Cognitive Therapy For Schizophrenia: From Conceptualization to Intervention

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Cognitive Therapy For Schizophrenia
FromConceptualization to Intervention

• Neil A Rector Aaron T Beck
• Can J Psychiatry Feb. 2002
• Presented by
• Dr Fayez Hakim

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Objectives

• To outline the cognitive understanding of
  symptoms of schizophrenia
• To review the cognitive therapy approach to
  ameliorating these symptoms

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Method

• Studies examining cognitive factors associated
  with symptoms of schizophrenia were identified by
  electronic search (using Medline and Psychinfo)
• This paper integrates experimental findings and
  clinical treatment

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Introduction

• Of patients with diagnosis of schizophrenia, 25
  to 50 continue to experience persistent
  symptoms.
• There is need to develop effective psychological
  interventions that target persistent symptoms and
  that also address frequently occurring co-morbid
  conditions, such as depression and anxiety
• In a recent review of controlled trial studies
  testing the efficacy of cognitive therapy for
  schizophrenia

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Introduction (cont.)

• Cognitive therapy reduces delusions,
  hallucinations, and negative symptoms and that
  these gains are sustained over time
• Patients receiving cognitive therapy as well as
  routine care that is, pharmacotherapy case
  management show significantly greater
  improvement than do patients receiving supportive
  therapy routine care.

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General Structure of Therapy

• Cognitive therapy for psychosis is active,
  structured, time-limited (between 6 and 9 months)
• Establish a strong therapeutic alliance through
  gentle questioning and guided discovery aiming to
  create a climate of openness and trust
• Develop and prioritize problem list
• Pursue psychoeducation and normalize symptoms of
  psychosis

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General Structure of Therapy (cont.)

• Develop cognitive conceptualization
• Cognitive and behavioral techniques to treat
  positive and negative symptoms
• Cognitive and behavioral strategies to treat
  co-morbid depression and anxiety
• Relapse Prevention
• Establish step-by-step action plan to deal with
  setbacks

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Typical cognitive therapy session (25 to 50
minutes)

• Update on mood since last session
• Bridge from last session
• Structured agenda is set
• Working on areas from the session agenda with
  summaries and planned homework assignments
• Summary and patient's feedback on session
• Overview of treatment Plan until next session

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Cognitive Focus in Delusions

• The content of delusions often reflects everyday
  concerns, predelusional beliefs
• Cross-sectional analysis of delusional thinking
  reveals common cognitive biases which may distort
  the perception of usual life experiences
• Egocentric bias
• Externalizing bias

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Cognitive Focus in Delusions (cont.)

• Intentionalizing bias
• Exaggerated self-serving bias
• Tendency to jump to conclusions
• Failure to consider alternative explanations for
  their interpretations

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Cognitive Therapy of Delusions

• Attempts to understand the patient's life
  context including important past life events and
  their appraisal
• Assessment phase
• Predelusional beliefs are ascertained by
  inquiring into fantasies and daydreams
• Identify proximal events critical to the
  delusions formation

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C. T. of Delusions (cont.)

• Current events likely to trigger the delusions
  (external or internal)
• The specific consequences created by the
  delusions (emotional or behavioral)
• Psycho education
• Learn to identify the links between his thoughts,
  feelings, and behaviors

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C. T. of Delusions (cont.)

• Learn the role of cognitive biases and
  distortions
• The therapist deals with interpretations and
  explanations
• Try to find another alternative (Verbal
  strategies)
• What leads you to believe this is likely?
• What is the evidence that supports this
  interpretation?

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C. T. of Delusions (cont.)

• Are there any possible alternative explanations ?
• Repeated practice in generating alternative
  explanations the certainty of the delusional
  beliefs gives way to more balanced and less
  distressing interpretations
• Behavioral strategies
• Behavioral experiments that test the accuracy of
  different interpretations

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Cognitive Focus in Hallucinations

• Problem discriminating between internally
  generated and externally generated events
• Neuropsychological deficit in the internal
  monitoring system
• Neuropsychological deficit but through the role
  of cognitive biases (beliefs and expectations)

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Cognitive Focus in Hallucinations (cont.)

• So Cognitive Therapy intervention in
  hallucination
• Helps patients to identify, test, and correct
  cognitive distortions in the content of voices
• Identify, question, and construct alternative
  beliefs about the voices' identity, purpose, and
  meaning.

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Cognitive Therapy of Hallucinations

• Therapeutic alliance
• Thorough assessment
• Careful questioning of the frequency, duration,
  intensity, and variability of the voices
• Triggering situations
• Stressful situations interpersonal difficulties,
  negative life events

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C.T. of Hallucinations (cont.)

• Internal cues emotional upset
• Modified thought record
• Get verbatim accounts of what the voices say
• The beliefs the patient has about the voices and
  the evidence supporting them
• Emotions experienced by the patient
• Identify the life circumstances both distal and
  proximal, to the initial voice onset
• Patient's reactions to the voices

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C.T. of Hallucinations (cont.)

• Alternative perspectives on both the voice
  content and the patient's beliefs about the
  voices
• Questioning the evidence that patients offer to
  support their interpretation
• Generate alternative explanations for the
  evidence
• Education (and normalizing) about the role of
  expectations and hearing voices
• Behavioral experiments

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C.T. of Hallucinations (cont.)

• Asked whether they have ever considered other
  explanations for their voices
• Highlights any inconsistencies in the beliefs
• The aim of the work here is to help patients
  recognize that the voices simply reflect either
  their own attitudes about themselves or those
  they imagine others to have about them

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Cognitive Focus in Negative Symptoms

• Anhedonia, apathy, low motivation, and emotional
  withdrawal, are not specific to schizophrenia and
  found to be even more in depression
• Affective flattening the problem may lie in
  expressing emotions rather than in a deficit in
  the ability to feel
• Alogia may reflect difficulty in finding the
  right words rather than representing a dearth of
  communication skills

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Cognitive Focus in Negative Symptoms (cont.)

• In summary, negative symptoms reflect cognitive,
  emotional, and behavioral dysfunction rather than
  stable deficits
• These may be amenable to change through cognitive
  technique

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Cognitive Therapy of Negative Symptoms

• Thorough functional analysis of the patient's
  behavior
• Identifying barriers of engagement including
  co-morbid depression and anxiety
• 20 to 50 have severe depression at the time of
  relapse

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C.T. of Negative Symptoms (cont.)

• More than two-thirds of schizophrenia patients
  will experience a depressive episode at some time
• Withdrawal and apathy may be due to fears
  associated with anxiety conditions (unmanageable
  somatic experiences, feelings of helplessness,
  and negative evaluation)

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C.T. of Negative Symptoms (cont.)

• Anhedonia, apathy and withdrawal may be the
  result of avoidances to prevent the onset of
  distressing positive symptoms which will lead to
  readmission, overmedication or medication side
  effects

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C.T. of Negative Symptoms (cont.)

• The same strategies used for depression
• Behavioral self-monitoring
• Activity scheduling
• Mastery and pleasure ratings
• Graded task assignment

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C.T. of Negative Symptoms (cont.)

• Assertiveness training methods
• Eliciting the patient's reasons for inactivity
• Behavioral experiments for testing these beliefs
• Stimulate new interests or reactivate previously
  held interests

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Clinical Implications

• Delusions and hallucinations can be
  conceptualized in familiar cognitive terms that
  facilitate psychotherapeutic interventions
• Cognitive therapy is shown to be an important
  adjunct to standard treatments of schizophrenia

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Conclusions

• Psychosis can benefit from cognitive strategies
  that identify, test, and correct distorted
  interpretations that underly the production of
  delusions and hallucinations
• Cognitive Therapy can enhance motivation, reduce
  emotional withdrawal and improve engagement in
  social events
• More attention to therapist training in this
  modality is needed
• More studies testing its effectiveness in
  community clinical settings are wanted

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Thank you