Most Patients Have Self-Doubt; CBT May Help
By Icelini Garcia-Sosa, MD and Michael Garrett, MD Psychiatric Times | October 29, 2010
Most delusional patients, even those with high positive symptom scores, may have at least 1 Reason for Doubt (RFD) that precedes a clinical intervention specifically directed toward encouraging doubt. These preexisting “islands of doubt” may offer a useful foothold to begin the Cognitive Behavioral Therapy process. The therapist can initiate treatment by allying with the patient’s antecedent uncertainties; later he can challenge beliefs the patient holds with more certainty.
An estimated 25% to 50% of patients with schizophrenia experience residual symptoms, including medication-resistant delusions. These persistent symptoms contribute to the chronic, debilitating course of the illness. Delusions are defined as “fixed false beliefs” that have the following attributes:
• Certainty: held with absolute conviction
• Incorrigibility: not changeable by compelling counterargument or proof to the contrary
• Impossibility or falsity of content: implausible, bizarre, or patently untrue convictions
In addition, a delusional belief is generally not shared by other members of a person’s culture or community.
According to this definition, delusional patients would not be expected to express doubt about their delusional beliefs. However, recent research suggests that delusions in fact are multidimensional and that they vary over time in degree of conviction, distress, preoccupation, action, insight, and interference with daily functioning. Some of the factors thought to contribute to the origin of delusions and maintenance of delusional conviction are belief inflexibility and a “jumping to conclusions” bias.
Studies have shown that cognitive-behavioral therapy (CBT) reduces acute and medication-resistant psychotic symptoms, including delusional beliefs. In this setting, CBT aims to enlist the patient in a collaborative investigation of evidence for and against his or her beliefs.
The clinician attempts to separate event from belief about event by gently kindling doubt about the delusions and therefore decreasing the patient’s belief inflexibility. Garety and colleagues found that among patients who received CBT, the ability to acknowledge “the possibility of being mistaken” about their delusional beliefs was a strong predictor of success of therapy.
While CBT for psychosis attempts to increase the patient’s doubts about his delusional beliefs during treatment, little is known about preexisting doubts patients may harbor before receiving CBT.