[Show abstract][Hide abstract] ABSTRACT: Metacognitive training (MCT) for schizophrenia spectrum is widely implemented. It is timely to systematically review the literature and to conduct a meta-analysis.
Eligible studies were selected from several sources (databases and expert suggestions). Criteria included comparative studies with a MCT condition measuring positive symptoms and/or delusions and/or data-gathering bias. Three meta-analyses were conducted on data gathering (three studies; 219 participants), delusions (seven studies; 500 participants) and positive symptoms (nine studies; 436 participants). Hedges' g is reported as the effect size of interest. Statistical power was sufficient to detect small to moderate effects.
All analyses yielded small non-significant effect sizes (0.26 for positive symptoms; 0.22 for delusions; 0.31 for data-gathering bias). Corrections for publication bias further reduced the effect sizes to 0.21 for positive symptoms and to 0.03 for delusions. In blinded studies, the corrected effect sizes were 0.22 for positive symptoms and 0.03 for delusions. In studies using proper intention-to-treat statistics the effect sizes were 0.10 for positive symptoms and -0.02 for delusions. The moderate to high heterogeneity in most analyses suggests that processes other than MCT alone have an impact on the results.
The studies so far do not support a positive effect for MCT on positive symptoms, delusions and data gathering. The methodology of most studies was poor and sensitivity analyses to control for methodological flaws reduced the effect sizes considerably. More rigorous research would be helpful in order to create enough statistical power to detect small effect sizes and to reduce heterogeneity. Limitations and strengths are discussed.
Psychological Medicine 07/2015; DOI:10.1017/S0033291715001105 · 5.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Un porcentaje significativo de clientes con psicosis ha experimentado trauma infantil y sufre de trastorno de estrés postraumático comórbido. Las investigaciones indican que la exposición a eventos angustiosos los primeros años de vida juega un
papel importante en la aparición y persistencia de síntomas psicóticos, ya sea directa o indirectamente. El Enfoque de Dos Métodos para la conceptualización de EMDR y los recientes descubrimientos sobre el reprocesamiento de las imágenes relacionadas
con la psicosis encajan con los modelos cognitivos actuales de psicosis. En este artículo se presentan una serie de pautas preliminares para conceptualizar el tratamiento EMDR de la psicosis, basadas tanto en la teoría como en la experiencia clínica, y se ilustran con
ejemplos de casos. Se describen diversos obstáculos y estrategias de tratamiento para el uso de EMDR en la psicosis. El EMDR para la psicosis puede combinarse muy bien con otras intervenciones estándar, tales como la medicación psicotrópica y la terapia cognitivo-conductual.
Journal of EMDR Practice and Research 02/2015; 9(1):2015-29. DOI:10.1891/1933-3196.9.1.E29
[Show abstract][Hide abstract] ABSTRACT: Background:
There is an increasing interest in cognitive-behavioural therapy (CBT) interventions targeting negative symptoms in schizophrenia. To date, CBT trials primarily focused on positive symptoms and investigated change in negative symptoms only as a secondary outcome. To enhance insight into factors contributing to improvement of negative symptoms, and to identify subgroups of patients that may benefit most from CBT directed at ameliorating negative symptoms, we reviewed all available evidence on these outcomes.
A systematic search of the literature was conducted in PsychInfo, PubMed and the Cochrane register to identify randomized controlled trials reporting on the impact of CBT interventions on negative symptoms in schizophrenia. Random-effects meta-analyses were performed on end-of-treatment, short-term and long-term changes in negative symptoms.
A total of 35 publications covering 30 trials in 2312 patients, published between 1993 and 2013, were included. Our results showed studies' pooled effect on symptom alleviation to be small [Hedges' g = 0.093, 95% confidence interval (CI) -0.028 to 0.214, p = 0.130] and heterogeneous (Q = 73.067, degrees of freedom = 29, p < 0.001, τ 2 = 0.081, I 2 = 60.31) in studies with negative symptoms as a secondary outcome. Similar results were found for studies focused on negative symptom reduction (Hedges' g = 0.157, 95% CI -0.10 to 0.409, p = 0.225). Meta-regression revealed that stronger treatment effects were associated with earlier year of publication, lower study quality and with CBT provided individually (as compared with group-based).
The co-occurring beneficial effect of conventional CBT on negative symptoms found in older studies was not supported by more recent studies. It is now necessary to further disentangle effective treatment ingredients of older studies in order to guide the development of future CBT interventions aimed at negative symptom reduction.
Psychological Medicine 02/2015; 45:453-465. DOI:10.1017/S0033291714001147 · 5.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: ACHTERGROND Van oudsher zijn psychotherapieën gericht op de verbale representaties (gedachten) van patiënten.
Dit is onder andere nuttig gebleken in de cognitief gedragstherapeutische behandeling van psychose.
Echter, steeds meer studies suggereren dat ook visuele representaties (imagery) een belangrijke rol
spelen in het veroorzaken en in stand houden van psychotische symptomen. Er zijn aanwijzingen
dat een hogere emotionaliteit en levendigheid van psychosegerelateerde imagery samenhangt met
de ernst van psychotische belevingen. Dit impliceert dat het verminderen van de levendigheid en
emotionaliteit van die mentale beelden een potentieel effect heeft op de lijdensdruk en beperkingen
rondom psychotische ervaringen.
DOEL Introduceren van emdr als een mogelijke psychologische behandelmethode gericht op
psychosegerelateerde mentale beelden bij patiënten met psychose.
METHODE Drie ambulante patiënten met een psychotische stoornis die last hadden van stemmen en wanen
werden behandeld met gemiddeld zes sessies emdr. De behandelingen werden uitgevoerd door drie
therapeuten in verschillende psychiatrische instellingen met ervaring met zowel cgt als emdr bij
RESULTATEN Er werden positieve resultaten geboekt op angst, depressie en psychotische symptomen. Tevens
verminderde het vermijdingsgedrag en verbeterde het cognitief inzicht.
CONCLUSIE De resultaten van dit onderzoek suggereren dat emdr de mate van de levendigheid en de
emotionaliteit van de mentale beelden reduceert, waardoor de psychotische symptomen verminderen.
Verder onderzoek naar interventies voor mentale beelden bij psychose wordt aanbevolen.
Tijdschrift voor psychiatrie 09/2014; 56:568-576..
[Show abstract][Hide abstract] ABSTRACT: Historically, psychotherapy has focused on the treatment of patients' verbal representations (thoughts) and has proved particularly successful in the cognitive behavioural treatment of psychosis. However, there is mounting evidence that visual representations (imagery) play an important role in the onset and maintenance of psychiatric disorders, including psychotic symptoms. There are indications that heightened emotionality and vividness of visual representations are associated with severity of psychotic experiences. This may imply that a reduction in the vividness and emotionality of the psychosis-related imagery can lessen the suffering and stress, caused by the the psychotic symptoms..
Tijdschrift voor psychiatrie 09/2014; 56(9):568-576.
[Show abstract][Hide abstract] ABSTRACT: Un grand nombre de patients présentant une psychose ont vécu des traumatismes infantiles et souffrent d'un état de stress post-traumatique comorbide. La recherche indique que l'exposition à des événements perturbants en début de
vie joue un rôle considérable dans l'émergence et la persistance de symptômes psychotiques – directement ou indirectement. L'approche des deux méthodes pour la conceptualisation EMDR et les données récentes sur le retraitement d'imagerie
psychotique répondent bien aux modèles cognitifs existants de la psychose. Cet article présente une série de lignes directrices préliminaires pour la conceptualisation du traitement EMDR dans la psychose, fondées à la fois sur la théorie
et sur l'expérience clinique, et illustrées par des exemples de cas. Plusieurs obstacles et stratégies thérapeutiques associées concernant l'utilisation de l'EMDR dans la psychose sont décrits. L'EMDR dans la psychose peut très bien se combiner
avec d'autres interventions standard telles que les psychotropes et la thérapie cognitive comportementale.
Journal of EMDR Practice and Research 08/2014; 8(3):2014-67. DOI:10.1891/1933-3196.8.3.E67
[Show abstract][Hide abstract] ABSTRACT: Non-compliance with medication constitutes a large problem in medicine. Recently the results of a cluster randomised controlled trial were published in which financial incentives were offered to patients with psychotic disorders. The objective of this study was to test if financial incentives effectively improved adherence to maintenance treatment with depot antipsychotics. The financial incentives increased acceptance of depot medication but did not lead to any clinical benefits. Therefore, the implementation of contingency management using financial incentives is not yet desirable.
Nederlands tijdschrift voor geneeskunde 01/2014; 158(4):A7309.
[Show abstract][Hide abstract] ABSTRACT: A significant proportion of clients with psychosis have experienced childhood trauma and suffer from
comorbid posttraumatic stress disorder. Research indicates that exposure to distressing early life events
plays an important role in the emergence and persistence of psychotic symptoms—either directly or
The Two Method Approach of EMDR conceptualization and recent findings on reprocessing
related imagery fit with the existing cognitive models of psychosis. This article presents
a series of preliminary guidelines for conceptualizing EMDR treatment in psychosis, which are based
on both theory and clinical experience and are illustrated with case examples. Several obstacles and
related treatment strategies for using EMDR in psychosis are described. EMDR in psychosis can very
well be combined with other standard interventions such as psychotropic medication and cognitive
Journal of EMDR Practice and Research 11/2013; 7(4):208-224. DOI:10.1891/1933-3184.108.40.206
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND AND OBJECTIVES: The treatment of negative symptoms in schizophrenia is a major challenge for mental health care. One randomized controlled trial found that cognitive therapy for low-functioning patients reduced avolition and improved functioning, using an average of 50.5 treatment sessions over the course of 18 months. The aim of our current pilot study was to evaluate whether 20 sessions of Cognitive Behavioral Therapy for negative symptoms (CBT-n) would reduce negative symptoms within 6 months. Also, we wanted to test the cognitive model of negative symptoms by analyzing whether a reduction in dysfunctional beliefs mediated the effects on negative symptoms. METHOD: In an open trial 21 adult outpatients with a schizophrenia spectrum disorder with negative symptoms received an average of 17.5 sessions of CBT-n. At baseline and end-of-treatment, we assessed negative symptoms (PANSS) and dysfunctional beliefs about cognitive abilities, performance, emotional experience, and social exclusion. Bootstrap analysis tested mediation. RESULTS: The dropout rate was 14% (three participants). Intention-to-treat analyses showed a within group effect size of 1.26 on negative symptoms (t = 6.16, | Sig = 0.000). Bootstrap analysis showed that dysfunctional beliefs partially mediated the change. LIMITATIONS: The uncontrolled design induced efficacy biases. Also, the sample was relatively small, and there were no follow-up assessments. CONCLUSIONS: CBT-n may be effective in reducing negative symptoms. Also, patients reported fewer dysfunctional beliefs about their cognitive abilities, performance, emotional experience, and social exclusion, and this reduction partially mediated the change in negative symptoms. The reductions were clinically important. However, larger and controlled trials are needed.
Journal of Behavior Therapy and Experimental Psychiatry 02/2013; 44(3):300-306. DOI:10.1016/j.jbtep.2013.01.004 · 2.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In a population of dually diagnosed patients receiving assertive community treatment we used the theoretical framework of the transtheoretical model to establish (a) the proportions and characteristics of patients who were not motivated for treatment for psychiatric symptoms and substance use, (b) the proportion of patients who moved towards behavioral change after about 1 year, and examine how this change was related with clinical outcome; and (c) the sequence of change processes. Chi square tests and T tests were used to compare the patient characteristics and outcomes of patients who remained in precontemplation with those who progressed. During follow-up, 47 % of the patients came out of the precontemplation phase for treatment of psychiatric symptoms and 38 % for substance use behavior. Those who remained in precontemplation benefited less from treatment. Of those who did move forward, most appeared to become motivated for psychiatric treatment before becoming motivated to reduce substance use.
Community Mental Health Journal 01/2013; 49(6). DOI:10.1007/s10597-012-9582-2 · 1.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In this article we describe three interactions between trauma, post-traumatic stress disorder (PTSD) and psychosis: 1. many patients with psychotic disorders suffered from traumatic life experiences that play an important role in the onset and content of their psychosis; 2. the experience of psychosis as well as its psychiatric treatment may result in post-traumatic stress symptoms; 3. if psychosis and PTSD occur simultaneously, there is a substantial risk for reciprocal negative reinforcement of both symptom groups as well as for potentially on going traumatization. Although these interactions are highly relevant from a clinical perspective, they usually remain unattended in routine care. The three interactions will be illustrated by a case history as well as an impression of the psychological treatment including EMDR. We recommend to pay attention to traumatization and comorbid PTSD in routine care for people with psychosis, as well as to offer them treatment.
[Show abstract][Hide abstract] ABSTRACT: Adherence interventions in psychotic disorders have produced mixed results. Even when an intervention improved adherence, benefits to patients were unclear. Treatment Adherence Therapy (TAT) also improved adherence relative to Treatment As Usual (TAU), but it had no effects on symptoms or quality of life. TAT may or may not reduce healthcare costs.
To determine whether TAT reduces the use of healthcare resources, and thus healthcare costs.
Randomized controlled trial of TAT versus TAU with 98 patients. Interviews were conducted at baseline (T0), six months later, when TAT had been completed (T1) and at six-month follow-up (T2). We have used admission data and part of the Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness (TiC-P). We compared total costs in the TAT group with those in the control group with the help of multivariate analysis of covariance.
TAT did not significantly minimize total costs. In the TAT group, the mean one-year health-treatment cost per patient (including TAT sessions) was € 23 003.64 (SD=19 317.95), whereas in the TAU group it was € 22 489.88 (SD=25 224.57) (F(1)=.652, p=.42). However, there were two significant differences at item-level, both with higher costs for the TAU group: psychiatric nurse contacts and legal proceedings for court-ordered admissions.
Because TAT did not reduce total healthcare costs, it did not contribute to cost-minimization. Its benefits are therefore questionable. No other adherence intervention has included analysis of cost-effectiveness or cost-minimization.
Schizophrenia Research 12/2011; 133(1-3):47-53. DOI:10.1016/j.schres.2011.09.025 · 3.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: While lack of insight is often predictive of antipsychotic nonadherence, some inconsistency in the literature remains unexplained. Verbal memory deficits may moderate the association between insight and adherence. Based on cross-sectional data, outpatients treated with antipsychotics for a psychotic disorder were divided into those with good (n=53) and poor (n=59) memory. Poor insight predicted nonadherence only among the subgroup with relatively good memory (r=0.43; P<0.01), but had no effect in the subgroup with worse memory (r=0.08; ns). Structural equation modelling revealed significant moderation (χ=4.72; df=1; P<0.05), which means that a significantly better model fit was found by allowing the analysis to differentiate between the two memory groups. Thus, poor insight was only associated with poor medication adherence among patients with relatively good memory. We speculate that memory deficits commonly associated with schizophrenia may partly explain why poor insight does not always lead to poor medication adherence.
Journal of Psychiatric Practice 09/2011; 17(5):320-9. DOI:10.1097/01.pra.0000405362.95881.48 · 1.34 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We investigated whether Assertive Community Treatment (ACT) combined with Integrated Dual Diagnosis Treatment (IDDT) is associated with a decrease in nuisance acts and crime convictions in dual-diagnosis repeated offenders. Forty-three patients were monitored from 21 months before until 12 months after the start of ACT-IDDT, using police data and the Health of the Nation Outcome Scales (HoNOS). Results show that while nuisance acts and convictions increased in the 21 months before the start of ACT-IDDT, nuisance acts decreased and convictions stabilized during the next 12 months. The decrease in nuisance acts was associated with a decrease in substance abuse.
Community Mental Health Journal 05/2011; 48(2):150-2. DOI:10.1007/s10597-011-9406-9 · 1.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although people with schizophrenia use various coping strategies, it is largely unknown how their coping style contributes to remission of the illness. The concept of recovery style-either by sealing over or integrating-reflects an important distinction. We wanted to examine whether recovery style predicts remission at a 1-year follow-up. We examined the recovery style, insight, therapeutic alliance, and symptoms in 103 patients with psychotic disorders. To assess the remission status, the symptoms were measured at 6 and 12 months. Logistic regression analyses were used. Results showed that scoring an extra category toward integration (six categories exist) increased the odds of remission 1.84-fold (95% confidence interval, 1.11 to 3.03). Insight and therapeutic alliance were not predictive. Although remission was also predicted by positive symptom levels at baseline, this did not influence the effect of recovery style. In conclusion, independently of symptom levels, insight, or therapeutic alliance, an integrating recovery style increases the odds of remission at a 1-year follow-up.
The Journal of nervous and mental disease 05/2011; 199(5):295-300. DOI:10.1097/NMD.0b013e3182174e97 · 1.69 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To compare the effects of 'Treatment adherence therapy' (TAT) with standard treatment on treatment adherence, symptoms, quality of life, and the number of voluntary or involuntary admissions in patients with a psychotic disorder. TAT is a new treatment that takes into account individual reasons for non-adherence per patient. DESIGN: A randomised controlled trial (RCT) among 109 out-patients who were did not comply well with treatment. This RCT is registered in the Dutch Trial Registry: NTR1159. METHOD: Tests were conducted to assess treatment adherence, symptoms and quality of life before intervention (t0), immediately following 6 months of intervention (t1), and after another 6 months follow-up (t2). These were predominantly performed by blinded interviewers. An 'intention-to-treat' multivariate analysis was used. RESULTS: In comparison with standard treatment TAT had a significantly more beneficial effect on medication adherence (Cohen's d = 0.43) and on treatment compliance (Cohen's d = 0.48). Results for medication adherence remained significant at 6-month follow-up. A trend was also found regarding involuntary admissions (1.9% versus 11.8%). Psychiatric symptoms and quality of life did not improve. CONCLUSION: Treatment Adherence Therapy (TAT) improved treatment adherence, and may have prevented involuntary admissions.
Nederlands tijdschrift voor geneeskunde 01/2011; 155(18):A3135.
[Show abstract][Hide abstract] ABSTRACT: Samenvatting In dit artikel wordt geschetst hoe postpsychotische demoralisatie en zelfstigmatisatie bij patiënten met schizofrenie te behandelen. Dit wordt geplaatst in de context van een cognitief model van demoralisatie. Hierbij ligt de nadruk op overdreven negatieve verwachtingen omtrent de eigen capaciteiten en sociale acceptatie. Deze verwachtingen vinden hun basis in de verliezen en cognitieve achteruitgang die patiënten hebben ondergaan, maar zijn desalniettemin vaak onrealistisch en werken vermijding en inactiviteit in de hand. Twee patiënten worden beschreven. Beiden hebben ziektebesef en ziekte-inzicht, maar zitten vast in een toestand van demoralisatie met zelfstigmatiserende ideeën. Bij beide patiënten werd vooruitgang geboekt door creatief cognitief-gedragstherapeutische technieken toe te passen. Het doel was niet herstel tot hun oorspronkelijk niveau van functioneren, maar om ze te helpen bij het doorbreken van isolatie en inactiviteit.
Abstract In this article a treatment is presented for post-psychotic demoralisation and self-stigmatization in patients with schizophrenia. This is placed within the context of a cognitive model of demoralisation. Its focus is on patients’ negative expectations concerning their capabilities and social exclusion. These expectations are based on experiences of loss, shame and cognitive deterioration. Yet, they are often unrealistic and lead to avoidance and inactivity. The treatments of two patients are described. Both have insight into their illness, but are trapped in a state of demoralisation and self-stigmatizing thought patterns. In both patients, progress was achieved by creatively using cognitive behavioural techniques. The goal was not to restore the patients to their old level of functioning, but rather to help them overcome isolation and inactivity.