Schizophrenia: Cognitive Theory, Research, and Therapy

432 Pages·2008·1.87 MB·English

by  Aaron T. Beck

Schizophrenia

Schizophrenia
Cognitive Theory,
Research, and
Therapy
aaron T. Beck
neil a. rector
neal Stolar
paul Grant
The GUiLForD preSS
new York London
© 2009 The Guilford Press
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The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
of practice that are accepted at the time of publication. However, in view of the
possibility of human error or changes in medical sciences, neither the authors,
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or publication of this work warrants that the information contained herein is in
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Library of Congress Cataloging-in-Publication Data
Schizophrenia: cognitive theory, research, and therapy / Aaron T. Beck . . .
[et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-60623-018-3 (hardcover: alk. paper)
1. Schizophrenia—Treatment. 2. Cognitive therapy. 3. Cognition.
4. Cognition disorders. I. Beck, Aaron T.
[DNLM: 1. Schizophrenia—therapy. 2. Cognitive Therapy.
WM 203 S337223 2009]
RC514.S33468 2009
616.89′8—dc22
2008034198
The characteristics of patients in the case examples are composites so as to
prevent identification, and the details of the case histories and the dialogue were
modified without detracting from their significance.
To my wife, children, and grandchildren
—A.T.B.
To Debora and Zoe
—N.A.R.
In memory of Cyrell,
and to Kyler, Eden, Brady, and Shannon
—N.S.
To Amy, Leone, and Greg
—P.G.

about the authors
Aaron T. Beck, MD, is University Professor Emeritus of Psychiatry at the
University of Pennsylvania and President of the Beck Institute for Cognitive
Therapy in Philadelphia. Dr. Beck developed cognitive therapy in the early
1960s as a psychiatrist at the University of Pennsylvania. He has published
over 500 articles and 19 books and has lectured throughout the world.
Dr. Beck is the recipient of many honors from professional and scientific
organizations, including “America’s Nobel,” the Lasker Clinical Medical
Research Award.
Neil A. Rector, PhD, is Director of Research in the Department of Psychia-
try at the Sunnybrook Health Sciences Centre in Toronto and Associate Pro-
fessor of Psychiatry at the University of Toronto. He is a Founding Fellow
of the Academy of Cognitive Therapy, an editorial board member of several
cognitive therapy journals, and a Canadian Institutes of Health Research
and Social Sciences and Humanities Research Council of Canada-funded
investigator for the study of cognitive mechanisms and cognitive therapy
treatments for psychiatric disorders. In addition to having an active cogni-
tive therapy practice, Dr. Rector is involved in the training and supervision
of cognitive therapists.
Neal Stolar, MD-PhD, is a Medical Director and Director of the Cognitive
Therapy for the Treatment of Psychosis Special Project at Project Transition
in the Philadelphia area; a psychiatric consultant for Creative Health Ser-
vii
viii about the authors
vices and Penn Behavioral Health; a researcher at the University of Penn-
sylvania’s Psychopathology Research Unit and Schizophrenia Research
Center; and is in private practice. Dr. Stolar is a Founding Fellow of the
Academy of Cognitive Therapy. He has lectured on cognitive therapy of
schizophrenia in the United States, China, and Brazil.
Paul Grant, PhD, is Director of Schizophrenia Research and a Fellow in
the Psychopathology Research Unit in the Department of Psychiatry at the
University of Pennsylvania. Dr. Grant’s research interests include cogni-
tive psychopathological models of positive and negative symptoms as well
as cognitive therapy of schizophrenia. He is the author of several journal
articles and book chapters.
preface
T
he disorder or disorders labeled “schizophrenia” have historically posed
many questions and offered a number of challenges. Is it possible to make
sense out of the varied, often fantastic, beliefs of the patients? Are there any
principles that apply to all patients? Is it possible to treat them with psycho-
therapy? What is the relationship of organic findings to the clinical picture?
Our attempt to answer these questions provided the impetus for preparing
this volume. The material evolved from our clinical experience and investi-
gations at the universities of Pennsylvania and Toronto. We have all treated
many cases of schizophrenia, supervised other professionals, and engaged
in systematic research in this area.
Initially, the success in the application of cognitive therapy (CT) to
schizophrenia in the United Kingdom prompted us to conduct randomized
controlled trials of CT, first in Toronto and most recently in Philadelphia.
As we indicate in our summary of the controlled trials of CT (or cognitive-
behavior therapy, as it is frequently called), the results of the previously
reported clinical trials are promising—but there is still much room for
improvement. Indeed, the fact that a psychological intervention could sub-
stantially improve clinical outcomes beyond usual care (generally including
pharmacotherapy) has been, of course, a surprise to many investigators and
clinicians engaged in the study and treatment of schizophrenia.
We should note at the outset that the preparation of a treatment for a
complex disorder such as schizophrenia requires far more than the descrip-
tion of specialized strategies and techniques. Successful treatment depends
ix
x preface
on an in-depth understanding of its phenomenology and causes. Further,
the therapist needs a conceptual framework to serve as a guide, just as a
builder needs a blueprint. In this volume we have attempted to provide,
first, an understanding of the origin, development, and maintenance of
the symptoms (delusions, hallucinations, thinking disorder, and negative
symptoms). Second, we have used our understanding of the symptomatol-
ogy and our therapeutic experience fortified by the research in this area to
present our suggestions for the treatment of this disorder. Finally, we have
attempted to integrate the vast amount of research on the biology of schizo-
phrenia with the relatively sparse work on its psychological aspects into a
comprehensive psychobiological model of schizophrenia.
Following an overview of schizophrenia in Chapter 1 and a review of
the disorder’s complex and intriguing neurobiology in Chapter 2, we pro-
vide a broad survey of the clinical and psychological aspects of delusions
(Chapter 3). What struck us are the commonalities across all types of delu-
sions. Most crucially, the hypersalient beliefs (whether paranoid or grandi-
ose) usurp the information processing of the afflicted individuals. Further,
the patients’ capacity to view their aberrant thoughts, interpretations, and
beliefs as mental products subject to evaluation is attenuated. They view
their paranoid or grandiose ideas as facts and perceive their fantasies as
reality. A number of biases are present in all of the delusions. When the
patients slip into the paranoid mode, for example, all their experiences
are subjected to the triad of egocentric, externalizing, and internalizing
biases: they are the object of other people’s investment, their unexpected or
unusual experiences are caused by external entities, and these entities are
motivated to affect their well-being or autonomy.
Chapter 4, on hallucinations, indicates how these experiences are
related to the patients’ own thoughts and ideas, which are transformed into
auditory images. The key problem is the patients’ delusion that the voices
are externally produced (often by some inimical entity) and that they are
omnipotent, omniscient, and uncontrollable. The hallucinatory experience
is often embedded in paranoid delusions and indeed is on a continuum with
delusions of mind control (thought insertion, thought capture, and mind
reading).
Chapter 5, on negative symptoms, addresses the problem of why
impairments in attention, memory, and mental flexibility are related to loss
of productivity, anhedonia, and social withdrawal. The missing link, as we
describe it, is the patients’ negative attitudes about their abilities, expec-
tations of pleasure, and interpersonal competencies—all resulting from a
history of frustrations related to actual neurocognitive dysfunction. Our