PSY30010 Critical Review PDF

Preview

Summary

Critical review on the use of CBT as treatment for schizophrenia....

Description

A Critical Review of Cognitive Behavioural Therapy in the Treatment of Schizophrenia

PSY30010 Assignment 2 Due date: Word Count: 2857 eLA: Student ID:

COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF SCHIZOPHRENIA

2

Abstract

Schizophrenia is a complex mental disorder with a range of symptoms that vary in nature and severity. These symptoms regularly result in a number of social and psychological difficulties that often cause great distress to the individual. There is no single most effective treatment for the symptoms of schizophrenia though there is growing evidence for the role of therapy in addition to antipsychotic medication in improving a patient’s quality of life. Cognitive Behavioural Therapy is the leading variation of therapy used in the treatment of schizophrenia. This critical review outlines the aims in the use of CBT in the treatment of schizophrenia and examines a variety of literature on its efficacy as a form of treatment. This review finds that there is little evidence for the use of CBT the reduction of primary symptoms, though there are still significant benefits for its use in teaching patients long-term coping skills and in the reduction of patient distress.

COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF SCHIZOPHRENIA

3

Of the primary mental disorders, schizophrenia is one of the most challenging to diagnose and treat. The symptoms are diverse in both nature and severity, and vary not only between patients, but can vary within a single patient over a lifetime (Mckenna, 2007). In addition to primary symptoms, individuals with schizophrenia often deal with a number of internal and social problems that occur as a result of experiencing psychotic symptoms (Gumley et al., 2006). In many cases these internal and social problems lead to lifelong struggles with depression, unemployment, poverty, and in some cases, suicide (Thaker, 2011). Treatment for schizophrenia is difficult and often requires a combination of both medication and psychotherapy. While antipsychotic medications are available and continue to be improved, they are not always effective, the side effects are numerous, and poor adherence is common (Turkington et al., 2008). One form of therapy that has become widely used in the treatment of schizophrenia is Cognitive Behavioural Therapy (CBT). This variation of psychotherapy uses symptom targeted treatment to reduce the severity of symptoms and symptom-related distress through the use of a range of coping strategies (Tarrier, 2005). This critical review will explore the effects of Cognitive Behavioral Therapy on the symptoms of schizophrenia and its effect on relapse rates and rehospitalisation.

Diagnosis, causes, and treatment of schizophrenia Schizophrenia affects just under 1% of people worldwide with different risk rates for different people over different stages in life. A greater portion of cases are first diagnosed between the ages of 18 and 30 years for both males and females and so far, attempts to find an underlying cause for schizophrenia have been unsuccessful. though a number of risk factors have been identified. Individuals with a family history of the disorder are found to be

COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF SCHIZOPHRENIA

4

of the highest risk, with between a 5 and close to 45 percent chance of developing the disorder depending on closeness of blood relationship (Hooley et al., 2017). Those with schizophrenia experience a range of psychotic symptoms. These are classified as either negative or positive-syndrome symptoms. Negative-syndrome schizophrenia is characterised by behaviours where an individual appears to lack what would be considered normal responses, such as lack of expression, an absence of motivation, or little ability to feel pleasure. Those with positive-syndrome schizophrenia report psychotic symptoms, most commonly, delusions and or hallucinations (Hooley et al., 2017). Delusions are intrusive beliefs that are held by the individual despite opposing evidence. Often schizophrenic delusions are of external forces sending personal messages encoded in the world around them. Hallucinations, while less common than delusions, are still experienced by at least three quarters of schizophrenia patients (Thaker, 2011). The most frequently reported form of hallucinations are auditory, which can come in the form of incomprehensible muttering or clear and elaborate conversation (McKenna, 2007). The more distressing of these hallucinations are ‘command voices’, where an individual hears directives coming from what they perceive as a powerful person or entity. Commands that are of the greatest concern are those that instruct harm towards the individual or others, leading to often unpredictable behaviour or violence (Birchwood et al., 2017). Individuals with schizophrenia are not only subject to psychotic symptoms but also the fall-out from these symptoms, including regular hospitalisation, loss of employment, homelessness, and a high risk of suicide (Thaker, 2011).

Relapse during treatment also presents its own challenges. This occurs when the patient has a return of or large increase in psychotic symptoms, often paired with an increase in emotional stress and impaired social functioning. Relapse is often associated with an

COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF SCHIZOPHRENIA

5

increased risk of depression and suicide. The depression that follows a psychotic relapse can, in many cases, be linked to a patient’s feelings of hopelessness or lack of control over the prevention of their relapse, leading to greater feelings of humiliation and loss of autonomy. Studies have found schizophrenia patients who had developed depression after relapse were also most likely to report loss of employment and are more likely to blame themselves for their own psychosis (Gumley et al., 2006). A number of studies have found links between self-esteem and rates of relapse, delusion formation, and rates of distressing auditory hallucination. Due to the complicated nature of the disorder there is currently no single, most effective treatment for schizophrenia (Thaker, 2011). Pharmacotherapy is the leading treatment for schizophrenia worldwide and is often used in conjunction with various forms of therapy. Used regularly, antipsychotic medication has been linked to lower mortality rates which are thought to be related to relapse prevention that have lead to lower rates of suicide (Morrison et al., 2014), though, over the long-term, consistent use of medication is linked to many unwanted side-effects and a heightened risk of relapse (Li et al., 2015). The unwanted side-effects of long-term antipsychotic use have also been known to become permanent in some patients (Tarrier, 2005). While antipsychotic medication continues to be improved, less than 40% of schizophrenia patients report more than small improvements in symptoms throughout their use (Tarrier, 2005), and over 70% of patients were found to discontinue their antipsychotic medication over an 18 month period (Morrison et al., 2014). These challenges in the use of antipsychotic medication have led to an increase in the development of psychological therapies. From this movement Cognitive Behavioural Therapy has become a common variation of therapy in the treatment of schizophrenia (Tarrier, 2005).

COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF SCHIZOPHRENIA

6

Cognitive Behavioural Therapy for schizophrenia In the past, schizophrenia had been thought to be a mental illness that could not be improved with traditional psychotherapies, though a number of studies on the use of Cognitive Behavioural Therapy (CBT) have found evidence for its benefits in the treatment of psychotic symptoms (Tarrier, 2005) and social functioning (Li et al., 2015). Cognitive Behavioural Therapy is a variation of psychotherapy that focuses on the effects of the individual’s thoughts on their behaviour. This form of therapy develops and employs techniques to help the individual change learned maladaptive thought and behaviour patterns with the aim of improving self-regard and making space for personal growth for a better quality of life (Hooley et al., 2017). Cognitive Behavioural Therapy was the first form of psychotherapy to be widely regarded as a treatment for schizophrenia (Jauhar et al., 2014). In a number of studies, the practice of symptom targeted CBT was found to be helpful in teaching strategies that allow the patient to recognise and cope with hallucinations and delusions. These learned strategies have been found to reduce patient distress caused by psychotic symptoms and in some cases, reduce the psychotic symptoms themselves (Tarrier, 2005). There is debate over the benefits of CBT over the long-term and whether it plays a significant role in the prevention of psychotic relapse. While a number of published studies have contributed to its growing use in the treatment of schizophrenia, there are questions surrounding its efficacy and the advantages of its use over less-sophisticated forms of therapy (Jauhar et al., 2019).

The effectiveness of CBT on psychotic symptoms In a 2005 review of CBT in the treatment of schizophrenia, Nicholas Tarrier summarised the findings of 20 controlled trials across Northern America and Europe in order to describe the development of CBT and find evidence to support the use of CBT in

COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF SCHIZOPHRENIA

7

schizophrenia treatment. Tarrier concluded that when compared to trials of treatment as usual, a number of studies found CBT groups experienced a reduction of persistent psychotic symptoms. Reviewed trials consistently reported results of a significant reduction in both positive and negative symptoms when therapy was integrated with regular psychiatric care and adherence to antipsychotic medication. While this review found evidence for the reduction of positive psychotic symptoms with the introduction of CBT, studies that had also included groups treated with non-specific therapies, such as supportive counselling, found no significant difference between the CBT groups and the non-specific therapy groups, suggesting the addition of either types of therapy was beneficial. It was predicted in these studies that the CBT groups would show greater improvements than the non-specific therapy groups due to symptom and phase-specific coping strategies taught in its treatment, though no evidence for this was found. Despite numerous positive findings for the effective use of CBT as treatment for schizophrenia, Tarrier concluded that more research on treatment settings and patient characteristics is required to understand who is most likely to benefit from CBT as treatment and how treatment is best administered. Although there was evidence for the reduction of symptoms in an overall summary of the reviewed trials, Tarrier acknowledged methodological weaknesses in many trials, including lack of blinds trials that appeared to be associated with studies that had reported medium to large effect sizes. This review was also limited in its lack of information on the CBT approaches used in the studies, and whether the CBT being practised targeted psychotic symptoms, such as auditory commands, or whether therapy was used to target negative self-beliefs and improve social skills. A number of approaches to CBT for schizophrenia have developed over time, though Tarrier (2005) believed that no specific approach has proven to be more effective than another. Further studies have also found that the benefits of therapy may not be unique to the

COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF SCHIZOPHRENIA

8

practise of CBT. Morrison et al. (2014) in a single randomised blind control trial examined patients treated with CBT and patients receiving their regular therapy and found no significant deterioration in condition between either group after a period of 18 months. Adding to this, a randomised control trial by Tarrier et al. (2004) on the effects of CBT in first-episode schizophrenia, found no significant difference in the effects of CBT over Supportive Therapy, though both styles of therapy displayed a greater effect in reducing symptoms over treatment as usual. In the search for the benefits of CBT over other, less targeted variations of therapy, a randomised trial by Li et al. (2015) compared the use of CBT as treatment alongside Supportive Therapy (ST) for Chinese patients. The results displayed significantly greater long-term effects for those who had received CBT over patients who received Supportive Therapy. These results were believed to be due to specific techniques used in CBT such as the development of rational explanations, normalisation techniques, and the modification of dysfunctional behaviours that were taught to patients throughout their treatment that could then be used after CBT treatment had ceased. Medication compliance techniques taught to patients in the CBT group were thought to have played a large role in the positive long-term outcomes. This study found, however, that there were no significant advantages of either style of therapy in the short term. This study concluded that CBT used in addition to antipsychotic medication may have long-lasting benefits in reducing symptoms and improving the social functioning of schizophrenic patients.

Most available research into the benefits of CBT combine therapy with treatment as usual where medication is prescribed. Although antipsychotic medication can be an effective treatment for many symptoms it is not without its own set of problems. Most antipsychotics come with side effects from weight gain to structural brain abnormalities and risk of heart

COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF SCHIZOPHRENIA

9

attack. Medication also comes with a chance of adherence problems leading to relapse and the return of symptoms in many schizophrenia patients who prematurely discontinue or refuse pharmacological treatment (Morrison et al., 2014). In a small trial of 20 schizophrenia patients who had been off medication for 6 months or more, Morrison et al. (2014) found the use of individualised, psychosis-response targeted cognitive therapy as treatment resulted in significantly reduced psychotic symptoms in comparison to the control group receiving treatment as usual. CBT for the treatment of relapse A number of trials have found benefits in the use of CBT in the reduction of hospitalisation but little evidence has been found on the effectiveness of CBT in the prevention of relapse (Jauhar et al., 2019). In a short assessment of the role of CBT in relapse prevention and reduction, Tarrier (2005) found a reduction in recovery time for patients in CBT groups across 20 different studies, though there was little evidence that CBT was effective in the reduction of patient relapse. One trial noted in Tarrier’s review did show promising results in relapse reduction through phase-specific, intensive CBT at the early signs of relapse. This targeted approach displayed significant results in its ability to reduce the duration and number of relapse occurrences over a 12 month period. However this study found no effect for the use of CBT on relapse severity.

The long-term benefits of CBT As schizophrenia is often a life-long disorder the results of the above mentioned trials did not conclude whether any positive effects of therapy in the short-term continue to benefit the patient over the long-term. In a study examining the lasting benefits of CBT as treatment over the mid to short-term, Turkington et al. (2008) conducted a randomised control trial of

COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF SCHIZOPHRENIA

10

90 schizophrenia patients with persistent hallucinations and delusions. Patients were split into therapy treatment groups, receiving 20 sessions of either a CBT or Befriending (BT). Patients were then re-assessed in both a 9-month and a 5-year follow-up after the conclusion of the trial treatment sessions. Although CBT and BT displayed significant benefits in the reduction of symptom severity by the end of the treatment sessions, only the CBT group reported less severe symptoms in both the 9-month and 5-year re-assessments. Despite the significant findings for the durability of CBT in reducing symptom severity, there was no significant difference between the therapy groups in the reduction of overall symptoms at any follow-up period. While this was one of the few studies to give insight into the longer-term effects of CBT it was limited by the little information provided on patient antipsychotic use and adherence, and by the lack of a control group receiving treatment as usual. It is hard to conclude whether the reduction of symptom severity in the long-term was entirely due to CBT or antipsychotic adherence. Over the past 20 years, several countries around the world have adopted CBT as part of their national official treatment guidelines for schizophrenia though a number of researchers believe that there is little evidence for the advantages of CBT over other, less complicated variations of therapy (Jauhar et al., 2019). In a systematic review of pooled data from multiple studies and meta-analyses on the study of CBT in schizophrenia treatment, Jauhar et al. (2014) found that in the majority of large and rigorous trials of therapies in schizophrenia treatment, use of CBT resulted in no significant improvement in either the symptoms or relapse rates of patients. A summary of the reviewed meta-analyses concluded that CBT was, however, effective in reducing hospital readmission and length of stay, while also effective in mood improvement and reducing social anxiety in patients. In their review on these positive conclusions, Jauhar et al. (2014) established that many positive findings for the use of CBT in schizophrenia treatment were from what they believed to be a number of

COGNITIVE BEHAVIOURAL THERAPY IN THE TREATMENT OF SCHIZOPHRENIA

11

low-quality studies that had been included in the results of the meta-analyses. Jauhar et al. believed publication bias to be a reason for the inclusion of many low-quality studies, noting that trials with positive results tended to have greater success in finding publishers than those that reported negative results. Jauhar et al. concluded that many of the positive results had been exaggerated when reported and most positive results only displayed a small effect on overall schizophrenia symptoms. In a follow-up meta-analysis to the 2014 review, Jauhar et al. (2019) concluded that CBT is overall ineffective in the treatment of auditory hallucinations and negative symptoms and displayed no effect on the prevention of relapse. Despite these overall results, CBT was found to be effective in the reduction of patient distress caused by delusions and harmful auditory hallucinations.

Conclusion In the treatment of schizophrenia, Cognitive Behavioural Therapy has grown to be one of the more widely implemented forms of psychological therapies. While a number of studies have found evidence for the effectiveness of CBT in the improvement of self-belief and reduction of the distress caused by psychotic symptoms, there are mixed results on its effectiveness on the reduction of hallucinations and positive-syndrome symptoms. None of the studies in this review found evidence for the use of CBT in the reduction of negative-syndrome symptoms and while multiple trials saw a reduction in the duration of hospitalisation and promising signs for relapse duration, CBT was not found to be effective for relapse prevention. While a number of trials have found significant beneficial results in the use of CBT over treatment as usual, few found a significant difference between the results of trials using CBT and trials using less targeted forms of therapy, such as Supportive Therapy or Befriending, though CBT was found to display longer-lasting effects in the reduction of symptom severity.