I’ve actually witnessed this happen to myself, twice, as the two major episodes in my life took hold. The first episode was during my psychology PhD, which I had to abandon, and the second was 15 years later, after hitting my head on a concrete water slide. Both times, my ability to process what I was reading slowed down until it felt like I was wading through treacle. It eventually became so bad that I couldn’t hold on to the gist of a paragraph and follow a sentence from one word to the next both at the same time. Both times I was terrified that my ability to learn would never return, and reading books has always been a core part of my identity. The ability did return months later when I began to stabilise, but I think that for me, the cognitive slowdown could have been a result of my brain being overwhelmed by so much internal noise and very strong fear responses that became stronger than my logical reasoning. The underlying cause of my second episode of psychosis was indisputably inflammation caused by a blow to the head. The symptoms were almost identical to the first episode, which was caused by an overwhelming amount of psychological pain caused by trying to think my way out of an impossible dilemma with two life changing options to choose between, both of which had catastrophic consequences for everyone involved. A double bind situation in soul crushing circumstances. Inflammation again in my CNS? Makes sense to me considering what I had to go through.
It seems to me that schizophrenia (and especially MDD) are imperfect, albeit useful, categories that umbrella together multiple independent etiologies.
If so, the question becomes 'why not both neurodevelopmental and neuro degenerative?'. From what I can tell, there are a subset of people given a schizophrenia diagnosis who follow the predictable neuro developmental course you describe. The map in this case matches the territory very well.
Others' prognosis are more variable (but still meet criteria for schizophrenia). Like you mention, maybe immune or neuro degenerative processes are at play.
I really don't know what to make of the studies you go through because of concern of this problem. It's promising to find any correlations!
I think that’s definitely possible, and have heard Robin Murray say that schizophrenia will one day be like heart failure, with multiple disease pathways.
However, I haven’t seen convincing evidence that the disorder can be subtyped in practice. When looking at inflammatory markers, for example, they seem to be generally a little raised across the population with schizophrenia rather than raised in a subgroup and normal in others.
Likewise in this Jonas study - I don’t get the sense they found a subgroup who had early cognitive deficits and a subgroup with cognitive decline but rather these were found across the entire schizophrenia/psychosis group. Maybe they didn’t look for cognitive trajectories in this way though!
True schizophrenia is doubtless a single disease entity. What we call schizophrenia today though is hopelessly fragmented.
You confuse me. You say you've seen no convincing evidence, I would have said the state of play is entirely the reverse, to date there is no evidence, convincing or otherwise to so much as suggest what we call schizophrenia today is a single entity.
All evidence, and indeed basic common sense, suggests it is currently a highly heterogeneous category. I thought this was self evident and generally accepted. Every study on it in last quarter century has produced heterogeneous results, blind Freddy could tell you why that is.
What have you actually been reading this whole time? What kind of empirical observations have you personally made? What evidence would you like to see?
What attracted me to psychiatry as a medical student, the specialty I eventually chose, were these ambiguities and unanswered questions. Most all psychiatric diagnoses are based not on an understood underlying cause but similarities in presentation. The hope is that by researching similar presentations of symptoms such as in this study we can understand the root causes. But … the brain is complex, human consciousness is complex, and we understand so little. My personal guess is schizophrenia represents a type of wiring error that is unavoidable in how biology requires neural tissue to develop. A sort of neurodiversity with pathologic implications. But who knows?? I am quite excited about how recent developments in AI may help us understand at an information processing level how thought emerges.
Yes, the "clinical picture". But course, not symptoms is the most important part of any clinical picture, Kraepelin taughtus that.
A presentation is just a cross section at a moment in time. The problems with the conceptualisation of schizophrenia are starkly revealed when you examine individual course.
"Let the old men read the new books; you students should read the journals, and the old books." - William Osler
Or if you want to save a bit of time, read the history books.
I’ve actually witnessed this happen to myself, twice, as the two major episodes in my life took hold. The first episode was during my psychology PhD, which I had to abandon, and the second was 15 years later, after hitting my head on a concrete water slide. Both times, my ability to process what I was reading slowed down until it felt like I was wading through treacle. It eventually became so bad that I couldn’t hold on to the gist of a paragraph and follow a sentence from one word to the next both at the same time. Both times I was terrified that my ability to learn would never return, and reading books has always been a core part of my identity. The ability did return months later when I began to stabilise, but I think that for me, the cognitive slowdown could have been a result of my brain being overwhelmed by so much internal noise and very strong fear responses that became stronger than my logical reasoning. The underlying cause of my second episode of psychosis was indisputably inflammation caused by a blow to the head. The symptoms were almost identical to the first episode, which was caused by an overwhelming amount of psychological pain caused by trying to think my way out of an impossible dilemma with two life changing options to choose between, both of which had catastrophic consequences for everyone involved. A double bind situation in soul crushing circumstances. Inflammation again in my CNS? Makes sense to me considering what I had to go through.
Thanks for sharing your personal experience - really fascinating to hear this perspective!
Thank you. Literally, the only good thing about my battle with psychosis is what other people can learn from it. Maybe it can help others.
It seems to me that schizophrenia (and especially MDD) are imperfect, albeit useful, categories that umbrella together multiple independent etiologies.
If so, the question becomes 'why not both neurodevelopmental and neuro degenerative?'. From what I can tell, there are a subset of people given a schizophrenia diagnosis who follow the predictable neuro developmental course you describe. The map in this case matches the territory very well.
Others' prognosis are more variable (but still meet criteria for schizophrenia). Like you mention, maybe immune or neuro degenerative processes are at play.
I really don't know what to make of the studies you go through because of concern of this problem. It's promising to find any correlations!
I think that’s definitely possible, and have heard Robin Murray say that schizophrenia will one day be like heart failure, with multiple disease pathways.
However, I haven’t seen convincing evidence that the disorder can be subtyped in practice. When looking at inflammatory markers, for example, they seem to be generally a little raised across the population with schizophrenia rather than raised in a subgroup and normal in others.
Likewise in this Jonas study - I don’t get the sense they found a subgroup who had early cognitive deficits and a subgroup with cognitive decline but rather these were found across the entire schizophrenia/psychosis group. Maybe they didn’t look for cognitive trajectories in this way though!
True schizophrenia is doubtless a single disease entity. What we call schizophrenia today though is hopelessly fragmented.
You confuse me. You say you've seen no convincing evidence, I would have said the state of play is entirely the reverse, to date there is no evidence, convincing or otherwise to so much as suggest what we call schizophrenia today is a single entity.
All evidence, and indeed basic common sense, suggests it is currently a highly heterogeneous category. I thought this was self evident and generally accepted. Every study on it in last quarter century has produced heterogeneous results, blind Freddy could tell you why that is.
What have you actually been reading this whole time? What kind of empirical observations have you personally made? What evidence would you like to see?
What attracted me to psychiatry as a medical student, the specialty I eventually chose, were these ambiguities and unanswered questions. Most all psychiatric diagnoses are based not on an understood underlying cause but similarities in presentation. The hope is that by researching similar presentations of symptoms such as in this study we can understand the root causes. But … the brain is complex, human consciousness is complex, and we understand so little. My personal guess is schizophrenia represents a type of wiring error that is unavoidable in how biology requires neural tissue to develop. A sort of neurodiversity with pathologic implications. But who knows?? I am quite excited about how recent developments in AI may help us understand at an information processing level how thought emerges.
Yes, the "clinical picture". But course, not symptoms is the most important part of any clinical picture, Kraepelin taughtus that.
A presentation is just a cross section at a moment in time. The problems with the conceptualisation of schizophrenia are starkly revealed when you examine individual course.
"Let the old men read the new books; you students should read the journals, and the old books." - William Osler
Or if you want to save a bit of time, read the history books.