CBT OF SZP

University of Dhamar
 Definition of CBT
Cognitive Therapy is a system of psychotherapy that attempts
to reduce excessive emotional reactions and self-defeating
behaviours, by modifying the faulty or erroneous thinking
and maladaptive beliefs that underlie these reactions
• * Focused form of psychotherapy based on a model
suggesting that psychiatric/psychological disorders involve
dysfunctional thinking
• The way an individual feels and behaves in influenced by
the way s/he structures his experiences
• Modifying dysfunctional thinking provides improvements
in symptoms and modifying dysfunctional beliefs that
underlie dysfunctional thinking leads to more durable
improvement
• Therapy is driven by a cognitive conceptualization and uses
Environment

Body

Psych:
Cognition

Emotions

Behaviou
r
 COGNITIVE FUNCTION

INPUT PROCESSING OUTPUT

Brain receives Brain sorts, Brain controls

input from sense organizes, stores, and produces
organs and compares, output as a
filters out categorizes, verbal statement
irrelevant data; foresees, plans, or other behavior
also called formulates that is hopefully
“perception” using the an adaptive
incoming response to
information the original
(thinking) input
 Automatic thoughts
• Meanings we take from what happens around us or
within us (words or images)
• Happen spontaneously in response to situation
• Brief, frequent, habitual – often not heard
• Do not arise from reasoning
• No logical sequence
• Plausible and taken as obviously true, especially
when emotions are strong
• Hard to turn off
• May be hard to articulate
 COGNITIVE DYSFUNCTON

• Cognitive distortions:
Errors in interpretation that involve faulty
content of thoughts and can be associated with
changes in mood and behavior
• Cognitive deficits:
Information processing operations that are
missing or working poorly
 Cognitive distortions
• Jumping to conclusion without supporting evidence (arbitrary
inference)
• Holding unrealistic EXPECTATIONS for a given situation
– Expecting self, others or situation to be perfect
– Pessimism: expecting things to always go wrong
– Dichotomous thinking (“black and white” or “all or nothing” thinking)
– Emotional reasoning
• Distorting the MAGNITUDE of a situation:
– Selective abstraction
– Catastrophizing, Magnifying
– Overgeneralizing
– Labelling--You identify with your shortcomings.
• Making the wrong ATTRIBUTION for a situation:
– Assuming the wrong intent for another person’s actions
– Assuming the wrong locus of control in a given event
– Personalization (Excess responsibility) or blaming others
 Cognitive Deficits
• INPUT:
– Problems with sensory perception
– Inability to filter out irrelevant stimuli
– Problems attending to relevant stimuli

• PROCESSING:

– Problems comparing information

– Incorrect labeling or categorizing stimuli
– Poor memory capacity or retrieval
– Slow processing speed
– Problems following a sequence
– Problems with foresight or planning
– Inability to use internal language or “self-talk”
 Schemas (Core believes)
• “stable cognitive patterns” that actively
“screen, code, categorize, and evaluate
stimuli” in our environment.
• Those hypothetical organizing structures
that guide our processing of the
overwhelming number of stimuli that
impinge on our senses at any given
moment.
 Early Experiences

Cognitive
 
Model Core Beliefs &
  Assumptions

Beck (1979)
Critical Incident

Negative Automatic
Thoughts (NATS)

Behaviour Feelings

Physical symptoms
 CBT of SZP
• SZP is:
- Frequently associated with impairments of cognition,
emotion, volition, behavior, somatic, educational and socio-
economic functioning
- Prodromal, Acute, Residual and Remission phases,
- Comorbidity: Anxiety disorders, depressive disorders,
substance abuse
- Biologically determined and psychotherapy was thought to
has no benefit and could be harmful
- NICE (2002) - ‘Psychological interventions should play a
key role in the treatment of schizophrenia. The best
evidence is for CBT and Family Intervention (FI)’
- Currently, NICE Guidelines (2003) recommended CBT as a
treatment modality for SZP - based on rigorous meta-
analysis of ‘high-quality’ RCTs (20)
 Clinical Model
• Diathesis-Stress Model
(Vulnerability-Stress)
• Vulnerability (predisposing factors):
4) Biological factors: hereditary, constitutional or acquired
5) Psychological factors: constitutional or acquired eg:
cognitive deficits or maladaptive schemas
6) Social factors
* Stress: Precipitating factors (physical, psychological, social)
• Symptoms are normal responses to abnormal situations
• Psychotic symptoms are the extremes in a continuum of
psychological experience
* Maintaining factors (physical, psychological, social)
 Clinical Model

Bio-psycho- Cognitive
social Trigger Emotional Anomalous
vulnerability Bio- Changes experience
psychosocial
Stressor

Appraisal of experience Positive

symptoms Maintaining factors
as external
 Aim of CBT for SZP
• To reduce the distress and disability
caused by symptoms
• To improve mood and self-esteem
• To improve social-functioning
• To reduce psychotic symptoms
• To reduce the risk of further relapse
• To enhance early identification and
prevention
 Overview of a typical course of therapy
• Assessment: wider picture, measures
• therapeutic relationship
• Formulation (ongoing): precipitating factors,
maintaining factors, predisposing factors,
problem analysis, sharing model, rationale for
treatment
• Problem list & prioritise (identify specific
problem)
• Action plan and Goals for therapy (SMART)
 - Course of therapy - cont
• Psycho-education
• Collaboratively construct a model that makes symptoms and
distress understandable and explainable
• Develop an alternative, non-psychotic model of experiences
that is acceptable and non-stigmatizing
• Develop a plausible ‘biases-in-psychological-processing’
explanation of experiences
• Connect up seemingly unconnected factors - beliefs, life
events, emotions, thoughts, behaviors and symptoms
• Normalize the psychotic experience (you are not alone)
• Installation of hope
 CBT of Hallucinations
• Identify the type of hallucination
• Explore associated environment, cognition,
emotions, somatic symptoms and behavior
• Psycho-education and Normalizing experience
• Change the situation
• Use behavioral techniques:
- Change behavioral responses
- Behav. Exps
- Exposure
• Cognitive techniques
 CBT of Delusion
- Direct confrontation should be avoided
- Think about the psychological need of the patient
- Encourage development of arguments against
beliefs by patients
- Focus not on the belief but on the evidence for it
- Discuss the belief as an assumption not as a fact
- Discuss evidence, Cognitive distortions
- Alternative explanations
- Behavioral Exps
and finally…

DON’T PANIC

It can be done !