Cognitive Therapy For Schizophrenia: From Conceptualization to Intervention

1. Cognitive Therapy For Schizophrenia: FromConceptualization to Intervention Neil A Rector & Aaron T Beck Can J Psychiatry Feb. 2002 Presented by Dr Fayez Hakim

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

3. 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

4. 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:

5. 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.

6. 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

7. 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

8. 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

9. 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

10. Cognitive Focus in Delusions (cont.) • Intentionalizing bias • Exaggerated self-serving bias • Tendency to jump to conclusions • Failure to consider alternative explanations for their interpretations

11. 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

12. 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

13. 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?

14. 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

15. 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)

16. 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.

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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)

25. 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

26. C.T. of Negative Symptoms (cont.) • The same strategies used for depression • Behavioral self-monitoring • Activity scheduling • Mastery and pleasure ratings • Graded task assignment

27. 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

28. 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

29. 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

30. Thankyou