Cognitive model and cognitive behavior

therapy for schizophrenia: An overview

FREDDY SARIN, LENNART WALLIN

Sarin F, Wallin L. Cognitive model and cognitive behavior therapy for schizophrenia: An
overview. Nord J Psychiatry 2014;68:145–153.

Background: Schizophrenia causes great suffering for patients and families. Today, patients are
treated with medications, but unfortunately many still have persistent symptoms and an impaired
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quality of life. During the last 20 years of research in cognitive behavioral therapy (CBT) for
schizophrenia, evidence has been found that the treatment is good for patients but it is not
satisfactory enough, and more studies are being carried out hopefully to achieve further
improvement. Purpose: Clinical trials and meta-analyses are being used to try to prove the
efficacy of CBT. In this article, we summarize recent research using the cognitive model for
people with schizophrenia. Methods: A systematic search was carried out in PubMed (Medline).
Relevant articles were selected if they contained a description of cognitive models for
schizophrenia or psychotic disorders. Results: There is now evidence that positive and negative
symptoms exist in a continuum, from normality (mild form and few symptoms) to fully
developed disease (intensive form with many symptoms). Delusional patients have reasoning
bias such as jumping to conclusions, and those with hallucination have impaired self-monitoring
For personal use only.

and experience their own thoughts as voices. Patients with negative symptoms have negative
beliefs such as low expectations regarding pleasure and success. In the entire patient group, it is
common to have low self-esteem. Conclusions: The cognitive model integrates very well with
the aberrant salience model. It takes into account neurobiology, cognitive, emotional and social
processes. The therapist uses this knowledge when he or she chooses techniques for treatment
of patients.
• Aberrant salience, Cognitive behavior therapy, Cognitive model, Psychosis, Schizophrenia.
Freddy Sarin, Järvapsykiatrin, Psychiatry, Praktikertjänst AB, Rinkebysvängen 70 A, SE-163 74
Spånga, Sweden, E-mail: [email protected]; Accepted 20 March 2013.

S chizophrenia is one of the most difficult-to-treat dis-

eases today, and causes great suffering to both the
person who has the disease and close relatives. It not
psychotic improvement was maintained at follow-up, at
least 3–15 months after treatment. The effect sizes var-
ied from low to moderate. One RCT by Grant et al. (7)
only affects the mental health of patients, but they also investigated the treatment effect of CBT in patients with
die 12–15 years prematurely on average (1). Patients are schizophrenia who were low-functioning, and they were
often unemployed (80%) and even worse, they have been able to demonstrate improvement in negative symp-
stigmatized and misunderstood (2). Anti-psychotic ther- toms—especially avolition–apathy. Another meta-analysis
apy is the mainstay of treatment for schizophrenia, by Lynch et al. (8) questioned the evidence on CBT for
reducing psychotic symptoms and preventing relapses. treatment of schizophrenia, and they could not find that
Even so, 25–40% of patients continue to experience psy- CBT had a better outcome than that in a control group
chotic symptoms despite taking doses that would nor- regarding psychotic symptoms and relapse. Despite this,
mally be efficacious (3). Many patients discontinue their now the National Board of Health and Welfare in Swe-
medication (4). den (9) has recommended CBT for patients with schizo-
Research in cognitive behavior therapy (CBT) in phrenia and the National Institute for Clinical Excellence
schizophrenia has grown from simple case studies to (NICE) in the UK (10) has the following recommenda-
large randomized controlled trials (RCTs). Recently, sev- tions: “Offer CBT to all people with schizophrenia. This
eral meta-analyses have been done; Wykes et al. (5) can be started either during the acute phase or later,
found improvement in social functioning and also in including an inpatient setting”. “CBT should be delivered
psychotic symptoms, and Sarin et al. (6) showed that on a one-to-one basis over at least 16 planned sessions”

© 2014 Informa Healthcare DOI: 10.3109/08039488.2013.789074

 F SARIN & L WALLIN

(10; p. 218); “offer CBT to assist in promoting recovery symptoms such as flat affect, avoliation and alogia; cog-
in people with persistently positive and negative symp- nitive impairment; insidious onset; and the progression
toms and for people in remission” (10; p. 219). of the disease is often chronic and deteriorative. These
The purpose of the current review is to describe the patients respond poorly to medication and have poor out-
latest research and knowledge about the cognitive model come. (2) The positive syndrome, mainly characterized
for schizophrenia (hallucination, delusion, negative symp- by symptoms such as hallucination and delusions; acute
toms and formal thought disorder, FTD), and to give onset; and an episodic course. These respond better to
some examples of CBT techniques for the different medication and have good outcome (1, 18).
symptoms. Research from neurobiology has given a better
understanding of the biological mechanisms of positive
symptoms in psychosis, which also contribute to cog-
Method nitive distortion, and how psychosis is expressed in the
This overview is based on a search of publications in individual (19, 20). One important explanation is the
PubMed concentrating on the cognitive model, cognitive aberrant salience model of Kapur (20), dysregulation
behavior therapy and schizophrenia. Only articles in Eng- of dopamine. The model proposes that development of
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lish were reviewed. Manual searches were also done in psychotic symptoms, such as delusions and hallucina-
reference lists of the articles included. Current books in tions, is driven by inappropriate processing of stimuli
this area have also been selected from the articles (4, that would normally be considered irrelevant, due to
11–15). The search terms in PubMed were as follows: aberrant saliences. Examples of such inappropriate pro-
(“Schizophrenia and Disorders with Psychotic Features” cessing are “jumping to conclusions”, “confirmation
[Major Topic]) AND (“Cognitive Therapy/methods” bias” and “externalization”, which are specific to
[Medical Subject Headings]) AND “Review” [Publication positive symptoms. One contribution factor is hyper-
Type] AND (English [language]). dysregulation of dopamine in the lower part of the
brain (2, 20–22). The positive psychotic symptoms
have almost the same neurochemical dysregulation, but
For personal use only.

Results have varied expression in different individuals. The

A cognitive model for schizophrenia explanation is that patients construct their own beliefs
The vulnerability to schizophrenia has partly genetic about the psychotic symptoms, from life experience
causes, as has been demonstrated in twin studies. It is and social contexts (20, 21). As Howes and Kapur (19)
not a single gene but several that cause the disease. There state: “Psychosis is, therefore, aberrant salience driven
is genetic overlap with other diseases such as autism and by the dopamine and filtered through the individual’s
bipolar disorder, which indicates that schizophrenia is existing cognitive and sociocultural schemas—thus
heterogeneous. On the other hand, from epidemiological allowing the same chemical (dopamine) to have differ-
research, high rates of schizophrenia have been observed ent clinical manifestations in different cultures and dif-
in large cities, immigrant populations, traumatized indi- ferent individuals” (p. 555).
viduals and cannabis users, at least some of which are Negative symptoms, on the other hand, have hypo-
thought to be the result of underlying environmental dysregulation of dopamine signals (combined with other
exposure. Even perinatal and early childhood factors are neuropathological factors) linked to stimuli indicating
important (1). Furthermore, genes and environment can- reward, and the result would be lack of motivation. In
not alone explain the causality of schizophrenia; recent the long term, this leads to negative symptoms, i.e.
epidemiological research and the progress of genome- social withdrawal and neglect of interests (19). The loss
wide mass-marker technology have given us a better of motivational drive, negative experiences and cogni-
understanding about the complex etiology of schizophre- tive impairment lead to a situation whereby patients
nia. Such studies have found considerable evidence that have a “defeatist attitude” both to themselves and to
there is an interplay of “genes” and “environment” to others (2, 22).
produce schizophrenia, i.e. gene–environment interaction In addition, there is now evidence that psychotic
(G ! E). For example, some individuals can have a symptoms exist in a continuum from normality (few
genetic vulnerability regarding drug abuse, which leads symptoms that do not need medical care) to full-blown
to dysregulation of dopamine and causes psychotic disor- disease (many symptoms with need for medical care) (2,
ders; or exposure to drugs may change the expression of 22, 23). This provides an opportunity in therapy to begin
genes that are on the causal pathway to the psychotic a process of normalization, whereby psychotic experi-
disorder (16, 17). ence is seen to be less strange and more understandable
From a clinical point of view, the disease has differ- (2, 22).
ent expression and can be roughly divided into two Whatever symptoms the patient has, there are two
main forms: (1) the negative syndrome, characterized by important approaches for therapists to have in CBT. The

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first is motivation and engagement, not only in early ses- (2, 4, 22). Voices are there for “hot cognitions” that
sions but throughout the whole treatment period. The the persons already have. This gives indicates that hallu-
second is to work on the patient’s low self-esteem. Most cinations are representative of the “inner voice” (2),
patients have had bad experiences from having a severe thoughts that occur in the stream of consciousness that
disease and have therefore developed negative attitudes “pop up”—either spontaneously or in response to stimu-
about themselves and others (2, 4, 11, 22). lus situations—and become audible.
Experience of hearing voices does not usually lead to
Positive symptoms—hallucination a psychosis, but it is more the belief in them (delusions)
Hallucinations are a common symptom in patients with that leads to psychosis, such that they attributed to an
schizophrenia. They can be derogatory and critical, but external cause or to a particular person. These beliefs are
may even be positive and friendly. Some voices are com- also responsible for the continuation of the voices. In the
manding; these are especially important because they can long term, patients may build up a “relationship” with
make the patient dangerous to others and to themselves. these voices, just as they would with other people. This
Hallucination is described as an experience of the senses type of relationship can be positive, ambivalent or nega-
(hearing, sight, touch, smell, taste) that occurs in the tive for the patient (4).
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absence of an appropriate sensory stimulus but has all

the characteristics of real perception (11). The most THERAPEUTIC APPROACHES TO HALLUCINATIONS
common hallucinations are voices, which can categorized At the start of the treatment, it is important to motivate,
into three different types (4, 24): to engage and to explore hallucination. The therapist can
use some key questions with a view to making the voices
(1) Voices that make comments on the patient’s behavior
more comprehensible. It is important to be sensitive to
in the second person, “Look, you are going up the
patients’ reactions when using some of these questions; a
stairs … perhaps you should stop and rest now”.
few examples are (4, 11):
(2) Voices that address the patient in the third person, e.g.
“She is useless” or “He will never find a job”. • “Is the voice male or female? Do you have a name for
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(3) The thoughts of the patient spoken aloud. the voice?”

• “Where does the voice appear to be coming from?”
The cognitive explanation of hallucination is as cognitive
• “Do you hear voices that others can hear? What does
dysfunction such as information processing problems,
the voice say?”
which can lead to anomalous experiences, and which
• “When do you hear the voice? How do you feel? What
means that patient have difficulty in monitoring of inter-
do you do?”
nal events (self-monitoring) (2, 22) and may not be aware
• “Is there more than one voice? Do you speak to the
of the fact that inner speech has been generated (4). They
voice?”
also have a low threshold in construing sounds or voices
• “How forceful or loud is the voice?”
that seem real or almost real (4). The aberrant saliences
model, hyper-dysregulation of dopamine is the mediator Patients may think that to hear voices is odd and stu-
of this phenomenon (20). As Kapur et al. (21) describe pid, and often they will not talk about it. To prevent
it: “the dopaminergic dysregualtion provides the fuel for this, the therapist can use a technique called normaliza-
the creation of the hallucination and delusion; it is the tion (11, 13). Normalization means that one maintains
patient’s personal and cultural history that give it precise that there are many people who hear voices—both
form” (p. 62). healthy and mentally ill. If several people have these
Furthermore, patients have problems such as inhibi- experiences, the patient is not alone. As part of the
tion of mental processes and weaker functioning of early treatment plan, apart from engaging, asking key
reality-testing. For example, anyone who hears sounds questions, and normalization, the therapist can use psy-
because of tinnitus—or hears music or voices related to choeducation to explain the stress-vulnerability model
the aging process—might check the radio or television, (i.e. gene–environment interaction (16) and the aberrant
or test their perception with others. If they do not find salience model (19–21)). Hallucination is often more
an external cause of the sounds or music, they have a intense under stress situations, anxiety and depression,
more ready-made medical explanation because they and an improved understanding of this could reduce the
already know they that have a medical disorder (4). voices (4).
Patients with schizophrenia have appraisal problems (rea- A key goal in the treatment is to reduce the nega-
soning and attribution biases) (2, 22) and would explain tive emotions that the patient associates with the hal-
these sounds as real voices—that somebody is singing or lucinations (2); some specific cognitive approaches can
talking to them. be helpful. For example, modified dysfunctional
The content of voices is usually negative thoughts thought recording for voices (Table 1) could be used
(dysfunctional schema) about themselves or others to find out alternative or balanced thoughts about the

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 F SARIN & L WALLIN

Table 1. Dysfunctional thought recording for voices.

Situation Emotions Voices Automatic thoughts Behaviors

Tom argues with Feeling sad “Hit him”. I am a dangerous person. Staying at home and
his brother and angry “Do it” I am worthless not going outside

voices. The therapist or patient can write down what To determine whether an individual belief is a delu-
the voices say and their conclusions (thoughts) about sion can be difficult, but some questions can be asked to
voices, and then examine the evidence for and against help in the decision:
the statement (4).
Patients with schizophrenia often have poor self- • How strongly the patient believes (conviction).
esteem (negative core schemas), which means that • How impervious the belief is to contradictory evidence,
they believe what the voices say. Patients construct a logic or reason (inflexibility).
belief system about the voices and about themselves. • How unrelated to the person’s situation and life circum-
Typical core beliefs for schizophrenia could be “I am stances it is (context).
•
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useless”, “I am evil”, “I am stupid”, “I am worthless” How much time the person spends thinking about the
etc. To challenge this absolute statement—or even experiences (preoccupation).
small shifts from these negative core beliefs—can be • How understandable the belief is (plausibility).
of value for the treatment. Techniques such as exam- • Whether it has changed over time (persistence).
ining the evidence or use of the cognitive continuum Research has revealed some important cognitive factors
can be helpful for the therapists to increase the self- that may help to explain delusions. One such factor is
esteem of the patient. The use of metacognitive that patients have deficiencies in the processing of infor-
approaches (to think about their own thoughts) could mation and draw hasty conclusions (JTC, jumping to
help change their attitude about themselves. Most of conclusions) (2, 26). Also, the patients often try to have
the techniques are meant to establish a change for the
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their conclusions confirmed, and they have difficulty in

patient, but unfortunately, the symptoms still persist in finding alternative explanations (BADE, bias against dis-
a number of patients, even though they receive medi- confirmatory evidence) (26, 27). They are highly inter-
cine and CBT. Learning to live with the symptoms ested in attaching personal meanings to irrelevant external
and perhaps accepting the situation can also be a tar- events; they also tend to attribute internal psychological
get for treatment (11). and somatic events to external causes. The powerful
A research team in England (25) helped patients to externalization bias that the patients have makes it diffi-
manage voices by building on existing simple behavior cult for them to accept reasonable explanations for their
strategies that patients already used. Enhancement of paranoid thoughts that the therapist tries to put to them
these coping strategies was a valuable technique in (4, 28). Furthermore, there is emerging evidence that
reducing hallucinations. For example, what works for schizophrenia patients lack metacognitive awareness, not
one person may not work for another, so the behavioral only due to neuropsychological dysfunction but also to
strategies must be individualized (25). Two strategies cognitive bias, which means that they need to learn to
that are useful are distraction, e.g. listening to music, think about their own thinking (26, 27).
walking or playing a computer game, and focusing, e.g. These patients are excessively suspicious of other people,
writing down what their voices say and then checking and find it difficult to trust them. They actively monitor
the truth in them (11). other people’s behavior for signs of malevolent intent about
being demeaned, manipulated or physically harmed (4).
Positive symptom—delusions
The cognitive model proposes that skewed informa-
Another symptom in people with schizophrenia is delu-
tion processing plays a central role in delusional think-
sions (paranoid thoughts), which are faulty convictions
ing, and that this skewing is driven by a system of
based on erroneous conclusions regarding their external
dysfunctional beliefs maintained by a variety of biases
reality. They usually maintain that these are correct, in
and behaviors. Patients with paranoid delusions have
spite of what almost everyone else would argue and even
negative beliefs such as “it’s them against me” orienta-
though there is uncontroversial and conclusive evidence
tion, which is expressed in the content of their delusions
that their belief is incorrect (4, 11). The cognitive model
and stems from their own history. For example, those
explanation of delusions is similar to that in the aberrant
with persecutory delusion have beliefs like (4):
salience model, which is “top-down” regulation: the
patient is trying to construct his or her own explanation • “I have a right”, “I am innocent”, “I’m being treated
of aberrant salience in an attempt to understand the delu- unfairly”, “I’m vulnerable”, “I must be on my guard”,
sions (20, 21). “I cannot trust anyone”, “I’m looking for motives”.

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• “Others are malicious”, “others are unjust”, “others are In the third step, sometimes the therapist must admit
false”, “others may harm me”. to himself/herself that further discussion to find alterna-
tive explanations for paranoid thoughts will not lead the
These beliefs are different from those of people with
treatment forward. The patient’s delusions are fixed and
grandiose delusion, who focus on self-fulfillment and—or
are not able to be changed. It will not help the patient to
the most part—detachment from others’ input, often in a
continue, and it is then time to stand back and identify
solipsistic way. The content of their self-centered beliefs
the remaining key issues and concerns. It is better to
consist of unrealistic self-enhancement (4):
focus on stress or other issues in the patient’s life. Some-
• “I’m king of the universe, I’m the richest man in the times development of alternative beliefs is less necessary
world, I’m the greatest scientist, and I have universal in the treatment of delusions (11, 13). Trying to allay
power”. fears of delusions and interpersonal threats, and together
finding acceptable alternative explanations for this may
THERAPEUTIC APPROACHES TO DELUSIONS be enough.
As always in the treatment of people with schizophrenia,
it is important to have a good mutual relationship between Negative symptoms
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the therapist and patient. Even in this area, Socratic ques- When CBT for schizophrenia began, there was focus on
tioning, normalization and psychoeducation are good positive symptoms but nowadays CBT even concentrates
techniques to use in the therapy (4, 11). Because the on negative symptoms (29). Some research teams (in the
patient has reasoning bias in delusions, the main goal for USA and Canada), e.g. Rector et al. (29), have published
the therapist is to compensate for this (2). What follows research on negative symptoms. Differentiation of posi-
is a suggested approach to CBT for delusions. tive and negative symptoms dates back to the 1980s, and
The first step for the therapist and patient is to iden- negative symptoms are as follows: blunted affect, alogia,
tify which type of stress (consequence) the delusions anhedonia, avoliton and asociality. Negative symptoms
cause, and to develop new ways of understanding about can be subdivided into primary and secondary ones. The
the patient’s psychotic experiences (11). Good help is to primary symptoms are caused by the disease itself and
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find the origin of paranoia, which allows the therapist to the secondary ones are derived from positive symptoms,
understand the patient’s paranoid thoughts. To discuss e.g. when patients have voice hallucinations that tell them
and define delusions without the therapist having his/her to stay at home or when patients are terrified of persecu-
own opinion gives the patient the opportunity to talk tion thoughts and cannot meet other people (30).
about his/her delusions, and perhaps to become more It is clear that there are neurobiological explanations
understandable (11). One technique is ABC (Activating (i.e. dysfunction in the prefrontal cortex and hypo-
event, Belief and Consequence), which comes from the dysregulation of dopamine) (31) for negative symptoms,
basic CBT model (Table 2). This intervention can be a but there are also psychological and cognitive factors
useful way of teaching patients about the influence of that contribute to the symptoms. The cognitive factors
beliefs on behavior, and can be used further for imple- are that the patients have negative assumptions about
mentation of behavioral changes (15). themselves, such as low expectations of pleasure or suc-
The second step is to co-operate with the patient to cess, stigma and perception of limited resources (4, 29).
examine paranoid thoughts and to try to find alternative
explanations. A useful technique is dysfunctional thought LOW EXPECTATIONS OF PLEASURE
recording, which makes it possible to find out patients’ Patients with negative symptoms may experience plea-
paranoid thoughts. Often, patients find it easier to begin sure when they get involved in activities, but what stop
with exploring the evidence for the delusion, why they them are their expectations, i.e. they do not believe that
believe it and then explore the evidence against the para- they should experience pleasure. It is therefore important
noid thoughts (4, 11). Another technique that can help that the patient judges his/her experiences directly in
patients examine their delusional beliefs is to ask them direct connection with the activity; if this is done after-
to put themselves in other peoples’ positions, e.g. by wards, they usually tend to underestimate their level of
taking a different point of view (decentering) (11). enjoyment. Their negative thoughts take over and coun-
teract the fact that they have actually experienced plea-
Table 2. The ABC technique. sure (4, 29).
Activating event Belief Consequence
LOW EXPECTATIONS OF SUCCESS
Brenda goes to her job, The boss thinks Goes home and Patients do indeed have greater difficulties in concentra-
and the boss is I am a worthless cries, and stays tion, with fine motor skills and with execution of task,
laughing as she person at home for 2 weeks which is important in order to complete a task success-
enters the mall fully. This creates frustrations and low self-esteem, such

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 F SARIN & L WALLIN

as feelings of worthlessness and failure, resulting in a level of activity. For patients with schizophrenia, this
double burden for the patient. Patients become hypervi- involves a few simple behavioral plans in collaboration
giliant and sensitive to not starting a new task, even if it with the therapist so that the patient feels engaged, after
is simple; they have no motivation. Their low expecta- which it will be easier to carry out the activity. Some
tion of success prevents them from coping with everyday examples would be “ask sister to visit, spend time with
tasks, which even they should manage (4, 29). friends, walk around the park”. If the behavioral plan is
too complex and difficult, the patient will not carry it
LOW EXPECTATIONS DUE TO STIGMA out and will feel a failure (11). The target for therapy
The symptoms of disease introduce real limitations to here is the belief of low expectation of success (4).
achieving broader goals, such as work and finding a life An activity schedule means that patients should record
partner. However, the diagnosis of schizophrenia is the events of a day—or a whole week—and then to rate
demoralizing to the patient and confirms their negative their sense of achievement (mastery) and pleasure on a
and dysfunctional beliefs, e.g. “I have schizophrenia, and scale from 0 to 10 points. Often, the patient has forgot-
that is why I am incompetent, worthless, and a failure”. ten that he/she had fun during the activity when talking
Stigmatizing illness-related beliefs becomes part of the to the therapist afterwards. It is therefore better to rate
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patient’s self-image, adding to person’s disability (4, the pleasure immediately after the activity instead of
29). waiting to the end of the week (11). The goal is to dis-
prove their beliefs of low expectation of pleasure (4).
PERCEPTION OF LIMITED RESOURCES Another intervention is graded task assignments,
It has been shown repeatedly that patients have limited which is a step-by-step approach that can help patients
cognitive capacity to perform everyday activities, such as break down the task to achieve their personal goals. This
concentration, remembering and executive functioning. method is a very commonsense approach that is used
This helps to create dysfunctional beliefs about low routinely by most people in their daily life. A very
energy and discomfort: “Why bother; it is too much” and important issue is to set reasonable goals because the
“I can’t handle it”. The consequences are that patients patients often have too high a target, which is difficult
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have behavior patterns of passivity and avoidance (4, 29). to achieve. It requires great skill on the part of the ther-
apist to set reasonable goals that the patient believes in
THERAPEUTIC APPROACHES TO NEGATIVE SYMPTOMS and is able to succeed with (11). The aim is that patients
Conversing with patients with negative symptoms is not will overcome their perception of limited resources (4).
easy, and it requires considerable patience because they Cognitive methods can be integrated with behavioral
do not talk much. They have difficulty in expressing techniques in an overall CBT strategy for treating mal-
emotions and have limited initiative. Use of behavioral adaptive schema linked to negative symptoms. The basic
methods can be repetitive and may be of little interest to cognitive interventions are similar to those for other dis-
clinicians who have done this many times with many orders such as depression and anxiety, e.g. Socratic ques-
patients, but it is a method that is necessary to achieve tioning, modifying automatic thoughts, thought recording,
progress in the treatment of the patient. CBT with nega- examining the evidence, re-attribution, revising schemas
tive symptoms has many similarities to therapies for (11). It is very important that the therapist pays attention
severe depression. The methods that are more specific for to—and discusses a lot—the patient’s stigma due to the
negative symptoms are behavioral activation, activity schizophrenia (4).
scheduling, graded task assignment and cognitive inter- Grant et al. (7) ran an RCT to evaluate the efficacy
vention (4, 11). of cognitive therapy for negative symptoms in patients
The concept of behavioral activation (Table 3) is with low functioning. There were 60 participants in the
often used to describe an effort to improve the patient’s study, and half of them had CBT and the other half had
only standard care. After 18 months of follow-up, the
patients had achievements rated on the scales for the
Table 3. Important areas to consider during cognitive behavioral
therapy (CBT) for patients with schizophrenia. assessment of negative symptoms (SANS). The conclu-
sion was that CBT works even for patients who have
The importance of motivation and engagement low functioning and negative symptoms. Their improve-
Reduce the negative emotions that the patient connects with the
hallucination
ment was in avolition symptoms.
Help the patient to compensate for reasoning bias in delusional thoughts
For negative symptoms, use simple behavioral intervention so that the Formal thought disorder in schizophrenia
patient may succeed FTD in schizophrenia is probably least explored in the
For thought disorders, try to identify the main theme and important field of CBT. Very few studies have reported the effects
feelings that the patient is trying to communicate
of CBT, and specific techniques have not been systemati-
Work on low self-esteem (negative schema)
cally tested for their effectiveness. One problem with

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thought disorder is that it interferes with the therapy pro- (2) The negative form, which is not necessarily part of the
cess due to the great problems in communication, and psychomotor poverty syndrome (the negative syn-
these patients are often excluded in studies (4, 11). drome), includes:
FTD is a term used to describe incomprehensible lan-
! Blocking—interruption of speech before a thought
guage—either speech or writing—that is presumed to
or idea has been completed.
reflect thinking. In psychiatry, FTD is being one of two
! Poverty of content of speech (empty speech)—the
types of thinking or thought disorder, the other type
language tends to be vague, repetitive or stereo-
being delusions. The latter involves “content” while the
typed. The consequence is that the communication
former involves “form” (4). Perhaps it is better to write
gives little information.
“disorganized speech”, although FTD is so widely used
! Concreteness—a lack of generalization from an
in texts and in clinics that the concept is considered in
immediate stimulus.
this article (32).
! Perservation—continuous repetition of words,
In the cognitive model, hallucinations are elicited from
ideas or subjects.
events. Perhaps it is the patient’s own thoughts, delu-
! Clanging—sounds rather than meaningful rela-
sions are interpreted as underlying assumption and nega-
tionships appear to control the choice of words.
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tive symptoms are the behavioral responses, e.g.

! Echolalia—a pattern of speech in which the patient
inactivity. Regarding FTD, it is viewed here as part of a
echoes words or phrases of the interviewer. Typi-
stress response to the automatic thoughts elicited by var-
cal echolalia tends to be repetitive.
ious events. There is evidence that symptoms of FTD
disorders become worse when the patient is exposed
THERAPEUTIC APPROACHES TO FTD
to increased stress (4). An explanation based on the
What has been described above is that manuals of CBT
information-process model is that “the supervisory atten-
for schizophrenia have been sparse in their handling of
tional system (or central executive) is malfunctioning,
specific techniques for FTD. However, FTD is so com-
leading to insufficient inhibition of irrelevant stimuli and
mon in patients with schizophrenia that there are some
poor choice of appropriate words, sentences, or topics”
For personal use only.

help strategies the therapist can use to teach the patient

(4, p. 173).
to improve his/her communication (4).
FTD is a complex symptom that is difficult to under-
It can be difficult to understand normal healthy peo-
stand. It is divided into two main forms of speech. The
ple in what they are trying to say because of the
first is a positive form, such as loosening of associations
thoughts and speech being so general and unspecific. It
and idiosyncratic use of language. The second is a nega-
is even less easy when a patient’s thinking is completely
tive form.
muddled, which symptoms of FTD can be. However,
(1) Loosening of associations (positive form) consists of there is evidence that most thought-disordered content
various forms of losing track in the conversation. Indi- still has meaning for the patient. One technique that the
vidual examples of this category include: therapist can use is thought linkage, which means going
back to the flight of ideas and saying, “you seem to
! Derailment (loose associations, flight of ideas)—a
have jumped from A to C; can you put in the B for
pattern of spontaneous speech in which ideas slip
me?” Furthermore, following list has 12 tips that the
off track onto completely unrelated way.
therapist can use (11):
! Tangentiality—answering a question in a wrong
or distant way. (1) Clarify the core issues and the main emotions that
! Loss of goal—failure to follow a train of thought patients are trying to communicate.
through to its naturals conclusions. (2) Keep a small number of clear goals for the session.
! Incoherence (or word salad)—a series of words or (3) Try to be clear with your speech with the patient.
phrases seem to be joined together at random. (4) Gently encourage the patient to clarify what he/she
Communication becomes completely incoherent. is trying to say.
! Illogicality—a pattern of speech in which conclu- (5) Carefully explain to the patient that he/she has been
sions are reached that do not follow logical getting off track.
steps. (6) Use paper and pencil to demonstrate disruptions in
the flow of thinking and show examples of effective
Idiosyncratic use of language (positive form)
patterns of communication.
includes:
(7) Ask the patient about the conclusion of their story.
! Neologism—a completely new word formation (8) Ask the patient to slow down and explain how one
that no other person can understand. point leads to another.
! Word approximations—old words that are used in (9) Identify automatic thoughts in the patient’s speech.
a new, unconventional way. (10) Focus on the key underlying theme.

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 F SARIN & L WALLIN

(11) Use standard CBT methods of structuring, summariz- explanations depending on which symptoms patient has.
ing and feedback. For positive symptoms (hyper-dysregulation of dop-
(12) Use an audio or video recording so that the patient amine), patients develop dysfunction in cognitive pro-
can get feedback on how he/she communicates. cessing, such as “jumping to conclusions” in delusions
and “self-monitoring” in hallucinations. Together, these
lead to paranoid thoughts and unhelpful beliefs.
CBT and antipsychotic medication For negative symptoms, “dopamine dysregulation may
Today’s anti-psychotics block neurotransmitter receptors; increase the noise in the system, ‘drowning out’ dop-
in particular, they have a dopamine-blocking action and aminergic signals linked to stimulus indication reward.
are efficacious in positive psychosis because they all share The net result would be reduced motivational drive, that
a common property by reducing the symptoms. Medica- would lead over time to negative symptoms, such as
tion may differ in chemical structure or in receptor affin- social withdrawal and neglect of interests” (19, p. 555).
ity, but they all have a psychological effect by “damping This and other pathological mechanisms give “limited
salience” (20). It has an almost immediate effect on the resources”, and with negative life experiences, the patient
receptor (within hours), but damping of the hallucinations adopts a “defeatist attitude”.
Nord J Psychiatry Downloaded from informahealthcare.com by RMIT University on 09/09/14

and delusions can take up to 4 weeks (21). The anti- However, irrespective of the symptoms, almost all
psychotic only provides attenuation of salience; the pro- patients with schizophrenia have low self-esteem and
cess of symptomatic improvement of delusions requires stigmatization. The CBT techniques normalization and
further psychological and cognitive resolution. Medication psychoeducation can be used in treatment of the differ-
dampens the intensity of and preoccupation with symp- ent symptoms.
toms, but it does not necessarily change the paranoid Currently, there is evidence that CBT can reduce the
thoughts. Abandonment of the psychotic ideas and their patient’s psychotic symptoms and improve functioning;
own cherished beliefs takes time, and some patients never unfortunately, the treatment effect is low to moderate.
stop experiencing hallucinations and delusions. Outcomes are often to reduce symptoms. For the future,
Psychosis is seen as dynamic interaction between a perhaps we should concentrate more on life quality, psy-
For personal use only.

bottom-up neurochemical drive and CBT is a top-down chological well-being and better self-esteem—and try to
process. CBT helps the patient to deconstruct the para- find more outcome measures than just PANSS (Positive
noid ideas and to have more healthy and functional and Negative Syndrome Scale), SANS (Schedule for the
beliefs (20, 33). This can take even more time, e.g. sev- Assessment of Negative Symptoms) and BPRS (Brief
eral months or even years (6). Specific psychotherapies Psychiatric Rating Scale).
such as CBT for schizophrenia would not only be feasi- Based on RCT studies, it has been possible to find
ble but also synergistic with medication (20). predictors of better outcome in CBT, such as a low level
When the anti-psychotic treatment is stopped (or of conviction and inflexibility of beliefs, a higher level
sometimes even when it is not), dopamine dysregulation of insight and a shorter duration of illness (34). This
is re-instated. Often, the same ideas and content of delu- indicates that effect size could be higher for a subgroup
sion came back with the psychosis. Medication does not of schizophrenia patients. This is important for selection
eradicate the symptoms, but creates a state of “detach- of people, both in research and in clinical practice.
ment” from them. Limitations of the cognitive model are that much is
Unfortunately, anti-psychotic medications can have unknown; it is understood that the cognitive model will
side effects, and one of these is reduced motivation be revised as more data become available. Research on
(drive). The gives the patient a double burden: not only CBT for positive symptoms has been going on for a
does he or she have the disease, but the medication takes much longer time than for negative symptoms, and more
away a core characteristic, namely drive (20, 21). must be done—especially for FTDs (speech disorders),
Medication is not as efficacious with negative symp- where there has been no CBT research (11). If the result
toms as with positive symptoms. One explanation is that with CBT does not improve in the future, the model will
negative symptoms probably have hypo-dysregulation of be a disappointment and will have to be revised. To
dopamine transmission and other pathological mechanisms improve our knowledge, research must explain more and
(19). Thus, CBT is even more important in helping help us to understand in more detail which cognitive
patients to increase their motivational drive (avolition) and processes, and how it should be treated, e.g. reasoning
teaches them to take initiatives so that they may succeed. processes, belief flexibility and their relationship to delu-
sional (22). Furthermore, as Garety et al. (22) described:
“the recent research findings, based on cognitive models
Discussion of psychosis, point to new directions in neurobiological
The cognitive model and the aberrant salience model research. These include the potential benefit of incorpo-
complement each other well; they have developed ration of cognitive processes into more sophisticated,

152 NORD J PSYCHIATRY·VOL 68 NO 3·2014

 COGNITIVE BEHAVIOR THERAPY FOR SCHIZOPHRENIA

bidirectional and interactive causal models, of adding 12. Fowler D, Garety P, Kuipers E. Cognitive behaviour therapy for
psychosis—Theory and practice. Chichester: John Wiley & Sons;
cognitive and emotional processes to phenotypes in neu- 1995.
robiological investigations; and of adopting greater speci- 13. Kingdon DG, Turkington D. Cognitive therapy of schizophrenia.
ficity in clinical phenotypes” (p. 1388). New York: The Guilford Press; 2005.
14. Morrison AP, editor. A casebook of cognitive therapy for psychosis.
The main limitation of the aberrant salience model is Hove and New York: Brunner-Routledge, Taylor & Francis group;
the same as that for the cognitive model: that so much 2002.
is unknown. The aberrant salience model, which is not 15. Chadwick P, Birchwood M, Trower P. Cognitive therapy for hal-
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an etiology hypothesis but a pathophysiological one, is 16. Van Winkel R, Esquivel G, Kenis G, Wichers M, Collip D, Peer-
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2010;16:e185–92.
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which contribute to the schizophrenia. Furthermore, if a schizophrenia: Review of epidemiological findings and future direc-
new drug is found to treat psychosis without having any tions. Schizophr Bull 2008;34:1066–82.
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then the aberrant salience model will be discredited—or 19. Howes OD, Kapur S. The dopamine hypothesis of schizophrenia:
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Acknowledgements—We are grateful to Professor Bruno Hägglöf for nia. Am J Psychiatry 2003;160:13–23.
his comments on an earlier draft of the paper. 21. Kapur S, Mizrahi R, Li M. From dopamine to salience to psycho-
sis—Linking biology, pharmacology and phenomenology of psy-
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22. Garety P, Bebbington P, Fowler D, Freeeman D, Kuipers E. Impli-
Declaration of interest: The authors report no conflicts of cations for neurobiological research of cognitive models of psycho-
interest. The authors alone are responsible for the content sis: A theoretical paper. Psychol Med 2007;37:1377–91.
and writing of the paper. 23. van Os J, Linscott RJ, Myin-Germeys I, Delespaul P, Krabbendam
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