A Cognitive Model of Schizophrenia

Aaron T. Beck
University of Pennsylvania
Philadelphia
The poor reality testing and the thinking disorder in schizophrenia may be attributed to a
deficiency in cognitive resources related to the neurobiological deficiencies. Recent therapy
and research have demonstrated that, far from being a bizarre psychologically incompre-
hensible phenomenon, schizophrenia can be understood within our conventional
conception of human nature. This humanizing trend is especially evident in the cognitive
approaches to this disorder. Research has established that there is a continuum from nor-
mal experiences of paranormal beliefs, hallucinations, thinking problems, and withdrawal
to their counterpart in schizophrenia. The kinds of biases in schizophrenia are also evi-
dent in common social problems such as prejudices and ethnocentrism as well as in
interpersonal strife. Dysfunctional attitudes about attachment and performance in schiz-
ophrenia form the infrastructure for persecutory delusions and negative symptoms,
respectively. Grandiose delusions, on the other hand, are shown to be an overcompensation
for a sense of loneliness, inferiority, and vulnerability.
Keywords: schizophrenia; delusions; hallucinations; negative symptoms; cognitive
therapy
T
he investigation of the cognitive factors in psychosis is still at a relatively early stage
of development and has been largely obscured by the mass of neuro-anatomical,
neuro-cognitive, genetic, and pharmacological studies. Despite the relatively low pro-
file of the psychological approaches (especially of the cognitive factors) in psychosis, steady
progress has been made as indicated by the articles in this issue. Various researchers such as
Richard Bentall (2003) have steadfastly pursued studies for more than 2 decadesin the face
of the dominant biological orientation in the field.
The articles in this issue are important for at least two major reasons. First, these arti-
cles demonstrate that, despite a common notion that psychotic symptoms are beyond com-
prehension, they are understandable within the framework of what is known about human
nature generally and clinical disorders such as depression and anxiety, specifically. These
articles demonstrate that the same clinical and research strategies used in exploring the
structure of the nonpsychotic disorders can be utilized in understanding psychosis. Thus,
they have established commonalities extending from the psychological aberrations in normal
behavior to the more pronounced distortions in the nonpsychotic disorders to the extreme
deviations in psychosis. This approach has had a humanizing influence on the way we see
patients with psychosis: We view these patients as similar to the rest of us, struggling with
the same kinds of problems and experiencing the same types of distress, albeit that because
2004 Springer Publishing Company 281
Journal of Cognitive Psychotherapy: An International Quarterly
Volume 18, Number 3 2004

of particular vulnerabilities, they have psychological experiences that the rest of us experi-
ence rarely or only under severe stress. These experiences in patients are far more devastat-
ing then the occasional mental lapses in the general population.
Second, a major contribution of these articles is their practical application to the treat-
ment of psychosis. They provide the important formulations not only for understanding
delusions, hallucinations, negative symptoms, and thought disorder, but also for modifying
them. They show that the significant biases in the way patients process information distort
their interpretations of their internal experiences and their interactions with other people.
This roadmap then provides the clinician with a specific guide of where and when to inter-
vene with the patients.
CONTINUUM FROM NORMALITY TO PSYCHOSIS
There is considerable evidence from community surveys and population studies that the
symptoms associated with schizophrenia are not experiences with nothing in common
with usual experiences. Surveys show that the symptoms generally ascribed to psychosis
are experienced by a significant number of people who are not mentally ill (e.g., Barrett,
1992; Johns, Nazroo, Bebbington, & Kuipers, 2002; Romme & Escher, 1989). Only when
these experiences become intensified and pervasive and produce distress and/or unusual
behavior and involve some attenuation of insight is the diagnosis psychosis made.
Studies have shown, for example, that many adolescents have auditory hallucinations but
they transition into schizophrenia only if they have delusions about voices (e.g., coming
from the devil) (van Os, Hanssen, Bijl, & Ravelli, 2000; Verdoux et al., 1998). Similarly,
although suspiciousness is widespread, it generally does not develop into the paranoid
thinking of psychosis unless it is constant and generalized. The typical thinking disor-
der manifested by some patients with schizophrenia (e.g., overgeneralization, arbitrary
inference) is also experienced to a lesser degree and only intermittently by the population
at large.
Thus, we can trace a continuum on the severity dimensions extending from the mild
phenomena generally identifiable within the normal population to the more salient of those
typical of psychosis. The greater severity plus the greatly diminished objectivity toward the
unreality of the experience constitutes the psychosis. A person with social phobia may state
I think everyone is judging me, whereas the patient with psychosis states I know that they
are judging me.
The continuity between the symptoms of the population at large and those of the patient
with psychosis is paralleled by a comparable continuum in the progression of subclinical
symptoms in the prodromal to full-blown psychosis. Patients with auditory hallucinations,
for example, have frequently experienced them during an earlier prepsychotic period. Also,
their tendency to make delusional interpretations is frequently manifested in a subtle form
in the nonpsychotic period. Early indications of social withdrawal may be detected prior to
the full-blown negative symptoms, such as amotivation, alogia, and withdrawal.
The kind of paranormal ideas that are often woven into delusions (e.g., clairvoyance,
thought projection, etc.) is also common (Peters, Joseph, & Garety, 1999). Of especial
interest is the clinical observation that many patients who believe in thought capture,
thought insertion, and mind reading had these beliefs prior to their psychosis. As the psy-
chosis develops, however, these beliefs move to the center of their information processing
and are used inappropriately as explanatory constructs. The patients, for example, attrib-
ute unexpected blanking of thoughts or intrusion of obsessive thoughts to interference by
an external agent. Similarly, they draw on their beliefs regarding extrasensory perception
to explain coincidences such as another person uttering what they were thinking at the
282 A Cognitive Model of Schizophrenia

time. Also, there is a continuity between the patients usual thought content and their
more flagrant symptoms. Investigators have shown, for example, that in many cases, the
content of auditory hallucinations reflects the automatic thoughts of patients (Beck &
Rector, 2003).
BIASED THINKING, DELUSIONS, AND HALLUCINATIONS
The symptoms of psychosis can be analyzed in terms of the various biases in thinking.
These biases are reflected in the selective attention to specific aspects of their experiences
as well as in their misinterpretations. Three kinds of biases in psychosis may be identified.
First, the thinking in schizophrenia is dominated by an egocentric bias (Temple, this issue).
The patients relate a host of irrelevant events to themselves and consequently attach a per-
sonal meaning to impersonal or irrelevant events. A patient, for example, had always been
self-conscious and acutely aware of other people in social situations. He felt that every-
ones eyes were on him. When he became psychotic, this conception extended to the con-
viction that he was continually being watched or even followed. He was comfortable only
when alone. When they develop schizophrenia (particularly of a paranoid nature), these
patients are essentially in a survival or vulnerable mode. They perceive themselves at
the vortex of a hostile environment. They become hyperattentive and hyperreactive to
much of their animate environment. It is as though they are being constantly evaluated and
therefore subject to verbal or physical attacks. Of course, in some cases, the patients eval-
uate others as protectors or champions but even then, this benign appearance often
changes to malevolence. The belief that people are unfriendly leads to an expectancy of
being attacked. As the expectancy becomes stronger the patients misinterpret even friend-
ly behavior of other people as hostile. The dysfunctional attitudes lead to the typical bias-
es observed in psychosis.
At the same time the belief that other people are dangerous or contemptuous leads to
an externalizing bias. The belief that other people are hostile leads the patients to scan their
environments for signs of danger and to prematurely jump to conclusions that they are
being influenced or harmed. The externalizing bias is expressed in the construction of
causal explanations. We all are concerned about what factors may be responsible for our
personal distress and, indeed, may mistake the true causality at times. The patients with
schizophrenia tend to overattribute causality to external entities (other people or supernat-
ural entities) to the exclusion of much more obvious accidental or internal causes. Any dis-
tressing feeling is due to an external agent. Thus, a patient interpreted the late delivery of
his mail as due to an interference by the FBI. He also attributed a bout of stomach cramps
to a death ray from an enemy. Interestingly, despite these patients suspiciousness and para-
noid thinking, they endorse most of the Dysfunctional Attitude Scales (DAS) sociotropic
items, including concern about others evaluations and wanting to pleasure others (Rector
& Beck, 2004).
It is possible to show that although the symptom domains (delusions, hallucinations,
and negative symptoms) appear to be distinct, they all arise from common sets of core and
derived beliefs. When they are fully developed, they are expressed largely in separate
domains: sensory (auditory/visual), cognitive (delusions), and behavioral (negative symp-
toms). Starting with the most basic (or core) belief, we can determine that the patients regard
themselves as vulnerable and others as contemptuous or dangerous. These concepts, embed-
ded in schemas, mold their biased interpretations of events. As they make repeated evalua-
tions of being diminisheddebased, deprived, discriminated againstthese soft beliefs
harden into absolute beliefs. The initial ad hoc beliefs are transformed into dominant, per-
vasive convictionsfor example, I am being watched/followed/influenced/debased.
Beck 283

The end result of this process is the formation of delusions, which control the informa-
tion processes, at least in certain domains and thus lead to the biased interpretations. When
the belief incorporates a presumed causal agent (FBI, mafia, aliens), the delusion has an even
more profound impact on the patients feelings and behavior. The formation of hallucinations
may follow a similar pathway. The belief in ones vulnerability and other peoples antagonism
leads to a variety of frightening thoughts. These are perceptualized and consequently experi-
enced as hallucinations (Beck & Rector, 2003). This sequence is illustrated in Figure 1.
THE NEGATIVE SYNDROME: A COGNITIVE SYNTHESIS
Writings on schizophrenia have traditionally emphasized the so-called negative symptoms
as a manifestation of a deficit or impairment across cognitive, affective, and behavioral
domains. The patients are impoverished in affect, motivation, social interest, speech, and
even in the content of their thought. There is, however, an alternative cognitive model to the
deficit or neurocognitve model for these symptoms. We know, for instance, that these
patients feel hurts deeply, and although they do not indicate having much pleasure or satis-
faction in life, they do acknowledge these emotional responses in experimental situations
(Earnst & Kring, 1999). Moreover, the lack of pleasure may not be specific to the negative
syndrome. Both the reduction of pleasure and the flattening of facial expression could be
explained as a manifestation of a chronic mental set. Like patients with acute depression,
their relatively stable expectation, possibly reflected in their relatively immobile facial
expressions, is that they will not get much pleasure out of anything. Unlike the depressives,
however, they do not necessarily have an expectation of continuing unremitting pain, per-
haps because their cognitive and behavioral strategies (detachment, avoidance, etc.) protect
them from the kind of pain experienced by depressives. Of course, patients who have the
284 A Cognitive Model of Schizophrenia
VULNERABLE
+
PEOPLE ARE DANGEROUS
SELF-CENTERED BIAS
+
EXTERNALIZING BIAS
DELUSIONS HALLUCINATIONS
Figure 1. The common features of positive symptoms.

negative syndrome also can become depressed and experience the typical depressive symp-
toms including suicidal impulses and suicide attempts.
Empirical findings on the Dysfunctional Attitude Scale (Rector & Beck, 2004), as well
as in-depth clinical interviews, suggest a new way of viewing these negative symptoms.
Specifically, we propose that certain active psychological processes contribute to what seem
on the surface to be simply deficiencies.
It is certainly true that these patients do not perform well on certain neurocognitive
tests, such as card sorting, and consequently seem to have a significant impairment in basic
neurocognitive functions. However, these cognitive impairments do not, in themselves,
account for the negative expectations, for one. We suggest that a complex series of interact-
ing events involving the individuals psychological, social, and intellectual handicaps pro-
duce dysfunctional attitudes that may reinforce the limitations on intellectual functioning and
lead to the clinical negativity picture. First, patients infer (sometimes correctly) that they are
consistently being evaluated negatively for their behavior (internalizing bias). Because they
have cultivated social withdrawal as a mechanism for relieving social distress, they volun-
tarily detach themselves from others (a safety behavior). They have learned to insulate
themselves from social embarrassment through disengagement until it becomes practically a
reflex reaction. Thus, verbal inhibition is manifested as a poverty of speech. An automatic
process of social withdrawal is activated and is especially prominent in social interactions.
Because this process is automatic, the patients may not even be aware of its operation. Most
of these patients have always been shy (by their own statement), and I have observed they
have taut faces under social pressure. The automatic inhibition of facial expressions may be
a manifestation of shyness in these cases.
Thus, social withdrawal, paucity of speech, and inhibition of facial expression may be
viewed as components of the disengagement process. Another negative symptom, the obvi-
ous lack of motivation to engage in complex activities, can be understood partly in terms of
their negative beliefs about their performance and expected negative evaluation for poor per-
formance. They endorse the item on the Dysfunctional Attitude Scale (Rector & Beck, 2004)
Its better to do nothing than to risk failure. They also equate failure on a single task with
being a failure as a person. Their automatic loss of constructive motivation represents a
retreat into safetya strong avoidance of engaging in activities that would lead to
Beck 285
SENSITIVITY TO NEGATIVE PERFORMANCE EVALUATION
IF I CANT DO WELL, IM A FAILURE
DISENGAGEMENT (SAFETY BEHAVIOR)
FLAT AFFECT AMOTIVATION WITHDRAWAL
Figure 2. Sequence in development of negative symptoms.

further self-devaluation. This urge to avoid possible failure overrides any motivation to
engage in constructive actions (Figure 2). Of course, there are other contributing factors in
operation. These patients function on the assumption that they have meager resources and,
consequently, attempt to conserve these resources through inactivity. Interestingly, they tend
to view their personal world as devoid of personal satisfactions and themselves as lacking in
positive assets rather than possessing negative attributes.
In a typical case, a shy adolescent finds it difficult to form a bridge between himself and
his peers. This social disability together with, in many cases, some cognitive impairment pro-
vides the matrix for a number of dysfunctional attitudes: a basic belief of being inferior and
socially (and perhaps intellectually) inept. Being teased or bullied reinforces this belief.
These core beliefs shape the goals and the kinds of strategies used by the patient to maintain
a safe adjustment. These strategies consist of active avoidance of social interactions, a way to
protect the patient (often unsuccessfully) from shame and other forms of pain. This kind of
coping strategy may be distinguished from that of the social phobics, who strongly desire
social interactions and, indeed, maintain the active goals of having an expanded social life
as long as they are not exposed to the possibility of disapproval. In contrast, the patients with
negative symptoms relinquish the social goals in order to reach a more tolerable comfort
level.
There is also evidence that these patients with negative symptoms have certain impair-
ments of cognitive and perceptual skills (such as recognizing other peoples emotional dis-
plays; see Penn, Corrigan, Bentall, Racenstein, & Newman, 1997). These impairments result
in poor cognitive tuning manifested in missing the more subtle cues in other peoples
behavior and thus interfere with interpersonal relations. Thus, the problem of the patients
lifelong shyness is compounded by his social estrangement. The ultimate outcome is a with-
drawal from social interactions, a kind of behavior that becomes automatic and habitual, but
not necessarily irreversible (see Figure 2).
THE NEGATIVE MODE/SCHIZOID PERSONALITY DISORDER
The continual interplay of characterological and experiential factors leads eventually to the
formation of what we propose to label the negative mode. A mode has been defined as a
suborganization of the personality consisting of structures (or schemas) relevant to cogni-
tion, affect, and motivation (Beck, 1996). At the core this mode is the patients belief (con-
solidated by adverse social experiences) that he is different, inferior, and inept. To a lesser
extent, others are perceived as distant and often critical. In response to these core beliefs, he
builds up a series of conditional beliefs such as, If I expose myself, I will get hurt, and
Other people regard me as different and undesirable.
These beliefs lead to rules and goals distancing himself from social interactions (which
are risky) and avoiding demanding tasks at which he might fail. In a sense, the passivity and
relative immobility are security operations. The prominent feature of the negative mode is
the apparently immutable withdrawal. It is as though some archaic protective mechanism
has been activated and gained ascendance over a normal adjustment to the real world. The
cognitive, affective, motivational, and behavioral components are embedded in specific
structures (schemas), which are integrated into the mode. When the mode is activated, then
the component parts are manifested as the totality of the clinical picture of the negative syn-
drome. Since this mode becomes so strongly entrenched, it appears irreversible. It is possi-
ble, however, to reduce the salience of this mode and to energize certain compensatory
mechanisms. Both pharmacotherapy and cognitive therapy have been shown to reduce the
negative symptoms (Dickerson, this issue). In terms of the cognitive model, these interven-
tions attenuate the negativity mode and reenergize more productive modes.
286 A Cognitive Model of Schizophrenia

For many patients, the negative mode permeates the entire personality. We find that the
negative symptomatology in these cases is in the surface expression of a long-standing per-
sonality structure, which has been traditionally labeled schizoid personality disorder.
Thus, these personality traits become exacerbated as the patient slips into psychosis and
remain after the psychosis has remitted. For other patients, however, the negative mode is
more encapsulated and becomes less active or even inactive during remission of the positive
symptoms.
CONCLUSION
One of the challenges in developing a psychological model of schizophrenia is to find a uni-
fying principle including the positive and negative symptoms as well as the neurocognitive
deficits. One approach is to examine the role of attenuated psychological resources in indi-
viduals with psychosis. This deficiency may be formulated in neurophysiological terms as a
profound loss of synaptic connections during the patients adolescence (McGlashan &
Hoffman, 2000), but it may also be framed in terms of the impoverishment of basic functions
involved in information processing and interpersonal interactions. The relative inadequacy
of reality testing during adolescence leads to uncritical integration of paranormal beliefs. The
same functional impairment later allows the transformation of persecutory or grandiose
beliefs into delusions. Further, the normal inhibitions of the perceptualization of cognitions
during the waking period is attenuated. This allows hypersalient cognitions to be trans-
formed into auditory hallucinations, so that these cognitions are heard rather than
thought during sleep (Beck & Rector, 2003). The totality of the negativity syndrome may
also be viewed as a reaction to the perceived reduction in resources. The patients follow the
line of least resistancesocial and emotional withdrawalas a kind of conservation meas-
ure. The proximal factors in this generalized inhibition are beliefs regarding their lack of
competence and fear of failure, leading to a retreat into passivity and noninvolvement.
Finally, the various deficits on neuropsychological tests are an obvious manifestation of the
patients meager resources. They have problems mobilizing their attention and reasoning and
often will seek the easiest responses, even though they are incorrect.
In sum, the relatively meager resources may be considered the common denominator of
the positive and negative symptoms and the cognitive dysfunction. Further research is obvi-
ously necessary to test out this hypothesis. However, we do know from clinical trials and
experience that the impoverishment is not absolute. Pharmacotherapy has been shown to
neutralize the disturbed brain physiology, and psychosocial interventions have been suc-
cessful in mobilizing the patients latent resources to improve their reality testing and their
interpersonal functioning. By focusing on the patients latent resources (or neuroplastici-
ty), clinicians can help to move them to a more fulfilling, less distressing life.
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288 A Cognitive Model of Schizophrenia

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