’ probably isn’t the same as in neurology.

    As far as cognitive decline goes in schizophrenia, prepare to have your mind blown. Or very very rapidly shrunk, actually.

    Really, this the crazyest thing i’ve ever seen mickey. I don’t know what else to say..

    August 30, 2013 | 3:22 AM

    I’ve said it elsewhere. Psychiatry’s greatest sin is to present the idea that “mind issues” can be treated as “organ issues”. The notion that the brain is “just another organ that can get sick” as the metaphor to explain why people go through extreme mental states is preposterous.

    In computer science the analogy would be to deny the existence of software and to treat every single software glitch as a hardware problem that requires a hardware intervention.

    Psychiatry is a fallacious endeavor. To continue with the analogy, in the world of computer science, it is very clearly understood that the nosology of hardware is very different from that of software. The people who work on software issues have very different training, and mindset, from those who work on hardware issues.

    Only in psychiatry one finds the notion that having a “broken brain” is like having a “broken brain” acceptable.

    August 30, 2013 | 12:12 PM

    Oh. my. God. From that NYT article, Side Effects May Include Lawsuits

    “Contentions that the new drugs are superior have been “greatly exaggerated,” says Dr. Jeffrey A. Lieberman, chairman of the psychiatry department at Columbia University. Such assertions, he says, “may have been encouraged by an overly expectant community of clinicians and patients eager to believe in the power of new medications.”

    The nerve of that man.

    Emergency Room
    August 30, 2013 | 12:49 PM

    By “emergency room situations” you no doubt mean forced tranquilizer drugging, which is extreme violence against people, mostly law abiding people, and a total human rights abuse. For the crime of thinking thoughts that get labeled ‘out of order’. There are better ways. Psychological crises are not ‘medical events’. Calling a round-up-and-forcibly-drug-the-problem people facility an ’emergency room’, masks the extreme violence and human rights abuses that are forever on your conscience.

    August 30, 2013 | 7:26 PM

    Per Wiley above, Lieberman says from one end (of his mouth hopefully) that antipsychotics might be exaggerated in expectation, yet didn’t we just recently hear from the other end (of his mouth again, hopefully) that pharmacology has to return to prominence for psychiatry.

    This guy has to be a politician, but, for whom is the question. And from what end will the next answer be from him as well.

    August 30, 2013 | 7:27 PM

    I echo the sentiments in this comment section. First of all, we have a problem with the construct of schizophrenia. Secondly, we have the confound of the influence of neuroleptics. Check out Eleanor Longden’s TED talk. If she has a cognitive problem, her baseline intellect must have been on a par with Einstein. Many psychiatrists confronted by someone like her, call her the exception or inaccurately diagnosed. Courtney Harding and others showed that the majority of pele given this diagnosis go on to do quite well.

    August 30, 2013 | 7:27 PM

    Have just been scanning, Clinical Neurology for Psychiatrists by David Mylund Kaufman— mostly reading the parts about MS. According to the author, about 20% of patients who had not been given a thorough examination and were diagnosed with psychogenic illness were later found to have neurologic conditions.

    There is a whole lot in this book on checking for neurological causes of problems with cognition, too. Of course, I already have my own bias toward thorough physical exams and testing before looking for psychiatric causes. The tests recommended in the book are interesting, I don’t think it would take a specialists, but it would take a significant amount of training, and retraining— he has test questions for psychiatrists so that they can see if they’re getting it.

    August 30, 2013 | 7:29 PM

    Oh, yeah. I just subscribed to the Scrib-D website, I’m not supposed to reproduce or copy what’s in it, just thought it was interesting that there was a book written by a neurologist for psychiatrists.

    August 30, 2013 | 7:32 PM

    I am writing from a conference in Norway. If want to see someone who is “onto something”, check out Jaakko Seikkula’s research on Open Dialogue.

    August 30, 2013 | 10:13 PM

    I didn’t mean to take emphasis off of the cited study’s importance, but it sounds from the publication that Psychiatry is trying to become more like Neurology.

    The problem is, whatever method of cognitive measurment was employed is unable to discern the difference form a normal person from one with the effects of psychotorpic drugs (on cognition), specifically antipsychotics..

    The effect of anitpsychotics on cognition is pretty outrageously severe.

    Measuring ‘cognition’ doesn’t change psychiatry’s approach significantly. The approach was wrong because it only works on the belief the mind is seperate from the brain. In other words, like software running on hardware.

    This is wrong because the brain doesn’t have software. Neurons are hard wired to perfrom their job. The same way transisters can be hard wired to store memories and perfrom logic without software. Structure therefore affects cognition and subjective ‘symptoms’, as does function.

    The approach that neurology took was to measure ‘cognition’ and brain function and brain structure and to correlate all 3 domains with eachother. Structure and Function directly affect ‘cognitive’ function. From this, it is implied that brain function will effect subjective symptoms of “mental illness”.

    Measuring cognitive function by itself doesn’t neccassarily work. It can be prone to that same errors as psychiatric diagnosis when cognition is measured subjectivly.

    If two psychiatrists can’t diangoses the same patient with schizophrenia using subjective symptoms, and also can’t tell a patient on an anitpsychotic apart from a non-medicated patient using subjective cognitive measurements instead, then the same problem exists unchanged.

    So to some it up, this change is more like putting a cork with a hole in it into a hole in a sinking ship.

    August 31, 2013 | 4:17 AM

    @TinCanRobot. With all due respect, I think the entire Software/Hardware metaphor is misleading. If, as you say, the brain has no software, then neither does it have hardware (at least in the sense that a computer has hardware). If you consider thoughts/ideas/perceptions to result from the differential activation of various neurones arranged in a network, you need to keep in mind that such a network is constantly dynamic at a number of levels. That is, the activation of neurones in the network, the connections between the neurones, the sensitivity of the neurones to each other, the gross structure of the network itself are in constant flux as they adapt to environmental stimulus. The sort of software-on-a-chip that you describe is not dynamic, and bears almost no resemblance (metaphorical or otherwise) with the human brain.

    Let’s not forget that the human mind has been described using analogies of clockwork, of hydraulic pressure, of computers. Just because it appeals to our sense of simplicity, don’t make it right.

    August 31, 2013 | 9:17 AM

    I remember reading as a freshman in 1990’s stuff from some philosophers and cognitive scientists (such as Daniel Dennett, etc) about this idea that mind to brain is like software to hardware, etc. The idea seemed silly then and it still is so. I stopped reading reading from that kind of thinkers, they didn’t seem useful in any way for me.

    I think that maybe in future we will figure out different kinds of network or neural algorithm level descriptions of neural communication. For instance, maybe we’ll understand the rules and algorithms by which different areas of brain function, such as general cortical algorithms of the way neurons communicate with each other, etc. I think there’s a level of thinking about brain and networks of neurons where it’s much easier to bridge the “gap” between brain and mind. However, while I think we can explain the functioning of cognition, etc, with neural algorithms, etc, much better than we can today, even that kind of explanation doesn’t explain why we have this subjective consciousness.

    Heh, this comments section has gone from neuroleptics to Open Dialogue to software/hardware analogy. Sorry. 🙂

    August 31, 2013 | 2:56 PM

    Seems to me there’s a certain tenuous thread in this thread. I’m just now looking at the radical psychological concept of “embodied cognition,” which I think is similar to what has been said about trauma and sexual abuse for some time. The idea that the effects of sexual abuse and other kinds of abuse (and healing) are embodied, and not merely a psychological, neurological, or chemical phenomenon makes sense because we humans are all these things in a web of being that is more complex than a single brain. We cannot be islands. We cannot exist outside of the web of life and living that we are in— it’s much bigger than we are. Is it so strange or “abnormal” that sometimes in the face of life that a person might become too overwhelmed to fit in or find a place in which we don’t feel hopelessly out of place and impotent or too conflicted to hold one’s self together well enough to move forward? Especially when socially isolated or trapped in pathological relationships in which we can’t win?

    The Cartesian mind/body split posits that if our bodies were shaped like vats instead of our primate form, we’d think of ourselves as a brain in a vat, as it the vat were merely a container and not as much of who we have been, are, and will be as our brain.

    We aren’t just vats with brains, or brains in a vat— we are brains/vats among brains/vats from whom we co-create identities, relationships, pecking orders, the present, the future… We do this in real-time, historic time, memory, projections into the future, in a web of relationships that is more complex than the brain itself.

    Humans can no more be separate from other humans than we can be separate from our body, or our brain can be separate from our body and have a consciousness and identity.

    Bio-bio-bio psychiatry, though it has done some good services (I suppose), is currently deluded about what it means to be a human being and what it means to be whole and to live in reasonable harmony with other humans with our dignity and respect intact.

    It is impossible to dismiss all aspects of being human but one hypothesis and not contribute to dehumanization in the name of “help”— that’s cruelty.

    And, as I’m sure everyone here knows, there is a host of what we think of as “physical” ailments with psychogenic symptoms, up to and including “depression” and “psychosis”.

    August 31, 2013 | 5:02 PM


    You are deeply misguided. The HW/SW metaphor is perfectly appropriate. We have been able to build CPUs with billions of transistors. Computers long time ago surpassed humans in doing basic computations. Even recently they have been beating world chess champions . Remember, this is “what is possible” now with current technology.

    My beef with psychiatry goes even deeper. They go around claiming the “difficulty” of “curing” such a complex organ as the brain with tens of billions of neurons. However, their “cures” and “models” are simplistic “chemical imbalance” type of solutions.

    Very contradictory. They cannot have it both ways. Either the human brain is uber complex or it is “curable” with serotonin affecting chemicals. That is where the HW/SW analogy plays a role, since it shows perfectly the kind of problems that pop up when “software” issues are dealt with as if they were “hardware” issues.

    August 31, 2013 | 5:32 PM

    Here is another excellent, amazing survivor story showing that what is stigmatized as psychosis and/or schizophrenia is often a coping device to try to cope with child abuse and trauma with insights for anyone coping with trauma:


    August 31, 2013 | 5:33 PM


    Actually, while the software/hardware analogy is annoying and misleading, the brain actually is hardware. Software is just an extension of hardware, where zeros and ones represent on and off states and are fed to transitors to perform tasks that are not hardwired.

    An ASIC chip would be an example of computer software turned into hardware. The difference between neurons and transisters is that neurons can change there hard wired connections, but transisters can not. However, they only do so to learn, not to perfrom a task.

    You should look up something called Neural Networking Software. This software was developed by applying what was known to science from Computational Neuroscience. It is a direct software emulation of components (basically a software emulation of hardware) which perform information processing the same way as neurons do.

    As a result, neural networks can learn the same way neurons do. Emotions and other types of cognitive processes stem from the physical structures of the brain which evolved to produce them. We don’t understand how that works, but we do understand the basic principle on which neurons work.

    All systems which perform information processing do it on the same basic principle. A neuron either fires or it doesn’t, a transistor is either on or it’s off. It’s not mysterious, or dynamic in perpatual flux, or anything like that.

    Neurology produced Functional tests which can detect deviation from what is considered normal brain activity. These are mathematical models, not subjective ones. EEG was invented by engineers applying what was known to science all the way back in 70’s, the new version is better and quantitative, QEEG records Voltage, Aplitude, and Frquenency. This test is used by neurology diagnose seizures (formally a mental illness). The human brain has 100 billion neurons, and no test exists to determine which neuron is connected where. We can only tell that they are either firing properly or not. It does not matter how they are connected however, either they are working properly or they are not. Mind altering drugs with treat neither situation.

    Mental illness is currently defined as deviation from a subjective norm. These subjective conditions are then treated with brain disrupting drugs, electrical injury (as QEEG changes are permanent), or psychosurgury or worse. This disruption skews all current diagnostic tests and prevents any possibility of legitimately studying patients to determine a cause or correlation using Functional or Structural tests. As a result of ingoring the brain producing the mind, psychiatry has made it impossible for anyone to study their patients in a meaningful way, one that is not qeually subjective.

    Psychiatry’s current crisis is the same as the one from 70’s – the rationalization a subjective diangosis does not exceed chance no matter how well defined a disorder is with words alone (this was the result of the DSM5 field trials). This is the same rationalization in philosophy that resulted in the creation of the scientific method in the first place.. Observations must be objective to be reproducable from one observer to another.

    That’s basically what i was trying to say. Sorry for the length! 🙂 Hope that explains it clearly, i’ll stop posting now for fear of coking up the hread.

    August 31, 2013 | 6:29 PM

    TinCanRobot ,

    You explained it very well. And to what you say, I’ll add the power of Moore’s law. You described the state of the art but if history is any guide, 10-20 years from now we’ll have computers/electronic systems with the capacity of doing more than any of us can imagine.

    And yet, in the hw/sw world, no software engineer would be taken seriously if he/she pretended to ignore the abstraction(s) that we call “software”. Imagine writing an operating system, let alone debugging it, thinking only in terms of “0s” and “1s” or “conductivity of transistors”.

    August 31, 2013 | 7:58 PM

    There aren’t any like buttons out here in these forums, so I’ll have to say that what adam said is most consistent with the way I see the world. It almost blew my mind that someone on these comment threads understands the thing.

    August 31, 2013 | 8:11 PM

    I think my explinations are too long and complicated myself; that’s what i get for being raised the son of an engineer, lol.

    I remeber a horrible experiment from the 1950’s during the cold war. I guess you could say the ‘Cartesian mind/body spli’t was actually tested – on an dog.

    This is a bit graphic, and I have no idea how we ended up talking about mind body splits. lol. It was relevant to the cognitive measurements however.

    Our bodys are complicated, our hormones influence the function of our brain, and our extended nervous system gives the brain feedback to perform information processing and learn.

    Everything is connected in medicine, every part of the body. If a person has a neurological problem it could be from a thyroid problem treated in another field, and the patient is then reffered there.

    Psychiatry claims to treat an entity sperate from the body. In fact, the latin greek roots of the word ‘psych-iatry’ means “”the specialty of healing the soul/mind”.

    The Bio-bio-bio model is basically fabricated. There aren’t special dyfunctions that produce ‘Mental illness’, rather symptoms of ‘Mental illness’ are just random symptoms of biological illness – all biological illness in general that affect the nervous system, including all known medical conditions.

    Then we have society, and oh man is that complicated. Social influences differ only in that there is no brain dysfuction. The only way to tell a patient with social factors apart from one with brain dysfuction is to use diagnostic tests for brain function and structure to rule it out or confirm it.

    Hearing voices probably isn’t learned behavior, it’s a brain dysfuction easily and realiably induced by drug overdoses, withdrawal syndromes, mercury poisoning, neurospyhilis, severe B-12 defficnecies, thyroid dysfunction etc. While the symptom itself is pure subjective conjecture to describe, an objective QEEG shows abnormal activity – just not necessarily in the same way between two patients (because symtoms are random). This doesn’t bother neurology, but undermines psychiatry.

    Cognitive decline is iplied, but it’s still subjective by itself, still prone to the same problems as diagnosing symptoms of ‘mental illness’.

    September 1, 2013 | 4:02 PM

    This is an article I found to be very interesting and relevant


    This new theory of consciousness suggests to me that some psychosis induced by extreme stress and related to trauma may be the unraveling of a model that is no longer useful or is untruthful. Working through the mental and emotional anguish can be a necessary process in order to form a newer and more serviceable model with which to perceive reality and one’s self.

    September 1, 2013 | 4:18 PM


    I, at least, loved it.


    Nonsense. Let’s be scientific for a while (I know that psychiatrists have a difficult relationship with science in general 😀 ). There is only a way to “test” the validity of any theory about “consciousness” and that would be to build a computer that is “conscious” as say Wiley is “conscious” and that would pass a “Turing test” of consciousness. Until that happens, this is just the n-the pseudoscientific attempt by neuroscientists at denying the existence of the mind.

    September 1, 2013 | 9:10 PM

    I dunno. I have assessed a lot of paranoid schizophrenics, many of whom had superior intellects, as measured by psychometric testing. Think Ted Kaczynski, the Unabomber, as an example. Maybe this new viewpoint only applies to disorganized types?

    September 1, 2013 | 10:06 PM

    CannotSay2013, that’s an odd conclusion. Michael Graziano is a neuroscientist, science is far more than proofs, and no computer could mimic human consciousness because humans aren’t computers.

    I see nothing nonsensical about thinking about some psychotic episodes as possibly being a result of a model of a particular reality that can no longer function, or that can’t be expressed through the normal language of thought, especially when it involves overwhelming psychic pain.

    The article in no way denied mind. There is no mind without consciousness. How we interpret what we are conscious of is a product of mind that models reality through many learned processes and experience.

    A child who learns “I am a monster, and everything horrible that is done to me is my fault” from birth, has a model of self that could lead to psychosis (I suppose). Any behavior contrary to that model of self could cause sufficient confusion on top of the stress of being degraded, hurt, and humiliated, that, hypothetically, a psychotic breakdown could result from that model of self and its clash with the reality of the self as innocent victim, and from being too emotionally and/or physically exhausted to deal with the pain without stepping out of the rest of life’s demands for a bit.

    September 1, 2013 | 11:16 PM


    Several things I disagree with in your posting,

    – “science is far more than proofs”. It isn’t. At least “IT SHOULDN’T”. What gives science its prestige and its high consideration in society is its ability to make falsifiable predictions that turn out to be accurate. When psychiatric charlatans talk about “science” they want to evoke in people’s minds the type of feats that are accomplished by the science that is primarily about making accurate falsifiable predictions, like, sending probes to Neptune, self driven robots to Mars or building the LHC that detects the Higgs boson. Now, psychiatry is not the only discipline that has tried to highjack science by adopting its language (all while ignoring the scientific method), but it’s the most obvious example there is of this phenomenon. Psychiatry is a belief system, a religion or a pseudo science at best. It is no science whatsoever.

    – One of the dogmas that modern neuroscience wants to pass as “fact”, despite it being a dogma, is the notion that the mind doesn’t exist as an abstraction independent of the biology that supports it. This dogma is responsible for almost everything that is wrong with psychiatry, from the very notion of “mental illness”, to the “chemical imbalance” chimera that has cut short so many innocent lives by way of SSRI induced suicides/acts of violence or the side effects of the drugs. The mind is real, just as, in the previous analogy, “Windows”, “MacOS” and Linux are real, even though if I give you a computer you cannot see either by looking at its brain (CPU/hard disk).

    If neuroscience wants to be taken seriously in this area, it will have to produce falsifiable predictions. Otherwise we are just assisting at the psychiatrization of neuroscience. Neuroscience will end up as corrupt as every area that psychiatry has touched.

    Science is not a panacea. It is a very narrow area of human knowledge. One that produces very palpable results but it is far from being the only one or the most important one for everybody. I still have to understand the “scientific” way of enjoying classical music or to love a woman.

    In my years in academia, I knnew many people who professed http://en.wikipedia.org/wiki/Scientism, which is becoming increasingly popular among neuroscientists. Alas, “popularity” and “validity” are two very different concepts, as Tom Insel pointed out in his critique of the whole DSM approach.

    September 3, 2013 | 7:32 PM

    This something all psychiatrists and interested parties should read

    Kaufman looked first to see whether the kids’ mental health tracked their SERT variants. It did: The kids with the short variant suffered twice as many mental-health problems as those with the long variant. The double whammy of abuse plus short SERT seemed to be too much.

    Then Kaufman laid both the kids’ depression scores and their SERT variants across the kids’ levels of “social support.” In this case, Kaufman narrowly defined social support as contact at least monthly with a trusted adult figure outside the home. Extraordinarily, for the kids who had it, this single, modest, closely defined social connection erased about 80 percent of the combined risk of the short SERT variant and the abuse. It came close to inoculating kids against both an established genetic vulnerability and horrid abuse.
    Or, to phrase it as Cole might, the lack of a reliable connection harmed the kids almost as much as abuse did. Their isolation wielded enough power to raise the question of what’s really most toxic in such situations. Most of the psychiatric literature essentially views bad experiences—extreme stress, abuse, violence—as toxins, and “risk genes” as quasi-immunological weaknesses that let the toxins poison us. And abuse is clearly toxic. Yet if social connection can almost completely protect us against the well-known effects of severe abuse, isn’t the isolation almost as toxic as the beatings and neglect?


Sorry, the comment form is closed at this time.