Schizophrenia and Cognitive Therapy
by Lynn Marcinko McFarr, Ph.D., Founding Fellow, ACT
What is Schizophrenia?
Schizophrenia can be a devastating illness. It affects approximately one percent of the population. People afflicted with schizophrenia generally develop symptoms in their late teens or early twenties. Men tend to develop symptoms before women, but the lifetime prevalence of the disorder effects men and women equally.
What are the symptoms of Schizophrenia?
The prominent symptoms of schizophrenia include three broad categories of symptoms:
1. Positive Symptoms: hallucinations, including hearing voices, smelling odd things that others don’t smell, and to a lesser extent, seeing other things that other people do not see. People with schizophrenia often hear voices of people they know and the voices often say negative things.
2. Negative Symptoms: People with schizophrenia may lose motivation to do many day to day tasks. They may lose their “joy of life” and become less expressive with emotions and facial expressions.
3. Disorganized Symptoms: People with schizophrenia may also talk in ways that are difficult to understand. They may also be hard to follow and jump from topic to topic without completing sentences. They may engage in behavior that looks odd, or doesn’t make sense to most people (e.g., digging through trash, wearing odd clothing).
Having these symptoms also affects a person’s mood. Many people with schizophrenia become depressed and anxious. People with schizophrenia may become very fearful of the voices and thoughts they are having and may not want to go to sleep or may want to sleep during the day when they feel safer. This can lead to irritability and increased depression. People with schizophrenia may also have problems with thinking, planning, and memory.
What Causes Schizophrenia?
There are multiple causes of schizophrenia. Although genetics plays a role, over two thirds of people with schizophrenia have no relatives with the disorder. The risk of developing schizophrenia increases in patients with a history of problems with their functioning as children. For instance, mothers of patients with schizophrenia were much more likely to have had difficulties with their pregnancies. Also people who later develop schizophrenia were more likely to have developmental delays, have social difficulties in childhood or have suffered head injuries. The normal development of the brain may be complicated in some way and the long term impact may be the development of schizophrenia.
What treatments are available?
1. Medications: Most people with schizophrenia will need to take some sort of antipsychotic medication. The two main categories of medications for schizophrenia are typical antipsychotic medications and atypical antipsychotic medications. Both categories of medications seek to balance brain chemicals involved in schizophrenia. Both medications decrease the positive symptoms of schizophrenia. However, the atypical antipsychotics tend to have fewer side effects and work on negative symptoms as well. People with schizophrenia may have to try several different types of medications before finding one that works well for them.
2. Cognitive Therapy: Although medications are crucial in the management of schizophrenia, many people with the disorder are not compliant with taking the medications, and even if they are compliant, over 50% of people with schizophrenia will continue to have distressing symptoms. Thus, complementary and additional treatments are needed. Cognitive and behavioral interventions have demonstrated effectiveness with depression, panic, eating disorders, OCD, insomnia, phobias, and other disorders. Cognitive Therapy has also been shown to be very effective in helping patients with schizophrenia manage their symptoms. Outcome studies suggest that patients who receive CT have fewer and less intense hallucinations and delusions, and recover their functioning to a greater extent than patients who do not receive Cognitive Therapy.
The cognitive model suggests that the way people think about themselves, the world and the future influences emotions and behavior. In the cognitive model of schizophrenia, symptoms are believed to lie on a continuum with normal experiences. For example, many people have thought they have heard their name called. The cognitive model of schizophrenia suggests that this is a similar and smaller version of what people with schizophrenia experience when they hear voices.
People with schizophrenia have distorted beliefs which influence their behavior in maladaptive ways. For instance, people with schizophrenia may assume and believe that a neutral comment is directed at them and designed to give them a message, often negative, when it is not. Or they may believe that something that is happening to them physically is being controlled by something outside of them.
In the cognitive model, delusions are thought to result from faulty interpretations of events. In cognitive therapy, therapists help the patient identify and correct those faulty interpretations. This often results in a decrease of distress and fear.
In cognitive therapy for schizophrenia, the course of treatment follows the same basic structure as traditional cognitive therapy. Therapy is usually delivered in individual sessions, lasting 50-60 minutes. However, it can be delivered in shorter durations or the patient can be offered breaks depending on the patient’s level of agitation or acute distress. The primary goal of cognitive therapy for schizophrenia is to decrease the patient’s distress associated with the symptoms of schizophrenia.
In CT, patients are taught to trace back the origins of their symptoms to get a better understanding of how they developed. Patients are also taught to evaluate the content of their voices and delusions. Patients are encouraged to collaborate with their therapists to design experiments to test the validity of their beliefs. Patients are also assigned behavioral assignments to improve their day to day functioning. Psychiatric medications and Cognitive Therapy have also been shown to be more effective than psychiatric medications alone or psychiatric medications and supportive interventions.
3. Psychosocial Rehabilitation: Structured programs designed to enhance the functioning of people with schizophrenia have been shown to have a positive impact. Programs include symptom management group, medication management, case management, and other programs designed to enhance the lives of people with schizophrenia.
4. Other Psychotherapies: Other therapies that have been shown to be helpful with schizophrenia include social skills training, Acceptance and Commitment Therapy (another form of cognitive behavioral therapy) and family therapy.
Can people with Schizophrenia have other illnesses?
Contrary to popular belief, schizophrenia is not the same thing as “split personality.” “Multiple Personality Disorder” (Dissociative Identity Disorder) is a far more rare and unrelated disorder.
Patients with schizophrenia may suffer from a host of other psychiatric disorders including depression, mania, anxiety disorders, etc. Although patients with depression and mania may experience hallucinations and delusions, it does not necessarily mean that they have schizophrenia. Additionally, patients who abuse drugs may also hallucinate without ever developing schizophrenia. However long term abusers of crystal methamphetamine and other stimulants may develop unrelenting hallucinations and delusions even after they discontinue the drugs.
Where can I get more information?
1. National Alliance on Mental Illness (www.nami.org)
2. Mental Health Organization (www.mentalhealth.org)
3. National Mental Health Organization (www.nmha.org)
Books for Patients and Families
1. “Surviving Schizophrenia” – E. Fuller Torrey (link here to amazon)
2. “I’m Not Sick and I Don’t Need Your Help” – Xavier Amador (link here to amazon)
3. “Understanding Schizophrenia : A Guide to the New Research on Causes and Treatment” -- Richard Keefe, Philip D. Harvey
Books for Clinicians
1. Cognitive Therapy of Schizophrenia (Guides to Individual Evidence Base Treatment) -- David G. Kingdon, Douglas Turkington
2. Social Skills Training for Schizophrenia, Second Edition : A Step-by-Step Guide by Alan S. Bellack, Kim T. Mueser, Susan Gingerich, Julie Agresta
Referrals to Cognitive Therapists in Your Area:
Lynn Marcinko McFarr, Ph.D.
Director -- Cognitive Behavioral Therapy Clinic
Assistant Clinical Professor --Department of Psychiatry
David Geffen School of Medicine
Harbor UCLA Medical Center
1000 W. Carson St., Box 498