“The great thrill,” Beck recently confided, “has been in showing that an individual’s beliefs, attitudes and expectations play a far more important role in the negative symptoms and poor social and occupational functioning in schizophrenia than does the neurocognitive impairment."

From Breakthroughs, 2010

Aaron Beck, M.D., a NARSAD Distinguished Investigator, is probably the most famous psychotherapist alive today. The system of treatment he created 40 years ago, cognitive therapy (CT) — frequently called cognitive behavioral therapy (CBT) — is used all over the world in the treatment of a broad range of mental illnesses. It has improved the lives of countless thousands of suffering people. Now, at 88, Dr. Beck has chosen to tackle what many believe to be the hardest problem in mental health: the untreated symptoms of schizophrenia.

A major advance in schizophrenia treatment came with the introduction, in the 1980s, of a second generation of antipsychotic drugs that significantly improved so-called positive symptoms of the illness — hallucinations and delusions.  While positive symptoms are the most initially apparent and frightening manifestations of schizophrenia, it is negative symptoms — the loss of volition, the flat affect and social isolation — that are ultimately the most debilitating. Negative symptoms are typically exacerbated by neurocognitive problems, which include deficits in memory, attention and decision-making.

In his work as director of the psychosocial schizophrenia research unit at Penn, Beck has come to recognize that “the cognitive deficits are important, but more important is the reaction of the individual to all the psychological and social problems, the stigmatization, the bullying, and such. Rather than trying to find some magic bullet to fix the cognitive problems, we get patients to deal with their negative beliefs.”

In 2006, Beck was granted a NARSAD Distinguished Investigator Award for a pilot study to evaluate the effectiveness of the form of therapy he pioneered, CBT, in countering the negative symptoms. The study won’t be fully completed until 2011. But based on preliminary results — not to mention six decades of hands-on experience — the doctor says he is “optimistic.”

Entrenched, automatic misperceptions often the root of difficulties

In the chain of causality in schizophrenia, each negative symptom is associated with a characteristic set of negative thoughts. For example, with the symptom that therapists called avolition — a lack of drive or desire — the patient expresses low expectation of success or pleasure. “Why bother, I’m just going to fail,” the patient says, “so it’s best not to get involved.” With the symptom therapists call alogia — problems in verbal expression — the thinking goes: “I’m not going to find the right words”; “I’m slow and it’ll be boring and I’m going to sound stupid or weird.” The typical flattened affect seen in people with schizophrenia masks such fears as: “If I show my feelings, people will see how inadequate I am”; or, “I don’t feel the way I used to”; or “My face looks stiff and contorted.”

Participants in Beck’s NARSAD trial are chronically ill, mostly poor and unemployed, often homeless and without family support. Randomized to receive either CBT or standard treatment, which includes antipsychotic medication and a range of social services provided by Philadelphia, they attend weekly sessions for a year and their progress is assessed every six months for two years thereafter. Paul Grant, Ph.D., who co-directs Penn’s psychosocial schizophrenia research unit, explains: “We developed the hypothesis that a missing link in the chain of causality might be a person’s belief in the inevitability of failure.”

CBT helps patients identify and correct entrenched, automatic misperceptions at the root of their difficulties. And not only in schizophrenia. With or without drug treatment, CBT has been shown to be effective in easing depression, bipolar disorder, eating disorders, obsessive-compulsive disorder, drug abuse, suicidal thinking, and more. Several of the scientists highlighted in this issue of Breakthroughs use versions of CBT adapted for their particular patient populations.

An individualized approach

How do Beck and colleagues approach a patient who tells them, “There’s no point in trying”?

Dimitri Perivoliotis, Ph.D., a research associate in the Penn program, who works closely with patients and therapists on Beck’s pilot study, says that because most of the patients are impaired, some severely, therapists have had to be “pretty creative” in adapting treatment. “For example,” he says, “we’ve used electronic aids, programmable alarm watches or Palm Pilots set to go off at different times of the day. Many of the patients are very inactive, so these wake them up and remind them to go to treatment, call a friend, look for a job. Families love these. One mother says she’s happy when the Palm Pilot goes off because ‘it gets him off the couch.’”

“We need to use a variety of methods that particularly fit the patients’ level of functioning and their interests,” Dr. Beck says. “For example, one therapist frequently uses computer games to get patients engaged in an activity. All patients have problems with attention, and this type of activity can capture their attention, and it can also provide a ‘mastery experience’ as they find that with practice they can do increasingly better

” At each treatment session, patient and therapist set goals and an action plan for the next session. Perivoliotis cites a patient whose goal was to return to school, but with little hope of success or pleasure because he couldn’t concentrate on reading. With the therapist’s support, he agreed to try to read a small excerpt on a subject he liked. Before he started, he was asked to rate how much he thought he would enjoy the reading. He answered “zero.” He was then asked what he thought he would score on a quiz afterward. He predicted 10 percent. After the reading, he raised his pleasure rating to 40 percent, and he scored 70 on the quiz. In another case, a patient afraid to talk to people agreed to practice “small talk” with the therapists although he was sure he would fumble for words and freeze. “He was a bit slow,’ Dr. Perivoliotis says, “but he was able to keep the conversation going for the duration of the session, and afterward rated his pleasure at 50 percent

” A number of patients, although stabilized on antipsychotics, have residual paranoid feelings. “With one,” Perivoliotis says, “the Palm Pilot reminds him to do a technique we call the three Cs: Catch it, Check it, Correct it. It’s a way to help him distance himself from his paranoia.” Look, Point, Name is another simple but effective device. The patient is directed to select an object in the room to look at, which concentrates the visual system; then to point to it, which engages the motor system; then to name it: ‘doorknob.’ “It’s a way of damping down auditory hallucinations and, at the same time, it demonstrates to patients that they have some control over the voices,” Beck explains.

Beck has a warm spot for one patient who was almost completely nonfunctioning and spending all her time calling the FBI because, she thought, people were trying to kill her. One of the therapists got her interested in making coffee. Now when she comes in for her session, she makes coffee for the people on the second floor and then the people on third floor and then some others. “Serving coffee makes her feel benevolent toward people and they in turn are benevolent toward her and she forgets that they’re trying to kill her.

“Simple, isn’t it?” says Beck.

Concerning the NARSAD trial, based on the evidence of the first group of patients now nearing completion, Dr. Grant says: “We have evidence that it’s working pretty well. It looks like the folks in the CBT group are functioning better compared to the control group. What’s very important is that they appear to be doing better on the neurocognitive tests. We need to complete follow-up. We should have that data soon.”