Download Psychosis – the basics

Psychosis – the basics
Stuart Sorensen – RMN
Loosely defined, ‘psychosis’ might be described as ‘loss of touch with reality’. Certainly this
is the traditional view. In recent years, however, the notion of ‘reality’ itself has been
challenged and, with it, the concept of psychosis too.
The argument goes something like this:
If psychosis is loss of touch with reality and yet reality is changeable depending upon a
person’s individual perspective, then how can the notion of psychosis have any validity in
the first place?
Regardless of these philosophical and sometimes even metaphysical musings the majority of
people – doctors in particular by virtue of the assumptions inherent in their medical training –
persist in adopting the narrow and arguably very superficial view that reality is an objective
thing which can be defined and explained scientifically. This assumption about the nature of
reality is know as ‘modernism’ which also insists that there can be only one reality and that
the only way to understand it is by adopting scientific principles. This explains the heavy
emphasis upon scientific methodology (RCTs for example) and the tendency of the
therapeutic community to dismiss other ‘ways of knowing’ which are deemed to be
unscientific and therefore ‘less worthy’ of consideration.
Unfortunately, even with the aid of scientific methodology it has proven impossible to define
reality or adequately to demonstrate the nature of mental illness despite the huge amounts of
time, effort and public money which have been showered upon the search.
Positive and negative symptoms of schizophrenia/psychosis
Positive symptoms are those symptoms which exist ‘in addition’ to the norm. For example
visual hallucinations are extra experiences which most people do not have
Negative symptoms are detractions from the norm. For example apathy is a negative symptom
which represents a lack of ‘normal’ interest in life. Lethargy is ‘lack of energy’.
So positive symptoms represent ‘extras’ and negative symptoms represent ‘absences’
Hallucinations
Hallucinations are sensory experiences in any modality (sight, hearing, touch, taste, smell)
which do not have any observable external source. For example an hallucination may be a
voice which no one but the voice-hearer can detect or a vision which only they can see.
It is a remarkable double standard that many of the chief religious and political figures across
the world achieved their status precisely because of experiences such as these and yet many
psychiatrists, whilst accepting these figures as sane or even gifted, castigate less influential
individuals who display the same characteristics. Jesus, Joan of Ark, Buddha, Sister Fatima,
Moses, Saul, Samuel, Noah, Ghandi, Martin Luther King, Hitler, Alexander the Great,
Various Catholic saints including the virgin Mary, and of course her husband, Joseph all
reported ‘textbook’ hallucinations.
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Delusions
According to traditional thinking on the subject Delusions are ‘fixed, false beliefs’ which are
‘not amenable to reason’. To put it another way, the client believes something which the
clinician does not and won’t change his mind simply because he is told to.
It is true that delusions do seem to exist and people do tend to believe things which seem to be
impossible. However, where the early observers of delusions fell down was in their
prematurity. They were unable to reason the beliefs away because they lacked the therapeutic
techniques to do so. Furthermore they failed to appreciate the symbolic nature of these beliefs,
their protective function for the individual’s psyche or the awareness that it may, actually be
they who were wrong and not the hapless inmate of the asylum. Examples of delusions
include:
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1.
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3.
4.
‘Persecutory’ or ‘paranoid’ delusion
‘Ideas of reference’ – apparently innocuous things appear to have significance for the
client and indeed ‘refer’ to him. For example a pigeon landing on a tree top at a
particular time of day may suggest the presence of an international espionage ring
plotting to kill him.
‘Delusions of grandeur’ – the belief in one’s own importance. For example clients
may consider themselves to be Jesus or the worlds greatest pizza maker or anything
which has an air of ‘specialness’ about it. Arguably paranoid delusions are also
grandiose as they tend to imply that the client is seen as important or special enough to
warrant having others plot against them in the first place.
‘Delusions of guilt’ – the client believers themselves guilty of some crime (known or
unknown) despite contrary evidence.
‘Hypochondriasis’
‘Somatic delusions’ – pertaining to bodily metamorphosis
‘Nihilistic delusions’ – pertaining to the death of all or part of the body. Clients may
believe that their intestines are dead for example or that they are actually dead
themselves.
‘Religiosity’ – also often grandiose - clients may believe that they have a special role
in religious matters. Perhaps they must save the world or battle with the Devil for
example. Or maybe a particular demon is trying to kill them to prevent them from
developing into the next Messiah.
‘Passivity’ – the client believes that they are being externally controlled – rather like a
puppet. Passivity delusions include:
automatism – physical movements controlled by external force
thought insertion – thoughts inserted by external force
thought withdrawal – external influence robbing the client of thoughts
thought broadcasting – external forces broadcast client’s thoughts to others.
Work in Europe – particularly in the UK and in Holland has overturned the assumptions of
‘fixed false beliefs unamenable to reason’ as clients with delusional beliefs have entered into
discussion about those beliefs with skilled therapists and subsequently reasoned themselves
out of their delusions. This is often done without the aid of medication – even by withdrawing
medication - and is just one more piece of evidence supporting the increasingly obvious
conclusion that psychiatry is badly flawed.
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Thought disorders
There are many types of thought disorder. These tend to be differences in the ‘process’ of
thought itself rather than in the ‘outcome’ of thought. Thought disorders include:
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‘Flight of ideas’ – thoughts rapidly replace each other in the client’s mind, often with
only very spurious links to each other.
‘Clang association’ – clients associate different concepts or subjects because of links
such as rhymes, synonyms, or puns. For example:
“I’m telling you – ewes are female sheep and He is a very sheepish man but you
shouldn’t eat a mandrake – male ducks don’t lay eggs.”
‘Poverty of thought’ – absence of thoughts
‘Thought blocking’ – the client’s chain of thought abruptly ceases.
‘Knight’s move thinking’ – in chess the knight moves one square forward and one
diagonal – to put it another way he ‘goes off at a tangent’. Thought and conversation
make apparently unconnected leaps from one topic to another which seems quite
unrelated.
‘Word salad’ – a jumbled mass of apparently unrelated and incoherent words.
‘Neologism’ – The client uses words they have just invented as though they are part of
normal vocabulary.
‘Perseveration’ – similair to obsession – particular thoughts or perhaps even phrases or
syllables repeat in the mind and/or conversation over and over again. They
‘persevere’.
‘Concrete thinking’ – inability to think abstractly
‘Over-inclusivity’ – the client includes a great deal of insignificant information when
relaying information. For example an account of a walk to the shops may contain a
lengthy description of the sound the front door made as it closed behind the departing
client which ultimately adds nothing to the real information in question.
Specifics and ‘one-offs’
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Othello syndrome – a delusional jealousy. Named after Shakespeare’s Othello who,
becoming jealous of his wife smothered her with a pillow. In fact Othello’s wife,
Desdemona, had been faithful but Othello refused to believe that.
Cap Gras syndrome – the belief that one’s loved ones or familiar associates are
imposters. Think of the film ‘invasion of the body snatchers’ to get a feel for this
syndrome. Arguably it’s not strictly psychotic in the medical model sense as it seems
to be a way to make sense of the fact that people don’t ‘feel’ familiar any more,
which, apparently is the result of a communication problem between the amygdala and
other brain centres.
Folie a deux – literally ‘foolishness shared by two’ this is a delusional belief shared by
two individuals, generally close to one another such as lovers.
Psychosis and dissociation
Dissociation is an experience which comes in many forms. The concept can be confusing
because it is interpreted very differently by separate cultures and communities. These
explanations range from voice hearing to ‘absences’ or at the extreme end of the spectrum
‘Dissociative Identity disorder’ (formerly known as ‘multiple personality disorder’). Rather
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than worry too much about precise definitions within the spectrum of dissociation it may be
helpful to consider a continuum of dissociative experiences which incorporates all these
phenomena and explanations. This continuum might look something like this:
Absences
preoccupation
voice hearing
‘personality’ changes
DID
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It is important to bear in mind that the experiences along the continuum do not increase in
severity so much as in severity of interpretation. My own experiences suggest to me that
what American culture clearly insists is evidence of DID may be no different from the
phenomena that my own, British culture describes as voice-hearing. The only significant
difference appears to be related to interpretation, explanation and treatment protocols.
So what is ‘dissociation’ all about? The bottom line is that it has to do with responsibility. At
every point along the continuum above the client is attempting to ‘close off’ or ‘dissociate
from’ aspects of their experience or mental life which they find too unacceptable to
acknowledge as their own. The voice-hearer wants to believe that the voices are emanating
from another individual whilst the DID client seeks refuge in the presumption that their own
actions were the behaviours of a different person. In both cases the clinical goal seems to be
to help the client to accept and acknowledge the parts of themselves which they would rather
not admit to. It is fascinating to note the speed with which psychotic clients improve and
regain their equilibrium once they acknowledge that their voices are really auditory
representations of their own thoughts, internally generated and entirely within their control
just as any other thought is within their control.
How, why and what to do about it
Stress and vulnerability
Back in 1977 Zubin & Spring (Zubin J. & Spring B. 1977) published a then new approach to
the understanding and treatment of mental disorder. They posited that episodes of mental
disorder, especially psychoses, are directly related to the amount of stress that individuals
experience. They further suggested that individuals vary in the amount of stress that they can
cope with. Thus the onset of psychosis is a function of the interaction between the amount of
stress a person can stand and the situation in which they find themselves.
This does not, as some suppose, entirely disregard the traditional bio-medical model which
argues that illness is inherent within the individual. Rather it acknowledges the reality that
some people have biological vulnerabilities but sees this as only part of the picture. According
to the Stress-Vulnerability model the degree of stress experienced by clients is a major
determinant in the development of episodes of mental disorder (Craig T.K.J. 1996) (British
Psychological Association 2000) (Norman R.M.G. & Malla A.K. 1993).
In addition the model argues that the degree of skill the individual has in coping with stress
(coping mechanisms), together with the pressures of their environment such as familial high
expressed emotion (Hirsch S.R. & Bristow M.F. 1993) ( Moorey S. 1996) (Leff J. 1998)
(Haddock G. 1999) (Bradley S.J. 2000) (Morrisey M. 1999) are vital parts of the picture as a
whole. Today there is, of course, a wealth of research in the professional literature to support
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this assertion (Diamond E.A. 2001) (Chua S.E. & McKenna P.J. 1995) (McGrath J. &
Emmerson W.B. 1999) (King J. 2000).
“All children, even those who were believed to be carrying some genetic vulnerability, did well in
‘healthy’, adaptive families. In other words, families seemed to play a crucial role both in increasing and
protecting against genetic risk.” (British Psychological Association 2000)
High stress
Serious
mental
disorder
Coping
well
Mild depression, anxiety
or confusion, prodrome
and delusional mood.
Low stress
Low vulnerability
High Vulnerability
It seems that, given the huge part played by environmental stressors in the development and
maintenance of mental disorders, work aimed at helping people to reduce stressors and to deal
with those that remain is a logical response (May R. 2000).
Social Rank Theory
This is particularly useful when dealing with voices, delusions and peer pressure – all
significant issues for many members of our target population. The basic idea is that
individuals feel obliged to obey or to conform to standards set by others whom they perceive
as more important or more powerful than themselves. By working specifically to alter the
perceived ‘rank’ of voices, peers or delusional cognition it is possible to reduce the
significance of persistent psychotic symptoms until they no longer concern or interfere with
the client.
Attribution
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One of the most significant variables in psychosis is that of ‘attribution’. Briefly put, if the
client attributes their experiences to their own thinking processes they can develop ways to
control them. If, on the other hand they attribute their experiences to external forces (demons,
aliens, government organisations, God etc.) they find themselves unable to control them
because they are seen as ‘not me’ and therefore ‘beyond my influence’. This is why the notion
of accepting personal responsibility is so important. People can only impact upon things
which they are responsible for and which they believe themselves able to change. This is also
the basis of the ‘disassociation’ argument outlined above.
Systems Theory
Briefly put, the part of any system which has the most choices also has the most control. By
consciously examining the amount of options available to clients and helping them to increase
those options in a responsible manner we help individuals to reassert control over their own
lives. This approach is particularly important if we are to combat the effects of long term
traditional mental health treatment or institutionalisation.
The Cognitive Model
Cognitive Behavioural Therapy (CBT) is based upon the ‘Cognitive Model’ and relies upon
an ever-evolving ‘formulation’ which outlines the development and maintenance of problems
by examining the ‘triad’ of ‘thoughts, feelings and behaviours’. By focusing upon ‘core
beliefs’ and the events which contradict them it is possible to plot the individual’s responses
which create and then maintain their difficulties. This formulation is the basic explanation
which informs treatment and helps the client to develop insight as well as learn to overcome
their symptoms.
The following is a relatively superficial illustration of the process by which individuals can
develop and maintain psychotic symptoms and ultimately gain diagnoses like ‘schizophrenia’
because of their attempts to deal with traumatic events. This example concerns the
hypothetical case of an adult who experienced sexual abuse as a child. By making the process
conscious and by helping the clients to examine the assumptions they made at the time of
trauma it is possible to overturn not only the initial self-beliefs but also the behavioural and
psychological patterns which maintain their symptoms.
On a simpler level it is possible to dispense with the first part of the formulation should the
client be unable to address it and concentrate purely upon the cycle of thoughts, feelings and
behaviours as a means of addressing patterns of behaviours which maintain dysfunction. The
depth and ‘comprehensiveness’ of the work depends primarily upon the client and their
developmental needs at the time.
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Situation
Sexual abuse by father
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Core belief
I’m a naughty girl
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Conditional (if, then) Assumption
If I’m a good girl Daddy won’t do that to me
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Event
Abuse continues in spite of attempts to be a ‘good girl’
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Thought
I’m a bad girl
I’m only good for sex
My life is meaningless
I need to feel better
I need drugs to survive
(Voice) You’re worthless
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Behaviour
Withdraw
Promiscuity
Self harm
Substance misuse
Develop psychotic symptoms
More substances to avoid voices
Feeling
Worthlessness
Dirty

`
Hopelessness
Desperation
Inadequate
Scared
Mental Health Recovery
Inspired by commentators such as those listed above as well as the results of research projects
such as the ‘International Study of Schizophrenia’ (Harrison G. et al 2001), we can see that
mental health recovery is far from impossible. In fact, in many situations and cultures it is the
norm. This represents something of a departure from the traditional, Western, bio-medical
view of serious mental disorder as it views recovery in a very different way (May R. 2000)
(Harrison G. et al 2001).
Recovery can be defined in the following ways:
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Clinical recovery – The absence of clinical symptoms;
Psychological recovery – Symptoms remain but do not distress the client or cause
dysfunction in activities of daily living;
Social recovery – The client is accepted by their society and culture regardless of
symptomatology.
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Any two of these three constitutes meaningful recovery. It is interesting to note that the vast
majority of voice-hearers for example do not have any difficulty with their voices and have
not come into contact with mental health services at all (Romme M. & Escher S. 2000).
Active work on psychotic content (hearing voices work)
For almost two decades now Professor Marius Romme and Sandra Escher (Romme M. &
Escher S. 1993, 2000) have championed the principles of active exploration and interpretation
of voice-hearing as an effective therapeutic tool.
The basic principles of ‘hearing voices work’ as it has come to be known include acceptance
of the reality of the voice-hearer’s experience and an attempt to understand what the
experience means to them on many levels including the ‘social’ and ‘psychological’.
Although active exploration of psychotic experience is contrary to the perceived wisdom of
traditional psychiatry there is good evidence, anecdotal and otherwise, that such an approach
is extremely beneficial.
“…exploration of these experiences can help subjects to cope with
them and conversely, attempts to ignore or suppress
them may paradoxically increase the subject’s preoccupation
with them.” (Leudar I & Thomas P. 2000 p.114)
Trauma resolution work
In keeping with the principles of ‘stress and vulnerability’ as outlined above it is common
during formulation of psychotic experiences to uncover significant trauma which often lies at
the root of first and subsequent episodes of psychosis. The basic theory is that life events
contradict beliefs and assumptions upon which the individual relies to maintain their sense of
safety or self esteem. In order to restore their self esteem they have various options:
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Incorporate the new information into their belief system and adapt (healthy);
Deny reality altogether (a common strategy in racism for example);
Invent some way to neutralise the importance of the new information, perhaps by
deluding oneself about conspiracies designed to trick (paranoia, delusions etc.)
Once a psychotic strategy has been put into place a process known as ‘selective abstraction’
serves to dismiss contradictory evidence and accentuate supporting evidence. The effect is
psychological ‘retraumatisation’ and fear which ultimately leads to the development of other
‘symptoms’ such as withdrawal or hallucinations. Many of the symptoms of schizophrenia,
for example, particularly so-called ‘negative’ symptoms can be attributed to coping strategies
to deal with a world which the individual perceives as too dangerous.
In trauma work we help the client to examine the assumptions they made as a result of stress
or trauma and then examine the effect those assumptions have had upon their lives
subsequently. We agree hypotheses and test out alternative assumptions in the here and now
until the client is able to dispense with, or perhaps modify, the delusional beliefs until they
become harmless.
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Assessment protocols
Trauma is always a feature in the development of psychotic phenomena. The problem is that
people have different definitions of trauma. This is because events are interpreted as traumatic
in relation to an individual’s own unique belief systems and expectations. So, what may
represent a trauma for one may be only mildly irritating or even a positive experience for
another.
The formulation above illustrates in fairly obvious ways the manner in which a person’s belief
system can come into conflict with events. This conflict is the basis of psychological trauma.
Even physical trauma is dependent upon the same mechanism. For example – most people
would find bodily pain traumatic but for some the experience of pain is pleasurable. The
difference lies in the individual’s beliefs and expectations.
Similairly – seemingly innocuous events (receiving a bill through the letter box for example)
may be extremely traumatic to an individual if they believe that such events are catastrophic
and impossible to deal with. Therefore, when dealing with psychosis the issue is never ‘would
I think this traumatic?’ and always ‘what belief is this in conflict with for the client?’ Only by
considering experiences in the light of the client’s own belief system, particularly their ‘core
beliefs’ (schema) and their ‘conditional assumptions’ (if this, then that) can we truly identify
causative trauma.
A few more cognitive dynamics
Selective abstraction (aka mental filtering) is something which all people do. Basically we
tend to focus only upon evidence which supports our preconceived notions and minimise or
dismiss evidence which does not. Therefore – if a client has a paranoid delusion involving bus
drivers he may remember episodes in which bus drivers appeared uncaring or dismissive of
him whilst ignoring occasions when they were pleasant with him. Furthermore he may
actually reinterpret their nice attitudes as simply evidence of an attempt to lull him into a
sense of false security, thus prompting the belief that the conspiracy was nearing its climax
and bus drivers were about to murder him. This concept can be further refined and terms such
as ‘mental filter’ or ‘theory of mind’ also refer to refinements of the process of ‘selective
abstraction’.
Delusional mood is part of the ‘prodrome’ of psychosis. This is the period of time following
undeniable evidence in the real world which conflicts with preconceived beliefs. For example
if I believe that all doors are painted red and I see a door which is painted blue that means that
the world is in conflict with my beliefs. Whilst I reintegrate and assimilate the new
information into either a delusional or objective belief system (it can go either way) I will
experience some emotional distress. This is the delusional mood. There are two reasons why
this is important.
Firstly – identifying past episodes of delusional mood will provide information about the
nature of the trauma which prompted the psychosis.
Secondly – identifying current delusional mood states allows us to intervene and prevent
psychotic episodes from occurring at all.
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Relapse prevention
This is one of the main aspects of recovery work. In order to prevent relapse it is necessary to
understand it. Individual clients have unique ‘relapse profiles’ and most will have between
three days and one month prior to relapse in which, with the aid of a good relapse profile, the
problem can be predicted and successfully averted.
It is always vital to spend several sessions defining exactly what happens in relapse, how
much warning the client has, what order symptoms appear in, what works for each symptom
and what the ‘early warning signs’ are which will trigger intervention. The vast majority of
clients are extremely keen to collaborate with relapse prevention planning and will recognise
and act upon triggers and early warning signs long before clinicians can providing that we are
clear about the circumstances in which to summon help. Incidentally, one of the best ways to
sabotage relapse prevention work is to intervene with medications in the early warning stage.
This more or less guarantees that the client will not tell you about future relapse with the
result that by the time you notice the problem for yourself they are likely to be in full blown
psychosis with limited insight and significantly fewer realistic treatment options.
Medication, like all interventions should be negotiated in advance in the relapse prevention
plan, the client should know in advance what to expect when they summon help and should
be encouraged to collaborate in every stage of planning and delivery of relapse prevention.
Other ways to prevent relapse include implementing practical measures such as ‘sleep
hygiene’, ‘dietary changes’, ‘advocacy in stressful situations’, ‘Socratic questioning’
regarding the issue giving rise to the delusional mood, ‘involvement of significant others’
(within prearranged boundaries) and, of course, anything else specific to the needs of the
individual concerned. As you will appreciate a good relapse prevention plan takes
considerable time to set up but is well worth the effort, both in terms of quality of life for the
client and ultimately in terms of time management for the clinician. Better to spend several
sessions achieving meaningful change than interminable months simply maintaining illness.
Therapeutic optimism
The best way to keep someone ill is to tell them that they will always be ill. Other variants of
this are:
“You’ll need medication for ever”
“You’re a schizophrenic”
“Schizophrenia’s incurable”
More insipid is the absence of conversation about recovery. If we don’t speak openly about
the realistic prospect of recovery our clients will assume that it’s not an option. In that case
we have maintained illness just as surely as if we had told them they will always be ill.
Real progress is only possible from a perspective of therapeutic optimism. We must openly
tell our clients that they can expect to recover and then involve them in active collaboration
toward that aim. Part of this philosophy involves advocacy on their behalf – often against
medical colleagues – and a demonstrable faith in their potential. Remember that to do this
often means to be a lone voice amid a sea of colleagues who for years have told the client
precisely the opposite. It is necessary to be congruent and consistent and be able to explain
the reasons for your optimism to all comers.
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The problem with psychiatry and the medicalisation of distress
Psychiatry is based upon the principles of medicine which place the source of all disorder
solely in the body. So mental disorder is deemed to be caused entirely by physical or
physiological pathology. It is for this reason that psychiatrists rely so heavily upon medication
despite the well-documented damage these substances cause their clients. It would be unfair
however to assume that medics are indifferent to the sufferings their treatments cause. They
genuinely are trying to help people but given that their medical training permits them only the
narrow view enshrined within the medical model they are unaware of the majority of
successful treatment modalities.
It is true, of course, that some of the symptoms which psychiatrists deem indicative of
disorders like schizophrenia are to be found in undeniably organic disorders such as the
dementias or following brain injury. However, none of these symptoms when taken
individually are exclusively physiological or physical in nature. It is also the case that many
of the symptoms can be directly attributed either to coping mechanisms designed to protect
the individual from trauma (such as delusions for example) or the side effects of antipsychotic
medications (negative symptoms of schizophrenia for example). By refusing to accept nonphysical explanations for mental health problems psychiatrists have locked themselves into a
mindset which, of necessity, ignores many of the different causes and treatments for
psychosis. Arguably, by perpetuating assumptions of incurability the medical approach
actually exacerbates and maintains mental health problems which could otherwise be
overcome.
This is why all clinicians, including doctors, but especially mental health nurses with our
particular status, credibility and access to clients have a duty to argue against the bio-medical
view of mental disorder.
This has been no more than a very superficial overview of a deep and fascinating topic.
If you have any questions please don’t hesitate to ask.
Radically,
Stuart
[email protected]
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References
Bradley S. J. (2000) Affect regulation and the Development of Psychopathology
The Guildford Press: New York
British Psychological Association (2000) Recent advances in understanding mental illness
and psychotic experiences British Psychological Association:Leicester
Chua S.E. & McKenna P.J. (1995) Schizophrenia – a brain disease? A critical review of
structural and functional cerebral abnormality in the disorder The British Journal of
Psychiatry: 166: pp.563-582
Craig T.K.J. (1996)
Adversity and Depression International Review of Psychiatry: Vol. 8, pp.341-353
Diamond E.A. (2001)
A conceptual Structure for Diagnoses Psychiatric Times Vol. XVIII Issue 11
Haddock G. (1999)
Cognitive-Behavioural Treatment of Psychosis Continuing Professional Development
Bulletin – Psychiatry: Vol. 6, pp.53-57
Harrison G. et al (2001)
Recovery from psychotic illness: a 15 and 25 year international follow up study
British Journal of Psychiatry: Number 178, pp.506-517
Hirsch S.R. & Bristow M.F. (1993) Current opinion in psychiatry
Vol 6, pp.53-57
King J. (2000) What in fact is schizophrenia? British Medical Journal: 320: p.800
Leff J. (1998) Needs of the families of people with schizophrenia Advances in Psychiatric
Treatment Vol. 4, pp.277-284
Leudar I & Thomas P. (2000) Voices of reason, Voices of insanity Routledge: London
May R. (2000) Psychosis and Recovery Open Mind Magazine: No. 106. pp.24-25
McGrath J. & Emmerson W.B. (1999) Treatment of Schizophrenia British Journal of
Medicine: 319: pp.1045-1048
Moorey S. (1996) Cognitive behaviour therapy for whom? Advances in Psychiatric
Treatment: Vol. 2 pp. 17-23
Morrisey M. (1999) Fellow Feelings Nursing Times: Vol. 95, No. 21 pp. 38-39
Norman R.M.G. & Malla A.K. (1993) Stressful life events and schizophrenia 1: A review of
the research British Journal of Psychiatry; Vol. 162. pp.161-166
Romme M. & Escher S. (1993) Accepting Voices Mind Publications: London
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Romme M. & Escher S. (2000) Making sense of voices Mind publications: London
Zubin J/ & Spring B. (1977) Vulnerability – a new view of schizophrenia Journal of
Abnormal Psychology Vol. 86, No. 2, pp. 103-124
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