A CBT Approach to Mental Health Problems in Psychosis

Emma Williams

• Publisher: Routledge
• Year: 2017
• Topic: Psychology
• eBook ISBN:
  9781351706926
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book draws together advances in the understanding, assessment and treatment of stress, negative symptoms, social anxiety, OCD, PTSD and mood disturbance in people with a diagnosis of psychosis, providing a practical guide for clinicians. CBT for psychosis draws on the principles and interventions developed for anxiety and depression and adapts these to treat psychotic symptoms. CBT for schizophrenia is now widely accepted as an effective treatment in the reduction of psychotic symptoms. A review of findings led the National Institute for Health and Clinical Excellence (NICE) to recommend offering CBT to all people with schizophrenia. Content includes: the role of stress in psychosis; negative symptoms - emotional, motivational and behavioural deficits; social anxiety disorder; obsessional compulsive disorder; post-traumatic stress disorder; mood disturbance in psychosis; and client handouts. It features: 174 pages, perfect bound (246 x 171mm).

1 Stress and psychosis

Stress appears to have both a general and a specific effect on people with psychosis. In general, stress has a clear impact on both physical health and psychological wellbeing. It is implicated in the exacerbation of many medical conditions and diseases including coronary heart disease, stroke, stomach ulcers and heart attack (Powell and Enright, 1990). In addition, stress is commonly implicated in the development and maintenance of many psychological disorders including anxiety, depression, obsessive- compulsive disorder and phobia. Stress plays a specific critical role in psychosis, indeed Zubin and Spring’s (1977) seminal ‘vulnerability- stress model’ of schizophrenia continues to inform research and clinical practice today. The model proposes that certain characteristics such as limited attentional capacity and hyper- autonomic arousal serve as vulnerability factors and that environmental and personal stressors can precipitate psychotic episodes in vulnerable individuals (Nuechterlein and Dawson, 1984). Individuals who have poor coping skills or inadequate coping resources might have an underlying vulnerability to the development of psychosis (Norman and Malla 1993). A comparison of people at very high risk of developing psychosis with a control group found that they were significantly more distressed by events, felt that they coped more poorly and used more emotion- oriented coping strategies than did the comparison group (Phillips et al, 2012). The authors suggest that preventative interventions should include treatment focusing on stress management and enhancing coping skills.

Assessment of stress

Stress can be measured and monitored in a number of ways. A formal measure of emotional distress can be helpful in gauging a client’s current emotional state. A range of measures to assess stress, stressors and coping is available:

• The Depression Anxiety Stress Scales (DASS) (Lovibond and Lovibond, 1995) are a set of three self-report scales designed to measure the negative emotional states of depression, anxiety and stress. The stress scale is sensitive to levels of chronic non-specific arousal. It assesses difficulty relaxing, nervous arousal, and being easily upset or agitated, irritable or over- reactive and impatient. Clients use four- point severity- and- frequency scales to rate the extent to which they have experienced each state over the past week. The DASS is presented in the Appendix (see p. 146).
• The Lifestyle Appraisal Questionnaire (LAQ) (Craig et al, 1996) provides a comprehensive assessment of health and stress. It is an instrument designed to assess lifestyle from a multi- factorial perspective. It assesses cumulative risks and perceived stress of life. Th e questionnaire provides a sensitive measure of change with treated clients reporting a reduction in their cognitive appraisal of life stress (Craig et al, 1996).
• Hassles scale (Kanner et al, 1981) measures minor distressing events. Th is can be particularly useful as day- to- day stressors often have more impact than infrequent major life events (Malla and Norman, 1992). One hundred and seventeen potential irritants in the areas of work, health, family, friends, the environment, practical considerations and chance occurrences are listed. Th e client rates by severity (1–3) any item that occurred in the past month. Th e scale can be administered as a one- offmeasure of current hassles or completed over consecutive months to monitor stressors over time. Derived scores include frequency (number of items checked), cumulative severity (sum of the three-p oint rating scale) and intensity (cumulative severity divided by frequency), thus providing an index of how strongly or intensely the average hassle was experienced, regardless of the number of hassles checked.
• Perceived Stress Scale (Cohen et al, 1983) is a 14- item measure of the degree to which situations in one’s life are appraised as stressful. It is designed to examine the role of non- specific appraised stress in the aetiology of disease and behavioural disorders and as an outcome measure of experienced levels of stress. General stress and perceived coping are measured.

Once a client has become proficient at recognising their stress levels, daily monitoring using a simple analogue scale can be helpful. Technical measurement is also possible; stress in ‘real-world’ daily functioning has been measured by experience sampling using palm computers to assess stress at various intervals during the day (Kimhy et al, 2010).

Working model of stress and psychosis

A working model of the role of stress in psychosis is presented in Figure 1.1. The model is informed by the vulnerability-stress model of schizophrenia (Zubin and Spring, 1977) together with models of stress in the general population proposed by Cooper (1981) its adaptation (Powell and Enright, 1990) and the work of Lazarus (1971) on stress and disease. Lazarus identifies three important components which are incorporated into the model of stress: 1) the notion of demands taxing a system, 2) the appraisal or perception of threat, and 3) the importance of the response of that system.

FIGURE 1.1 Working model of stress and psychosis

The environment

1) Life events

Life events which involve change – even positive change such as going on holiday or getting married – have been found to have significant effects on a person’s susceptibility to stress-related health problems (Holmes and Rahe, 1967). An accumulation of life events is often found in the period leading up to a psychotic episode. It appears that people with psychosis have a lower threshold for experiencing stress; indeed the course of psychosis seems to be less influenced by relatively rare major life events and more by the build-up of more common minor life events (Malla and Norman, 1992).

In addition, the development of a psychotic illness is itself a very significant life event and commonly leads to other profound changes in relationships, living environment, work, education, financial situation, recreation and personal achievement.

2) Social environment

Social contact is important: it enables people to have fun; can provide alternative perspectives, distraction, opportunity to talk about difficulties and to receive information and help, and can reduce rumination and introspection. People with mental illness often have minimal social contact due to reduced social abilities, fear of social situations, stigma and discrimination or simply due to being unable to attend work or other social settings because of psychotic symptoms. Social isolation reduces a person’s opportunities to express their feelings and to gain support from others. This not only increases stress but can also provide fertile ground for the development of paranoid or suspicious beliefs because opportunity to receive feedback from others, which can help to reduce the expansion of inaccurate appraisals, is limited.

3) Work environment

People commonly show deterioration in work performance in the period prior to developing acute psychotic symptoms. This frequently leads to increased stress due to attempts to work harder or longer hours to make up for lost efficiency. In the prodromal phase a person is likely to struggle with tasks which were previously manageable, find difficulty relating to colleagues, and fear being reprimanded or made redundant. The effect of stress is to further reduce performance and a vicious cycle of deterioration and increased stress can ensue.

4) Living environment

Psychosis often develops in early adulthood when people are becoming independent and moving out of the family home, sometimes to a different geographical location and usually coinciding with changes in social environment, employment or education. The experience of psychosis itself commonly results in changes in living environment such as moving back in with family, living in shared accommodation or hospitalisation. This brings with it increased stress due to loss of independence, noise, lack of privacy and the demands of other people. Alternatively, social isolation and having to fend for oneself can result in significant stress.

The individual

1) Predisposition and traits

There are a number of personality characteristics commonly found in children who go on to develop schizophrenia: they tend to be more introverted and withdrawn and prefer to spend time on their own rather than with others (Ellison et al, 1998). Traits such as a tendency to suspiciousness or making external attributions might also be considered both to predispose to psychosis and to create stress.

2) Attitudes

There appear to be some people who are ‘stress resistant’: they experience significant stress but seem to be unaffected by it. In a study of such individuals three factors were found to be important in maintaining this resilience to stress: a sense of control over situations and events, having a sense of purpose and commitment, and an ability to be flexible and to deal with ambiguity (Kobasa, 1982). People with psychosis frequently lack a sense of control in their lives, they can feel at the mercy of their symptoms and indeed often delusional beliefs develop around the feeling of literally being controlled by others. Avolition and lack of motivation are common negative symptoms which can manifest as lacking a sense of purpose. People with psychosis often struggle with ambiguity and tend to be concrete rather than flexible. Similarly, many have defeatist attitudes, are sensitive to perceived criticism and have low expectancies for pleasure or success (Beck et al, 2009). Thus, people with a predisposition to psychosis might be said to be stress-pr one rather than stress-resistant.

3) Physiology

Genetic variability creates individual differences in physiological arousal in the general population. The autonomic nervous system which controls the body’s response to stress appears to be more reactive in people who develop schizophrenia. Electrodermal over-activity can lead to hyper-responsivity and such individuals become more easily aroused to stressors (Zubin and Spring, 1977). Overactive dopamine systems together with other biological components might be important in the development of schizophrenia. It has been proposed that normal life stressors might cause exacerbations of hormonal (eg cortisol) activity and neurotransmitter responses, particularly dopamine. Positive symptoms might result from the increase in dopamine activity, whereas...

Table of contents

• Cover
• Title
• Copyright
• Contents
• About the author
• Dedication
• Acknowledgements
• Introduction
• 1 Stress and psychosis
• 2 Negative symptoms
• 3 Social anxiety disorder and psychosis
• 4 Obsessional compulsive disorder and psychosis
• 5 Post-traumatic stress disorder and psychosis
• 6 Mood disturbance in psychosis
• Appendix
• References
• Index