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Cognitive Therapy of Schizophrenia
By David G. Kingdon Douglas Turkington
The Guilford Press Copyright © 2005 The Guilford Press
All right reserved.
Chapter One What Is Schizophrenia?
Schizophrenia has been problematic in terms of causation and classification since it was first described over a century ago, initially as dementia praecox. It has also become a very stigmatized and misunderstood condition. Schizophrenia can now be diagnosed reliably using criteria developed over the past few decades and is recognized as a diagnostic entity by international classification systems. However, the diagnosis covers a very diverse group of individuals who present in a variety of ways and require a wide range of therapeutic approaches-indeed, Bleuler (1911), when he first used the term, referred to it as "the group of schizophrenias." As a result of the diversity of presenting symptoms, Persons (1986) and Bentall and colleagues (1988) have argued the case for focusing on individual symptoms such as hallucinations, delusions, and thought disorder rather than on diagnosis. There is also an intermediate position that considers possible clinical subgroups within the overarching schizophrenia diagnosis (described in detail later in this chapter). Schizophrenia can therefore be viewed from three vantage points: disorder, subtype, and symptom.
These approaches can be considered complementary:
The broaddiagnostic category "schizophrenia" has been useful for communication, education, and research purposes. Information about research into characteristics of people with schizophrenia (e.g., age of onset) and their outcomes with treatment is given in this and the next chapter.
Subgroups provide a way of unifying symptom clusters to further guide therapy where the condition is so diverse in presentation. For example, hallucinations can occur in different circumstances and be linked to different symptoms. They may be abusive and very distressing and require direct work on the effects of trauma. Alternatively, they can support a systematized set of paranoid delusions (e.g., voices attributed to "the CIA"), and the primary focus will then be on dealing with the beliefs underlying the delusional system rather than much direct work on the voices.
A focus on individual symptoms is also valuable. Identifying symptoms is relatively straightforward. Therapy focused on symptoms is simple to understand and can be used in psychological management based on an individualized case formulation.
This chapter describes:
1. The characteristics of schizophrenia, including symptoms and demographic information
2. The cognitive model of schizophrenia, which draws on vulnerability-stress conceptualizations of schizophrenia involving the interaction between
Biological, social, and psychological vulnerabilities and
Individual stresses or stressful circumstances
3. Clinical subgroups of schizophrenia with illustrative cases
4. Ways of understanding psychotic symptoms
CHARACTERISTICS OF SCHIZOPHRENIA
The course of schizophrenia is reasonably well understood but unfortunately has changed little over time. New treatments, both pharmacological and psychosocial, may be beginning to have an impact on this, but it is too early to be demonstrable. Of those who develop the illness, traditional teaching has been that approximately 20% make a full recovery, 20% have relapses with no intervening deterioration, 40% have relapses with some deterioration, and fewer than 20% remain chronically ill and show little recovery. There is some evidence (presented below) that this may be a gloomier picture than the reality. However, there is no question that the clinical presentation of schizophrenia to clinicians is a variable one that hinges strongly on the stage of the disorder and the mixture of symptoms.
People with schizophrenia tend to experience a variety of psychiatric symptoms, including certain types of hallucinations (particularly auditory, visual, and somatic-i.e., causing physical sensations), delusions, thought disorder, and loss of insight. These symptoms usually coexist with negative symptoms (alogia, affective blunting, poor motivation, and social withdrawal; see the definitions and explanations later and in Chapter 12), which can be either primary or secondary to depression or medication side effects. Cognitive deficits-interference with thinking-such as disturbed attention, impaired short-term memory, and poor recognition of facial expressions also occur and lead to or perpetuate poor coping abilities and social isolation.
Schizophrenia has been defined by the presence or absence of specific symptoms. A combination of these symptoms and a measure of duration is necessary to make the diagnosis, according to criteria established by the International Classification of Diseases (10th edition; ICD-10;World Health Organization [WHO], 1992) and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association [APA], 2000). ICD-10 requires one very clear-cut schizophrenic symptom or two less clear symptoms to have been present most of the time for a duration of 1 month. DSM-IV-TR requires one characteristic symptom to have been present for a significant proportion of time for a 1-month period or two less characteristic ones (see APA, 2000, for further details).
Symptoms used for diagnostic purposes include:
Hearing his or her own thoughts spoken aloud.
Third-person hallucinations (voices talking about him or her).
Hallucinations in the form of a running commentary on what he or she is doing or thinking.
Somatic hallucinations (experiencing feelings that are believed by the person to originate externally but to others do not appear to do so).
Delusions of thought withdrawal or insertion (beliefs that others can remove thoughts from, or put them into, a person's mind).
Delusions of thought broadcasting (the belief that his or her thoughts are broadcast to others).
Delusional perception (when the person sees or hears the same thing as other people but attaches a meaning to it that is delusional, i.e., not shared by others).
Delusions of passivity ("made" acts, thoughts, or emotions-when the person is convinced that he or she is being made to do, think, or feel things by an external force or by other people when this does not appear to be the case).
Negative symptoms and the medium-term course of the disorder are included in the diagnostic criteria of DSM-IV-TR but not ICD-10. The introduction of such classificatory systems has improved reliability, but the validity of the diagnosis remains in question. In other words, it is now possible to get good agreement on whether someone has signs and symptoms that characterize schizophrenia, but there is still uncertainty about how meaningful a diagnosis (or group of diagnoses) it is in terms of putative causes, prognosis, or treatment response. Prior to the advent of stricter criteria during the 1970s, schizophrenia was diagnosed much more often in the United States as compared to Europe. With the introduction of agreed-upon criteria and major international studies, it has become clear that the incidence of schizophrenia is much the same throughout the world, although there are a small number of groups who do have higher rates (Boydell et al., 2001).
Many other symptoms occur as well as those that are used in diagnosis, and these may be as distressing and disabling, or even more. These include psychotic symptoms such as abusive or command hallucinations (in the second person-e.g., "You're useless" or "Kill yourself") and thought disorder-where the train of thought is very difficult to follow-and nonpsychotic symptoms such as depression, anxiety, obsessions, compulsions, social phobia, and agoraphobia.
Of the general population, 0.5-1% will develop schizophrenia at some point in their lives, although the rate of onset of schizophrenia is quite low (10-20 cases per 100,000 population per year). There is no difference in rates between men and women, but women have a mean age of onset 3-4 years later than their male counterparts. The rate of incidence is higher in urban than in rural areas. Social outcome in developed countries, as opposed to that in less developed countries, has generally been conceived as poor, with episodic relapse or chronic deterioration and heightened suicide risk. People with schizophrenia have a higher-than-expected mortality rate, owing to a number of different causes, with suicide accounting for some of the difference. Young men with relapsing schizophrenia and evidence of repeated self-harm are particularly at risk.
Schizophrenia is arguably the most debilitating psychiatric disorder-psychologically, financially, and socially. It is the 13th most expensive illness in terms of health expenditures, according to the World Bank. The traditional view has been that people suffering from this disorder are seldom employed, are unlikely to develop meaningful relationships, and have a tendency to drift down through the social classes into living in isolation or even on the streets. But this negative view has been repeatedly challenged. A study of people who had been diagnosed as having schizophrenia recently showed that approximately 50% of them, at 15-year and 25-year follow-up, had favorable clinical outcomes (Harrison et al., 2001). Whatever the long-term perspective, much of the workload of community mental health teams involves working with people with schizophrenia and related diagnostic categories (schizoaffective disorder, bipolar disorder, and delusional disorder).
THE COGNITIVE MODEL OF SCHIZOPHRENIA
Models used to explain schizophrenia have been based on biological, social, and psychological conceptualizations (see Table 1.1). Biological models have emphasized physical causes for the disorder, including abnormalities in structure and function caused by, for example, genetics, birth injury, abnormal development, or viral influences. Social models have focused on environmental influences, including poverty, influences of the inner city and culture, and family and societal pressures. Psychological models have taken a variety of perspectives, often considering complexities in interpersonal relationships.
None of these models has found universal acceptance since all of them have limitations in explaining the available research findings or in being substantiated by them. As a result, models incorporating elements of each have been proposed-based on the interactions between vulnerabilities and stress. These vulnerabilities may have a biological origin (e.g., genetic predispositions), may be inborn psychological characteristics, or may result from social circumstances during intrauterine or early development. Stresses also can be biological (e.g., infection or drug intoxication), psychological, or social. Cognitive models of delusions have recently been set forth by Garety and colleagues (2001) and Beck and Rector (2002), and of hallucinations by Morrison (1998). These syntheses are based on a biopsychosocial model and attempt to include and explain recent research findings.
Schizophrenia certainly has a genetic component in terms of vulnerability. This may be due to a small number of genes acting independently on a "multiple-hit" basis with an additive effect. Evidence of a genetic contribution, or predisposition, to schizophrenia derives from studies of identical and nonidentical (monozygotic and dizygotic) twins. The risk of developing schizophrenia is nearly 50% among children both of whose parents have schizophrenia. One influential follow-up study of twins found that both developed schizophrenia in 36% of the cases where the twins were identical, while for nonidentical twins the figure was 14%. This confirms the importance of heritability in schizophrenia, but since only just over a third of those who are genetically identical develop the disease there must also be an important environmental component to etiology. Confirmation of a genetic proclivity also derives from adoption studies, where it has been demonstrated that twins bought up in different environments have similar (i.e., higher-than-normal) rates of schizophrenia to those bought up together. There are some problems with these studies, in part attributable to other linked factors-for example, a tendency for mothers with schizophrenia to receive poorer antenatal care and a lack of reliability in diagnoses in studies. Twins are also clearly unusual in many ways, and their identity issues in particular may affect their susceptibility to schizophrenia. Viewed from the other direction, 89% of people with schizophrenia will have parents who do not have schizophrenia, 81% will have no affected first-degree relative, and 63% will show no family history of any kind of the disorder. So, the current consensus is that there is a genetic vulnerability in some people with schizophrenia that is probably due to multiple genes acting independently, with an additional environmental component.
Schizophrenia also carries a biological predisposition linked to birth trauma and maternal viral infection. Geddes and Lawrie (1995) estimated that complications in pregnancy and delivery may increase the incidence of schizophrenia by 20%. More specifically, Verdoux and colleagues (1997) found that subjects with onset of schizophrenia before age 22 were three times more likely than those with onset at a later age to have had a history of abnormal presentation at birth and 10 times more likely to have had a history of complicated cesarean birth. The risk of developing schizophrenia for people with obstetric complications, such as prolonged labor (which can cause oxygen deprivation), is four times greater than those who have none, and a history of such complications has been found in 40% of those with schizophrenia. A complicating factor here is that those with schizophrenia have an increased likelihood of obstetric complications due to psychosocial factors.
There is also a seasonal effect: People who develop schizophrenia are more likely to have been born in the late winter or spring. Epidemics of viral illnesses such as measles, influenza, and chickenpox have been shown to correlate with an increase in the numbers of births of people who later develop schizophrenia. The increased risk of developing the illness in this way is probably very small. However, these risk factors may combine with genetic risk to create significant vulnerability to schizophrenia. Individuals with schizotypal personality traits (eccentric behavior with anomalies of thinking and affect) are overrepresented in the families of people with schizophrenia, possibly showing that these personality traits may be markers of an underlying vulnerability or independent risk factors.
Excerpted from Cognitive Therapy of Schizophrenia by David G. Kingdon Douglas Turkington Copyright © 2005 by The Guilford Press. Excerpted by permission.
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