Transcript Assessment

Assessment
• Life history, critical incidents, current
environment, congruence with symptoms
• Standardised measures
– PSYRATS
– BAVQ, IVI, BAPQ
– Mood, Safety behaviour interview, TCQ etc.
– PTCI, DES, CTQ, THQ
• SMART goals, belief ratings etc.
Formulation
4 levels:
• basic / horizontal
• maintenance
• internal generation
• historical / developmental / vertical
Basic Formulation
EVENT
THOUGHT
FEELING
BEHAVIOUR
hear voice
it’s the devil
scared
pray & visit church
see ceefax
p666
I’m the devil
scared
burn self
Maintenance Formulation
Triggers (cannabis, paranoid thoughts, arousal, religious )
Hear Voices
scared, increased arousal
no sleep
pray, hide in church,
attend to relevant stimuli
It is the devil trying to possess make me harm people
Historical Formulation
Early Experiences
mental and sexual abuse from religious mother
physical abuse from father to both
told to harm father; told she was evil
catholicism
Beliefs Formed
I am evil and the devil is in me
I might harm other people
Must think good thoughts
Thinking something evil is as bad as doing it
Critical Incident
Raped
Hear voices saying bad things
Intrusions / event
Social situations / reminders
Flashbacks / dissociation
Critical voices
Making sense of things
They are talking about me / want
to hurt me
I’m mad / not normal
It’s a Bully from beyond the
grave
Beliefs / strategies / rules
I am vulnerable / useless
I am mad / not normal
People will hurt you & can’t be trusted
‘Paranoia’ keeps me safe
Bullying was my fault
If I keep busy or spaced out then I won’t
have time to think / feel bad
Cog. & Beh. responses
Safety behaviours
Dissociation
Thought supression
Avoid situations
Run away
Look out for danger
Don’t express self
Mood & physiology
Experience
Bullying
Physical Abuse
Emotional abuse
Anxious
Hyperarousal
Paranoid
Depressed
Sleep problems
Experiences that worry me
Hear whispering and laughing
See bodies
See people staring
What I make of it
They might be ghosts
I must be going mad
They might harm me
What I make of the self / world
I should be in total control
I am bad
Need to be alert for danger
Other people cannot be trusted
What I do
Try to stay in control of thoughts
Hide from ghosts
Look out for things happening to me
Early experiences
Baby brother died, mum blamed me
Sexually abused aged 14
Dad horrible to me
How I feel
scared
agitated
angry
sad
Formulation Exercise
• Role play assessment of patient and
formulation
Video
• Developing case formulation
Exercise
• Suggest intervention strategies based on
formulation
Normalising psychotic experiences
•
•
•
•
•
Trauma (assault, bullying, kidnap, combat)
Drug abuse
Isolation / Sensory deprivation
Bereavement
Sleep deprivation
Some well known voice
hearers:
• Philosophers and
thinkers:
Socrates
Plato
Aristotle
Descartes
Mahatma Gandhi
• Authors, musicians and
creative artists:
Jonathan Swift
Beethoven
Mozart
Byron
Edgar Allen Poe
Charles Dickens
Philip K Dick
Anthony Hopkins
Zoe Wanamaker
Paul McCartney
Brian Wilson
Spiritual and religious figures:
Moses
Jesus
Mohammed
Joan d'Arc
George Fox (Founder of the Quakers)
Leaders and rulers
Alexander the Great
Caesar
Oliver Cromwell
Napoleon
Churchill
Scientists,Discoverers & Explorers
Christopher Columbus
Galileo
Isaac Newton
John Nash
Footballers
Tony Cascarino
Paul Gascoigne
• “I’ve learnt a lot...erm I guess about mental
health it happens to a lot of people and things
like... I thought I was abnormal, especially
when I was down I thought what is wrong with
me erm and [therapist] would always say well
would you think somebody was normal if they
had green eyes, and you’d be like yeah, and
she’d say like... well more people have
mental health problems than have green
eyes” (8)
• “…all these thoughts, I was thinking when I
felt fine, oh my god they’re crazy but
[therapist] helped me to see that the thoughts
weren’t crazy, after looking at what
happened” (1)
Common Treatment Strategies
•
•
•
•
•
•
Advantages and disadvantages
Normalisation and formulation
Evidence for and against
Explore meaning / downward arrows
Modify environment
Belief restructuring:
–
–
–
–
Historical review
Meaning of event
Continuum
Evidence, data log
• List alternative explanations
– Conviction ratings
– Pie chart
– Refer to feelings and behaviour
Common Treatment Strategies
• Behavioural experiments:
– Drop safety behaviours
– Exaggerate and drop
– Attentional focus
– Test reality
– Practical stuff
– Test alternatives
– Monitoring
– Symptom induction
– Surveys
• Metacognitive
– beliefs (e.g. positive/negative beliefs about
paranoia/rumination/worry)
– strategies (e.g. postponing perseverative processing)
– attentional strategies (e.g. external focus)
• “We could test out our predictions, and
like look for other explanations like,
there was some exercises in the CBT
that I could do...so eventually I’d feel,
like I’d get a de-escalating feeling of
anxiety” (1)
• “I think the evidence thing’s kind of
good, sort of it is real and you have to
sort of work out well, is it likely to be
real. Like if you think, say, people taking
thoughts out of my head, and erm, it’s
sort of well what’s the proof that they
are” (2)
Intervention: Delusions
• Identify thoughts, feelings & behaviour
• Evaluate advantages and disadvantages
• Evaluate thoughts:
– evidence for and against
– generate alternative explanations
– advantages & disadvantages
• Education
– anxiety, intrusions, metacognition,
– reasoning biases, thinking errors, selective attention
• Behavioural experiments
Advantages
Disadvantages
Makes me feel special
Frustration when Richard and I do not meet.
Keeps my belief in a soulmate
Causes difficulties with present partner
Makes life feel special
Has got me into trouble with the police in the
past
My psychiatrist thinks this is a problem
It upsets my daughter a lot
I’m distraught when Richard tells me he is not
in love with me
Anger towards Richards wife
Unable to go away for the weekend as need to
stay near house in case Richard decides to
come and see me
Evidence for
“The neighbours are going to attack
me”
Evidence against
“The neighbours are going to attack
me”
There are rowdy noises from next
door
I have seen them 3 times this week
and they haven’t attacked me
I have been assaulted by other people
in the past
I have never been assaulted by anyone
from my street
They can read my mind
I have never seen the neighbours be
violent to anyone
I don’t think they are going to attack
me when I am drunk or when I am
with other people
Evaluating interpretations
The rowdy noises from next door are due to:
Initial belief: The neighbours want to attack me
80%
The neighbours are having a party
25%
The neighbours are having an argument
50%
The neighbours are making noises to wind me up
50%
I am imagining the noises
10%
The noises are being beamed into the house from outer space
0%
Stress, lack of sleep & beliefs are making me misinterpret noises
25%
Interpretations of Voices
• mediate distress
• identify
•
•
•
•
•
•
use modified DTR
use questionnaires
use interviewing
use downward arrows to access personal meaning
use content
use qualities of voice
Interpretations of Voices
• evaluate by
•
•
•
•
•
use of list of interpretations
generate alternative interpretations
relate to normalising information
rate & rerate belief each session
use diaries / monitoring
» include how related were the voices to your thoughts
or worries or yourself
Interpretations of Voices
• Evaluating...
• examine evidence for and against
» including content
» use shadowing
» compatibility of modulators
• behavioural experiments
» drop/modify safety behaviours
» manipulate attentional biases
» control
Interpretations of Voices
• encourage one to be internally generated
•
•
•
•
•
•
provide information re: research
behavioural experiments using subvocalisation
analysis of voice content in relation to thoughts
education re: intrusive thoughts
identify metacognitive beliefs
challenge metacognitive beliefs
Video
Content of Voices
• Can mediate distress
• Identify using:
– modified DTR
– shadowing
– role play
– diaries
Content of Voices
• Challenge using:
– link between thoughts and voices
– evidence for and against
– alternative explanations
– role play
– flashcards
Content of Voices & Schema
• Content of voices often related to
experience
•
•
•
•
•
•
bullying
sexual abuse / rape
worthlessness
evil
guilty
threat
Content of Voices & Schema
• Challenge using Padesky’s (1994)
techniques:
– continuum methods
– surveys
– historical test
– positive data logs
Why homework?
The rationale for homework
• The idea that homework enhances therapy
should be replaced by the idea that therapy
enhances homework.
Secondary gains of homework
• active
• achievement
• collaborative
nature
of
the
therapeutic
relationship
• empowerment
6 golden rules for maximising
homework compliance
• Decide work to be done jointly.
• Clearly identify the rationale for doing the
homework.
• Check out obstacles.
• Make the homework meaningful but
achievable.
• Establish prompts.
• Begin the use of homework from the first
session.
• “I feel if I hadn’t done the homework that I
had, then, and showed up to the sessions as
well, I think it would have taken me a lot
longer” (1)
• “…when I first like you know got told I was
gonna have CBT you just expect you get
better but it doesn’t, there’s a lot of like, you
got a put a lot in yourself to get a lot out
really” (7)
• “So once we had worked out that I was
actually doing it right I could do it by myself”
(1)
Behavioural experiments
• A powerful way to test alternative belief
derived from verbal testing
• Facilitates ‘gut’ level change
• Links behaviour with personal meaning
• Specifically targeted - increases efficiency
and effect
• Wider range of uses
Behavioural experiments
• Can include:
– Observations
– Surveys
– Acting ‘as if’
– Hypothesis testing (A/B)
– Increasing / Decreasing responses
– Symptom induction
– Role plays
Issues of design
• Be collaborative
• Motivation to complete them
• Practical implementation
‘People can hear my thoughts’
• Behavioural experiments
– Drop safety behaviours
– Suppression vs. counter-suppression
– Recording
– Deliberate broadcasting to provoke responses
– Surveys
Principles of Cognitive Therapy
 A cognitive model is required from which to empirically derive
effective treatments:
FORMULATE USING MODEL
• What are you concerned about?
SHARE A GOAL
• You are not mad, you are normal:
NORMALISE
• Either it is real or you believe it to be real:
SIT ON A COLLABORATIVE FENCE
• How you appraise events contributes to distress:
EVALUATE USING E-T-F-B
• It’s not always what you think, sometimes it’s how you think
MODIFY CONTROL STRATEGIES
• Test it out – drop your safety behaviours:
EXPERIMENT IN & OUT OF SESSION
Tips
• Important to relate to goals (usually
emotional change or changing ‘what I do’
to improve QoL)
• Use match between appraisal and
emotion, and emotion and behaviour
• Only draw in arrows with agreement –
otherwise investigate relationships
• Normalise the ‘story’
• Use arrows to plan treatment
Tips
•
•
•
•
Agree a shared goal first and foremost
Explicit structure and labels
Focus on specifics, not general
Leave plenty of time for ‘between session
tasks’
CBT for psychosis
• NICE guidelines say at least 16 sessions
over at least 9 months
• Numerous meta-analyses in support (BUT
as adjunct to antipsychotics in most
participants)
• Aims to reduce distress and improve
quality of life
Inclusion criteria
• 1) either meet ICD-10 criteria for schizophrenia,
schizoaffective disorder or delusional disorder or meet
entry criteria for an Early Intervention for Psychosis
service (operationally defined using PANSS) in order to
allow for diagnostic uncertainty in early phases of
psychosis
• 2) either have at least 6 months without antipsychotic
medication and experiencing continuing symptoms OR
never have received antipsychotics and be currently
refusing
• 3) score at least 4 on PANSS delusions or hallucinations
or at least 5 on suspiciousness/persecution, conceptual
disorganisation or grandiosity
Measures
• Symptoms:
– PANSS
– Psychotic Symptom Rating Scales
(PSYRATS; Haddock, McCarron, Tarrier and
Faragher, 1999).
• Recovery
– A user-defined measure of recovery (QPR;
Neil et al., 2009)
• Functioning
– PSP
CONSORT diagram
Referred (n = 43)
Assessed for eligibility (n=
26)
Enrollment
Allocation
Follow-Up
Analysis
Allocated to intervention
(n= 20)
Received allocated intervention
(n= 19, 1 withdrew after 1
session)
Assessed n =17
declined n = 1 withdrew n = 2
Analysed (n= 20)
Excluded from analysis
(n=0)
Last observation carried
forward (LOCF) at end of
treatment analysis (n = 3)
LOCF at follow up analysis
(n = 5)
Excluded (n= 6)
Not meeting inclusion criteria
(n= 5)
Refused to participate
(n= 1)
Patient characteristics
• Gender
– Male N = 10
– Female N = 10
• Age
– Mean = 26
– Range 16 - 56
• Ethnicity
–
–
–
–
White British N = 16
Black African N = 1
Black Caribbean N = 1
Other N = 2
Diagnosis
•
•
•
•
•
•
Schizophrenia N = 15
Schizoaffective Disorder N = 4
Delusional Disorder N = 1
Disabling hallucinations N = 13
Disabling delusions N = 17
Both delusions and hallucinations N = 10
CT
• 8 therapists contributed to the delivery of
CT within the trial.
• The number of participants treated by
each ranged between 1 and 10.
• participants received a mean of 16.7
sessions (S.D. = 7.26; range 1 to 26)
• Acceptability: no participant not attending
any sessions, and 19/20 receiving 6 or
more sessions
Effect size analyses (Cohen’s d)
Variable
Baseline to end of
treatment
Baseline to 6 month
follow up
PANSS positive
0.87
1.05
PANSS negative
1.00
0.77
PANSS general
0.51
1.06
PANSS total
0.85
1.23
PSYRATS delusions
0.98
0.99
PSYRATS voices
0.56
0.79
PSYRATS total
0.90
1.07
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)
45
39.55
40
35
29.05
30
25
21.88
20
15
10
5
0
baseline (SD=11.9)
end of treatment
(SD=19.1)
6 month follow up
(SD=17.1)
Secondary outcomes
PANSS positive – mean scores at baseline,
end of treatment and follow up
A significant difference from baseline to end of treatment was identified
(p = 0.01)
A significant difference from baseline to follow up was identified (p =
.001)
14
12
11.75
10
7.65
8
5.94
6
4
2
0
baseline (SD = 4.74)
end of treatment (SD = 6 month follow up (SD =
7.37)
5.99)
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)
16
14.7
14
12
10
8
6.45
5.23
6
4
2
0
baseline (SD=6.66)
end of treatment
(SD=7.07)
6 month follow up
(SD=6.3)
PSYRATS voices – mean scores at baseline, end
of treatment and follow up
A significant difference from baseline to end of treatment was identified
(p = 0.02)
A significant difference from baseline to follow up was identified (p =
.003)
25
20
19.35
15
10.81
10
9.48
5
0
baseline (SD=15.02)
end of treatment (13.55)
6 month follow up
(12.34)
Secondary outcomes
Variable
Pre
treatment:
Mean (SD)
Post
Treatment:
Mean (SD)
Follow
up:
Mean
(SD)
Pre- treatment to posttreatment
Pre-treatment to follow-up
t
p
d
95% CI
t
p
d
95% CI
QPR total
48.83
(15.69)
57.22
(18.59)
60.96
(18.80)
-1.69
.110
.41
0.09,
0.90
-2.50
.024
0.65
0.08,
1.11
PSP total
47.4
(13.80)
56.45
(18.37)
66.05
(18.31)
-2.44
.025
0.54
0.07,
1.01
-3.99
.001
0.87
0.34,
1.37
Good and poor clinical
outcomes.
25%+ Decrease on PANSS = Good clinical outcome
25% +Increase on PANSS = Poor clinical outcome
Table 2. % decrease on PANSS total scores at end of therapy and follow up
Total N
0 – 24%
increase
0% - 24%
reduction
25% - 49%
Reduction
50% - 74%
reduction
75% 100%
reduction
End of
therapy
20
3
7
3
5
2
6 month
follow up
20
2
7
1
6
4
Secondary outcomes: initiation
of antipsychotic medication
17
18
16
14
12
10
8
6
3
4
2
0
0
Started on anti
psychotic medication
during therapy
Started on anti
psychotic medication
post therapy
Not started on anti
psychotic medication
Predictors at 9 months
PANSS total
change
PSYRATS delusions
change
PSYRATS voices
change
BAPS: negative change
.465*
.426
-.078
IVI: metaphysical
change
-.187
.038
.277
IVI: control change
.255
.388
.707**
Age
.443
-.295
-.529*
DI
-.774**
-.817**
-.017
DUP
-.307
-.476
.127
Number of sessions
-.096
-.026
-.083
Gender
.000
-.018
-.152
Predictors at 15 months
PANSS total
change
BAPS: negative change
PSYRATS delusions
change
PSYRATS voices
change
.647**
.468*
-.280
IVI: metaphysical
change
-.314
-.096
.318
IVI: control change
.088
.260
.470*
Age
-.318
-.348
-.385
DI
-751**
-717**
.036
DUP
-.377
-.368
.089
Number of sessions
0.22
.002
-.007
Gender
-.038
-.024
-.149
Limitations
• Pilot study
– Small (N = 20)
– No control group
– No randomisation
– Rater bias?
– LOCF (but only one condition)
ACTION: Assessing Cognitive
Therapy Instead Of Neuroleptics
• Two site single blind RCT with two conditions
(CT plus TAU vs. TAU) for people with
psychosis not taking antipsychotic medication
(due to refusal or discontinuation)
• Assessments are 3 monthly following the initial
baseline assessment (i.e. at baseline, 3, 6,
and 9 months)
• Follow-up assessments are at 12, 15 and 18
months
• n=74
Baseline PANSS data
PANSS subscale
Mean
(S.D)
PANSS positive total
20.89
(4.91)
PANSS negative total
14.31
(4.61)
PANSS general total
36.18
(7.70)
PANSS total
71.55
(13.76)
Reasons for not taking
antipsychotics
Antipsychotic naïve: discontinued ratio
Reasons for not taking anti-psychotic medication
Side effects
Philosophical view on psychosis – disagrees with the
medical model/ preference for psychological treatment
Health reasons including pregnancy
Symptoms are unresponsive to anti-psychotic
medication
Disagrees with diagnosis
Other
Data unable to be captured
34:40
23 (31.08)
15 (20.27)
5 (6.76)
4 (5.41)
6 (8.11)
16 (21.62)
5 (6.76)
• Treatment options for first episode
psychosis
– If the child or young person and their parents or
carers wish to try psychological interventions
(family intervention with individual CBT) alone
without antipsychotic medication, advise that
psychological interventions are more effective
when delivered in conjunction with antipsychotic
medication. If the child or young person and their
parents or carers still wish to try psychological
interventions alone, then offer family intervention
with individual CBT. Agree a time limit(1 month or
less) for reviewing treatment options, including
introducing antipsychotic medication. Continue to
monitor symptoms, level of distress, impairment
and level of functioning, including educational
engagement and achievement, regularly.
1.3.27 CBT should be delivered on a one-to-one basis over at least 16
planned sessions (although longer may be required) and:
follow a treatment manual* so that
- children and young people can establish links between their thoughts,
feelings or actions and their current or past symptoms, and/or
functioning
- the re-evaluation of the child or young person’s perceptions, beliefs or
reasoning relates to the target symptoms
also include at least one of the following components:
- normalising, leading to understanding and acceptability of their
experience
- children and young people monitoring their own thoughts, feelings or
behaviours with respect to their symptoms or recurrence of symptoms
- promoting alternative ways of coping with the target symptom
- reducing distress
- improving functioning.
Case study
• 1-8
– Problems and goals (confidence, self-esteem,
low mood and self-harm, voices, low
motivation)
– Formulation
– Continuum for low self-esteem
– Evidential analysis of self-critical thoughts
– Positive imagery
– Survey / results (judged, relationship, employ)
Experiences that worry me
Social situations
Voices
What I make of it
I am not good enough
I must harm myself
Voices are bullies
Others will harm me
What I do
Try to stay in control of thoughts
Isolate self and withdraw
Negative comparisons
Rituals
Daydreaming / dissociation
What I make of the self / world
I am different
I am unimportant and worthless
Need to be alert for danger
Other people cannot be trusted
Others will leave and reject me
Early experiences
Family criticism
Never fit in
Severe bullying at school and work
Wrongful arrest and harassment
How I feel
Low mood
Hopeless
Anxiety
Anger
Case study
• 9-11
– Revisit goals
– Negative comparisons
– I’m a failure
– Activity for mood
• 12-15
– Daydreaming and dissociation (normalising;
pros/cons; diary; modified GAD model)
– Voices
Case study
• 16-18
– PTSD (grounding, attentional focus,
reconsider meaning)
• 19-22
– Social anxiety (stop post-mortems,
anticipation > event, stop safety behaviours,
external focus, update image)
trigger
Social situations
Negative thought
Others will judge me
Others will reject me
Image of self
Weak
Vulnerable
Hunched
Ugly
Very skinny
Unconfident
Shaky
What I do
Arrive late
Avoid eye contact
Only speak to people I know
Speak with hand over mouth
Doodle/fidget
Hunch up and try to disappear
How I feel
Anxiety
Tense
Palpitations
Sweaty
Shaky
Case study
• Progress:
– I am good enough
0% 80%
– Social confidence
10% 70%
– I am different
100% 50% (neutral)
– I’m as important as others
0% 80%
– No flashbacks, no self-harm, no suicidal thoughts
– Voices only at night and managable
– Getting married
– Doing postgraduate course
Does CBT work for transition?
12 month outcomes
CBT
Study or Subgroup
SC
Risk Ratio
Events Total Events Total Weight M-H, Random, 95% CI
ADDINGTON2011A
0
16
3
15
2.5%
0.13 [0.01, 2.40]
MORRISON2004
2
26
5
16
9.0%
0.25 [0.05, 1.12]
MORRISON2011
7
95
10
93 24.4%
0.69 [0.27, 1.72]
PHILLIPS2009
7
29
6
19 24.3%
0.76 [0.30, 1.93]
VAN DER GAAG2012
9
75
20
86 39.7%
0.52 [0.25, 1.06]
229 100.0%
0.55 [0.35, 0.87]
Total (95% CI)
Total events
Risk Ratio
241
25
44
Heterogeneity: Tau² = 0.00; Chi² = 2.77, df = 4 (P = 0.60); I² = 0%
Test for overall effect: Z = 2.57 (P = 0.01)
M-H, Random, 95% CI
0.5
0.7
1
1.5
Favours CBT Favours SC
2
Does CBT+AP work for transition?
CBT + risperidone
Study or Subgroup
Events
SC
Risk Ratio
Risk Ratio
Total Events Total Weight M-H, Random, 95% CI
MCGORRY2002
6
24
10
17 56.2%
0.42 [0.19, 0.94]
PHILLIPS2009
7
27
6
19 43.8%
0.82 [0.33, 2.06]
36 100.0%
0.57 [0.30, 1.08]
Total (95% CI)
Total events
51
13
16
Heterogeneity: Tau² = 0.02; Chi² = 1.13, df = 1 (P = 0.29); I² = 11%
Test for overall effect: Z = 1.73 (P = 0.08)
M-H, Random, 95% CI
0.5
0.7
1
1.5
Favours CBT + risperidone Favours SC
2
Does CBT work for symptoms in
UHR?
CBT
Study or Subgroup
Mean
SC
SD Total
Mean
Std. Mean Difference
SD Total Weight
IV, Random, 95% CI
PHILLIPS2009
2.8
2.9
27
3.1
3
18 12.9%
-0.10 [-0.70, 0.50]
ADDINGTON2011A
5.2
5.6
27
6.6
4.7
24 15.1%
-0.27 [-0.82, 0.29]
35 10.9286 2.99908
23 16.6%
-0.13 [-0.65, 0.40]
95
93 55.4%
-0.36 [-0.64, -0.07]
158 100.0%
-0.27 [-0.49, -0.06]
MORRISON2004
MORRISON2011
10.5417 3.05001
14.88
15.54
Total (95% CI)
20.84
17.75
184
Heterogeneity: Tau² = 0.00; Chi² = 0.94, df = 3 (P = 0.82); I² = 0%
Test for overall effect: Z = 2.48 (P = 0.01)
Std. Mean Difference
IV, Random, 95% CI
-1
-0.5
0
0.5
Favours CBT Favours SC
1
What do service-users want?
60
% of dropouts
50
40
30
20
10
0
PACE
McGorry et al. 2002
[CBT plus
risperidone]
PRIME
EDIE-2
Morrison et
al. 2004
EDIE
McGlashan et
al. 2006
Morrison et
al. 2012
[CT]
[Olanzapine]
[CT]
NICE draft guideline:
Psychosis and schizophrenia in children and
young people: recognition and management
• Treatment options for symptoms not sufficient for a
diagnosis of psychosis or schizophrenia
• When transient or attenuated psychotic symptoms or
other mental state changes are not sufficient for a
diagnosis of psychosis or schizophrenia, consider:
– treatments recommended in NICE guidance for any recognised
conditions such as anxiety, depression, emerging personality
disorder or substance misuse, or
– individual or family cognitive behavioural therapy (CBT) to
decrease distress (delivered as set out in recommendation
1.3.27). [1.2.5]
• Do not offer antipsychotic medication for psychotic
symptoms or mental state changes that are not sufficient
for a diagnosis of psychosis or schizophrenia, or with the
aim of decreasing the risk of psychosis. [1.2.6]
EDIE-2 vs ACTION: Stigma
ARMS
Mean (SD)
Psychosis
Mean (SD)
t
P
95% CI
Self as abnormal
13.56 (2.53)
13.56 (3.33)
-.001
.999
-.760 - .759
Expectations
10.43 (2.70)
10.95 (2.64)
-1.531
.127
-1.20 - .150
Shame
5.69 (1.36)
5.88 (1.42)
-.979
.328
-.562 - .189
Depression
9.73 (4.48)
9.61 (4.73)
.187
.851
-1.09 - 1.32
40.77 (18.03)
.172
.864
-4.33 - 5.16
Social anxiety
41.18
(16.98)
EDIE-2 vs ACTION: Stigma
BDI
SIAS
ARMS
Psychosis
ARMS
Psychosis
Self as abnormal
.471**
.375**
.405**
.376**
Expectations
.452**
.543**
.422**
.426**
Shame
.332**
.486**
.325**
.442**
Stigma
PBEQ score
30
25
20
CT
15
Monitoring
10
5
0
baseline
6
12
24
• “I never expected it to be a wondercure,
and that Edie 2 at the end of it I was going
to feel normal again, but in terms of
looking at the horrible side of mental
health, I feel as though they’ve confirmed
that I’m not going down that road, and
that’s helped me feel better inside I guess”
(m2)
Summary
• Minimise harm from medication, especially if
no benefits
• Promote choice and alternatives
• Normalise / understand psychosis from a
psychosocial perspective
• Reduce distress with CBT
• Promote recovery
• Promising for preventing first episodes of
psychosis and reducing symptoms in UHR
• Work in genuine partnership with young
people
Conclusions
• More research required
– Who benefits from antipsychotics
– Who benefits from CBT
– Alternatives evaluated in comparison to
antipsychotics
– Other alternatives
• Reasons for optimism
– CBT reduces transition and symptoms in ARMS
– CBT is encouraging as an alternative to
antipsychotics for established psychosis
– CBT without antipsychotics seems to work well for
early phases of psychosis / young people
• “I feel if I hadn’t done the homework that I had, then, and showed
up to the sessions as well, I think it would have taken me a lot
longer” (1)
• “…when I first like you know got told I was gonna have CBT you
just expect you get better but it doesn’t, there’s a lot of like, you got
a put a lot in yourself to get a lot out really” (7)
• “I think what I struggled with was the fact that I was having to look
at myself and em, and then there was like homework that came
with it you know, and I struggled with that for a while purely and
simply because I was having to look at myself” (t8)
• “To be honest there would have been times where there was no
way I would have engaged with it or benefited from it…think you’ve
got to be ready and motivated for it cos there is quite a lot of
thinking and you need to be fairly open minded.” (3)