Schizophrenia Daily News Blog

Cognitive Behavioral Therapy and Schizophrenia

I want to focus on these two papers for this posting which both talk about the use of Cognitive Behavioral Therapy and its role in treating schizophrenia.

Cognitive behavioral therapy (CBT) is a form of psychotherapy in which the patient is given challenges to certain beliefs they have. Using changes in behavior and changes in the way people process certain ideas, a patient can try and understand the world differently. CBT is very often used to treat depression; patients often perceive the world negatively and put a negative spin on most thoughts. CBT is used to help change those perceptions to a view more based on reality. In this way, people with depression are more able to focus on their problems and solve them rather than letting them build up to insurmountable obstacles.

In schizophrenia, CBT can be useful for many symptoms. Other studies have shown benefits in stable outpatients in decreasing rehospitalizations, increased social skills and decreased distress from symptoms such as voices and other hallucinations/delusions. It also has shown benefit in treating negative symptoms (flat affect, decreased pleasure, decreased emotion, etc.) However, conventional wisdom used to hold that in an acute setting such as the hospital, patients were too sick to utilize psychotherapy because they were too symptomatic to concentrate on the ideas of the therapy. These articles begin to break down that assumption.

In the first article, the authors describe the use of CBT to treat command auditory hallucinations (CAH). CAH can cause significant damage to people with schizophrenia because they are often destructive messages that the person feels compelled to follow or else they may face serious risks. THe voices often speak very sternly and invoke the power of god or the devil to compel the person to act in ways they might not otherwise. CBT can be useful in trying to utilize what the authors describe as "social rank" theory. This theory ultimately tries to teach the consumer that they "outrank" the voices and therefore will help to diminish the importance of the message from the voices. It does not decrease the loudness, frequency or change the messages necessarily, but can help make the voices less of a threat. The subjects of this study had all complied with their voices in some sort of destructive manner prior to entering the study and were considered to be very high risk of doing so again. They were either given this special therapy or randomized to not get the therapy in addition to receiving their regular treatment and medications. The authors of this study found that their therapy did as they expected. The voices "topography", meaning how they sounded, what they said, and how often they were present did not change but the patients who recieved the psychotherapy had fewer episodes or compliance or other acts that were seen to appease the voices. Though this therapy can be labor intensive and expensive, the benefits were notable and ultimately could be seen as cost effective in addition to symptomatically effective.

The second study was done with inpatients admitted for psychotic exacerbation in Wales. Patients were randomized to either receive regular treatment or regular treatment plus CBT. THey could have up to 25 weekly sessions and were followed over the course of one year. The authors found that at one year, the patients who had the CBT, starting with their hospitalization and while acutely psychotic, showed benefits over those who did not receive the additional therapy. They noted that the benefits extended to both positive (delusions, hallucinations, paranoia) symptoms and negative symptoms as well as overall social functioning.

Both of these studies looked at the use of CBT, a very commonly practiced form of psychotherapy, on people with schizophrenia in more acute and high risk settings. The use of CBT in conjunction with medications seems to have benefits. It should be noted that not everyone with schizophrenia may benefit from CBT. However, people who are able to attend to the group and have the cognitive capacity to follow the thinking in CBT can show great progress and may ultimately require fewer hospitalizations and have better quality of life. CBT is not a replacement for medication but should if used should be used in conjunction with medications.

Trower P, Birchwood M, Meaden A, Byrne S, Nelson A, Ross K.
Cognitive therapy for command hallucinations: randomised controlled trial.
Br J Psychiatry. 2004 Apr;184:312-20.

Startup M, Jackson MC, Bendix S.
North Wales randomized controlled trial of cognitive behaviour therapy for acute schizophrenia spectrum disorders: outcomes at 6 and 12 months.
Psychol Med. 2004 Apr;34(3):413-22.

Click here for the link to article #1 on PubMed

Click here for the link to article #2 on PubMed

Author: Jacob Ballon