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.
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.