Cognitive Impairment in an Episode of Schizophrenia Spectrum Disorder

In 2013, my third and longest episode of psychosis began with suspicious thoughts and paranoid delusions. In 2017, we moved to Bangalore, a new location that helped reduce the level of delusions. However, I began to experience severe symptoms of cognitive impairment, which were truly debilitating to my functioning as a normal human being. Cognitive Impairment, in my view, was the single biggest contributing factor to my inability to do a job or function normally in day-to-day life. This symptom was the one, among others, in which one loses one’s confidence to function normally because of an underlying intellectual impairment. The resultant personality is a tentative, hesitant, low energy, scared, and much slower one bearing no resemblance to the one before the illness took root.

My symptoms:

1. Reading anything with sustained attention was impossible. As I would try to read, the point wouldn’t register in my brain, so at the end of glancing at an article, I would feel as if I have not understood anything and that it has just been a waste of time. I struggled with the newspapers every day. I would spend time from 9.00 am to 12.00 pm trying to read the articles in the newsapers but I was not able to focus on the articles and always ended with the feeling that I had not grasped anything in the three hours. My doctor would tell me not to spend so much time reading all the articles in the newspaper as it would be normal to skim through the newspapers in half an hour. I recalled the good times when I could do that and was very agitated by the loss of this basic skill. Consequently, I didn’t know what to do with my time as I couldn’t read books and magazines either to keep me gainfully occupied.

2. Given that sustained attention was compromised, doing anything with concentration and focus became an issue. I was finding it hard to prepare a case for a lecture I had planned to give, so holding on to a job at this level of intellectual impairment was out of the question. This had an impact on the quality of life I was experiencing. In some job interviews, I was asked to answer some multiple-choice analytical questions. I couldn’t apply myself to a single one of them and responded to all the questions by guessing the correct answer. This was the situation for someone who had cleared the CAT exam, India’s equivalent of the GMAT.

3. Short Term Memory also became a major issue as I couldn’t remember numbers, making it very difficult for me to remember passwords and secret codes. Being blessed with an excellent memory in my youth, I had never got into the habit of noting things down and now I would need to push myself very hard to remind myself to make lists, note down numbers, etc. For example, if I went to the vegetable market with the intent of purchasing three vegetables, by the time I reached the vendor, I would have forgotten two of them.

4. Connecting with people on any subject became very difficult. Since I was always feeling that my cognitive abilities, which formed the very basis of my identity were diminished, I didn't really want to meet people and expose my  impairment to them. Also, I was finding it difficult to articulate anything fluently as thoughts were not flowing in my head and hence, my interactions were usually filled with awkward silences. This was further complicated by a reduction in the volume of my voice and so my functional life became very difficult.

5. My reaction times also became very slow. What I could do involuntarily and almost instantaneously now took a very long time to do. For example, if I were to read the instructions on an oven to bake something, it would take me an inordinate amount of time to figure out what to do, by which time, one of my children would figure it out and do the task much faster. Mental slowness translated into physical slowness as well. Walking, which used to be my favorite hobby, slowed down substantially and I was no longer able to sustain walks over a long time. During this period, the digital revolution was taking place and I was unable to operate any of the apps as it requires some level of logical thinking and ability to follow sequential instructions, usually within a given amount of time. This handicap set me back by quite a few years.

6. I used to be able to perform multiple tasks at one time as it was required for my job. In my current condition, I had very poor coordination when it came to multitasking and parallel processing. It was as if the connections in my brain were not working making it impossible to do more than one thing at a time.

Some of the practical manifestations of these cognitive deficits included:

1. Filling up long forms with a lot of instructions on them became practically impossible. I feared filling up long forms and was hesitant to travel or plan any international trips as visa forms, immigration forms, etc. would be a major stumbling block.

2. Google Maps was increasingly becoming the choice of most people to get from one place to another. For several years, I would look at the Uber drivers navigating their cabs wholly with Google Maps and wonder how they became so intelligent to be able to follow Google Maps quite effortlessly, while I couldn’t figure out the navigation system at all.

3. I would find it difficult to organize documents in a file adequately. I once had to make a file for putting together my insurance claims. I was finding it very difficult to do this task as I couldn’t distinguish the sequence of events in which the bills were to be put together in the file.

4. In interactions on my financials, I would ask my wife to take the lead in discussions with our bank relationship managers, since I could not grasp the suggestions made by them. Fortunately, she was able to grasp the fundamental concepts quickly and took charge.

These symptoms persisted for at least 9 months and I was advised that there was no medicine to address these issues.

On hearing my consistent complaints about my cognitive problems, my primary psychiatrist put me on to another doctor from Rehabilitation Services as he felt that some cognitive remediation might help with the issues as there was no medication available for the same.

I was advised to undertake a battery of neuropsychiatric tests that included approximately two hour long tests which involved several seemingly simple questions. I was told that this testing was necessary to find out whether there really were any deficits in cognition.

A couple of weeks later my wife and I visited the Psychiatrist to hear the outcome of the testing. While he did not reveal everything in the report, he told me that they had found severe deficits in

• a) Sustained attention

• b) Recall memory and

• c) Mental Speed

severe deficits implied the results were more than two Standard Deviations worse than a comparable sample, by age and educational qualifications.

Among the potential reasons, I was advised that impairment could be because of

• a) A stroke that had occurred 2 years ago.

• b) The long-term use of anti-psychotic drugs.

• c) The psychiatric illness itself.

Although I was not very sure, I suspected that this impairment was happening because of the illness.

Based on the outcome of the neuropsychiatric tests, the doctors and psychologists at the Psychiatric Rehabilitation Services Department put me onto a program of Cognitive remediation. This involved undertaking some tasks which would retrain the brain in an attempt to improve attention and control.

The exercises involved the cancelation of letters from a maze of letters and analyzing errors of commission and omission in the letter cancellation task. The exercises also involved separating two kinds of grains from each other in a fixed time duration. Coloring tasks were also introduced to modulate the loss of inhibition.

After a period of about 9 months, one day I found that I was able to read. My conceptual abilities and general functioning were still not very stable. There didn’t seem to be any obvious cause for the reversal in my cognitive abilities. So I came to believe in brain plasticity. My psychiatrist also couldn’t explain what had happened and I began believing that nobody had a definitive idea about how the brain works. In light of this belief, erroneously I discontinued my medicines setting myself up for another severe bout of suspicious, paranoid thoughts, and delusional beliefs. This condition lasted for 3 more years, since when my brain started stabilizing and though it’s not what it used to be, there has been substantial improvement since.