Cognitive Behavioral Therapy for Schizophrenia

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Development and techniques

Cognitive behavioral techniques in psychosis were first used in 1952 by Beck11 in a patient who was paranoid about the Federal Bureau of Investigation. The patient was encouraged to trace the antecedents of the delusion and behavioral techniques such as reality testing were used. The patient was eventually able to recognize that all his alleged persecutors were normal people going about their daily business. Subsequently, Hole and colleagues12 described 8 patients with chronic delusions, half

Evidence

More than 30 randomized controlled trials and meta-analyses have been published reporting the efficacy of CBT. Some of the early reviews include those of Bouchard and colleagues19 who reviewed 15 studies focusing on changes in positive symptoms as the main outcome measure and Rector and Beck20 who examined 7 randomized controlled trials. Pilling and colleagues21 included the results from 8 randomized trials; a review published by NICE7 included 13 randomized clinical trials (including the

Neurobiological evidence

There is emerging evidence that gray matter volume of the frontal, temporal, parietal, and cerebellar areas that are known to be involved in the coordination of mental activity, cognitive flexibility, and verbal learning and memory predict responsiveness to CBT in patients with psychosis.36 In this study, improvement in positive symptoms was associated with greater right cerebellum gray matter volume and with the left precentral gyrus and right inferior parietal lobule gray matter volumes in

Predictors of outcome

Being female,38, 39 a shorter duration of untreated illness, a shorter duration of illness,39 higher levels of insight, higher levels of admissions,40 and patients with low level of convictions in their delusions38 have been associated with better outcome with CBT. Despite its potential to improve insight,26 CBT has been less successful with patients with very low levels of insight40, 41 and severe primary negative symptoms42 including affective blunting and alogia43 although modification of

Cultural adaptations of CBT

Cultural adaptations and understanding of ethnic, cultural, and religious interpretations is an area that currently remains underdeveloped.47, 48 In the Insight study, the African Caribbean group at 3 months and the Black African group at 1 year follow-up analysis showed higher dropout rates and significantly poorer change in insight compared with the White group.49 Literature from other cultural groups recommends the adaptation of CBT for use with ethnic minority populations as necessary and

Limitations

Criticisms of CBT research have been made30; specifically that studies did not shown effects better than those of nonspecific intervention or effects on relapse. These criticisms have been refuted as, for example, studies dismissed as negative showed enduring effects present at 18 months and 5 years and in general, the assertions of noneffect may be attributed to the limited selection of studies. Relapse prevention has been more difficult to demonstrate and a large new study has produced

Summary

CBT should be considered as a component of a comprehensive treatment package with social interventions and antipsychotic medication. In the United Kingdom, and even more elsewhere, there remain limitations in service delivery because of inadequate numbers of trained providers. There also needs to be more research into the active ingredients of CBT, predictors of outcome, role in comorbidities and benefits of cultural adaptations.

CBT for schizophrenia continues to be more widely practiced in the

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