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A Case Study: Cognitive Behavioural Approach in the Treatment of Schizophrenia

Tanis Payne

Yorkville University

PSYC 6333: Psychopathology for Counsellors

Dr. Kelly Collins

February 11th, 2024

A Case Study: Cognitive Behavioural Approach in the Treatment of Schizophrenia

A Beautiful Mind, based on a true story, depicts the life of John Nash, a mathematician

struggling with schizophrenia (Howard, 2001). He attends Princeton University, where he works

tirelessly to develop an original idea for a paper to get published, which creates much stress and

pressure. While dedicated to being a mathematician, he engages in a few social events. His

schizophrenic symptoms appear as delusions and hallucinations as he battles his thoughts and

behaviours between reality and non-reality. John gets an opportunity to work with the

government, and his paranoia begins, and he believes he is deciphering Russian intelligence. He

meets and marries his wife, Alicia Larde, who notices strange behaviours and calls a psychiatrist,

Dr. Rosen. John is then taken away to a mental institution, diagnosed with schizophrenia, and

given insulin and shock therapy. His wife attempts to help John recognize his schizophrenic

disorder (IMDB, 2002). In this case study, the examination of John will explore his presenting

symptoms, history and background, predisposing, precipitating, perpetuating and protective

factors of his schizophrenic diagnosis, and treatment interventions will be outlined.

Presenting Problems

John Nash is a 30-year-old male attending Princeton in the mathematics program. John is

under much stress and pressure in his mathematics program. John often works tirelessly,

sacrificing sleep and staying up all night working, resulting in papers taped all over his walls and

equations written all over his windows. He does not eat regularly. John’s classmates have

described him as socially withdrawn, irritable, and confrontational. Peers see John talking to

someone, but nobody is there, impacting his social life. He does not often join his classmates for

social activities, but when he does, he is awkward and has trouble conversing. He was asked to

participate in a significant conference and teach, which caused him much stress. His speech was
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disorganized when presented, and his ideas seemed unrelated. He had sporadic thoughts and

trouble focusing on one subject, leading to decreased work. John worked for the government,

and paranoia ensued, causing him to be unable to work. Alicia noticed John exhibiting frantic

and odd behaviour. She called a psychiatrist, Dr. Rosen, due to his frightening behaviour. Dr.

Rosen arrived and took John forcefully to a psychiatric hospital. John explained that Russians

were targeting him. John was diagnosed with schizophrenia. At the mental hospital, John could

not distinguish between reality and fantasy. John received shock treatments five times a week for

ten weeks, as well as insulin injections. John returned home from treatment; his wife explained

that he is reticent and stares blankly for long periods. She explains that John is unable to engage

in daily routines or work. He does not display much joy and is unable to be intimate.

Background/Historical Information

Life Domains

Present Living Situation/Family Constellation

John lives with his wife and newborn baby in a single-family home in a safe city. He has

no contact with his mother or father or information regarding other family members. He is well-

regarded in his community and worked as a professor. He is not currently working due to his

condition, and therefore, they are struggling financially. His wife’s mother helps with the baby

when Alicia goes to work. Alicia does not trust John to care for the baby due to his unpredictable

behaviour.

Problems with Substance Use and Legal Problems

John has not had any issues with substance misuse. He rarely drinks socially.

Mental Health Issues in the Family

This information is not known as John has not provided any family history.
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Mental Health Issues of the Client

John has been diagnosed with schizophrenia by his prior referring doctor, Dr. Rosin. John

lacks social skills, suffers from paranoia, and has delusions and hallucinations.

Current Friendship and Romantic Relations

John has a history of antisocial behaviour. He lacks social skills and is often very direct

and offensive in conversations. His behaviour is often seen as bizarre, and he often gets ridiculed

by others, causing him to isolate for weeks at a time. John has no real friendships. He has a wife

that supports and cares for him.

Educational and Occupational History

John received a scholarship to Princeton in math. He has always been brilliant and

received high accolades for his brilliance within the math community. He is employed at the

university as a professor and has worked with the government. He also worked as a professor

teaching math concepts. He is not currently working or enrolled in school due to his symptoms.

This area evokes tremendous stress.

Cultural Considerations

John has described his family as privileged. John is Caucasian. John has no cultural ties,

which can be a concern, furthering the lack of connections to his environment.

Critical Incidents

John experienced a few critical incidents in this film. John is seen in the courtyard

speaking to himself on the campus by his classmates, walking backwards, and engaging in what

they term odd behaviour. This odd behaviour continues when he lectures at a conference and in

class, displaying disorganized and nonsensical speech, jumping from one idea to another, and

being unable to focus. In the middle of his speech, he gets frightened and runs off stage as if
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someone is chasing him. This paranoia continued after work; he was late getting home. When he

arrived late, he entered the house in a state of panic and paranoia, alarming Alicia. He was

dishevelled, locked himself in a room, and would not open the door. Alicia called Dr. Rosin.

After he was in treatment for his schizophrenic diagnosis, he attempted to go back to work.

However, he still displayed erratic behaviour.

Overview of the Diathesis Stress Model

It is critical when working with psychiatric disorders to incorporate and understand the

links between biological, psychological, sociocultural and environmental factors on perspectives

of mental illnesses (Flett et al., 2017). A focus must be on characteristics that heighten the

probability of a person developing a disorder; relations of several components, from a

predisposition to the disease and diathesis to environment, experiences, and stress, are vital (Flett

et al., 2017; Kendler, 2020). In the biological domain, many disorders seem to have a genetic

transmission of diathesis; stress is critical in this model as it explains how a diathesis is

expressed in a disorder, such as unpleasant environmental stimuli (Flett et al., 2017). Thus,

diathesis and stress are required to develop disorders (Flett et al., 2017).

Case Formulation

Predisposing Factors

John has not shared any family history with me. However, much research states that a

predisposition to schizophrenia is transmitted genetically (Flett et al., 2017). However, it is not

the gene alone that established schizophrenia; the environmental factors can have significant

effects when combined with this genetic vulnerability (Flett et al., 2017). John seems

predisposed to stress as he has always been highly cerebral.

When I explored John’s background and history, he exhibited signs of social struggles in

his childhood and was described as unsympathetic. Growing up, John did not have many friends,

which could be attributed to his lack of social skills and inability to engage in small talk in

adulthood. He explained that he does not like people and that people do not like him, lacking

personal connections. This temperament and outlook in relating to others could predispose John

to engage less in social situations as an adult, reinforcing an isolated and withdrawn lifestyle.

Precipitating Factors

While at Princeton, John attempted to engage in social situations but was met with

negative responses, causing him significant stress and anxiety, precipitating his presenting issues.

John’s segregation spurred safety-seeking coping behaviour to isolate himself for extended

periods, facilitating his awkwardness and distress in social situations.

John’s schooling and work create substantial stress and pressure, and high expectations

create distress and facilitate his presenting symptoms of erratic behaviour and disorganized

thoughts. John has obsessive tendencies that are displayed as work pressure increases, manic-

type episodes where he will write on the windows and tape papers everywhere, precipitating his

erratic behaviour. John’s stress causes irregular sleep patterns, precipitating an inability to focus,

keep thoughts together and participate in everyday functioning, accelerating his symptoms. John

does not eat regularly, neglecting his self-care, facilitating the severity of his symptoms.

Perpetuating Factors

John seeks out friendships with his peers periodically, but when they see him behaving

oddly, he is embarrassed and withdraws again, maintaining his avoidant behaviour, thus

increasing his isolation. In his relationship with his delusion, he maintains his isolation. John’s

work and schooling have played a significant role in maintaining his presenting symptoms of
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stress and erratic behaviour. The stress and pressure of a professor lecturing in front of large

crowds and working for the government maintain his symptoms and worsen paranoia. He

continues to display obsessive behaviours and manic episodes while studying and working,

maintaining his symptoms. John’s cognition and struggle to understand what is real or fake

maintain his presenting concerns. John is currently taking medication for his diagnosis of

schizophrenia; this has caused him to have a lack of interest in life, maintaining his presenting

symptoms.

Protective Factors

John is married with a baby and has a good relationship with his wife, who loves and

cares for him deeply, John’s main protective factor. The desire to be a father could be a

protective factor for him. John also enjoys mathematics and working at Princeton University,

which could help increase his desire for treatment to continue his work. Although his social

relationships are temperamental, John still has some connection to them, which could protect

him from withdrawing. John is an intelligent man, and although he has delusions and

hallucinations, his dedication to understanding and making sense of the world is a protective

factor. John is resilient, and although he has had struggles in his life, he continues to try to

engage, work and teach, which protects him from succumbing to his mental illness.

Diagnostic Formulation

When factoring in the information I received, there are several areas of concern regarding

John’s presenting symptoms that substantiate Dr. Rosen’s diagnosis of schizophrenia. The

leading indicators are John’s positive symptoms of schizophrenia, which have lasted well over

six months, including delusions, auditory hallucinations and disorganized thinking, which is

necessary for a diagnosis of schizophrenia (American Psychological Association, 2022; Correll

& Schooler, 2020; Flett et al., 2017). John often withdraws into the fantasy of his delusions and

hallucinations, which is common in people with schizophrenia (Modesti et al., 2020). The

delusions that John experiences demonstrate a fixed false belief (APA, 2022; Harrigan, 2005).

John has described persecutory delusions, perhaps from stress and paranoia, a symptom of

schizophrenia (APA, 2022; Harrigan, 2005). John’s anxiety and stress can precipitate delusions,

which are common in patients with schizophrenia (Flett et al., 2017). John’s hallucinations are

sensory experiences that occur without external sensory stimuli when he is fully conscious and

alert, marking psychosis as a symptom of schizophrenia (APA, 2022; Flett et al., 2017; Harrigan,

2005). John also presented with disorganized thinking, apparent in his speech pattern, and loose

associations where his thoughts did not follow logical patterns, which is a sign of functional

impairment in those with schizophrenia (APA, 2022; Lecomte et al., 2021).

John also exhibits many negative symptoms of schizophrenia. Social isolation, lack of

social skills, and withdrawn and isolating behaviours are common in those with schizophrenia,

which John displays (Kart et al., 2021). Research has shown that people with schizophrenia tend

to be cognitively and severely socially impaired; the term for this is asociality, which John

displays (Dong et al., 2019; Flett et al., 2017). Research shows those with schizophrenia have

trouble sleeping, often stay up and awaken late when experiencing delusions and hallucinations,

which John displays, prominent in those with schizophrenia (Lecomte et al., 2021).

John displays negative symptoms, a flat affect at times, vacant staring and lifeless eyes,

impeding his emotional expressiveness, which research shows is a side effect of antipsychotic

medication and is present in those with schizophrenia (Flett et al., 2017). John experiences

apathy and a lack of interest in everyday activities, including personal hygiene, grooming and

eating and interpersonal relationships, a symptom of schizophrenia (Correll & Schooler, 2020).
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Due to these side effects, John stopped taking his medication. This increased his auditory

hallucinations, delusions and catatonia, which presents as much excitement, a significant

expenditure of energy and obsessive behaviour typical in patients with schizophrenia (Flett et al.,

2017; Kart et al., 2021).

The Diagnostic and Statistical Manual 5 (DSM-5) outlines the symptoms that must be

present for a diagnosis of schizophrenia. The DSM-5 outlines schizophrenia spectrums,

indicating that two or more of the following symptoms, delusions, hallucinations, and

disorganized speech, must be established for a significant amount of time during the initial

month when symptoms present (APA, 2022; Substance Abuse and Mental Health Services

Administration, n.d.). John displays all the primary symptoms needed for a diagnosis of

schizophrenia; the other main components of schizophrenia are negative symptoms. John

displays asociality, apathy, and, at times, catatonic behaviour (APA, 2022, A 4,5; Lecomte et al.,

2021). Since the onset of John’s symptoms, his level of functioning at work, school,

interpersonal relationships, and self-care has been below the level of functioning prior to his

presenting symptoms (APA, 2022, B; SAMHSA, n.d.). The duration of most of his symptoms is

continuous, with no reprieve since the onset, including his delusions and hallucinations (APA,

2022, C; Lecomte et al., 2021; SAMHSA, n.d.).

There have been no symptoms of depression displayed, and no mood episodes have

occurred in active-phase symptoms, ruling out a depressive disorder and a mood disorder (APA,

2022, D; Léger et al., 2022; SAMHSA, n.d.). I can rule out a schizoaffective disorder due to his

persistent psychotic symptoms, whereas with a schizoaffective disorder, there are briefer

episodes of psychotic symptoms (APA, 2022; Léger et al., 2022). John also does not have any

substance use, ruling out section E (APA, 2022, E). John also does not display any of the
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symptoms needed for a diagnosis of autism (APA, 2022). Based on this information, I would

conclude that John is presenting with symptoms of Schizophrenia.

Treatment Plan

Based on John’s presentation of schizophrenia, the following treatment will assist in

lessening his symptoms. However, they might be present for life; the goal is to allow him to live

independently, return to work and enjoy his marriage, baby and interpersonal relationships (Flett

et al., 2017). Due to John’s mental illness stemming from biological, psychological and social

stress, it is critical that in his treatment, we focus on all these areas. John’s intelligence and desire

to manage his mental illness lend to solid cognition. Thus, CBT's well-researched and proven

effectiveness in treating schizophrenia would impact John (Modesti et al., 2023). Antipsychotic

medications are the first choice of treatment; only around 30% of patients using medication are

satisfied; due to John’s significant decrease in quality of life due to medications, it is critical to

focus on his cognitive processes and social skills training (Kart et al., 2021). (Kart et al., 2021).

Dr. Rosen might change his current medication to risperidone, which has proven effective in

treating delusions and hallucinations and shows more effectiveness in combination with CBT

(Modesti et al., 2023).

In applying CBT for delusions and hallucinations, the focus is on cognitive biases,

identifying antecedents, assessing their content as to what is happening, formation of delusional

thinking regarding how it is happening, an explanation of what is happening, the expectations of

where this will end up and what will be the result, and response in the action of what will he do

about it, shown to reduce delusions and hallucinations significantly (Kart et al., 2021). Specific

interventions of social cognition and interaction training are vital; a component of CBT called

cognitive behavioural social skills training (CBSST) is efficacious in improving cognitive

flexibility, metacognitive skills, and a significant improvement in social functioning, facilitating

social ability improvement in John’s interpersonal relations (Modesti et al., 2023). Cognitive

processing improves delusional thoughts by lessening the illness-related stigma, improving their

emotional response, and considering their reactions as understandable (Kart et al., 2021).

The second cognitive wave of CBT was adapted for psychotic disorders (CBTp) to focus

on the psychological aspects of mental illness as well as the stress factor model (Kart et al.,

2021). The interventions of CBTp focus on the links between patients’ thoughts, feelings, or

actions and their symptoms and their functioning, monitoring them and influencing a re-

evaluation of perceptions, beliefs and reasoning related to symptoms (Kart et al., 2021). This will

improve John’s stress response, promoting different coping methods, reducing distress and

improving functioning (Moritz et al., 2019). Cognitive interventions of identifying automatic

negative thoughts, such as “The Russian spies are following me,” and their re-evaluation,

lessening John’s adverse reactions (Mortiz et al., 2019). The behavioural intervention of

exposure is used to develop new adaptive coping strategies for distressing symptoms, gentler for

those with psychosis, “reality testing” John’s unrealistic automatic thoughts that induce fear

(Moritz et al., 2019).

The third wave of CBT is metacognitive therapy, which focuses on unhelpful

metacognitive beliefs about thinking style; for example, thought suppression and training bring

distorted cognitive biases to client awareness (Moritz et al., 2019). John and I would discuss and

challenge his negative thoughts and maladaptive beliefs, reinforcing thoughts are thoughts and

should not be mistaken for facts, facilitating an understanding of reality vs fantasy (Moritz et al.,

2019). John will start to understand that dysfunctional cognitive strategies are the contributory

factor for paranoid thinking and hallucinatory experiences (Kart et al., 2021).
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This CBTp intervention will allow John to improve his social skills, regain his sense of

reality, influence an improvement in his desire for interpersonal relationships, provide increased

interest in everyday functioning, intimate relationship with his wife and a better overall quality

of life (Kart et al., 2021; Moritz et al., 2019). If John returns to work, one risk factor to look out

for and monitor is increased stress or pressure. Ensuring that he is taking it slow is critical. We

can use John’s wife, Alicia, and his boss as protective factors to help monitor his stress levels

and ensure that work is less demanding.

It is important to note that CBTp main strength is targeting the emotional impact of

psychotic symptoms rather than the presence or frequency of them (Thomas, 2015). Due to the

adaptive cognitive and behavioural methods of treating psychosis, CBTp is limited to use by

practitioners with advanced levels of CBT skills (Thomas, 2015). CBTp is also more effective in

treating the positive symptoms of schizophrenia, potentially requiring supplemental therapies for

the negative symptoms (Moritz et al., 2019).

Conclusion

Based on John's presenting symptoms, history and background, it is evident John is

presenting with symptoms in line with a diagnosis of schizophrenia. Due to these presenting

symptoms that John displays, treatment in the form of cognitive behavioural therapy adapted for

psychosis would significantly decrease his symptoms and improve his quality of life by

improving cognition, social skills, and adaptive coping mechanisms, allowing him to return to

work and enjoy his family life.

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