The prevalence of diagnostic comorbidity between psychosis and anxiety disorders has been found to be considerable. Cognitive models of psychosis suggest that anxiety does not arise directly from positive symptoms of schizophrenia but rather from an individual interpretation of such experiences. In the United Kingdom, cognitive-behavioural therapy for psychosis (CBTp) has been recommended within clinical guidelines as a psychological treatment of choice for those diagnosed with schizophrenia. However, despite empirical evidence supporting CBTp, the treatment provision remains infrequent and not routinely available. This case describes a successful implementation of CBTp. Sixteen sessions were delivered to a 40-year-old male with diagnoses of paranoid schizophrenia and comorbid anxiety, focusing primarily on cognitive restructuring of paranoid appraisals of auditory hallucinations and behavioural experiments employed progressively via graded exposure to anxiety-inducing stimuli. Standardised measurements, behavioural frequency sampling, and subjective data indicated a considerable reduction in both paranoia and anxiety. Also, the client’s psychosocial functioning improved substantially. This report indicates that the treatment may help those with experiences of psychosis and comorbid anxiety reach a significant improvement in their quality of life and offers an encouraging and innovative perspective on direct engagement with the content of paranoia and voices at the onset of therapy.
The specific causes of psychosis-type experiences remain unclear [
For instance, the gene-stress interaction hypothesis suggests that prolonged exposure to psychosocial distress (e.g., childhood traumas, life events, and discrimination) may with time contribute to sustained dysregulation of the hypothalamic-pituitary-adrenal axis leading to dopamine sensitization in mesolimbic areas and increased stress-induced striatal dopamine release; individual vulnerability to such neurochemical change is proposed to be genetically influenced [
Furthermore, it has been widely acknowledged that persons with psychosis present with much higher rates of alcohol and illicit drug misuse than the general population, and such misuse may inevitably contribute to increased severity of symptoms [
The cognitive-behavioural approach to psychosis describes psychotic phenomena through the underlying cognitive, emotional, and behavioural processes, which are hypothesised to constitute a psychological aftermath of distressing, often overwhelming, depriving, and traumatic experiences [
Evidence suggests that experiencing positive symptoms of psychosis, particularly auditory hallucinations, as dominating, insulting, and commanding correlates with higher levels of psychological distress [
In the past decade empirical investigations of CBTp have flourished and the results of studies examining the effectiveness of CBTp appear encouraging. In their meta-analytical evaluation of controlled research and qualitative reviews, Roth and Fonagy [
In the United Kingdom, the growing evidence supporting CBTp affected the recommendations made by the National Institute for Health and Care Excellence in their clinical guideline for schizophrenia. In 2009, the guideline recommended CBTp as one of the core interventions for adults with psychosis [
In order to put the above into the context of clinical practice, we will consider the case of “Raymond,” who received a full course of CBTp in line with the clinical guidelines in the UK. This case provides the opportunity for reflection on the effectiveness of cognitive-behavioural treatment in schizophrenia, with particular focus on the interventions of cognitive restructuring and graded behavioural exposure, delivered to an individual with a longstanding history of auditory hallucinations, paranoia, and comorbid anxiety. Raymond has consented for the case study to be written and used for educational and publishing purposes. A pseudonym has been used to protect the client’s identity.
Raymond was a 40-year-old male referred to a specialist service for adults with psychosis and complex mental health needs in one of the National Health Service Trusts in East Midlands, UK, for an individual psychotherapeutic input. Raymond was diagnosed with paranoid schizophrenia and a comorbid anxiety disorder (not otherwise specified). A number of ongoing symptoms were reported, including derogatory and threatening auditory hallucinations, paranoid delusions, high anxiety levels, and social avoidance and withdrawal. Past and ongoing interventions consisted of pharmacotherapy with a maintenance dose of antipsychotics and tranquilisers, social inclusion activities facilitated by a community based team, and recurrent crisis oriented admissions to acute mental health wards.
Since early adolescence, Raymond regularly used excessive amounts of alcohol and cannabinoids, which initially seemed to be his way of conforming to peer pressure in the deprived area where he lived. He received strict upbringing from his father; thus spending hours in pubs appeared to function as an avoidance of exposure to distressing stimuli at home. With time, Raymond became dependent on the use of illicit substances. He was trained as a builder and enjoyed his work. Yet, after the onset of psychosis Raymond gave up his trade. His first episode of hearing voices occurred at the age of 30 and involved his first admission to an acute mental health ward, where he underwent an alcohol detoxification. Raymond has managed to remain abstinent from alcohol since and yet continued to use cannabinoids on a regular basis. After a few years of remission, the second episode of psychosis occurred and was followed by another inpatient admission. Subsequently, Raymond remained abstinent from cannabis as well. However, auditory hallucinations persisted on a daily basis. Additionally, Raymond developed a range of paranoid appraisals of voices and delusional beliefs about other people’s vicious intentions towards him, which precipitated social withdrawal and triggered high anxiety levels. At the time of referral, Raymond lived isolated on his own in a house, where he had installed surveillance cameras and barricaded his bedroom at nights. He was unemployed and in receipt of social benefits.
As in generic cognitive-behavioural models, assessment in CBTp aims to evolve into a case formulation; hence a range of cognitive interview methods were employed. Furthermore, to formally assess the person’s symptomatic presentation and evaluate the intervention outcomes, a standardised psychiatric measure, the Brief Symptom Inventory (BSI), was administered with the client. The BSI is a 53-item self-report inventory, which has been designed to reflect the symptom patterns among mental health in- and outpatients. Each BSI item is rated on a five-point scale (0–4) reflecting a person’s distress from “not at all” to “extremely.” The BSI is a measure of the current symptom status and is scored on the following subscales: somatisation, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, psychoticism, and paranoid ideation [
For the purpose of Raymond’s assessment, the BSI subscales of paranoid ideation (PAR) and anxiety (ANX) were administered. Raymond’s preintervention PAR score was 2.20 and his ANX score was 2.50. Both scores were elevated by more than one standard deviation above the UK outpatient mean and indicated heightened levels of difficulties in both symptom areas.
As depicted in Figure
Diagrammatic depiction of case formulation, based on Morrison et al. [
During the assessment, Raymond identified a number of triggers. He noticed that he would hear voices while he was bored at home, kept silent, or had nothing to occupy his mind with. Furthermore, the voices would become particularly active in the late evening, upon nightfall. The voices felt like they were coming from inside of his head and were screaming derogatory and threatening comments. Raymond misinterpreted the voices as hearing someone else’s thoughts and was becoming increasingly delusional in his beliefs about other people, including his neighbours and random pedestrians. In consequence, he experienced elevated emotional, cognitive, and bodily symptoms of anxiety and employed a range of safety behaviours. These, in turn, contributed to his hypervigilance and preoccupation with the voices and prevented disconfirmation of his paranoid beliefs.
Based on the recommendations made in the clinical guideline for schizophrenia, 16 sessions of individual CBTp were contracted. The following intervention goals were agreed on: enhancement of strategies to cope with voices, paranoid/delusional beliefs and anxiety, and reestablishment of autonomy at nights. The intervention plan was informed by a CBTp manual [
Based on the formulation diagram, the cognitive model of psychosis was thoroughly discussed. Raymond was educated about the significance of cognitive mediation in psychosis, where particular appraisals of voices predict individual distress and coping behaviour [
Furthermore, the concept of “punishment paranoia” [
In order to compassionately challenge and restructure the paranoid appraisals of auditory hallucinations, this module of the treatment began with evidential analysis of the content of delusional beliefs [
Once the initial doubt in delusional explanations was instigated, cognitive restructuring proceeded to the reattribution of beliefs about voices [
Subsequently, Raymond was encouraged to practice identification of internal dialogues on a daily basis. Such dialogues occurred mainly in the moments of boredom. To restructure such unhelpful and dysfunctional cognitive experiences, Raymond begun implementing a range of modified self-statements [
Following completion of the cognitive restructuring module, Raymond reported a noticeable reduction in his experiences of anxiety. Subsequently, he voiced a growing readiness to relax a range of his safety behaviours he employed predominantly in the night time. Hence, behavioural experiments were used to address the unhelpful behaviour maintaining the cycle of paranoid appraisals of voices and comorbid emotional distress [
Behavioural experiments utilised through graded exposure affected further improvements in Raymond’s psychosocial functioning. Tested assumptions were disconfirmed and replaced with
Following completion of cognitive and behavioural interventions for the symptoms of psychosis, Raymond experienced a considerable reduction in his psychological distress and reported low anxiety levels. Therefore, it was no longer necessary for the symptoms of comorbid anxiety to be addressed in a separate module of the intervention.
The self-management planning focused initially on recognising early warning signs for antecedents of derogatory voices and addressing them accordingly. Organising activities in the evening was already addressed in earlier therapy stages. Hence, prevention of boredom became the focus towards the end of therapy. A family meeting was organised with the community-based mental health team and plans were made for gradual reinstatement of Raymond’s interaction with his relatives and acquaintances. Furthermore, during the course of intervention, Raymond reflected on his life and realised that, despite his intellectual capacities and learning potential, he never felt confident enough to undertake further education. Since his abilities to cope with voices and persecutory beliefs increased considerably and anxiety levels reduced, Raymond decided to explore evening courses provided in the local college and pursue further qualifications. Finally, a CBTp self-help guide [
Subjectively, Raymond reported numerous substantial improvements in his psychological functioning at the end of therapy. Some of his pre- and postintervention comments, evidencing subjective importance of the therapy outcomes, are quoted in Table
Subjective pre- and postintervention reflections on the patient’s own difficulties.
Preintervention quotes | Postintervention quotes | |
---|---|---|
Voices |
|
|
Appraisals |
|
|
Anxiety |
|
|
Night time |
|
|
Coping |
|
|
Not only did the client’s strategies to cope with voices, paranoia, and anxiety improved considerably, but also, as illustrated by the pre- and postintervention behaviour frequency samples (Table
Self-reported frequency of safety seeking behaviour.
Preintervention | Postintervention | |
---|---|---|
Setting alarm system | Every night | Irregularly, only some of the nights |
Barricading bedroom | Every night | Just closing doors |
Watching cameras | Every night | Sometimes briefly during the day/watching movies at night to relax |
Hiding at home | Every night/most days | Visiting family, attending outpatient appointments, attending college |
Furthermore, as shown in Table
BSI pretreatment assessment and posttreatment evaluation scores for the case.
BSI scale | UK outpatient mean/SD | Pretreatment score | Posttreatment score |
---|---|---|---|
PAR | M = 1.54/SD = 1.08* | 2.20 | 1.50 |
ANX | M = 1.87/SD = 1.03* | 2.50 | 1.60 |
The present case report portrays a range of considerable improvements in psychosocial functioning of a person diagnosed with paranoid schizophrenia and comorbid anxiety disorder, following a course of 16 sessions of CBTp, which primarily focused on cognitive restructuring of paranoid appraisals of voices and graded behavioural exposure to anxiety-inducing stimuli. Such outcomes were evaluated by the means of standardised measurements, subjective reflections, and behaviour frequency samples. The intervention outcomes were consistent with previous research findings supporting the effectiveness of CBTp [
The client did not only arrive at more functional appraisals of his psychosis-type experiences but also achieved a marked improvement in his behavioural functioning, including increased frequency and quality of socially inclusive efforts, reduced withdrawal and isolation, and enhanced functionality of strategies to cope with emotional distress. Such behavioural change seems, again, consistent with the principles and desired goals of both cognitive restructuring and graded exposure in psychosis [
Yet, the original contribution the reported case attempts make to the clinical and research literature concerns the delivery method of CBTp strategies and the particular way through which the substantial psychosocial improvements were achieved, rather than the outcomes themselves. CBTp interventions have traditionally focused on the enhancement of cognitive and behavioural abilities to cope with psychological distress (i.e., secondary/comorbid symptoms, such as anxiety and/or depression) among individuals experiencing psychosis, as a primary therapeutic focus. For instance, as proposed two decades ago by Fowler et al. [
The reported improvements, however, would not have been achieved without the client’s consistent collaboration and engagement, readiness for change, openness to new knowledge, and expressed motivation to overcome his complex and enduring mental health difficulties, which contributed to the development of the functional, helpful, and trusting therapeutic alliance and relationship. The fundamental importance of such client-related factors and their affirmative effects on therapy outcomes have long been acknowledged in research literature [
In the UK, clinical guidelines, which define the current standards for evidence-based procedures in care and health practice in England and Wales, have at times been criticised for being too prescriptive in their recommendations, thus limiting the clinical judgement of mental health professionals [
The authors declared no potential conflict of interests with respect to the case study, authorship, and/or publication of this paper.