esquizofreniaconceptualizacion

In Re view

Cognitive Therapy For Schizophrenia: FromConceptualization to Intervention

Neil A Rec tor, PhD1, Aaron T Beck, MD2

Key Words: schizophrenia, cognitive therapy, cognition, outcomes, delusions,hallucinations

Schizo phre nia is a dev as tat ing ill ness char ac ter ized by se -vere im pair ments in cog ni tion, af fect, and be hav iour. Al -

though pharmacotherapy is largely ef fec tive in treat ing acutepsy cho sis and in pre vent ing fre quent re lapses, a sig nif i cant

pro por tion of pa tients ex pe ri ence per sis tent de lu sions, hal lu -ci na tions, and emo tional with drawal. This causes dis tress anddis rupts so cial and oc cu pa tional func tion ing. Of pa tients witha di ag no sis of schizo phre nia, 25% to 50% con tinue to ex pe ri -ence sub stan tive prob lems even while ad her ing to op ti malpsychopharmacotherapy (1). There is thus a clear need to de -velop ef fec tive psy cho log i cal in ter ven tions that tar get per sis -

tent symp toms and that also ad dress fre quently oc cur ringcomorbid con di tions, such as de pres sion and anx i ety.

A prom is ing new ap proach adapts the cog ni tive and be hav -ioural in ter ven tion strat e gies that were de vel oped and provenef fec tive for the treat ment of de pres sion (2) and anx i ety dis or -ders (3). This ap proach has been de tailed in sev eral books(4–6). Cog ni tive ther apy for schizo phre nia, un like otherpsychosocial in ter ven tions cur rently avail able (for ex am ple,case man age ment, sup port ive ther apy, so cial skills train ing,fam ily ther apy, and cog ni tive remediation), is tai lored to treatthe spe cific symp toms of schizo phre nia di rectly within a

W Can J Psy chia try, Vol 47, No 1, Feb ru ary 2002 41

Ob jec tives: To out line the cog ni tive un der stand ing of symp toms of schizo phre nia, such asde lu sions, hal lu ci na tions, and emo tional with drawal, and to re view the cog ni tive ther apyap proach to ame lio rat ing these symp toms.

Method: We iden ti fied stud ies ex am in ing cog ni tive fac tors as so ci ated with symp toms ofschizo phre nia by elec tronic search (us ing Med line and Psycinfo). This pa per in te grates ex -peri men tal find ings and clini cal treat ment.

Re sults: Re cent stud ies fo cus ing on the psy cho logi cal as pects of schizo phre nia dem on -strate the im por tance of com mon cog ni tive bi ases and dis tor tions that are func tion ally re -lated to the main te nance of symp toms. Un der stand ing the dis or der in cog ni tive termspro vides a frame work for psy cho thera peu tic in ter ven tion. Adapt ing cog ni tive strate giessuc cess fully used in cog ni tive ther apy of de pres sion and anxi ety pro vides an im por tant ad -junct to stan dard treat ment of schizo phre nia.

Con clu sion: Given that the out come of cur rent treat ment for schizo phre nia re mains poor,at ten tion to thera pist train ing in psy cho logi cal ap proaches is es sen tial.

(Can J Psy chia try 2002;47:39–48)

Clini cal Im plic a tions• De lu sions and hal lu ci na tions can be con cep tu al ized in fa mil iar cog ni tive terms that fa cili tate

psy cho thera peu tic in ter ven tions.• Cog ni tive ther apy for schizo phre nia has been shown to be an im por tant ad junct to stan dard

treat ments of schizo phre nia.

Limi ta tions• The ef fec tive ness of cog ni tive ther apy in “real life” clini cal set tings in North Amer ica has yet

to be de ter mined.

diathesis-stress frame work (7). Em pir i cal ev i dence for the ef -fi cacy of this new ap proach has now ac cu mu lated.

In a re cent quan ti ta tive re view of con trolled trial stud ies test -ing the ef fi cacy of cog ni tive ther apy for schizo phre nia(8–17), we de ter mined through metaanalytic pro ce dures thatcog ni tive ther apy re duces de lu sions, hal lu ci na tions, and neg -a tive symp toms and that these gains are sus tained over time(18). Fur ther, pa tients re ceiv ing cog ni tive ther apy as well asrou tine care (that is, pharmacotherapy plus case man age -ment) show sig nif i cantly greater im prove ment than do pa -tients re ceiv ing sup port ive ther apy added to rou tine care.This sug gests that the ben e fits of cog ni tive ther apy are due tocog ni tive, and not gen eral ther a peu tic, fac tors (for ex am ple, agood ther a peu tic al li ance). While we pre vi ously re viewed re -search de vel op ments in this area (18), the cur rent re view aims to ac quaint cli ni cians with a cog ni tive un der stand ing of

pos i tive and neg a tive symp toms of psy cho sis and with spe cific cog ni tive treat ment strat e gies.

General Structure of Therapy

A tem plate of a typ i cal treat ment in ter ven tion can be seen inTa ble 1. Sim i lar to cog ni tive ther apy for de pres sion and anx i -ety, cog ni tive ther apy for psy cho sis is ac tive, struc tured,time-limited (be tween 6 and 9 months), and usu ally de liv eredin an in di vid ual for mat. The early ses sions em pha size the de -vel op ment of the ther a peu tic re la tion ship through gen tle ques -tion ing and guided dis cov ery. The ther a pist’s aims are toun der stand and val i date the pa tient’s life per spec tive, cre at inga cli mate of open ness and trust. The ther a pist grad u ally movesto a more for mal as sess ment of symp toms and the es tab lish -ment of mu tu ally agreed-upon goals for ther apy. Teachingabout the role of per sonal vul ner a bil ity and stress ful life

42 W Can J Psy chia try, Vol 47, No 1, Feb ru ary 2002

The Ca na dian Jour nal of Psy chia try—In Re view

Table 1. Cognitive therapy for schizophrenia

Es tab lish a strong thera peu tic al li anceAc cep tance, sup port, col labo ra tion

De velop and pri ori tize problem listSymp toms (for example, de lu sions, hal lu ci na tions, with drawal, and low mo ti va tion)Life Goals (for example, work, re la tion ships, hous ing, and edu ca tion)

Pursue psycho edu ca tion and nor mal iz e symp toms of psy cho sisThe role of stress on the pro duc tion of symp tomsDis cus s biopsychosocial as pects of the ill nessRe duc e stigma through edu ca tion

De vel op cog ni tive con cep tu ali za tionIden ti fy links be tween thoughts, feel ings and be hav ioursIden ti fy un der ly ing themes in the prob lem listShar e for mu la tion and cog ni tive fo cus with pa tient

Cog ni tive and be hav ioural tech niques to treat posi tive and nega tive symp tomsUse So cratic ques tion ing (for example, Co lumbo tech nique)Test and re frame be liefsWeigh the evi denceAl ter na tive ex pla na tionsBe hav ioural ex peri mentsElic it self- beliefs (for example, weak vs strong or wor thy vs worthless)In ves ti gate hi er ar chy of fears and sus pi cionsUse im agesUse role play ing

Cog ni tive and be hav ioural strate gies to treat comorbid de pres sion and anxi etyAdapt stan dard cog ni tive ther apy strate gies for anxi ety and de pres sionTest and re frame be liefs re lated to anxi ety (for example, dan ger and vul ner abil ity) and de pres sion (forexample, worth less ness and hope less ness)Fo cus on mis in ter pre ta tionsUse re laxa tion ex er cisesUse ex po sure ex er cises and ac tiv ity sched ules

Re lapse Pre ven tionIden ti fy high- risk situa tionsPur sue skills train ing

Establish step-by-step action plan to deal with setbacks

cir cum stances and their in ter ac tion in the pro duc tion of de lu -sions, hal lu ci na tions, and emo tional with drawal is an in te gralcom po nent of ther apy. This nor mal iz ing strat egy, pi o neeredby Kingdon and Turkington (4), high lights the uni ver sal ity ofthe pa tient’s ex pe ri ences and re duces per ceived stigma.

As in cog ni tive ther apy for other con di tions, the ther a pist so -cial izes pa tients to the cog ni tive model by di rect ing their at -ten tion to the re la tion be tween thoughts, feel ings, andbe hav iours. Un der lying be liefs and as sump tions about the self (for ex am ple, “I’m un lov able”), about oth ers (for ex am ple,“peo ple are dan ger ous”), and about the world (for ex am ple,“it’s ma lev o lent”) are iden ti fied and linked to the pa tient’spast and pres ent dif fi cul ties. This for mu la tion pro vides an in -di vid ual map for nav i ga tion in ther apy and for the tim ing ofspe cific cog ni tive and be hav ioural strat e gies (out lined in de -tail be low).

As seen in Ta ble 2, in di vid ual cog ni tive ther apy ses sions in -volve check ing on the pa tient’s mood over the pre vi ous weekand iden ti fy ing any ir reg u lar i ties in med i ca tion use. The ther -a pist main tains con ti nu ity be tween ses sions by re view ing theim por tant ar eas ad dressed in the pre vi ous ses sion and bycheck ing for up dates over the past week. Fol low ing this, astruc tured agenda is set that in cludes a mu tu ally agreed-uponpri or ity fo cus for the ses sion (typ i cally a prob lem from theprob lem list de vel oped dur ing the as sess ment phase). Fol low -ing the im ple men ta tion of in-session cog ni tive and be hav -ioural strat e gies, home work is as signed to fo cus pa tients onmon i tor ing and then test ing their be liefs ex per i men tally.While the for mat of cog ni tive ther apy for schizo phre nia issim i lar to that of other cog ni tive ther apy in ter ven tions, ses -sions may be of shorter du ra tion (15 to 45 min utes), may

in clude breaks, may set more fo cused and lim ited home worktasks, and may of fer greater flex i bil ity in terms of ses -sion-to-session goals. Ag i tated or con fused pa tients may beseen for mul ti ple short vis its rather than 1 com par a tively longses sion.

In the fol low ing sec tions we will dis cuss the ap proaches to de -lu sions, hal lu ci na tions, and neg a tive symp toms sep a rately, al -though these ap proaches are syn chro nized in ac tual prac tice(19).

Cognitive Focus in DelusionsHis tor i cal con cep tu al iza tions of de lu sions have main tainedthat they rep re sent ab nor mal be liefs which are qual i ta tivelydif fer ent from nor mal be liefs. How ever, ex am i na tion of theirna ture within the con text of what we know about the role ofspe cific be liefs in nonpsychotic con di tions shows many sim i -lar i ties. For in stance, di men sions com mon to both are per va -sive ness (the ex tent to which the pa tient’s con scious ness iscon trolled by the be lief), con vic tion (the de gree to which thepa tient be lieves it), sig nif i cance (the be lief’s im por tance inthe pa tient’s over arch ing mean ing sys tem), in ten sity (the de -gree to which it pre vents or dis places more re al is tic be liefs),and in flex i bil ity (the de gree to which the be lief is im per vi ousto con tra dic tory ev i dence, logic, or rea son). In one ex tremeview, de lu sions have been said to be “empty speech acts,whose in for ma tional con text re fers to nei ther world nor self.They are not the sym bolic ex pres sion of any thing” (20). Yet, it is pos si ble to make sense of the seem ing bi zarre ness of de lu -sions and hal lu ci na tions and other as pects of the ill ness whenthey are un der stood within the in ter per sonal con text of theper son’s life. The con tent of de lu sions of ten re flects ev ery day


Cognitive Therapy For Schizophrenia: From Conceptualization to Intervention

Table 2. Typical cognitive therapy session (25 to 50 minutes)

1. Up date on mood since last ses sion May com plete brief mood rat ingsCheck on medi ca tion ad her enceUp date on use of other serv ices and prog ress

2. Bridge from last ses sion Sum mary of pre vi ous ses sion and im por tant is sues ad dressedIden ti fy pos si ble items for fo cus in the ses sion

3. Struc tured agenda is set For ex am ple, con tinu ing with cog ni tive strate gies for de lu sionsFor ex am ple, de vis ing and car ry ing out be hav ioural ex peri ment to test be liefs about voicesFor ex am ple, fo cus ing on cop ing strate gies to man age un an tici pated hous ing cri sis

4. Work ing on ar eas from the ses sion agenda with sum ma ries and planned home work as sign ments(that is, short and fo cused tasks for prac tice be tween ses sions)

5. Sum mary and pa ti ent’s feed back on ses sion 6. Overview of treatment plan until next session (for example, schedule of day-service visits, meetings

with case manager, and medication repeats)

con cerns, such as be ing de meaned, ex cluded, ma nip u lated,and at tacked. The con tent of de lu sions also of ten re flects thepa tient’s predelusional be liefs. Strong re li gious be liefs, forex am ple, pro vide the foun da tion for de lu sions about Je sus,whereas an in ter est in and net work of be liefs about the para -nor mal may lead to de lu sions about alien con trol. Un der -stand ing the pa tient’s predelusional be lief sys tem maypro vide di rect clues to the de lu sions’ for ma tion and con tent.For in stance, gran di ose de lu sions may de velop to com pen -sate for an un der ly ing sense of lone li ness, un wor thi ness, orpow er less ness, whereas the prox i mal an te ced ents of a para -noid de lu sion may in clude the fear of re tal i a tion for hav ingdone some thing that of fended an other per son or group (21).In creas ingly, de lu sions are seen to lie at the ex treme end of abe lief con tin uum rather than to rep re sent cat e gor i calab nor mal i ties.

In con trast to the mech a nis tic and reductionist fram ing of de -lu sions as rep re sent ing fixed neuropsychological def i cits, thecog ni tive ap proach tries to make sense of the way pa tientsmake mean ing of their life ex pe ri ences and the way com moncog ni tive bi ases may dis tort the per cep tion of these ex pe ri -ences. For in stance, cross-sectional anal y sis of de lu sionalthink ing dem on strates sev eral com mon cog ni tive char ac ter -is tics. These in clude an ego cen tric bias, by which pa tients be -come locked into an ego cen tric per spec tive and con strue even ir rel e vant events as self-relevant; an externalizing bias, inwhich in ter nal sen sa tions or symp toms are at trib uted to ex ter -nal agents; and an intentionalizing bias, which leads the pa -tient to at trib ute ma lev o lent and hos tile in ten tions to otherpeo ple’s be hav iour (21). Fur ther, ex per i men tal re search hasshown that, when some pa tients with persecutory de lu sionsat tempt to make sense of rel e vant life ex pe ri ences, they havean ex ag ger ated ten dency to blame ex tra ne ous fac tors, par tic -u larly other peo ple, when things do not go well (22). This ex -ag ger ated self-serving bias is es pe cially prom i nent when theneg a tive event is sig nif i cant to the per son (23,24), point ing toa po ten tial func tion of this bias in pro tect ing (vul ner a ble)self-esteem.

An other strik ing char ac ter is tic of de lu sional pa tients is theirten dency to jump to con clu sions and fail to con sider al ter na -tive ex pla na tions for their in ter pre ta tions. Ex per i men tal stud -ies have dem on strated that de lu sional pa tients are dis posed tomake overly rapid and over con fi dent judge ments based onlim ited in for ma tion (25–27). This ten dency is most pro -nounced when the judge ment con cerns emo tion ally sa lientma te rial (28,29).

Just as de pres sion pa tients are more likely to ex pe ri ence ac ti -vated cog ni tive dis tor tions of the self, oth ers, and their fu turefol low ing a mean ing ful neg a tive life ex pe ri ence, the dis torted cog ni tive lens of de lu sional pa tients is likely to op er ate in

sit u a tions where the out come is deemed to be im por tant and inwhich they ex pe ri ence per sonal threat and vul ner a bil ity.

Finally, the his tor i cal def i ni tion of de lu sions as fixed and im -per vi ous to change by ra tio nal meth ods has been disproven byob serv ing both the nat u ral flux in their con tent and form (thatis, con vic tion, per va sive ness, and in ten sity) over time and thedi rect re duc tion in de lu sions that can be pro duced by cog ni tivether apy. Col lec tively, this set of con cep tions pro vides an un -der stand ing that fa cil i tates psychotherapeutic in ter ven tions.The cog ni tive ap proach to de lu sions will now be out lined.

Cognitive Therapy of DelusionsFifty years ago, Beck de scribed the first cog ni tive treat ment ofa man with a 7-year para noid de lu sion (30). The pa tient was a28-year-old World War II vet eran who, upon re turn ing homefrom the war, came to be lieve that for mer mem bers of his mil i -tary unit were work ing with the FBI to mon i tor his ac tiv i ties.Treat ment fo cused on iden ti fy ing the an te ced ents of his de lu -sional sys tem and their re la tion to the cur rent con text of his de -lu sional sys tem. Misperceptions of ev ery day oc cur rences thatwere taken as ev i dence of the FBI’s per se cu tion were iden ti -fied and gently ques tioned. The ques tion ing and test ing of al -ter na tive ex pla na tions for events even tu ally led to changes inthe pa tient’s be lief sys tem. By the end of treat ment, the pa tientwas able to stand back and rea son him self out of the er ro ne ousbe liefs when ever he be came sus pi cious of be ing watched. Two de cades later, this case re port was fol lowed by a re port of cog -ni tive in ter ven tions with 8 pa tients with on go ing de lu sions(31). Through care ful ques tion ing of the ev i dence that the pa -tient held to sup port the de lu sion, the pa tient be gan to see thede lu sions as hy poth e ses about the mean ing of events ratherthan as ab so lute, rigid “truths.” Other clin i cal re search ers us -ing the same cog ni tive fo cus be gan to re port sim i lar ben e fits(32).

The ther a peu tic ap proach in volves sev eral cog ni tive and be -hav ioural strat e gies aimed at un der min ing the rigid con vic tionand cen tral ity of the de lu sion(s). Be fore at tempt ing to shift thepa tient to a ques tion ing mode, the ther a pist first at tempts to un -der stand the pa tient’s life con text, in clud ing im por tant past life events and their ap praisal. In the as sess ment phase, the pat-ient’s predelusional be liefs are as cer tained by in quir ing intofan ta sies and day dreams (“Did you ever have day dreams orim ages when you were grow ing up?” “How did you see your -self in your day dreams or im ages?”). The ther a pist also at -tempts to iden tify prox i mal events crit i cal to the de lu sions’for ma tion (“How were things go ing in your life when youstarted hav ing this idea?”) as well as cur rent events likely totrig ger the de lu sions. Spe cific trig gers for de lu sions can be ex -ter nal (for ex am ple, a pass erby in the mall) or in ter nal (for ex -am ple, sen sa tions in the body). The spe cific con se quences—both emo tional (for ex am ple, fear, an ger, or sad ness) and



be hav ioural (for ex am ple, with drawal, avoid ance, or con fron -ta tion)—cre ated by the de lu sion’s ac ti va tion are alsoas sessed.

Once the ther a pist has a thor ough un der stand ing of the pat-ient’s de lu sional be liefs and the past and cur rent events thatare in ter preted as sup port ing them, the ev i dence is gentlyques tioned. Pa tients are so cial ized to the cog ni tive model andlearn to iden tify the links be tween their thoughts, feel ings, and be hav iours. Later, they learn the role of cog ni tive bi ases (forex am ple, egocentricity) and dis tor tions (for ex am ple, mag ni -fi ca tion and se lec tive ab strac tion in their think ing).

The ap proach is col lab o ra tive and So cratic. Ini tially, the ther -a pist deals with in ter pre ta tions and ex pla na tions that are pe -riph eral to more cen tral and highly charged be liefs. Take, forex am ple, a pa tient with a 12-month de lu sion that he is be ingper se cuted by school staff and po lice in a co or di nated ef fort tohave him framed for a crime he did not com mit. On a givenday, he ar rives at school to find that his locker is ajar. His au to -matic thoughts (and con clu sions) are that the staff have bro -ken into his locker to plant in crim i nat ing ev i dence, that theywill do what ever it takes to “put him away,” and that he can not trust any one. The ther a pist might ask the fol low ing ques tions:“What leads you to be lieve this is likely?” “What is the ev i -dence that sup ports this in ter pre ta tion?” “Are there any pos si -ble al ter na tive ex pla na tions?” By ques tion ing the in fer ence,the pa tient is able to con sider al ter na tive pos si bil i ties: “I’mnot 100% sure I re mem bered to lock, it since I was rushed,” or“They could n’t be sure how long I would be away at lunch,since I some times come right back, and so would they re allytake the risk?” and then, fi nally, “What dif fer ence would itmake? There’s noth ing to find any way.” In con sid er ing thisev i dence, the pa tient states that this was likely a false as sump -tion and ex pe ri ences im me di ate re lief. With re peated prac ticein gen er at ing al ter na tive ex pla na tions in the ther a pist’s of ficeand then, in creas ingly, as part of as signed home work, the cer -tainty of the pa tient’s de lu sional be liefs gives way to morebal anced and less dis tress ing in ter pre ta tions.

In ad di tion to us ing ver bal strat e gies, the cog ni tive ther a pistaims to change de lu sional think ing by set ting up be hav iouralex per i ments that test the ac cu racy of dif fer ent in ter pre ta tions.For in stance, one of our pa tients had a 9-year para noid de lu -sional be lief that once a group reached crit i cal mass (that is, 20 mem bers) it was likely to be come vi o lent and at tack him.When ever he saw large groups of peo ple, he would quickly es -cape to a quiet and safe place. The treat ment ap proach in -cluded hav ing the pa tient fo cus on his hy poth e sis aboutgroups of 20 or more and ob serve their be hav iour. Af ter ini -tially watch ing groups on tele vi sion and in the mov ies, he pro -gressed to ob serv ing large-group be hav iour from a safedis tance (for ex am ple, 100 yards from a large crowd watch ingvar sity sport). Con sidering this ev i dence in re la tion to his

de lu sional be lief, “large groups have it in for me,” pro videdenough change to per mit this pa tient (aided by the ther a pist)to be gin en ter ing sit u a tions where large groups gath ered.

An other of our pa tients was ex pe ri enc ing long-standing de lu -sions of ref er ence. She be lieved that when peo ple spat on theground they were ac tu ally spit ting to com mu ni cate to her thatshe was not wel come there. Af ter sev eral ses sions con sid er ing al ter na tive ex pla na tions for this be hav iour, 2 hy poth e ses were en ter tained for test ing: ei ther peo ple truly were spit ting tocom mu ni cate a mes sage to her, or peo ple some times spat, andthis was not meant to com mu ni cate a spe cific mes sage to her.Her ex per i ment was to go to the busy down town street wherethis hap pened of ten and to ob serve the fre quency of this be -hav iour, first while away from the side walk and then whilewalk ing on the side walk. The data gen er ated by the be hav -ioural ex per i ment were re viewed (the fre quency of the be hav -iour was the same whether she was pres ent or ab sent from theside walk), and the pa tient was able to ac com mo date this in for -ma tion and shift her in ter pre ta tion. While this ex per i mentaimed to pro duce an al ter na tive per spec tive on the ev i dencefor her de lu sions of ref er ence, later ses sions fo cused on iden ti -fy ing the un der ly ing be liefs of in ad e quacy and unloveabilitythat gave rise to her mis in ter pre ta tions of oth ers’ be hav iour.Be hav ioural ex per i ments near the end of ther apy fo cused ontest ing the ev i dence for her old self-beliefs that she was in ad e -quate and unloveable against newly cre ated self-beliefs thatshe was some times ad e quate and some times love able.

Cognitive Focus in HallucinationsWhile au di tory hal lu ci na tions are the most fre quently re -ported symp tom in schizo phre nia, they are also pres ent in sev -eral other psy chi at ric con di tions. For in stance, au di toryhal lu ci na tions are com monly re ported dur ing pe ri ods of be -reave ment, fol low ing sig nif i cant sleep de pri va tion, and in ad -verse sit u a tions such as sol i tary con fine ment or hos tagetak ing. Com mu nity-based stud ies in di cate that from 5% to25% of the gen eral pop u la tion re port ex pe ri enc ing au di toryhal lu ci na tions at some time (33,34). Studies have shown thatsome peo ple ex pe ri ence au di tory hal lu ci na tions but do not re -gard them selves as ei ther psy chi at ri cally ill or re quir ing help;nei ther are they re garded by oth ers as ill. For in stance, in acom mu nity-based study, Romme and col leagues found that39% of re spon dents ex pe ri enc ing au di tory hal lu ci na tionswere not ac tu ally re ceiv ing treat ment (35). Other re search hasdem on strated that stress (36), cul tural norms (37), ex pec tancysets (38), and sex (39) af fect the oc cur rence (and in ter pre ta -tion) of au di tory hal lu ci na tions. These stud ies sug gest thathal lu ci na tory phe nom ena may lie on a con tin uum with nor mal ex pe ri ences.

The o rists agree that au di tory hal lu ci na tions may re sult from aprob lem dis crim i nat ing be tween in ter nally gen er ated and



ex ter nally gen er ated events. Some the o rists have pro posedthat hallucinators have a neuropsychological def i cit in theirin ter nal mon i tor ing sys tem that causes in ter nal cog ni tiveevents to be come misattributed to an ex ter nal source (40).Other the o rists have rec og nized the pos si bil ity o f aneuropsychological def i cit but al lot ted greater im por tance tothe role of cog ni tive bi ases, such as the pa tient’s be liefs andex pec ta tions (41). For in stance, Bentall and Slade tested pa -tients with and with out hal lu ci na tions in a sig nal de tec tionpar a digm in which the task was to lis ten to white noise and de -ter mine whether a voice was pres ent (a voice was pres ent50% of the time) (42). Those with hal lu ci na tions showed theex pected bias of as sum ing that a voice was pres ent when, infact, it was not. In an ex ten sion of this work, Young and col -leagues sug gested, “Close your eyes and lis ten to the re cord -ing ‘Jin gle Bells’,” to pa tients with and with outhal lu ci na tions. They found that those with hal lu ci na tionswere more likely than those with out to re port hear ing the mu -sic, al though it was never played (43). A more re cent study byMor ri son and Had dock showed that, in a word as so ci a tiontask, pa tients with hal lu ci na tions, com pared with de lu sionalpa tients with out hal lu ci na tions and nor mal con trol sub jects,were more likely to at trib ute their own thoughts to the in ves ti -ga tor (44). Fur ther re search by Chadwick and Birchwoodsug gests that the dis tur bance as so ci ated with hear ing voicesin part de pends on the id io syn cratic be liefs the per son hasabout the voices’ iden tity (45,46). For in stance, the ex tent towhich the agent of the voice is per ceived as pow er ful, con trol -ling, and all-knowing has been found to be more pre dic tive ofthe emo tional and be hav ioural con se quences of the voicesthan their fre quency, du ra tion, and form.

These find ings have pro vided the im pe tus for de vel op ing acog ni tive ther a peu tic in ter ven tion that helps pa tients: first,iden tify, test, and cor rect cog ni tive dis tor tions in the con tentof voices with the as sump tion that voice con tent is sim i lar totheir own (neg a tive) think ing (which has been ex ter nally at -trib uted); and sec ond, iden tify, ques tion, and con struct al ter -na tive be liefs about the voices’ iden tity, pur pose, andmean ing.

Cognitive Therapy of HallucinationsWhile pa tients re port a range of au di tory phe nom ena (in clud -ing non ver bal ma te rial such as mu sic, buzz ing, and tap ping)cog ni tive ther apy spe cif i cally aims to help pa tients with thedis tress that is cre ated by voices. Be fore im ple ment ing cog ni -tive and be hav ioural strat e gies to help pa tients con struct anal ter na tive view of their voices, the ther a pist un der takes athor ough as sess ment, with care ful ques tion ing of the fre -quency, du ra tion, in ten sity, and vari abil ity of the voices. Forex am ple, the ther a pist in ves ti gates what sit u a tions or cir cum -stances are likely to trig ger the voices and whether in some

cir cum stances the pa tient ei ther does not ex pe ri ence voices orthey are at ten u ated. Stress ful sit u a tions are most likely to trig -ger voices. For in stance, pa tients re port hear ing voices morefre quently in the con text of in ter per sonal dif fi cul ties, dailyhas sles, and neg a tive life events (for ex am ple, fi nan cial strain,or hous ing cri ses). In ter nal cues (par tic u larly emo tional up set)can also trig ger voices. As part of the early as sess ment phase,pa tients can use a mod i fied thought re cord to mon i tor the re la -tion be tween sit u a tional trig gers, mood states, and the ac ti va -tion of voices.

The cog ni tive ther a pist at tempts to get ver ba tim ac counts ofwhat the voices say. Typically, pa tients will re port hear ingcrit i cal 1-word ut ter ances, such as “jerk” and “loser,” or sim i -lar 2-word ut ter ances, such as “you’re worth less,” “go on,”and the like. At other times, voices may speak in phrases, suchas the daily re peated phrase, “Are you sure you are who yousay you are?” Voices might of fer a run ning com men tary on the pa tient’s ac tiv i ties or com mand the pa tient to per form cer tainac tiv i ties rang ing from the mun dane (such as, “Pick up thoseclothes”) to more dan ger ous and po ten tially vi o lent edicts. Pa -tients are taught to re cord the spe cific voice con tent be tweenses sions, us ing the mod i fied thought re cord.

The ther a pist also aims to elicit all of the be liefs the pa tient hasabout the voices. For ex am ple, what agents—God, the devil,or dead rel a tives—are pur port edly talk ing to the pa tient? Be -liefs about the voices can range from the bi zarre to the or di nary and vary from known, un known, and de ceased per sons to su -per nat u ral en ti ties, and even ma chin ery. A sig nif i cant num berof pa tients in ter pret their voices pos i tively and ex pe ri ence pos -i tive emo tions when they oc cur. For in stance, re ceiv ing di rectcom mu ni ca tion from God, Je sus, or a Knight of the Round Ta -ble sets the per son apart from oth ers and con fers feel ings of ex -cite ment and power. The ther a pist asks how the pa tient wouldfeel if the voices were not pres ent to un mask the un der ly ingfeel ings of lone li ness and in ad e quacy from which these voicesmay be pro vid ing com pen sa tory pro tec tion (un pub lishedstudy). All be liefs are iden ti fied and the ev i dence that has beenin ter preted as sup port ing these be liefs is re corded.

Just as when as sess ing de lu sions, the ther a pist tries to iden tifythe life cir cum stances both dis tal and prox i mal to the ini tialvoice on set; of in ter est are events oc cur ring just prior to theiron set and how the spe cific voice con tent and be liefs about thevoices re flect the per son’s prehallucinatory fears, con cerns,in ter ests, pre oc cu pa tions, and fan ta sies.

Finally, the ther a pist as sesses the pa tient’s re ac tions to thevoices. Fre quent rep e ti tion of crit i cisms, in sults, com mands,and other at tack ing com ments of ten leads to feel ings of sad -ness, de spair, an ger, and help less ness. Pa tients’ be hav iouralre sponses can in clude shout ing back at the voices or es cap ingspe cific sit u a tions to ex tin guish them. While pa tients first



re spond to their voices with sur prise and puz zle ment, overtime they tend to es tab lish an in ter per sonal re la tion ship withthem. Their be liefs about the voices de ter mine their emo tional re ac tion and be hav ioural re sponses. If the voices are seen to be be nev o lent, they are fre quently fol lowed by pos i tive emo -tions, and the pa tient en gages with them. Con versely, if theyare seen as ma lev o lent, pa tients are likely to ex pe ri ence arange of neg a tive emo tions and cope by re sist ing them (45).

Fol low ing the as sess ment phase and the es tab lish ment of astrong ther a peu tic al li ance, the ther a pist be gins to em ploygen tle ques tion ing to elicit al ter na tive per spec tives on boththe voice con tent and the pa tient’s be liefs about the voices.With some pa tients, it is better to start by fo cus ing on the be -liefs about the voices, while with other pa tients it may bebetter to first tar get the voice con tent. For in stance, the con tent of the voices in one of our pa tients led di rectly to de spair andsui cidal thoughts, and the ini tial fo cus was there fore the de -mean ing con tent. An other pa tient ex pe ri enced com mand hal -lu ci na tions to steal from stores, and the fo cus was there fore onthe in ter pre ta tions of the voice as pow er ful and on the be liefsabout the con se quences of not com ply ing with the com mands.

The ap proach to un der min ing the be liefs about voices is sim i -lar to the cog ni tive ap proach in treat ing de lu sions. The ther a -pist be gins by gently ques tion ing the ev i dence that pa tientsof fer to sup port their in ter pre ta tion. For in stance, a pa tientwho be lieved that his neigh bours were con spir ing to have himre moved from the apart ment com plex heard them speak ing tohim daily. As the neigh bours ar rived home from work and as -cended the build ing’s stairs, the creak ing of the stairs wouldac ti vate the voices. When asked in ses sion how he knew it was his neigh bours’ voices, he re sponded,“They sound just likemy neigh bours, and they speak to me ev ery time they pass mydoor.” To gen er ate al ter na tive ex pla na tions for the ev i dence,the ther a pist asked the fol low ing ques tions: “Are there anypos si ble al ter na tive ex pla na tions?” “Has it ever been the casethat you heard the creak ing stairs and not the voices?” “Has itever hap pened that you heard the creak ing stairs, then thevoices, and then checked and found that it was n’t your neigh -bours pass ing your door?” “If this did, by chance, hap penwould it change your view?” The ther a pist could also haveasked: “Do you ever ex pect to hear the voices when peo plecome up the stairs?” and pro vide ed u ca tion (and nor mal iz ing)about the role of ex pec ta tions and hear ing voices. It is im por -tant to ad dress in con sis ten cies in the net work of be liefs in agen tle and col lab o ra tive way and not as a di rect chal lenge. Be -hav ioural ex per i ments can also be in cor po rated to testwhether the voice heard as some one passed the door ac tu allycor re sponded to the per son pass ing by the door at thatmo ment.

In ad di tion to work ing with the ev i dence, pa tients are askedwhether they have ever con sid ered other ex pla na tions for their

voices. Through col lab o ra tion, the ther a pist and pa tientat tempt to gen er ate as many al ter na tive ex pla na tions as pos si -ble. The ther a pist also high lights any in con sis ten cies in thebe liefs (for ex am ple, by ques tion ing whether a Chi nese war -lord from the 15th cen tury would re ally speak Eng lish). Of -ten, the con se quences of the voices are taken as proof of theirin ter pre ta tion. For in stance, one pa tient heard the voices of 2men with whom he had fought. He be lieved that the voiceswere a form of pun ish ment for fight ing. The ac ti va tion of thevoices led to feel ings of frus tra tion and an ger that, in turn, hetook as ev i dence that he was be ing pun ished. Al ter na tive ex -pla na tions for these feel ings (for ex am ple, not be ing able tocon trol the voices) helped to re duce what would oth er wise betaken as con fir ma tory ev i dence.

As sug gested, be liefs per tain ing to the om nip o tence, om ni -science, and un con trol la bili ty of the voices are es pe cially im -por tant and can be al le vi ated by sev eral strat e gies. Theun con trol la bili ty be lief can be ad dressed by dem on strat ing tothe pa tients that they can ini ti ate, di min ish, or ter mi nate thevoices. Using knowl edge from the as sess ment phase, the ther -a pist pres ents the pa tient with the cues that ac ti vate the voices(for ex am ple, imag in ing an up set ting event from the past) andthen di rects the pa tient to en gage in an ac tiv ity that is known to ter mi nate the voices (for ex am ple, en gag ing in con ver sa tion).This ex per i ment not only helps to chip away at the be lief thatthe voices are un con trol la ble but also pro vides fur ther ev i -dence that they are gen er ated in ter nally. Om nip o tence andom ni science is sues are tack led by set ting up ex per i ments thatwill dem on strate that the pa tient can ig nore com mands with -out con se quence.

Al ter na tive per spec tives to the voice con tent are gen er ated byex plor ing the ev i dence for what the voices ac tu ally say. Forin stance, a pa tient heard sev eral voices, in clud ing one that was be lieved to be the “devil spirit,” fre quently tell ing her that shewas “worth less.” The pa tient was first asked, “What ev i dencedo you have that sup ports the truth of this state ment made bythe voices?” Her re sponse in cluded feel ing that she some times dis ap pointed her par ents and could not al ways cope with herill ness. How ever, she was also able to con sider a range of ev i -dence that did not fit with what the voices said, in clud ing thefact that she was a good friend, daugh ter, stu dent, and vol un -teer. With re peated prac tice she be came ad ept at iden ti fy ingthe cog ni tive dis tor tions in the voices’ com ments (for ex am -ple, all-or-none think ing, catastrophizing, and la bel ling) andgen er at ing an al ter na tive per spec tive when they oc curred.This, in turn, led to less hope less ness and with drawal.

The fi nal aim in work ing with the voice con tent is to help pa -tients rec og nize that the voices sim ply re flect ei ther their ownat ti tudes about them selves or those they imag ine oth ers tohave about them. By hav ing pa tients keep sep a rate thought



re cords—one for their au to matic thoughts in re sponse to dis -tress ing sit u a tions and an other for re cord ing what the voicessay—the par al lel re cords con vinc ingly dem on strate the over -lap (Here, the ther a pist could ask, “Do you see any sim i lar i -ties in the col umns that you have re corded on the 2 forms?”)

Cognitive Focus in Negative Symptoms

As pects of the neg a tive syn drome, such as anhedonia, ap a thy, low mo ti va tion, and emo tional with drawal, are not spe cific to schizo phre nia and have been found to be even more prev a lentamong in pa tients with de pres sion than in hos pi tal ized pa -tients with schizo phre nia (47). The neg a tive symp toms ofschizo phre nia have been shown to share many fea tures withde pres sion (48), and a re cent study dem on strated that the cog -ni tive def i cits com monly as so ci ated with neg a tive symp tomswere pri mar ily ac counted for by the pres ence of de pres sion inthose with chronic schizo phre nia (49). Not with stand ing thepu ta tive over lap be tween neg a tive symp toms and de pres sion, they re main dis tinct symp tom do mains that can be dis tin -guished re li ably (50). Other neg a tive symp toms, such as af -fec tive flat ten ing and alogia, have been con cep tu al ized interms of def i cit states (51). Re cent ex per i men tal re search onaf fec tive flat ten ing sug gests that the prob lem may lie in ex -press ing emo tions rather than in a def i cit in the abil ity to feel(52–54), while alogia may re flect dif fi culty in find ing theright words rather than rep re sent ing a dearth of com mu ni ca -tion skills (55). In sum mary, it may be that some neg a tivesymp toms re flect cog ni tive, emo tional, and be hav ioural dys -func tion rather than sta ble def i cits. These may be ame na ble to change with strat e gies sim i lar to those that have ef fec tivelyhar nessed mo t i va t ion and so cial and emo t ionalreengagement (2).

Many pa tients with prom i nent neg a tive symp toms ex pe ri -ence other in di vid u als (that is, fam ily, friends, and health pro -fes sion als) as de mand ing more from them in terms of ac tiv ityand en gage ment then they are ca pa ble of giv ing. This may bees pe cially per ni cious for some pa tients who, prior to be com -ing ill, also held ex ces sively high ex pec ta tions for them -selves, in con se quence of which they now see them selves asfail ing to live up to both their own and oth ers’ ex pec ta tions. In a re cent study (un pub lished), higher scores on a mea sure ofdys func tional at ti tudes and be liefs re gard ing per for manceand achieve ment (that is, the Dys func tional At ti tude Scale-Per fec tion ism Di men sion) were as so ci ated with a greaternum ber and se ver ity of neg a tive symp toms. These scoreswere un re lated to the pres ence or se ver ity of pos i tive symp -toms. Re peated un met de mands may fur ther im pact on

per ceived self-efficacy and fuel the cy cle of hope less ness. Thefirst step for the ther a pist is to re duce this pres sure.

Cognitive Therapy of Negative SymptomsPrior to im ple ment ing change, the cog ni tive ther a pist aims tocom plete a thor ough func tional anal y sis of the pa tient’s be -hav iour. How are they spend ing their time? What do they takeplea sure in? What helps cre ate feel ings of mas tery? Whatwould they like to do more of but cur rently find dif fi cult to do?What do they not like to do? What do peo ple in their lives wantthem to do more of ten? Iden tifying bar ri ers to en gage mentshould in clude an as sess ment of comorbid de pres sion and anx -i ety dis or ders. The prev a lence of se vere de pres sion at the timeof re lapse has been es ti mated at 20% to 50%, and more thantwo-thirds of schizo phre nia pa tients will ex pe ri ence a de pres -sive ep i sode at some time (56). Fur ther, many pa tients arewith drawn and ap a thetic be cause of fears as so ci ated with thespec trum of anx i ety con di tions, in clud ing (but not lim ited to)an tic i pated panic at tacks and other un man age able so matic ex -pe ri ences, feel ings of help less ness, and neg a tive eval u a tion.Sim i larly, symp toms of anhedonia, ap a thy, and with drawalmay be the con se quence of stra te gic avoid ances to pre vent theon set of dis tress ing pos i tive symp toms and their feared con se -quences (for ex am ple, re ad mis sion). An other po ten tial bar rierto en gage ment may be the prob lem of overmedication or med -i ca tion side ef fects.

The cog ni tive ap proach to treat ing neg a tive symp toms fol lows from the cog ni tive and be hav ioural strat e gies pre vi ously de -scribed in the treat ment of de pres sion (2). It in cludes be hav -ioural self-monitoring, ac tiv ity sched ul ing, mas tery andplea sure rat ings, graded task as sign ments, and as ser tive ness-train ing meth ods. Cog ni tive strat e gies in clude elic it ing the pa -tient’s rea sons for in ac tiv ity and test ing these be liefs di rectlywith be hav ioural ex per i ments; di rect at tempts ei ther to stim u -late new in ter ests or to re ac ti vate pre vi ously held in ter ests; and iden ti fy ing, test ing, and chang ing self-critical au to maticthoughts con cern ing per for mance.

Di men sional lev els of de pres sion and anx i ety may be ad -dressed within the con text of treat ing neg a tive symp toms. Forthe sig nif i cant num ber of pa tients who are ex pe ri enc ing bonafide de pres sive and anx i ety dis or ders, how ever, more com -plete and stan dard cog ni tive ther apy in ter ven tions can bepro vided.

ConclusionsThere is in creas ing em pir i cal ev i dence that pa tients with psy -cho sis can ben e fit from cog ni tive strat e gies that iden tify, test,and cor rect dis torted in ter pre ta tions of ex pe ri ence that underly



the pro duc tion of de lu sions and hal lu ci na tions. Fur ther, be -cause the re spon sive ness of neg a tive symp toms toantipsychotic med i ca tions is no ta bly worse than that of pos i -tive symp toms (57,58), the find ing that adapt ing cog ni tivether apy to stan dard treat ments can har ness mo ti va tion, re duceemo tional with drawal, and im prove en gage ment in so cialevents is of spe cial im por tance. Given that most of the in ter estin cog ni tive ther apy for schizo phre nia has come from the UK,more at ten tion to ther a pist train ing in this mo dal ity and morestud ies test ing its ef fec tive ness in com mu nity clin i cal set tings

in Can ada and the US are now re quired.

Ac knowl edge ments

The prep a ra tion of this manu script was sup ported in part by agrant from the On tario Men tal Health Foun da tion (OMHF)awarded to the first au thor. The au thors thank EilennaDenisoff for her com ments on an ear lier draft of thismanu script.

Ref er ences

1. Har row M, Carone BJ, Westermeyer J. The course of psy cho sis in early phasesof schizo phre nia. Am J Psy chi a try 1985;142:702–7.

2. Beck AT, Rush AJ, Shaw BF, Em ery G. Cog ni tive ther apy of de pres sion. NewYork: Guilford; 1979.

3. Beck AT, Em ery G, Greenberg RL. Anx i ety dis or ders and pho bias: a cog ni tiveper spec tive. New York: Ba sic Books; 1985.

4. Kingdon D, Turkington D. Cog ni tive be hav ioral ther apy of schizo phre nia. NewYork: Guilford; 1994.

5. Fowler D, Garety P, Kuipers E. Cog ni tive be hav iour ther apy for psy cho sis: the -ory and prac tice. New York: Wiley; 1995.

6. Chadwick PD, Birchwood MJ, Trower P. Cog ni tive ther apy for de lu sions,voices, and para noia. New York: Wiley; 1996.

7. Zubin J, Spring B. Vul ner a bil ity: a new view on schizo phre nia. J AbnormPsychol 1977;86:103–26.

8. Kuipers E, Garety P, Fowler D, Dunn G, Bebbington P, Free man D, and oth ers.Lon don-East Anglia ran dom ized con trolled trial of cog ni tive-behaviour ther apyfor psy cho sis: I. Ef fects of the treat ment phase. Br J Psy chi a try1997;171:319–27.

9. Tarrier N, Beckett R, Har wood S, Baker A, Yusupoff L, Ugarteburu I. A trial oftwo cog ni tive be hav ioural meth ods of treat ing drug-resistant re sid ual psy choticsymp toms in schizo phrenic pa tients. Br J Psy chi a try 1993;162:524–32.

10. Tarrier N, Sharpe L, Beckett R. A trial of two cog ni tive be hav ioural meth ods oftreat ing drug-resistant re sid ual psy chotic symp toms in schizo phrenic pa tients: II.Treat ment spe cific changes in cop ing and prob lem solv ing skills. Soc Psy chi a tryPsychiatr Epidemiol 1993;28:5–10.

11. Tarrier N, Yusupoff L, Kinney C, Mc Car thy E, Gledhill A, Had dock G, and oth -ers. Ran dom ized con trolled trial of in ten sive cog ni tive be hav iour ther apy for pa -tients with chronic schizo phre nia. BMJ 1998;317:303–7.

12. Tarrier N, Wittkowski A, Kinney C, Mc Car thy E, Mor ris J, and oth ers. Du ra bil -ity of the ef fects of cog ni tive be hav ioural ther apy in the treat ment of chronicschizo phre nia. Br J Psy chi a try 1999;174:500–4.

13. Drury V, Birchwood M, Cochrane R, MacMillan F. Cog ni tive ther apy and re cov -ery from acute psy cho sis: a con trolled trial. I. Im pact on psy chotic symp toms. BrJ Psy chi a try 1996;169:593–601.

14. Drury V, Birchwood M, Cochrane R, MacMillan F. Cog ni tive ther apy and re cov -ery from acute psy cho sis: a con trolled trial. II. Im pact on re cov ery time. Br JPsy chi a try 1996;169:602–7.

15. Sensky T, Turkington D, Kingdon D, Scott JL, Scott J, Siddle R, and oth ers.TRE: a ran dom ized con trolled trial of cog ni tive be hav ioural ther apy for per sis -tent symp toms in schizo phre nia re sis tant to med i ca tion. Arch Gen Psy chi a try2000; 7:165–72.

16. Pinto A, La Pia S, Mannella R, Domenico G, DeSimone L. Cog ni tive be hav -ioural ther apy and clozapine for cli ents with treat ment-refractory schizo phre nia.Psychiatr Serv 1999;50:901–4.

17. Rec tor NA, Seeman MV, Segal ZV. Cog ni tive ther apy for schizo phre nia: treat -ment out comes and fol low up ef fects from the To ronto trial study. Trial pa perpre sented at the An nual Meet ing of the Amer i can Psy chi at ric As so ci a tion; 2000;Chi cago (IL).

18. Rec tor NA, Beck AT. Cog ni tive be hav ioral ther apy for schizo phre nia: an em pir i -cal re view. J Nerv Ment Dis 2001;189:278–87.

19. Beck AT, Rec tor NA: Cog ni tive ther apy of schizo phre nia: a new ther apy for thenew millenium. Am J Psy cho ther apy 2000;54:291–300.

20. Berrios G. De lu sions as ‘wrong be liefs’: a con cep tual his tory. Br J Psy chi a try1991;159 (Suppl):6–13.

21. Beck AT, Rec tor NA. De lu sions: a cog ni tive per spec tive. Jour nal of Cog ni tivePsy cho ther apy 2002. (forth com ing)

22. Bentall RP, Kinderman P, Kaney S. Self, attributional pro cesses and ab nor malbe liefs: To wards a model of persecutory de lu sions. Behav Res Ther1994;32:331–41.

23. Kaney S, Bentall RP. Persecutory de lu sions and attributional style. Br J MedPsychol 1989;62:191–8.

24. Bentall RP, Kaney S, Dewey ME. Para noia and so cial rea son ing: an at tri bu tionthe ory anal y sis. Br J Clin Psychol 1991;30:13–23.

25. Garety PA, Hemsley DR, Wessely S. Rea soning in de luded schizo phrenic andpara noid pa tients: bi ases in per for mance on a proba bil is tic in fer ence task. J NervMent Dis 1991;179:194–202.

26. Fear CF, Healy D. Proba bil is tic rea son ing in ob ses sive-compulsive and de lu -sional dis or ders. Psychol Med 1997;27:199–208.

27. Pe ters E, Day S, Garety P. From pre con scious to con scious pro cess ing: wheredoes the ab nor mal ity lie in de lu sions? Schizophr Res 1997;24:120.

28. Young JF, Bentall RP. So cial rea son ing in in di vid u als persecutory de lu sions: theef fects of ad di tional in for ma tion on at tri bu tions for the ob served be hav ior ofother. Br J Clin Psychol 1997;36:569–73.

29. Dudley REJ, John CH, Young AW, Over DE. Nor mal and ab nor mal rea son ingand peo ple with de lu sions. Br J Clin Psychol 1997;36:243–58.

30. Beck AT. Suc cess ful out pa tient psy cho ther apy with a schizo phrenic with a de lu -sion based on bor rowed guilt. Psy chi a try 1952;15:305–12.

31. Hole RW, Rush AJ, Beck AT. A cog ni tive in ves ti ga tion of schizo phrenic de lu -sions. Psy chi a try 1979;42:312–9.

32. Watts FN, Powell GE, Aus tin SV. The mod i fi ca tion of ab nor mal be liefs. Br JMed Psychol 1973;46:359–63.

33. Tien, AY. Dis tri bu tion of hal lu ci na tions in the pop u la tion. Soc Psy chi a tryPsychiatr Epidemiol 1991;26:287–92.

34. Slade, PD, Bentall RP. Sen sory de cep tion: a sci en tific anal y sis of hal lu ci na tions.Lon don (UK): Croom Helm; 1988.

35. Romme MA, Honig A, Noordhoorn EO, Escher ADMAC. Coping with hear ingvoices: an emancipatory ap proach. Br J Psy chi a try 1992;16:99–103.

36. Slade PD. The psy cho log i cal in ves ti ga tion and treat ment of au di tory hal lu ci na -tions: a sec ond case re port. Br J Med Psychol 1973;46:293–6.

37. Al-Issa I. So cial and cul tural as pects of hal lu ci na tions. Psychol Bull1978;84:572–87.

38. Young HF, Bentall RP, Slade PD, Dewey ME. The role of brief in struc tions andsug gest ibil ity in the elic i ta tion of hal lu ci na tions in nor mal and psy chi at ric sub -jects. J Nerv Ment Dis 1987;175:41–8.

39. Rec tor NA, Seeman MV. Au di tory hal lu ci na tions in men and women. SchizofrRes 1992;7:233–6.

40. Frith CD, Done DJ. To wards a neuropsychology of schizo phre nia. Br J Psy chi a -try 1987;153:437–43.

41. Bentall RP. The il lu sion of re al ity: a re view and in te gra tion of psy cho log i cal re -search on hal lu ci na tions. Psychol Bull 1990;107:8–-95.

42. Bentall RP, Slade PD. Re al ity test ing and au di tory hal lu ci na tions: a sig -nal-detection anal y sis. Br J Clin Psychol 1985;24:159–69.

43. Young HF, Bentall RP, Slade PD, Dewey ME. The role of brief in struc tions andsug gest ibil ity in the elic i ta tion of hal lu ci na tions in nor mal and psy chi at ric sub -jects. J Nerv Ment Dis 1987;175:41–8.

44. Mor ri son AP, Had dock G. Cog ni tive fac tors in source mon i tor ing and au di toryhal lu ci na tions. Psychol Med 1997;27:669–79.

45. Birchwood M, Chadwick PDJ. The om nip o tence of voices: test ing the va lid ity of a cog ni tive model. Psychol Med 1997;27:1345–53.

46. Chadwick PD, Birchwood MJ. Chal leng ing the om nip o tence of voices: a cog ni -tive ap proach to au di tory hal lu ci na tions. Br J Psy chi a try 1994;164:190–201.

47. Andreasen, NC. Af fec tive flat ten ing and cri te ria for schizo phre nia. Am J Psy chi -a try 1979;136:944–7.

48. Siris SG, Adan F, Co hen M, Mandeli J, Aronson A, Casey E. Post-psychotic de -pres sion and neg a tive symp toms: an in ves ti ga tion of syndromal over lap. Am JPsy chi a try 1988;145:1532–7.

49. Holthausen EAE, Wiersma D, Knegterin RH, Van den Bosch RJ.Psychopathology and cog ni tion in schizo phre nia spec trum dis or ders: the role ofde pres sive symp toms. Schizophr Res 1999;39:65–71.

50. Kay S, Fiszbein A, Opler L. The pos i tive and neg a tive syn drome scale (PANSS)for schizo phre nia. Schizophr Bull 1987;13:261–76.

51. Car pen ter W, Douglas W, Heinrichs D, Wagman A. Def i cit and non-deficitforms of schizo phre nia: the con cept. Am J Psy chi a try 1988;145:578–83.

52. Berenbaum H, Oltmanns TF. Emo tional ex pe ri ence and ex pres sion in schizo -phre nia and de pres sion. J Abnorm Psychol 1992;101:37–44.

53 Kring AM, Neale JM. Do schizo phrenic pa tients show a disjunction among ex -pres sive, ex pe ri en tial, and psychophysiological com po nents of emo tion? JAbnorm Psychol 1996;105:249–57.

54. Earnst KS, Kring AM. Emo tional re spond ing in def i cit and non-deficit schizo -phre nia Psy chi a try Res 1999;88:191–207.



55. Alpert M, Clark A, Pouget ER. The syn tac tic role of pauses in the speech ofschizo phrenic pa tients with alogia. J Abnorm Psychol 1994;103:750–7.

56. Siris SG. De pres sion in schizo phre nia. Wash ing ton (DC): Amer i can Psy chi at ricPress; 1995.

57. Tollefson GD, Sang er TM. Neg a tive symp toms: a path an a lytic ap proach to adou ble blind pla cebo and haloperidol con trolled clin i cal trial with olanzapine.Am J Psy chi a try 1997;154:446–74.

58. Meltzer HY, Casey DE, Garver DL, Marder SR, Masand PS, Miller D, and oth -ers. As sessing the ef fects of atyp i cal antipsychotics on neg a tive symp toms. JClin Psy chi a try 1998;59:28–34.

Manuscript received and accepted December 2001.1Staff Psy chol o gist, Cen tre for Ad dic tion and Men tal Health, Clarke Site, To -ronto, On tario; As sis tant Pro fes sor, Uni ver sity of To ronto, To ronto, On tario.2Uni ver sity Pro fes sor of Psy chi a try Emer i tus, De part ment of Psy chi a try, Uni -v er sity of Penn syl va nia, Pitts burgh, Pensylvania.Ad dress for cor re spon dence: Dr NA Rec tor, Cen tre for Ad dic tion and Men talHealth, Clarke Site, 250 Col lege Street, To ronto, ON M5T 1R8e-mail: neil_rec [email protected]



Rés umé : La thérapie cognitive du comportement pour la schizophrénie : de la conceptualisation àl’intervention

Ob jec tifs : Pré senter la com préhen sion cog ni tive dessymptômes de la schizo phré nie comme les idées dé li ran tes,les hal lu ci na tions et le re trait émo tion nel, et ex am iner l’ap -pro che de la thé ra pie cog ni tive du com por te ment pour amé -liorer ces symptômes.

Méth ode : Par une re cher che élec tronique (Med line etPsycInfo), nous avons repéré des études qui exami nent lesfac teurs cog ni tifs as so ciés aux symptômes de la schizo phré -nie. Cet ar ti cle intègre les résul tats expé ri men taux et letraite ment clin ique.

Résul tats : Des études ré cen tes por tant sur les as pectspsy cholo giques de la schizo phré nie démontrent l’im por -tance de défor ma tions et bi ais fréquents qui sont fonc tion -nel le ment re liés au main tien des symptômes. Lacom préhen sion du trou ble en termes cog ni tifs four nit uncadre à l’in ter ven tion psy chothé ra peu tique. L’a dap ta tionde straté gies cog ni tives util isées avec succès dans la thé -ra pie cog ni tive de la dépres sion et de l’anxiété of fre unajout im por tant au traite ment ré gu lier de la schizo phré nie.

Con clu sion : Étant donné que le résul tat du traite mentcou rant de la schizo phré nie de meure médio cre, il est es -sen tiel d’en vis ager la for ma tion de thé ra peu tes en ap pro -ches psy cholo giques.

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