BACKGROUND: Guidance in the United States and United Kingdom has included cognitive behavior therapy for psychosis (CBTp) as a preferred therapy. But recent advances have widened the CBTp targets to other symptoms and have different methods of provision, eg, in groups. AIM: To explore the effect sizes of current CBTp trials including targeted and nontargeted symptoms, modes of action, and effect of methodological rigor. METHOD: Thirty-four CBTp trials with data in the public domain were used as source data for a meta-analysis and investigation of the effects of trial methodology using the Clinical Trial Assessment Measure (CTAM). RESULTS: There were overall beneficial effects for the target symptom (33 studies; effect size = 0.400 [95% confidence interval [CI] = 0.252, 0.548]) as well as significant effects for positive symptoms (32 studies), negative symptoms (23 studies), functioning (15 studies), mood (13 studies), and social anxiety (2 studies) with effects ranging from 0.35 to 0.44. However, there was no effect on hopelessness. Improvements in one domain were correlated with improvements in others. Trials in which raters were aware of group allocation had an inflated effect size of approximately 50%-100%. But rigorous CBTp studies showed benefit (estimated effect size = 0.223; 95% CI = 0.017, 0.428) although the lower end of the CI should be noted. Secondary outcomes (eg, negative symptoms) were also affected such that in the group of methodologically adequate studies the effect sizes were not significant. CONCLUSIONS: As in other meta-analyses, CBTp had beneficial effect on positive symptoms. However, psychological treatment trials that make no attempt to mask the group allocation are likely to have inflated effect sizes. Evidence considered for psychological treatment guidance should take into account specific methodological detail.

http://www.reading.ac.uk/web/files/psychology/paper_4.pdf

Cognitive Behavior Therapy for Schizophrenia: Effect Sizes, Clinical Models, and Methodological Rigor

Anxiety Disorders and Phobias: A Cognitive Perspective

Since publication of the original Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations in 1998, considerable scientific advances have occurred in our knowledge about how to help persons with schizophrenia. Today an even stronger body of research supports the scientific basis of treatment. This evidence, taken in its entirety, points to the value of treatment approaches combining medications with psychosocial treatments, including psychological interventions, family interventions, supported employment, assertive community treatment, and skills training. The most significant advances lie in the increased options for pharmacotherapy, with the introduction of second generation antipsychotic medications, and greater confidence and specificity in the application of psychosocial interventions. Currently available treatment technologies, when appropriately applied and accessible, should provide most patients with significant relief from psychotic symptoms and improved opportunities to lead more fulfilling lives in the community. Nonetheless, major challenges remain, including the need for (1) better knowledge about the underlying etiologies of the neurocognitive impairments and deficit symptoms that account for much of the disability still associated with schizophrenia; (2) treatments that more directly address functional impairments and that promote recovery; and (3) approaches that facilitate access to scientifically based treatments for patients, the vast majority of whom currently do not have such access.

The Schizophrenia Patient Outcomes Research Team (PORT): Updated Treatment Recommendations 2003

The Schizophrenia Patient Outcomes Research Team (PORT) psychosocial treatment recommendations provide a comprehensive summary of current evidence-based psychosocial treatment interventions for persons with schizophrenia. There have been 2 previous sets of psychosocial treatment recommendations (Lehman AF, Steinwachs DM. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr Bull. 1998;24:1-10 and Lehman AF, Kreyenbuhl J, Buchanan RW, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2003. Schizophr Bull. 2004;30:193-217). This article reports the third set of PORT recommendations that includes updated reviews in 7 areas as well as adding 5 new areas of review. Members of the psychosocial Evidence Review Group conducted reviews of the literature in each intervention area and drafted the recommendation or summary statement with supporting discussion. A Psychosocial Advisory Committee was consulted in all aspects of the review, and an expert panel commented on draft recommendations and summary statements. Our review process produced 8 treatment recommendations in the following areas: assertive community treatment, supported employment, cognitive behavioral therapy, family-based services, token economy, skills training, psychosocial interventions for alcohol and substance use disorders, and psychosocial interventions for weight management. Reviews of treatments focused on medication adherence, cognitive remediation, psychosocial treatments for recent onset schizophrenia, and peer support and peer-delivered services indicated that none of these treatment areas yet have enough evidence to merit a treatment recommendation, though each is an emerging area of interest. This update of PORT psychosocial treatment recommendations underscores both the expansion of knowledge regarding psychosocial treatments for persons with schizophrenia at the same time as the limitations in their implementation in clinical practice settings.

/pdf/the-2009-schizophrenia-port-psychosocial-treatment-1fjw29af6n.pdf

The 2009 Schizophrenia PORT Psychosocial Treatment Recommendations and Summary Statements

A comprehensive semi-structured questionnaire was administered to 100 psychotic patients who had experienced auditory hallucinations. The aim was to extend the phenomenology of the hallucination into areas of both form and content and also to guide future theoretical development. All subjects heard 'voices' talking to or about them. The location of the voice, its characteristics and the nature of address were described. Precipitants and alleviating factors plus the effect of the hallucinations on the sufferer were identified. Other hallucinatory experiences, thought insertion and insight were examined for their inter-relationships. A pattern emerged of increasing complexity of the auditory-verbal hallucination over time by a process of accretion, with the addition of more voices and extended dialogues, and more intimacy between subject and voice. Such evolution seemed to relate to the lessening of distress and improved coping. These findings should inform both neurological and cognitive accounts of the pathogenesis of auditory hallucinations in psychotic disorders.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S003329170003381X

The auditory hallucination: a phenomenological survey.

Despite neuroleptic medication, many schizophrenic patients continue to experience residual positive psychotic symptoms. These residual symptoms cause distress and disability. We report a controlled trial of two cognitive-behavioural treatments to alleviate residual hallucinations and delusions. Forty-nine patients were recruited into the trial, of whom 27 entered the trial and completed post-treatment assessment, and 23 were reassessed at six-month follow-up. Patients were randomly allocated to either coping strategy enhancement (CSE) or problem solving (PS). Half the patients were allocated to a high-expectancy positive demand condition and half to a counter-demand condition to evaluate expectation of improvement. Patients receiving either cognitive-behavioural treatment showed significant reductions in psychotic symptoms compared with those in the waiting period, who showed no improvement. There was some evidence, although equivocal, that patients receiving CSE improved more than those receiving PS. There was no evidence that improvements generalised to negative symptoms or social functioning, nor was there evidence that expectancy of treatment benefit contributed to the treatment effect.

A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients: I. Outcome.

A method of teaching coping skills to patients with schizophrenia who experience unremitting psychotic symptoms is described. This method (Coping Strategy Enhancement CSE) is based on a thorough behaviour analysis of each symptom and the assessment of any coping strategy the subject may already employ. The subject is then systematically trained in the use of appropriate coping strategies in response to the occurrence of their psychotic symptoms. Two case studies are described in which CSE was used. Both patients showed considerable improvements over treatment. In one patient improvement continued at 6 month follow-up, in the other there was some deterioration at follow-up. Possible reasons for these results were discussed.

Coping Strategy Enhancement (CSE): A Method of Treating Residual Schizophrenic Symptoms

Changes in coping skills and problem-solving skills were examined in two groups of schizophrenic patients. The groups received either coping skills enhancement or problem-solving treatments to reduce their drugresistant residual psychotic symptoms. The coping skills group showed significant increases both in the number of positive coping strategies used and in their efficacy, whereas the problem-solving group showed a decrease in these measures during treatment. Both groups showed significant improvements in problem-solving skills. Changes in coping but not problem solving were significantly related to decreases in psychotic symptoms during treatment. It was concluded that treatment involving the teaching of coping skills had a specific treatment effect.

A trial of two cognitive behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients. II. Treatment-specific changes in coping and problem-solving skills.

Jealousy is a common emotion which can be considered pathological in some circumstances. The term ‘morbid jealousy’ has been used to signify this abnormal or extreme condition. However, the literature on morbid jealousy is sparse and the empirical data fragmentary. The aims of this paper are to briefly review the concept, to define the dimensions of the disorder and to apply a cognitive-behavioural framework to it. Such a summary paper is timely, to draw together the different aspects of the problem and to provide a theoretical base from which to generate further research.

Richard Beckett

Papers

A trial of two cognitive-behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients: I. Outcome.

Coping Strategy Enhancement (CSE): A Method of Treating Residual Schizophrenic Symptoms

A trial of two cognitive behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients. II. Treatment-specific changes in coping and problem-solving skills.

Morbid jealousy: a review and cognitive-behavioural formulation.

Comparison of a morbidly jealous and a normal female population on the Eysenck Personality Questionnaire (EPQ)