A Holistic (Integrated) Model of Disorders

In recent years there has been an increasing focus on the presence of depression in schizophrenia and at the same time, there has been a strong interest in identifying various functions that are presumed to be defective in schizophrenia. In this memorandum, I will attempt first to a) show how these different functions are represented in unipolar, bipolar depression and the negative symptoms in schizophrenia as well as in normal functioning, b) indicate that each of the functions can be best conceived of as quantitative, and c) propose a cognitive model for accounting for the poor performance in these various functions. I will also indicate that this model can be applied to all mental disorders.

The various disorders may have different etiologies and treatments, but these differences obscure the essential unitary features that are shared across the disorders. Take, for example, the different forms of depression such as unipolar and bipolar and mania and for purposes of comparison, include the negative syndrome of schizophrenia. These disorders have the same functions in common which may be viewed on a continuum. The continua have a negative or positive orientation represented by either a negative bias (both forms of depression and the negative syndrome) or a positive bias (mania). I have also included the adaptive mode, which does not have a fixed orientation but fluctuates flexibly according to the context (internal and external). The disorders are characterized further by extreme content which is relatively fixed and therefore, not adaptive to the specific context. These characteristics are shared by a wide variety of functions such as interpretation, attention, memory, and cognitive processing. The intensity may vary between disorders, and the orientation may vary as well (for example, in mania).

For purposes of convenience, I have described each function in terms of adjectives such as minimal or maximal. It should be noted that as these disorders improve, their level of functioning moves increasingly closer to adaptation. When the individuals improve, the abnormal activation (low in depression and negative symptoms and high in mania) become deactivated and the opposite end of the continuum becomes activated. When in the normal mode, the specifies characteristics of the disorder are no longer present. A special exception is bipolar in which there may be a direct switch from depression to mania or vice versa. Bipolar disorder is of interest in that the positive and negative orientations are extreme and dissociated. This disorder shows that the psychological apparatus is composed of positive as well as negative functions. The other disorders exhibit a similar deactivation and activation but are within normal limits when the adaptive state is reached. Thus, in our treatment of the negative syndrome, it is important to use approaches that deactivate the negative functions and activate the positive.

Note: Practically all tests of the psychological functions are deficient in the negative syndrome. Moreover, these deficiencies are observed across disorders and functions as noted in an early paper regarding depression by Braff & Beck (1974) and other disorders since then (Beck, Himelstein, Bredemeier, Silverstein &Grant, 2018). Further, the supposed deficiency is explained by poor test performance (rather than an absolute and specific deficiency) as a result of lack of effort and motivation caused by negative, defeatist attitudes. Finally, it is necessary to mention that although I have only included depressive disorders and schizophrenia in the table, other disorders, for example, OCD and anxiety disorders, which are driven by different dysfunctional beliefs can be fitted into the integrated model.

Practically all tests of the psychological functions are deficient in the negative syndrome. Moreover, these deficiencies are observed across disorders and functions as noted in an early paper regarding depression by Braff & Beck (1974) and other disorders since then (Beck, Himelstein, Bredemeier, Silverstein &Grant, 2018). Further, the supposed deficiency is explained by poor test performance (rather than an absolute and specific deficiency) as a result of lack of effort and motivation caused by negative, defeatist attitudes. Finally, it is necessary to mention that although I have only included depressive disorders and schizophrenia in the table, other disorders, for example, OCD and anxiety disorders, which are driven by different dysfunctional beliefs can be fitted into the integrated model.

References:

  1. Beck, A.T., Himelstein, R., Bredemeier, K., Silverstein, S. M., & Grant, P. (2018). What accounts for poor functioning in people with schizophrenia: a re-evaluation of the contributions of neurocognitive v. attitudinal and motivational factors. Psychological Medicine, 1-10.
  2. Braff, D. L., & Beck, A. T. (1974).Thinking disorder in depression. Archives of General Psychiatry, 31, 456-459.

ATB~