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  1. #1

    Cognitive-Behaviour Therapy for Schizophrenia

    Cognitive-Behaviour Therapy for Schizophrenia: A Review
    May 18, 2005
    by Shanaya Rathod and Douglas Turkington
    Current Opinion in Psychiatry

    Purpose of Review: Most studies demonstrating the benefits of cognitive-behaviour therapy for schizophrenia were carried out in the 1990s. The majority targeted treatment resistant positive symptoms. Recent research is now focussing on the impact of cognitive-behaviour therapy on prodromal states, acute schizophrenia, negative symptoms, loss of insight and relapse prevention.

    Recent Findings: There is mounting evidence to suggest that cognitive-behaviour therapy is an effective adjunct to antipsychotic medication in the management of positive symptoms of acute schizophrenia as well as negative and residual symptoms of chronic schizophrenia. The effect size at the end of therapy is strong, with durability at short-term follow up. There is also evidence that cognitive-behaviour therapy can be combined with family therapy and assertive community treatment programs targeted to reduce relapse. Cognitive-behaviour therapy improves the prognosis of patients with schizophrenia through improved adherence and symptom management leading to reduced relapse. It may prevent transition to psychosis in high-risk prodromal states.

    Summary: In conclusion, recent literature provides fairly strong evidence that cognitive-behaviour therapy in addition to antipsychotic medication is effective in the management of acute as well as chronic schizophrenia, However, despite its proven efficacy, it remains a rare commodity, especially outside the United Kingdom.

    Cognitive-behaviour techniques in psychosis were first used in 1952 by Beck[1] in a patient who believed he was being followed and watched by the FBI. The patient was encouraged to trace the antecedents of the delusion and reality testing was used. Beck and colleagues[2] followed this earlier work with a description of eight patients with chronic delusions of whom half appeared to improve using cognitive and behavioural techniques. Since then a number of studies have demonstrated the efficacy of cognitive-behaviour therapy (CBT) in the treatment of positive symptoms[3] and negative symptoms[4] of schizophrenia. Compliance has been cost effectively[5] improved by a brief CBT intervention in patients with schizophrenia.[6]

    In the one-year period (September 2003 to September 2004) further important issues have been reported in the literature and are covered in this review. These include further reports of impact on psychopathology and treatment resistance; insight and compliance; relapse and early intervention; impact on comorbid pathology.

    Psychopathology and Treatment Resistance
    Over the past few years, a number of excellent reviews have updated the impact of CBT on psychopathology of schizophrenia. Rector and Beck[7] studied seven randomized controlled trials testing the efficacy of CBT for schizophrenia. A review by Pilling et al.[8] included the results from eight randomized trials, while a review published by the UK National Institute for Clinical Excellence in 2002[9] included 13 randomized clinical trials with data from 1297 patients. While the studies in the above reviews differed on a number of dimensions - including duration of intervention, number of sessions, comparison treatment, and outcomes - post-intervention and at follow-up, common findings emerged. CBT seemed to be particularly effective in helping people with the psychopathology of schizophrenia. It was reported to be more effective in improving overall symptoms at the end of treatment and at 9-12-month follow-up in comparison with standard care and other psychological approaches. Gould et al.[10] reported a large effect size with CBT in residual positive symptoms at the end of therapy (effect size 0.65) and continued gains over time (effect size 0.93).

    CBT for schizophrenia differs from other psychosocial interventions as it uses the stress vulnerability model,[11] which emphasizes that owing to our individual genetic, physiological, psychological, and social predispositions, we vary in our vulnerability to a psychotic breakdown. Another distinctive technique used in CBT for schizophrenia is the normalizing rationale.[12] Patients with schizophrenia usually have very poorly developed coping strategies, so that they withdraw socially and disengage from services easily. Effective coping strategies can be collaboratively developed with CBT, leading to symptomatic improvement.[13] In a recent study, Rector et al.[14*] reported the results with 42 patients randomized to either CBT, plus enriched treatment-as-usual (TAU) or enriched TAU only. Enriched TAU comprised comprehensive treatment within specialized schizophrenia treatment services. Significant clinical effects were reported for positive, negative and overall symptom severity for patients in the intervention group, although there were no statistically significant differences between the groups after treatment. The most pronounced effect of CBT-enriched TAU in comparison with enriched TAU alone in this study was in the reduction of negative symptoms at follow-up. However, the number of participants in this study was small and it is questionable how much enriched TAU may be generalized.

    It is a common notion that statistical significance is not equal to clinical significance and to what extent research may be generalized is difficult due to the non-replicability of the research environment in clinical practice. Startup et al.[15*] evaluated the effectiveness of CBT for in-patients suffering acute psychotic episodes, when delivered under conditions representative of current clinical practice and reported that the CBT group gained greater benefit than the TAU group on symptoms and social functioning. Similarly, Tarrier et al.[16**] reported the 18-month follow-up of a multicentre prospective trial of CBT or supportive counselling administered as an adjunct to treatment as usual, compared with TAU alone, for patients hospitalized for an acute episode of schizophrenia of recent onset. There were significant advantages for CBT and supportive counselling over TAU alone on symptom measures. However, in this study no group difference was seen for relapse or re-hospitalization.

    Insight and Compliance
    The importance of neuroleptic treatment in schizophrenia is well accepted and prognosis of illness is shown to be associated with compliance.[17] The benefits that could be realized with consistent use of long-term antipsychotic medication are usually not achieved because of poor adherence. Poor adherence similarly hinders involvement in rehabilitation programmes, leading to the progressively debilitating effects of repeated relapse and rehospitalization. While some studies have shown measures of insight to be correlated with the course of the illness,[18] others have related improved insight to increased suicidal risk.[19]

    CBT work to improve adherence with medication arises out of sessions attempting to understand the individual formulation of the patient's schizophrenia. The patient's view of taking antipsychotic medication is carefully explored. It is generally noted that some patients are keen to comply with treatment and accept their illness. Other patients comply despite a reluctance to accept that they are ill. The third group of patients either use antipsychotic medication erratically or completely refuse. As understanding improves through the use of behavioural homework (e.g. diary records), patients will often consider other explanations that are much more compatible with the use of medication. The insight study[20] used the above model and reported a statistically significant improvement in overall insight and symptoms of depression at post-therapy assessment with a brief insight oriented CBT intervention delivered by trained nurses to patients with schizophrenia in the community. A sub-analysis of the components revealed that the CBT group demonstrated significantly greater improvement in insight into compliance with treatment and the ability to relabel their psychotic symptoms as pathological compared with the control group at post-therapy assessment. Those participants who demonstrated improved insight into having a mental illness tended to become depressed. At 1-year follow-up, the result on total insight and compliance was durable.[21]

    Although the original compliance therapy,[6] based on CBT, motivational interviewing and psychoeducation showed an improvement in compliance, a similar study by O'Donnell[22*] could not replicate the same results at 1 year. However, there were important methodological differences between the studies, which could explain the different findings. For example, in the O'Donnell study, evaluators at baseline and 1 year were blind to the intervention offered to the patients. Furthermore, this study focused exclusively on people with schizophrenia. The possibility of booster sessions maintaining positive results needs consideration. Similarly, in a recent review of insight and psychosis, Henry and Ghaemi[23*] reported only one study of CBT in the review period with no notable changes in insight. It is possible that improvement in only certain aspects of insight, such as compliance, may have an impact on prognosis and need to be targeted. Other aspects, for example, acceptance, of illness may add to perceived stigma of mental illness and need handling sensitively. Due to the collaborative nature of work involved in CBT, it is possible that certain aspects of insight are selectively enhanced that may benefit patients.

    Relapse and Early Intervention
    Relapse is one of the most costly aspects of schizophrenia.[24*] The practice of early recognition and early intervention to prevent psychotic relapse in patients with schizophrenia using cognitive therapy[25] and acceptance and commitment therapy[26] have shown successful results. Gumley et al.[27**] randomized a total of 144 participants with schizophrenia or a related disorder to receive either TAU or CBT plus TAU. At 12 months, 15.3% of participants in the CBT group were admitted to hospital compared with 26.4% of the TAU group and a total of 18.1% participants in CBT relapsed compared with 34.7% in the TAU group. In addition, the CBT group showed significantly greater improvement in positive symptoms, negative symptoms, global psychopathology, performance of independent functions and social activities. This study provides evidence for the feasibility and effectiveness of targeting CBT on the appearance of early signs of relapse in schizophrenia.

    In a similar recent study, Bechdolf et al.[28**] randomized 88 in-patients with schizophrenia to receive a therapy envelope of 8 weeks including either 16 sessions of group CBT or 18 sessions of group psychoeducation treatment. Patients who received CBT were significantly less often rehospitalized than patients in the psychoeducation group during the follow-up period. On a descriptive level, CBT resulted in lower relapse rates and higher compliance ratings after treatment and at follow-up than psychoeducation. The brief group CBT intervention showed some benefit, which could be of considerable clinical and economical importance. Similarly it would be of great health economic interest to evaluate specific relapse prevention CBT group therapy packages for schizophrenia patients in the community.

    Early intervention in psychosis has generated significant interest as it has a bearing on prognosis. The Early Psychosis Prevention and Intervention Centre group[29] reported that their early intervention with pharmacological and CBT strategy delayed transition to psychosis in high-risk individuals (reduced the point prevalence) but did not prevent it. A recent randomized trial on a small sample of patients at high risk of developing psychosis reported significant benefits of a 6-month package of CBT in reducing the likelihood of making the progression to psychosis[30**] over a 12-month period. This study had its limitations due to small sample size and increased drop out rate. Nevertheless it addresses an important issue of preventative intervention. A randomized trial by the Croydon Outreach and Assertive Support Team (COAST)[31*] offered a range of interventions, including optimum atypical medication, psychological interventions (individual CBT and family intervention if appropriate) and a range of vocational and welfare help according to need. Compared with TAU for first contact clients, the trial demonstrated that overall both COAST and TAU clients improved over time, but there were no significant improvements for COAST clients. This study did not evaluate the benefits of CBT alone and does not compare with the other studies. While access to early intervention is helpful, services should aim to offer high quality input, which is evidence based, in order to meet client and carer needs.

    Patients with schizophrenia often drift down on the social ladder, which leads to further isolation and stigmatization. In such situations they are frequently victimized[32] and often develop secondary psychiatric illness such as post-traumatic stress disorder, agoraphobia or social phobia, that further exacerbate core symptoms.[33] These patients are more prone to depression as well. The context is provided by the patient's appraisal of psychosis which embodies loss, humiliation, entrapment and their consequent 'down ranking' of themselves.[34] These comorbid problems have an impact on the prognosis of illness.

    Recently, in a study by Kingsep et al.,[35**] 33 individuals with schizophrenia and comorbid social anxiety were allocated to a group-based cognitive behaviour intervention or waitlist control. All outcome measures of social anxiety displayed statistical improvement in the intervention group compared with no change in the control group. These treatment gains were maintained at follow-up validating the above discussion and demonstrating the positive effects of CBT on comorbid anxiety. However the sample size was small and there was lack of a comparable control group.

    Future Directions
    Schizophrenia is a multifaceted condition with the potential for far-reaching consequences. A number of approaches have been developed that attempt to improve functioning in these domains, including psychoeducation, social skills training, cognitive remediation, family therapy, and assertive community treatment services. In a recent article, Turkington et al.[36**] reviewed the rationale and evidence for the use of these interventions in patients with schizophrenia and compared them with CBT. They concluded that psychoeducation alone is of little benefit to patients suffering from schizophrenia, although it may well be helpful to patients and their families as an adjunctive component of treatment. There was little evidence that social skills training reduces relapse rates or length of stay or improves quality of life. However, there is some limited evidence that social skills training can improve mental and social functioning. The review broadly stated that no evidence was found to suggest that cognitive remediation improved outcomes in the cognitive functions of people with schizophrenia. While there may be improvements on some specific tasks, there was an absence of general improvement across tasks or generalization outside the treatment setting. Although cognitive remediation also seems inadequate on its own, there is a possibility of synergy with CBT. Although family therapy does not produce symptomatic improvement in the patient, it does have a potent effect in preventing relapse in a sub-group of patients at high risk of relapse. Family therapy could therefore be seen as an ideal accompaniment to individual CBT for this sub-group of patients. CBT could be added to the assertive community treatment programmes by developing symptom management strategies for delusions and hallucinations based on an individualized formulation.

    Despite the empirical evidence supporting the use of CBT in patients with schizophrenia, this treatment is relatively unknown to the psychiatric community. An interesting debate on whether CBT for psychosis is effective[37] makes a similar point. In a recent review on this subject, Marcinko and Read[38**] discuss the mechanisms and findings associated with CBT and schizophrenia, and suggest future directions for dissemination in the psychiatric community.

    CBT has emerged as an effective adjuvant to antipsychotic medication in the treatment of schizophrenia. It should be considered as a component of a comprehensive treatment package. As it is an intervention that focuses on distress, beliefs and understanding of the symptoms it may be of more value if offered very early in the illness. It can be cost-effectively delivered in the inpatient or outpatient setting.

    Reprint Address
    Correspondence to Dr Shanaya Rathod, MD, MRCPsych, Consultant Psychiatrist, Hampshire Partnership NHS trust, Mulfords Hill Centre, 37-39 Mulfords Hill, Tadley, Hampshire, RG26 3HX, UK. Tel: +44 1189 810 033; e-mail:

    Abbreviation Notes
    CBT = cognitive-behaviour therapy; COAST = Croydon Outreach and Assertive Support Team; TAU = treatment-as-usual

  2. #2

    Re: Cognitive-Behaviour Therapy for Schizophrenia

    CBT has emerged as an effective adjuvant to antipsychotic medication in the treatment of schizophrenia. It should be considered as a component of a comprehensive treatment package. As it is an intervention that focuses on distress, beliefs and understanding of the symptoms it may be of more value if offered very early in the illness. It can be cost-effectively delivered in the inpatient or outpatient setting.
    What great news! I keep hoping this will become standard practice. The Schizophrenia Society of ON newsletter recently had a brochure for recruitment for a study by Dr. Jean Addington involving CBT for prevention in people at risk for developing psychosis. Here is a PDF for contact information.

  3. #3

    Cognitive-Behaviour Therapy for Schizophrenia

    One of the things I don't think is mentioned or emphasized in the article is the role that CBT can play in helping patients to develop "reality checking" skills -- to look for social cues or even ask people questions directly to challenge their perceptions and help them to differentiate symptoms (e.g., hallucinations, delusional thinking, ideas of reference) from reality.

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