a cognitive model of schizophrenia

8/11/2019 A Cognitive Model of Schizophrenia

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A Cognitive Model of Schizophrenia

Aaron T. BeckUniversity of Pennsylvania

Philadelphia

The poor reality testing and the thinking disorder in schizophrenia may be attributed to a

deficiency in cognitive resources related to the neurobiological deficiencies. Recent therapy

and research have demonstrated that, far from being a bizarre psychologically incompre-

hensible phenomenon, schizophrenia can be understood within our conventional

conception of human nature. This humanizing trend is especially evident in the cognitive

approaches to this disorder. Research has established that there is a continuum from nor-

mal experiences of paranormal beliefs, hallucinations, thinking problems, and withdrawal

to their counterpart in schizophrenia. The kinds of biases in schizophrenia are also evi-

dent in common social problems such as prejudices and ethnocentrism as well as in

interpersonal strife. Dysfunctional attitudes about attachment and performance in schiz-

ophrenia form the infrastructure for persecutory delusions and negative symptoms,respectively. Grandiose delusions, on the other hand, are shown to be an overcompensation

for a sense of loneliness, inferiority, and vulnerability.

Keywords: schizophrenia; delusions; hallucinations; negative symptoms; cognitivetherapy

The investigation of the cognitive factors in psychosis is still at a relatively early stageof development and has been largely obscured by the mass of neuro-anatomical,

neuro-cognitive, genetic, and pharmacological studies. Despite the relatively low pro-file of the psychological approaches (especially of the cognitive factors) in psychosis, steadyprogress has been made as indicated by the articles in this issue. Various researchers such asRichard Bentall (2003) have steadfastly pursued studies for more than 2 decadesin the faceof the dominant biological orientation in the field.

The articles in this issue are important for at least two major reasons. First, these arti-cles demonstrate that, despite a common notion that psychotic symptoms are beyond com-prehension, they are understandable within the framework of what is known about humannature generally and clinical disorders such as depression and anxiety, specifically. Thesearticles demonstrate that the same clinical and research strategies used in exploring thestructure of the nonpsychotic disorders can be utilized in understanding psychosis. Thus,

they have established commonalities extending from the psychological aberrations in normalbehavior to the more pronounced distortions in the nonpsychotic disorders to the extremed i ti i h i Thi h h h d h i i i fl th

Journal of Cognitive Psychotherapy: An International QuarterlyVolume 18, Number 3 2004


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of particular vulnerabilities, they have psychological experiences that the rest of us experi-ence rarely or only under severe stress. These experiences in patients are far more devastat-ing then the occasional mental lapses in the general population.

Second, a major contribution of these articles is their practical application to the treat-ment of psychosis. They provide the important formulations not only for understanding

delusions, hallucinations, negative symptoms, and thought disorder, but also for modifyingthem. They show that the significant biases in the way patients process information distorttheir interpretations of their internal experiences and their interactions with other people.This roadmap then provides the clinician with a specific guide of where and when to inter-vene with the patients.

CONTINUUMFROMNORMALITY TOPSYCHOSIS

There is considerable evidence from community surveys and population studies that thesymptoms associated with schizophrenia are not experiences with nothing in common

with usual experiences. Surveys show that the symptoms generally ascribed to psychosisare experienced by a significant number of people who are not mentally ill (e.g., Barrett,1992; Johns, Nazroo, Bebbington, & Kuipers, 2002; Romme & Escher, 1989). Only whenthese experiences become intensified and pervasive and produce distress and/or unusualbehavior and involve some attenuation of insight is the diagnosis psychosis made.Studies have shown, for example, that many adolescents have auditory hallucinations butthey transition into schizophrenia only if they have delusions about voices (e.g., comingfrom the devil) (van Os, Hanssen, Bijl, & Ravelli, 2000; Verdoux et al., 1998). Similarly,although suspiciousness is widespread, it generally does not develop into the paranoidthinking of psychosis unless it is constant and generalized. The typical thinking disor-der manifested by some patients with schizophrenia (e.g., overgeneralization, arbitrary

inference) is also experienced to a lesser degree and only intermittently by the populationat large.

Thus, we can trace a continuum on the severity dimensions extending from the mildphenomena generally identifiable within the normal population to the more salient of thosetypical of psychosis. The greater severity plus the greatly diminished objectivity toward theunreality of the experience constitutes the psychosis. A person with social phobia may stateI think everyone is judging me, whereas the patient with psychosis states I know that theyare judging me.

The continuity between the symptoms of the population at large and those of the patientwith psychosis is paralleled by a comparable continuum in the progression of subclinicalsymptoms in the prodromal to full-blown psychosis. Patients with auditory hallucinations,

for example, have frequently experienced them during an earlier prepsychotic period. Also,their tendency to make delusional interpretations is frequently manifested in a subtle formin the nonpsychotic period. Early indications of social withdrawal may be detected prior tothe full-blown negative symptoms, such as amotivation, alogia, and withdrawal.

The kind of paranormal ideas that are often woven into delusions (e.g., clairvoyance,thought projection, etc.) is also common (Peters, Joseph, & Garety, 1999). Of especialinterest is the clinical observation that many patients who believe in thought capture,thought insertion, and mind reading had these beliefs prior to their psychosis. As the psy-chosis develops, however, these beliefs move to the center of their information processingand are used inappropriately as explanatory constructs. The patients, for example, attrib-ute unexpected blanking of thoughts or intrusion of obsessive thoughts to interference by

an external agent. Similarly, they draw on their beliefs regarding extrasensory perceptionto explain coincidences such as another person uttering what they were thinking at the

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time. Also, there is a continuity between the patients usual thought content and theirmore flagrant symptoms. Investigators have shown, for example, that in many cases, thecontent of auditory hallucinations reflects the automatic thoughts of patients (Beck &Rector, 2003).

BIASEDTHINKING, DELUSIONS, ANDHALLUCINATIONS

The symptoms of psychosis can be analyzed in terms of the various biases in thinking.These biases are reflected in the selective attention to specific aspects of their experiencesas well as in their misinterpretations. Three kinds of biases in psychosis may be identified.First, the thinking in schizophrenia is dominated by an egocentric bias (Temple, this issue).The patients relate a host of irrelevant events to themselves and consequently attach a per-sonal meaning to impersonal or irrelevant events. A patient, for example, had always beenself-conscious and acutely aware of other people in social situations. He felt that every-ones eyes were on him. When he became psychotic, this conception extended to the con-

viction that he was continually being watched or even followed. He was comfortable onlywhen alone. When they develop schizophrenia (particularly of a paranoid nature), thesepatients are essentially in a survival or vulnerable mode. They perceive themselves atthe vortex of a hostile environment. They become hyperattentive and hyperreactive tomuch of their animate environment. It is as though they are being constantly evaluated andtherefore subject to verbal or physical attacks. Of course, in some cases, the patients eval-uate others as protectors or champions but even then, this benign appearance oftenchanges to malevolence. The belief that people are unfriendly leads to an expectancy ofbeing attacked. As the expectancy becomes stronger the patients misinterpret even friend-ly behavior of other people as hostile. The dysfunctional attitudes lead to the typical bias-es observed in psychosis.

At the same time the belief that other people are dangerous or contemptuous leads toan externalizing bias. The belief that other people are hostile leads the patients to scan theirenvironments for signs of danger and to prematurely jump to conclusions that they arebeing influenced or harmed. The externalizing bias is expressed in the construction ofcausal explanations. We all are concerned about what factors may be responsible for ourpersonal distress and, indeed, may mistake the true causality at times. The patients withschizophrenia tend to overattribute causality to external entities (other people or supernat-ural entities) to the exclusion of much more obvious accidental or internal causes. Any dis-tressing feeling is due to an external agent. Thus, a patient interpreted the late delivery ofhis mail as due to an interference by the FBI. He also attributed a bout of stomach crampsto a death ray from an enemy. Interestingly, despite these patients suspiciousness and para-

noid thinking, they endorse most of the Dysfunctional Attitude Scales (DAS) sociotropicitems, including concern about others evaluations and wanting to pleasure others (Rector& Beck, 2004).

It is possible to show that although the symptom domains (delusions, hallucinations,and negative symptoms) appear to be distinct, they all arise from common sets of core andderived beliefs. When they are fully developed, they are expressed largely in separatedomains: sensory (auditory/visual), cognitive (delusions), and behavioral (negative symp-toms). Starting with the most basic (or core) belief, we can determine that the patients regardthemselves as vulnerable and others as contemptuous or dangerous. These concepts, embed-ded in schemas, mold their biased interpretations of events. As they make repeated evalua-tions of being diminisheddebased, deprived, discriminated againstthese soft beliefs

harden into absolute beliefs. The initial ad hoc beliefs are transformed into dominant, per-vasive convictionsfor example, I am being watched/followed/influenced/debased.

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The end result of this process is the formation of delusions, which control the informa-

tion processes, at least in certain domains and thus lead to the biased interpretations. When

the belief incorporates a presumed causal agent (FBI, mafia, aliens), the delusion has an evenmore profound impact on the patients feelings and behavior. The formation of hallucinations

may follow a similar pathway. The belief in ones vulnerability and other peoples antagonism

leads to a variety of frightening thoughts. These are perceptualized and consequently experi-

enced as hallucinations (Beck & Rector, 2003). This sequence is illustrated in Figure 1.

THENEGATIVESYNDROME: A COGNITIVESYNTHESIS

Writings on schizophrenia have traditionally emphasized the so-called negative symptomsas a manifestation of a deficit or impairment across cognitive, affective, and behavioral

domains. The patients are impoverished in affect, motivation, social interest, speech, andeven in the content of their thought. There is, however, an alternative cognitive model to thedeficit or neurocognitve model for these symptoms. We know, for instance, that thesepatients feel hurts deeply, and although they do not indicate having much pleasure or satis-faction in life, they do acknowledge these emotional responses in experimental situations(Earnst & Kring, 1999). Moreover, the lack of pleasure may not be specific to the negativesyndrome. Both the reduction of pleasure and the flattening of facial expression could beexplained as a manifestation of a chronic mental set. Like patients with acute depression,their relatively stable expectation, possibly reflected in their relatively immobile facialexpressions, is that they will not get much pleasure out of anything. Unlike the depressives,however, they do not necessarily have an expectation of continuing unremitting pain, per-

haps because their cognitive and behavioral strategies (detachment, avoidance, etc.) protectthem from the kind of pain experienced by depressives. Of course, patients who have the


VULNERABLE

+

PEOPLE ARE DANGEROUS

SELF-CENTERED BIAS

+

EXTERNALIZING BIAS

DELUSIONS HALLUCINATIONS

Figure 1. The common features of positive symptoms.


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negative syndrome also can become depressed and experience the typical depressive symp-toms including suicidal impulses and suicide attempts.

Empirical findings on the Dysfunctional Attitude Scale (Rector & Beck, 2004), as wellas in-depth clinical interviews, suggest a new way of viewing these negative symptoms.Specifically, we propose that certain active psychological processes contribute to what seem

on the surface to be simply deficiencies.It is certainly true that these patients do not perform well on certain neurocognitive

tests, such as card sorting, and consequently seem to have a significant impairment in basicneurocognitive functions. However, these cognitive impairments do not, in themselves,account for the negative expectations, for one. We suggest that a complex series of interact-ing events involving the individuals psychological, social, and intellectual handicaps pro-duce dysfunctional attitudes that may reinforce the limitations on intellectual functioning andlead to the clinical negativity picture. First, patients infer (sometimes correctly) that they areconsistently being evaluated negatively for their behavior (internalizing bias). Because theyhave cultivated social withdrawal as a mechanism for relieving social distress, they volun-tarily detach themselves from others (a safety behavior). They have learned to insulatethemselves from social embarrassment through disengagement until it becomes practically areflex reaction. Thus, verbal inhibition is manifested as a poverty of speech. An automaticprocess of social withdrawal is activated and is especially prominent in social interactions.Because this process is automatic, the patients may not even be aware of its operation. Mostof these patients have always been shy (by their own statement), and I have observed theyhave taut faces under social pressure. The automatic inhibition of facial expressions may bea manifestation of shyness in these cases.

Thus, social withdrawal, paucity of speech, and inhibition of facial expression may beviewed as components of the disengagement process. Another negative symptom, the obvi-ous lack of motivation to engage in complex activities, can be understood partly in terms of

their negative beliefs about their performance and expected negative evaluation for poor per-formance. They endorse the item on the Dysfunctional Attitude Scale (Rector & Beck, 2004)Its better to do nothing than to risk failure. They also equate failure on a single task withbeing a failure as a person. Their automatic loss of constructive motivation represents aretreat into safetya strong avoidance of engaging in activities that would lead to

Beck 285

SENSITIVITY TO NEGATIVE PERFORMANCE EVALUATION

IF I CANT DO WELL, IM A FAILURE

DISENGAGEMENT (SAFETY BEHAVIOR)

FLAT AFFECT AMOTIVATION WITHDRAWAL

Figure 2. Sequence in development of negative symptoms.


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further self-devaluation. This urge to avoid possible failure overrides any motivation toengage in constructive actions (Figure 2). Of course, there are other contributing factors inoperation. These patients function on the assumption that they have meager resources and,consequently, attempt to conserve these resources through inactivity. Interestingly, they tendto view their personal world as devoid of personal satisfactions and themselves as lacking in

positive assets rather than possessing negative attributes.In a typical case, a shy adolescent finds it difficult to form a bridge between himself and

his peers. This social disability together with, in many cases, some cognitive impairment pro-vides the matrix for a number of dysfunctional attitudes: a basic belief of being inferior andsocially (and perhaps intellectually) inept. Being teased or bullied reinforces this belief.These core beliefs shape the goals and the kinds of strategies used by the patient to maintaina safe adjustment. These strategies consist of active avoidance of social interactions, a way toprotect the patient (often unsuccessfully) from shame and other forms of pain. This kind ofcoping strategy may be distinguished from that of the social phobics, who strongly desiresocial interactions and, indeed, maintain the active goals of having an expanded social lifeas long as they are not exposed to the possibility of disapproval. In contrast, the patients withnegative symptoms relinquish the social goals in order to reach a more tolerable comfortlevel.

There is also evidence that these patients with negative symptoms have certain impair-ments of cognitive and perceptual skills (such as recognizing other peoples emotional dis-plays; see Penn, Corrigan, Bentall, Racenstein, & Newman, 1997). These impairments resultin poor cognitive tuning manifested in missing the more subtle cues in other peoplesbehavior and thus interfere with interpersonal relations. Thus, the problem of the patientslifelong shyness is compounded by his social estrangement. The ultimate outcome is a with-drawal from social interactions, a kind of behavior that becomes automatic and habitual, butnot necessarily irreversible (see Figure 2).

THENEGATIVEMODE/SCHIZOIDPERSONALITYDISORDER

The continual interplay of characterological and experiential factors leads eventually to theformation of what we propose to label the negative mode. A mode has been defined as asuborganization of the personality consisting of structures (or schemas) relevant to cogni-tion, affect, and motivation (Beck, 1996). At the core this mode is the patients belief (con-solidated by adverse social experiences) that he is different, inferior, and inept. To a lesserextent, others are perceived as distant and often critical. In response to these core beliefs, hebuilds up a series of conditional beliefs such as, If I expose myself, I will get hurt, andOther people regard me as different and undesirable.

These beliefs lead to rules and goals distancing himself from social interactions (whichare risky) and avoiding demanding tasks at which he might fail. In a sense, the passivity andrelative immobility are security operations. The prominent feature of the negative mode isthe apparently immutable withdrawal. It is as though some archaic protective mechanismhas been activated and gained ascendance over a normal adjustment to the real world. Thecognitive, affective, motivational, and behavioral components are embedded in specificstructures (schemas), which are integrated into the mode. When the mode is activated, thenthe component parts are manifested as the totality of the clinical picture of the negative syn-drome. Since this mode becomes so strongly entrenched, it appears irreversible. It is possi-ble, however, to reduce the salience of this mode and to energize certain compensatorymechanisms. Both pharmacotherapy and cognitive therapy have been shown to reduce the

negative symptoms (Dickerson, this issue). In terms of the cognitive model, these interven-tions attenuate the negativity mode and reenergize more productive modes.



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For many patients, the negative mode permeates the entire personality. We find that the

negative symptomatology in these cases is in the surface expression of a long-standing per-

sonality structure, which has been traditionally labeled schizoid personality disorder.

Thus, these personality traits become exacerbated as the patient slips into psychosis and

remain after the psychosis has remitted. For other patients, however, the negative mode is

more encapsulated and becomes less active or even inactive during remission of the positive

symptoms.

CONCLUSION

One of the challenges in developing a psychological model of schizophrenia is to find a uni-

fying principle including the positive and negative symptoms as well as the neurocognitive

deficits. One approach is to examine the role of attenuated psychological resources in indi-

viduals with psychosis. This deficiency may be formulated in neurophysiological terms as a

profound loss of synaptic connections during the patients adolescence (McGlashan &

Hoffman, 2000), but it may also be framed in terms of the impoverishment of basic functions

involved in information processing and interpersonal interactions. The relative inadequacy

of reality testing during adolescence leads to uncritical integration of paranormal beliefs. The

same functional impairment later allows the transformation of persecutory or grandiose

beliefs into delusions. Further, the normal inhibitions of the perceptualization of cognitions

during the waking period is attenuated. This allows hypersalient cognitions to be trans-

formed into auditory hallucinations, so that these cognitions are heard rather than

thought during sleep (Beck & Rector, 2003). The totality of the negativity syndrome may

also be viewed as a reaction to the perceived reduction in resources. The patients follow the

line of least resistancesocial and emotional withdrawalas a kind of conservation meas-

ure. The proximal factors in this generalized inhibition are beliefs regarding their lack ofcompetence and fear of failure, leading to a retreat into passivity and noninvolvement.

Finally, the various deficits on neuropsychological tests are an obvious manifestation of the

patients meager resources. They have problems mobilizing their attention and reasoning and

often will seek the easiest responses, even though they are incorrect.

In sum, the relatively meager resources may be considered the common denominator of

the positive and negative symptoms and the cognitive dysfunction. Further research is obvi-

ously necessary to test out this hypothesis. However, we do know from clinical trials and

experience that the impoverishment is not absolute. Pharmacotherapy has been shown to

neutralize the disturbed brain physiology, and psychosocial interventions have been suc-

cessful in mobilizing the patients latent resources to improve their reality testing and their

interpersonal functioning. By focusing on the patients latent resources (or neuroplastici-

ty), clinicians can help to move them to a more fulfilling, less distressing life.

REFERENCES

Barrett, T. R. (1992). Verbal hallucinations in normals: I. People who hear voices. Applied Cognitive

Psychology, 6, 379-387.

Beck, A. T. (1996). Beyond belief: A theory of modes, personality, and psychopathology. In P. Salkovskis

(Ed.), Frontiers of cognitive therapy(pp. 1-25). New York: Guilford Press.

Beck,A. T., & Rector, N. A. (2003). A cognitive model of hallucinations. Cognitive Therapy and Research, 27,

19-51.Bentall, R. P. (2003). Madness explained: Psychosis and human nature. London: Penguin Books.

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Earnst, K. S., & Kring, A. M. (1999). Emotional responding in deficit and non-deficit schizophrenia.

Psychiatry Research, 88, 191-207.

Johns, L. C., Nazroo, J. Y., Bebbington, P., & Kuipers, E. (2002). Occurrence of hallucinatory experiences in

a community sample and ethnic variations. British Journal of Psychiatry, 180, 174-178.

McGlashan, T. H., & Hoffman, R. E. (2000). Schizophrenia as a disorder of developmentally reduced synap-

tic connectivity. Archives of General Psychiatry, 57, 637-648.

Penn,D. L., Corrigan, P. W., Bentall, R. P., Racenstein, J. M., & Newman, L. (1997). Social cognition in schiz-

ophrenia. Psychological Bulletin, 121, 114-132.

Peters, E. R., Joseph, S. R., & Garety, P. A. (1999). Measurement of delusional ideation in the normal popu-

lation: Introducing the PDI. Schizophrenia Bulletin, 25, 553-576.

Rector, N. A., & Beck, A. T. (2004). Dysfunctional attitudes and symptom expression in psychosis. Paper

accepted for presentation at the meeting of the Society for Research in Psychopathology, Toronto,

Canada. Manuscript submitted for publication.

Romme, M., & Escher, D. (1989). Hearing voices. Schizophrenia Bulletin, 15, 209-216.

van Os, J., Hanssen, M., Bijl, R. V., & Ravelli, A. (2000). Strauss (1969) revisited: A psychosis continuum in

the general population? Schizophrenia Research, 45, 11-20.

Verdoux, H., Maurice-Tison, D., Gay, B., van Os, J., Salamon, R., & Bourgeois, M. L. (1998). A survey of

delusional ideation in primary-care patients. Psychological Medicine, 28, 127-134.

Offprints. Requests for offprints should be directed to Aaron T. Beck, MD, Psychotherapy Research Unit,

Department of Psychiatry, 3535 Market Street, Room 2032, Philadelphia, PA 19104-3309. E-mail:

[email protected]



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a cognitive model of schizophrenia

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