Transcript Effects of psychotherapy in schizophrenia

Psychotherapy in Psychotic disorders:
Principles and practice of Personal therapy
Matcheri S Keshavan MD
Harvard Medical School, and University of Pittsburgh
NIMH MH 60902, 92440 and 105596; Disclosures: Sunovion, Otsuka
Psychosocial treatments in schizophrenia: a historical
overview
Disorder relevant
interventions
SST
Personal
therapy
Tandon, Nasrallah and Keshavan Schiz Res 2010
Effects of psychotherapy in schizophrenia: II. Comparative
outcome of two forms of treatment.
Gunderson et al Schiz Bull 1984;10(4):564-98.
Psychoanalytic therapy is largely ineffective
Major role therapy: -Psychotherapy (if used alone) is
ineffective
Hogarty et al 1974
Family therapy reduces relapse rates
Multi-family therapy is effective in maintaining remission
McFarlane et al 1995
Psychoeducation may prevent relapse
Key aspects of schizophrenia
relevant for personal therapy:
Schizophrenia is..
• A disease of Brain Development
• A disease of risk and diathesis (Zubin:
Environmental stress- Biological
vulnerability model)
• A disease of stages
• A disease of affect as well as cognition.
Schizophrenia is related to the normal pruning of gray
matter going haywire
Gray matter loss might heighten
stress responsivity (Zubin)
Schizophrenia is a Cognitive and
an affective disorder
• Pervasive cognitive deficits
– Speed
– Memory
– Attention
– Reasoning
– Tact
– Synthesis
• Affect (the “affective paradox”)
– Decreased expression
– Increased arousal
– Impaired regulation
Positive symptoms
(40-50 %)
Hallucinations
Delusions
Loose associations
Affective symptoms
(40-50 %)
Depression
Anxiety
Stress induced relapses
Functional
Impairment
Cognitive impairment
Strongly predicts
Functional outcome
Negative symptoms
(60-70 %)
Avolition
Anhedonia
Anergia
Asociality
Alogia
Cognitive
(80-90%)
Working memory
Selective attention
Schizophrenia is a disorder of stages
Prodromal
Transitional
Premorbid
Recovery
Psychotic
Premorbid
alterations
Decline begins
in prodrome
Post-illness onset
Functional decline
Psychosis
Typically begins in
adolescence
Psychosis is actually a “late” stage of schizophrenia!
Psychological aspects of schizophrenia vary with the phase of the illness and can be prevented/minimized.
Prevention/early intervention
Stabilization/ relapse prevention
Remediation
Integration
Personal therapy
Prodromal
Premorbid
Transitional
Recovery
Psychotic
Psychosis
Denial/ non-compliance
Stress sensitivity, Depression/ anxiety
Social incompetence
Cognitive impairment
Toward second- generation, disorder-relevant
Psychotherapies for schizophrenia
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Psychoanalytic
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Reality-adaptive therapy (Gunderson), Major role therapy (Hogarty) •
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Psychoeducation (Dixon)
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Increasing illness awareness
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Family psychoeducation (Leff)
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Primary environmental stress modification
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Social skills training (Liberman)
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Correcting maladaptive behavioral excesses or
deficits
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Cognitive Behavioral treatments
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Correcting faulty cognitive schemata
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Personal therapy (Hogarty)
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Recognition, self monitoring and adaptive control
of psychotic prodromes
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Cognitive enhancement therapy Hogarty,
Flesher, Eack, Keshavan
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Systematic rebuilding of cognitive and social
cognitive abilities
Faulty defenses, regression to earlier developmental stages
Early case management and supportiive help
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Keshavan and Eack, 2014. in: Treatment of Psychiatric
Disorders, Gabbard G. Ed. American Psychiatric Press.
Psychotherapeutic interventions in
schizophrenia: effect sizes in meta-analyses .
Treatment
modality
Most commonly
reported outcome
variable
Effect size
(Hedge’s g)
References
Psychoeducation
Relapse (2 years)
.Moderate
Pharo, Pilling,
Pischall-Waltz
Lincoln
Cognitive
Behavior Therapy
(CBT)
Positive symptoms
Relapse rates
.Moderate
Tarrier, Zimmerman,
Lynch
Family
psychoeducation
Relapse
.Moderate
Pfammater et al 2006
Social skills
training
Skill acquisition
Community
functioning
.ModerateHigh
Benton and
Schroeder, Corrigan
Kurtz and Mueser
Key principles of Enriched
supportive therapy (Personal
therapy)
• Integrated composite of CBT,
psychoeducation and basic
social skills training principles
• Disorder relevant
practice principles
• Gradual staging of
interventions
• Centrality of affect dysregulation
Hogarty et al 1995
Personal therapy Goals: Phase 1
(3-6 months):
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Illness education
Goal setting and progression
Internal coping
Basic stress avoidance skills
Hogarty et al 1995
Psychoeducation
• Schizophrenia as a “no-fault” brain disorder
• Tailored to individual’s illness stage and ability to process
• Correcting mis-information (e.g. that it is a split-mind disorder, that it
is incurable, etc)
• Initially provided in a formal educational workshop followed by
individual sessions
• Teaching pathophysiology (e.g. dopamine imbalance) as connected
to treatments (e.g. antipsychotic medications)
• Emphasis on risk- liability models (e.g. asthma, high blood
pressure)
• Some repetition is good; emphasize interaction
Resumption of daily tasks
• Goal setting: Start from basic steps ( Focus on self care
personal hygeine, nutrition, sleep)
• Set up reasonable goals: “Internal yardstick” approach
• Expectations to be adjusted to clinical state
• Connect small goals to larger, long term goals
• Expect set-backs; “ one step back and 2 steps forward
rule)
How do I measure
Up to them?
How do I measure
Up to myself,
then and now?
Internal Coping
– Understanding schizophrenia as an environmentally sensitive
psychobiological illness
– Identification of what patient means by “distress”, in his own
words
– Identifying the interpersonal context or life event with which
he/she associates this distress
– Identification of internal cues of affect dys-regulation (prodromal
signs)
– Identification of patient’s existing autoprotective strategies to
cope with stress (helpful as well as unhelpful)
– Stress avoidance skills: Reinforcing prosocial statements; “one
thing at a time”
Early or Warning Signs of
Psychosis
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Behavioral
Strange posturing
Odd or bizarre behavior
Excessive writing without meaning
Cutting oneself; threats of self-mutilation
Deterioration of personal hygiene
Hyperactivity or inactivityStaring
Agitation
Sleep disturbances
Drug or alcohol abuse (This may be a
coping mechanism: self-medicating)
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Thinking and Speech
“Things seem changed in some way”
Rapid speech that is difficult to interrupt
Irrational statements
Preoccupation with religion or occult
Peculiar use of words or odd language
Unusual sensitivity to stimuli (noise, light,
colours, textures)
Memory problems
Severe distractibility
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Herz and Melville 1985
Social
Sensitivity and irritability when touched by
others
Refusal to touch persons or objects; wearing
gloves, etc.
Severe deterioration of social relationships
Dropping out of activities - or out of life in
general
Social withdrawal, isolation, and reclusive
Unexpected aggression
Suspiciousness
Emotional
Inappropriate laughter
Inability to cry, or excessive crying
Feelings of depression and anxiety
Inability to express joy
Euphoric mood Personality
Reckless behaviours that are out of character
Significantly prolonged drops in motivation or
speech
Shift in basic personality.
Reinforcing adaptive autoprotective strategies
Adaptive
• Passive distraction (e.g.
radio or TV)
• Active distraction
(reading, writing)
• Change in environment
(e.g. going for a walk)
• Supportive contact (calling
family, friends)
• Exercise
• Calling therapist
Maladaptive
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Alcohol/ drugs
Excessive sleep
Smoking
Social withdrawal
Excessive praying
Self-protective measures
(e.g. sleeping with a
weapon)
Basic stress avoidance skills
• Role restructuring (e.g. reduce class load,
cut down on extracurricular activities
• Conflict avoidance
– Avoiding behaviors that evince negative
reactions from others
– Taking breaks
• Positive assertions
– Complements
– Positive self statements
Role play and Homework for all above goals
Personal therapy: stages (contd)
• Phase II (intermediate; 7- 18 months)
– Continued psychoeducation (goal: selfawareness; recognition of prodromal signs of
relapse
– Acquisition of adaptive techniques: Relaxation
training; guided imagery/ music; active
distraction techniques; basic conflict
resolution skills
Hogarty et al 1995
Intermediate phase of PT: Goals
• Maintenance and enhancement of clinical stability
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Managing comorbidity- depression, anxiety, substance abuse
Minimizing side effects
Achieving minimal effective dose
Monitoring and addressing suicidality
• Personalized crafting of psychoeducation
– 20-30 minute interactive sessions on cues of distress,
incremental conflict avoidance skills, concepts of disability and
adjustment to it
• Increasing resumption of responsibilities within home
• Adjustment to disability
Resumption of household
responsibilities
• Go with patient’s own choice
• Simple, relevant, feasible, compatible with
clinical state
• Avoid unreasonable expectations
• Consider cooperative sharing with another
family member
• Progressive increase in complexity
• Consider timing (maximize at times of highest
enegy)
• Revisit stress- vulnerability model regularly
Adjustment to disability
• Exclusive strengths based approach may
be counterproductive
• Address denial, “Flight to normalcy”
• Learning what to say and not say about
one’s illness
Other techniques
• Deep breathing and simple relaxation
• Visual imagery
• Criticism management
PT advanced phase (Interfaces and overlaps
with Cognitive enhancement therapy
19- 36 months)
• Psychoeducation with a greater emphasis placed on the refined
assessment of genuine, individual prodromes.
• Addressing social and cognitive deficits, “one step at a time”
• Managing Criticism, an assessment of its validity, learning a
repertoire of verbal and behavioral responses designed to lessen
the other person's intensity and to enhance the patient's social
perception and negotiation skills
• Advanced internal coping strategies include progressive relaxation
training, which is designed to reduce autonomic arousal.
• Independent application of various PT strategies in differing social
contexts,
Conclusions
• Schizophrenia is a developmental disorder of affect, behavior and
cognition
• Schizophrenia sequentially evolves with prodromal and psychotic phases
Characterized by psychosis and affective dysregulation, followed by a
transitional phase with recurrent relapses before finally a stable, chronic
phase sets in, primarily with cognitive and negative symptoms
• Treatment is best tailored to the aspects of illness prominently
manifesting at the specific phases of the illness
• Personal therapy is designed as a compehensive, step-wise approach to
early phases of schizophrenia, involving psychoeducation, stress
management and development of coping skills, setting a stage for
rehabilitative approaches such as cognitive remediation
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