Question about CBT with Schizophrenic

A quick synopsis of the case:

“Bob” is a 47-year-old, divorced, Caucasian male who was given the following DSM-IV diagnosis:

AXIS I 295.10 Schizophrenia, Disorganized Type

AXIS II Deferred

AXIS III Asthma, Emphysema

AXIS IV Chronic Mental Illness

AXIS V 45 (on average when not decompensated)

Before going any further, I feel it is necessary to establish what I consider to be a mistake in his diagnosis that I believe it to be pertinent to this paper. The diagnosis of Schizophrenia is correct, but the type I feel is not. He does not meet the criteria for Disorganized Type, which are the prominence of disorganized speech and behavior as well as flat or inappropriate affect. Bob does meet the criteria for Paranoid Type as he has a preoccupation with delusions and frequent auditory hallucinations and does not meet the criteria for Disorganized or Catatonic Type Schizophrenia. He has suffered from auditory hallucinations for the past 13 years. With regards to his diagnosis, Bob is able to function well in the community, living on his own and maintaining employment. As for regards to this particular behavior I have chosen, I feel that with appropriate treatment, coupled with psychoeducation, this behavior stands a good chance of being eradicated.

For the past two months, Bob has been washing his face with, and drinking, his own urine. This problem originated 3 months ago when Bob started ingesting his own feces as well as canine feces on numerous occasions. While conducting an assessment interview, Bob stated two reasons for his behavior. The first reason he states, is that it is a punishment for a blasphemous act he committed when he was 23 years old. This blasphemous act was placing a sexual device (a “dildo“) on a Christmas tree and hanging two ornaments under it to represent testicles, as well as squirting shaving cream on the tree to represent it ejaculating. The second reason he stated is to appease God and avoid harm befalling his family as a result of his behavior. Bob says that he feels that if God sees that he is punishing himself by continuing this behavior of drinking his urine, God will let him smoke cigarettes and drink coffee without any harm coming to his family. According to Bob, when he indulges in these two acts that he enjoys, having a cigarette and drinking coffee or soda, God tells him that he is going to somehow harm his mother, son or girlfriend. He also believes that if he drinks his urine, it will prove that he is sorry for his past behavior. At the onset of this paper I thought that perhaps his behavior of drinking his urine was strictly due to his psychosis and hallucinations, but he has confirmed that the decision to punish himself in this manner is his own choice and that “God” has never told him to do this. When questioned as to why feces and then urine, Bob states simply, “because they are easily accessible and I can do this anytime I go to the bathroom”.

After interviewing Bob, it was ascertained that he was raised in a strict Catholic family. Bob was forced to attend church each and every Sunday as well as all Holy days of obligation. He was required to attend Catechism classes as well as serve as an altar boy. Bob’s mother was devoutly religious and, as Bob states, “forced me to believe in something that I was not sure about”. He states doing all of these things because it was what his mother wanted for him and all the time thinking how wonderful it would be to be an adult, on his own and not having to do anything he did not want to do, particularly attend church or believe in something he was not so sure about.

Bob’s belief in God is now enmeshed with his symptomology. His negative core belief is that “I am a bad person, particularly in the eyes of the church and of course God“, for his blasphemous act and for straying from the path of God in order to “have fun and enjoy life” as he puts it. Seeing that core beliefs influence views of a situation and in turn influence how one thinks, feels and behaves, it is important to modify these thoughts in order to produce symptom relief (Beck, 1995). Believing that he is a bad person, Bob’s intermediate thought is “if I continue to do certain things (i.e. smoke, drink coffee, not be sorry for my blasphemous past), God will hurt my family”. His automatic thought is “I should be punished”. He thoroughly believes in God and believes him to be a spiteful and cruel God unlike the kind God people are taught to believe. These thoughts and actions are triggered by his intake of caffeine and nicotine (when he drinks soda and coffee and when he smokes).

PROBLEM: I can find no research data on this particular target problem. What do you feel would be appropriate CBT interventions. Are you familiar with methods for similar target problems? Have they been effective or not? What do you believe would be the most appropriate intervention given the brief synopsis I have given? (Is there research data back this up and where might I find it?)

I believe that perhaps I should have been a bit easier on myself by picking a pretty basic problem but this was really interesting. So perhaps much of the information regarding treatment and intervention would be CBT & psychosis focused?

Replies:

Re:Question about CBT with Schizophrenic, by Jim Pretzer, 01/06/01

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