The Cognitive Neuropsychology of Schizophrenia (Classic Edition)

Christopher Donald Frith

• Publisher: Psychology Press
• Year: 2015
• ISBN:
  9781317608295
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This is a classic edition of Christopher Frith's award winning book on cognitive neuropsychology and schizophrenia, which now includes a new introduction from the author. The book explores the signs and symptoms of schizophrenia using the framework of cognitive neuropsychology, looking specifically at the cognitive abnormalities that underlie these symptoms. The book won the British Psychological Society book award in 1996, and is now widely seen as a classic in the field of brain disorders.

The new introduction sees the author reflect on the influence of his research and the subsequent developments in the field, more than 20 years since the book was first published.

1 THE NATURE OF SCHIZOPHRENIA

DOI: 10.4324/9781315749174-1

What is schizophrenia?

Case 1.1

PL first entered hospital at the age of 22. He had previously been taken to prison after a violent attack on his father, whom he believed to be the devil. During the preceding few weeks PL had become withdrawn and perplexed, making reference to religious themes. At interview PL described a mass of psychopathology. Abnormalities of perception were described, “Everything was very loud. I could hear the ash cracking off the end of the cigarette and hitting the floor. When I tapped the cigarette it went ‘boom boom’. When I threw the cigarette on the floor it went thundering down”. Isolated words and auditory hallucinations of water pouring out were present day and night, and PL described himself as holding his head a few inches off the pillow to alleviate this. He was sure he had been hypnotised by unknown persons and that this had caused him to believe his father was the devil. Olfactory and tactile hallucinations were also present, and in particular all his food “tasted the wrong way round”. He believed he had “been crazy” and feared that he still was. He described with a measure of distress his loss of emotional response to things and people round him.

Case 1.2

SW was a 24-year-old mathematics teacher who was admitted to hospital after a four-week history of increasingly odd behaviour. He had left his flat and returned home, only to later leave and then return home again. SW took up sports and pursued them excessively, became uncharacteristically irritable and aggressive, unable to tolerate any music being played. He became preoccupied with incomprehensible life difficulties and expressed odd ideas, saying he should go to the police as his rent book was falsified and that he was teaching the wrong syllabus at school.

A few days after admission, SW became floridly psychotic, with grossly disordered speech¹. His affect fluctuated from tears to elation over minutes. His general manner was distant, absorbed and perplexed. He expressed the beliefs that television and radio referred to him and certain records on radio were chosen deliberately to remind him of his past life. He was convinced his food was poisoned and felt his head and genitals were compressed as a result of an aeroplane flying overhead. SW described thought insertion and thought echo and heard hallucinatory sounds of a klaxon, and occasionally single words.

There was a slow reduction of these positive² psychotic features over a four-month period of treatment with antipsychotic drugs.

Following discharge SW had severe disabling negative symptoms: a lack of spontaneity and volition, and poverty of speech. After a year, he returned to work. He remained free of psychotic features, but his family was well aware of his persisting defect.

1. see Table 6.1 for examples and definitions of disordered speech.
2. see Table 1.2 for definitions of positive symptoms.

These cases are from a large collection made by Fiona Macmillan and Eve Johnstone which are reported in Fiona Macmillan’s MD thesis (Macmillan, 1984) and are reproduced by kind permission of the author. As these cases illustrate, schizophrenia is a devastating disorder that can occur out of the blue; it wrecks promising careers; it destroys personal relationships; it ruins lives. In a survey of over 500 patients previously diagnosed schizophrenic in Harrow, a relatively affluent area on the edge of London, it was found that less than 20% were in full time work and that more than 30% had attempted to kill themselves at least once (Johnstone et al., 1991). Gunderson and Mosher (1975) have estimated that the cost of schizophrenia, in terms of treatment, care, and skills lost to the community, is at least 2% of the gross national product, i.e. about £2-3 billion per year.

The cases described above are typical of schizophrenia, and yet each case is so different from the next that it is difficult to say what they have in common. Schizophrenia is so varied in its manifestations and course that some (e.g. Boyle, 1990) have questioned whether it is a single entity at all.

Case 1.3

HM, aged 47, was a plump, pleasant woman, with an easy social manner. One year before her admission she had begun divorce proceedings, but her husband died before these plans came to fruition. The proceedings were prompted by HM developing the idea that a colleague from work had an interest in her, and that this man had enlisted the aid of groups of people who observed her. He also organised radio personalities to make reference to their liaison. HM described this surveillance as due to both paranormal and physical forces and believed it to be protective; but she had at times been fearful and was concemed that a carving knife was missing from her home and that she was followed by private detectives. These ideas had continued unabated despite having no contact with the man concerned for the preceding year. HM was admitted and rapidly transferred to day care. She clung to her ideas and was still in day care eight months later.

Nevertheless, using modern classification schemes such as PSE-CATEGO (Wing et al., 1974) and DSM-III-R (American Psychiatric Association, 1987), psychiatrists can reliably and consistently specify a group of patients whose illness may be labelled “schizophrenia” (Table 1.1).

Case 1.4

Prior to her illness, CR, aged 20, had left home and was contemplating marriage. The most striking feature at interview was CR’s disorganised behaviour. She would sit for only moments in a chair and then wander round the room, picking up articles and occasionally sitting on the floor. Her limited spontaneous speech consisted often of abrupt commands to be given something. It was almost impossible to gain her attention. She repeatedly removed her dressing gown and made highly inappropriate sexual advances to the male staff, and then tore bits off a picture of a swan. She appeared neither depressed nor elated and moved slowly. She said that God talked to her, saying “Shut up and get out of here”. When replying to an enquiry as to interference with her thinking the patient said, “The thoughts go back to the swan. I want the cross to keep it for ever and ever. It depends on the soldier Marcus the nurse”.

After 6 months in hospital, CR returned to her mother’s home, and 14 months after her first admission remains there attending a day centre. She is now extremely lethargic with affective flattening and some incongruity.

Many epidemiological studies have been conducted using classification schemes of this type (see Hare, 1982 for a review). These studies show that schizophrenia is a surprisingly common illness with a life-time risk of approximately 1 in 100 people. This risk seems to be largely independent of culture and socio-economic status. In men the most likely age of onset is in the mid-20s, but the illness can occur in children as young as eight, and typical schizophrenic symptoms can occur for the first time in the elderly. The illness is equally common in women, but the average age of onset is a few years later than in men, that is in the early 30s.

TABLE 1.1 DSM-III-R definition of schizophrenia

The patient must have characteristic psychotic symptoms for at least one week social functioning below previous levels during the disturbance no major changes in mood (depression or elation) continuous signs of the disturbance for at least 6 months no evidence of organic factors (e.g. drugs) Characteristic psychotic symptoms must include two of the following: delusions prominent hallucinations incoherence catatonic behaviour flat or grossly inappropriate affect OR (2) bizarre delusions (e.g. thought broadcasting) OR (3) prominent hallucinations of a voice with content unrelated to mood.

(see Table 1.2 for definitions of these symptoms)

The cause of schizophrenia remains unknown (for a review see Cutting, 1985), but it is generally assumed that it has an organic basis. There is strong evidence for a genetic component and some evidence that risk is increased by birth injury and by viral infection during pregnancy. There is no evidence that psychosocial factors can “cause” schizophrenia, except, possibly, in individuals already at risk.

In order to be diagnosed as schizophrenic the patient must report particular kinds of bizarre experiences and beliefs. Many of the symptoms involve hearing voices (hallucinations). These voices are described as, “discussing my actions”, “talking to me”, “repeating my thoughts”. Commonly found bizarre beliefs (delusions) are that “others can read my thoughts”, that “alien forces are controlling my actions”, that “famous people are communicating with me”, that “my actions somehow affect world events”. Table 1.2 lists these symptoms, which are often called “positive” because they are abnormal by their presence.

More rarely the patient’s speech becomes extremely difficult to understand and is described as incoherent. On the next page is an example of such speech recorded by Til Wykes from a psychiatric interview. I shall look more closely at language disorders in schizophrenia in Chapter 6.

TABLE 1.2 The major positive symptoms associated with schizophrenia

Thought insertion	Patients experience thoughts coming into their mind from an outside source
Thought broadcast	Patients experience thoughts leaving their mind and entering the minds of others
Thoughts spoken aloud/thought echo	Patients hear their thoughts spoken aloud, sometimes just after they have thought them
Thought withdrawal	Patients experience their thoughts being removed from their head
Third person auditory hallucinations	Patients hear voices discussing them in the third person, sometimes commenting on their actions
Second person auditory hallucinations	Patients hear voices talking to them
Delusions of control	Patients experience their actions as being controlled by an outside force
Delusions of reference	The actions and gestures of strangers are believed to have special relevance to the patient
Paranoid delusions	Patients believe that people are trying to harm them

We only know about the bizarre experiences and beliefs because the patient tells us about them (symptoms). In addition there are abnormalities in behaviour that we can observe (signs). For instance, the patient may show a reduction in spontaneous behaviour in many areas, resulting in poverty of speech, poverty of ideas, poverty of action, and social withdrawal (Table 1.3). These signs are called “negati...