Cognitive and Meta-cognitive Dimensions of Psychoses

Abstract

T he cognitive approach distinguishes between the normality of psychotic experiences and the later appraisal and (sub)cultural context making sense of the experience and emotional reaction to the thoughts. A key claim here is that the symptoms of a psychotic experience, for example, voice hearing, delusions, persecutory ideas, and dissociations, are all phenomena that have been experienced at one time by most people without psychosis. What makes the symptoms more persistent in the case of psychosis is a peculiar combination of emotional stress, feelings of vulnerability, threat appraisals, cognitive styles, and cultural and personal beliefs that together create distress and dysfunction about anomalous experiences.Thus cognitive models represent a sharp shift away from a medical model focusing on symptoms toward viewing the psychotic experiences as a product of an interaction of several psychological process dimensions. Further, most of these process dimensions, which include external attribution, threat appraisal, resistance to thoughts coupled with low self-esteem, and fluctuations in affective state, if taken separately, constitute also processes present in different degrees in nonclinical populations. This paper outlines cognitive approaches to understanding and treating positive psychotic symptoms, such as hallucinations, delusions, and dissociations. Recent cognitive accounts of psychosis are reviewed along with the claim that it is not the symptoms themselves but cognitive and meta-cognitive appraisals (attributions and beliefs) about the significance of the symptoms that cause distress and dysfunction. Psychotic symptoms do lie on a continuum with normal experience. Cognitive appraisal dimensions may interact with reasoning styles such as inferential confusion, cognitive slippage, fantasy proneness, and perceptual immersion (styles also normally distributed in the population) and together persuade the person with psychosis to live in fictional narratives as if they were real. Recent clinical studies suggest that addressing beliefs about symptoms modifying inferential styles and normalizing experiences may help symptom management.Can J Psychiatry. 2009;54(3):152-159. Highlights· Psychoeducation techniques normalizing anomalous experiences in psychosis could help relieve symptom distress. · Cognitive therapy may usefully target beliefs and meta-worries in response to anomalous experiences rather than the experiences themselves. · Hallucinations and delusions may not result from perceptual distortion but rather from cognitive styles, which encourage cognitive, affective, and sensory immersion in fictional narratives.that the thought has been injected into them by an evildoer, instead of treating the sensation as a maturational event.Someone who understands that stress narrows attention may well let go that they forgot an important errand when stressed. For someone who does not or cannot accept such forgetfulness, even under stress, some other unusual cause must be sought and the memory lapse means they are m...

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