Cognitive therapy for psychosis:

Evidence base and new directions.

Douglas Turkington, NTW NHS Foundation Trust & Newcastle

University

Roger Hagen, Norwegian University of Science and Technology

Lecture plan:

Cognitive therapy for psychosis

What is CBT for psychosis and does it work? How might it work and are there adverse

effects? Does „low intensity‟ CBT work? What is the new direction (3rd wave

cognitive therapies) How do 3rd wave cognitive therapies

understand and treat psychotic symptoms Does 3rd wave cognitive therapies work? Final conclusions and role play

“An asteroid is going to crash into the

earth in 2012…”

Thomas:- CBT formulation

Window broken/ BBC news

Dreams of floods

“asteroid impact 2012”

Anxiety, Insomnia

Stops Medication, Thought suppression

Rumination

Key ingredients of CBT for

schizophrenia

Therapeutic alliance…………“time” Normalising explanations… “Mayan calender” Formulation……………………A-B-C

“anxiety” Coping strategies…… “distraction, focussing” Reality testing……….. “Google the delusion” Improve adherence………….. “partnership” Work with core schemas… “I am weak, the

world is dangerous” Relapse prevention… “signature & action plan”

Thomas:-What worked?

Improve sleep and reduce anxiety

Nostradamus predicted a different date

All asteroids are closely monitored

Massive impact due in 2036!

Did accept a non-sedating antipsychotic

Worry postponement

Effect Sizes from expert CBT studies

(Tarrier & Wykes, 2004)

-0,6

-0,4

-0,2

0

0,2

0,4

0,6

0,8

1 Data available from 19 studies.

Mean ES =0.37 (sd=0.39,

median=0.32, range -0.49 to

0.99).

74% achieved at least a small

ES,

32% a least a moderate ES,

16% a large ES

Important RCTs since 2004

Klingberg, S. et al (2011) negative symptoms -

moderately improved by CR and CBT.

Klingberg, S. et al (2011) positive symptoms -

moderately improved by CBT and not by ST.

Foster et al (2010) paranoia & worry - strong

effect size.

Morrison et al (2011) antipsychotic refusing

patients - strong effect size.

PANSS total – mean scores at baseline, end of

treatment and follow up

A significant difference from baseline to end of treatment was identified (p = 0.001)

A significant difference from baseline to follow up was identified (p = .0001)

39.55

29.05

21.88

0

5

10

15

20

25

30

35

40

45

baseline (SD=11.9) end of treatment

(SD=19.1)

6 month follow up

(SD=17.1)

Secondary outcomes

PSYRATS delusions – mean scores at baseline, end of

treatment and follow up

A significant difference from baseline to end of treatment was identified (p = 0.0001)

A significant difference from baseline to follow up was identified (p = .001)

14.7

6.455.23

0

2

4

6

8

10

12

14

16

baseline (SD=6.66) end of treatment

(SD=7.07)

6 month follow up

(SD=6.3)

Secondary outcomes: initiation of

antipsychotic medication

0

3

17

0

2

4

6

8

10

12

14

16

18

Started on anti

psychotic medication

during therapy

Started on anti

psychotic medication

post therapy

Not started on anti

psychotic medication

Important RCTs since 2004

CBT and MI for comorbid substance

dependence - negative result.

CBT in the acute episode for relapse

prevention - negative result.

Grant, Beck et al (2011) CBT improves

functioning in deficit syndrome

schizophrenia.

Meta-analyses: CBT for schizophrenia

NICE (2009) Priority recommendation „ CBT should be offered to all people with schizophrenia‟

Lynch et al (2009) CBT doesn‟t work for anything due to problems with loss of blinding and control groups.

Cochrane (Jones et al , 2011) no real advantage over other psychosocial therapies on any outcome measure.

DTB (2010) CBT has a modest effect size when compared to other active comparators.

Interpretation issues.

No publication bias.

Protection of blinding is difficult in all

research.

Controls are at least active placebos or

head- to- head comparators.

CBT benefits are over and above that

achieved with antipsychotics.

32 YEAR OLD FEMALE WITH SCHIZOPHRENIA AND

PERSISTENT AUDITORY HALLUCINATIONS (9 months CBT)

1ª RM 2ª RM

31.8 % REDUCTION ACTIVATION

Case 1.

CBT and fMRI (Emotional Paradigm)

32 years Male with Schizophrenia and Persistent Auditory Hallucinations (6months

CBT)

1ª RM 2ª RM

4.81 % Reduction of activation

Case 2.

CBT and fMRI (Emotional Paradigm)

CBT:- Are there adverse effects?

Increase in anxiety

Disclosure of painful affect

Increase in systematisation

Reduced cognitive confidence

Increase in insight into the schizophrenia label.

772 Patients/carers

referred

422 entered &

randomized

Treatment

as usual

Total = 165 Completed = 128

Follow up = 126

Low intensity CBT

Total = 257 Completed = 225

Follow up = 213

0

5

10

15

20

Overall symptoms

(CPRS)

Insight (IRS) Depression (MADRS)

Insight CBT (n=225)

Treatment as usual (n=128)

***

*p<0.05;

***p<0.001 *

Symptom improvement

end of therapy

Turkington et al (2002)

Improvement (%)

*

Symptom change at 12-month follow-up

-10

0

10

20

30

40

Negative symptoms

(CPRS)

Insight (IRS) Depression (MADRS)

Insight CBTTreatment as usual

*

**

Turkington et al (2006)

*p<0.05;

**p<0.001

Improvement (%)

Results at 2 year follow up

64/205 (31.2%%) relapsed in the CBT group vs. 57/125(45.6%) in

the TAU group (P< 0.05).

Patients rehospitalised from CBT group spent a total of 6710 days in

hospital (mean = 32.73 days), while those from TAU group were

inpatients for 6114 days (mean = 48.91 days) (P< 0.05).

Mean time to relapse was 356.8 days (SD 241.85) for the CBT group

and 296.1 (SD 215.7) for the TAU group (OR 1.592, CI 1.038-

2.441) (Malik et al, 2009)

Individual talking treatments work in

schizophrenia.

CBT works for positive, secondary negative and overall symptoms with durable benefit.

Supportive counselling, Befriending, Arts therapies, cognitive remediation all work for specific indications.

What is the 3rd wave of cognitive

therapy?

Examples of 3rd wave therapies related in the understanding and treatment of psychotic symptoms:

Mindfulness-Based Approaches

Acceptance and Commitment Therapy (ACT)

Meta-Cognitive Therapy

Differences between CBT and 3rd wave cognitive

therapies in the treatment of psychosis?

Traditional CBT is primarily engaged in working with the content

of thoughts

Disputing, change and restructuring thought content through

verbal and behavioural methods

“What‟s the evidence....”

3rd wave cognitive therapies try to work to change the relationship

between the person and his thoughts or feelings

Developing mindfulness and acceptance of your thoughts and

feelings play a leading role in all 3rd wave cognitive therapies

“What is the benefits of worrying about this and why don‟t

you stop....”

Mindfulness Based Approaches

Several approaches: Mindfulness based stress reduction,

mindfulness based cognitive therapy

Training of the mind to disengage from unhelpful and

automated patterns of thinking

Instead of becoming preoccupied with difficult

experiences (hallucinations, delusional thoughts),

individuals are encouraged to focus attention to their

experiences in order to develop different ways of

reacting to them, no matter how unpleasant they are.

Mindfulness Based Approaches (cont)

„When you get the voices, let them do what the voice is saying, let the voices happen and you‟ll find out that they meant nothing anyway. How can I put it? If you‟ve got voices controlling you, try and just let it and then you‟ll find out that it didn‟t control you after all, it‟s just a voice‟.

Mindfulness Based Approaches (cont)

Abba et al, 2008; Chadwick, 2009; Chadwick et al; 2005

Clinical example:

Traditional CBT utilize distraction or coping techniques

or reappraise their thoughts related to their voices

Mindfulness based approaches the person encourage to

engage with the voice with an emphasis on altering the

emotional experiences associated with is presence

Even though the results are encouraging and promising

further research and controlled studies are warranted

Acceptance and Commitment Therapy

(ACT)

Psychopathology develops mainly because individuals

have problems in separating the process of thinking from

the products of thinking (cognitive fusion)

This cognitive fusion between process and products of

thinking leads to an excessive or improper regulation of

behaviour by verbal processes (thoughts)

People start to fear and avoid their own thoughts, feeling

and bodily sensations as a way to cope and regulate their

emotions

Acceptance and Commitment Therapy

(ACT) (cont)

ACT strives to increase psychological flexibility

ACT shift the focus from modifying the private

experience (content) to modifying one’s reaction to the

private experience

Interventions through mindfulness and

acceptance of private experiences, contact with

the present moment and see themselves and their

experiences in a context

Acceptance and Commitment Therapy

(ACT) (cont)

Bach and Hayes (2002); Gaudiano & Herbert (2006)

Clinical example Experiencing a frightening auditory hallucinations and then do a variety

of things to regulate them (talking back, complying with the voice, trying not to listen, argue back to what it says, etc)

These reactions makes the hallucinations more important, more central and more able to regulate behaviour (which was not intended)

ACT tries instead to develop new responses to these experiences (mindfulness), so the person could experience the hallucinations just like an experience

Bach and Hayes (2002); Gaudiano & Herbert (2006) demonstrated that ACT significantly reduced hallucinations and hospitalization days in psychotic patients

Metacognitive Therapy (MCT) What is metacognition?

Thinking about thinking (appraisal, control and monitoring)

MCT core question:

Why do people have problems regulating their preservative and fixative style of thinking?

The MCT answer: Cognitive Attentional Syndrome

Worry and rumination

Threat monitoring

Coping behaviours that backfire

Metacognitive Therapy (MCT) (cont)

CAS is driven by metacognitive beliefs and knowledge

Examples of positive metacognitive beliefs

Worrying helps me to be safe, looking out for danger

will help me to be prepared, etc

Examples of negative metacognitive beliefs

Worrying will make me loose control, worrying will

make me go mad

The metacognitive beliefs locks the person in a

processing style filled with worrying and rumination

which prolongs symptoms and other problems

Metacognitive Therapy (MCT) (cont) There is a large evidence base supporting the role of the CAS and

the importance of metacognitions in psychotic disorders (see

Wells, 2009)

Clinical example

MCT focuses on detecting and modifying the aspect of the CAS

Preservative thinking, maladaptive attentional strategies and

unhelpful coping strategies

Example: Worrying, threat monitoring and avoidance in

paranoid delusions

Conclusions about 3rd waves cognitive

therapies in the treatment of psychosis

CBT has shown that it is an affective psychotherapeutic treatment approach for psychotic symptoms

Some results from clinical trials related to the treatment of psychotic disorders are promising but;

Further research related to understand cognitive processes in psychosis is needed and controlled studies related to treatment efficacy are warranted

3rd wave CT need to be compared to already evidence based treatment (like CBT) in larger controlled trials to prove if this is a more effective treatment of psychotic symptoms

Roleplay: 11.11.11