Cognitive Behavioral Therapy for Schizophrenia: An Empirical Review
Centre for Addiction and Mental Health, Clarke Institute of Psychiatry and Department of Psychiatry, University of Toronto, Ontario, Canada. Journal of Nervous & Mental Disease
(Impact Factor: 1.69).
06/2001; 189(5):278-87. DOI: 10.1097/NMD.0b013e31826dd9af
Early case studies and noncontrolled trial studies focusing on the treatment of delusions and hallucinations have laid the foundation for more recent developments in comprehensive cognitive behavioral therapy (CBT) interventions for schizophrenia. Seven randomized, controlled trial studies testing the efficacy of CBT for schizophrenia were identified by electronic search (MEDLINE and PsychInfo) and by personal correspondence. After a review of these studies, effect size (ES) estimates were computed to determine the statistical magnitude of clinical change in CBT and control treatment conditions. CBT has been shown to produce large clinical effects on measures of positive and negative symptoms of schizophrenia. Patients receiving routine care and adjunctive CBT have experienced additional benefits above and beyond the gains achieved with routine care and adjunctive supportive therapy. These results reveal promise for the role of CBT in the treatment of schizophrenia although additional research is required to test its efficacy, long-term durability, and impact on relapse rates and quality of life. Clinical refinements are needed also to help those who show only minimal benefit with the intervention.
Available from: Neil Thomas
- "The efficacy of CBTp for symptom improvement in schizophrenia initially showed considerable promise. Several early meta-analyses reported large and important clinical effects [6-8] providing key evidence that CBTp was an effective treatment for positive psychotic symptoms. This led to CBTp becoming an established evidence-based treatment for residual psychotic symptoms [1,9] and it has been recommended for routine provision in clinical practice guidelines now for many years [10-12]. "
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Cognitive behavior therapy for psychosis has been a prominent intervention in the psychological treatment of psychosis. It is, however, a challenging therapy to deliver and, in the context of increasingly rigorous trials, recent reviews have tempered initial enthusiasm about its effectiveness in improving clinical outcomes. Acceptance and commitment therapy shows promise as a briefer, more easily implemented therapy but has not yet been rigorously evaluated in the context of psychosis. The purpose of this trial is to evaluate whether Acceptance and Commitment Therapy could reduce the distress and disability associated with psychotic symptoms in a sample of community-residing patients with chronic medication-resistant symptoms.
This is a single (rater)-blind multi-centre randomised controlled trial comparing Acceptance and Commitment Therapy with an active comparison condition, Befriending. Eligible participants have current residual hallucinations or delusions with associated distress or disability which have been present continuously over the past six months despite therapeutic doses of antipsychotic medication. Following baseline assessment, participants are randomly allocated to treatment condition with blinded, post-treatment assessments conducted at the end of treatment and at 6 months follow-up. The primary outcome is overall mental state as measured using the Positive and Negative Syndrome Scale. Secondary outcomes include preoccupation, conviction, distress and disruption to life associated with symptoms as measured by the Psychotic Symptom Rating Scales, as well as social functioning and service utilisation. The main analyses will be by intention-to-treat using mixed-model repeated measures with non-parametric methods employed if required. The model of change underpinning ACT will be tested using mediation analyses.
This protocol describes the first randomised controlled trial of Acceptance and commitment therapy in chronic medication-resistant psychosis with an active comparison condition. The rigor of the design will provide an important test of its action and efficacy in this population.
Australian New Zealand Clinical Trials Registry: ACTRN12608000210370. Date registered: 18 April 2008
Available from: Paul H Lysaker
- "We found that persons with more significant neurocognitive impairments were more likely to have more severe alexithymia, raising the possibility that for such persons, certain treatments may be complicated by both neurocognitive compromise and self-reflective deficits. To be specific, difficulties with memory and identifying feelings could pose challenges for cognitive-behavioral therapy for schizophrenia, which has been found to be efficacious, though not for all persons with the disorder (Rector and Beck, 2012). With less developed or lost abilities to remember and process specific events and thoughts, and identify corresponding emotions, other treatments may be necessary in order to promote recovery from schizophrenia. "
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ABSTRACT: While alexithymia, or difficulties identifying and describing affect, has been commonly observed in schizophrenia, little is known about its causes and correlates. To test the hypothesis that deficits in emotion identification and expression result from, or are at least related to, deficits in neurocognition and affective symptoms, we assessed alexithymia using the Toronto Alexithymia Scale (TAS-20), symptoms using the Positive and Negative Syndrome Scale (PANSS), and neurocognition using the MATRICS battery among 65 adults with schizophrenia spectrum disorders in a non-acute phase of illness. Partial correlations controlling for the effects of social desirability revealed that difficulty identifying feelings and externally oriented thinking were linked with greater levels of neurocognitive deficits, while difficulty describing feelings was related to heightened levels of emotional distress. To explore whether neurocognition and affective symptoms were uniquely related to alexithymia, a multiple regression was conducted in which neurocognitive scores and affective symptoms were allowed to enter to predict overall levels of alexithymia after controlling for social desirability. Results revealed both processing speed and anxiety uniquely contributed to the prediction of the total score on the TAS-20. Results suggest that dysfunctions in both cognitive and affective processes may be related to alexithymia in schizophrenia independently of one another.
Available from: Mark van der Gaag
- "To date meta-analyses of CBT for psychosis (CBTp) have evaluated the effects in terms of effects on the frequency and severity of positive symptoms (Gould et al., 2001; Rector and Beck, 2001; Zimmermann et al., 2005; Wykes et al., 2008; NICE, 2009), negative symptoms (Rector and Beck, 2001; Wykes et al., 2008) and general symptoms (Tarrier and Wykes, 2004; NICE, 2009; Jones et al., 2012), but none focussed on and differentiated between auditory hallucinations and delusions . CBTp does not aim to reduce the frequency and severity of symptoms, but rather to reappraise the meaning and purpose of hallucinations and delusions to reduce distress and improve coping in daily life (Birchwood and Trower, 2006). "
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ABSTRACT: There is no meta-analysis of cognitive behavioural therapy for delusions and hallucinations separately. The aim of this meta-analysis is to evaluate the end-of-treatment effects of individually tailored case-formulation cognitive behavioural therapy on delusions and auditory hallucinations using symptom-specific outcome measures.
A systematic search of the trial literature was conducted in MEDLINE, PSYCHINFO and EMBASE. Eighteen studies were selected with symptom specific outcome measures. Hedges' g was computed and outcomes were pooled meta-analytically using the random-effects model.
Our main analyses were with the selected studies with CBT using individually tailored case-formulation that aimed to reduce hallucinations and delusions. The statistically significant effect-sizes were 0.36 with delusions and 0.44 with hallucinations, which are modest and in line with other recent meta-analyses. Contrasted with active treatment, CBT for delusions lost statistical significance (0.33), but the effect-size for CBT for hallucinations increased (0.49). Blinded studies reduced effect-size in delusions (0.24) and gained some in hallucinations (0.46). There was no heterogeneity in hallucinations and moderate heterogeneity in delusion trials. We conclude that CBT is effective in treating auditory hallucinations. CBT for delusions is also effective, but the results must be interpreted with caution, because of heterogeneity and the non-significant effect-sizes when compared with active treatment.
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