Research suggests that one-third to one-half of patients with schizophrenia continue to experience residual symptoms or have intolerable adverse effects relating to their treatment. The effect of medications on functional outcomes has been modest, even when drug regimens are optimized. Compounding the problem are the disorganized and negative symptoms associated with schizophrenia, which are less responsive to medications than hallucinations and delusions.
Today, more patients with schizophrenia are being treated in the community, but many continue to function at a low level. As such, additional interventions like cognitive therapy have been explored for schizophrenia, but these approaches have had varied success. Most cognitive therapy treatments assessed in studies have addressed delusions and hallucinations and have not focused on patients with neurocognitive impairment and poor functioning.
A Novel Approach in Managing Schizophrenia
In the October 3, 2011 Archives of General Psychiatry, my colleagues and I had a study published in which we assessed a novel version of cognitive therapy aimed at increasing functional outcomes and promoting recovery in low-functioning patients with schizophrenia. In addition to residual positive and negative symptoms, these individuals had trouble with information processing for memory, attention, and executive functioning. By design, our intervention shifted the emphasis from taking a symptom-oriented approach to using a person-oriented therapeutic strategy based on interests, assets, and strengths. We wanted to improve the level of functioning by enhancing productivity, independence, and the quantity and quality of social interactions. The intervention treated functional outcomes as a primary target of therapy.
More patients with schizophrenia are being treated in the community, but many continue to function at a low level.
Participants in the cognitive therapy intervention received up to 18 months of outpatient sessions that provided a goal-directed framework and personalized treatment planning. The sessions focused on building a therapeutic relationship and engaging patients in treatment. We wanted to stimulate their interest and motivation and have them focus on achievable long-term goals by setting intermediate and short-term goals and devising action plans to attain the goals. A variety of cognitive and behavioral techniques were used, including games, role-playing, community outings, problem solving, and cognitive restructuring. Intersession action plans were devised collaboratively when sessions concluded to enable patients to practice skills out in the community. Impediments to goal attainment were also addressed, and specific deficiencies were targets for therapy. Treatments were tailored to patients’ level of functioning.
Cognitive Therapy Improves Functioning in Schizophrenia
Patients receiving our cognitive therapy intervention experienced improved functioning, motivation, and drive, as well as reduced positive symptoms when compared with those who received standard treatment. Patients became motivated to engage in tasks that moved them out of their withdrawn state. They also became more in touch with reality, experienced fewer hallucinations and delusions, and had less disorganization. The reduction in positive symptoms allowed them to become more engaged in activities, leading to better functional outcomes and enhanced motivation.
The treatment strategy assessed in our study triggered recovery by targeting the self-defeating and dysfunctional beliefs that inhibit patients from actively engaging in constructive activities. More research is planned to further assess the effectiveness of our intervention, to adapt it for inpatient settings, and to address potential limitations of our research. Although greater resources are required to treat patients with this approach, the strategy appears to be helpful.
Readings & Resources (click to view)
Beck AT, Grant PM, Huh GA, et al. Dysfunctional attitudes and expectancies in deficit syndrome schizophrenia. Schizophr Bull. 2012. In press.
Grant PM, Huh GA, Perivoliotis D, et al. Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Arch Gen Psychiatry. 2011. Oct 3 [Epub ahead of print]. Available at: http://archpsyc.ama-assn.org/cgi/content/full/archgenpsychiatry.2011.129.
Turkington D, Sensky T, Scott J, et al. A randomized controlled trial of cognitive-behavior therapy for persistent symptoms in schizophrenia: a five-year follow-up. Schizophr Res. 2008;98:1-7.
Grant PM, Beck AT. Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia. Schizophr Bull. 2009;35:798-806.
Grant PM, Beck AT. Asocial beliefs as predictors of asocial behavior in schizophrenia. Psychiatry Res. 2010;177:65-70.
Grant PM, Beck AT. Evaluation sensitivity as a moderator of communication disorder in schizophrenia. Psychol Med. 2009;39:1211-1219.
Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophr Bull. 2008;34:523-537.
Blanchard JJ, Kring AM, Horan WP, Gur RC. Toward the next generation of negative symptom assessments: the collaboration to advance negative symptom assessment in schizophrenia. Schizophr Bull. 2011;37:291-299.