Schizophrenia Bulletin vol. 32 no. S1 pp.

S24–S31, 2006
doi:10.1093/schbul/sbl014
Advance Access publication on August 2, 2006

Cognitive, Emotional, and Social Processes in Psychosis: Refining Cognitive

Behavioral Therapy for Persistent Positive Symptoms

Elizabeth Kuipers1,2, Philippa Garety2, David Fowler3, Introduction

Daniel Freeman2, Graham Dunn4, and Paul Bebbington5
As an inpatient, I was in a psychiatric ward for people who
2
King’s College London, Institute of Psychiatry, Department of seemed worn out by life. I was entertaining competing the-
Psychology, PO Box 77, London SE5 8AF, UK; 3School of Med- ories of why I was there. A part of me was aware that other
icine, Health Policy and Practice, University of East Anglia, UK; people saw me as mentally ill and that I had become a social
4
Biostatistics Group, Division of Epidemiology and Health outcast.
Sciences, University of Manchester, UK; 5Department of Mental
Rufus May1
Health Sciences, UCL, University of London, UK
Schizophrenia and related psychotic disorders create
enormous burdens for individuals who suffer from
Psychosis used to be thought of as essentially a biological them, for their carers, for the mental health services,
condition unamenable to psychological interventions. How- and for society at large.2 People with psychosis have
ever, more recent research has shown that positive symp- always endured very poor social outcomes, including
toms such as delusions and hallucinations are on 80% unemployment rates.3,4 Even worse, they have
a continuum with normality and therefore might also be been stigmatized and misunderstood. The lifetime risk
susceptible to adaptations of the cognitive behavioral ther- of committing suicide is 5%5 with up to 13% showing
apies found useful for anxiety and depression. In the con- moderate to severe suicidal behavior in a recent study.6
text of a model of cognitive, emotional, and social processes For most of the 20th century, scientific explanations
in psychosis, the latest evidence for the putative psycholog- of schizophrenia emphasized its otherness. The state-
ical mechanisms that elicit and maintain symptoms is ments and experiences of people with the disorder were
reviewed. There is now good support for emotional pro- regarded as quintessentially incomprehensible.7,8 Such
cesses in psychosis, for the role of cognitive processes formulations encouraged the conceptualization of schizo-
including reasoning biases, for the central role of phrenia as a distinct and distinguishable category and
appraisal, and for the effects of the social environment, in- the postulation of a discreet biological causation. It
cluding stress and trauma. We have also used virtual envi- also led to a focus on biological treatment at the expense
ronments to test our hypotheses. These developments have of psychological interventions. Partly as a consequence,
improved our understanding of symptom dimensions such the symptoms of psychosis were seen primarily as the
as distress and conviction and also provide a rationale building blocks of diagnosis, rather than having an inter-
for interventions, which have some evidence of efficacy. esting and meaningful content.
Therapeutic approaches are described as follows: a collab- Toward the end of the 20th century, it became increas-
orative therapeutic relationship, managing dysphoria, help- ingly apparent that the focus on biological mechanisms
ing service users reappraise their beliefs to reduce distress, and treatment was restricting the possibilities of amelio-
working on negative schemas, managing and reducing rating the condition. Medication remains the first line of
stressful environments if possible, compensating for reason- treatment. However, it is far from wholly effective, not
ing biases by using disconfirmation strategies, and consid- only because 50% of people do not take their prescrip-
ering the full range of evidence in order to reduce high tions reliably.9 Many patients remain treatment resistant
conviction. Theoretical ideas supported by experimental despite adequate doses of antipsychotic drugs, and side
evidence can inform the development of cognitive behavior effects may impair consistent and optimal treatment.10,11
therapy for persistent positive symptoms of psychosis. Persistent positive symptoms such as hallucinations and
delusions can be severely distressing and disruptive of
Key words: schizophrenia/model/continuum/ daily functioning.
psychological interventions The ineffectiveness of intensive psychotherapy (which
sometimes makes outcomes worse12) also contributed
1
To whom correspondence should be addressed; tel: þ44-20-7848- to an increasing pessimism. However, the 1990s saw the
0414, fax: þ44-20-7848-5006, e-mail: e.kuipers@iop.kcl.ac.uk. emergence of a paradigm shift, brought about by the
Ó The Author 2006. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.
For permissions, please email: journals.permissions@oxfordjournals.org.
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 Cognitive, Emotional, and Social Processes in Psychosis

to anomalous experiences. In contrast to Morrison

Bio-psycho-
social et al,16 we see this as distinguishing between psychosis
Trigger Emotional
vulnerability changes and disorders such as anxiety or depression. Further,
we suggest that reasoning biases play a particular role
in symptom formation and their subsequent mainte-
Basic nance. Our research group have been able to test some
Cognitive Appraisal
Positive
dysfunction of
Symptoms
of the putative pathways in our model, as indeed
Anomalous experience have other researchers. The most recent results are
experience as external
summarized below.

Studies of Psychosis As a Continuum—A Biopsychosocial

Vulnerability
Appraisal influenced by
Reasoning & attributional Maintaining factors One of the consequences of moving away from a rigid
biases reasoning & attributions
Dysfunctional schemas of dysfunctional schemas categorical view of the symptoms of schizophrenia is
self & world emotional processes that it reconfigures the problem of the threshold for rec-
Isolation & adverse appraisal of psychosis
environments ognizing the condition. We now think that the biopsycho-
social vulnerability of psychosis is best conceived in terms
of various criteria. In the late 1980s, evidence began to
accumulate that the experiences described by patients,
Fig. 1. A Cognitive Model of the Positive Symptoms of such as feelings of paranoia and hearing voices, were
Psychosis (As Discussed in Garety et al).14 not confined to clinical groups. Bentall et al17 showed
that up to 25% of the normal population experienced
user movement,1 new ideas about recovery,13 and hallucinations at least once, and Tien et al18 in the gen-
renewed interest in psychological treatments. Some years eral population found an annual incidence of 4–5%
ago, we proposed a social and cognitive model of psycho- for hallucinations. Johns et al19 showed that up to 4%
sis (figure 1) as a way of summarizing what was known of individuals in a population survey had these ex-
and, hopefully, of guiding new research.14 Since then, periences. Freeman et al20 have recently found that up
a considerable amount of research has illuminated social to 30% of a nonclinical population have paranoid
and psychological mechanisms in psychosis. Related to ideas. P. E. Bebbington, D. Freeman, C. Steel, J. Coid,
this has been increasing support for a view of psychosis E. Kuipers, T. Brugha, R. Jenkins, H. Meltzer, N. Singleton
as existing on a continuum with normal experience. These (unpublished data, 2006) have confirmed in a large popu-
findings have between them begun a process of normali- lation study that the normal population is also vulnerable to
zation, whereby psychotic experience is seen as less such experiences.
strange and more understandable. In this article, we This overlap between clinical and nonclinical groups
use our model as an organizing principle to describe has been confirmed in other studies. Romme21 was one
this new research. of the first to publish in this area, with a study of voice
hearers, 30% of whom experienced voices. In this group,
the distinguishing feature of those in contact with mental
A Cognitive Model of Psychosis14
health services was their level of distress. Davis et al22
Our cognitive model of psychosis conceptualizes the com- compared people with psychosis with evangelical Chris-
bination of factors that shape and maintain positive tian groups. The main difference was not their experience
symptoms such as delusions and hallucinations. It incor- of voices but in the fact that the evangelical group felt
porates the continuity of psychotic and nonpsychotic more positive about them, while the clinical groups
experiences and the idea of a biopsychosocial vulnerabil- were more distressed. Similarly, Peters et al23 found
ity which can be triggered by events. We posit that that when members of new religious movements such
appraisal plays a central role in that it is not un- as Hare Krishna or Druids were compared with patients
usual experiences per se but a person’s appraisal of with psychosis, the former had similar levels of conviction
them that can lead to symptoms. We think that emotional in their beliefs but less distress. Van Os et al24 and Hanssen
changes and low self-esteem are particularly important. et al25 also showed that the differences between those with
We have also tried to incorporate findings that relate psychosis and ‘‘normals’’ were quantitative rather than
to adverse social environments. Unlike Broome et al,15 qualitative and that distress contributed to patient status.
we do not specify biological explanations, although these Again, unusual experiences overlapped but reactions such
are implicit. We emphasize, as one route to symptom as distress did not. Distress was consistently found in clin-
development, the importance of cognitive dysfunction ical rather than nonclinical groups and was much more
such as information processing deficits which can lead likely to bring people to clinical services.
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E. Kuipers et al.

Research Into Individual Symptoms and pressed mood. We have also found this for persecutory
Their Dimensions delusions.46 Further, negative appraisals of symptoms,
of self and of others relate to suicidal ideation and high
Since the 1980s, Richard Bentall has maintained that
alcohol intake.47 Morrison et al16 showed that, like
schizophrenia is a ‘‘failed category’’ in terms of being
people with phobic disorders, individuals with psychosis
able to predict specific treatment or outcomes consis-
exhibit safety behaviors. We have recently confirmed
tently.26 He has argued for ‘‘single symptom’’ research
this and have shown that they relate specifically to delu-
into delusions or hallucinations instead of research
sional persistence.48,49 Along with other investigators,
into schizophrenia as a whole. This argument has been
we have also looked at illness appraisals, using methods
persuasive, and much psychological research has con-
developed in health psychology. Lobban and colleagues
centrated on developing a clearer understanding of
have shown that these measures can be used in psychosis50
delusions,27 paranoia,28 and hallucinations.29 This has
and that patients make similar appraisals in both phys-
allowed a clearer focus on the dimensions of individual
ical and mental health conditions. We also found that
symptoms, such as distress, conviction, and preoccupa-
negative illness appraisals of psychosis were associated
tion, and has led to more targeted psychological interven-
with distress.51
tion, for instance for paranoia.30 Recently, genetic studies
have also raised doubts about the utility of separate
categories of schizophrenia and bipolar disorder.31 Cognitive Processes: Reasoning and Attributional Biases
The importance of reasoning biases in psychosis has been
Emotional Changes in Psychosis confirmed by recent research. Many of us hold with con-
A diagnosis of schizophrenia has tended to discount the viction ideas that do not have much basis in evidence, for
considerable amount of emotional disorder associated instance, beliefs in astrology, alien beings, telepathy, or
with it, in a manner that can also inform psychological ghosts. A quarter of us act on the basis of beliefs in
treatment options. For instance, depression is often asso- our star signs. Further, once we hold a strong belief, it
ciated with schizophrenia, such that up to 40% of people is normal for us not to consider alternatives impartially,
with the latter also have clinical levels of depression,32,33 the so-called ‘‘confirmatory bias.’’ For those with psy-
accompanying low levels of self-esteem,34 and a high chosis, it has been found that in addition to these normal
risk of suicide5. In all, 30% fit the criteria for posttraumatic biases, they tend to use less evidence before making a
stress disorder,35 20% may have panic disorder,36 25% have decision, the ‘‘jumping to conclusions’’ (JTC) reasoning
evidence of obsessional compulsive disorder,37 40% have bias,27 which has particular relevance for delusional
a dual diagnosis of comorbid substance misuse,38 and thinking. We have found that reasoning biases contribute
50% a comorbid personality disorder.39,40 This comorbid- differentially to delusional symptom dimensions, specif-
ity adversely affects outcome, with accompanying high in- ically to conviction.52 In sample of 100 patients with psy-
patient bed use. It may also reflect on processes underlying chosis, 50% showed a JTC reasoning bias, and this
the development of psychotic symptoms. contributed to delusional conviction, whereas disturbed
Our group is particularly interested in the impact of affect was linked to delusional distress.
emotional changes on symptom formation and mainte- JTC is found both in people with delusions and also
nance. Using a new version of a schema questionnaire,41 in those in recovery from delusions.53 Further, JTC is re-
we have found that the positive symptoms of psychosis, lated to belief inflexibility and to an inability to generate
delusions and hallucinations, are associated with extreme alternative explanations for experiences.54
negative evaluations of the self and others.42 In corrob- Bentall and colleagues55 have also found evidence of
oration of this possible pathway, Barrowclough et al43 ‘‘attributional biases,’’ although this is now less well sup-
found that low self-esteem in patients was associated ported.56 In particular, some people with persecutory
with negative evaluations (criticism) by carers and higher delusions have an ‘‘externalizing bias,’’ being more likely
symptoms. Similarly, Krabbendam et al44 have shown to attribute blame for negative events to external factors,
that depression contributes to the later development particularly to other people. This contrasts markedly
in delusions in people with preexisting anomalies of with the self-blame of people with depression.
experience. Myin-Germeys and colleagues45 demon- Another elegant set of experiments supports the idea of
strated that fluctuations in positive symptoms of psycho- ‘‘self-monitoring problems’’ in psychosis,57,58 which can
sis are associated with time-sampled changes in negative lead to hallucinations or delusions of control.19,59 There
affect. is also evidence for what Hemsley has called ‘‘disruption
to a sense of self’’60,61 in that poor use of contextual in-
formation can disrupt the ability to process ongoing
The Central Role of Appraisal
experiences.62 Kapur63,64 has recently argued that abnor-
Birchwood33 has found that appraisals of auditory hallu- malities of dopaminergic activity are related to our un-
cinations as powerful and controlling are linked to de- derstanding of the salience of experiences, and an
S26
 Cognitive, Emotional, and Social Processes in Psychosis

excess may form one of the routes to ideas of reference been able to show that nonclinical individuals may de-
in acute episodes. velop persecutory thoughts about avatars: eg, ‘‘they
We also know that people with psychosis have well- were telling me to go away.76’’ Anomalous experiences
established ‘‘cognitive deficits’’ in attention and working differentiated in normal samples between individuals
memory.65 These are factors to bear in mind while offer- who were just anxious and those who had persecutory
ing interventions but may also contribute to symptom ideas.77 Preliminary work on prodromal samples suggests
formation. Clancy et al66 in an experimental investigation that such thinking is on a continuum, as predicted from
of individuals claiming to have experienced alien abduc- earlier studies. We plan to extend this work into clinical
tion found that these experiences were related both to samples with the intention that it will inform treatment
a high rate of sleep paralysis and to false recall and approaches.
recognition deficits.

Therapeutic Approaches in Cognitive Behavior Therapy

Psychosis and the Social Environment: Triggering and (CBT) for Positive Symptoms of Psychosis
Maintaining Events
Evidence Base
A recent study reported that supportive social environ-
ments are associated with reduced positive symptoms The first description of a cognitive behavioral approach
of psychosis and that family support relates particularly to delusional ideas was provided by Beck,78 who dis-
to reduced hospital admissions up to 3 years after a first cussed his client’s persecutory ideas in a case study. How-
episode.67 Aspects of adverse family environment can be ever, Beck did not pursue cognitive research in psychosis
tapped by the expressed emotion measure, which is well at that time, and the next reports were of case studies and
established as a predictor of relapse.68 We have recently uncontrolled studies in the 1970s and 1980s. The main
found that high levels of expressed emotion in carers re- evidence for CBT for psychosis comes from the United
late to negative affect. In particular, in patients with a Kingdom and has been driven by 4 main research groups,
recent relapse of psychosis, criticism on the part of associated particularly with the names of Garety,
carers predicted anxiety but not more severe psychotic Kuipers, and Fowler in London and East Anglia, Tarrier
symptoms.69 and Bentall in Manchester, Kingdon and Turkington
It is becoming increasingly acknowledged that high in Southampton and Newcastle, and Birchwood and
rates of trauma and adversity occur before the onset of colleagues in Birmingham. These groups published a
psychosis, often years before.70–72 These studies confirm series of randomized controlled trials on CBT for psycho-
that bullying and sexual abuse are associated with nega- sis, which have now been the subject of several meta-
tive self and other schemas and with positive symptoms analyses.79–82 The last of these covered 14 randomized
such as persecutory delusions and hallucinations. There controlled trials (RCTs) (N = 1484). Studies have varied
may be a particular relationship with hallucinations, al- in their approach with some negative findings. Overall,
though direct links between trauma and hallucinatory there is an effect size of around 0.37 for CBT, with
content were relatively rare.73 Recent studies have shown best effects on improvements in persistent positive symp-
links between specific attributes of recent events and the toms. All trials include participants already on antipsy-
content of delusions and hallucinations in a first episode chotic medication. Jones et al81 call CBT ‘‘a promising
sample.74 but under-evaluated intervention.’’ There is some evi-
We have hypothesized that trauma and adversity affect dence emerging for the value of early intervention serv-
both information and emotional processing, leading to ices and for intervention in prodromal states, but there
intrusions which are then misinterpreted and appraised are few controlled trials of treatment at this stage.83–87
as symptoms of psychosis.41,75 In the United Kingdom, the National Institute of Clin-
ical Excellence published guidelines for the treatment of
schizophrenia on the basis of its own review of the evi-
Virtual Reality Studies dence in 2002.88 These recommended that CBT be offered
Alongside the above studies, we have developed novel to those with persistent positive symptoms of psychosis
virtual reality paradigms in collaboration with Professor for at least 10 sessions over at least 6 months. This guide-
Mel Slater at University College London, UK. It is pos- line will be reviewed 2006/2007.
sible to immerse people in a virtual reality ‘‘cave’’ such
that they are able to move around in virtual environments The Importance of Engagement
in real time. This allows for the control of an environment In line with our treatment manual89 and those of other
peopled with avatars (computer generated human figures groups,90–93 we have established that intervention to
that provoke emotional reactions in people in the same help people with persistent positive symptoms requires
way that cartoons do). Within these environments (a consideration of engagement and the formation of a ther-
library scene and an underground tube train), we have apeutic alliance, not just in early sessions but throughout
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E. Kuipers et al.

treatment (R. Rollinson, B. Smith, S. Steel, S. Jolley, It can also be useful to reappraise external attributions
J. Onwumere, D. Freeman, P. A. Garety, E. Kuipers, as internal states, so that individuals can recategorize
P. E. Bebbington, G. Dunn, M. Startup, D. Fowler, un- paranoid ideas as internal worries, critical voices as
published data, 2006). This entails therapists taking re- mirroring self-blaming cognitions, or as memories of
sponsibility for keeping sessions nonaversive. It also the critical voices of others.43
requires that therapists remain aware of the possibility
that the patient may have cognitive deficits such as Work on Negative Schemas and to Manage and
poor concentration, poor memory, or poor executive Reduce Stress
and planning abilities and tailor interventions appropri-
Given the research on abuse72 and its effects on schemas
ately. Sessions may need to be kept short and be con-
and views about the self, other people, and the world,41,95
ducted flexibly; adhering to a rigid agenda may not be
together with the likely increase in intrusions that can re-
appropriate. It is also likely that during sessions, an in-
sult,75 interventions may need to be attempted at the
dividual may become suspicious of the therapist or other-
schema level. Work on reevaluating underlying schema
wise distracted by cognitive distortions or intrusions such
and understanding how they continue to feed into the ex-
as voices. Therapists need to be alert to such probabilities
perience of negative voices or delusional ideas such as
to check them out and discuss them and, if possible, re-
paranoia may be particularly useful for those with histo-
assure the client, aiming in the process to reduce the am-
ries of abuse that continue to be triggered by everyday
biguities that can cause such disturbances. The aim of
events and render people vulnerable to relapse.96
sessions initially, say the first five or six, is to conduct
We know that isolated or critical social settings relate
a thorough assessment and from this to collaborate in de-
to dysfunctional affect, poor self-esteem, and increased
veloping a formulation for distressing experience that can
positive symptoms.69,43 Work on such aversive environ-
be shared by the therapist and the client. This then leads
ments can help in reducing tensions, negotiating changes,
on to appropriate cognitive and behavioral interventions.
managing disagreements, and building up more support-
ive and positive environments. If carers are involved,
Managing Affect in Hallucination and Delusions family interventions97–100 may reduce relapses of positive
We know from the research described above that depres- symptoms and improve functioning.88
sion, anxiety, and social isolation are particularly as-
sociated with the development and maintenance of Dealing With High Conviction; Helping to Compensate
hallucinations and delusional distress.42 In order to offer for Reasoning Biases
effective treatment, it is often helpful to consider assess-
We know that delusional conviction relates to JTC,52
ing and treating the affect that usually precedes and
which is in turn linked to belief inflexibility and an inabil-
accompanies distressing voices44 and trying to interrupt
ity to generate alternative explanations.54 This suggests
cycles of low mood and anxiety. Clinically, it can be seen
that for those people who hold their beliefs with strong
that introducing behavioral activity scheduling for low
conviction, it is important to work slowly on the ac-
mood can not only improve affect but may also itself re-
knowledgment that other explanations are credible. It
duce isolation and improve social networks and social
may be necessary for the therapist to provide these be-
support. Monitoring and enhancing coping strategies
cause clients may not be able to generate them for them-
for hallucinations can be helpful in reducing feelings of
selves. Testing out new explanations to see if they are
powerlessness and pessimism and improving the effec-
credible seems to be an important part of this process
tiveness of coping.29 This in itself can sometimes reduce
and should be attempted if possible.
the frequency of voices.94
Developing new strategies for clients to gather more
information before making a decision can help with
Reappraisal JTC biases and can become part of a more general style
Our model particularly focuses on the importance of of ‘‘thinking the second thought’’ before coming to a con-
reappraisal, especially of negative beliefs.46 We know clusion. We also know that disconfirmation is less com-
that delusional distress for instance is related to negative monly used as a way of testing competing theories about
illness appraisals,51 and it can be helpful to decatastroph- what is happening: individuals usually employ confirma-
ize symptoms, to discuss and manage stigma and nega- tory strategies.54 Looking instead for instances, which do
tive illness consequences, and to emphasize recovery not fit in with predictions (eg, not everyone I passed was
models.13 Trower et al,29 in an RCT for individuals looking at me), can help to counter both confirmation
with command hallucinations, found it particularly help- and attributional biases.
ful for individuals to deal directly with the consequences Therapists should try to work collaboratively with cli-
of the commands and to discover that the voices were not ents to ‘‘see what happens’’ and encourage the gradual
so powerful and controlling. Reduced distress was related dropping of safety behavior and avoidance.49 Clinical ex-
to changes in cognitions of power and control. perience suggests that this has to be done slowly and in
S28
 Cognitive, Emotional, and Social Processes in Psychosis

small steps in order to reduce dysphoria-induced worsen- 7. Jaspers K. General Psychopathology (1912). Hoenig J,
ing of symptoms of psychosis. It is a good argument for Hamilton MW, trans-ed. Manchester, UK: Manchester Uni-
versity Press; 1963.
not using ‘‘flooding’’ techniques with this population.
8. Berrios GE. The History of Mental Symptoms: Descriptive
Psychopathology Since the Nineteenth Century. Cambridge,
Conclusion England: Cambridge University Press; 1996.
9. Kemp R, Hayward P, Applewhaite G, Everitt B, David A.
We are still developing CBT for the treatment of the dis- Compliance therapy in psychotic patients: random con-
tressing delusions and hallucinations associated with psy- trolled trial. BMJ. 1996;312:345–349.
chosis. There is some evidence that it can be helpful, 10. Kane JM. Treatment-resistant schizophrenic patients. J Clin
particularly for persistent positive symptoms, and good Psychiatry. 1996;57:35–40.
evidence that it does not make things worse. It does 11. Lieberman JA, Stroup TS, McEvoy JP, et al. Clinical Anti-
not, for instance, increase suicide rates.6 Our research psychotic Trials of Intervention Effectiveness (CATIE)
Investigators. Effectiveness of antipsychotic drugs in
group has been interested in specifying a cognitive model patients with chronic schizophrenia. N Engl J Med. 2005;
of such symptoms in order to test out putative mecha- 353:1209–1223.
nisms that elicit and maintain them. Results so far pro- 12. Mueser KT, Berenbaum H. Psychodynamic treatment of
vide evidence for the influence of several of the schizophrenia: is there a future? Psychol Med. 1990;20:
hypothesized cognitive, emotional, and social factors. 253–262.
These are already improving our understanding of symp- 13. Borkin JR, Steffen JJ, Ensfield LB, et al. Recovery attitudes
tom dimensions and leading to a clearer rationale for questionnaire: development and evaluation. Psychiatr Reha-
bil J. 2000;24:95–102.
intervention. Our current study, not yet completed,
14. Garety PA, Kuipers E, Fowler D, Freeman D, Bebbington
will allow us to investigate the mechanisms of any ther- P. A cognitive model of the positive symptoms of psychosis.
apeutic change. This should in turn illuminate the pro- Psychol Med. 2001;31:189–195.
cesses involved in symptom formation and maintenance. 15. Broome MR, Wooley JB, Tabraham P, et al. What causes
the onset of psychosis? Schizophr Res. 2005;79:23–34.
Untangling worries of things that might be,
Controlling and broadcasting all about me, 16. Morrison AP. The interpretation of intrusions in psychosis:
an integrative cognitive approach to hallucinations and
The tills in the shops or a panic alarm,
delusions. Behav Cogn Psychother. 2001;29:257–276.
Untangling worries that may cause me harm.
17. Bentall RP, Claridge G, Slade PD. The multidimensional
Untangling voices for they cannot hurt nature of schizotypal traits: a factor-analytic investiga-
And I’m in control and I’m on the alert, tion with normal subjects. Br J Clin Psychol. 1989;28:
A voice has no body, it’s all an illusion, 363–375.
Untangling voices and all their confusion. 18. Tien AY. Distributions of hallucinations in the population.
Psychiatr Rehabil J. 1991;26:287–292.
Extracts from an untitled poem by Wendy Baker, repro- 19. Johns LC, Rossell S, Ahmad F, et al. Verbal self-monitoring
duced with the author’s permission. and auditory verbal hallucinations in patients with schizo-
phrenia. Psychol Med. 2001;31:705–715.
20. Freeman D, Garety PA, Bebbington PE, et al. Psychological
Acknowledgment investigation of the structure of paranoia in a non-clinical
This work was supported by a programe grant from the population. Br J Psychiatry. 2005;186:427–435.
Wellcome Trust No. 062452. 21. Romme MA, Honig A, Noorthoorn EO, Escher AD. Cop-
ing with hearing voices: an emancipatory approach. Br J
Psychiatry. 1992;161:99–103.
References 22. Davis MF, Griffin MY, Vice S. Affective reactions to audi-
tory hallucinations in psychotic, evangelical and control
1. May R. Routes to recovery from psychosis: the roots of groups. Br J Clin Psychol. 2001;40:361–370.
a clinical psychologist. Clin Psychol Forum. 2000;146:6–10. 23. Peters ER, Day S, McKenna J, Orbach G. The incidence of
2. Knapp M, Mangalore R, Simon J. The global costs of delusional ideation in religious and psychotic populations.
schizophrenia. Schizophr Bull. 2004;30:279–293. Br J Clin Psychol. 1999;38:83–96.
3. Marwaha S, Johnson S. Schizophrenia and employment: 24. Van Os J, Hverdoux H, Maurice-Tison S, et al. Self-reported
a review. Soc Psychiatry Psychiatr Epidemiol. 2004;39: psychosis-like symptoms and the continuum of psychosis.
337–349. Soc Psychiatry Psychiatr Epidemiol. 1999;34:459–463.
4. Thornicroft G, Tansella M, Becker T, et al. The personal 25. Hanssen M, Peeters F, Krabbendam L, Radstake S, Verdoux
impact of schizophrenia in Europe. Schizophr Res. 2004;69: H, van Os J. How psychotic are individuals with non-
125–132. psychotic disorders? Soc Psychiatry Psychiatr Epidemiol.
5. Palmer BA, Pankratz VS, Bostwick JM. The lifetime risk of 2003;38:149–154.
suicide in schizophrenia: a re-examination. Arch Gen Psychi- 26. Bentall RP. Madness Explained: Psychosis and Human
atry. 2005;62:247–253. Nature. London, England: Penguin; 2003.
6. Tarrier N, Haddock G, Lewis S, Drake R, Gregg L. Suicide 27. Garety PA, Hemsley DR. Delusions: Investigations Into the
behaviour over 18 months in recent onset schizophrenic Psychology of Delusional Reasoning. Oxford, England:
patients: the effects of CBT. Schizophr Res. 2006;83:15–27. Oxford University Press; 1994.

S29
E. Kuipers et al.

28. Freeman D, Garety PA. A cognitive model of persecutory 46. Green CEL, Garety PA, Freeman D. Content and affect in
delusions. In: Freeman D, Garety PA, eds. Paranoia: The persecutory delusions. Br J Clin Psychol. In press.
Psychology of Persecutory Delusions. Maudsley Monograph 47. Fialko L, Freeman D, Bebbington, et al. Understanding sui-
No. 45. Hove, England: Psychology Press; 2004:115–135. cidal ideation in psychosis: findings from the Psychological
29. Trower P, Birchwood M, Meaden A, Byrne S, Nelson A, Prevention of Relapse in Psychosis (PRP) Trial. Acta Psy-
Ross K. Cognitive therapy for command hallucinations: chiatr Scand. In press.
randomised controlled trial. Br J Psychiatry. 2004;184: 48. Freeman D, Garety PA. Connecting neurosis and psychosis:
312–320. the direct influence of emotion on delusions and hallucina-
30. Freeman D, Freeman J, Garety P. Overcoming Paranoid and tions. Behav Res Ther. 2003;41:923–947.
Suspicious Thoughts. A Self-Help Guide Using Cognitive 49. Freeman D, Garety P, Kuipers E, Fowler D, Bebbington
Behavioural Techniques. London, England: Constable PE, Dunn G. Acting on persecutory delusions: the impor-
Robinson; 2006. tance of safety seeking. Behav Res Ther. In press.
31. Craddock N, O’Donovan MC, Owen MJ. Genes for schizo- 50. Lobban F, Barrowclough C, Jones S. The impact of beliefs
phrenia and bipolar disorder? Implications for psychiatric about mental health problems and coping on outcome in
nosology. Schizophr Bull. 2006;32:9–16. schizophrenia. Psychol Med. 2004;37:1165–1174.
32. Sands JR, Harrow M. Depression during the longitudinal 51. Watson PWB, Garety PA, Weinman J, et al. Emotional dys-
course of schizophrenia. Schizophr Bull. 1999;25:157–171. function in schizophrenia spectrum psychosis: the role of
33. Birchwood M. Pathways to emotional dysfunction in first- illness perceptions. Psychol Med. 2006;36:761–770.
episode psychosis. Br J Psychiatry. 2003;182:373–375. 52. Garety P, Freeman D, Jolley S, et al. Reasoning, emotions
34. Freeman D, Garety P, Fowler D, et al. The London East and delusional conviction in psychosis. J Abnorm Psychol.
Anglia RCT of CBT for Psychosis IV: self esteem and perse- 2005;114:373–384.
cutory delusions. Br J Clin Psychol. 1998;37:415–430. 53. Peters E, Garety P. Cognitive functioning in delusions: a lon-
35. Mueser KT, Goodman LB, Trumbetta SL, et al. Trauma gitudinal analysis. Behav Res Ther. 2006;44:481–514.
and posttraumatic stress disorder in severe mental illness. 54. Freeman D, Garety PA, Fowler D, Kuipers E, Bebbington
J Consult Clin Psychol. 1998;66:493–499. PE, Dunn G. Why do people with delusions fail to choose
36. Turnball G, Bebbington P. Anxiety and the schizophrenic more realistic explanations for their experiences? An empir-
process: clinical and epidemiological evidence. Soc Psychia- ical investigation. J Consult Clin Psychol. 2004;72:671–680.
try Psychiatr Epidemiol. 2001;36:235–243. 55. Bentall R, Kinderman P, Kaney S. The self, attributional
37. Berman I, Kalinowski A, Berman SM, Lengua J, Green AI. processes and abnormal beliefs: towards a model of persecu-
Obsessive and compulsive symptoms in chronic schizophre- tory delusions. Behav Res Ther. 1994;32:331–341.
nia. Compr Psychiatry. 1995;36:6–10. 56. Jolley S, Garety P, Bebbington P, et al. Attributional style in
38. Scott H, Johnson S, Menezes P, et al. Substance abuse and psychosis—the role of affect and belief type. Behav Res Ther.
risk of aggression and offending among the severely men- In press.
tally ill. Br J Psychiatry. 1998;172:345–350. 57. Frith CD. The Cognitive Neuropsychology of Schizophrenia.
39. Keown P, Holloway F, Kuipers E. The prevalence of per- Hove, England: Lawrence Erlbaum Associates; 1992.
sonality disorders, psychotic disorders and affective disor- 58. Frith CD. The neural basis of hallucinations and delusions.
ders amongst the patients seen by a community mental C R Biol. 2005;328:169–175.
health team in London. Soc Psychiatry Psychiatr Epidemiol.
59. Blakemore SJ, Oakley DA, Frith CD. Delusions of alien
2002;37:225–229.
control in the normal brain. Neuropsychologia. 2003;
40. Keown P, Holloway F, Kuipers E. The impact of severe 41:1058–1067.
mental illness, comorbid personality disorders and demo-
60. Hemsley DR. The disruption of the ‘sense of self’ in schizo-
graphic factors on psychiatric bed use. Soc Psychiatry Psy-
phrenia: potential links with disturbances of information
chiatr Epidemiol. 2005;40:42–49.
processing. Br J Med Psychol. 1998;71:115–124.
41. Fowler DG, Freeman D, Smith B, et al. The brief core
61. Hemsley DR. The schizophrenic experience: taken out of
schema scales (BCSS): psychometric properties and associa-
context? Schizophr Bull. 2005;31:43–53.
tions with paranoia, depression and grandiosity in non-
clinical and psychosis samples. Psychol Med. 2006;36: 62. Barch D, Mitropoulou V, Harvey PD, New AS, Silverman
749–759. JM, Siever LJ. Context-processing deficits in schizotypal
personality disorder. J Abnorm Psychol. 2004;113:556–568.
42. Smith B, Fowler DG, Freeman D, et al. Emotion and psy-
chosis: direct links between depression, self-esteem, negative 63. Kapur S. Psychosis as a state of aberrant salience: a frame-
schematic beliefs and delusions and hallucinations. Schiz- work linking biology, phenomenology, and pharmacology in
ophr Res. In press. schizophrenia. Am J Psychiatry. 2003;160:13–23.
43. Barrowclough C, Tarrier N, Humphreys L, Ward J, Gregg 64. Kapur S, Arenovich T, Agid O, Zipursky R, Lindborg S,
L, Andrews B. Self-esteem in schizophrenia: relationships Jones B. Evidence for onset of antipsychotic effects within
between self-evaluation, family attitudes, and symptomatol- the first 24 hours of treatment. Multicenter study. Random-
ogy. J Abnorm Psychol. 2003;112:92–99. ized controlled trial. Am J Psychiatry. 2005;162:939–946.
44. Krabbendam L, Myin-Germeys I, Hanssen M, et al. Devel- 65. Joyce E. Origins of cognitive dysfunction in schizophrenia:
opment of depressed mood predicts onset of psychotic disor- clues from age at onset. Br J Psychiatry. 2005;186:93–95.
der in individuals who report hallucinatory experiences. Br J 66. Clancy SA, McNally RJ, Schacter DL, Lenzenweger MF.
Clin Psychol. 2005;44:113–125. Memory distortion in people reporting abduction by aliens.
45. Myin-Germeys I, van Os J, Schwartz J, Stone A, Delespaul J Abnorm Psychiatry. 2002;111:455–461.
P. Emotional reactivity in daily life stress in psychosis. Arch 67. Norman RMG, Malla AK, Manchanda R, Harricharan R,
Gen Psychiatry. 2001;58:1137–1144. Takhar J, Northcott S. Social support and three-year

S30
 Cognitive, Emotional, and Social Processes in Psychosis

symptom and admission outcomes for first episode psycho- Randomised controlled trial. Br J Psychiatry. 2004;185:
sis. Schizophr Res. 2005;80:227–234. 291–297.
68. Bebbington P, Kuipers L. The predictive utility of EE in 85. Craig TKJ, Garety P, Power P, et al. The Lambeth Early
schizophrenia: an aggregate analysis. Psychol Med. 1994; Onset (LEO) team: randomized controlled trial of the effec-
24:707–718. tiveness of specialized care for early psychosis. BMJ.
69. Kuipers E, Bebbington P, Dunn G, et al. Influence of carer 2004;329:1067.
expressed emotion and affect on relapse in non-affective psy- 86. Kuipers E, Holloway F, Rabe-Hesketh S, Tennakoon L. An
chosis. Br J Psychiatry. 2006;188:173–179. RCT of early intervention in psychosis: Croydon Outreach
70. Krabbendam L, Myin-Germeys I, De Graaf R, et al. Dimen- and Assertive Support Team (COAST). Soc Psychiatry
sions of depression, mania and psychosis in the general Psychiatr Epidemiol. 2004;39:358–363.
population. Psychol Med. 2004;34:1177–1186. 87. Garety PA, Craig TKJ, Dunn G, et al. Specialised care for
71. Bebbington PE, Bhugra D, Brugha T, et al. Psychosis, vic- early psychosis: symptoms, social functioning and patient
timisation and childhood disadvantage: evidence from the satisfaction: randomised controlled trial. Br J Psychiatry.
second British National Survey of Psychiatric Morbidity. 2006;188:37–45.
Br J Psychiatry. 2004;185:220–226. 88. NICE Guidelines for Psychological Treatment in Schizophre-
72. Read J, van Os J, Morrison AP, Ross A. Childhood trauma, nia. London, England: Gaskell Press; 2003.
psychosis and schizophrenia: a literature review with theo- 89. Fowler D, Garety P, Kuipers E. Cognitive Behaviour Therapy
retical and clinical implications. Acta Psychiatr Scand. for People with Psychosis. East Sussex, England: Wiley; 1995.
2005;112:330–350. 90. Chadwick P, Birchwood M, Trower P. Cognitive Therapy for
73. Hardy A, Fowler D, Freeman D, et al. Trauma and halluci- Delusions, Voices and Paranoia. West Sussex, England:
natory experience in psychosis. J Nerv Ment Dis. 2005; Wiley; 1996.
193:503–507. 91. Kingdon DG, Turkington D. The Case Study Guide to Cog-
74. Raune D, Bebbington P, Dunn G, Kuipers E. Event attrib- nitive Behaviour Therapy of Psychosis. Chichester, UK: John
utes and the content of psychotic experiences in first-episode Wiley & Sons; 2002.
psychosis. Psychol Med. 2006;36:221–230. 92. Kingdon DG, Turkington D. Cognitive Therapy of Schizo-
75. Holmes EA, Steel C. Schizotypy: a vulnerability factor for phrenia: Guides to Evidence-Based Practice. New York,
traumatic intrusions. J Nerv Ment Dis. 2004;192:28–34. NY: Guilford; 2005.
76. Freeman D, Slater M, Bebbington PE, et al. Can virtual 93. Turkington D, Kingdon D, Weiden PJ. Cognitive behaviour
reality be used to investigate persecutory ideation? J Nerv therapy for schizophrenia. Am J Psychiatry. 2006;163:
Ment Dis. 2003;191:509–514. 365–373.
77. Freeman D, Garety PA, Bebbington P, et al. The psychol- 94. Kuipers E, Fowler D, Garety P, et al. The London East
ogy of persecutory ideation II: a virtual reality experimental Anglia randomised controlled trial of cognitive behaviour
study. J Nerv Ment Dis. 2005;193:309–315. therapy for psychosis III: follow up and economic evalua-
78. Beck AT. Successful outpatient psychotherapy of a chronic tion at 18 months. Br J Psychiatry. 1998;173:69–74.
schizophrenic with a delusion based on borrowed guilt. Psy- 95. Fowler D, Freeman D, Steel C, et al. The catastrophic inter-
chiatry. 1952;15:305–312. action hypothesis: how does stress, trauma, emotion and in-
79. Pilling S, Bebbington P, Kuipers E, et al. Psychological formation processing abnormalities lead to psychosis. In:
treatments in schizophrenia: I meta-analysis of family inter- Morrison A, Larkin W, eds. Trauma and Psychosis. John
vention and CBT. Psychol Med. 2002;32:763–782. Wiley and Sons: In press.
80. Tarrier N, Wykes T. Is there evidence that cognitive behaviour 96. Myin-Germeys I, Krabbendam L, Delespaul PAEG, Van Os
therapy is an effective treatment for schizophrenia? A cautious J. Do life events have their effect on psychosis by influencing
or cautionary tale? Behav Res Ther. 2004;42:1377–1401. the emotional reactivity to daily life stress? Psychol Med.
81. Jones C, Cormac I, Silveira Da Mota Neto JI, Campbell C. 2003;33:327–333.
Cognitive behaviour therapy for schizophrenia. Cochrane 97. Addington J, Burnett P. Working with families in the early
Database Syst Rev. 2005;4:1–57. stages of psychosis. In: Gleeson JFM, McGorry PD, eds.
82. Zimmermann G, Favrod J, Trieu VH, Pomini V. The effect Psychological Interventions for Early Psychosis. Chichester,
of cognitive behavioural treatment on the positive symptoms UK: Wiley and Sons; 2004.
of schizophrenia spectrum disorders: a meta-analysis. 98. Kuipers E, Leff J, Lam D. Family Work for Schizophrenia: A
Schizophr Res. 2005;77:1–9. Practical Guide. 2nd ed. London, England: Gaskell Press;
83. Lewis S, Tarrier N, Haddock G, et al. Randomised con- 2002.
trolled trial of cognitive-behavioural therapy in early schizo- 99. Barrowclough C, Tarrier N. Families of Schizophrenic
phrenia: acute-phase outcomes. Br J Psychiatry. 2002; Patients: Cognitive Behavioural Intervention. London,
181(suppl 43):s91–s97. England: Chapman & Hall; 1992.
84. Morrison AP, French P, Walford L, et al. Cognitive therapy 100. Falloon IRH, Boyd JL, McGill CW. Family Care of Schizo-
for the prevention of psychosis in people at ultra-high risk. phrenia. New York, NY: Guilford Press; 1984.

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