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Cognitive Therapy For Schizophrenia: From Conceptualization to Intervention

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Cognitive Therapy For Schizophrenia: From Conceptualization to Intervention Neil A Rector & Aaron T Beck Can J Psychiatry Feb. 2002 Presented by Dr Fayez Hakim – PowerPoint PPT presentation

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Title: 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
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