Schizophrenia: Cognitive Psychology and treatment

1
Schizophrenia Cognitive Psychology and
treatment

• Professor Michael Joseph
• PS 3013 Clinical Health Psychology
• 5/10/2004

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Psychiatric Diagnosis

• Functional Psychoses (cf Organic
  Psychoses)
• Schizophrenia
• Manic Depression
• (Bipolar Affective Disorder)
• Psychotic Depression (Unipolar)
• Schizo-Affective Disorder

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Symptoms of schizophrenia

• Positive symptoms (unusual by presence)
• Hallucinations Unusual Perceptions
• Delusions Unusual Beliefs
• Thought disorder and inappropriate affect
• Negative symptoms - unusual by absence
• (see later slides)
• Net result, especially of positive symptoms
  perceived by others as being
• out of touch with reality the schi(z)m

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Psychotic Experiences Hallucinations

• Any percept-like experience which
• occurs in the absence of appropriate stimuli,
• Has the full force or impact of the corresponding
  actual (real) perception
• is not amenable to direct voluntary control by
  the experiencer
• (Slade Bentall 1988 p.23)

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Psychotic Experiences Delusions

• Belief that is firmly held on inadequate
• grounds, is not affected by rational
• argument or evidence to contrary, and is not
• a conventional belief which the person
• might be expected to hold given his/her
• educational cultural background
• Oxford Textbook of Psychiatry 1991

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Psychotic Experiences Thought disorder

• Manifests in bizarre incoherent
• communication with others
• Disordered discourse
• Clang associations, shifting topics, apparent
  puns and metaphors
• Disorganisation has been distinguished from
  positive symptoms (Liddle, 1987)

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Negative Symptoms

• unusual by absence of normal functioning
• Underactivity/apathy, e.g. lack of initiative,
• poor self care
• Attentional impairment, e.g. poor concentration
• Poverty of speech speech content
• Flattened affect, Loss of pleasure

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Schizophrenia DSM Criteria

• For at least one week (in the absence of
  treatment)
• (i) Two of
• Delusions
• Hallucinations
• Incoherence or loosening of associations
• Catatonic behaviour
• Flat/Grossly inappropriate affect
• and/or (ii) Bizarre Delusions
• and/or (iii) Prominent auditory hallucinations
• -- Voice or voices talking to or about the
  subject, especially if in the third person

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Historical Overview

• c. 1900
• Emergence of the concept of dementia praecox,
  later termed schizophrenia
• 1950s
• Neuroleptics introduced. Amphetamine and
  hallucinogenic psychoses
• Biological Models of schizophrenia
• Psychotherapy continues to be seen as of doubtful
  value

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More recent developments

• 1980s and onward
• Limitations of Neuroleptics side effects
• Introduction of atypical antipsychotics
• Psychological Models
• Symptom based approach
• might help to overcome limitations in
  available drug therapy

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Genetic evidence

• Bar chart, indicating lifetime risk of being
  diagnosed with schizophrenia, as a function of
  genetic relationship to another individual so
  diagnosed - see McKenna (1987)

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Psychological theories of schizophrenic symptoms I

• Nuechterlein et al (1992) Impaired use of
  activated or working memory to cue relevance of
  current stimulus
• Hemsley (1987, 1994a) Reduced influence of
  regular-ities of past experience on current
  perception (action)
• Frith (1987, 1992) Failures of self monitoring
  of willed intentions gt experience of alien
  control attribution of inner speech to external
  sources.
• Impaired theory of mind gt confusion of internal
  and external events poor interpretation of
  intentions of others

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Psychological theories of schizophrenic symptoms
II

• Slade Bentall Frith Awareness of partially
  processed and/or sub-threshold stimuli gt
  hallucinations and bizarre beliefs
• Bentall (1994) Strongly biased attributions for
  threat related stimuli gt persecutory delusions
• Will now look at hallucinations, as an example
• of a symptom, which can be manipulated, and
• perhaps understood, in psychological terms.

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Hallucinations

• Experienced by normal people as well
• Cultural differences
• Sub-vocalisation
• Increase occurrence
• Unpatterned noise
• Stress physiological arousal
• Decrease occurrence
• Concurrent verbal Tasks

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Model of Hallucinations

• Beliefs Environmental Stress
• Expectations Noise
• Perceived Discrimination Classification
• Event (real or imaginary)
• (internal or external)
• Reinforcement
• Anxiety Reduction
• (Slade Bentall 1988)

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Why do people misattribute internally generated
events to external or alien sources?

• Different theories about mechanism
• Cognitive Deficit - impairment in perception,
  memory attention
• OR Bias - People pay attention to particular
  types of information more than others,
  or interpret information differently,
  possibly due to life experiences etc.
• This latter is not a cognitive deficit, because
  it represents an unusual interpretation of
  normally processed data

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Bias Theory

• Halllucinators have a bias towards detecting
  external stimuli
• Signal Detection - Bentall Slade (1985)
• Hallucinators have a bias towards attributing
  their own thoughts to external sources
• Reality/Source Monitoring - Bentall et al (1991)
• Biases will be more pronounced for emotional
  verbal material than neutral material
• Morrison et al (1997) , Baker Morrison(1998)

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Distraction v Focusing

• Distraction
• Assumption If hallucinations arise from
  over-attention and bias towards real events, then
  distraction will reduce attention to them.
• Aims Develop and incorporate strategies to
• distract from and therefore reduce the voices
• Or, conversely Focusing
• Assumption If hallucinations arise from
  misattribution of internal events, attention to
  the experience and beliefs around it will reduce
  misattribution and increase reality monitoring
• Aims Gradually expose client to the experience
  and
• meaning of the hallucinations and develop
• strategies to help client deal with
  hallucinations

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Distraction

• Introduce techniques, monitor, review
• problem solve
• Personal stereo (music, radio. TV)
• Mental games reading
• Activity scheduling
• Collaboration/Monitoring/Problem Solving

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Focusing

• Gradual exposure
• Physical Characteristics -- Content
• Thoughts -- Meaning
• Formulation Interventions developed
• Chadwick and Birchwood (1996)
• Limitations of the relationship between content
  of voices emotions and coping
• Importance of beliefs about voices
• Strategies for challenging beliefs about voices

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Family Interventions

• Stress-Vulnerability Model
• Block diagram from Neuchterlein and Dawson
  (1984), Schizophrenia Bulletin, 10 300-312

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Expressed Emotion

• Brown et al (1958)
• Discharge from hospital
• Lower relapse when they live alone / in lodgings
  than when discharged to the family
• Importance of the family atmosphere in the course
  of schizophrenia

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Expressed Emotion (CFI)

• Hostility
• Rejection generalised negative comments
• Critical Comments
• Frequency of critical comments
• Emotional Over Involvement
• Exaggerated emotional response
• Positive Comments
• Statements of approval, praise, appreciation
• Warmth
• Warmth expressed

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EE Relapse

• Key Factors
• Hostility
• Critical Comments
• EOI
• Kavanagh (1992)
• Review 20 prospective studies
• High EE Relapse 48
• Low EE Relapse 21

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Physiological Arousal

• Associated with living in high EE environment
• Review Tarrier Turpin 1991
• Measure arousal of sympathetic nervous system
• High EE Level of arousal maintained/increased
• Low EE Level of arousal decreased
• Change in physiological arousal when family moved
  from High EE to Low EE over 9/12
• Stress model of EE

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Family Interventions

• Psycho-Education
• Communication Skills
• Problem Solving
• Stress Management
• Goal Setting

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Intervention Studies

• from
• Wykes, T., Tarrier, N. Lewis, S. eds., (1998).
  Outcome and Innovation in Psychological Treatment
  of Schizophrenia, Chichester, Wiley.
• (see reading list)

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A cognitive therapy perspective on psychosis

• It can be useful to understand the life
  predicament of a person with psychosis as one of
  coping with illness
• Psychosis is experienced by the patient as
  altered thoughts and feelings
• Various types of psychological processes may be
  involved in the formation and maintenance of
  psychotic symptoms, different in different cases

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Adapting cognitive behaviour therapy for
psychosis from CBT for other disorders

• Psychotic disorders are very severe
• Psychotic disorders are very heterogeneous
• Some clinical problems are due to, or at least
  present as, cognitive deficits
• Some clinical problems are associated with
  emotional sensitivity
• Some clinical problems are associated with lack
  of trust and misinterpretations of the therapist
• Some clinical problems are associated with
  strongly held delusional ideas

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Conclusions I

• Schizophrenia does appear to have a biological
  basis, and in most cases, to respond to drug
  treatment.
• We have some idea of the brain areas and
  transmitter systems involved in at least the
  expression of symptoms.
• Symptoms are not meaningless, either to the
  patients, or in allowing us to hypothesise which
  cognitive systems have gone awry.
• Some of these systems are likely to be involved
  in the control of consciousness.

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Conclusions II

• Symptoms are amenable to modification by
  psychological interventions, which can be guided
  by these theories.
• The overall state of the sufferer is not
  independent of the outside world, and reflect the
  emotional situation of the patient.
• CBT, usually used with drugs, can materially aid
  adjustment, recovery of social function, and also
  prevent or delay relapse.