CBT for psychosis

Cognitive models for psychosis

Stress-vulnerability model

Cognitive model of positive symptoms of psychosis (Garety et al. (2001, 2007))

Morrison (2001)

Delivery

Stages of CBPp

Intervention

Assessment and goal-setting

Relapse prevention

Engagement

What is psychosis?

On a continuum

Sizeable proportions of the non-clinical population have some symptoms present in psychosis

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Rationale

Issues with meds only

Medication adherence is poor

56% non-adherence (Semahegn et al. (2020)

Side effects reduce medication adherence

Persisting positive symptoms (40%)

Recurrent acute episodes (80%)

Depression & anxiety common (70%)

Enduring social disability with poverty, unemployment & restricted life (60-80%)

Suicide (10%)

Discontinuing medications increase relapse rate x5 (Robinson et al. 1999)

Meds & community support only partially effective for 40% (Kane, 1996)

Efficacy of CBTp

Small to moderate effect size (0.09-0.49)

Risk of bias?

Jauhar et al. (2014

Non-significant effects in studies at low risk of bias

No evidence of publication bias

Lower effect size when sources of bias controlled for

But combining heterogeneous trials = reflects clinical complexity of psychosis population (Peters, 2015)

Inverse relationship between methodological rigour and effect size (Wykes et al., 2008; Jauhar et al., 2014).

Shouldn't focus on symptom severity to measure CBTp effectiveness? (Birchwood & Trower, 2006)

Trials using psychological outcomes have higher effect sizes

Compliance with command hallucinations (Trower et al., 2004) - though still distress, depression

Global functioning (Grant et al., 2012),

Psychological well-being (Freeman et al., 2014)

Long term effectiveness in routine clinical practice (Peters, 2014)

Auditory hallucinations, delusions (van der Gaag, 2014)

Overall symptoms in those whose symptoms are persistent (Burns, 2014)

Better than other interventions (Turner, 2014)

New directions

Target specific processes

Use technology

Feeling safe programme (Freeman et al 2021)

Address maintenance factors of persecutory delusions

SlowMo Therapy (Garety et al 2021)

Address paranoia

Help specific sub-populations

STAR trial (Peters et al., 2022)

Psychosis + PTSD

GAMEChange VR (Freeman et al., 2022)

Virtual reality for anxiety/agoraphobia in psychosis

AVATAR Therapy (Craig et al., 2018; Garety et al., 2021)

Relational approach to distressing voices

Formulation

NICE guidelines

Preventative/FEP

Full range of interventions to be offered, including psychological

Subsequent episodes/SCZ

Psychological interventions e.g. CBT + meds

CBT details

1:1, 16+ sessions

Manualised

Include thoughts, feelings etc link

re-evaluations of perceptions etc

Plus 1+ of

thought/feeling etc monitoring

alternative ways of coping

reducing distress

improving functioning

Goals

Learn to cope with unsual experiences

Improve functioning in line with own goals

Come to understand experiences -> empowerment to manage experiences independently

Address depression, anxiety, trauma, emotion regulation etc, as these -> vulnerability, interfering with recovery

Destigmatize experiences

DOESN'T aim to eradicate unusual experiences

Biopsychosocial vulnerability due to socio-cognitive background

Including trauma

High rates in psychosis (Varese et al 2012)

Higher prevalence of PTSD

Associated with worse clinical outcome (Grubaugh et al 2011)

Stressful events

Emotional changes

Have an anomalous experience & already have cognitive dysfunction

Biased appraisal of experience

+ve symptoms

Influenced by

Maintaining factors

cognitive biases

schemas

emotional processes

secondary appraisal of psychosis

Basic CBT

Unsual experience/belief

Beliefs/interpretations/appraisals

Thoughts/emotions/behaviour/body 'hot cross bon'

Perceptual, noticing significance, feeling others control self

Jumping to conclusions (Bead task, Garety et al 1991)

Confirmation bias

Reasoning and attribution (externalising blame or cause of sensory disturbance)

"I am vulnerable"

"other people are dangerous"

environmental factors

Home: feel vulnerable if deprivation, living in high EE or abusive environment

External: danger where live, stigma/discrimination, religious environment

E.g. hearing scary sound -> demons!
losing job -> colleagues are conspiring against me!

"I'm losing my mind"

"I can't cope"

"I'm stigmatised"

-> low self-esteem etc (Wood et al 2017)

Intersectionality (Vyas et al 2021)

Trigger/situation

What happened

How you make sense of it (thoughts

Beliefs about self/others

Influenced by life experiences, thoughts, behaviours and feelings

What you do when it happens (behaviour)

How it makes you feel (feelings)

Initial

Explore how they felt about coming to the meeting

Normalise any feelings of paranoia, anxiety, voices

Validate success of even turning up

Convey: problems taken seriously

Listen empathically

Give ‘pocket summaries’

Suggest/enhance coping strategies if immediate concern

Collaborative & flexible

Start from neutral stance

Don't induce high emotional arousal

Get info on

maintenance - particularly important

triggers

consequences

onset

appraisals of unusual experiences and meaning for self

Goals

Collaborative

Therapy not just to 'offload'

May take several sessions

SMART

Negotiation

Early: share cross-sectional here and now formulation

Later, more longitudinal/complex

Separate from more complex, non-shared formulation

situation -> thoughts, behaviour, feelings

highlight vicious cycles, potential coping techniques

Psychoeducation

Introduce stress-vulnerability model

Offer psychological perspective on experiences

Normalise experiences

Clear that you believe they're experiencing what they say they are

Coping strategies

Start here, then they can start to challenge beliefs

E.g. things they can do to make themselves feel safer and leave the house, e.g. wear headphones so doesn't look odd that they're talking to themselves

Behavioural

Behavioural activation

Dropping safety behaviours

Reducing engagement with belief systems

Graded exposure

Improves mood

Where these are maintaining distress e.g. complying with voices

Like in anxiety work

Working with delusions

Aim is to reduce impact and distress

Make sure there's an acceptable alternative in place before challenging delusional belief

Start with less strongly held beliefs

consider available evidence

test beliefs and alternative with behavioural experiments

Metacognitive training to manage reasoning/attributional biases

Create cognitive 'flexibility'

Like in normal CBT, written records

Working with voices

Like in delusions, but also

Triggers?

Beliefs about level of power/control of voice on them?

Consequences of non-/full compliance?

Possibly reframe as communicating, develop different kind of relationship

Griffiths et al 2012 model shows how experience, power beliefs, behavioural and emotional consequences and background schema interact

Identify triggers/stressors

Document early warning signs (T, F, E, B)

Card sort

Create timeline

Identify action plan

CBT work not specific to unusual experiences

Schema/core belief work

Trauma work

Family work

To bear in mind

working with belief systems

aim is to reduce distress - don't challenge beliefs if they can't

they may have had a traumatic journey to therapy

especially if racial minority, esp Black African/Caribbean (MHA Statistics 2020-2021)

the CBP service will be linked with this for them

experiencing psychosis has likely impacted their mental health

FEP/ARMS often -> significant disability

psychosis associated with self-perceived drop in social rank (Allison et al 2012)

Post-psychosis trauma, depression and suicidality are common

1/2 experience PTSD symptoms, 1/3 full PTSD after FEP

Depression early associated with later depression/suicidality (Upthegrove et al. 2009)

ARMS have high prevalence of suicidal ideation (Taylor et al.,2014)

SU may fear relapse or be avoidant about it

Relapse prevention work can make them feel more in control due to understanding why FEP occurred

Psychological issues that need addressing

Often relationship with trauma

Important to make sense of experiences to move forward and recover

interactions between psycho-social vulnerabilities and stress -> psychosis

underpins how we intervene

Aim

Doesn't aim to get rid of psychotic experiences

Support client with coping, appraising in less problematic way, understanding, improve functioning, address depression, anxiety, trauma, emotion regulation

Not the event that causes distress, it's the beliefs and thoughts

Behaviours can be avoidance or isolation, which reinforce thought that you're not good enough etc.

Identifying vicious cycle isn't a bad thing because can break out of it

Work around appraisals, feelings, behaviours

Simplest, most common approach

More complex - wouldn't give to patient

Doesn't include -ve symptoms, though appraisals may -> them

People really do have threat in their lives - we should acknowledge their heightened sense of threat is understandable

if understand these are affecting your appraisals, can take a step back

e.g. someone may have low confidence/self-esteem, need to bolster to be able to cope

be curious - don't assume how they respond to experiences

Manage expectations - you may still hear voices, but feel better about it

Different from classic CBT

Behavioural experiments

Be attentive, collaborative, "how did you feel?" rather than "I told you so" if did behaviour and no negative outcome

Meanings and atributes they give to the voice and how they response to that

Less stigmatising, normalising

Not perfect solution, tool to give them agency

If they're deep in delusions and at risk, it might not be the right time for psychology

May not be effective for relapse in the long run

Bird et al. (2010) review - 4 trials

Reduced mean +ve and -ve symptoms up to 2 years followup

Not significantly better than standard care for relapse by 2-year followup

small to medium effect sizes

pooled 15 studies: 0.44 auditory hallucinations

pooled 12 studies: 0.36 delusions

worsening of delusions in 2 trials where patients medication resistant

no better than other active treatments

was better than other active treatments

data heterogeneous

unblinding increased effect size

so more effective for hallucinations than delusions - maybe do targeted CBT e.g. Trower et al. (2004) for command hallucinations

click to edit

Can lead directly to +ve symptoms without cognitive changes, but this is rare

Those that influence appraisal: cognitive biases, schemas, environment

Emotional changes (see left)

negative schema s provide content for psychotic attribution as well as increasing vulnerability

social isolation: don't have sources for more normal explanations

Externalising appraisals are the defining feature - if you can reject externality, you can self-correct

Life events disturb affect, directly activating bias appraisal

More likely delusions than hallucinations

Maintain because e.g. delusions confirm schemas and beliefs

processes associated with anxiety and safe for a meaning that fits the emotional response, e.g. threat

Garety et al. (2001) - positive symptoms

Helps person reappraise experience as self-caused, not external

Change negative self-schemata

Compensate for biased reasoning processes

If can't change externalising attribution, can still help to weaken maintenance from safety behaviours, disrupting vicious cycle

Extension to a specific symptom - persecutory delusions (Freeman et al. 2002)

Important symptom because

Likely common maintaining factors with anxiety disorders

Common, associated with distress and can lead to actions that -> hospitalisation

differences from Garety et al (2001)

Focus on processes associated with anxiety

Different maintenance factors

Includes aspects of persecutory belief content

differences from Bentall (1994)

Holds that sufferers have an internal negative self-schema but don't want to admit that to themselves, so they blame external things for bad events

but evidence shows this is only true for a minority

better evidence that they have an externalising self-schema

people with these delusions are more likely to put themselves down

Model

Trigger

Anomalous experiences/ambiguous events/arousal

Search for meaning

Influenced by emotion (anxiety, beliefs about the self and others), cognitive biases as well as the experience/event/arousal

Search for an explanation

Persecutory belief

Mediated by beliefs about illness, social factors, belief flexibility

Maintenance

Splits maintaining factors

Reinforce confirmatory evidence

Discard disconfirmatory evidence (e.g. the worst doesn't happen)

Attentional bias

Behaviours that engender conflict

Employ safety behaviours

"It didn't happen because I did x"

Develop further delusions

"They're trying to lull me into a false sense of security"

2 paths to emotional distress

Directly from content - pervasive threat, persecutors are powerful

Further appraisal

I have no control, I'm sad because this is horrible

Which is more important varies between people

Encouraged by belief-related anxiety

Freeman et al. (2002) recommendations for persecutory delusions

Rapport is key, as there's a high level of threat belief

based on their cognitive model

Sensitive to therapist thinking they're 'mad' - construct non-stigmatising alternative explanation

Use normalisation, talk about cognitive biases

Main goal: change degree of conviction

Work in coping strategies that reduce focus on delusions

Use individualised approach for maintenance factors

But reduce safety behaviours to test the threat belief indirectly

Discuss links between delusion content and emotion

Is normalising, brings up beliefs

Discuss the details of the threat, as they may be able to challenge it at certain points

Model includes importance of their social world for maintenance

discuss relationships and beliefs about others

Expert opinions on necessary components (Morrison et al. 2010)

High consensus on engagement, structure, principles, formulation, assessment, model, homework, change strategies, therapist assumptions

But it has collaboratively negotiated targets, so all aspects aren't always appropriate

Better to follow a decision tree and remain flexible to that patient

Note: this is just opinion - don't have evidence for which components -> good outcomes

Biosychosocial: Stress-vulnerability model

e.g. 25% of people experience hallucinations at lease once (Bentall et al. 1989)

Limitations: only 4 trials

Strengths: Looked at long-term followup, low heterogeneity

Blinding moderated effect sizes

Jauhar et al. (2014) - small effect on symptoms

Turner et al. (2020) m-a - small-medium effect sizes (c. 0.34) for hallucinations/delusions, up to date with lots of studies

but see Turner et al. (2020) higher effect sizes if low bias and van der Gaag (2014) higher if blinding for hallucinations

Though didn't consider long-term outcomes

even if low bias

Campodonico et al. (2022) SU perspectives on the effects of not being able to talk about it

Buswell et al. (2021) Prevalence of PTSD

Clinical implications

Inform any discussion of how we deliver CBT