Psychotherapy and Psychosis

Prof Anthony Bateman

Roskilde December 2019

CBT Meta-analyses

CBT for psychosis compared with usual care significantly improved overall

psychotic symptoms (standard mean difference [SMD] -0.33, 95% confidence

interval [CI] -0.45 to -0.21)

positive symptoms overall (SMD -0.34, 95% CI -0.58 to -0.10)

auditory symptoms (SMD 0.39, 95% Cl not reported, P < .005),

delusions (SMD 0.33, 95% CI not reported, P < .05)

negative symptoms (e.g., blunt affect) (SMD -0.32, 95% CI -0.59 to -0.04) at

end of treatment.

No significant differences generally observed for social function, distress

associated with psychosis, relapse, or quality of life.

Cochrane Review of CBT and other

Psychosocial treatments for Psychosis (2018)

Thirty-six randomised controlled trials, randomising in total 3542 people with

schizophrenia to CBT and other psychosocial treatment.

The quality of evidence from these trials is very low to low.

No real differences were found between CBT compared with other psychosocial

treatments for:

Relapse

Rehospitalisation

mental state

Death

social functioning

quality of life.

Results were not robust enough to make firm conclusions.

Relative intervention + carer TAU vs. carer TAU for

psychosis (N=106)

Leavey,

Gulamhussein,

Papadopoulos et

al. Psychol Med

2004

Multiple-family group treatment for

schizophrenia (n=59)

Bradley,

Couchman,

Perlesz et al 2006

Psychoeducation vs. routine care for patients

with schizophrenia and their families (n=236)

Bauml,

Frobose,

Kraemer et

al., 2006

Rehospitalization rates after 1 year and 2 years (*p < .05)

Psychoeducation vs. routine care for patients

with schizophrenia and their families (n=236)

Bauml,

Frobose,

Kraemer et

al., 2006

Days in hospital after 1 year and 2 years (p < .05)

Family-focused psychoeducational treatment vs

crisis management for bipolar disorder (n=101)

Miklowitz, Simoneau,

George et al 2000

A different approach

to

Treatment

Impairment

Externalizing Internalizing

Male FemaleGendered

Style

Gendered

‘Neurotic’ conditions

Partially gendered

Personality disorder

Ungendered chronic

Psychotic conditions

The ‘P’ Factor (Caspi et al., 2013)

How appraisal shapes our experience

EnoughNot

Except our experience is social: not with physical objects but with people

Appraisal (higher order cognition) theory

Stimulus

Mental representation

Higher order cognition

Emotional response

…but by context-dependent evaluation of motivational relevance

Client

imagined self

representation

Therapist image

of the client self

representation

Client image of the

clinician image of the

client self

representation

Clinician Client

Therapist

image of own

self

representation

Higher Order RepresentationUs/We Representation

Alone

and

Lonely

Loneliness and Schizophrenia

Self-reported annual rates of loneliness among individuals

with schizophrenia and other psychotic disorders (80%) are

approximately 2.3 times higher than those in the general

population (35%) (Aust and NZ National Survey Stain et al 2012)

Loneliness reported as a significant contributor to worse

quality of life in schizophrenia (Roe D, Mashiach-Eizenberg M, Lysaker PH Schizophr

Res. 2011 Sep; 131(1-3):133-8

Individuals with psychotic disorders cite loneliness as one

of the most important challenges in their life, second only

to financial concerns (Morgan VA, et al Aust N Z J Psychiatry. 2017 Feb; 51(2):124-140.)

Social Isolation and Schizophrenia

People with schizophrenia tend to be more socially isolated than

other groups in the population.

Social isolation in turn is linked to higher levels of symptoms, poor

quality of life and worse treatment outcomes.

Specific symptoms may contribute to this social isolation: negative

symptoms can affect motivation and ability to socialise and positive

symptoms can lead to an active avoidance of social situations.

Social isolation may also be driven by social exclusion, prejudice

and a tendency for others to distance themselves.

The perils of isolation: Maintaining social

connections is required for self-

coherence and social isolation kills

Loneliness across the age range in representative sample of men

and women living with or without a partner (Beutel et al., 2017)

BMC Psychiatry, 17-97

n=15,010Prevalence of a feeling of loneliness in the general population of about 10.5%

Depression, anxiety and suicidality predicted by feeling of

loneliness (Beutel et al., 2017)

BMC Psychiatry, 17-97

90% more Depression 20% more Anxiety 30% more Suicidal Ideation

Loneliness and Social Isolation as Risk Factors for Mortality:

A Meta-Analysis (Holt-Lunstad, et al. 2015)

Across 70 studies the weighted average effect sizes for increased mortality:social isolation odds ratio (OR) = 1.29

loneliness OR = 1.26

living alone OR = 1.32

No differences between measures of objective and subjective social isolation

More predictive of death in samples with an average age younger than 65 years.(premature death)

Perspectives on Psychological Science 10(2) 227–237

Mortality in single fathers compared with single mothers

and partnered parents (Chiu et al., 2018)

Lancet Public Health 2018; 3: e115–23

40,000 parents aged 15 years or older,

living in a household with one or more

biological or adopted child < 25

younger than 25 years,

We underestimate importance of

social context e.g. for our health

Holt-Lunstad et al. (2010, p.14):

Physicians, health professionals, educators,

and the public media take risk factors such

as smoking, diet, and exercise seriously;

the data presented here make a compelling

case for social relationship factors to be

added to that list.

PLoS Med. 7, 2–20

The propensity to underestimate the importance of social factors for

health (Haslam et al., 2018)

Social Science and Medicine, 198 14-23

The propensity to underestimate the importance

of social factors for health (Haslam et al 2018)

Social Science and Medicine, 198 14-23

Only 15% of people perceive social factors such as connectedness to others as important to mortality

The ‘we-mode’ in social cognition (Gallotti &

Frith, 2013)

Human sociality is explained by the unique capacity to

share the mental states of others.

when people are poised to interact, they achieve

interpersonal awareness through a ‘meeting’ of minds

Intentional states that are assumed by individuals in the

system to be joint or shared by everyone.

Tuomela (2005) has named this category jointly seeing

to it (jstit).

Feeling of we-ness social collaboration

being part of a set of thoughts and feelings that are

beyond one’s own

minds shared by cognizing in an irreducibly collective

mode of cognition called the we-mode.Trends in Cognitive Sciences April 2013, Vol. 17, No. 4

Do we need to target social adjustment in schizophrenia?

Take Home MessageTreating developing and full-fledged Schizophrenia Spectrum

and other Psychosis related disorders (SSPDs) remains clinically

challenging.

These challenges stem from two main sources: comorbidity and

the symptom-disability gap, with social dysfunction

representing the no.1 clinical frontier.

MBT works on the hypothesis that morbidity associated to

psychotic disorders stem from core self disturbances

(underlying psychopathology).

Preliminary results suggest that MBT may help with the profound

impact of psychotic pathogenesis on interpersonal and social

functioning.

Outline

I. The Developmental Sequence of

Psychosis

I. Traits and States along Psychotic

Pathogenesis

I. MBT and Developing Psychosis

Clinical Trajectory in SSPD

Debbané et al., 2016

Comorbidity

Clinical Challenges in Emerging Psychosis

Symptom - Disability Gap

Clinical Challenges: Comorbidity

Mood disorders

Anxiety Disorders

Alcohol Dependance

Cannabis Dependance

Cocaine

Paranoid

Schizotypal

Schizoid

Borderline

Avoidant

Antisocial

Fusar-Poli et al, 2012, 2014; Armando, Hutsebaut, Debbané, 2019

Requires a clinical

approach which can

tackle comorbidity…

…or the P Factor!

Axis 1 disorders

Personality disorders

The Symptom – Disability Gap

CHR FEP

Social functioning principal cause of poor outcome

Armando, Hutsebaut, Debbané, 2019

- Social dysfunction is present along the clinical continuum (Debbané et al., 2016), and can be

resistant to treatment with antipsychotics or even increase during the course of illness (Carbon & Correll, 2014)

- Social dysfunction may be more invalidating:

-predicts poor vocational outcome (Bell et al., 2009)

-poor quality of life (Penn et al., 1997)

-increased risk of relapse into a psychotic episode (Hafner et al., 1999; Penn and

Roberts, 2006)

What is the nature of the underlying psychopathology sustaining social

dysfunctions in psychotic disorders ?

Working hypothesis: Core self disturbances

Debbané, Salaminios et al., 2016

Psychotic Pre-Mentalizing modes?

Psychotic

Pretend Mode

Hyper-

reflexivity

Psychotic

Pretend Mode

Hyper-

reflexivity

Psychotic

Teleological

Mode

Paranoid

phenomena

Psychotic

Teleological

Mode

Paranoid

phenomena

Psychotic

Psychic

Equivalence

Depersonalizati

on

Psychotic

Psychic

Equivalence

Depersonalizati

on

Experiences of disturbance in core self