July 14, 2011 | 3
[PART 2 OF 2 BLOGS ON SCHIZOPHRENIA. PART 1.]
Before he got sick, my Uncle Glenn attended MIT and earned a master’s degree in electrical engineering. For a while, he made a living designing machine languages to, for example, recognize print and convert it to Braille. At about age 25, he had his first psychotic break. He began hallucinating and, for reasons unknown, publicly parading around in the buff. The diagnosis followed, and the treatment—Thorazine—which, along with his acumen, kept him employed as a programmer, for a time. He may have been too good at his job, because eventually got a promotion—to supervisor. The social skills required to supervise other made him so nervous he couldn’t function. His employer had to let him go.
Schizophrenia is defined as much by the absence or lack of normal functions—its so-called negative symptoms—as it is by the strange additional sensations and thoughts that accompany it. These include emotional and motivational deficits including a loss of interest in activities and an apparent emotional flattening, problems that are notoriously difficult to fix. Such problems also make socializing in a normal way an almost impossible undertaking.
Patients with schizophrenia also have cognitive difficulties. They often have trouble paying attention, remembering things, and planning or carrying out activities. And now it seems that these thinking problems also underlie many of their social and emotional issues, according to presentations made in May at the Association for Psychological Science (APS) Annual Convention in Washington, D.C. And that insight could point to new ways of ameliorating the emotional and social handicaps of the condition.
People with schizophrenia show very few outward expressions of emotion. My uncle did not laugh much. Nor did he show much annoyance, fear or sadness. But research by psychologist Ann M. Kring at the University of California, Berkeley, and her colleagues suggests that people with schizophrenia do feel. In fact, they experience emotions just as deeply as the rest of us do. One thing they don’t do as much, Kring says, is get excited about future events. Nor can they savor emotions, depriving them of a big part of a normal person’s emotional experience.
In one study Kring described at the APS convention, her team gave patients and mentally healthy individuals, who served as a comparison group, pagers that rang about eight times per day. When the pagers went off, the participants reported what they were doing, who they were with, what they were looking forward to, and whether they thought these future activities would be fun or pleasurable. Later, they relayed whether they did the activities they mentioned, and how they actually felt.
The schizophrenia patients did look forward to things, but they weren’t expecting to get much pleasure from those activities. (Those without psychosis were much more excited about what they were going to do later.) When the time for the activity came, however, the people with schizophrenia got just as much pleasure from it as others did. The schizophrenics predicted how they would feel more realistically than the regular folks. But realism, in this case, is not good. “Healthy people are overestimating how great everything is going to be. This compels us to follow through on goals,” Kring says. “So people with schizophrenia are less likely to follow through on their goals.”
In addition to predicting less pleasure, people with schizophrenia also cannot reflect on feeling good. In work published earlier this year, Kring’s team put both schizophrenia patients and mentally healthy individuals inside a scanner and showed them pictures, such as those of puppies, designed to produce positive feelings as well as images (a gun, an amputated arm) more likely to elicit negative responses. After looking at the pictures for five seconds, the participants stared at a blank screen during a 12-second delay, after which the scientists asked how the images made them feel.
The emotional reactions, and brain activity, during the five-second viewing period were similar in all the participants, Kring explained in her talk. After the delay, however, the mentally healthy people showed continued activation in the same emotional brain areas, which included the amygdala, as they savored their experience. But activity in those regions had died down in the patients, indicating that their feelings had faded. Indeed, other work by Kring’s group indicates that emotion evaporates for patients within three seconds after a stimulus disappears. “It’s out of sight, out of mind” for these individuals, she says.
In the real world, savoring an emotion often requires suppressing distracting thoughts and feelings using cognitive control mechanisms. Schizophrenics have trouble with this as well. Again, the researchers asked patients, along with mentally healthy individuals, to view emotionally evocative pictures and remember their emotions. During the 11-second interval between pictures, they were shown a new positive, negative or neutral image, after which they were supposed to press one of two buttons to indicate whether they wanted to see the original picture again (an indication of whether they remembered liking or disliking it).
Everyone did the task equally well, probably because it was fairly easy. But the brains of the schizophrenics reacted differently when the distracting pictures were emotional (as opposed to neutral). When they tried to remember their reaction, the patients’ brains showed far less activation in a region of their brains charged with cognitive control—the dorsolateral prefrontal cortex—than did the healthy people, suggesting that schizophrenia patients are less able to filter out emotional distractors. Under other circumstances, they might need this neural firepower to ignore distractions that last a lot longer or are more multifaceted, such as events that occur on a busy street. “People with schizophrenia might have more difficulty if they can’t marshal the appropriate brain resources,” Kring concludes.
Reframing the emotional difficulties schizophrenia sufferers have to include their cognitive components can aid diagnosis and treatment. Kring is co-developing a clinical rating scale for schizophrenia’s negative symptoms that distinguishes between anticipatory and in-the-moment pleasure, for example. Along with David Penn and Barbara Fredrickson at the University of North Carolina, Chapel Hill, she is also investigating the use of a new type of meditation to help people with schizophrenia identify and savor emotions, and to use emotions to guide their decisions in daily life. In one study, after six weeks of meditation, patients said they could better hold onto their emotions. The treatment also helped them experience more pleasure and made them more social, effects that lasted at least three months.
Thinking in tongues
Cognitive problems also may partly underlie the extreme social difficulties that schizophrenics have, according to Harvard psychologist Jill Hooley, who also spoke at the APS meeting. In careful observational studies, schizophrenics display weaker verbal skills—their speech is less coherent and fluent, for example. They also are less assertive and show less interest in a conversation. When they are challenged, schizophrenics tend to lie or deny any wrongdoing or inaccuracy rather than apologize or explain. They do not pick up on hints; nor do they spot faux pas.
As a result, people with schizophrenia seem odd to the rest of us, and most of them do not marry. Though more women marry than men—perhaps because the illness strikes later—as a group, these patients are more than six times less likely to find a life partner than a healthy person is.
Although most of us take for granted the ability to successfully interact with others and maintain meaningful relationships, these tasks are, in fact, quite demanding. Just having a conversation requires, for example, an ability to focus on the other person, filter out background noise, remember what he or she said and generate a relevant response—all while processing verbal and nonverbal cues and following subtle social rules. Obviously, if you can’t pay attention or remember, you will have trouble socially, Hooley says.
As a result, some clinicians have floated social skills training programs for schizophrenics that boil down complex sequences of behavior into component parts—eye contact, for example, or turn taking—then recombine them. A recent meta-analysis (statistical examination) of these programs suggests that they do improve social functioning. Early findings also indicate that targeted training may restore activity in some of the brain circuits charged with socializing that go awry in the disorder.
Some of that training might have benefited my uncle, who would have undoubtedly gained even more if he could have been tagged with a brain scan and treated before his first split with reality (see part I of this blog). I remember visiting Glenn at his home when I was a teenager. He told us about the people on the television who spoke to him. He shuffled around with little expression on his face. He didn’t ask me about my life, as most relatives did. He seemed trapped inside his head. He lived alone.
Now, though, I am daring to hope that Glenn’s experience, among those of others plagued by psychosis, will one day seem vaguely parallel to those of individuals in the past who succumbed to smallpox, rabies and polio. If there is no vaccine, exactly, for schizophrenia on the horizon, perhaps we can realistically envision a strategy that prevents it from becoming overwhelming.