schizophrenia is a disorder which affects approximately 1% of the world population, has a 10% suicide rate, an estimated $20 billion in lost productivity and $11.1 billion in medical costs in the United States in 1980 (Andreasen, 1995). The primary characteristics are disturbed language, communication, thought and perception (Davidson, 1993 p. 1). There are two distinct types of symptoms, the positive (abnormal activity, such as delusions and hallucinations) and the negative (lack of activity, such as avolition, affective blunting) (Andreasen, 1995). Davidson (1993, p. 2) also identifies three phases of the disease process, each of which presents its own unique problems. Onset begins with social skill deterioration, and difficulty completing everyday tasks. The acute phase encompasses such items as delusions, hallucinations, and distorted thinking. Finally, the remission phase is marked by the passing of the distortions, with a return to more normal functioning, although oftentimes not as effectively as before the onset. Depending upon the phase and severity of the disease, a patient may have severely different psychological fields as well (Anscombe, 1987). However, Green (1996) points out that in a literature review, it has been shown that the degree of psychosis does not act as an indicator of the subsequent recovery.
Schizophrenia can be expressed in a patient through positive and/or negative symptoms. Both positive and negative symptoms generally result in learning difficulties, though through different mechanisms. This specifically includes (for positive symptoms), derailment, tangentiality, incoherence, illogicality, circumstantiality, pressure, distractible speech and clanging (Andreasen, Arndt, Alliger, Miller, & Flaum, 1995). For negative symptoms, the effects include psychomotor poverty, amotivation, apathy, loss of self-esteem, and reduced concern for reward and reinforcements (Hogarty and Flesher, 1992).
The results of both spectrums are exhibited in learning deficits in different areas, including: decreased attention, poor abstract thinking, poor planning and problem solving, poor memory, decreased verbal skills, poor organizational skills (Davidson, 1993, pp. 4-5), selection between relevant and irrelevant stimuli, poor flexible shifting of attention, poor comparison of earlier stimuli to current stimuli, altered evaluative higher processes (Brenner, 1986, pp. 138-139), impoverished cognitive schema, visual impairments, and chunking impairments (Hogarty and Flesher, 1992).
Schizophrenia can also be defined as an inability to sustain an intentional focus to attention. This inability can lead to a lack of control over the mental processes. The patient is at times passive within their own mind. Additionally, according to Hogarty and Flesher (1992), it appears that the patient has an inability to “self-edit”, resulting in both verbal and internal established but inappropriate responses. A result of this inability to direct a train of thought, access to long-term memory is compromised (Anscombe, 1987).
(Brenner, Hodel, Roder, & Corrigan, 1992) provide the following pictorial description (Figure 1), which shows the “vicious circles” that serve to decrease cognitive functioning and the ability to learn
Effects on Cognitive Function
Schizophrenic patients have been studied extensively for cognitive functioning. Although not all schizophrenic patients exhibit cognitive deficits (Back et al., 1996), there is ample data to show that these defects do occur with regularity.
General testing of Schizophrenics shows that in specific tests, such as the Hiscock Forced-Choice Method, schizophrenics with cognitive impairments scored with 84.72% accuracy, compared to 97.44% accuracy for those with no cognitive impairment. Additionally, the time on Rey Dot Counting differed significantly. Cognitively impaired schizophrenics took over 4.6 seconds, while those without impairment were under 3 seconds (Back et al., 1996).
Extrapyramidal symptoms (EPS) are a result of long-term antipsychotic use in schizophrenic patients. Aside from the cognitive deficits attributable to the actual disease process, it appears that the EPS itself involves the presentation of additional difficulties in learning. While some noncognitive aspects of EPS such as bradykinesia can alter the results when testing for neuropsychological deficits, statistical analysis shows that neuropsychological deficits as a result of increasing severity of EPS in the area of learning are not related to the physical manifestations (Palmer, Heaton, & Jeste, 1999).
The decreased ability on these tasks is the result of deficits in two general areas, memory and attention. These are inextricably linked within the context of learning.
Attention can be divided into two subcategories: preattentive (automatic), and selective (effortful) (Anscombe, 1987). It has been suggested that the preattentive processes are impaired, with alternative stimuli in the environment not being filtered properly. However, it is the selective attention that has been found to be more affected. It appears that schizophrenics have difficulty with the first stages of processing new material, focusing on the stimuli with selective attention (Anscombe, 1987). This can be seen in the act of the patient’s attention being captured by an irrelevant word or thought. It is as if the selective attention required to process the stimuli has been sublimated. This loss of selective attention allows the initial, preattentive forms of attention to proceed with no controls. Patients describe it as follows:
If I am reading, I may suddenly get bogged down at a word. It may be any word, even a simple word that I know well. When this happens, I can’t get past it. It’s as if I am being hypnotized by it. It’s as if I am seeing the word for the first time and in a different way from anyone else. It’s not so much that I absorb it, it’s more like it absorbs me. (Anscombe, 1987)
It’s not that I can’t concentrate right, it’s just that I can’t concentrate on the major issues. I get fogged up with all the different bits and lose the important things in the picture. I find myself paying attention to all sorts of tiny things instead of getting on with the things I should be doing. (van den Bosch, J., 1994)
A theory of this is given by Knight (1984), who has shown through Visual Backward Masking (VBM) tests, that if a significant visual stimuli is presented and immediately followed by a meaningless pattern, the identification of the significant stimuli is reduced in Schizophrenic patients. This effect is lessened as the length of time between significant stimulus and masking stimulus are presented, but never reaches the level of the control group.
If successful in bringing the stimuli to the forefront of the consciousness to process, it must be selectively acted on and compared with previous experience. Once again, this ability is impaired. Conversely to short-term and simple recognition memories, which do not require active attention, searching memory for previous experiences requires long-term memory which is based upon directed attention, which is impaired (Anscombe, 1987). This is due to the attention in the schizophrenic being inflexible. The attention may be caught by another stimuli, during the act of searching long-term memory and it will remain there, not shifting back regardless of the amount of interest it actually holds.
Memory deficits in Schizophrenia can be severe. One instructor says:
He has trouble remembering words. If I ask him to give me another word for car, he can’t. But if I put five words down and ask him to find one which means car, he’ll get it. He has little memory for things from one moment to the next. He’ll read two paragraphs and not remember a thing when we goto the questions. (Davidson, 1993, p. 45-46)
This statement itself is indicative of difficulty with retrieval of information from memory. There is also diffifficulty with recognition (though not as severe), short- and long-term memory (with short-term memory storage being more severe) (Davidson, 1993, p. 46).
Lack of attention span is indicated as a major contributor to this. Two students describe their problems with attention:
My mind is flying all over my work and I can’t seem to assimilate. I can’t recognize what I have done. I can’t seem to remember what I did yesterday. Someone asks me to think about a problem or something and I find that I can’t think. I have to go back over anything I learn, many, many times. I rely almost entirely on what I learned before I got sick. (Davidson, 1993, p. 46)
I need help remembering little things because I don’t pay attention. I’m not paying attention right now. I get distracted pretty easy. If there were a dog barking outside, I’d listen to that. I can’t stand a lot of noise when I’m working. I come to a word like that one there and I start playing around with it. (Davidson, 1993 p. 47)
medications can positively affect the attention span deficits in schizophrenic patients. By decreasing the stimuli that are disctracting, they enable the patient to spend more quality time on the task at hand. However, medications themselves can also affect the memory processes.
Drowsiness, as experienced with antipsychotic and antiparkinsonian medications, is itself a distractor, with the mind wandering more often, making staying on task more difficult. The antiparkinsonian drugs have additionally been shown to create problems with short term memory (Davidson, 1993, p. 48)
There are a number of ways in which the ability to learn can be affected. These include internal cognitive compensation by the patient, hospitalizations, medications, therapy, and educator activities.
Patients in an acute stage of Schizophrenia percieve the world as a mass of information, without an overlying view to bring it together. They are unable to process sequentially and holistically, as do most people. Instead, they revert to analytical and sequential thinking (van den Bosch, 1994). This action in itself shows the symptom of the disease. People without the illness will also revert to this thinking, but only in new or unexpected situations. The fact that the Schizophrenic does so constantly infers that they are viewing the world with little regard for stored memories and ability to see it as a whole.
They have difficulty reacting, as they cannot compare the action that has been taken by the stimulus inducing person, to a historical perspective of “Does this mean they are mad, sad,etc.” They must try to pick up on any available clues to infer the meaning of their environment. With the extra mental strain required to attempt to ferret out the truth, the whole from the details, comes hyperawareness of the surrounding world via all senses. The patient sees more acutely, hears tones more readily, but still isn’t able to react appropriately.
Additionally, the patient will often take control of many functions normally processed, autonomically, such as motor control. This splits the attention even further, ending with more confusion, and less motor control. This can result in some of the negative symptoms of Schizophrenia such as decreased purposeful movement. (van den Bosch, 1994).
These compensations, while a necessary but unwilled act on part of the patient, are not beneficial in the holistic sense. They are mentally exhausting to the patient.
Hospitalizations, with over 50% of the sufferers requiring 2 or more hospitalization periods (Davidson, 1993, p. 1), also affect learning. Motivation can be greatly decreased when a person has to interrupt their studies and lifestyle on a frequent basis. Clearly, avoiding hospitalizations as much as possible allows the patient to continue with as normal a lifestyle as possible, and increases self-esteem and motivation.
Medications used to treat Schizophrenia can be very efficacious in decreasing delusions, hallucinations and thought disorders, resulting in an increased learning ability. When used judiciously, it has been shown in some studies to be up to a 20% percentile rank increase in various cognitive measures (Forness & Kavale, 1988), although as shown below, other learning functions are hampered. The antipsychotics, which are most commonly used, act to sedate the senses, decreasing (filtering) the flow of information that is received. They have the ability to increase vigilance, but have no noticeable effect on memory (Corrigan & Penn, 1995). However, the medications themselves can have side-effects which hinder learning. These include: Drowsiness, blurred vision, and extrapyramidal effects such as akathisia (Davidson, 1993, p. 7). Extrapyramidal symptoms are controlled via antiparkinsonian drugs, which have their own side-effects such as blurring and drying of the eyes, and dry mouth. The antiparkinsonian medications have the side-effect of decreasing verbal memory, as well (Corrigan & Penn, 1995).
Drowsiness affects the ability to pay attention and stay on task, also affecting memory. It can be described as thinking through molasses. Blurring of the eyes makes it difficult for the patient to read, especially with near vision. Dry eyes can make eye wear difficult to use due to constant itching of the eyes. A dry mouth may interrupt lessons, as a patient may need to take frequent drinks of fluids. Extrapyramidal symptoms can cause a difficulty in writing from tremors, inability to stay on task due to restlessness, and disinterest in activities from akinesia.
The effects of medication on a patient, as a result, have to be carefully evaluated. Doses that are too high can cause an increase in cognitive functioning problems as well as other side effects (Brown & Sawyer, 1998, p. 49). Doses that are too low may not provide enough filtration of the stimuli. It is a careful balancing act to minimize the total disruption (unfiltered stimuli + side-effects) to the patient. Only in this way can we reach the optimum level of functioning, which will vary from patient to patient. Additionally, medication side-effects may pass with time, being more severe with initial dosing, and decreasing with the body’s acclimation to the medication over time.
Cognitive and Psychosocial Therapy
Cognitive and Psychosocial therapies have long been assumed to have no place in the remission of an acute psychotic episode. This was the place for medication. According to Beck and Rector (1998), this assumption is untrue. Using cognitive therapy similar to that used with depressed patients, they believe that gentle questioning and empirical testing regarding delusions and hallucinations can help in the abatement of active psychosis. Once the psychotic episode is in remission, the therapies can focus on the integration of the patient back into the classroom, workplace, and social settings.
It has been hypothesized that patients with Schizophrenia can be treated similarly to those with traumatic brain injury (TBI). However, this comparison fails upon closer inspection. While TBI’s have an insult and infarction to the brain, it is almost always to the higher level processes and the outer layers of the brain, often the prefrontal cortex, in those that respond to cognitive rehabilitation. In contrast, it is hypothesized those with Schizophrenia have dysfunctions resulting from errors in the brainstem and midbrain structures as well as the prefrontal cortex (Hogarty & Flesher, 1992).
Seeming to support this view, psychosocial therapy does not have a strong track record as supported by research evidence in the outcome of Schizophrenia according to Scott & Dixon (1995). They note that “on average, individual treatment does not play an important role in reducing symptoms”, and psychodynamic theory failed “… to exert any beneficial outcomes, either alone, or in combination with antipsychotic medications.” They continue to note that studies suggest that Group psychotherapy in an institutional setting may actually be more harmful than beneficial, while in an outpatient setting there has been no consistent effect on the psychopathology of the disease. In contrast, Beck & Rector (1998) believe that cognitive therapy can reduce positive symptoms, as stated above, as well as negative symptoms. However, their studies were done with patients who were actively psychotic, not those in remission and attempting to return to normal daily routines.
Psychosocial skills training has been shown to have positive impacts on the patient with Schizophrenia when followed at one year, but these gains had been lost by the second year. Additionally higher complexity tasks were less like to be generalized into the novel situtations of life, as compared to simpler tasks such as meeting a person’s eyes. There has been defined an optimum setting and method for producing these results. They include (Liberman & Green., 1992):
- Engagement of patients in brief, assimilable dialogs to engage them in personalized goal setting and endorsement of training objectives.
- Video demonstrations of the skills to be learned, with Socratic questions and answers to promote vigilance in the video viewing.
- Role-play exercises in which the patients practice those skills previously observed in the viedo and during which abundant reinforcement, cuing, prompting, and coaching are provided.
- Problem-solving exercises in which the trainer leads the patients through a series of challenges or obstacles to the successful implementation of the skills in their natural environments, requiring the patients to inductively learn how to overcome these obstacles by using a problem-solving method.
- In vivo homework exercises in which the trainer gradually fades back from the patients as they use the skills learned earlier in real-life situations.
- Keeping the training settings uncluttered and devoid of distrating stimuli.
- Posting graphic charts for clear and simple visual cuing of the learning objectives; capitalizing on dual-channel inputs, both auditory and visual.
- Using differential feedback, including mild social censure or disapproval as well as exuberant positive praise, for inappropriate and appropriate responsiveness to training steps.
- Using task analyses to break down knowledge and skills to be learned, so that learning can proceed incrementally with a shaping paradigm of reinforcing successive approximations.
- Employing overlearning and repetition and other generalization-promoting techniques for transfer of learning from training to real-life settings.
There has been an addtional type of therapy, supportive psychotherapy (Scott & Dixon, 1995), which has begun to show impact upon the patient, but is still in the stages of growth. This therapy includes items such as strengthing the theraputic alliance, enacting environmental interventions, setting limits and prohibitions, and undermining maladaptive defenses while strenghtening adaptive defenses. Brenner, Hodel, Roder & Corrigan (1992) show us a model of the relationship between social and cognitive skills. It must be identified, as noted in figure 2, what the goal of the therapy is, in order to determine what skills and abilities are to the outcomes.
It must be noted, that all forms of therapy are based upon the assumption that the patient has sufficient cognitive functioning and learning ability to benefit. According to Corrigan and Penn (1995), the level of learning ability has been shown to be directly related to outcomes of therapy.
Strategies for Help
Educators and therapists can help patients achieve their optimum learning with understanding and assistance in a number of areas, including: attendance, attention, vision problems, comprehension, delusions and hallucinations, sedation, regression, problem solving and organization, responsiveness, extrapyramidal symptoms.
Patients with Schizophrenia may have attendance problems for a number of reasons including, hospitalizations, “drug holidays” (times when a drug is stopped for a period of time, often to give relief from side-effects), and frustration with progress. Encouraging patients to return to school, being compassionate rather than angry, and working with times that side-effects of medication are less severe all can encourage the best attendance possible. (Davidson, 1993, p. 97-98)
Attention problems with from both the illness and medication occur from having to switch tasks frequently, or from distractors. Actions that will help students to maintain maximum attention include: keeping projects short, and uncomplicated, using auditory, visual and stimulus (alternate writing with reading, etc.), and asking questions concretely to refocus the student (Davidson, 1993, p. 101-102). Additionally, it has been shown that attention remediation has been helpful in attention span deficits. Options for this include training in self-instruction during a task and training by computer (Medalia, Aluma, Tryon, & Merriam, 1998).
Vision problems affect the students ability to stay on task, as they can either not see clearly, or are constantly having to rub their eyes. Patients with blurred vision can see at a distance better than near. Using big print, colored paper (or wearing colored, such as yellow, sunglasses), avoidance of flourescent lights, and magnifying glasses have been shown to be of help. Dry eyes can be assisted through the use of saline drops (Davidson, 1993, pp. 102-103).
Comphrehension is affected in schizophrenics due to their decreased ability to think abstractly, as well as decreased attention. Keeping the material to be understood short and succinct, and then asking questions that are concrete can assist in the comprehension and retainment of the material (Davidson, 1993, p. 108).
Delusions and Hallucinations are very detrimental to learning, as the patient is in a psychological state in which their reality is altered. There are a number of ways to assist this patients during their learning process. Avoidance of emotionally charged situations can help prevent the triggering of delusions. They are more likely to learn factual information, rather than emotional. Additionally, many patients with Schizophrenia have identified strategies that they can use to either “encapsulate” (essentially, to put in the background) or decrease the severity of the attack. Asking the student about these strategies beforehand, so that the instructor can coach them to use them when needed is beneficial. Continuing to stay with the subject matter, and not become a therapist to the patient during these times, with frequent cues to refocus the attention is also successful (Davidson, 1993, pp. 110, 114-115).
Sedation is a common side-effect of many of the medications used to treat Schizophrenia. Accommodation for the student is paramount. Completing more complex tasks earlier in the day is useful. Physical activity can help to offset sedation, even just a short walk when they are feeling particularly fatigued. Taking a short nap, even for a half hour has been found to be beneficial by students as well (Davidson, 1993 pp. 111-112).
Mental regression in the form of the loss of abstract thinking ability can also be seen in the schizophrenic patient. The use of less abstract and more concrete questions is the best. The same end result can be achieved, although with a more circuitous route (Davidson, 1993 pp. 118-119).
The patient may also be suffering from deficits with problem solving and organization. Teaching the student to actively and consciously problem solve is essential (such as: identify the problem, making a plan, following the plan, evaluating the results). Writing the problem and solution out for a number of different scenarios can be beneficial (Davidson, 1993 pp. 122-123).
A lack of responsiveness to the task at hand, or to the environment in general is not uncommon in schizophrenic patients. This is a difficult situation to deal with, as you are not provided with feedback as you continue. While there is no outside expression, these patients may still be experiencing internal sensation, and not be able to express it. Keeping a positive attitude, and not withdrawing from the student is important.
Extrapyramidal symptoms are physical manifestations that result from the use of antipsychotics over a long time period. There are no specific interventions that can be used other than promoting tolerance. This includes within the class setting, where other learners need to be educated about the physical manifestations, and within the educator, that the learner will often not provide neat work, and written work may not be always within the given timelines.
Memory impairment, particularly implicit as discussed earlier, can be offset by using “errorless learning” (O’Carrol, Russell, Lawrie & Johnstone, 1999). When a patient is asked the answer to a question, and they provide the wrong answer, and are eventually told the right answer, they are participating in “errorful learning” such as when a patient is told “I am thinking of something clear, cold, and wet” and then are given the chance to answer until they guess correctly or a given time period elapses. Errorless learning is when a learner is told the situation and then the answer such as “I am thinking of something clear, cold, and wet, I am thinking of ice.”, the learner will remember that answer. In the errorful learning, there are two hypotheses: that the patient has difficulty determining whether a stimulus was internally or externally generated after a time lag occurs; and all answers being remembered via implicit memory, with subsequent confusion. With errorless learning, with only one answer being provided, the patient has only one stimulus to remember, and is more likely to remember it correctly.
Schizophrenia is a disease that strikes many people while they are young, while they are still in their learning and formative years. As a result, the deficits in attention and memory that result have long-lasting consequences for the remainder of their lives.
It has been shown that there are a number of treatments available for Schizophrenia, but none of them cure the underlying pathologies that result in impaired learning. Medical treatments such as medication have been shown to have positive impacts, but also carry their own burdens, which in turn hamper the learning process, even when used judiciously. Cognitive and psychosocial therapies in the past have not shown great success with long-lasting changes. However, as we learn more about the way the human animal learns, and the effects of the disease, we are discovering more ways in which we can effect changes for longer periods of time. Many of these are outlined within this paper.
In the end result, the burden of enabling patients to learn falls to both the patient and the educator working with them. There are many simple changes, also noted, that can be made to the educational process that will assist the patient in focusing attention, and storing information more effectively. It is, in the end, a position that requires extra effort, but the skills can be easily learned, and possibly generalized to other populations with organic brain disorders.
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