Schizophrenia

What is schizophrenia?

Schizophrenia is a type of psychotic illness, where people lose touch with reality, thinking things which cannot be true and/or hearing voices or seeing visions when there is no sensory stimuli to create them.

Is Schizophrenia is an episodic illness?

Yes, periods of psychotic disturbance are usually interspersed with normal periods of functioning.

What is schizophrenia characterised by?

A profound disruption of cognition and emotion, which affects language, thought, perception and sense of self.

What is psychosis?

Psychosis is used to desrcibe a severe mental health problem where an individual loses conatct with reality.

**Stirling and Hellewell (1999):**

25% of sufferers will get better after only one episode of the illness

50 -65% will improve but continue to have bouts of the illness.

The remainder will have persistent difficulties.

What is classification?

Classification is taking a set of symptoms and categorising them. If an indiviudal has a particular set of symptoms, we can then say that they have schizophrenia (as oppposed to having depression, or OCD for example)

What is Diagnosis?

Diagnosis is the clincal judgement that the individual is suffering from that disorder.

Classification of mental health disorders

We need to be able to classify disorders. This is done through identifying groups of symptoms that occur together and classify this as a disorder.

**DSM :** Diagnositic Statistical Manual of Mental Disorders

**ICD:** International Classification of Diseases

Diagnosis of Mental Health Disorders

For each disorder, there is a specified list of symptoms, all of which must be present for a specified period time, in relation to age and gender.

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The aim of this is to make diagnosis more reliable and valid by laying down rules for the inclusion or exclusion of cases.

What is the function of diagnostic criteria?

* Inform effective treatment selection
* Administrative function
* Provides vocabulary for professionals to communicate
* Provides information on prognosis

What are prodromal symptoms?

Early symptoms indicating the onset of a disease or illness.

In the weeks or months preceding schizophrenia, an indivudal may show some prodromal symptoms. These symptoms cannot diagnose schizophrenia as they occur in other illnesses.

What are the prodromal symptoms of schizophrenia?

* Loss of interest in usual activities
* Avoiding company of others
* Staying away from work or school
* Being irritable and oversensitive
* Lack of interest in personal appearance and hygiene
* Generalised anxiety
* Mild degrees of depression

What are the positive symptoms of schizophrenia?

**Hallucinations:** Sensory experiences. Some halluncinations are related to events in the enviroment whereas others bear no relationship to what the senses are picking up from the environment.

**Delusions:** Delusions are irrational beliefs.

Delusions of grandeur; involve being important historical, politcial or religious figures such as jesus.

Delusuions of Paranoia; Can involve being persecuted by Government, aliens or superpowers.

Can concern the body - may belive some part of them is under external control.

Some delusions can lead to violence.

What are the negative symptoms of schizophrenia?

**Avolition:** Loss of interest and motiviation.

Andreason (1982) identified 3 signs of avolition:


1. Poor hygiene and grooming
2. Lack of persistence in work/education
3. Lack of energy

**Lack of concentration**

**Alogia:** Less likely to engage in conversation and speech poverty.

Schizophrenia is characterised by changes/reduction in speech - the ICD-10 recognises this as a negative symptom:

* Because of the reductuon in amount and quality of speech
* Delay in sufferer’s verbal responses during conversation


* DSM focuses more on speech disorgainisation: incoherent speech (+ symptom)

Why Classify?

* Without classification you can’t diagnose
* When researching e.g. Cause or course of disorders, it provides a way to ensure clinicians are referring to the same thing.
* Comparable groups for research

Why diagnose?

* Informed judgements about what treatment is more likely to alleviate symptoms
* Comformying for the individual that there is something medically wrong with them
* Can give patients information about the course of the disorder.

What is reliability?

Reliability refers to whether something is consistent or not over time. In relation to SZ, for the classification system to be reliable, different clinicians using the same guide (e.g., DSM) should arrive at the same diagnosis for the same individual.  Also, there should be consistency between the two systems of ICD and DSM when diagnosing the same person, in that both should either agree that a person’s symptoms mean they are, or aren’t, schizophrenic.

What is validity?

Validity refers to whether something is measuring what it claims to be measuring.  For a diagnosis of schizophrenia to be valid, the label should be a valid measure of the symptoms being shown by the patient. 

Cultural Bias

* Both manuals (ICD 10 and DSM) are culturally biased as they are created in Western society and are based on western ideology of mental health
* **Simon et al (1973):** Black people are more likely to be diagnosed with Schizophrenia - this is backed up by **Cochrane and Sashidharan (1995):** Black Afro-Caribbean people are 7 more times likely to be diagnosed with SZ
* This shows that the diagnositc manuals are cuturally biased.
* **Counterpoint: Barnes (2004)** established cultural and racial differences in diagnosis - norms have changed so questions the temporal validity

Gender Bias

* Defintions and the symptoms of schizophrenia are created by men and based on men rather than women.
* **Leo and Cartagena (1999):** Most studies on SZ exclude women because of confounding variables from hormones and psychiatrists are familiar with male examples.
* **Fisher and Buchanan (2017):** Men are diagnosed in a 1.4:1 ratio.
* **Counterpoint: Loring and Powell (1988)** behaviour seen as psychotic in men not seen in women.

Validity and Reliability

* The DSM has various subtypes of SZ whereas the ICD doesn’t (constantly changing criteria)
* **Cheniaux (2009)** - found inter-rater reliability was poor
* **Counterpoint: Osorio (2009)** Showed that reliability in diagnosis of SZ was used - only used DSM!

What does the genetic explanation for schizophrenia suggest?

It suggest that the closer the bioogical relationship, the greater the risk of developing schizophrenia.

What genes are responsible for schizophrenia?

There isn’t one single gene that seems to be responsible, but a number of genes. As a result, schizophrenia is polygenetic.

COMT,DRD4 and AKT1 have all been associated with excess dopamine in specific D2 receptors, leading to positive symptoms.

Twin Studies

**Gottesman and Shields (1966)** reviewed the results of 5 twin studies looking for concordance rates for schizophrenia.

They looked at 210 MZ twins and 319 DZ twins.

It was found that in monozygotic twins there was a concordance rate of 35-38% compared to dizygotic twins rates which were 9-26%. They also found a concordance rate in MZ twins of 75-91% when the sample was restricted to the most servere form of schizophrenia.

What are neural correlates?

Neural correlates refer to brain structure and how this may explain schizophrenia

What is dopamine?

Dopamine is a neurotransmitter manafactured in the brain that transmits messages between neurons.

How is dopamine important in the brain?

Dopamine is particularly important in the functioning of several brain systems that may cause symptoms of schizophrenia - in particular the cortex and subcortex.

How does the original dopamine hypothesis state?

The original dopamine hypothesis states that the brain of schizophrenic pateints produces more dopamine that the brain of a ‘normal’ person.

What is the updated dopamine hypothesis?

More recent explanations suggest that there are more dopamine receptors which leads to more firing and more messages are produced.

What is hyperdopaminergia?

Excessive levels of dopamine in the subcortex & Broca’s area

What is hypodopaminergia?

Low levels of dopamine in the prefrontal cortex

Where did the dopamine hypothesis come from?

The hypothesis is based principally on the knowldege that antipsychotic drugs reduce dopamine activity.

What are agonists?

A substance which initiates a physiological response when combined with a receptor

What are antagonists?

A substance that depresses the effects of an agonist.

**Grilly (2002)**

* Indivduals with Parkinson’s disease suffer from low levels of dopamine
* They were prescribed L-Dopa (the precursor to dopamine) to raise dopamine in the brain.
* Some individuals went on to develop schizophrenia-like symptoms.

What are amphetamines?

* Drugs that act as a dopamine agonist
* Synapses get flooded with dopamine
* Large doses can cause hallucinations and delusions
* Can exacerbate the symptoms of schizophrenia in individuals with the disorder

Post-Mortem studies into schizophrenia?

**Seidman (1990) -** Found that people with schizophrenia have a larger than usual number of dopamne receptors.

PET Scan supportive evidence?

**Gjedde and Wong (1987)**

There are more than twice as many dopamine receptors in schizophrenics compared to controls.

**Farde** ***et al*** (1990)

There is no difference in the number of dopamine receptors between schizophrenics and controls.

**Copolov and Crook (2000)**

Have not found evidence of altered dopamine activity in schizophrenic’s brains.

Supportive evidence for genetics

* **A strength of the genetic explanation of schizophrenia is that there is supportive evidence from twin studies to show a genetic link.**
* For example, Gottesman and Shields (1991) showed that there was a higher concordance rate of schizophrenia between MZ twins (48%) compared with DZ twins (17%). 
* This shows that genetics can, to some extent, explain the development of schizophrenia as MZ twins share 100% of their genes and the likelihood is increased. 
* However, no study has ever found 100% concordance between MZ twins for schizophrenia, which implies genetics are not the only factor in explaining the illness. 

**Counterpoint:**

* No study has found 100% concordance rate which shows that other factors must also have an effect on schizophrenia e.g., environmental factors.

Real - World Application

* **A strength of the dopamine hypothesis explanation is that it has led to useful applications in terms of treatments for schizophrenia, with the development of anti-psychotic drugs.** 
* For example, typical anti-psychotics, such as Chlorpromazine and Haloperidol, have been developed due to this explanation and work by arresting dopamine production by blocking the D2 receptors in synapses that absorb dopamine. 
* Evidence from Thornley et al (2003) shows their use is associated with better functioning and reduced symptom severity compared with a placebo. 
* This provides further evidence to validate the dopamine explanation as, if drugs that balance dopamine levels help with symptoms, we could argue that that dopamine is linked to schizophrenia.

**Counter:**

* Lack of cause and effect
* Not clear whether whether raised dopamine levels cause SZ or raised dopamine levels are becuase of SZ

What are the two psychological theories for explanations of scizophrenia?

* The role of dysfunctional families (Schizophregenic mothers, Double-bind theory and expressed emotion)
* Cognitive explanations

Who came up with the Schizophrenogenic mother?

Frieda Fromm-Reichmann (psychodynamic approach)

Who did Fromm-Reichmann blame for schizophrenia?

The blame for SZ is with mothers

What did Lidz and Lidz (1949) suggest?

Some studies suggested that the mother-child relationship disordered in cases where the child was schizophrenic

Schizophrenogenic Mothers

* Fromm-Reichmann suggested schizophrenia was caused by mothers who were overly dominant in the home, and dominant particularly towards the schizophrenic child


* However whilst being controlling and overprotective, they were also cold and distant/rejecting
* The overprotection stifles the child’s development, and their distance leaves the child feeling emotionally insecure (as you would growing up in an atmosphere of tension and secrecy!)
* These mixed messages and general distrust could lead to the paranoia and delusions (belief you’re being persecuted by s/o!)
* She called this type of mother **schizophrenogenic** (schizophrenia causing).

How does double-bind theory explain SZ?

* Double bind thoery explains SZ as being a consequence of abnormal and inadequate patterns of communication within the families of schizophrenics


* Bateson (1956): families of schizophrenics communicate in a destructively ambigous fashion

What does the double-bind theory state?

It states that it is the way the parents or other family members interacts with the child that causes the schizophrenia.

What happens if a child is repeatedly exposed to double - bind statements?

If a child is repeatedly exposed to this sort of communication, they become unable to respond logically to others.

What is a paralanguage?

Paralanguage is tone of voice, body language, facial expression etc.

Paralanguage may not match with words said by parents

Double-Bind Theory

* The child is therefore getting two separate messages, and as these two messages contradict each other, it causes a conflict.
* Whatever the child’s actions, they cannot win. They are in a **double-bind.**


* Children learn that they have no idea how to respond in a reasonable way in conversations.


* They will grow up believing that this is how normal relationships work, and in the future they will struggle in establishing normal relationships.


* **R.D. Laing** went as far as to say that what we call schizophrenia is a reasonable response to an insane world.

What Bateson argue?

* **Bateson** argued that these double-bind statements could eventually lead to the hallucinations and delusions of schizophrenia.
* These symptoms arise as a means of escaping the conflict caused by these contradictory double-bind statements.
* Double-bind statements can also cause the child to respond with maladaptive thinking patterns (see cognitive explanations later!) to help them navigate social situations such as:
* “All things said to me contain hidden meanings that are harmful”
* “All statements are to be taken literally”
* “I should avoid all people so as not to misunderstand what they say”
* “All statements are derogatory towards me”

What did Berger (1965) find?

**Berger (1965)** interviewed schizophrenics, and found that they had a higher recall of double-bind statements by their mothers than non-schizophrenic controls.

Mischler and Waxler (1968)

**Mischler and Waxler (1968)** found that mothers talking to their schizophrenic daughters were rather aloof and unresponsive. However, the same mothers behaved in a much more normal and responsive way when talking to their neurotypical daughters.

* While not specifically investigating the effect of double-bind statements, this does provide support that there are differences in communication between schizophrenics and their family members and non-schizophrenics.

What is expressed emotion?

A measure of the family environment related to the extent that family members express critical, hostile and emotionally over-involved attitudes towards a family member with a disorder

What do families who engage in expressed emotion show?

Families who engage in **expressed emotion (EE)** show high levels of criticism, hostility and emotional over-protectiveness:

* ***Verbal criticism, sometimes even violent***
* ***Anger, rejecting, and often hostile***
* ***Over-protectiveness and over-involvement, sometimes to the extent of needless self-sacrifice***
* ***Communication that is low in EE is typically characterised by warmth and UPR.***

What did Kavanagh (1992) find?

Found that schizophrenics in families with high expressed emotion were four times more likely to relapse compared with those who live in families with low expressed emotion

What are the two cognitive explanations - dysfunctional thinking?

* Metarepresentation Dysfunction
* Central control dysfunction

Dysfunctional thinking

* Behaviour is a product of internal mental processes
* Brain is a computer
* Mental illness is caused by problems with these processes – dysfunctional thinking

Frith (1992)

* Schizophrenics misattribute their inner voice to the outside world
* Frith speculated that the cognitive deificts were linked to an irregularity in the nueronal pathways running between the septo-hippocampal system and the prefrontal cortex

What is the theory of mind?

* The ability to understand that we have our own minds, that other people have their own minds, and that our minds are different and distinct.
* ToM helps us understand that our own desires and points of view are not necessarily the same as others.
* Also, we understand that other people may not have access to the information we have. 

When does Theory of Mind develop?

* Starts to develop at 2-3 years old, but not fully formed until much later
* Young children unable to understand that other peple have minds sperate from their own

Theory of mind helps us understand our minds

We are able to understand that our actions and thoughts are caused by ourselves, and are generated internally rather than by any external force.

What did Frith (1992) argue?

**Frith (1992)** argues that some of the cognitive impairments shown by schizophrenics are due to a faulty ToM.

* Schizophrenics do not have a clear grasp of their own minds, and that they misunderstand their own thought processes.
* Unable to distinguish between actions that are brought about through external forces, and those that are generated internally.
* This is called METAREPRESENTATION (Dysfunction thereof!)
* For example, a schizophrenic may believe that they are controlling what another person is saying (misattributing an internal force for an external action) or believe that their thoughts have been inserted by aliens (misattributing an external force for an internal action)

What are the three cognitive processes that Frith argues can be used to explain sympotoms of SZ?

* Inability to generate willed action
* Inability to monitor willed action
* Inability to monitor the beliefs and intentions of others

Inability to generate willed action

* Unable to effectively generate action
* Not be able to plan and carry out a behaviour.
* May not be able to do tasks that they need to do, or may forget which tasks that have done and which ones that haven’t.
* This could explain the negative symptom of avolition.

Inability to monitor willed action

* Unaware of their own intentions and the “sense of effort” that goes into generating behaviour.
* Only able to monitor their actions on the basis by observing the consequences of their behaviour once it has already been carried out.
* Schizophrenics may interpret their actions as being caused by an external force.
* E.g. a schizophrenic may drink a glass of water because they are thirsty.
* However, the motivation and the intention behind the action is inaccessible to the patient, so they interpret the behaviour as mind control messages from their TV screen.

Inability to monitor the belifs and intentions of others

* Schizophrenics may struggle to monitor and interpret the behaviour of others.
* Leads to misunderstandings that could result in some of the delusions of persecution experienced by many schizophrenics.
* For example, a schizophrenic may believe that others can hear their thoughts, or that a stranger who seems angry is angry because of them and intends to do them harm.

Central control dysfunction: Lack of preconscious filters

* Brain constantly recieves information from the world around us
* If we tried to pay attention to all of the infomration in our environment, we would soon become overwhelemed and unable to function

Frith (1979) ‘Attention Deficit Theory’ of SZ

* Schizophrenia is the result of the breakdown of thought filtering process.
* Issues with attention, not able to effectively filter non-pertinent information
* Inability to properly focus causes disordered thought
* Can possibly account for hallucinations, delusions and disorganised speech



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* Things in the environment that would usually be filtered out as irrelevant or unimportant are now interpreted in conscious awareness as more significant than they really are.
* These cognitive deficits may be caused by abnormalities in those areas if the brain that use dopamine,especially the prefrontal cortex
* Frith’s research has shown that schizophrenics have reduced blood flow to these areas.

Bentall (1994)

* Schizophrenics have attentional bias towards stimuli of a threatening and emotional nature e.g. violence, pain etc.
* More likely to perceive a stimuli as threatening when it isn’t.
* Could explain paranoid delusions.
* The inability of schizophrenics to effectively focus their attention on the appropriate elements of the environment may also account for why many schizophrenics have problems with memory recall of events.
* They are not attending to the world in a logical way, and so the memories that they form are incomplete or incomprehensible.

Supportive evidence (Family dysfunction)

**One strength of family dysfunction explanations, such as double bind theory, is that there is supportive evidence**. For example, Berger (1965) found that schizophrenics reported a higher recall of double bind statements by their mothers than non-schizophrenics when asked to think back and describe their upbringing.  This suggests family communication styles could be the reason for the development of schizophrenia. However, evidence from studies that ask patients to report on past experiences may not be reliable as patient’s recall may be affected by their schizophrenia. Therefore, family dysfunction theories might not be as supported as first thought

Applications for treatments (Family dysfunction)

**A second strength of family dysfunction explanations is that they have led to useful applications, in terms of treatments for schizophrenia.**  For example, research into expressed emotion (EE) led to Hogarty (1991) to devise a type of family therapy session, which aims to reduce social conflicts between parents and their children by teaching communication skills, listening skills, etc.  This has been found to be linked to reduced EE communication styles and, thus, lower relapse rates. This suggests that gaining an insight into family relationships allows psychiatric professionals to help improve the quality of patient’s lives and help manage symptoms.

Cause and effect (Family dysfunction)

**A weakness of the family dysfunction explanation is that there is a problem of explaining cause and effect.** For example, Mischler & Waxler (1968) found significant differences in the way mothers spoke to their schizophrenic daughters compared to their normal daughters, which suggests that dysfunctional communication may be a result of living with the schizophrenic rather than the cause of the disorder in the first place. This suggests that there is a problem of the chicken and egg scenario in relation to expressed emotion causing schizophrenia.

Supportive evidence (Cognitive explanations)

**One strength of the cognitive explanation of schizophrenia is that there is supportive evidence that schizophrenics do suffer with information processing and attention deficits.**  For example, Stirling (2006) compared patients with schizophrenia to a control group of those without schizophrenia on cognitive tasks, such as a Stroop task.  In this task, participants have to name the ink colour of colour words.  Results showed that those with schizophrenia took over twice as long as the control group to suppress the impulse to read the word rather than the ink colour of the word.  This shows how schizophrenics do have problems with attention and processing information in their environment, which could then explain their disorganised speech.

Identifying cause and effect (Cognitve explanations)

**A weakness, however, of the cognitive explanation is that there are problems with identifying cause and effect.** Cognitive explanations do not explain the underlying causes of cognitive deficits and biases – where they come from in the first place. Is it the cognitive deficits that causes the schizophrenic behaviour or is it the schizophrenia that causes the cognitive deficits? This suggests that the cognitive accounts of schizophrenia may just represent the symptoms of schizophrenia, rather than outline a cause for it.

Reductionist (Cognitive explanations)

**A final weakness of the cognitive explanation for schizophrenia is that it is considered reductionist. The reason for this is because the approach does not consider other factors such as genes and neurotransmitters.**  Evidence from Gottesman and Shields has shown how there is a much higher concordance rate between MZ twins than DZ twins for schizophrenia, suggesting there is a role of nature to play in explaining schizophrenia. It could be that genetic dysfunctions create the cognitive deficits, which then lead to symptoms. This suggests that the cognitive approach is over simplistic when considering explaining schizophrenia.

The dopamine hypothesis

* Antipsychotics work by altering levels of neurotransmitters (eg dopamine) in the brain, so it links with the dopamine hypothesis.
* Dopamine is a neurotransmitter
* High levels of dopamine have been implicated in schizophrenia…
* Dopamine attaches to dopamine receptors
* There are a number of *types* of D receptor
* D1-D5 receptors –
* Different types found in different areas of the brain
* D2 receptors, found in the limbic system (ie the subcortex), are the receptors that seem to be linked to schizophrenia, specifically positive symptoms

Updated dopamine hypothesis

Too much dopamine in the subcortex, and too little (hypodopaminergic) in the cortex.

Antipychotic medications

* Developed in the 1950s, and was revolutionary in treatment of SZ
* First drug was **Chlorpromazine**
* Psychiatrists did not know how it worked, as it also acted as a sedative
* This may be because it blocks histamine receptors… either way it reduced psychotic symptoms!
* Since then, many more antipsychotics have been developed, which have a great variety in effectiveness and side-effects, thus there is no one cure-all drug, and it’s just a treatment, not a cure, however, it can allow SZs to live normal(ish) lives

What are the two types of antipsychotics?

* Typical (First generation/convential)
* Atypical (Second generation)

What are typical antipsychotics?

* These antipsychotics lead to a reduction in positive symptoms
* They block D2 recptors in the synapses in the brain which reduces the amount of dopamine in the brain e.g. Chlorpromazine

What side-effects do typical antipsychotics?

* One example of such side-effects is when the *extrapyramidal network* in the (cerebral) cortex (ie not the *sub*cortex) is impacted: this is the motor area, which is concerned with movements and motor activity.
* Prolonged use of Typical neuroleptics (antipsychotics) can lead to side-effects such as involuntary movements of tongue, face, jaw etc. (*Tardive Dyskinesia*), as well as dizziness, agitation, stiff jaw, weight gain, and itchy skin.
* Typical antipsychotics have also led to side-effects, such as weight gain and NMS.

When were atypical antipsychotics developed?

* 1970’s
* One well known atypical antipsychotic is Clozapine, which was developed in 1961, but not used clinically until the 1970s
* Very effective antipsychotic but still serious,new side-effects
* Only used where the schizophrenic has not responded

What are antipsychotics?

* These lead to a reduction in negative symptoms and side effects
* These anitypsychotics bind to D2 receptors and acts of the serotnin receptors which balances serotnin levels.

Are atypical antipsychotics dopamine antagonist or agonists?

A partial agonist

Research Support for antipsychotics

* Shows the effectiveness of antipsychotics %%(Lobos 2010)%%
* For example, Thornley et al (2003) reviewed a number of studies and showed that using typical anti-psychotics, like chlorpromazine, helped to reduce symptoms compared with a placebo drug. 
* Furthermore, Meltzer et al (2012) showed that atypical anti-psychotics, like Risperidone, were even more effective than typical ones at reducing symptoms, especially with negative symptoms and positive symptoms, whereas typical anti-psychotics tended to only help positive symptoms.
* Therefore, the use of biological treatments should be encouraged, especially atypical anti-psychotics, as evidence suggests that can help sufferers of the disorder.
* However, there are issues in adherence as some schizophrenics struggle to adhere (attrition rates)

Risk of side-effects

A major limitation of using biological treatments like anti-psychotics is the risk of side-effects.  This is truer with typical anti-psychotics, such as chlorpromazine.  For example, such drugs are associated with dizziness weight gain and, even more severe, tardive dyskinesia (muscle spasms).  This is a limitation as it may mean that a patient may not adhere to their treatment if the side-effects are unpleasant, and their symptoms will then not be helped. 

CBT

* The aim is to challenge delusions
* It uses the ABC model to help manage their symptoms
* Patient is encouraged to develop rational interpretations or alternative perceptions, e.g. viewing voices as interesting rather than threatening
* Promotes increase in social activity and use of relaxation strategies

What are the aims of CBTp?

* Challenge and modify delusory beliefs
* To help the patient to identify delusions
* To challenge those delusions by looking at evidence
* To help the patient to begin to test the reality of the evidence

Key components of CBTp

* CBTp usually takes place weekly or fornightly for between 5 and 20 sessions.
* Patients are ecouraged to trace back the origins of their symptoms in order to gain insight into the way in whcih they may have developed
* Offering a range of psychological explanations for their delusions and hallucinations can be viatl for some patients, and may help reduce the stress and anxiety that can go along with the illness

How does the cognitive approach explain schizophrenia?

* Cognitive apporach sees mental illness as being caused by problems with the internal mental processes
* CBTp aims therefore to alter the way in which schizophrenics think, to help them manage and orgainse their disordered thinking, and to challenge maladaptive thoughts and replace them with constructive thinking that leads to healthy behaviour
* Schizophrenic people are often unaware that they are subject to cognitive errors or that there are problems with their thinking
* The therapost will try to make theses maladapative thoughts conscious and then by challenging them, the patient will see that there is no basis for these thoughts
* CBTp cannot prevent hallucinations or delusions but can help them cope with symptoms

What ways are there to help schizophrenics cope with symptoms?

Hallucination investigation - reality testing

Delusion investigation - reality testing

Psychoeducation

What is Hallucination investigation?

* For schizophrenics who hear voices , CBTp may help them attribute these voices as originating in their own mind , rather than from an external source
* This may be done by getting the patient to focus on the nature of the voices that they hear - e.g. thinking about their tone, or whether they are male or female and thus working out that it's them . This is called Normalisation

What is delusion investigation?

* For those who experience delusions, these can be tested and challenged in a controlled environment so that the schizophrenic may see them for the false beliefs that they are

What is psychoeducation ?

* The therapist teaches the patient about their illness , and how it can be managed. This decatastrophises, and normalises the symptoms such as delusions and hallucinations
* Once completed, they will go into more detail , such as identifying specific 'triggers' for the patient, and how to avoid them

What are some cognitive strategies used in CBTp?

* Dysfunctional thought diary
* Behavioural experiments

What is a dysfunctional thought diary?

* The patient notes down each time they have a thought that may be classed as dysfunctional (such as a delusion) or encounter a situation that they feel unhappy about.
* They are then challenged to think differently about the event or thought and are asked to come up with possible alternative outcomes or to supply evidence that their way of thinking was appropriate.
* These are discussed with the therapist.

What are behavioural experiments?

* A patient may be given a behavioural “homework” task, such as testing out an irrational belief.
* They may be asked to do a behavioural experiment and then report back on their findings.
* This can be done both within or outside of therapy.
* By testing these beliefs and finding them not to be true, hopefully the schizophrenic will change their maladaptive thinking, and realise that their delusions are not based on reality.

Key components of CBTp?

* Cognitive strategies
* Behavioural skills training
* Relapse prevention strategies
* Socratic questioning

Cognitive strategies

These are the methods taught to the patient to help them deal with the cognitive symptoms of the illness

Behavioural skills training

The behavioural aspects of CBTp aim to give the patient behavioural strategies that can help them cope both with the symptoms of schizophrenia, and the negative secondary symptoms such as anxiety or depression.