CLINICAL HANDBOOK OF SCHIZOPHRENIA

8. Psychosocial Factors 79This model of cognitive, emotional, and social process in schizophrenia is currently beingtested.CLINICAL MANAGEMENTIt is clear that social reactivity is often a central feature of schizophrenia: either too muchor too little stimulation. Too little input on the one hand and we have evidence that peoplewith schizophrenia (as do others) have increasing amounts of negative symptoms,such as reduced motivation. Too much stimulation, on the other hand, particularly ifanxiety provoking, appears to be able to trigger renewed symptoms. Some of the lifeevent literature adds to this by suggesting that, for some people with schizophrenia,events, particularly those with an intrusive content, might be particularly likely to lead tosymptoms of paranoia over a relatively short time period.The first-line treatment for schizophrenia is medication, which is discussed in detailin Chapters 16–19, this volume. One of the functions of medication is probably todampen down social reactivity (i.e., the interaction of the cognitive and emotional processingof stresses in those vulnerable to episodes of schizophrenia). Given that stress andlife events cannot readily be eliminated, use of medication in effect to reduce this socialsensitivity may be an effective alternative.In addition to medication (which is often incompletely effective), there is evidencefor the effectiveness of psychological interventions.If there are foreseeable life events, monitoring someone’s reaction to events and discussingthem can be helpful in reducing negative appraisals. Extra medication and supportare indicated until emotional reactions have subsided.Events that are particularly upsetting because they trigger preexisting cognitions,negative schemas, or emotional vulnerabilities can be explored and reviewed, as in treatmentsfor depression. Cognitions such as “I am useless”; “The world is an evil place”;and “I’m never going to recover” can be evaluated and the evidence for them reexamined.If possible, forthcoming events should be thought through or minimized, if there is achoice, for instance, about taking a trip or making a life-changing decision. However, itmay be argued that a life free of events or stress is not much of a life, and that peopleshould be supported, if possible, through events and their possible negative reactions,rather than totally avoiding them.COGNITIVE-BEHAVIORAL THERAPY FOR PSYCHOSISThe evidence is that cognitive-behavioral therapy (CBT) approaches to medicationresistant,positive symptoms of psychosis such as delusions and hallucinations are moderatelyeffective, particularly if continued for at least 6 months. This is now a recommendedtreatment in the United Kingdom, according to National Institute of ClinicalExcellence (NICE) guidelines produced in 2003. Such treatments focus on engaging clients,discussing their view of events, and formulating a joint model of the interactionof certain life experiences (including negative schemas) with current concerns, emotionalreactions, and their appraisal. The emphasis is primarily on increasing understanding,making sense of the experience, and reducing distress. There is evidence thatthis may also reduce the frequency of hallucinations and sometimes allow the level ofconviction in distressing delusions to attenuate. The latter can be accomplished byhelping people to increase their cognitive flexibility, to consider alterative views and