Cognitive Distortions in the Psychotic Mode: Part I

Until now, I have not written much about the psychotic mode. There arehowever a number of challenging questions which I would have to confront sooner or later. The first question has to do with the origins of biased beliefs. Does the content of an irrational belief have any relationship to what I have described previously in the conception of the negative cognitive triad –namely the biased view of the self, the outside world and the future? Secondly, do the distortions of reality have any bearing on or are they related to the cognitive distortions of the various disorders that individuals experience prior to the onset of psychosis (depression, anxiety, OCD, personality disorders, etc.)?

A recent paper showed that a large proportion of individuals with schizophrenia had preexisting psychiatric disorders (Albert, In Press). I assume that the cognitive distortions in schizophrenia are in some way related to the preexisting cognitive distortions associated with these non-psychotic disorders (depression, anxiety, OCD, personality disorders, etc.). The biases in the cognitive triad are reflected in the biases in the inferential and anticipatory processes.

The key concept that helps to explain psychosis is the word bias. Ordinarily we think of this term as a process by which external stimuli are warped to fit into an internal representation. However, individuals may already have an internal representation (belief) of say a stranger who they automatically dislike. Similarly, in psychosis, it is possible to view the impermeability of delusions as due to an extremely powerful bias, in this case, an externalizing bias. As an example of the differences in biases, say I have a pain in my chest, I may have a hypochondrical bias and immediately think it was due to a heart attack even though the pain was on the wrong side of the chest and I know that my chest pains are usually eating related.This is an example of catastrophizing, however, this incorrect conclusion remains relevant in the context of chest pain. By contrast, in psychosis an individual with chest pain may have an extreme externalizing bias and will jump to the conclusion that it is due to death rays sent by an enemy. This bias is so strong that the individual believes that the conclusion is incontrovertible. Take another example, an individual who believes that the staff and some of the other individuals on the unit represent the FBI.This conclusion is reached on the basis that the individual feels anxious in the presence of the staff. As a final example, an individual complained that his food tasted differently. He concluded that his family had poisoned his food (which was highly improbable since he was in the hospital and his family was some distance away).These examples show a variety of cognitive distortions and biases occurring in the psychotic mode, including emotional reasoning and extreme catastrophizing.

We generally do not directly address the more extreme beliefs that take the form of delusions, but instead attempt to facilitate the reinvestment of the energy driving the delusions in the following ways:

  • When possible, by satisfying the needs that are represented in the delusion
  • Through our general CT-R using aspirations, problem solving, group participation etc.

At times it is valuable to elicit the actual distortions in the individuals “reasoning.” This is particularly valuable when one is conducting a chain analysis to understand an individual’s inappropriate or aggressive behavior. For example, a woman wanted to punish another woman on the unit whom she believed had insulted her. A chain analysis revealed that the other woman had simply disagreed with her about the contents of a movie they had both seen. The individual had the following sequence: “Since she disagreed with me, she doesn’t respect me” > (belief: “If someone insults you, you need to punish them or else they will repeat this act.”) > urge to strike the other woman. The clinician attempted to divert the individual at this point and asked if that is the way she had brought up her two daughters. The woman replied that she would not want her daughters to act in this way and that she had tried to teach them to rise above it when they got angry. She then went over to the other woman and re-established a positive relationship. The clinician noted that the individual had greatly exaggerated the meaning of being disagreed with and when she gained the objectivity regarding her daughter’s upbringing, she was able to modify her interpretation and make peace with the other person.


Albert, U. et al. (In Press). Prevalence of non-psychotic disorders in ultra-high risk individuals and transition to psychosis: A systematic review.PsychiatryResearch.