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IP was in her mid-50s and had been living with chronic schizophrenia since her early 20s. Diagnosis was confirmed with a Structured Clinical In- terview for DSM-IV-TR (SCID; First et al., 2002). She has had three psychi- atric hospitalizations during her lifetime, but experienced numerous additional episodes of acute psychotic exacerbation. She reported that during such exacerbations her symptoms have been severe. She also noted that during the first two years of her illness she had inability to work or have friends. While living with schizophrenia, IP completed several post-graduate programs from prestigious institutions and con- tinues to maintain a highly successful academic career. She maintains strong interpersonal relationships, including an ongoing successful mar- riage, several close friendships, and cordial professional relationships with colleagues and students. At the same time, she still has some psycho- pathologic symptoms and is taking antipsychotic medications. IP also re- ported having previously had several serious physical illnesses, including a subarachnoid hemorrhage, and three different primary cancers, but has survived and even overcome these medical problems.
IP is a highly ac- complished person, yet is neither fully symptom-free nor without any neurocognitive or biological alterations. The logical question is thus what factors have enabled her to achieve and maintain such high func- tioning, despite the challenges of these symptoms and deficits in epi- sodic memory and visual-spatial reasoning? IP’s identified strengths do not necessarily indicate compensatory mechanisms (abilities that allow IP to compensate for schizophrenia-related deficits), as not every strength is necessarily involved in compensating for deficits. However, they do represent strong candidates for further study.
Although definitive conclusions cannot be made from this single study, IP’s exceptional working memory and activation in brain regions relevant to facial recognition and the processing of visual information may help explain her ability to achieve and maintain exceptional occu- pational and psychosocial functioning, despite living for decades with chronic schizophrenia.
A plausible model warranting further research and testing is that a strong working memory may permit a person to experience a delusion or other psychotic thought or perception, while simultaneously being at least partially aware of/entertain the possibility of the psychotic nature of that thought or perception, and to choose not to act on it and/ or take it as a sign that treatment may need adjustment (Davies et al., 2017; Nicolo et al., 2012).
The above model is also related to the concept of “belief flexibility,” defined as “the metacognitive skill of reflecting on one’s own beliefs, reviewing their likelihood, considering the evidence for them and that of alternative hypotheses” (Colbert et al., 2010, p. 45), which has in turn been suggested as a target for psychotherapies focused on delusions (Garety et al., 2015). The neurobiological underpinning of belief flexibility have not been established, and there may be an important distinction to be made between the neurobiology of psychotic thoughts