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Cognitive Implications of a “Journey Through Madness”

Misconceptions about schizophrenia http://schizophreniasucks.blogspot.com/2013/07/schizophrenia-memes.html

Elyn Saks, an accomplished Professor of Law, Psychology, and Psychiatry and the Behavioral Sciences at University of Southern California Gould School of Law, has lived with schizophrenia for her entire life.  In her memoir, “The Center Cannot Hold: My Journey Through Madness”, Saks explains that the cognitive nature of her illness was a large factor in her decision to write a book. She speaks out about how she has struggled every single day living with this disorder, yet she was ultimately incredibly cognitively and professionally successful.  Her disorder made it very difficult to hold attention in class or on school work when she was having a schizophrenic episode, and her diminished memory abilities made her work and relationships endure a different level of impairment. Elyn struggled with schizophrenia at a time when mental health was not at the forefront of societal concerns as it is today, and all of the symptoms she dealt with left her feeling alone and depressed, as making and keeping emotional connections with others was quite a troublesome task for her.  So, here is an incredibly accomplished woman working at a prestigious institution who has endured a debilitating disorder that is stereotypically portrayed and misunderstood with a connotation of violent, dangerous, and potentially crazy individuals.  The impressive work that Saks has done in sharing her story has contributed significantly to reducing the stigma of schizophrenia and has provided useful information in terms of the efficacy of various forms of treatment for the disorder, and you can click here to learn more about the efficacy of psychological treatment in schizophrenia.  My interest focused on how this crippling disorder affects individuals’ cognitive processes, in particular considering the detrimental effects it has on both memory and attention.

It is important to first give a quick overview of schizophrenia because in general, people’s beliefs about these individuals are quite often misconstrued from reality.  Schizophrenia is a serious mental disorder in which people interpret reality abnormally as it affects their ability to think, feel, and behave clearly (Tripathi, Kar, & Shukla, 2018) and impacts about 1.1% of the world’s population.  The disorder is characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behavior, and decreased participation in daily activities, as well as impaired concentration and memory. Additionally, a major issue related to the cognitive impairment of schizophrenics is that they often display poor learning and retention of verbal information.  Memory impairment is well documented in schizophrenia and various examinations of schizophrenic versus healthy individuals have suggested that there is a significant association between this disorder and the cognitive process of memory (Aleman, Hijman, de Haan, & Kahn, 1999).  But what is it about memory that makes it quite a problem for schizophrenic individuals?

All of the components of our daily lives we attempt to store into our memory systems https://meteoreducation.com/long-term-memory/

Simply put, memory can be considered as an organized filing system for information.  Classified by duration, there are three different types of memories: sensory memories, short term memories, and long term memories.  Sensory memories are the briefest form of memory, while short term memories are short term storage of a memory with minimal processing that is forgotten quickly, and long term memory is the long term storage of memory after elaborative processing has occurred. It is also critical to define the three main types of memories that can be stored in and retrieved from this long term memory, and these are episodic, semantic, and procedural memory.  Episodic memory characterizes remembrance of specific episodes or experiences in one’s life, semantic memory is for facts or knowledge, and procedural memory is for a skill or procedure.  And the last term that will need defining is working memory, which is processing a unit of information that is the current form of attention.  What has been found throughout schizophrenia research is that there is considerable impairment in both working memory and episodic memory for these individuals, with less issues discovered in terms of verbal short term memory and procedural memory (Kraguljac, Srivastava, & Lahti, 2013).  So, why might schizophrenics have a problem with working memory and episodic memory? Well, it is quite difficult to focus on anything in order to process and encode it when experiencing hallucinations, delusions, and voices inside your head.  Because working memory controls our consciousness and we need to process life instantly, it makes sense that schizophrenics might have trouble with this while experiencing an episode.  Similarly, schizophrenics have difficulty remembering specific experiences in their lives which makes sense because they are not consistently mentally present.  For example, when Elyn Saks experienced a schizophrenic episode while needing to study for an exam, she was unable to process the information she was learning due to impairment with her working memory from voices and distractions in her head.  Her episodic memory for this event would be quite poor because there was so much going on in her mind that she would hardly remember studying for a seemingly unimportant exam at the time.  For similar reasons, attention deficits are also highly common in schizophrenic individuals.

Brain activity https://www.firstpost.com/tech/science/world-schizophrenia-day-understanding-the-mental-disorder-what-you-can-do-to-help-6697541.html

Attention has been described as a filter of information, a spotlight focused on an aspect of the environment, and a glue that binds features of the environment together.  Attention is an incredibly crucial aspect of our lives as it is the first step in the learning process because we must attend to something in order to process and encode it into our memories.  An important distinction within the cognitive process of attention is that of automatic and controlled processes.  Automatic processing is processing that occurs that we are not consciously aware of, is used for tasks that we how to do, and occurs quickly.  Controlled processing, on the other hand, is processing that requires intentional effort and is slow, more time consuming, and used for new and complex tasks.  It is interesting to look at how patients with schizophrenia respond to automatic and controlled processing tasks in order to understand how they might attend to various real life attentional situations.  It has been found that schizophrenia patients have considerable issues with controlled processing tasks; however, their automatic processing stays intact (Crider, 1997).  Because controlled processes are more conscious and arduous, schizophrenics experience limited cognitive capacity in these situations.

Additionally, an important aspect of our attention and of these automatic and controlled processes is consideration of facilitation and inhibition and how these concepts might further affect schizophrenic patients.  Facilitation is the tendency to perform tasks both faster and better, while inhibition is just the opposite as it is the tendency to perform tasks slower and more poorly.  Relating to automatic and controlled processes, controlled processes can produce facilitation or inhibition, and automatic processes can produce facilitation or no effect.  Consequently, schizophrenic patients tend to struggle more with inhibition and related functions, which are detrimental effects that largely impact those who struggle.  Inhibition is arguably more important because it allows humans to resolve conflicts and distinguish between reality and fantasy, a critical skill that schizophrenics do not possess. This comes in the form of hallucinations and delusions in which, unlike healthy individuals who are able to inhibit this incoming information, schizophrenics see, hear, and believe things outside of reality because their brains cannot distinguish between reality and fantasy.

Depression’s prevalent role in schizophrenia https://psychscenehub.com/psychinsights/depression-in-schizophrenia-causes-importance-and-treatment/

Now, how do these cognitive impairments affect schizophrenic individuals? Most concretely, these people suffer from an impaired quality of life (Pascal de Raykeer et al., 2019).  Due to impaired attention and memory cognitive processes, schizophrenics struggle in many aspects of life.  And this struggle unfortunately often leads to a subsequent diagnosis of depression.  About 40% of schizophrenic individuals are reported with depression (Upthegrove, Marwaha, & Birchwood, 2017) which is an incredibly unfortunate statistic, but again not surprising after taking into account all of the mental difficulties these individuals endure.  Interestingly, older schizophrenic adults suffer most from this impaired quality of life because the discussed cognitive impairments and depression more negatively impact this population range.  Pascal de Raykeer and colleagues explain that for schizophrenic individuals aged 60 and older, schizophrenia ranks as high as third on a list of psychiatric disorders that result in a shortened life span.  It is quite sad to think that these individuals endure the challenges of this disorder their whole lives and that instead of potentially getting better as they get older, their quality of life actually decreases as they get older.  Obviously, this is not the case for all schizophrenics and treatment can be very helpful for many, however this trend has been researched and discussed consistently.

Because people subconsciously rely on their cognitive processes, episodes that take away one’s ability to think clearly, attend to information in the environment, and remember experiences make for a very dark quality of life that in turn leads to depression and other complex psychological issues.  Schizophrenia is an incredibly complicated and debilitating disorder, specifically for its impacts on daily life.  Could you imagine being in a bad enough mental state that you don’t remember to shower for a week, eat, or brush your teeth?  Or attempting to write a paper and not being able to write as much as five words because voices inside your head are talking to you? I certainly could not, but I am optimistic that there are myriads of research examining how to effectively treat Schizophrenia and that there are people, such as Elyn Saks, who are willing to share their stories and explain to the world exactly how this disorder manifests itself.



Aleman, A., Hijman, R., de Haan, E., & Kahn, R. (1999). Memory impairment in schizophrenia: A meta-analysis.  The American Journal of Psychiatry, 156, 1358–1366. doi:10.1016/s0920-9964(03)00060-4

Crider, A. (1997). Perseveration in schizophrenia. Schizophrenia Bulletin, 23(1), 63–74. doi:10.1093/schbul/23.1.63

Kraguljac, N., Srivastava, A., & Lahti, A. (2013). Memory deficits in schizophrenia: A selective review of functional magnetic resonance imaging (fMRI) studies. Behavioral Sciences, 3(3), 330–347. doi:10.3390/bs3030330

Pascal de Raykeer et al. (2019). Psychiatric symptoms and quality of life in older adults with schizophrenia spectrum disorder: results from a multicenter study. European Archives of Psychiatry and Clinical Neuroscience, 270(6), 673–688. doi:10.1007/s00406-019-01026-9 

Saks, E. (2007). The center cannot hold: My journey through madness. New York: Hachette Books. 

Tripathi, A., Kar, S. K., & Shukla, R. (2018). Cognitive deficits in schizophrenia: understanding the biological correlates and remediation strategies. Clinical Psychopharmacology and Neuroscience, 16(1), 7–17. doi:10.9758/cpn.2018.16.1.7

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