Jy CT psychosis

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Published on January 17, 2008

Author: Dorotea

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Paul French:  Paul French Psychology Services of Salford Bolton Salford & Trafford Mental Health Trust & Department of Psychology Manchester University A Cognitive Approach to Psychosis Early Detection and Intervention Team Slide2:  Acknowledgements David Clark, Paul Salkovskis, Adrian Wells, Ann Hackmann Tim Beck Richard Bentall, Tony Morrison Paul Chadwick, Max Birchwood David Kingdon, Doug Turkington David Fowler, Philippa Garety et al Nick Tarrier Overview:  Overview What is psychosis? Models of psychosis Formulation Normalisation Cognitive Therapy Cognitive Therapy applied to psychosis Conclusions Drury et al. Cognitive therapy and recovery from acute psychosis. BJP 1996:169;593-601.:  Drury et al. Cognitive therapy and recovery from acute psychosis. BJP 1996:169;593-601. N=62: 22 excluded: 10 not suitable for CT - did not disclose symptoms/engage/took <50% medn: 12 not suitable for activity programme: inpatients into study Krawiecka ratings by first author: blind at 9/12 Individual & group CBT v. Structured activities & informal support Results at week 12: CT less positive symptoms: reduction in delusional conviction: med 75 (CBT) v 53 mg stel equiv 9 mths (n=37): CT fewer positive symptoms: 95% cf 44% reported no or only minor positive symptoms on PAS Recovery time reduced by 25-30% Kuipers E et al. London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. I: Br J Psychiatry 1997;171:319-327:  Kuipers E et al. London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. I: Br J Psychiatry 1997;171:319-327 CBT vs. treatment as usual (defined key worker): n=60: randomised, independent raters not blind BPRS fell by 25% no change in control at 9 & 18 months 14% failed to complete CBT: 29% not 12 sessions specific measures: positive symptoms, mood & social function not differentiate Kemp et al (1996) Compliance therapy in psychotic patients: RCT. BMJ, 312, 345-349: 18 month follow-up. British Journal of Psychiatry, 172, 413-9:  Kemp et al (1996) Compliance therapy in psychotic patients: RCT. BMJ, 312, 345-349: 18 month follow-up. British Journal of Psychiatry, 172, 413-9 N=47 inpatients: not blind initially but was so at 6 & 18 mths. Compliance therapy v non-specific counselling: 4-6 sessions Sign. improvements in attitudes to medication & insight BPRS & GAF - improvement; non-sig difference CPZ equivalent - 869mg v 776 mg at 18 mth, n=74: DSM-IIIR psychosis (18/12) no difference in symptomatology - both improved BPRS sig. on measures of insight, attitudes to treatment & observer-rated compliance: survival in community prior to readmission: global social functioning improved relatively more over time: 30% non-participation - refusal or rapid discharge: 35% drop-out Healey, A., Knapp, M., Astin, J., Kemp, R., Kirov, G., & David, A. (1998) Cost-effectiveness of compliance therapy for people with psychosis. B J Psychiatry, 172, 420-4.:  Healey, A., Knapp, M., Astin, J., Kemp, R., Kirov, G., & David, A. (1998) Cost-effectiveness of compliance therapy for people with psychosis. B J Psychiatry, 172, 420-4. More effective and no more expensive: therefore more cost-effective at 6, 12 & 18 mths. Client Service Receipt Inventory; therapy cost - £147 (psychologist); £57 (nurse) inpatient & costs - less but non-sig at all points Tarrier et al. Randomised controlled trial of intensive cognitive behaviour therapy for patients with chronic schizophrenia. British Medical Journal 1998: 317; 303-7.:  Tarrier et al. Randomised controlled trial of intensive cognitive behaviour therapy for patients with chronic schizophrenia. British Medical Journal 1998: 317; 303-7. coping strategy/problem solving/relapse prevention: control supportive therapy - treatment as usual: 20 sessions-10/52 n= 87 (72) persistent positive symptoms, complied with medication CPZ equivs - 425 CBT: 518 ST: 450 routine care - atypicals(9) randomised & raters blind to group: at three months: significant improvements in severity & number of symptoms in CBT: ST non-significant improvement Significantly more CBT patients showed improvement of 50% or more in symptoms (18 of 33: 4 of 36: 3 of 28): Routine care - more exacerbations and time in hospital Sensky et al 2001:  Sensky et al 2001 Multi site RCT Compared CBT to BF to RC Measures include CPRS MADRS SANS APA Guidelines on Schizophrenia (1997):  APA Guidelines on Schizophrenia (1997) ‘Several controlled and uncontrolled studies have extended Beck’s cognitive therapy to schizophrenia, with encouraging clinical results, including reduction or removal of delusions and hallucinations. Furthermore, the techniques are still undergoing modification. At this stage of development, they are not recommended for routine clinical use.’ Hearing Voices Exercise:  Hearing Voices Exercise Please get into groups of 3 One person volunteer to be the subject One person talk to the subject on a normal topic of conversation One person to say things to the subject giving commands or comments Do this for 5 minutes Feedback What is psychosis:  What is psychosis ‘psychosis marked by introversion, dissociation, inability to distinguish reality from unreality, delusions etc.’ Consider: eating disorders ‘I am fat’ depression ‘I am worthless’ OCD ‘I must do this to stop my family dying’ panic / health anxiety ‘I have a brain tumour’ What is schizophrenia?:  What is schizophrenia? Two or more of: delusions, hallucinations, disorganised speech, grossly disorganised/catatonic behaviour, negative symptoms (flat affect, poverty of speech, avolition) Social/occupational dysfunction - at least one of work/interpersonal relationships/self-care At least 6 months (with at least 1 month of symptoms above) Exclusions for mood disorders/schizoaffective disorder/ organic damage/ substance induced Sx Why symptoms?:  Why symptoms? Lack of reliability and validity with syndromes (eg Bentall, 1990) More likely to facilitate understanding of underlying mechanisms Why Voices?:  Why Voices? Most common symptom of schizophrenia 60% of such patients hear voices Often most distressing & disabling symptom Single symptom approach Why Delusions?:  Why Delusions? Garety’s work not absolute conviction vary on many dimensions jumping to conclusions - rapid, overconfident reasoning ‘self-evident truths’, ‘not amenable to reason or modifiable by experience’ common reference 67% persecution 64% control 48% Why CT for psychosis?:  Why CT for psychosis? Response to drugs can be delayed several weeks 70% of first episode patients respond to neuroleptics 60-70% of these will relapse within 2 years despite drug prescription Side effects: tardive dyskinesia in 35-72% of patients (66% of these irreversible) neuroleptic malignant syndrome in 0.2-1.4% (can be fatal - 19-30% die within few days; conservative estimate => 190,000 deaths up to '92) autonomic~ dry mouth etc. Variable compliance Client satisfaction Principles of Cognitive Therapy for Anxiety Disorders:  Principles of Cognitive Therapy for Anxiety Disorders A cognitive model is required from which to empirically derive effective treatments You are not mad – you are normal Either it is real or you believe it to be real How you appraise events causes what you feel Test it out – drop your safety behaviours What you attend to and how you attend to it is important Intervention strategies:  Intervention strategies Formulation Normalisation Working with metacognitive beliefs Generating possibilities for intrusions Safety behaviours Selective attention Activity scheduling Relapse prevention Assessment:  Assessment Elicit information to flesh out formulation Standard cognitive behavioural assessment Experiences – interpretations – responses Use blank conceptualisation as guide Exercise:  Exercise Get into same groups as before What would you want to know about the following case? Young lady referred by GP. He was concerned that she was developing a psychotic illness. She had begun to stay in, not attend her job as a dinner lady, isolating herself from her family. Jane was very frightened and anxious, thought that people may be able to read her mind and if they could they would have her child taken away from her due to her thoughts. Assessment:  Assessment Life history, critical incidents, current environment, congruence with symptoms Standardised measures PSYRATS BAVQ Mood, Safety behaviour interview, TCQ etc. SMART goals, belief ratings etc. Assessment:  Assessment The process of assessment is designed to provide information that will assist with the collaborative development of a shared formulation that describes the client’s difficulties in a way that is testable and can be translated into strategies for change. Therefore, the model can guide the topics to be covered in an assessment. What was going through your mind at the time? What was the first thing that you thought? Did anything trigger the way you were feeling? Did you have an image of the event in your mind? What did it look like? These questions can be particularly helpful when used in conjunction with affect shifts or in vivo situations. Questions:  Questions ·    When you were in that situation, what were you (most) aware of? ·     What did you notice first? · Were you on the look out for such thoughts/feelings/behaviours? ·   When you felt scared/sad/angry what were you most conscious of? ·   How do you think you seemed to other people? Once you noticed that, were you able to focus on anything else? Questions to assess Safety Behaviours:  Questions to assess Safety Behaviours When you thought that this was happening/going to happen, what did you do to prevent it? If you had not done this, what would have happened? Is there anything you do to control your symptom? Do you do anything to help you cope or to hide the difficulty? Is there anything that you avoid doing because of this problem? Do you ever try to escape from this situation? Does this difficulty stop you from going anywhere? Further areas of assessment:  Further areas of assessment Overall impression of childhood Family history (siblings, parents, any separations) Happiest memories Worst memories School Friendships Sexual history Cultural / religious history Any uncomfortable sexual experiences Any physical violence Current environment (accommodation, finances, activities, employment/education, culture) Relevant historical factors for specific symptoms (e.g. if paranoia is an issue, asking about drug use, personal safety considerations such as living in an area of high street crime, contact with police and prison services) PSYRATS (Haddock 1999):  PSYRATS (Haddock 1999) 1 How often have you heard voices?  2 How long do the voices last when you hear them? 3 From where do the voices seem to be coming? 4 How loud are the voices? 5 From where do you think the voices come? 6 When they occur, how often are the voices saying unpleasant or negative things? 7 How negative are what the voices say? 8 When they occur, how often are the voices distressing? 9 How intense is the distress from the voices? 10 How disrupting are the voices? 11 How often can you control the voices? 12 How often do you think about _____? 13 When you think about this, how much time do you spend thinking about it? 15 When these thoughts occur, how often are they distressing? 16 How intense is the distress? 17 How disrupting are these thoughts? Can psychosis be normal?:  Can psychosis be normal? TRIGGERS: Trauma (Sexual abuse, kidnap, combat) Drug abuse Isolation / Sensory deprivation Bereavement (82% - Grimby, 1983) Sleep deprivation From Kingdon & Turkington (1994) Can psychosis be normal? 1. Voices:  Can psychosis be normal? 1. Voices Often unrelated to psychopathology (Romme et al., 1992; Posey & Losch, 1983) 35-40% students (Barrett & Etheridge, 1992; Posey & Losch, 1983; Morrison et al., 2000) 5% general population annual incidence (Tien et al., 1991) 10-25% lifetime incidence (Slade & Bentall, 1988) Can psychosis be normal? 2. Delusions:  Can psychosis be normal? 2. Delusions Verdoux et al. (1998) up to 70% of general population endorsed delusional beliefs Peters et al. (1999) not the content of beliefs that distinguished between delusional patients on a psychiatric ward and the general population, but rather the degree of conviction, distress and preoccupation (c.f. differentiation between individuals with obsessive-compulsive disorder from normal individuals who have intrusive thoughts with very similar content (Rachman and De Silva, 1978; Salkovskis and Harrison, 1984)) Large polls cited by Kingdon & Turkington (1994) and Garety and Hemsley (1985) ghosts 25% telepathy 25-50% Slide32:  Negative Appraisals Kingdon and Turkington (1993): "the meaning invested in hallucinations may also be of importance - whether a person says to himself, 'The devil is talking to me' or 'I must be going crazy', or dismissively; 'That was a strange sensation, I must have been overtired'" Chadwick and Birchwood (1994): beliefs regarding a voice’s malevolence (either that the voice is ‘a punishment for a previous misdemeanor or an undeserved persecution’) lead to negative emotions Chadwick and Birchwood (1995): strong correlation between appraisals of malevolence and resistance of the voices Models of Psychosis:  Models of Psychosis Chadwick et al (1996) ABC approach Bentall et al (1994) defence against low self-esteem Garety et al reasoning biases, perceptual disturbances & making sense of experience Morrison (1998) ‘normal’ cognitive model - culturally unacceptable misinterpretations Formulation:  Formulation Basic / horizontal Maintenance Historical / developmental / vertical Basic Formulation:  Basic Formulation EVENT THOUGHT FEELING BEHAVIOUR hear voice it’s the devil scared pray & visit church see ceefax I’m the devil scared burn self p666 Slide36:                                                  Event Interpretation of event Feelings Behaviours Paul leaves the room He will return with other people and force me to go to hospital Fear Anxiety Want to leave the room Paul leaves the room He has gone to get a glass of water for me Relaxed Sit and wait Formulation Slide37:  Morrison (1998) Triggers Auditory Hallucinations Mood & Physiology Safety Behaviours Misinterpretation of Hallucinatory Experience Maintenance Formulation:  Maintenance Formulation Triggers (cannabis, paranoid thoughts, arousal, religious ) Hear Voices scared, increased arousal pray, hide in church, no sleep attend to relevant stimuli It is the devil trying to possess make me harm people Historical Formulation:  Historical Formulation Early Experiences mental and sexual abuse from religious mother physical abuse from father 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 Historical Formulation:  Historical Formulation Early Experiences told worthless by mum; told was special by mum mum bipolar - regular admissions, responsibility mixed race - racism Beliefs Formed I am worthless (unless I help others) I am special Other people are dangerous Critical Incident Drugs & Gang trouble & Police Ideas of reference from radio & TV I am Christ & people want to crucify me A Cognitive Model of Psychotic Symptoms:  A Cognitive Model of Psychotic Symptoms Common Processes:  Common Processes Misinterpretation of ‘normal’ stimuli causes distress (such appraisals include imagery) Dysfunctional responses safety behaviours thought control strategies selective / self-focused attention Metacognition - including positive beliefs Positive Beliefs:  Positive Beliefs Chadwick and Birchwood (1994) voices believed to be benevolent were engaged Miller, O’Connor & DiPasquale (1993) 50% of inpatients reported some positive effects of hallucinating most commonly cited benefits: hallucinations were relaxing or soothing voices provided companionship French et al 2001 Positive beliefs can impact on DUP CLINICAL IMPLICATIONS:  CLINICAL IMPLICATIONS Normalise experience of symptoms and distress - not that different Offer formulation as additional option Identify and modify (if indicated): interpretations (including imagery) safety behaviours strategies for control attentional focus positive and negative beliefs Intervention:  Intervention Formulation driven Based on cognitive model Follow principles of CT Follow session structure of CT Intervention - Process:  Intervention - Process Assessment Establish shared problem list Translate into ‘smart’ goals Formulation Develop therapeutic relationship Interventions derived from formulation Relapse prevention Differences:  Differences Check if involved in symptoms Make allowances for memory & attention Written copies of hw tasks, rationale etc Session summary sheets Shorter, more frequent sessions Importance of tape as homework Importance of structure & instilling process Shorter agenda Importance of therapeutic relationship & engagement Engagement:  Engagement Focus on areas of distress Shared problems & goals list Use of generic cognitive model Collaboration & guided discovery Normalisation Expectations of treatment (especially because of psychiatric system) Normalisation:  Normalisation Stress-vulnerability model Information about triggers Information about prevalence Information about intrusive thoughts Information about suppression Information about schizophrenia Could psychosis and PTSD both be responses to trauma?:  Could psychosis and PTSD both be responses to trauma? Just as the symptoms of psychosis can be categorised as either positive or negative clusters, so can those of PTSD (McGorry, 1991). Both psychosis and PTSD frequently involve positive symptoms such as unwanted, intrusive mental experiences (e.g. voices and flashbacks), paranoid ideation, hypervigilance, and increased arousal. Could psychosis and PTSD both be responses to trauma?:  Could psychosis and PTSD both be responses to trauma? Some of the negative symptoms of PTSD, such as emotional numbing, affective constriction, estrangement from others, difficulty concentrating, feelings of derealisation, detachment and general neglect overlap significantly with negative symptoms of psychosis (Fowler, 1997; McGorry, 1991; Shanner & Eth, 1989; Stampfer, 1990). Intervention: Delusions:  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 Positive Beliefs:  Positive Beliefs Morrison, Wells & Nothard (2000) belief that unusual perceptual experiences are beneficial predicts vulnerability Romme & Escher (1989) voices may occur as a coping response 70% identify link with traumatic event Morrison (2003) Paranoia as a survival strategy – examine functional aspects and positive beliefs – weigh up advantages and disadvantages prior to intervention – search for alternative ways Interpretations of Voices:  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:  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:  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:  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 Content of Voices:  Content of Voices Can mediate distress Identify using: modified DTR shadowing role play diaries Content of Voices:  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 & Schema Content of voices often related to experience bullying sexual abuse / rape worthlessness evil guilty threat Content of Voices & Schema:  Content of Voices & Schema Challenge using Padesky’s (1994) techniques: continuum methods historical test positive data logs Negative Symptoms:  Negative Symptoms Apathy, anhedonia, avolition, flat affect, poverty of speech Role of experience Functional in past/present? Safety behaviours / coping strategies Depression Over-medication Anxiety - social, ptsd avoidance Safety Behaviours / Negative symptoms:  Safety Behaviours / Negative symptoms Critical incident experienced a panic attack Felt he was again “going crazy” Did not want people to see was going crazy Minimised communication and contact Experimented in session with his communication Thought Disorder:  Thought Disorder Awareness: play tape/listen as homework feedback from others (and video) therapist struggling - slow down Attentional factors Stress and arousal Beliefs about speech and communication Themes to revisit Safety behaviour? Why people not symptoms?:  Why people not symptoms? Called for by Chadwick et al (1996) Many other needs ptsd (40% +) anxiety & depression (40% +) hopelessness stigma self-as-illness axis II problems social, housing, financial, occupational etc. Cognitive models and framework applicable Slide70:  Entry Criteria 14-35 Within first 3 years of psychosis IMPACT Protocol IMPACT Assessment/Engagement Cases allocate on basis of geography Waiting List Family Interventions Family/friends group DG FQ GHQ-12 KASI Cognitive Therapy CORE, PSYRATS PANSS within first 3 sessions Up to 30 sessions if positive symptoms Up to 15 sessions if no positive symptoms N.B. Additional protocol available for booster/additional sessions Relapse prevention 8 sessions plus 2 boosters Consultation back to referrer Group work Client referred to the team Post group assessments Further assessment where indicated Individual family treatments Treatment allocation Conclusion:  Conclusion CT for psychosis has a developing evidence base It is acceptable to our clients Our clients want a talking based intervention It makes sense

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