By no means, however, did we reject the notion that schizophrenia has a biologic basis. Even if “schizophrenia” is never mentioned, this diagnosis still guides treatment.
Viewing psychotic symptoms as normal reactions. The therapist extensively examined Mr. K’s safety concerns for himself and his family. The therapist acknowledged that these concerns were legitimate, as the patient lives in an inner-city neighborhood plagued by violent crime. Mr. K was then praised for his devotion to his family.
By applying normalization techniques,9 the therapist found fact-based aspects of the delusional beliefs. Normalizing Mr. K’s safety concerns made him feel validated. From there, we could map out a plan for him to periodically leave his home. We devised a routine that addressed his safety concerns: He went to the library only in daylight. He chose a subway route that was less convenient but made him feel more comfortable. Once at the library, he called home to make sure his family was safe, then sat at an open table so he could watch other library patrons come and go.
Once this routine was established, we could address the more idiosyncratic delusions that caused Mr. K considerable stress and anxiety. We asked him to explain the evidence behind his belief that trained assassins were targeting his family. He could not do so and eventually admitted that this thinking was misguided. His fears gradually shifted from specific threats targeted at him and his family to nonspecific fears of the randomness and unfairness of life.
Placing psychosis in psychological context. We tried to understand the psychology of his paranoid thoughts while viewing his symptoms as part of a neurobiologic disorder.
What initially looked like “garden variety” paranoid delusions had a psychological meaning to Mr. K. His dread of public humiliation was intertwined with his fear of assassination. Once understood, these two fears could be isolated and became easier to treat.10 We traced Mr. K’s fear for his family’s safety to his being the oldest male in a matriarchal household. Because his illness prevented him from assuming the role of breadwinner, all that was left was for him to guard his family from the imagined threat of assassination.
Caveats The CBT techniques outlined in the literature for schizophrenia vary greatly from those used in depression or anxiety disorders. In order for CBT to be effective in schizophrenia, the therapist must have considerable experience working with patients with schizophrenia and must receive specialized training and supervision in CBT techniques modified for persons with schizophrenia.
Further, Mr. K continued to take his antipsychotic medication during the 3-month CBT course. We are not suggesting that CBT be administered in lieu of drug therapy, nor can we claim that CBT will be consistently effective against positive symptoms. What’s more, this case does not take into consideration patients who are persistently psychotic because of suboptimal dosing, poor compliance, or substance abuse.
Follow-up: Continued progress
Mr. K continued to improve after the CBT sessions ended. He completed a summer art class despite recurrent paranoia and lingering fears of social interaction. As of this writing, he was considering taking another course.
Three months after his last session, Mr. K was still regularly visiting the library. He also began walking his niece to and from school each day. His paranoid ideation and ideas of reference appeared to be lessening in intensity. Last fall, he joined a gym. He also reported comfortably conversing with people other than immediate family members or mental health clinicians.
Related resources
- Grech E. A review of the current evidence for the use of psychological interventions in psychosis. Int J Psychosoc Rehab 2002;6:79-88.
- Jones C, Cormac I, et al. Cognitive behaviour therapy for schizophrenia. Cochrane Library Issue 4, 2001. Available at: http://www.mediscope.ch/cochrane-abstracts/ab000524.htm. Accessed Feb. 10, 2003.
Drug brand names
- Clozapine • Clozaril
- Haloperidol • Haldol
- Olanzapine • Zyprexa
- Risperidone • Risperdal
Disclosure
Dr. Weiden reports that he receives research/grant support from, is a consultant to, and/or is a speaker for AstraZeneca Pharmaceuticals, Bristol-Myers Squibb Co., Pfizer Inc., and Janssen Pharmaceutica.
Dr. Burkholder reports that she is a consultant and speaker for Pfizer Inc. and Eli Lilly and Co.
Acknowledgments
The authors wish to thank Catie Camille for her assistance in preparing this article, and Drs. Motaz El Rafae and Najma Khanani for the care they provided to Mr. K.