A prodrome is an early stage of a condition that might have different symptoms than the full-blown version. In psychiatry, the prodrome of schizophrenia is the few-months-to-few-years period when a person is just starting to develop schizophrenia and is acting a little bit strange while still having some insight into their condition.
There’s a big push to treat schizophrenia prodrome as a critical period for intervention. Multiple studies have suggested that even though schizophrenia itself is a permanent condition which can be controlled but never cured, treating the prodrome aggressively enough can prevent full schizophrenia from ever developing at all. Advocates of this view compare it to detecting early-stage cancers, or getting prompt treatment for a developing stroke, or any of the million other examples from medicine of how you can get much better results by catching a disease very early before it has time to do damage.
These models conceptualize psychosis as “toxic” – not just unpleasant in and of itself, but damaging the brain while it’s happening. They focus on a statistic called Duration of Untreated Psychosis. The longer the DUP, the more chance psychosis has had to damage the patient before the fire gets put out and further damage is prevented. Under this model it’s vitally important to put people who seem to be getting a little bit schizophrenic on medications as soon as possible. (...)
After learning more about the biology of schizophrenia, I’ve become more willing to credit the DUP model. I can’t give great sources for this, because I’ve lost some of them, but this Friston paper, this Fletcher & Frith paper, and Surfing Uncertainty all kind of point to the same model of why untreated schizophrenia might get worse with time.
In their system, schizophrenia starts with aberrant prediction errors; the brain becomes incorrectly surprised by some sense-data. Maybe a fly buzzes by, and all of a sudden the brain shouts “WHOA! I WASN’T EXPECTING THAT! THAT CHANGES EVERYTHING!” Your brain shifts its resources to coming up with a theory of the world that explains why that fly buzzing by is so important – or perhaps which maximizes its ability to explain that particular fly at the cost of everything else.
Talk to early-stage schizophrenics, and their narrative sounds a lot like this. They’ll say something like “A fly buzzed by, and I knew somehow it was very significant. It must be a sign from God. Maybe that I should fly away from my current life.” Then you’ll tell them that’s dumb, and they’ll blink and say “Yeah, I guess it is kind of dumb, now that you mention it” and continue living a somewhat normal life.
Or they’ll say “I was wondering if I should go to the store, and then a Nike ad came on that said JUST DO IT. I knew that was somehow significant to my situation, so I figured Nike must be reading my mind and sending me messages to the TV.” Then you’ll remind them that that can’t happen, and even though it seemed so interesting that Nike sent the ad at that exact moment, they’ll back down.
But even sane people change their beliefs more in response to more evidence. If a friend stepped on my foot, I would think nothing of it. If she did it twice, I might be a little concerned. If she did it fifty times, I would have to reevaluate my belief that she was my friend. Each piece of evidence chips away at my comfortable normal belief that people don’t deliberately step on my feet – and eventually, I shift.
The same process happens as schizophrenia continues. One fly buzzing by with cosmic significance can perhaps be dismissed. But suppose the next day, a raindrop lands on your head, and there’s another aberrant prediction error burst. Was the raindrop a sign from God? The evidence against is that this is still dumb; the evidence for is that you had both the fly and the raindrop, so your theory that God is sending you signs starts looking a little stronger. I’m not talking about this on the conscious level, where the obvious conclusion is “guess I have schizophrenia”. I’m talking about the pre-conscious inferential machinery, which does its own mechanical thing and tells the conscious mind what to think.
As schizophrenics encounter more and more strange things, they (rationally) alter their high-level beliefs further and further. They start believing that God often sends signs to people. They start believing that the TV often talks especially to them. They start believing that there is a conspiracy. The more aberrant events they’re forced to explain, the more they abandon their sane views about the world (which are doing a terrible job of predicting all the strange things happening to them) and adopt psychotic ones.
But since their new worldview (God often sends signs) gives a high prior on various events being signs from God, they’ll be more willing to interpret even minor coincidences as signs, and so end up in a nasty feedback loop. From the Frith and Fletcher paper:
I think what they are saying is that, as the world becomes even more random and confusing, the brain very slowly adjusts its highest level parameters. It concludes, on a level much deeper than consciousness, that the world does not make sense, that it’s not really useful to act because it’s impossible to predict the consequences of actions, and that it’s not worth drawing on prior knowledge because anything could happen at any time. It gets a sort of learned helplessness about cognition, where since it never works it’s not even worth trying. The onslaught of random evidence slowly twists the highest-level beliefs into whatever form best explains random evidence (usually: that there’s a conspiracy to do random things), and twists the fundamental parameters into a form where they expect evidence to be mostly random and aren’t going to really care about it one way or the other. (...)
The Frith and Fletcher paper also tipped me off to this excellent first-person account by former-schizophrenic-turned psychologist Peter Chadwick:
There’s a big push to treat schizophrenia prodrome as a critical period for intervention. Multiple studies have suggested that even though schizophrenia itself is a permanent condition which can be controlled but never cured, treating the prodrome aggressively enough can prevent full schizophrenia from ever developing at all. Advocates of this view compare it to detecting early-stage cancers, or getting prompt treatment for a developing stroke, or any of the million other examples from medicine of how you can get much better results by catching a disease very early before it has time to do damage.
These models conceptualize psychosis as “toxic” – not just unpleasant in and of itself, but damaging the brain while it’s happening. They focus on a statistic called Duration of Untreated Psychosis. The longer the DUP, the more chance psychosis has had to damage the patient before the fire gets put out and further damage is prevented. Under this model it’s vitally important to put people who seem to be getting a little bit schizophrenic on medications as soon as possible. (...)
After learning more about the biology of schizophrenia, I’ve become more willing to credit the DUP model. I can’t give great sources for this, because I’ve lost some of them, but this Friston paper, this Fletcher & Frith paper, and Surfing Uncertainty all kind of point to the same model of why untreated schizophrenia might get worse with time.
In their system, schizophrenia starts with aberrant prediction errors; the brain becomes incorrectly surprised by some sense-data. Maybe a fly buzzes by, and all of a sudden the brain shouts “WHOA! I WASN’T EXPECTING THAT! THAT CHANGES EVERYTHING!” Your brain shifts its resources to coming up with a theory of the world that explains why that fly buzzing by is so important – or perhaps which maximizes its ability to explain that particular fly at the cost of everything else.
Talk to early-stage schizophrenics, and their narrative sounds a lot like this. They’ll say something like “A fly buzzed by, and I knew somehow it was very significant. It must be a sign from God. Maybe that I should fly away from my current life.” Then you’ll tell them that’s dumb, and they’ll blink and say “Yeah, I guess it is kind of dumb, now that you mention it” and continue living a somewhat normal life.
Or they’ll say “I was wondering if I should go to the store, and then a Nike ad came on that said JUST DO IT. I knew that was somehow significant to my situation, so I figured Nike must be reading my mind and sending me messages to the TV.” Then you’ll remind them that that can’t happen, and even though it seemed so interesting that Nike sent the ad at that exact moment, they’ll back down.
But even sane people change their beliefs more in response to more evidence. If a friend stepped on my foot, I would think nothing of it. If she did it twice, I might be a little concerned. If she did it fifty times, I would have to reevaluate my belief that she was my friend. Each piece of evidence chips away at my comfortable normal belief that people don’t deliberately step on my feet – and eventually, I shift.
The same process happens as schizophrenia continues. One fly buzzing by with cosmic significance can perhaps be dismissed. But suppose the next day, a raindrop lands on your head, and there’s another aberrant prediction error burst. Was the raindrop a sign from God? The evidence against is that this is still dumb; the evidence for is that you had both the fly and the raindrop, so your theory that God is sending you signs starts looking a little stronger. I’m not talking about this on the conscious level, where the obvious conclusion is “guess I have schizophrenia”. I’m talking about the pre-conscious inferential machinery, which does its own mechanical thing and tells the conscious mind what to think.
As schizophrenics encounter more and more strange things, they (rationally) alter their high-level beliefs further and further. They start believing that God often sends signs to people. They start believing that the TV often talks especially to them. They start believing that there is a conspiracy. The more aberrant events they’re forced to explain, the more they abandon their sane views about the world (which are doing a terrible job of predicting all the strange things happening to them) and adopt psychotic ones.
But since their new worldview (God often sends signs) gives a high prior on various events being signs from God, they’ll be more willing to interpret even minor coincidences as signs, and so end up in a nasty feedback loop. From the Frith and Fletcher paper:
Ultimately, someone with schizophrenia will need to develop a set of beliefs that must account for a great deal of strange and sometimes contradictory data. Very commonly they come to believe that they are being persecuted: delusions of persecution are one of the most striking and common of the positive symptoms of schizophrenia, and the cause of a great deal of suffering. If one imagines trying to make some sense of a world that has become strange and inconsistent, pregnant with sinister meaning and messages, the sensible conclusion might well be that one is being deliberately deceived. This belief might also require certain other changes in the patient’s view of the world. They may have to abandon a succession of models and even whole classes of models.A few paragraphs later, they expand their theory to the negative symptoms of schizophrenia. That is: advanced-stage schizophrenics tend to end up in a depressed-like state where they rarely do anything or care about anything. (...)
I think what they are saying is that, as the world becomes even more random and confusing, the brain very slowly adjusts its highest level parameters. It concludes, on a level much deeper than consciousness, that the world does not make sense, that it’s not really useful to act because it’s impossible to predict the consequences of actions, and that it’s not worth drawing on prior knowledge because anything could happen at any time. It gets a sort of learned helplessness about cognition, where since it never works it’s not even worth trying. The onslaught of random evidence slowly twists the highest-level beliefs into whatever form best explains random evidence (usually: that there’s a conspiracy to do random things), and twists the fundamental parameters into a form where they expect evidence to be mostly random and aren’t going to really care about it one way or the other. (...)
The Frith and Fletcher paper also tipped me off to this excellent first-person account by former-schizophrenic-turned psychologist Peter Chadwick:
At this time, a powerful idea of reference also overcame me from a television episode of Colombo and impulsively I decided to write letters to friends and colleagues about “this terrible persecution.” It was a deadly mistake. After a few replies of the “we’ve not heard anything” variety, my subsequent (increasingly overwrought) letters, all of them long, were not answered. But nothing stimulates paranoia better than no feedback, and once you have conceived a delusion, something is bound to happen to confirm it. When phrases from the radio echoed phrases I had used in those very letters, it was “obvious” that the communications had been passed on to radio and then television personnel with the intent of influencing and mocking me. After all betrayal was what I was used to, why should not it be carrying on now? It seemed sensible. So much for my bonding with society. It was totally gone. I was alone and now trusted no one (if indeed my capacity to trust people [particularly after school] had ever been very high).
The unfortunate tirade of coincidences that shifted my mentality from sane to totally insane has been described more fully in a previous offering. From a meaningless life, a relationship with the world was reconstructed by me that was spectacularly meaningful and portentous even if it was horrific. Two typical days from this episode I have recalled as best I could and also published previously. The whole experience was so bizarre it is as if imprinted in my psyche in what could be called “floodlit memory” fashion. Out of the coincidences picked up on, on radio and television, coupled with overheard snatches of conversation in the street, it was “clear” to me that the media torment, orchestrated as inferred at the time by what I came to call “The Organization,” had one simple message: “Change or die!” Tellingly my mother (by then deceased) had had a fairly similar attitude. It even crossed my (increasingly loosely associated) mind that she had had some hand in all this from beyond the grave […]
As my delusional system expanded and elaborated, it was as if I was not “thinking the delusion,” the delusion was “thinking me!” I was totally enslaved by the belief system. Almost anything at all happening around me seemed at least “relevant” and became, as Piaget would say, “assimilated” to it. Another way of putting things was that confirmation bias was massively amplified, everything confirmed and fitted the delusion, nothing discredited it. Indeed, the very capacity to notice and think of refutatory data and ideas was completely gone. Confirmation bias was as if “galloping,” and I could not stop it.
As coincidences jogged and jolted me in this passive, vehicular state into the “realization” that my death was imminent, it was time to listen out for how the suicide act should be committed. “He has to do it by bus then?!” a man coincidentally shouted to another man in the office where I had taken an accounts job (in fact about a delivery but “of course” I knew that was just a cover story). “Yes!” came back the reply. This was indeed how my life was to end because the remark was made as if in reply to the very thoughts I was having at that moment. Obviously, The Organization knew my very thoughts.
Two days later, I threw myself under the wheels of a double decker, London bus on “New King’s Road” in Fulham, West London, to where I had just moved. In trying to explain “why all this was happening” my delusional system had taken a religious turn. The religious element, that all this torment was willed not only by my mother and transvestophobic scandal-mongerers but by God Himself for my “perverted Satanic ways,” was realized in the personal symbolism of this suicide. New King’s Road obviously was “the road of the New King” (Jesus), and my suicide would thrust “the old king” (Satan) out of me and Jesus would return to the world to rule. I then would be cast into Outer Darkness fighting Satan all the way. The monumental, world-saving grandiosity of this lamentable act was a far cry from my totally irrelevant, penniless, and peripheral existence in Hackney a few months before. In my own bizarre way, I obviously had moved up in the world. Now, I was not an outcast from it. I was saving the world in a very lofty manner. Medical authorities at Charing Cross Hospital in London where I was taken by ambulance, initially, of course, to orthopedics, fairly quickly recognized my psychotic state. Antipsychotic drugs were injected by a nurse on doctors’ advice, and eventually, I made a full physical and mental recovery.Chadwick never got too far along; he had all the weird coincidences, he was starting to get beliefs that explained them, but he never got to a point where he shifted his fundamental concepts or beliefs about logic in an irreversible way. As far as I know he’s been on antipsychotics consistently since then, and has escaped with no worse consequences than becoming a psychology professor.
by Scott Alexander, Slate Star Codex | Read more:
[ed. Interesting, how schizophrenia takes hold.]
