Testing a Schema Mode Model of Delusions: Implications for Cognitive and Emotional 

Processing Accounts of Psychosis

Brockman1, R., Walters2, E., & Brakoulias3, V. 1 Australian Catholic University, 2 University of Technology Sydney, 3 University 

of Sydney

CBTp now widely empirically tested. NICE Guidelines recommend CBTp for persons suffering 

psychosis (alongside medication). Despite the rise in popularity of CBT for psychosis, a recent 

Cochrane review concluded: “Trial‐based evidence suggests no clear and convincing advantage for cognitive behavioral therapy (CBT) over other—and sometime much less sophisticated—therapies for people with schizophrenia” (Jones, Hacker, Meaden, Cormac, & Irving, 2012). 

Jauhaur et al. (2014) reviewed 50 RCTs of CBTp and found an effect size of .26 on positive symptoms, an affect that decreased to .18 (with the confidence interval crossing zero) when studies were excluded that did not use blinded assessment.

High prevalence of childhood trauma reported by individuals with an established psychotic disorder or at risk of developing psychosis (Read, van Os, Morrison & Ross, 2005). 

A meta‐analysis of 46 studies found that up to 73% of individuals with psychosis report a history of childhood sexual, physical or emotional abuse (Bendall, Jackson, Hulbert & McGorry, 2008). 

A clear dose response, individuals who frequently experience childhood trauma or experience multiple forms of childhood trauma have a greater risk (up to 30 times) of developing psychosis (Shevlin, Houston, Dorahy & Adamson, 2008; Janssen et al., 2004).

Recent mediational studies have demonstrated that the development of negative core beliefs about others mediate the relationship between adverse childhood experiences and  delusions, paranoia, and Ultra high risk status (Hardy et al., 2016, Appiah‐Kusi et al., 2017).

Consistent with schema theory.

1. Delusions as a Function of Emotional Distress (Freeman et al, 2001).2. Delusions as a Function of Psychological Defense (Bentall, Kinderman & Kaney, 1994)

No clear evidence supporting the primacy of either theory.

1. Bortolon et al. (2013) examined EMS in patients (n = 48) with Schizophrenia ‐ Schizophrenia group endorsed higher scores across six EMS (Emotion Deprivation, Social Isolation, Defectiveness/Shame, Enmeshment, Failure and Subjugation). Schemas were associated with positive, but not negative psychotic symptoms.

2. Sundag et al. (2016) found that patients with psychosis or depression (compared to normal) endorsed a higher overall number and intensity of EMS, relative to healthy adults, but found no significant differences between the two clinical groups. 

3. Basal Exposure Therapy?Hammer, J., Heggdal, D., Lillelien, A., Lilleby, P., & Fosse, R. (2018). Drug‐free after basal exposure therapy. Tidsskr Nor Laegeforen, 138(6). doi:10.4045/tidsskr.17.0811

To date no studies have examined the relationship between Schema Mode processes and psychotic symptoms, or whether related processes such as avoidance, are associated with maladaptive Schema Modes among individuals with psychosisAim: To test a schema mode model of delusions.

Correlations1. There will be significant relationships between Delusionality and Schema Modes. The direction of these relationships remains unknown due to conflicting accounts regarding the function of delusions so the following mediation models will be tested:

Hypothesized Model 1 (Delusions drive distress):If delusions function as the direct expression of emotional distress and underlying schemas, consistent with Freeman and colleagues emotion‐consistent account, it is expected there will be a significant positive relationship between delusionality and maladaptive Schema Modes (vulnerable child, angry child, detached protector, punishing parent, demanding parent), and a significant negative relationship between delusionality and adaptive Schema Modes (healthy adult).

Hypothesised Model 2: If delusions function as a psychological defence against negative self‐schemas and associated emotional states, consistent with Bentall and colleagues delusion‐as‐defence account, it is expected there will be a significant negative relationship between delusionality and maladaptive Schema Modes (vulnerable child, angry child, detached protector, punishing parent, demanding parent), and significant positive relationship between delusionality and adaptive Schema Modes (healthy adult).

Mediation Model: Hypothesized model 2 would suggest that delusionality is negatively related to maladaptive Schema Modes as an attempt to avoid distressing emotional states. Therefore, a further test of Model 2 would be to test if experiential avoidance mediates any negative relationship between maladaptive schema modes and delusions.

Intense emotions/Threat schemas

E.g. “The world is Dangerous”

Delusional Mode

Vulnerable/Angry Child?

Avoidance?

The sample comprised of 26 recently admitted (< 3 days) adult psychiatric inpatients (19 males, 7 females, Mage = 38, SD = 12.26, age range = 21 to 62)

Diagnosis of relevant psychotic disorder (schizophrenia, delusional disorder.

Assessed to be experiencing at least one delusional belief using Brown Beliefs Scale.

Patients were excluded from the study if they exhibited signs of severe cognitive or intellectual impairment, severe thought disorder, disorganised speech, or posed significant risk of aggression or violence.

- Mini International Neuropsychiatric Interview.- Delusions (Brown Beliefs Scale).- Schema Modes (Schema Mode Inventory, Vulnerable Child,

Angry Child, Punitive Parent, Detached Protector, Healthy Adult Modes).

- Emotional Distress. Depression Anxiety Stress Scales (DASS21)

- Experiential Avoidance (Acceptance and Action Questionnaire – 2; AAQ2).

Diagnoses: Schizophrenia (n = 13), Schizoaffective Disorder (n = 5), Substance Induced Psychosis (n = 5), Delusional Disorder (n = 2) and Brief Psychotic Disorder (n = 1). Results from the MINI also indicated the presence of comorbid diagnoses, including Major Depressive Episode (50% current, 77% past), Hypomanic Episode (19% past), Manic Episode (19% past), Post Traumatic Stress Disorder (12% current, 12% past), Substance Use Disorder (68% current, 76% past) and Alcohol Abuse Disorder (8% current, 36% past).More than half of the sample (68%) reported experiencing a traumatic event at some time in their lives. The average level of reported suicidality was in the moderate range. All participants were currently being treated with medication, including antipsychotics (n = 24), mood stabilizers (n = 6), benzodiazepines (n = 26) and opioids (n = 2).Inter-rater reliability for the clinician rated measures (MINI and BABS) was high, ranging from .80 to 1.0.

AngryChild

Vulnerable Child

Delusionality

‐ Avoidance

‐ Avoidance

Punitive Parent

‐ Avoidance

Full Mediation

We hypothesized that this may be because delusions block negative (distressing) Schema Modes from reaching consciousness, thereby leading to a decrease in psychological distress.

Furthermore, self‐reported Experiential Avoidance, in this context, may represent a proxy for psychological distress (rather than avoidance per se), consistent with findings from a recent factor analysis of the Acceptance Action Questionnaire‐II (Wolgast, 2014).

Emotional Distress

EmotionalDistress

Delusionality

‐ Vulnerable Child

‐ Angry Child

Emotional Distress

‐ Punitive Parent

Full Mediation

Suicide Risk

Suicide Risk

Delusionality

‐ Depression

‐ Depression

Suicide Risk

‐ Depression

Full Mediation

Consistent overall with model 2 ‘delusions‐as –defence’. Delusions appear to be a powerful means of blocking the activation and experience of negative schemas, modes, and associated intense negative emotions.

Our delusional patients appeared to be more distressed (and suicidal) as they became LESS delusional ‐ Delusions as serving protective Function

Consistent with a schema mode model of delusions as representing an avoidant type coping mode.

Need to replicate again with more valid measure of avoidance to be more certain.

Hypothesised schema mode model of delusionality possible. At least in theory – Schema therapy formulation and treatment of 

delusional beliefs may be possible. Especially in cases of quasi‐psychosis linked to treatment of a personality disorder.

Further exploration of other psychotic sx warranted.