Understanding Cognitive Dysfunction in Mental Illness

Mental illness affects many people, but what most do not realize is that it does not just cause emotional problems – it causes cognitive problems too. The person with mental illness may find it difficult to think clearly, pay attention and remember.

For some, the cognitive problems are only evident during the episodes of illness. For others, the cognitive problems are more persistent. If mental illness is managed well, the person can lead a more productive life and have longer periods of stability. To better manage an illness it is important to understand the many ways it affects functioning. When people know what the cognitive symptoms of mental illness are, they can better manage the illness and function better.

What does the word Cognition mean?

Cognition refers to thinking skills, the intellectual skills that allow you to perceive, acquire, understand and respond to information. This includes the abilities to pay attention, remember, process information, solve problems, organize and reorganize information, communicate and act upon information. All these abilities work in a close, interdependent fashion to allow you to function in your environment.

Cognitive skills are different from academic skills. Academic skills include knowledge about different subjects like literature, math and history. Cognitive skills refer to the mental capabilities you need to learn academic subject matter, and more generally to function in daily life. Cognitive skills are the underlying skills that must be in place for you to think, read, understand, remember, plan and organize.

Some facts about cognition:

· Cognitive skills are different from academic skills

· Cognitive skills are the mental capabilities or underlying skills you need to process and learn information, to think, remember, read, understand and solve problems.

·  Cognitive skills develop and change over time.

·  We are born with certain cognitive capabilities - we may be better at some skills than others, but we can improve the weaker skills.

· Cognitive skills can be measured.

· Cognitive skills can be strengthened and improved.

Why do people with mental illness have cognitive dysfunction?

Families often ask what causes the cognitive problems. Research has shown us that it is the illnesses themselves that cause much of the cognitive dysfunction. For many years people thought that the cognitive problems were secondary to other symptoms, like psychosis, lack of motivation, or unstable mood – but now we know that is not the case. Cognitive dysfunction is a primary symptom of schizophrenia and some affective disorders. That is why the cognitive problems are evident even when other symptoms are controlled – even when people are not psychotic, or in an affective episode. Furthermore, research has shown that those parts of the brain that are used for specific cognitive skills, often do not function normally in people with schizophrenia and certain affective disorders. This indicates that mental illness affects the way the brain functions and that is what cause the cognitive problems. There are many myths about mental illness and cognitive dysfunction. Some of the most common ones are listed in the sidebar below.

Myths about cognition

·             The cognitive problems will go away when the hallucinations and delusions stop.

·             The cognitive problems will always go away between episodes of depression and mania.

·             The cognitive problems simply reflect a lack of effort.

·             The cognitive problems are all caused by medications.

·             The cognitive problems are caused by being in the hospital for too long.

The ability to attend, remember and think clearly is ultimately the result of a complex interaction of factors. While it is true that mental illness often causes cognitive impairment, it is also true that other factors will affect thinking skills. Most people think best, pay attention and remember better when they are not emotionally stressed, and when they have had the opportunity to learn adaptive cognitive skills.

Who is affected by cognitive dysfunction?

Most people with schizophrenia - at least 85% - will experience problems with cognition. These problems may be evident even before psychotic symptoms start, and they may lead to a decline in academic or work performance. One of the earliest cognitive symptoms of schizophrenia is poor attention, but difficulty with memory and visual motor speed may also be evident before the onset of psychotic symptoms.

How do these cognitive problems show up in daily life?

Cognitive impairment may be experienced in different ways. Let's look at how each of these cognitive problems may be manifested.

Attention

Some people report that they have difficulty paying attention when people talk and give directions. Others find it hard to concentrate on what they read, and find that they lose track of the important points, especially when reading longer passages. They may find it hard to focus on one thing when other things are happening. They may get distracted or conversely, become so involved in one thing that they fail to attend to something else that is happening. Multi-tasking, for example, answering a customer's question while operating the cash register, becomes difficult because they have to divide their attention.

Memory

The ability to remember and recall information, particularly verbal material, is often a problem. Directions may be forgotten, or the ability to recall what has been read or heard may be reduced. Most people who are depressed or in an affective episode will have difficulty with attention, concentration and thinking clearly! Those people with persistent mood problems and those who have psychotic symptoms are more likely to continue to experience cognitive problems between episodes.

Thinking skills

Critical thinking, planning, organization and problem solving are often referred to by psychologists as the executive functions; because those are the skills that help you act upon information in an adaptive way. Take the example of cooking a meal. Even if you know how to cook each dish, to actually serve a dinner you have to plan ahead to have all the ingredients, organize and manage your time so each dish is finished at the same time. You also need to be able to adapt your plans if problems arise, like the oven does not work or an ingredient or type of pan is missing. People with mental illness may seem less able to think of alternate strategies for dealing with problems that arise, or they may have difficulty coming up with a plan, or find it hard to listen critically to new information and know what is important and what is not.

Cognitive impairment: The impact on daily functioning

When people have trouble paying attention, remembering and thinking clearly, it impacts on their ability to function in the community, at school, at work and in relationships.

Community: Impairments in memory and problem solving are associated with greater problems living independently. In fact, it has been shown that for people with schizophrenia, cognitive abilities are more linked to successful independent living and quality of life than clinical symptoms. It is easy to understand that the ability to solve problems and remember verbal information is critical for negotiating transportation, home management, shopping, finances, health and psychiatric rehabilitation.

School: The school years are formative years, when the mind is developing and one's knowledge base and critical thinking skills are broadening. Unfortunately, mental illness often starts before people have finished this educational process. The problems with attention, concentration and thinking can make it very difficult to keep up with school work, and even students who once excelled may become discouraged by the lost time, or their declining grades. When students fall behind in their academics, they may start to view themselves negatively, and prefer to quit rather than keep exposing themselves to more academic failure. They also lose the opportunity to consolidate good study and learning habits, or worse, a poor learning style may develop. People with mental illness who have dropped out of school are at a disadvantage when competing for jobs yet the cognitive problems can make it difficult to complete the necessary degrees.

Work: People with mental illness who have difficulty with memory, problem solving, processing speed, and attention are more likely to be unemployed or have a lower occupational status. In many ways this is not surprising. Critical thinking has been identified as one of the most important skills that people need to compete in the modern workforce. Yet critical thinking/problem solving is often impaired in people with persistent mental illness. The problems that can arise at work when someone has difficulty paying attention, concentrating and remembering are also obvious. Most jobs are not just rote and repetitive, but require people to remember new information or deal with changing demands. This is difficult when cognition is not working well.

Relationships: One of the things that makes personal relationships rewarding is the give and take of support, caring and concern. People want others to really listen and pay attention to them. When someone with mental illness is not able to attend to or remember what their friend is saying, their friend may feel hurt or not listened to. At work, colleagues or bosses may think the person with mental illness does not care - or is lazy - when in fact it may be that they are not cognitively able to perform. The ability to pay attention, be focused and not get distracted is important for social functioning.

How can cognitive dysfunction be treated?

Cognitive dysfunction can be treated in three ways: (1) using remediation techniques, (2) compensatory strategies, or (3) adaptive approaches. Most experts agree that a comprehensive program of cognitive rehabilitation uses techniques from each approach. A mental health professional, such as a neuropsychologist, psychologist, or occupational therapist, usually makes the determination of how best to treat cognitive dysfunction. The professional would create a treatment plan that delineates the methods to be used to reach specific goals during cognitive rehabilitation. The approaches to be used (remediation vs. compensation vs. adaptation) would be determined by the individual's relative strengths and we

**** Written for Meridian Counseling by Trishna Patnaik, a BSc (in Life Sciences) and MBA (in Marketing) by qualification but an artist by choice. A self-taught artist based in Mumbai, Trishna has been practicing art for over 14 years. After she had a professional stint in various reputed corporates, she realized that she wanted to do something more meaningful. She found her true calling in her passion that is painting. Trishna is now a full-time professional painter pursuing her passion to create and explore to the fullest. She says, “It’s a road less traveled but a journey that I look forward to every day.” Trishna also conducts painting workshops across Mumbai and other metropolitan cities of India. Trishna is an art therapist and healer. She works with clients on a one on one basis in Mumbai. Trishna fancies the art of creative writing and is dappling her hands in that too, to soak in the experience and have an engagement with readers, wanderers, and thinkers.