Schizophrenia as a Disorder of Disorganized Focus of Attention ONLY.
Schizophrenia is THE psychiatric condition with variable manifestations involving all the major areas of a mental state examination, appearance and behaviour, thoughts and speech, cognitions, perceptions, mood, and most commonly, insight or reality-testing. Studies have long proposed schizophrenia being related to impaired regulation of attention; we propose a model explaining the entire range of manifestations as the result of a disorganized focus of attention.Explaining delusions
The cognitive model of depression proposes that patients with dysfunctional beliefs maintain these because of their selective attention to evidence that confirms these beliefs and their tendency to ignore the evidence against it. In the most severe cases, these dysfunctional beliefs may progress to delusions in which case they absolutely do not attend to evidence against their delusional beliefs and are preoccupied with the evidence and thoughts that confirm their belief system. In the case of schizophrenia, this regulation of attention is not mood dependent, it is disorganised but persistent.Autochthonous Ideas
Described as cognitive interference, the intrusive thoughts are often influenced by environmental cues (for example, thinking about alternative hypotheses of schizophrenia when reading a new one) or mood state (as in the case of anxiety or mood disorders where patients are preoccupied with worries or sad memories). The cognitive theory of obsessive-compulsive disorder proposes not the occurrence but the obsessional patient’s inability to control intrusive thoughts, which is the intrusive thoughts are normal in humans, but the inability to shift attention from them is not. A sudden delusional idea in patients with schizophrenia strongly favours the disorganized focus of attention in these patients. Objectively, ideas do not COME to mind, patients do not DEVELOP them, instead of the mind shifts (the focus of) attention to ideas.Explaining the Disorganised Behaviour and Speech
The most obvious evidence for a disorganised focus of attention in patients with schizophrenia is their disorganised speech and thoughts. Patients with the loosening of the association are said to “jump from topic to topic with now link between them.” We propose their disorganised focus of attention causes them to switch topics, much less influenced by environmental cues unlike in patients with mania, who exhibit a flight of ideas influenced by their distractibility and abundance of ideas. Patients exhibiting self-laugh or self-talk are not able to attend to the environment, despite being fully conscious. Patients with loss of self-care or avolition, in general, are not able to attend to their needs.Explaining Mood
The mood is highly intervened with the focus of attention both influencing each other. A patient with anxiety focuses attention on anxiety-related cues, a patient with infectious joviality focuses attention on cues of pleasure. In patients with schizophrenia, there is often a disconnect between the mood and their attention. A patient with incongruent affect may be describing (attending to) depressing events while smiling.Explaining Hallucinations
Affect illusions are mild perceptual abnormalities, for example, a person preoccupied with fears walking in the dark may misperceive a bush for a monster. Their perceptual abnormalities occur along a spectrum of severity. Patients with delirium may exhibit any of these, for example in a state of fear, misinterpreting a stethoscope for a snake or seeing giant scorpions on the wall.Interlinking with Biology
Attention, executive control of attention, cognitive interference are higher cognitive functions primarily ascribed to the prefrontal cortex. Dopaminergic medications, as in patients with attention deficit hyperactivity disorder, help sustain their attention. Hyperdopaminergia favours the persistence of attention to the delusional ideas and the hallucinatory voices in patients with schizophrenia unlike in patients with mood disorders in whom the delusions and hallucinations are fleeting.1. Fuster JM. Human Neuropsychology. 2015:183-235.
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