© Priory Lodge Education Ltd., 1994,1995,1996.
Dr. Sally Beeken, MBBS, BMedSc (Hons),
Registrar in Psychiatry,
Dr. Kedar Dwivedi, MBBS, MD, DPM, FRCPsych,
Consultant Child, Adolescent and Family Psychiatrist,
This paper describes the use of cognitive therapy techniques with a case of acute polymorphic psychotic disorder (not stress related). Cognitive behavioural therapy has been proven to be effective in the treatment and prevention of depressive disorder either alone or as an adjuvant to pharmacotherapy. There is increasing interest in the use of cognitive therapy in the treatment of psychosis particularly hallucinations (Chadwick & Birchwood, 1994) and delusions (Alford & Beck, 1994, Chadwick & Lowe, 1994). This article describes the adaptation of some cognitive techniques used over a period of six months in the management of a 14 year old girl who had three episodes of psychosis in one year.
The girl aged 14 is the youngest child in a 3 sibship stable nuclear family. Until the age of 14 she had had no previous contact with the psychiatric services. She had enjoyed a developmentally normal infancy and uneventful childhood. She is a high achiever at school, conscientious, bright and popular. At the time of her first presentation she was thoroughly investigated for an organic cause for her psychotic episode. Routine blood tests, an EEG and MRI scan were all normal.
Each psychotic episode was characterised by restlessness, disinhibition, thought disorder, delusions, visual and auditory hallucinations and marked mood swings. Each episode was short lived and resolved completely. Following the third episode she was well and stabilised on Carbamazepine (200mg twice daily). She then embarked on a series of cognitive therapy sessions as a means of relapse prevention.
Description of the Therapy
Cognitive therapy is well suited to work with adolescents as it is collaborative, non-confrontational, safe and fun. Sessions always began with an agenda which was shared between the patient and therapist. This included an item on news, feedback from homework, task for the day, any other business and a plan of future action. An attempt was made to create a relaxed and easy going atmosphere. This facilitated the use of humour in the examination of some otherwise potentially distressing material. Therapy proceeded in three main stages.
The first, an examination of the events of each episode within the categories of events, thoughts and feelings. The second, an examination of thinking errors and how they might apply to the thoughts surrounding each psychotic episode. The third, from the timeline of events, produced by the patient, key delusional beliefs were extracted and an effort made to check out the evidence for and against each sometimes searching for alternative explanations for her experiences.
It became clear on examination of events that each one was preceded by an episode of sleeplessness, anxiety and transient low mood. We attempted to understand her state of mind during the episodes in order to see her faulty thinking in context. It became possible therefore to question her delusional beliefs without being too challenging. She identified her main thinking errors as being dichotomous thinking and jumping to conclusions. Once we had shared our own thinking errors in everyday life we were able to take this exercise to her delusional beliefs. It became possible for her to safely question her thinking at the time, effectively `normalising' (and therefore affectively neutralising) her psychotic thinking. At the time of the therapy she had completely recovered and therefore conviction ratings were not done.
An example of her examining the evidence for her beliefs is illustrated below.
During each episode she developed a delusional belief that she was pregnant and was later able to examine this in the therapy. Following a session when she described in detail the events of the time she then used this to construct a case for her belief being true or false.
|Evidence For||Evidence Against|
|1. Periods stopped temporarily/or were late||1. I don't look fat|
|2. I felt sick in the morning||2. I haven't had sex|
|3. I had cravings||3. I've had my period since then|
|4. I went to the Doctor's a lot||4. No-one mentioned me being pregnant|
|5. I felt different inside||5. You can't get pregnant unless
sexual contact with someone of the opposite sex
|6. I felt happy, but people kept
I was ill and be careful
This technique of examining the evidence was used for other examples of her delusional beliefs and later she was able to think of practical tasks she might have done to add to her evidence, for example, getting a pregnancy test. She became very competent at looking rationally at her irrational material and generalised this to her everyday life, for instance, when she began to believe that her friends were talking about her behind her back she was able to look for the evidence and examine alternative explanations on her own. The work was consolidated by challenging material that the therapist provided in which she used her cognitive techniques with good effect.
An episode of psychosis is a frightening event. Cognitive therapy of psychosis challenges our traditional idea that a delusional belief is non-understandable and beyond reason. An examination of psychosis in the way described allows the events to become ultimately understandable, and seen in the context of a particular setting and in a particular mood state, reasonable. The patient can be helped to feel safe to examine otherwise deeply disturbing material. It is hoped that in conjunction with her medication this period of therapy will enable her to recognise the prodrome to a relapse and then work cognitively to safely examine its manifestations. Thus rendering the symptoms powerless whilst remaining rational and in control.
Alford, B A, and Beck, A T. (1994) Cognitive Therapy of Delusional Beliefs. Behaviour Research and Therapy. Vol. 32, No. 3, 369-380.
Chadwick, P, and Birchwood, M. (1994) The Omnipotence: a cognitive approach to auditory hallucinations. British Journal of Pyschiatry. 164, 190-201.
Chadwick, P D J, and Lowe, C F. (1994) A Cognitive Approach to measuring and modifying delusion. Behaviour Research and Therapy. Vol 32, No. 3, 355 - 367.