In and out of schizophrenia: Activation and deactivation of the negative and positive schemas - Beck et al. (2017) - Article

Schizophrenia has positive and negative symptoms that are both analysed using a traditional cognitive model. The model exists of the cognitive triad: schemas about self, world and the future. When interventions are made, they should target the meaning behind both positive and negative symptoms. However, in the current system, the content for both symptoms is similar. The view of the self is weak, vulnerable, ineffective and worthless. The view of others as controlling, dangerous and rejecting.

What are cognitive schemas?

Cognitive schemas are responsible for cognitive organization. The content originates from the cognitive triad. If schemas interfere with accommodation in life situations, they are called dysfunctional. If schemas are extreme of fantastic, they are called delusional.

How do cognitive schemas affect symptoms of schizophrenia?

Schizophrenia can develop due to a genetic predisposition in combination with the development of negative thoughts and stressful life-events. These negative thoughts become embedded into cognitive schemas and a person can develop negative symptoms, such as withdrawal, violence and isolation. On the other hand, positive symptoms can come from dysfunctional symptoms and get transformed into delusions. These symptoms start with an overstimulation of the HPA axis which leads to an excessive output of cortisol. That leads to an overflow of dopamine and the development of hallucinations.

Motivation is one of the main factors in developing negative symptoms. There are two ways that motivation affects the symptoms, in belief and expression.

1. Factor 1 of negative symptoms: amotivation factor. This symptom comes from a dysfunctional belief about the self. The self-image is focused on weakness, worthless and helplessness. To avoid pain and frustration, symptoms like avoidance and distancing arise. It is possible to get above these thoughts, for example when a positive expectation overrides the negative attitude.
2. Factor 2 of negative symptoms: expressive factor.  These symptoms evolve because of inhibition of behavioural responses. It includes inhibition of speech or general motor activity.

What is the empirical basis for the cognitive model of negative symptoms?

Evaluation of the self has an influence on negative symptoms. Positive evaluations lead to less negative symptoms. On the other hand, dysfunctional beliefs correlate to the severity of negative symptoms. It was found that a lower self-efficacy leads to more severe negative symptoms. The three components of the cognitive triad (self, others and future) express themselves in specific situations in the context of task orientation, pleasure, interpersonal relations and energy.

Negative symptoms are related to beliefs about the future, negative thoughts about task performance or future success corelate with severe negative symptoms. Individuals that have the deficit syndrome (more severe negative symptoms) have more defeatist beliefs then those that do not experience severe negative symptoms. Furthermore, a decrease in the expectation of pleasure can contribute to more negative symptoms. Asocial beliefs also play a role and correlate with asociality in schizophrenia.

How are positive symptoms developed?

Development of positive systems is labelled the transformational or imaginal system. It is isolated from other cognitive functions. The connection with the cognitive triad is the same. It is based on an exaggeration of fears or fantasy. However, negative symptoms represent expectancy of failure whereas positive symptoms embody the basic universal needs such as acceptance. Symptoms can become less prevalent after a series of positive experiences or by becoming part of an active social network. By helping other people both negative and positive symptoms can be reduced. Automatic thoughts can be positive, critical or about other people and events. These command hallucinations are often ascribed to a powerful individual such as god. They also reflect an exaggerated fear.

What is the empirical basis for the cognitive model and positive symptoms?

Delusions

Research has shown that negative cognitive schemas about the self, predict positive symptoms. It is suggested that negative symptoms occur before positive symptoms. A lower self-esteem and more negative evaluations result in delusions and greater suicidal ideation. Beliefs about the self being powerful lead to decreased distress. Beliefs about other correspond to more severe hallucinations. People with schizophrenia tend to believe they are inferior to others. Consequently, negative beliefs about the future result in the expectation of criticism and rejection. Negative self-esteem and expectations showed a high correlation with paranoid delusions.

Voices

Low self-esteem correlates with automatic thoughts (voices). Negative beliefs about these voices corresponded to negative self-evaluations. For example, malevolence, omnipotence, metaphysical beliefs and loss of control. These evaluations also reflect on thoughts about others. Interpersonal relationships are an important predictor in hearing voices. Individuals that feel inferior to others in life, also tend to feel inferior to the voices they experience.  

What is the concept of mode?

A mode is a situation-specific cognitive system including affect, motivation and behaviour. There are two modes:

1. The adaptive mode is active when someone is playing a game or listening to music
2. The “patient” mode is more active in schizophrenia patients and consists of negative attitudes. The motivation is to avoid and escape and resulting behaviour is withdrawal.

The goal of therapy is to diminish the expectation of failure when starting a task. Therefore, the individual should experience something as a success, rather than a failure. At times people can shift between modes, when delusions are happening people can show personalities that contrast to when they are in patient mode of inactivity. When patients are engaged in something meaningful, the patent mode is not longer present. Then the adaptive mode is activated. When this mode is activated for longer periods, this leads to cognitive restructuring and positive beliefs about experiences.  

What do the researchers conclude?

Both positive and negative symptoms of schizophrenia are related to the cognitive triad and more specific: the negative cognitive triad. Most literature focused on the negative symptoms. However according to this article, positive symptoms arise from the same nature. Therefore, it is important to use the cognitive model for delusions as well. Using the cognitive model for delusions and hallucinations can contribute to treatment. The observation that activation of positive beliefs lead to replacement of the patient mode with the adaptive mode can be used in cognitive therapy. More research should be done to stress the importance of activation of positive adaptive beliefs, rather than deactivating negative and dysfunctional beliefs.

BulletPoints:

• Cognitive schemas are responsible for cognitive organization. The content originates from the cognitive triad. If schemas interfere with accommodation in life situations, they are called dysfunctional. If schemas are extreme of fantastic, they are called delusional.
• A mode is a situation-specific cognitive system including affect, motivation and behaviour. There are two modes:
  1. The adaptive mode is active when someone is playing a game or listening to music
  2. The “patient” mode is more active in schizophrenia patients and consists of negative attitudes. The motivation is to avoid and escape and resulting behaviour is withdrawal.

ExamTickets:

• Make sure you can explain the (negative) cognitive triad and the relationship between this and the existence of negative and positive symptoms of schizophrenia.
• You should be able to explain how treatment of schizophrenia can benefit from the distinction between adaptive and patient mode.