Psychosis Ebooks Catalog

Coping With Psychosis And Schizophrenia Package

In the first part, you will learn about psychosis and schizophrenia, and how to identify different types of disorders, what the triggers for these disorders are, how to give first aid to someone going through a psychotic episode, what the hospitalization procedures are, and the disabilities that result from various psychotic disorders. The second part is devoted to coping with psychosis, schizophrenia, and its negative symptoms, with an emphasis on embarking on a new path. What post-psychotic depression is, and how to cope with it. What treatment options are available for someone who has experienced psychosis or for a consumer with schizophrenia. How to avoid future psychotic episodes. The layout approach, which refers to what is needed to successfully cope with psychosis. The family as a central support system in the life of the consumer. The place of the spouse in coping with psychosis and, for those who do not have a spouse, how to meet a new partner. Employment as a central factor in coping with psychosis and freeing oneself from feeling trapped, so as not to be dependent on other people. We focus on consumers getting a comfortable job, working on the Internet from home. What stigma is and how consumers and their families can cope with it. Finally, standing up for yourself as part of restoring your lost self-respect.

Coping With Psychosis And Schizophrenia Package Overview


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Author: Ronen David
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Insanity and Psychosis

The Tongui pogam's section on insanity covers symptoms that suggest epilepsy as well as insanity. Psychosis was considered true madness, and was thought to be caused by devils. The discussion in the Tongui pogam makes it clear that mental disease was thought to be of two main kinds. The first was epilepsy and insanity the other was psychosis or true madness. In ancient times, however, insanity was outside the domain of scholarly medicine treatment called for the mudang (Korean shaman) rather than the physician.

Studies of Cerebral Metabolism and Blood Flow in Schizophrenia

The frontal lobes have played a prominent role in hypotheses of schizophrenia since the conceptualization of the illness. Early functional neuroimaging studies, beginning with Ingvar and Franzen's (1974) seminal finding that patients with schizophrenia had relatively lower blood flow to frontal regions, provided evidence for the involvement of the frontal lobes. Changes in blood flow in response to cognitive activation were also first observed in these early studies. A large number of activation studies were published over the past 15 years that report frontal lobe impairment in schizophrenia. The overwhelming majority of these investigations have detected abnormal prefrontal response to a variety of cognitive activities designed to access and or control frontal neural circuitry, particularly working memory. The prefrontal site most commonly affected is the dorsolateral prefrontal cortex (DLPFC), and, until recently, the physiologic abnormality in this brain region was consistently...

Diagnosis And Classification Of Schizophrenia

Although schizophrenia is a developmental disorder with many neuropsychiatry manifestations, psychotic symptoms hallucinations, delusions, and disorganized thought and behavior have historically been the basis of diagnostic criteria. In the Fourth Edition, Revised, of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM IV), negative symptoms, duration of illness, and the temporal relationship to any depressive or manic syndrome are also part of the criteria but psychotic symptoms remain central (see Table 9.1). These diagnostic criteria may leave a misimpression that people with schizophrenia have a uniform illness. In fact, they vary greatly relative to their symptoms, course of illness, treatment response, and other features. Statistical studies of the symptoms of schizophrenia have consistently identified four factors or groups of symptoms (1) hallucinations + delusions, (2) disorganization, (3) negative symptoms, and (4) affective symptoms (manic...

The Genetic Epidemiology of Schizophrenia

Although we are aware of only one study reporting on the heritability of formal thought disorder itself (Gambini et al., 1997), a great deal of evidence is available demonstrating that genetic factors contribute substantially to the development of schizophrenia, accounting for about 80 of the risk of developing the disorder. The transmission pattern, however, is complex, involving at least several different genes as well as environmental factors (Cannon et al., 1998 Tsuang, Stone, & Faraone, 1999 Tsuang & Faraone, 1999). One consequence of the complexity of the inheritance pattern in schizophrenia is that an individual may carry some degree of genetic predisposition to the illness without expressing it phenotypically - or at least without expressing it to a degree severe enough to meet diagnostic criteria. Stated differently, only a subset of genetically vulnerable individuals actually develops a psychotic disorder. For many with such a genetic predisposition, an environmental...

Neural System Abnormalities in Schizophrenia

Although neither the specific neurobiolog-ical processes associated with the expression of formal thought disorder nor those associated with psychosis in general have been definitively isolated, disturbances in prefrontal and temporo-limbic systems and their interconnections are likely to play critical roles in both (Cohen & Servan-Schreiber, 1992 Grace & Moore, 1998 Gray et al., 1 991). The prefrontal cortex is thought to support higher-order cognitive processes such as working memory, the strategic allocation of attention, reasoning, planning, and Neuropsychological studies have shown that, against a background of generalized information processing impairment, schizophrenia patients manifest profound deficits in the areas of long-term and working memory (Cannon et al., 2000 Saykin et al., 1994). These deficits appear not to be merely secondary effects of impaired attention, disease chronicity, or medication exposure (Cirillo & Seidman, 2003). Such findings have been...

Childhoodonset Schizophrenia

Childhood-onset schizophrenia (COS) is a rare psychotic disorder that in certain ways resembles a pervasive developmental disorder. Information on its prevalence is limited, in part because diagnostic criteria have changed considerably over the last decade (Volkmar and Tsatsanis, 2002). COS is almost certainly less prevalent than autism, however, and it is often diagnosed in the presence of an autistic spectrum disorder. Males and females seem equally likely to be affected. Premorbidly, COS is associated with a number of developmental delays, including disturbances in motor, general cognitive, linguistic, and social development (Jacobsen and Rapoport, 1998 Nicolson et al., 2000). Some evidence suggests that the premorbid and clinical courses of COS are more severe than those of later onset schizophrenia (Alaghband-Rad et al., 1995). Episodes are more acute, and on average are of longer duration, in younger compared with older children (Werry, 1996). The course of illness is highly...

Suitability Of Cognitive Behaviour Therapy For Psychosis In Conditions Of High Security

The literature on cognitive behaviour therapy for psychosis in forensic settings is meagre (Ewers, Leadley & Kinderman, 2000). However, there are two ways in which cognitive behaviour interventions are relevant to the management of psychosis in conditions of high security. Such interventions are relevant to both improving mental health and reducing risk of offending (where there is a link between a patient's psychosis and his or her offending). Cognitive behaviour therapies have been shown to be beneficial in the treatment of chronic positive symptoms of psychosis, and intelligence and symptom severity do not appear to be associated with outcome (Garety, Fowler & Kuipers, 2000). Cognitive behaviour therapies have been demonstrated as beneficial in the treatment of patients resistant to conventional antipsychotic medication (Sensky et al., 2000). Provisional evidence from Italy suggests that the outcome of depression in people with a diagnosis of schizophrenia taking atypical...

Schizophrenia and Personality

The two primary traits of personality, namely extraversion (E) and neuroticism (N), have been studied with respect to schizophrenics, who seem to score low on E and high on N. They also exhibit, as stressed above, a peculiar or bizarre form of thinking, which might well implicate the third major trait of personality, namely psychoticism (P). Amajor contribution to the study of schizophrenia and personality has been made by Hans J. Eysenck (1916-1997), who designated P as a 'psychosis'-prone dimension. In Eysenckian theory, P is a dimension along which the various psychoses may be mapped as Eysenck writes, close to psychosis schizophrenia are behaviours variably diagnosed as schizoid, 'spectrum', or psychopathic P has been placed at the forefront of contemporary research looking at personality and psychopathology, but also at that looking at personality and creativity. Manic-depressives, for example, who have a clear propensity for creativity, seem to score high on E and, more...

Schizophrenia and Schizophrenic Thinking

Readers of this article - especially those interested in their own creativity - face the uncomfortable prospect that creativity is intricately related to psychopathology. This includes the potential relationship of mathematical creativity with autism, artistic creativity with bipolar disorder, and general creativity with schizophrenia. Such a notion appears in various guises in both the literature and the media the 'madman in the attic,' the 'mad genius,' the 'sensitive artist,' the 'troubled artist,' the 'deranged scientist,' and so forth. Biographical studies of various eminent individuals - artists, poets, musicians, scientists, explorers - discuss their creativity and their pathology, implying that their productivity comes at a personal price and that there is a genetic basis to both creativity and 'madness.' Thus, from the very outset, one has to consider such Romantic ideas concerning the 'troubled artist,' the notion of deviance - in both the positive (creativity) and negative...

Schizophrenia and Creativity

Heinz Werner (1890-1964) marked one dimension of development as that moving from a syncretic level to a discrete one, that is, from a state of relative globality and lack of differentiation to a state of increasing differentiation. Syncretic cognition entails a dedifferentiation of perceptual qualities in subjective experience, the most predominant example being synesthesia. But syncretic cognition, according to Werner, also refers to the lack of differentiation between what one dreams and what one sees, as is found in psychosis. Schizophrenic thinking could thus be characterized in terms of this 'primitive' level of syncretic experience. In fact, both creative thinking and schizophrenic thinking could rely on, or have access to, this same syncretic level of cognition. On the creative side, this dedifferentiation would allow for flexibility of perception and thought, as categories or concepts dissolve, become entwined and in general interact. On the schizophrenic side, this would...

Evolution of the secondary psychosis following TBI

The duration of the period following the injury that results in the emergence of a posttraumatic psychosis has been reported throughout the literature and can last as little as one month (Levine & Finkelstein, 1982), 12 months (Delahunty, Morice, Frost, & Lambert, 1991), three years (Barnhill & Gaultieri, 1989 Filley & Jarvis, 1987), 10 years (Barnhill & Gaultieri, 1989) or more (i.e., 11 years Levine & Finkelstein, 1982). Slater, Beard and Glithero (1963) also noted a prolonged lag of between 10 and 14 years from the onset of temporal lobe epilepsy to the appearance of the schizophrenia-like psychosis (Crowe & Kuttner, 1991). Fujii and Ahmed (2002) noted in their review that the period of delay before onset of the psychosis ranged from zero to 34 years with the mean number of years posttrauma to onset being 4.1 6.6. The mode of onset was less than one year (38 ) and the median was one year, with 72 of the cases reporting an onset before the mean. Twenty of the 59...

Schizophrenia and Schizotypy

Given the problems inherent in studying creativity amongst schizophrenics on medication, it is natural to consider other phenomena related to the pathology, that are more amenable to experimental research. This is the same line of thinking that one finds in research on normative psychopathy (i.e., 'normal' individuals who might be predisposed to psychopathic behavior, without actually being characterized as being psychopaths). So-called 'psychosis-prone' individuals (i.e., those individuals who might be prone to developing schizophrenia, given the necessary stressors in the environment, who score relatively high on psychosis-related, though normal personality dimensions, such as Psychoticism or Schizotypy) are of present concern. Common to all such endeavors is the reliance on a diathesis-stress concept of the development of psychopathology, namely that the predisposition interacts with environmental stress to result in the behavior and symptomatology observed. The normal personality...

Psychosis and Dementia in Parkinson s Disease

As the neurodegenerative process that underlies PD progresses, risk for developing psychotic ideation and a dementing illness increase significantly. At least 75 of PD patients who survive for more than 10 years will develop some form of PD dementia (PDD Aarsland & Kurz, 2010), but there is huge variation with some individuals not developing dementia at all, some developing a relatively mild form of dementia, and some not developing dementia until very late in the disease. The mean time from onset of PD to dementia is approximately 10 years. The strongest predictors for development of early dementia in PD are old age, postural and gait disturbances, and impairment in frontal ECFs (Janvin et al. 2006 Kulisevsky & Pagonabarraga, 2010 Marder, 2010). Because the ECFs are treated in this book as part of the agentic self system, in our terms, severe impairment in the agentic self system increases risk for later dementia in PD. Thus, if the agentic self system can be exercised so that...

Prevalence and incidence of psychosis following TBI

The rate of emergence of psychosis reported in the earlier literature (i.e., involving eight studies describing 12,385 patients between 1917 and 1964) were reviewed by Davison and Bagley (1969). They reported that the rate of the development of psychosis following TBI ranged from 0.07 to 9.8 with a median rate of 1.35 . They estimated the lifetime prevalence of posttraumatic psychosis over a 10- to 20-year period following the injury to be two to three times the expected incidence in the noninjured population. Goldney (2005) noted that both schizophrenia and TBI are relatively common clinical phenomena, with the lifetime risk of schizophrenia being 0.8 (Jablensky, 1995) and with as many as 5.7 of the population having a TBI with a loss of consciousness of more than 15 minutes (Anstey et al., 2004). As a result, the likelihood that these two diagnoses may co-occur, particularly as the peak incidence time for both conditions is in early adulthood, is not insubstantial. Lishman (1973)...


Explain the pathophysiologic mechanisms that are thought to underlie schizophrenia. 2. Recognize the signs and symptoms of schizophrenia and be able to distinguish among positive, negative, and cognitive symptoms of the illness. 3. Identify the treatment goals for a patient with schizophrenia. 4. Recommend appropriate antipsychotic medications based on patient-specific data. 6. Describe the components of a monitoring plan to assess the effectiveness and safety of antipsychotic medications. 7. Educate patients and families about schizophrenia, treatments, and the importance of adherence to antipsychotic treatment. O A diagnosis of schizophrenia is made clinically, as there are no psychological assessments, brain imaging, or laboratory examinations that confirm the diagnosis. Patients presenting with odd behaviors, illogical thought processes, bizarre beliefs, and hallucinations should be assessed for schizophrenia. The cornerstone of treatment is antipsychotic medications. Because most...


Baltimore Johns Hopkins University Press. Mueser, K. (1994). Coping with Schizophrenia A Guide for Families. Oakland, CA Guide to Childhood's Most Misunderstood Disorder. New York Broadway Books. Torrey, F. (1995). Surviving Schizophrenia A Manual for Families, Consumers and Sebastopol, CA O'Reilly & Associates. Weinstein, A. (1996). Madness, Psychosis, and Addiction (Lecture 7). Chantilly, VA The Teaching Company.

Basis in cognitive behaviour therapy

The use of CBT in schizophrenia has been drawn from Beck's theory of emotional disorders (Beck, 1976). It has been founded on a tradition of evaluation, using experimental and research studies of defined therapeutic techniques. These techniques are problem-oriented and are aimed at changing errors or biases in cognitions (usually thoughts or images) involving the appraisal of situations and modifying assumptions (beliefs) about the self, the world and the future. The Cognitive Therapy Scale (Young & Beck, 1980) is used in research studies to ensure fidelity to the treatment model described by Beck and colleagues, but it is also a valuable tool in training. There have been adaptations to this for general use (e.g.Milne et al., 2001) and also for use in psychosis (Haddock et al., 2001). It describes the general therapeutic skills used in psychological treatment and the more specific conceptualisation, strategy and techniques used in cognitive therapy. The use of CBT in schizophrenia...

Understanding patients explanations

Patients use a variety of explanations for their symptoms, and these are elicited. Romme and Escher (1989) found that people who experienced auditory hallucinations described them as being caused by trauma repressed, impulses from unconscious speaking, part of mind expansion, a special gift or sensitivity, expanded consciousness, aliens, astrological phenomena and, more rarely, a chemical imbalance or schizophrenia. To this can be added spiritual beliefs (God or the Devil speaking) and technological explanations (satellites or radar, etc.).

Case 1 John Douglas Turkington

There are a number of patients with antipsychotic-resistant schizophrenia who derive minimal benefit even with Clozapine (Kane et al., 1988). These patients often suffer from delusions which are systematised and entrenched. Such delusions are usually not only impervious to treatment with antipsychotic medication, but they are also very difficult to treat psychologically. The problem in relation to these cases is that the delusion is often systematised with a grandiose or paranoid theme and insight is usually virtually completely lacking. The delusion is often held with a very marked conviction and the patient sometimes acts in a dangerous way upon the content of the delusion. The questions then arise as to whether patients with such systematised grandiose or persecutory delusions can be understood within a cognitive therapy framework and whether the application of the principles of cognitive therapy (Fowler, Garety & Kuipers, 1995) can produce benefit. One of the key issues that...

Initial case formulation

Previously I had trained using Schneider's first rank symptoms of schizophrenia to help me, and had spent my early years in nursing trying to reason why all the people I ever met who had been given a diagnosis of schizophrenia seemed to have so little in common. Formulation, as opposed to diagnosis, seemed just as baffling at first but did seem to offer more to my clients and to me. The experience of psychosis is overwhelming to both the client (Romme & Escher, 2000) and the therapist. The formulation provides an opportunity to understand and normalise psychotic experiences. I shared a client's formulation with her recently and she announced at the end of the session It's no wonder I'm like this. It appears that the stress surrounding these critical incidents may have contributed to her first episode, although Janet did not recognize how stressed she was. As a result of her emerging psychosis she was removed from university and returned home. Following her return she discovered...

Case 4 Helena Isabel Clarke

I trained as a clinical psychologist in my mid-forties, having spent a long time in mental-health-related voluntary work while bringing up my family and doing an Open University degree in Psychology. I first became interested in psychosis as a Samaritan, and developed an approach based on helping someone who came to me in that capacity in the 1970s, to distinguish between her psychotic and ordinary style of thinking and experiencing, in order to reduce her distress and help her adaptation. I noted then the different quality of experiencing she described when the psychosis took over, and this is a theme I have followed up. During my training and in my early years of practice, 1989-1990s, I followed developments in CBT for psychosis closely through conferences and workshops, and developed my own practice, rather tentatively and in isolation. I have since been joined by other colleagues enthusiastic and knowledgeable in CBT for psychosis, and so find myself in a thriving department....

Features Context And Approach To Therapy

I work in a psychiatric rehabilitation service, catering for people with long-term problems, who need extra support in order to maximise their independence. My work as a therapist is therefore part of the input of a multi-disciplinary team, and this case illustrates this way of delivering CBT for psychosis. Individual therapy is a relatively small part of my contribution to the service. Indeed, my initial face to face contact with Helena came about through her membership of a Voices group I was facilitating, along with one of the nurses in the team. I was already familiar with her situation, as I had been involved in offering consultation over several years. Once individual therapy started, liaison with the team was central to the process. The ways of approaching symptoms that I negotiate with the individual are then shared with the keyworker, with permission, and so employed by the team. Another feature of this case is that breakdown occurred in middle life, and involved the...

Case 5 Kathy Paul Murray

This is a case study using a brief, manualised CBT intervention targeted on improving insight and generalised symptomatology in schizophrenia. The intervention comprises six structured sessions of psycho-education using a CBT model lasting approximately one hour. The case described was one of the patients with whom I worked when I became involved in the randomised community field study (Turkington et al., 2002) of the Insight into Schizophrenia programme which was compared with treatment as usual. I had qualified as a Registered Mental Nurse in Preston, Lancashire, in 1983 and have worked in acute psychiatry and, latterly, rehabilitation since then in Hertfordshire, Cleveland, Oxford and Southampton. My last NHS post was in a hospital hostel which is part of the rehabilitation service in Southampton before I came to work for Innovex (UK) Ltd. as a nurse adviser delivering the Insight Programme in Southampton and the Isle of Wight, initially as part of the randomised community field...

Cases 10 Mary and 11 Karen Nick Maguire

I trained as a clinical psychologist at Southampton University, qualifying in 1999. My particular interest during training was the treatment of psychosis using Cognitive Behaviour Therapy (CBT), supervised by Professor Paul Chadwick. My thesis extended this interest, firstly within a theoretical paper describing cognitive and evolutionary aspects of paranoia, and secondly an experiment to empirically investigate the theoretical and clinical observations that there are two distinct forms of paranoid thinking. I am currently working as a locality team psychologist, dealing with people with severe and enduring mental health problems, i.e. psychosis and personality disorder, all within a CBT framework, although I recently undertook the Dialectical Behaviour Therapy course for more specialist work with personality disorders. I am also currently extending the CBT model to the treatment of those with homelessness and alcohol substance abuse problems. This project is being evaluated, and some...

Case 12 Jane Jeremy Pelton

The following case involved work with both Jane, a patient with a 16-year history of mental health problems, and her parents. I met her while I was training in CBT for psychosis. I had first entered the mental health arena as a nursing assistant in 1980. This was a summer job to see me over my university years. After finishing university and not being able to find another job I continued on as a nursing assistant for nearly two years until my then nursing officer gave me a prod in the direction of my RMN training. I trained at Cherry Knowle Hospital in Sunderland, qualifying in 1986. For the first three years I worked in acute admissions and day hospital, working mainly with anxiety and depression. In 1990 I then moved into the community as a CPN and worked within a rehabilitation team, with a caseload of patients with schizophrenia who had been discharged into the community. It was during this time that I developed an interest in PSI and CBT, completing a PSI course in Sheffield and...

Cases 13 Malcolm and 14 Colin Andy Benn

This chapter* presents two case studies involving the use of cognitive behaviour therapy with patients detained in conditions of high security. The aim of this chapter is to examine the feasibility of applying cognitive behaviour therapy in this setting. While clinical trials have demonstrated the utility of cognitive behaviour therapy in various settings (see Chapter 16), there are no published clinical trials of this work in conditions of high security and few case studies (Ewers, Leadley & Kinderman, 2000). The chapter also highlights the useful contribution that cognitive behaviour therapy can make to risk reduction in situations where there are clear links between offending and psychosis. Readers are referred elsewhere for a more general discussion of prevalence, triggers, and determinants of offending and psychosis (Hodgins, 2000). The service aims for this setting will be outlined, alongside a discussion of key issues in engaging people with psychosis in this particular...

Challenges to engagement

Patient engagement within high secure psychiatric services in general is central to security in high secure hospitals. The identification and management of risk through the professional relationships between staff and patients and the differing elements of the treatment programmes is referred to as relational security (Kinsley, 1998). Strong working alliances between staff and patients with schizophrenia are associated with better outcomes (Frank & Gunderson, 1990 Gehrs & Goering, 1994). Supportive interpersonal skills, including empathic listening, the ability to explore meaning in symptoms and responding to patients' concerns, are central to engagement (Gehrs & Goering, 1994). Gentle persistence with attempts to engage patients, warmth, appropriate humour, and a willingness to explore patient misinterpretations of therapist behaviour are also helpful (Kingdon & Turkington, 1994 Kingdon, 1998). Kingdon warned against attempting to do too much in each session and to ensure...

Minimisation And Poor Insight Into Risk

Patients with psychosis may have difficulty tolerating the affect associated with remorse, or indeed be emotionally blunt as part of their negative symptoms. Affect associated with remorse maybe experienced as aversive, and avoided as a potential stressor that might trigger symptoms. Such presentations can be difficult to distinguish from lack of concern for the consequences of past action. Ensuring active efforts to identify and manage stressors and risk situations helps to confirm that the patient regards risk management and reduction as an internal goal. of adequate understanding of the relationship between the patients' mental health problems and offending. Such explanations omit key variables and factors linking the mental illness or symptoms with the offence. Interventions based on theoretical models of schizophrenia (Nuechterlien & Dawson, 1984) and symptoms (Fowler, Garety & Kuipers, 1995 Haddock & Slade, 1996 Kingdon & Turkington, 1994) aimto educate and enable...

Assessment of local need

Discuss with provider organisations' audit departments, local university departments and Department of Public Health (at health authority) or equivalent if any exercise to assess the number of patients with schizophrenia and related psychoses, e.g. schizoaffective delusional disorder, has Number of patients with schizophrenia or related psychoses For which of these will a service be relevant Care Programme Approach (Kingdon, 1994) or similar registers may be useful in providing lists of patients with severe mental illness, many of whom will have psychosis. Lists of patients who are being seen regularly in outpatients should be obtainable from computerised outpatient management systems by consultant. If consultants are supporting your proposal, they may be prepared to indicate on such lists which patients have the above psychoses.

For whom is CBT relevant

Studies demonstrating the successful use of CBT in the schizophrenia group of psychoses have included in and outpatients with positive and negative symptoms, early and later in their course, between 16 and 65. They have excluded patients who are too thought disordered to use rating scales with and who have a primary diagnosis of drug or alcohol misuse (although Barrowclough and colleagues have presented promising findings in this dual diagnosis group). Although some services have stressed that they are for patients with persistent positive symptoms, the evidence is increasing that patients with negative symptoms, e.g. affective blunting, may benefit most.

Evidence of effectiveness

The results of well-conducted and reported ongoing trials are eagerly awaited. Currently for those with schizophrenia willing to receive CBT, access to this treatment approach is associated with a substantially reduced risk of relapse it is a scarce commodity how effective is it when applied by less experienced practitioners. (Jones et al., 1998) Table 16.2 Randomised controlled trials of cognitive behavior therapy for psychosis Table 16.2 Randomised controlled trials of cognitive behavior therapy for psychosis There have also been studies on cognitive remediation, which focuses on, for example, concentration, attention and social skills development, but these are reviewed elsewhere (Hodel & Brenner, 1998). Similarly an initial study by Hogarty and colleagues (1997) describing personal therapy an individual psychotherapeutic intervention with some similarities to CBT has shown it to be effective with patients with schizophrenia living with families, but not living alone. There is...

Psychosocial Intervention Courses

Introduction to this area is well described by O'Carroll (Chapter 14). Users of services have often been involved to convey their experiences of their mental health problems and the response from services. Exercises which can be particularly effective are those developed by people from the hearing voices networks, such as getting two trainees to talk to each other while another whispers or speaks loudly in one of their ears. This can help to get across the experience of distraction and the emotions evoked, especially where the speech is unpleasant in content. An exercise used in normalising psychosis can be to list the number of ways that one person could drive someone else mad e.g. stop them sleeping, give them amphetamines, deceive them in various ways (see Kingdon & Turkington, 1994, for further examples). This assists trainees in understanding the many ways that psychotic symptoms can be evoked and the many statements that people experiencing strange phenomena use to explain...

Case 9 Carole Ronald Siddle

I was initially trained as a psychiatric nurse. I left school at 15 having just sat my GCE O levels and was persuaded by a friend to apply to the local psychiatric hospital as a cadet nurse. After two years of working in the various departments of the hospital I started training as a student nurse. Towards the end of the RMN training I applied for the shortened post-registration RGN course and was able to finish that training in about a year and a half. Swiftly returning to the safety of psychiatry I spent a year or so as a staff nurse before getting a relief charge nurse post. When I was allocated to a ward full time I tried to do what I could with the patients. Unfortunately it was an uphill struggle with schizophrenia and institutionalisation making psychological work difficult. Of course at that time (1980s) even though there was some evidence of effective therapeutic strategies, I did not know them, and was in any case trying to influence things at a more basic level. The ideal...

David Kingdon and Jeremy Pelton

Over the past few years, opportunities for training have increased in the UK from a situation where many mental health professionals working with schizophrenia had little or no access to courses that allowed them to develop a psychological angle to their work. Previously there were a number of books and articles being published on the broad range of psychosocial interventions and, more specifically, cognitive behaviour therapy, but there was no opportunity to develop skills unless you worked alongside the specialist practitioners and researchers within the area. The established courses for CBT in London, Newcastle and Oxford provided training in the therapy for depression and anxiety disorders, but limited instruction to those interested in working with schizophrenia. That has changed and these courses, and new ones developing since, now include modules on managing psychosis, although these still provide a limited focus on psychosis, albeit within a very valuable overall introduction...

Session 1 Engagement and developing alternative explanations

An agenda was set that started with discussing her diagnosis, exploring critical incidents and developing an agreed problem list. Kathy stated that she had been given a diagnosis of schizophrenia a number of years ago but could not remember anyone explaining to her what this actually meant. When asked what she thought this illness was, she associated it with violent mad people and did not see how this was relevant to her. When we started to look at literature that described the symptoms of schizophrenia in such terms as difficulty in solving problems, making plans and remembering things, she was able to identify with some of these symptoms. noticed that they were generally at the times when these critical incidents occurred. Kathy detailed a number of symptoms that included auditory and visual hallucinations, paranoia and thought disorder. However she identified her main problem as French agent mice with liquorice hats who had been developed for spying purposes by the CIA. They...

Paranoia and delusions Process and product

Both of the people presented hear received diagnoses associated with paranoia and delusions. However, paranoid thinking was the only clear symptom of psychosis manifested, as it is arguable whether their beliefs were delusional. The beliefs formed to account for the paranoid perceptions although involving some degree of malevolence were not inconsistent with cultural possibilities, i.e. they were conceivable. They both illustrate the usefulness of the distinction outlined above, in terms of the conceptualisation of the perceptual abnormalities, the maintaining factors in terms of selective abstraction, and the explanations developed to account for the perceptions. In addition, core or schematic beliefs were implicated in both formulations in terms of the aetiology of the perceptions. There are, therefore, several interesting conceptual points highlighted by these two cases. The first is, as discussed, the presence of paranoia (in terms of cognitive processes) in the absence of other...

Case 8 Sarah Pauline Callcott and Douglas Turkington

Kingdon and Turkington (1998) suggest four therapeutic subgroups relating to schizophrenia. They emphasise the complicated nature of the phenomenology and have therefore argued for the existence of separate syndromes within the schizophrenia spectrum. These subgroups not only provide a broad spectrum for understanding and normalising individual symptoms they also help to provide a framework for Cognitive Behaviour Therapy interventions. One of the subgroups relates to psychosis which occurs after trauma. Mueser and colleagues (1998) noted high levels of Post Traumatic Stress Disorder (PTSD) symptoms among individuals with severe mental illness. Ninety-eight per cent of those with a diagnosis of serious mental illness had a history of trauma, with 48 of these meeting criteria for PTSD. Romme and Escher (1989) found that 70 of voice hearers develop their hallucinations following a traumatic event. Honig et al. (1998) compared the form and content of chronic auditory hallucinations in...

Training In Cognitive Behaviour Approaches For Inpatients

The developments that have occurred in CBT over the past decade have been predominantly with outpatients (although many studies have enlisted patients while they have been acute inpatients). Developing therapeutic skills in inpatient staff is very important as so many patients spend weeks or months of their time in such settings when they are at the height of their illness. There has been major concern at the state of wards and that users express that they do not feel listened to. In 1999, John Allen, at the time a nurse tutor, and I developed a staff training initiative to try to begin to address some of these issues (Allen & Kingdon, 1998). Staff from inpatient wards in Nottingham were offered the choice of one of three training days. They were given a basic introduction to CBT with specific discussion of its application to psychosis and their views on this. There then followed use of videos of patient interviews and participation in role-plays to use techniques for working with...

Tracing antecedents of symptoms

Understanding the circumstances in which delusional ideas or hallucinations began, even when they may be 30 years previously, can be invaluable in finding out why particular beliefs have arisen. For example, paranoid delusions and hallucinations may have occurred for the first time during a drug-induced psychosis (bad trip) and need to be relabelled as originating with, although not currently caused by, that experience. Also, voices may relate to a specific traumatic event that is often accompanied by a depressive episode. A good conventional psychiatric assessment of the personal history can allow the pathological process to be charted using guided discovery. This is particularly important for patients who have

The Role Of Supervision And Teaching

As mentioned, the course was divided into three modules and those of us who had chosen to specialise in psychosis had to wait until the last module to get the teaching course. This meant that we theoretically had a relatively poor base to start off with, which obviously put extra pressure on the supervisor over the first months. During this period the supervisor and the other trainee in the group were especially indispensable. As soon as the teaching got underway pieces in the jig-saw would little by little fall into place, while understanding on a grander scale had to wait until the final written assignment was completed at the end of the course.

Session 2 Developing alternative explanations and formulation

The session began with a review of the homework. Kathy had read the leaflets and decided that there were quite a few symptoms of schizophrenia that she did not know about and it might have helped had these been explained when she first became ill. The cats remained a nuisance, but Kathy explained that they kept the agent mice away from her in the corner of the room.

Initial contact and voices group

Medical model opinion of voices and symptoms at the same time as entertaining other, incompatible, explanations for psychotic symptoms. In the presence of psychosis, explanatory systems and meaning-making become generally more fluid, and people will often toggle backwards and forwards between quite distinct positions according to whether the individual is operating more from the shared reality, or from their private, psychotic reality (see further in Clarke, 2001). Part of the focus of the group is in raising awareness of these two possibilities, and encouraging the ability to move into the more adapted, i.e. the less distressing, of the two. Reducing the state of arousal is frequently enough to achieve this.

Effectiveness of research in routine clinical practice

Training and supervision in research studies can be expected to be of higher quality and the therapists themselves are likely to have prior experience and skills above those expected in usual practice. This inevitably also affects how studies can be interpreted where staff with less skill, time and commitment are involved. The Insight into Schizophrenia study (Turkington et al., 2002) has attempted to address this concern by developing a brief intervention delivered by a range of nurses recruited directly from inpatient and community services with a basic, two-week training.

Developmental and social history

Looking back, Janet described how she had experienced intellectual paranoia during this time. Her fellow residents had been violent and hypnotic and her boyfriend had been using her. Janet started to experience difficulties at this time she was becoming more disorganised and her concentration was suffering. As a consequence she failed her end of term exams. It was at this time that she experienced her first hallucination. It had been an orange planet, accompanied by pictures of soldiers underground causing mass destruction and torture. She had returned home at this point, whereupon she was diagnosed with paranoid schizophrenia (though she was unaware of this until 1985). Her treatment was an antipsychotic depot injection and an oral major tranquilliser and she was still on this treatment regime when I started the therapy.

Case 6 Nicky David Kingdon

My introduction to cognitive behaviour therapy came from reading Aaron Beck's work as a trainee psychiatrist in the late 1970s. Previously I had read about a range of psychotherapies from non-directive therapy (Rogers, 1977), brief psychodynamic psychotherapy (Malan, 1979) and transactional analysis (Berne, 1968) and found them very illuminating. However, Beck's explanations of emotional disorders and way of working with them seemed to draw these together in a coherent and intuitively very satisfying way. I worked on a project led by Dr Peter Tyrer investigating treatment strategies, including CBT, in neurotic disorder (Tyrer et al., 1988) and adapted these techniques for use in psychosis (Kingdon & Turkington, 1991). The importance of understanding how problems developed and how they could be understood was central to this and Laing (Laing & Esterson, 1970) and Foudraine (1971), among others, were influential exponents of this. When I met Nicky, I had been using these...

Assessment formal and informal and formulation

Jane and her parents were assessed formally using a number of psychometric tests (see Table 11.1) and informally through observation and interview. Four psychometric tools were used to assess Jane's parents the Relative Assessment Interview (Barrowclough & Tarrier, 1992), the Knowledge About Schizophrenia Interview, the General Health Questionnaire (Goldberg & Williams, 1988) and the Family Questionnaire (Barrowclough & Tarrier, 1992). Knowledge About Schizophrenia Interview

Assess and building local support

If local support is not strong, it is more sensible to develop an educational strategy focused on individual groups by, for example, organising visits from speakers with expertise and experience in CBT of psychosis to local educational forums, or running workshops. Change may occur incrementally where there are examples of patients benefiting from contact with clinicians using CBT, although this may mean that just one or two people will develop such skills but demonstrate the value to others of gaining these skills in the future. Obtaining places on CBT courses (especially those focusing on SMI), Thorn (or equivalent) and in-service workshops lectures can start the process moving with the development of individual CBT nurse psychologist posts focused on psychosis. There is always a danger of isolation in such posts, but local centres (e.g. Newcastle and Southampton in the UK) can be a focus for peer support and supervision.

Application to therapy

A central feature of CBT is the need to be able to share a clear, easily grasped, rationale with the person with whom you are working, and obviously the exposition of the Interacting Cognitive Subsystems model given above does not match that description However, it does lead to some very simple and user-friendly ideas that have been central to Helena's therapy. In summary, if the desynchrony between propositional and implicational levels, mediated by high arousal, is at the root of at least the psychotic symptom part of the problem, getting these to work together is at the heart of the solution. The ideas of shared and non-shared reality, the ability to hold two ideas at once, and the role of state of arousal in mediating access to the more rational explanation, as introduced above, all relate directly to this model. Fundamentally, being in the world is seen as a balancing act rather than a given. In most mental health problems the balance becomes tipped, but in psychosis it becomes...

Case 2 Janet Laura McGraw and Alison Brabban

In 15 years as a community mental health professional there have been very few moments when I have wanted to leave my job. However, in the early 1990s I found myself working as a lecturer and a community psychiatric nurse and becoming increasingly exposed to an array of literature commenting on the practice of Psychiatric Nursing. The reports touched on all aspects of service delivery and found that practice did not match expectations, despite policy recommendations. Community psychiatric nurses' caseloads had a low proportion of people with long-term mental illness on them multidisciplinary team reviews rarely happened the Care Programme Approach was not fully implemented users and carers seemed poorly served clients' physical health education was unsatisfactory monitoring of medication was unsystematic and the training of staff in appropriate interventions for schizophrenia was minimal (Gournay, 1996). The overall conclusion appeared to be that community psychiatric nurse (CPN)...

Clinical Psychology

The Case Study Guide to Cognitive Behaviour Therapy of Psychosis Substance Misuse in Psychosis Approaches to Treatment and Service Delivery Early Intervention in Psychosis A Guide to Concepts, Evidence and Interventions THE CASE STUDY GUIDE TO COGNITIVE BEHAVIOUR THERAPY OF PSYCHOSIS

About The Editors

David Kingdon is a Professor of Mental Health Care Delivery and a consultant psychiatrist with a mental health team in Southampton. He is co-author, with Douglas Turkington, of Cognitive-Behavioural Therapy of Schizophrenia (New York Guilford Press, 1994) and has produced many papers and chapters on CBT in severe mental illness over past decade. He has worked as a senior medical officer with the Department of Health, is a member of many project groups, including the National Service Framework for Mental Health external reference group, and is chair of a Council of Europe expert working party on Psychiatry and Human Rights. Dr Douglas Turkington is a senior lecturer and consultant psychiatrist based at the Department of Psychiatry in the University of Newcastle-upon-Tyne. Having trained in Glasgow he moved to Sheffield where he received basic cognitive therapy training and achieved the advanced certificate in rational emotive therapy. He has worked with CBT for psychotic patients for...

List Of Contributors

Paul Murray Insight into Schizophrenia Nurse, Innovex (UK) Ltd., Innovex House, Marlow Park, Marlow, Bucks. SL71TB. Jeremy Pelton Field Manager, Insight into Schizophrenia Programme, Innovex NHS Solutions, Innovex (UK) Ltd., Innovex House, Marlow Park, Marlow, Bucks. SL71TB.


The individuality of the perception is established Can anybody else hear what is said not parents, friends, etc. This is agreed although it may involve the person checking with others about whether they can be heard. Beliefs about the origin of voices are explored Why do you think they can't hear them Often the patient is unsure of his or her origin or produces delusional beliefs. Techniques for delusions (see above) can be used if appropriate. Possible explanations will then be explored e.g. it may be schizophrenia. Stressful situations in which voices can arise may usefully be described as they can help to normalise the experience, i.e. many people under certain forms of stress can hallucinate. This can be induced through sleep deprivation (Oswald, 1984), sensory deprivation states (Slade, 1984) and other stressful circumstances, such as bereavement, hostage situations (Grassian, 1983), PTSD and severe infections. In other words, 'voices can be stress related...

Clinical subgroups

Although a symptomatic approach is valuable in working with patients with psychoses, there are limitations to it in that, for example, hallucinations may present quite differently and cause different levels of distress in a person presenting with a range of psychotic symptoms than in someone for whom this is the predominant symptom relating to previous life events. This has increasingly led us to consider whether psychoses, including the schizophrenias, can be subgrouped (see Kingdon & Turkington, 1998). If valid and reliable groups can be developed, this could help with their management in determining responses to medication, psychological treatment, family work and rehabilitation measures. Such groups would also be expected to give indications of prognosis and assist substantially in research and training. Differentiation into bipolar disorder and schizophrenia has, arguably defined a spectrum rather than discrete entities. Previous descriptions of the group of schizophrenias, as...


Cognitive behaviour therapy is a major advance in treating schizophrenia. In combination with medication, it offers effective interventions for a range of positive and negative symptoms and is very acceptable to most patients and carers. The techniques involved build on basic training for cognitive therapists and psychologists, and also case managers, nurses and psychiatrists, who are experienced in working with patients with schizophrenia. Manuals are available to assist with the development of skills. In some areas, training courses for mental health workers have been developed but there are currently far too few trained personnel however, this situation may change with the emerging evidence of effectiveness and increased training opportunities (see later chapters). Anxiety psychosis Sensitivity psychosis 1 'Post-traumatic stress psychosis'

Psychiatric history

At the age of 17 he was assessed as having signs of psychosis by a duty psychiatrist in an accident and emergency department, but he left the building before further action was taken. At 21 he was admitted and a diagnosis of schizophrenia was made. He responded to medication but was said to have been left with residual negative symptoms and soon dropped out of treatment. At 25 he was re-referred in a floridly psychotic state angry, volatile and described as easily becoming threatening, grimacing and with incongruous laughter, rapid speech thought disorder and idiosyncratic use of words. He was admitted to a secure mental health unit after the


In asking a few relevant demographic questions it was confirmed that Carole had a diagnosis of schizophrenia (and was comfortable with the label), and was prescribed the following medications Carole reported that her medications were effective in that they helped her to calm down and contributed to the voices being less persecutory. Around the time that her depot medication was due, Carole reported that her voices got worse and afterwards they got better. She had been an inpatient in the past, had nine siblings and her father had had a history of what Carole believed was manic-depressive psychosis.

Personal history

She was diagnosed as having schizophrenia at 18 and this was eventually modified to schizo-affective later in her illness. She spent most of 1985-89 in and out of hospital before having her longest period of remission to date. During this time out of hospital she lost the weight that she had gained while she was ill and became quite successful at golf, winning trophies and local championships. Her last admission was in 1994.

Course of treatment

Beck (1967) wrote about the importance of having an explanation of the symptoms of anxiety and depression, and described this as fundamental to the application of cognitive therapy in these conditions. Kingdon and Turkington (1991) reported the success of the same normalising strategies when working with schizophrenia. Nelson (1997) also reported on the importance of lessening the impact and distress of delusions and hallucinations prior to treatment. One of Jane's highlighted problems was her lack of sleep, and on assessment this could be linked to the above stress vulnerability and her psychotic symptoms, as illustrated in Figure 11.2.

Key service tasks

A variety of offence and mental health focused interventions on an individual or group basis. Within the services interventions are therefore focused broadly on risk behaviour (e.g. aggression, violence, self-injury, and suicide para-suicidal behaviour), mental health problems (e.g. psychosis, affective disorders) and social functioning (e.g. social isolation and social inclusion, communication, and interpersonal problem-solving). Remission of symptoms is not required for transfer to conditions of less security (Maden et al., 1995), merely the reduction of risk from being grave and immediate. This chapter concerns cognitive behaviour therapy for psychosis in cases where the management of patients' mental health problems is central to risk management. Cognitive behaviour interventions for delusions are relevant to high secure service provision with the aim of reducing the likelihood of them the delusions being acted upon (Ewers, Leadley & Kinderman, 2000). Attempts to analyse the...


Although the evidence base for the efficacy of cognitive behaviour therapy for psychosis in secure settings is extremely poor, combining interventions shown to be of value in community settings with individual formulation permits the development of feasible interventions within conditions of high security. The assumption that the risk of offending can be reduced by treating mental health problems is not new. Psychosocial interventions for psychosis have an increasingly impressive outcome data set, and it would be worth while researching the efficacy of cognitive behaviour therapy combined with atypical antipsychotic medication in a high secure setting. However, the institutional context involving a wide range of treatment services, the coexistence of offending, substance abuse problems, and dual diagnoses would require a complicated research design. Individualised formulation-based approaches to cognitive behaviour therapy in psychosis have advantages over the protocol-based...


There are a number of components to Nelson's work (1997) on promoting insight. The first involves eliciting the patient's views on mental illness and schizophrenia, and a similar approach is adopted in relation to students. Early in the course they are asked first to identify their personal beliefs regarding the causes of schizophrenia (they are not asked to share this with the group). Next the group as a whole are asked to brainstorm everything they have heard, or has been suggested, as a cause of schizophrenia. This generally covers a range of explanatory models, including biological, psychological, social and spiritual. The stress-vulnerability model is then offered as a framework for understanding how any of us can move from being well to unwell. This is followed by a discussion on how the factors identified by the students can be incorporated within a stress-vulnerability model.

David Kingdon

So far, a variety of practitioners with a range of cases and training have described their experience of using CBT, but how can this training and experience be made more widely available The widespread use of new evidence-based practices, like CBT of psychosis, develops through diffusion, dissemination and specific implementation initiatives (Koerner et al., 2001). Usually diffusion occurs through publication in scientific journals, conference presentations, etc., but this leads, at best, to very gradual incorporation into routine clinical practice. The exception is where the audience is open and seeking information, has minimal search costs for it, and staff are strongly motivated and highly reinforced by what they learn and their experiences. In the USA, this has been the case with the uptake of dialectical behaviour therapy (DBT) and to some extent this has also occurred with CBT for psychosis in the UK. Suicides, the repeated experience of treatment failure, and recurrent...

Professional groups

Professional organisations have also been supportive. The British Psychological Society has recently published a favourable review of the area (BPS, 2000). The development of techniques which fully utilise and build on the training of clinical psychologists, both CBT for psychosis and DBT, has led to a considerable increase in enthusiasm for working in the area of severe mental illness and the return of many to the practice. The late 1980s and early 1990s were a time when there had been a serious drift away, with the exception of a small number of stalwarts who remained working in rehabilitation services. Most have embraced the new developments and welcomed the increased interest, particularly among trainees, in the new developments. The Royal College of Psychiatrists has also given invaluable support through, for example, providing a platform for presentation of results at workshops and scientific meetings, and inclusion of mandatory training in CBT for psychiatrists. This is despite...

Subject Index

National Schizophrenia Fellowship, 209 108,143, 145, 148 Schematic, 124, 128, 129,134 Schizophrenia, ix, x, 2, 3, 4, 5, 7, 8, 9,10, 15, 16, 17, 18, 20, 27, 28, 29, 30, 35, 37, 40, 53, 79, 80, 81, 93, 99, 100, 109,110, 111,112, 123, 137,140, 145, 150,153, 154,161, 163, 166,179,185, 205, 206, 207, 208, 210, 212, 216, 218, 219 Schizotypy, 69


For many people the experience of psychosis is worsened by the fear that they see themselves as mad, a lunatic, a nutter. They are subject to the media portrayal of mental illness and fear the arrival of the knife wielding maniac that lies dormant within them. Many people diagnosed as having schizophrenia have little idea of what this actually means, clutching onto beliefs that it has something to do with a split personality or two minds. Along with that belief is the fear of the implications of madness. What is going to happen to them when will the alter ego emerge will they be carted off to the mental hospital and will the key be thrown away The cognitive model would predict that such an interpretation of events would be related to feelings of anxiety and general stress. Needless to say, the stress-vulnerability model (Zubin & Spring, 1977) links stress to relapse and further symptoms of psychosis. This adds to the importance of reducing the fear that is linked to the...

Users and carers

Nationally, the National Schizophrenia Fellowship, 'Rethink', MIND and other voluntary organisations have expressed support for the development of CBT in severe mental health problems. User and carer groups can be supportive, locally. The Hearing Voices Network in the UK and Holland (but not yet widespread elsewhere) has had a major impact on the way voices are perceived and, where necessary, managed by the patients with support from others. User groups generally favour non-pharmacological interventions (Rose, 2001) but there is little industrial support either PR or marketing and therefore prospects of making these forms of treatment available on a widespread basis are limited. One important example is of the Insight CBT programme as funded in several UK sites by Pfizer.


Damien has presented significant problems of isolation, hostility and psychosis precipitated by amphetamine abuse against a chaotic and disrupted family background. Conventional CBT using regular sessions, socialising to a cognitive model, homework, etc., have not been possible. Adopting a cognitive-behavioural approach to his symptoms and circumstances, however, has allowed us to negotiate, collaborate and gradually understand and formulate his psychotic symptoms (see Figure 7.1) which have ameliorated such that he has been amenable to community support. Family work and support for his mother has been an indispensable component of this.

Session 4 Adherence

This session is usually dedicated to issues surrounding medication unless the client wishes otherwise. However, there are few patients who have no issues regarding their medication. Kathy decided that she would like to know how antipsychotic medication works, and this was included in the agenda along with review of homework.

Reason for referral

She was diagnosed as having paranoid schizophrenia in the 1970s when she had a brief stay in an acute mental health ward. I met Janet in 1993 as her CPN when I was asked to maintain her mental state and ensure medication compliance. Since that time, I had been unable to offer her much in the way of therapeutic opportunities. Day services were unsuitable and visits were focused on coping strategy enhancement. When I offered a new therapeutic approach Janet was interested.


Evidence in support of CBT for severe mental illness from government in England goes back to the Clinical Standards Advisory Group report (1994) which advocated it as part of a service for patients with schizophrenia. The Review of Psychotherapy (NHS Executive, 1996) and accompanying supporting evidence on What Works (Roth et al., 1988) similarly provided endorsement. In the National Service Framework (Department of Health, 1999), psychosocial interventions are given strong encouragement For schizophrenia there is growing evidence of effectiveness for psychological therapies including some cognitive approaches (p. 46). Also, performance assessment of Standard 4, dealing with severe mental illness, will be assessed by access to psychological therapies (p. 66).

Medication issues

All the studies into CBT in schizophrenia have stressed the importance of medication. It is sometimes necessary to wait for medication to reduce acute psychotic symptoms before using CBT, especially with thought disorder, although the use of a CBT approach often allows negotiation on the use of medication or hospitalisation to occur. 'Compliance therapy', a brief form of CBT, has been specifically aimed at this. Where patients begin to understand that their voices are internal phenomena and that their beliefs just might be self-induced, they are more likely to take medication to alleviate these problems. Conversely, if medication has a positive effect, this reinforces work on helping them to accept voices as their own thoughts.


She was treated with a variety of medication at increasingly high doses. These included various antidepressants including the monoamine oxidase inhibitor, phenelzine, and antipsychotics, including newer atypical drugs. Unfortunately she also had serious physical problems, myocarditis (inflammation of the heart muscle) and hepatitis (inflammation of the liver), treated in a specialist unit in London. A cause for this was not found, although the possibility that it may have been medication related was considered. She also developed irritable bowel syndrome. Clozapine, a drug used in resistant psychosis, was considered but not administered because of these physical complications.


Malcolm is a 34-year-old man with a diagnosis of paranoid schizophrenia. He was admitted into high secure psychiatric care as a transfer from medium secure psychiatric care following absconsions and hostage-taking. His admission to medium security had been made by Court Order following a conviction for attempted murder. Assessment revealed a complex persecutory belief system (Delusions Rating Scale (DRS) 18

Initial assessment

Rating scales were discussed in supervision and the following three were decided upon the Health of the Nation Outcome Scale (HoNOS Wing, Curtiss & Beevor, 1996), the Psychosis Rating Scale (Haddock et al., 1999) auditory hallucinations (AHRS) and delusion rating scales (DRS). The ratings were carried out in session III

Family work

The relevance of family work to the CBT of psychosis is commonly raised. In most cases, working with the family is part of a care programme approach and is strongly conducive to patient recovery (see Jane above). Work on expressed emotion is fully consistent with work on negative symptoms managing expectations and reducing the pressure patients perceive. Rigidly working with patients to the exclusion of the family is guaranteed to lead to undermining of the therapeutic relationship and work being undertaken. It then seems logical to develop shared formulations with family and patient. The time involved is perhaps less than that described by proponents of family work (e.g. Barrowclough & Tarrier, 1992). Our brief intervention study (Turkington et al., 2002) offered three sessions to the families. Integrated family and individual work seems most economic in our experience, but skills for working with families need to be disseminated (as occurs in the Thorn courses).


Developing a working alliance with patients with schizophrenia can be difficult where they have paranoid symptoms or have had difficulties with services in the past. They may not feel listened to and may expect you to dismiss their beliefs as 'mad'. However, when they find that the therapist is interested in their symptoms, their content, what they mean to them and how they have developed, engagement can be effectively secured. Studies in this area consistently find that, once they agree to participate in a study, less than 15 drop out. Engaging them in such studies or therapy can be difficult but the opportunity to state their case about their beliefs is frequently taken up with alacrity. This can be further improved by allowing them to lead a discussion, where they are able to do so, taking their concerns as primary but prompting with known information when silence occurs with the ultimate aim of having sessions that are relatively relaxing and comfortable. When it becomes hard work...


Implementation of CBT in psychosis can mean pushing against open doors, but even where this is the case, enlisting support and planning carefully is least likely to waste resources financial, personnel or time. Where the door seems closed, even locked, it may take time to find the key, but gradual enlisting of support through information and examples of clinical success can make progress even where resistance seems strongest. We have certainly found it to be worth the trouble, and hope you do too.


Carole was referred to the psychology service by her psychiatrist. The referral letter told of a woman with a schizophrenia diagnosis who heard the voices of her mother and father talking to her. Carole believed that the voices she heard were actually caused by her parents despite the death of her father. The psychiatrist had begun to challenge these ideas, though she thought that CBT would be of help with the lady. In particular, the psychiatrist hoped that Carole could learn to cope with her voices better. The psychiatrist described Carole as having remarkable insight and a well-preserved personality.


Her family history was unsettled but she generally got on well with her family. Her father, now in his eighties, is well. Although she saw him as being very strict, dominant and religious, she was nevertheless his favourite. Nicky and her mother, now in her mid-seventies, got on well she was also on good terms with her sisters (one younger and two older) and brothers (one older and one younger). There was no family history of psychosis although one aunt became depressed on a number of occasions, requiring hospital admission.


History, i.e. the events leading up to her first psychotic episode, as well as to comprehend what had maintained her problems since the first episode of psychosis. I had never used many of the assessment tools I administered, and was anxious to ensure that Janet did not feel overwhelmed. During the assessment stage Janet talked at length about her experiences and I found it difficult to focus on gathering information without getting dragged into the therapy. I was not used to structuring my work, and when Janet described her delusions I was intrigued and found it difficult not to be pulled down a narrow path before I had a wider picture.

Creativity and Psychedelic Substances

The 'Model Psychosis' Assumption Some early researchers reported that LSD users gave highly imaginative, although bizarre, responses to Rorschach inkblots. In summarizing his observations of LSD users in 1976, the psychoanalyst Silvano Arieti found that the use of 'primary process mechanisms' was enhanced, but that the 'secondary processing' required to put the imagery to creative use was impaired. These studies and related research, conducted with both artists and nonartists and with both laboratory subjects and 'street users,' identified many dysfunctional results of informal psychedelic drug usage but no conclusive data supporting the notion that psychedelics could produce a 'model psychosis.' In 1988, T. E. Oxman and colleagues reported a content analysis of 66 autobiographical accounts of schizophrenia, psychedelic drug experience, and mystical experience, as well as 28 autobiographical accounts of personal experiences in ordinary consciousness. Finding that 84 of the samples...

Measures of Association and Impact Relative Risk Odds Ratio and Attributable Risk

To illustrate, suppose an investigator is interested in comparing the mortality rates of adults with and without a psychotic disorder in a community of 120,000. In this population, 1,200 persons (1 ) meet diagnostic criteria for a psychotic disorder, and 118,800 do not. Over a 1-year period, 312 deaths occur, including 15 individuals with a diagnosis of psychosis and 297 without. The rate (density) of dying for the group with psychosis (15 of 1,200 psychotics) and without this disorder (297 of 118,800) expressed as a mortality rate ratio (relative risk of dying) would be 5 (15 1,200 divided by 297 118,800). The ARe can be interpreted as the probability that an exposed case developed the condition as a result of the exposure. As a hypothetical example, in a study where exposure is family history and the outcome is schizophrenia, an ARe of 0.75 would indicate that 75 of the schizophrenic cases with a positive family history for this disorder developed their condition because of their...

Cognitive and Neural Constraints on Human Thought

Current work is making headway in linking thought processes to specific brain structures such as the prefrontal cortex in Chapter 20, Goel discusses the key topic of deductive reasoning in relation to its neural substrate. Brain disorders, notably schizophrenia, produce striking disruptions of normal thought processes, which can shed light on how thinking takes place in normal brains. In Chapter 21, Bachman and Cannon review research and theory concerning thought disorder.

Ultrapositivistic Psychopharmacology Era 1970present

Modern biological psychiatry started in 1952 when the French psychiatrists Jean Delay and Pierre Deniker first evaluated the efficacy of chlorpromazine (trade name Tho-razine) in a variety of psychiatric disorders and found it to be highly effective for ameliorating schizophrenic symptoms. This breakthrough was based on the recent discovery of surgeon Henri Laborit that such drugs were effective presurgical sedatives, and also potentially effective in controlling the agitation of various psychiatric disorders including schizophrenia. The robust calming effects and specific reductions in the positive symptoms of schizophrenia (e.g., delusions, hallucinations, and inappropriate moods) were so impressive that the use of chlorpromazine swept through psychiatry. The number of schizophrenics that had to be chronically institutionalized diminished precipitously as soon as these agents came into widespread use. With the recognition that one of the main targets of these agents were recently...

Functions Of Diagnostics

We should recall that medical diagnostics have three major functions (1) At the lowest level, they are designed to allow clinicians some assurance that they are talking about the same problems (DSM-IV fulfills that nicely). (2) They provide an efficient way to promote consistent therapeutic approaches (e.g., a short-hand path to prescription practices). (3) Also, they provide a rapid way to think about the etiology of disorders. Perhaps the take-home message of this last function should be that we must reach a better understanding of the basic emotional systems of the brain, especially as they contribute to both psychiatric disease and health. Of course, this is based on the assumption that most psychiatric disorders ultimately reflect disturbances of affect-generating processes of the brain, a position that remains controversial among both psychiatrists and psychologists. Indeed, for the cognitive disorders of schizophrenia (Chapter 9) and some of the pervasive developmental...

Directed Neurological Examination

The presence of a thought disorder will be conveyed during conversation and is independent of mood. When taking the history and examining patients, the clinician should look for loose associations of thought and the practice of skipping illogically from one idea to another seemingly unrelated idea. It should be observed whether a word with two meanings is used correctly the first time and then used incorrectly to develop an unrelated thought. A formal language examination may be helpful in distinguishing a thought disorder from an aphasia. But when the speech disorder is profound, the difference may be difficult to discern. There are certain features of psychotic speech that may be helpful and should be sought. Clanging, the use of similar sounding words together regardless of their meaning, is never present in aphasia, whereas dysarthria is not a feature of psychosis. Naming should not be impaired in thought disorder but is usually affected in aphasias. The examiner should note that...

Evaluation Guidelines Table31

The tests that should be performed on patients with mood, emotion, or thought disorders depend on the clinical situation. Patients who present for the first time are obviously to be evaluated differently from patients who were once fully evaluated but have suffered a relapse. Patients with long histories, although perhaps never fully evaluated with modern techniques, may not require testing because the natural course of alternative diagnoses may preclude their consideration (e.g., in a 65-year-old with a 40-year history of schizophrenia, a frontal lobe tumor is not the cause of the behavioral disorder). Electrophysiology. Electroencephalography (EEG) is helpful in the evaluation of seizure disorders and metabolic encephalopathy and, to a lesser extent, for documentation of regional physiological malfunctions. In patients with psychosis, the EEG should be normal, whereas metabolic disorders can cause disorganization and generalized slowing. The EEG can reveal physiological...

Anxiety and Obsessive Compulsive Disorder Syndromes

Anxiety is an extremely common occurrence that affects everyone at some time and is characterized by an unpleasant and unjustified sense of fear that is usually associated with autonomic symptoms including hypervigilance, palpitations, sweating, lightheadedness, hyperventilation, diarrhea, and urinary frequency as well as fatigue and insomnia. Anxiety is thought to be mediated through the limbic system, particularly the cingulate gyrus and the septal-hippocampal pathway, as well as the frontal and temporal cortex. The term anxiety disorder is used to denote significant distress and dysfunction resulting from anxiety, including panic attacks and anxiety with specific phobias. Chronic, moderately severe anxiety tends to run in families and may be associated with other anxiety disorders or depression. The differential diagnosis of anxiety states includes other psychiatric conditions such as anxious depression as well as schizophrenia, which may present as a panic attack with disordered...

Individual Differences

Latent inhibition (LI) is an attentional process by which both perceptual stimuli and conceptual information deemed irrelevant to current pursuits are automatically (i.e., latently) filtered from conscious awareness. At first blush, it would seem that this is an entirely adaptive process, the absence of which would promote confusion and disruption of ongoing behavior. Indeed, consistent with this inference, there is compelling evidence that individuals who exhibit lower LI are more prone to disordered thought and ultimately more likely to be diagnosed with schizophrenia. However, consistent with the foregoing proposition that broad conceptual attention facilitates creative cognition, it may be proposed that reduced LI should also increase the amount of information accessible to conscious awareness for use in devising innovative alternatives. To clarify, individuals who fail to filter out presumably irrelevant information will retain this information such that it may be considered...

Defining traumatic brain injury TBI

A disturbance of consciousness with reduced ability to focus, sustain or shift attention a change in cognition or the development of a perceptual disturbance that occurs over a short period of time and tends to fluctuate over the course of the day Historically, delirium also has been referred to as acute confusional state, acute brain syndrome and toxic psychosis. Although the symptoms of delirium typically resolve within 10-12 days and the majority of patients have full recovery, delirium is associated with increased morbidity and mortality. (Weber, Coverdale, & Kunik, 2004, p. 115)

Psychotic Syndromes

Antipsychotics (neuroleptics) can be used in patients with acute psychoses while a specific etiology is being sought ( .Table.3-4 ). Although some of these drugs are sedating, they have more specific effects on the thought and mood disorder. Many different agents are available including the phenothiazines, thioxanthenes, dibenzoxazepines, and butyrophenones. The acutely psychotic patient who is a danger to himself or others may be treated parenterally with intramuscular haloperidol (5 mg every hour over 4 hours) or chlorpromazine. In addition, oral doses of haloperidol (10 to 15 mg day) or chlorpromazine (300 to 400 mg day) or the equivalent should be started.

Journals and Publications

The two psychiatric journals that are published in Australia and New Zealand are the Australian and New Zealand Journal of Psychiatry and Australasian Psychiatry. Practice parameters and consensus reports on clinical practice in child psychiatry have been produced by the RANZCP and are available on its Web site. In addition, federal and state governments have also produced guidelines such as treatment guidelines for attention-deficit hyperac-tivity disorder, suicide risk assessment, and early intervention in autism. Health organizations have produced their own guidelines, such as for early intervention in psychosis.

Instrumental learning

Beginning with the extraordinary discovery by James Olds that animals would self-stimulate the reward circuit in the brain, we have learned a good deal about this circuitry (Kelley, 2004 Schultz, 2000). In brief, a system called the medial forebrain bundle projects dopamine containing neuron axons from the midbrain to forebrain structures, particularly the nucleus accumbens, the striatum and the prefrontal cortex. This system is activated by all types of rewarding stimuli, from food and water to sex. Importantly, this circuit, particularly the accumbens nucleus, is activated by all drugs of addiction. These drugs cause release of dopamine in the accumbens. Analysis of this reward-memory circuitry is a major field of research today. The dopamine projection to the striatum is of course essentially involved in Parkinson's disease and the projections to the prefrontal cortex and other higher brain regions are thought to be critically involved in schizophrenia.

Motivation and Cognitive Processes

Although Freud maintained that wishes are the motive force for cognition in the sense of setting the mental apparatus in motion and that the influence of motives and desires on cognition is ubiquitous, the nature of that influence is complex and subtle and varies with a number of factors, including the particular aspect of cognitive or ego functioning one has in mind. In short, it would be a mistake to interpret Freudian theory as proposing that cognitive or ego functioning is enslaved to or entirely dominated by our desires and passions (id). Indeed, in the context of Freudian theory and psychoanalytic ego psychology, such enslavement of the ego to id forces would be seen as the kind of loss of ego autonomy that is characteristic of severe pathology such as psychosis. We do, of course, observe ordinary misperceptions that may reflect the distorting effects of motives and needs. However, no system functions perfectly and one should expect errors. In addition, these slippages do not...

Methods in Psychiatric Genetics

Harvard Medical School, Department of Psychiatry at Massachusetts Mental Health Center, Harvard Institute of Psychiatric Epidemiology and Genetics, Pediatric Psychopharmacology Unit, Psychiatry Service, Massachusetts General Hospital (S.V.F) Department of Psychiatry and Behavioral Sciences, Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, Mental Illness, Research, Education and Clinical Center, VA Puget Sound Health Care System, Seattle Division (D.T.), Harvard Medical School, Department of Psychiatry at Massachusetts Mental Health Center, Harvard Institute of Psychiatric Epidemiology and Genetics, VA Cooperative Research Project on Genetics of Schizophrenia, Brockton-West Roxbury Veterans Affairs Medical Center, Department of Epidemiology, Harvard School of Public Health, Psychiatry Service, Massachusetts General Hospital (M.T.T.).

Is the Disorder Familial

However, psychiatric disorders affect emotions, thinking, and interpersonal relationships. Thus, nonparticipation may not be random with respect to illness status family members who are ill may be more likely to refuse participation than those who are well. Paranoid schizophrenia provides a good example of this problem. Paranoia leads to distrusts of strangers, friends, and family. This makes it difficult for a paranoid person to agree to answer the many questions required by psychiatric interviews. TABLE 2. Rates of Schizophrenia Among Relatives of Schizophrenic Patients In Andreasen et al.'s (1986) study the sensitivities and specificities of the family history method were consistent with previous reports. The sensitivities were low. They ranged from 31 for schizophrenia to 69 for psychotic disorder.'' As expected, the specificities were higher. These ranged from 84 for probable depressive disorder to 100 for schizophrenia and schizoaffective disorder....

The Patient with Posttraumatic Stress Disorder

Many trauma-related disorders have been recognized and include brief reactive psychosis, multiple personality disorder, dissociative fugue, dissociative amnesia, conversion disorder, depersonalization disorder, dream anxiety disorder, summarization disorder, borderline personality disorder, and antisocial personality disorder. Many other trauma-related disorders have been postulated. These disorders and the trauma that may precede them are indicated as follows Brief reactive psychosis any one or more events that would be stressful to anyone Multiple personality disorder abuse or other childhood emotional trauma Dissociative fugue severe psychologically stressful event such as marital quarrels, military conflict, natural disaster, or personal rejection

Mildly sociopathic Unable to control emotions Uncommunicative

(anxiety, uncontrolled behavior), psychopathic deviation, paranoia, psychasthenia (fears, phobias), schizophrenia, and hypomania. However, strong ego strength scores indicated they could better deal with their troubles. Psychologically, said Barron, they were both sicker and healthier than the average person.

Estimating Risk to Relatives

Most psychiatric disorders have a variable age at onset. In some cases the range of age at onset is very wide. For example, although most patients with schizophrenia experience their first symptoms in their twenties or early thirties, some cases can begin in childhood and others after fifty. Variable age at onset hinders any interpretation of simple rates of illness because these will depend on the age of the sample. For example, say that the rate of schizophrenia was 10 in a sample of addolescents and 10 in a sample of 50 year olds. We ought to have some means of adjusting these rates to reflect our intuitive sense that the rate among adolescents who have only just entered the period of risk indicates a greater risk for schizophrenia than the rate among the fifty year olds who have lived through most of the period of risk.