Read the full transcript of behavioural neuroscientist Dr James Kesby’s talk titled “Decisions and deliberations: how schizophrenia is more than psychosis” at TEDxUQ 2022 conference.
Listen to the audio version here:
TRANSCRIPT:
Introduction to Schizophrenia
DR JAMES KESBY: What’s the first thing that comes to mind when you hear the word schizophrenia? Psychosis? Recreational drug use? Danger, perhaps? These are commonly the focus when we think of psychotic disorders like schizophrenia, due to both fact and myth.
And although our dialogue is much more open about mental illness these days, severe mental illnesses like schizophrenia still carry a stigma. As a behavioral neuroscientist, I spent most of my adult life trying to understand how the brain ends up manifesting the behavioral syndromes we see in disorders like schizophrenia. Our brain, this little thing up here, has as many neurons as there are stars in the galaxy. Each neuron has thousands of synapses, the little mouths they use to talk to each other, somewhere near one hundred trillion in our brain. If you took one second to count each one, you’d be there for over 30 million years.
So understanding how the brain functions is a truly daunting task, but it’s really important if we’re going to find ways to prevent and alleviate the problems associated with schizophrenia. One of the most severe mental illnesses a person can suffer from.
Facts and Myths about Schizophrenia
So let’s talk some facts and myths about schizophrenia.
Psychosis is a key feature of schizophrenia.
Fact. Psychosis is actually a group of symptoms, and they tend to surface in early adulthood when trying to figure out who we are and what we want to do. Hallucinations are common, often hearing things that aren’t real. These can be narrative. “James is putting his hand up, he’s putting his hand down.”
Or they can be more disturbing. “What are you doing here? The audience hates you.” Delusions are another symptom. Believing in something that is clearly not true, and this is unshakable regardless of the evidence presented against it.
These are often laced with a level of paranoia. “The government has put a chip in my brain to read my thoughts.” But psychosis affects other disorders too, including psychotic bipolar disorder and neurodegenerative diseases. Or you can experience psychosis after taking drugs like methamphetamine.
Psychosis makes people angry and violent.
Myth. The classic Hollywood trope is that every serial killer has schizophrenia. This somehow explains all their scary and villainous behavior. Now our views of psychotic disorders are shaped by these representations, but more likely, you could be having a chat with someone and have no idea they’ve been diagnosed with schizophrenia.
One of the things I love about my job is I get to do exactly that, and talk to a lot of people with schizophrenia. This can be anything from chatting about music to talking about the symptoms and the lived experience they have. It’s a real privilege. Around 1% of the general population will be diagnosed with a psychotic disorder in their lifetime. So let’s just unpack that a little.
Here in Queensland, Australia’s third largest state, the average public high school has 1,200 students. Statistically speaking, 12 students or half a class from each high school will suffer from a psychotic disorder in their lifetime. That’s not a trivial number, but it just shows how common these disorders are in the community.
Myth. A psychotic episode represents the most severe end of the psychosis spectrum, and it’s a terrible event in someone’s life. But the severity of these symptoms differ between people and over time. With treatment and interventions, most people with schizophrenia go through their daily lives confident they’re not going to have a psychotic episode.
The Cognitive Burden of Schizophrenia
So we’ve cleared up a few common misconceptions regarding schizophrenia. You’ll notice I focused mainly on psychosis. But what if I told you that even though it’s the most obvious behavioral aspect of the disorder, It’s not the biggest problem. Many people think that if we can stop the psychosis, we can cure the disorder. Unfortunately, cognitive problems, such as issues with planning, memory, and decision making, are considered to be the biggest burden for these individuals. And to be clear, we’re not talking big problems.
It’s the little things that most of us take for granted every day. The calculations our brains make in the background that we use to progress through the days, weeks and years of our lives. So what does this mean for someone with schizophrenia when their psychotic symptoms are under control?
Decision Making and Cognition
To explore this, I’m going to take you on a theoretical tour of decision making. So cognition and decision making are fundamental to our ability to build and maintain a successful life in this complex world.
Think of all the decisions you might make in a day. If you’re like me, you’re probably counting on your fingers. I had toast for breakfast. I finished that project at work. I called a late bus home.
Three decisions. Now we all know that’s a gross underestimation. Throughout each day, our brain is seamlessly making thousands, if not millions, of small calculations and decisions without us even realizing it. Many of these decisions take very little thought or none at all, because the outcomes are really clear, and have experienced them thousands of times before. Take looking before you cross the road.
You don’t really think about it, but you’re aiming to avoid being hit by a car. That would be a bad outcome. Now our brain navigates this with ease for the most part, different areas acting in collaboration, using our past experiences to predict the future. But sometimes outcomes aren’t as clear.
Decision Making in Real-Life Scenarios
Let’s say you’re driving to an appointment and you get stuck in traffic. You have two lanes, and you’re worried you might be late. First, you have got to consider the speed of both lanes. Is one travelling faster?
Should you switch into that lane? Some people will switch as soon as a lane changes speed, try and save every last second of their trip.
Other people are content in their lane, thinking that overall, the difference between the two is negligible. It’s the situation that determines which of those strategies is actually best. The switching strategy is best when a lane is stopped up ahead. You get into the faster lane earlier. But we’ve all seen someone change up ahead, and then we slowly pass them by.
The key is to avoid the noise and figure out which lane is travelling faster overall. And as easy as that can be to see after the fact, “Ah, I should have changed lanes back there,” In real time, that can be quite difficult.
In behavioral neuroscience, we design tasks to see how people make these choices. Rather than traffic, we use pictures, And we can provide money rewards for good choices, and losses for poor choices. Now we’re not mean, but we do like to trick people, so we’ll throw in some misleading feedback, and maybe change the rules without people realizing.
But it’s all in the name of trying to imitate real life scenarios. So, let’s make some decisions together. And don’t worry, I’m not going to pick on anyone. On the screen you’ll see two shapes: a triangle and a circle. I want you all to choose one.
Okay, so who chose the triangle? Hands up. And who chose the circle? Okay, so we expect about fifty-fifty, right? We don’t know anything about this, it makes sense.
So for those of you who chose the triangle, I tell you, “Good job! You’ve earned fifty cents.” Okay. Now I want you to make that same choice again. Who here chooses the triangle this time?
So you see, some people chose the triangle first, they won some money, so they chose the triangle again. Now I am really interested in choices like this, because my research and research from other scientists have shown that people with schizophrenia are less likely to choose the same picture after a reward than someone without schizophrenia. So in this example, someone with schizophrenia is slightly more likely to choose the circle after that first triangle.
Decision Making Under Uncertainty
But let’s up the ante a little. We still know very little about these shapes. Maybe the circle won a dollar. Let’s say I offer you a bonus twenty dollars if you can tell me which of the two shapes will win the most over the next one hundred trials, the way I’ve coded it to be. But the catch, if you choose the wrong one, you have to give me one hundred dollars. Who here is confident picking the triangle? Not many takers. It’s It’s a real shame.
Those odds heavily favour me. What if I let you peek into the future? I will show you what you will get if you chose each shape five times. So for the triangle, you can see you won on that first attempt, but then lost the next four. And the circle, ah, the circle, you won four times and only lost once.
I’m feeling generous, so I’m going to offer you that same deal as before. Who here would now pick the circle? Yeah. Okay. So we got some more takers.
See, that’s not good for me, but I think it shows how our past experiences help shape our certainty, what a future choice will give us in return. Research has shown that people with schizophrenia use less information to make these same choices as people without schizophrenia. And we call this jumping to conclusions. And it’s really interesting because this could also shape some of the psychotic symptoms we see the formation of inaccurate associations.
When some of us walk into a room, we see a flashing light up in the corner, we think nothing of it, it’s a fire alarm or something insignificant. But someone with schizophrenia might jump to the conclusion that it’s actually a video tracking monitoring system following their whereabouts. My research is interested in how the decision making changes we see and psychotic symptoms intertwine. Can we reduce psychotic symptoms by improving decision making in people with schizophrenia? I think we can, but it’s going to take time to figure that out.
So these are just a few examples, and it’s important to know that no matter what test you did, I cannot tell if you had schizophrenia. Many people with schizophrenia perform above average, and many people without schizophrenia perform below average. When we look at the group differences, we see this shift towards different decision making in people with schizophrenia.
Our brains are constantly comparing our current and past outcomes, to try and predict what a future choice will give us in return. And when you’re making millions of micro decisions every day, small differences add up. They make things like maintaining productivity at work more difficult for people with schizophrenia.
Even the simple traffic analogy from before poorer planning for delays means potentially more rushing or more being late to work. These cognitive changes in schizophrenia and other severe mental illnesses currently have no treatments, so they are ever present in these people’s lives.
Conclusion
So that’s the end of our short Behavioral Neuroscience tour. I hope you’ve learned a few things. Psychosis is only one part of schizophrenia, and maybe not the most problematic.
But also, our brain is amazing at navigating this complex world without us even realizing it. So next time you get a chance, I ask you to slow down and focus on all the little decisions you might make without realizing. Next time you’re getting ready for work, or school, or any outing for that matter, take stock of each little decision and choice and all the outcomes that are possible. When you realize you’re running late, you’ll appreciate how seamlessly our brain does this in the background. And you’ll understand how difficult it can be for some people who make the advantageous choice less often or not as quickly.
We should all appreciate that people with schizophrenia and other severe mental illnesses suffer from symptoms that make their daily lives more challenging. By understanding how our brain makes decisions, and how that’s affected in disorders like schizophrenia. I believe the neuroscience community can and will find ways to overcome these problems, and I look forward to working towards this goal with my research. But in the meantime, we can all be more mindful, accommodating and supportive of the different challenges people face. We can all help to reduce the stigma associated with mental illness.
