Language in schizophrenia and aphasia: the relationship with non-verbal cognition and thought disorder.

Objective: To determine the relationship between language abnormalities and broader cognitive impairment and thought disorder by examining language and cognition in schizophrenia and aphasia (a primary language disorder).Methods: Cognitive and linguistic profiles were measured with a battery of standardised tests, and compared in a clinical population of n = 50 (n = 30 with schizophrenia and n = 20 with aphasia) and n = 61 non-clinical comparisons (n = 45 healthy controls and n = 16 non-affected first-degree relatives of patients with schizophrenia).Results: Both clinical groups showed linguistic deficits. Verbal impairment was more severe in participants with aphasia, whereas non-verbal performance was more affected in participants with schizophrenia. In schizophrenia, but not in aphasia, verbal and non-verbal performance were associated. Formal thought disorder was associated with impairment in executive function and in grammatical, but not naming, tasks.Conclusion: While patients with schizophrenia and aphasia showed language impairments, the nature and cognitive basis of these impairments may be different; language performance disassociates from broader cognitive functioning in aphasia but may be an intrinsic expression of a broader cognitive impairment in schizophrenia. Thought disorder may represent a core malfunction of grammatical processing. Results suggests that communicative ability may be a valid target in cognitive remediation strategies in schizophrenia.

Befriending: active placebo or effective psychotherapy?

Befriending allows for control of the non-specific factors of the therapist-patient interaction in psychosocial research. Manualised befriending is at the very least an active placebo and potentially an effective intervention. Befriending now merits increased research attention to determine indications for use and to elucidate mechanisms of action.

Brief cognitive-behavioural therapy for patients in the community with schizophrenia: randomised controlled trial in Beijing, China.

BackgroundBrief cognitive-behavioural therapy (CBT) is an emerging treatment for schizophrenia in community settings; however, further trials are needed, especially in non-Western countries.AimsTo test the effects of brief CBT for Chinese patients with schizophrenia in the community (trial registration: ChiCTR-TRC-13003709).MethodA total of 220 patients with schizophrenia from four districts of Beijing were randomly assigned to either brief CBT plus treatment as usual (TAU) or TAU alone. Patients were assessed at baseline, post-treatment and at 6- and 12-month follow-ups by raters masked to group allocation.ResultsAt the post-treatment assessment and the 12-month follow-up, patients who received brief CBT showed greater improvement in overall symptoms, general psychopathology, insight and social functioning. In total, 37.3% of those in the brief CBT plus TAU group experienced a clinically significant response, compared with only 19.1% of those in the TAU alone group (P = 0.003).ConclusionsBrief CBT has a positive effect on Chinese patients with schizophrenia in the community.

Design and protocol for the Focusing on Clozapine Unresponsive Symptoms (FOCUS) trial: a randomised controlled trial.

BACKGROUND: For around a third of people with a diagnosis of schizophrenia, the condition proves to respond poorly to treatment with many typical and atypical antipsychotics. This is commonly referred to as treatment-resistant schizophrenia. Clozapine is the only antipsychotic with convincing efficacy for people whose symptoms are considered treatment-resistant to antipsychotic medication. However, 30-40 % of such conditions will have an insufficient response to the drug. Cognitive behavioural therapy has been shown to be an effective treatment for schizophrenia when delivered in combination with antipsychotic medication, with several meta-analyses showing robust support for this approach. However, the evidence for the effectiveness of cognitive behavioural therapy for people with a schizophrenia diagnosis whose symptoms are treatment-resistant to antipsychotic medication is limited. There is a clinical and economic need to evaluate treatments to improve outcomes for people with such conditions. METHODS/DESIGN: A parallel group, prospective randomised, open, blinded evaluation of outcomes design will be used to compare a standardised cognitive behavioural therapy intervention added to treatment as usual versus treatment as usual alone (the comparator group) for individuals with a diagnosis of schizophrenia for whom an adequate trial of clozapine has either not been possible due to tolerability problems or was not associated with a sufficient therapeutic response. The trial will be conducted across five sites in the United Kingdom. DISCUSSION: The recruitment target of 485 was achieved, with a final recruitment total of 487. This trial is the largest definitive, pragmatic clinical and cost-effectiveness trial of cognitive behavioural therapy for people with schizophrenia whose symptoms have failed to show an adequate response to clozapine treatment. Using a prognostic risk model, baseline information will be used to explore whether there are identifiable subgroups for which the treatment effect is greatest. TRIAL REGISTRATION: Current Controlled Trials ISRCTN99672552 . Registered 29(th) November 2012.

Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial.

BACKGROUND: Antipsychotic drugs are usually the first line of treatment for schizophrenia; however, many patients refuse or discontinue their pharmacological treatment. We aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs. METHODS: We did a single-blind randomised controlled trial at two UK centres between Feb 15, 2010, and May 30, 2013. Participants aged 16-65 years with schizophrenia spectrum disorders, who had chosen not to take antipsychotic drugs for psychosis, were randomly assigned (1:1), by a computerised system with permuted block sizes of four or six, to receive cognitive therapy plus treatment as usual, or treatment as usual alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. Our primary outcome was total score on the positive and negative syndrome scale (PANSS), which we assessed at baseline, and at months 3, 6, 9, 12, 15, and 18. Analysis was by intention to treat, with an ANCOVA model adjusted for site, age, sex, and baseline symptoms. This study is registered as an International Standard Randomised Controlled Trial, number 29607432. FINDINGS: 74 individuals were randomly assigned to receive either cognitive therapy plus treatment as usual (n=37), or treatment as usual alone (n=37). Mean PANSS total scores were consistently lower in the cognitive therapy group than in the treatment as usual group, with an estimated between-group effect size of -6.52 (95% CI -10.79 to -2.25; p=0.003). We recorded eight serious adverse events: two in patients in the cognitive therapy group (one attempted overdose and one patient presenting risk to others, both after therapy), and six in those in the treatment as usual group (two deaths, both of which were deemed unrelated to trial participation or mental health; three compulsory admissions to hospital for treatment under the mental health act; and one attempted overdose). INTERPRETATION: Cognitive therapy significantly reduced psychiatric symptoms and seems to be a safe and acceptable alternative for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs. Evidence-based treatments should be available to these individuals. A larger, definitive trial is needed. FUNDING: National Institute for Health Research.

High-yield cognitive behavioral techniques for psychosis delivered by case managers to their clients with persistent psychotic symptoms: an exploratory trial.

Case managers spend more time with clients with schizophrenia than any other professional group does in most clinical settings in the United States. Cognitive behavioral therapy (CBT) adapted for individuals with persistent psychotic symptoms, referred to as CBT-p, has proven to be a useful intervention when given by expert therapists in randomized clinical trials. It is currently unknown whether techniques derived from CBT-p could be safely and effectively delivered by case managers in community mental health agencies. Thirteen case managers at a community mental health center took part in a 5-day training course and had weekly supervision. In an open trial, 38 clients with schizophrenia had 12 meetings with their case managers during which high-yield cognitive behavioral techniques for psychosis (HYCBt-p) were used. The primary outcome measure was overall symptom burden as measured by the Comprehensive Psychopathological Rating Scale, which was independently administered at baseline and end of intervention. Secondary outcomes were dimensions of hallucinations and delusions, negative symptoms, depression, anxiety, social functioning, and self-rated recovery. Good and poor clinical outcomes were defined a priori as a 25% improvement or deterioration. t-Tests and Wilcoxon's signed-ranks tests showed significant improvements in all primary and secondary outcomes by the end of the intervention except for delusions, social functioning, and self-rated recovery. Cohen's d effect sizes were medium to large for overall symptoms (d = 1.60; 95% confidence interval [CI], -2.29 to 5.07), depression (d = 1.12; 95% CI, -0.35 to 1.73), and negative symptoms (d = 0.87; 95% CI, -0.02 to 1.62). There was a weak effect on dimensions of hallucinations but not delusions. Twenty-three (60.5%) of 38 patients had a good clinical result. One (2.6%) of 38 patients had a poor clinical result. No patients dropped out. This exploratory trial provides evidence supportive of the safety and the benefits of case managers being trained to provide HYCBt-p to their clients with persistent psychosis. The benefits reported here are particularly pertinent to the domains of overall symptom burden, depression, and negative symptoms and implementation of recovery-focused services.

Case formulation-A vehicle for change? Exploring the impact of cognitive behavioural therapy formulation in first episode psychosis: A reflexive thematic analysis.

OBJECTIVES: Formulation is considered a fundamental process of cognitive behavioural therapy for psychosis (CBTp). However, an exploration into the personal impact of different levels of case formulation (CF) from a service user (SU) perspective is lacking, particularly for those experiencing a first episode of psychosis. DESIGN: This Big Q qualitative design used semi-structured interviews. METHODS: Reflexive thematic analysis (TA) was used to analyse 10 participant interviews. NVivo 12 computer-assisted qualitative data analysis software aided data organisation and analysis. RESULTS: One overarching theme 'CF - A vehicle for change?' was developed as a pattern of shared meaning across the data set. Three main themes related to the overarching theme: (1) Vicious cycles: 'I never really thought about it being me maintaining the problems' (including one subtheme - Self-empowerment: 'Only you can make the changes for yourself'); (2) Early life experiences: 'My experiences have shaped the person that I am, therefore, it's not my fault' (including one subtheme - Disempowerment: '[My] core beliefs have been damaged'); and (3) Keep it simple: 'Don't push it too far over the top in case it becomes like spaghetti'. CONCLUSIONS: Maintenance formulations may be experienced as self-blaming, but also self-empowering, which may help to facilitate change. Longitudinal formulations may be experienced as non-blaming, but also disempowering, which may inhibit change. Simple CF diagrams may also facilitate change, whereas overly complex CFs may inhibit change. How CBTp therapists might look to improve the impact of different levels of CF for service users (SUs) in first episode psychosis (FEP) are described.

Antipsychotics: is it time to introduce patient choice?

Evidence regarding overestimation of the efficacy of antipsychotics and underestimation of their toxicity, as well as emerging data regarding alternative treatment options, suggests it may be time to introduce patient choice and reconsider whether everyone who meets the criteria for a schizophrenia spectrum diagnosis requires antipsychotics in order to recover.

A semi-structured clinical interview for psychosis sub-groups (SCIPS): development and psychometric properties.

BACKGROUND: Clinical sub-groups of schizophrenia, namely drug related, traumatic, anxiety and stress sensitivity sub-types, have been proposed for use in research, training and practice. They were developed on the basis of clinical observation but have not yet been used in research or clinical practice to any great extent. AIMS: To develop a semi-structured clinical interview for psychosis sub-groups (SCIPS) and determine the best diagnostic criteria with the highest inter-rater reliability, test-retest reliability and concurrent validity for sub-grouping patients with schizophrenia according to a newly developed classification scheme. METHODS: The SCIPS was developed based upon discussion with the clinician researchers who had developed and were using the sub-groups. Kappa coefficients were calculated between two independent diagnostic assessments with the SCIPS (for inter-rater reliability and test-retest reliability, n = 20) and between the SCIPS diagnosis and the sub-groupings as determined independently with highest achievable validity (for concurrent validity, n = 21) for patients with schizophrenia. These inter-rater reliability and concurrent validity were compared among five different sets of diagnostic criteria to determine which was most reliable and valid. RESULTS: A set of diagnostic criteria with the highest inter-rater reliability and concurrent validity was determined. Kappa coefficients (95% confidence interval) for the inter-rater reliability and concurrent validity were 0.93 (0.66-1.20) and 0.73 (0.47-1.00), respectively, with these diagnostic criteria. CONCLUSIONS: The SCIPS is a promising tool with which to sub-group patients with schizophrenia according to this recently developed classification scheme. The semi-structured interview achieves acceptable inter-rater and test-retest reliability and concurrent validity.

A pilot study exploring the contribution of working memory to "jumping to conclusions" in people with first episode psychosis.

INTRODUCTION: People with delusional beliefs "jump to conclusions" (JTC). This finding is well replicated. However, there is only limited exploration of the factors that might lead a person to JTC. The aim of the present study was to explore the contribution of working memory processes (WM) and IQ to hasty decision making and to investigate the stability of this bias over time. METHODS: A single group cross-sectional design was utilised. The study was conducted in 2 phases: (1) an initial screening phase and (2) an experimental phase whereby we explored and tested hypotheses regarding the cognitive origins of the JTC bias. In Study 1, participants completed the beads task as well as measures of mood and symptoms. In Study 2, the same participants repeated the beads task, and completed a battery of neuropsychological tests designed to assess different facets of WM and IQ. RESULTS: In most cases, "jumpers" were indistinguishable from "nonjumpers" in terms of their neuropsychological profiles. The only exception to this pattern was for visual working memory, in which "jumpers" performed better than "nonjumpers". In terms of the temporal stability of the JTC bias, 8 individuals (out of the 29) effectively switched from being "jumpers" at T1 to "nonjumpers" at T2. CONCLUSIONS: This study casts doubt on reduced global WM as an explanation of JTC. Rather it may be that the differences in reasoning are related to the manipulation of visual material and do not extend to other areas of neuropsychological functioning. However, as our sample is small it may be underpowered to detect important differences. Future work is therefore needed to replicate these findings.

Clusters, lines and webs-so does my patient have psychosis? reflections on the use of psychiatric conceptual frameworks from a clinical vantage point.

Mental health professionals working in hospitals or community clinics inevitably face the realisation that we possess imperfect conceptual means to understand mental disorders. In this paper the authors bring together ideas from the fields of Philosophy, Psychiatry, Cognitive Psychology and Linguistics to reflect on the ways we represent phenomena of high practical importance that we often take for granted, but are nevertheless difficult to define in ontological terms. The paper follows through the development of the concept of psychosis over the last two centuries in the interplay of three different conceptual orientations: the categorical, dimensional and network approaches. Each of these represent the available knowledge and dominant thinking styles of the era in which they emerged and take markedly different stances regarding the nature of mental phenomena. Without particular commitment to any ontological positions or models described, the authors invite the reader into a thinking process about the strengths and weaknesses of these models, and how they can be reconciled in multidisciplinary settings to benefit the process of patient care.

Recovery from refractory chronic fatigue syndrome with CBT and modafinil.

Many patients with chronic fatigue syndrome (CFS) fail to derive benefit from evidence-based treatments such as cognitive-behavioural therapy (CBT) and graded exercise therapy leading to permanent disability. To discover whether a repeat prescription of modafinil might potentiate the benefits of CBT leading to social recovery as defined by 2 or more point improvement in energy and muscular pain/concentration and return to work or full-time training. Three patients with treatment-resistant CFS (mean duration 17.66 years) treated with modafinil and CBT in a Liaison Psychiatry clinic were retrospectively reviewed. Progress was reviewed at baseline, 4-6 months and 10-24 months. Patients rated their fatigue, pain and concentration using 10-point Likert scales. 2/3 achieved clinically meaningful improvements in energy and pain/concentration and 3/3 achieved social recovery. Modafinil, when prescribed over the medium term, would appear to be a potentially useful potentiating agent when added to CBT.

Psychosis REACH: Effects of a Brief CBT-Informed Training for Family and Caregivers of Individuals With Psychosis.

OBJECTIVE: Psychosis Recovery by Enabling Adult Carers at Home (Psychosis REACH) is a training for families of individuals with psychosis that consists of recovery-oriented psychosis psychoeducation, caregiver self-care, and skills training informed by cognitive-behavioral therapy for psychosis (CBTp). The authors assessed the effects of a 1-day and a 4-day training on the natural supports (i.e., family and other caregivers) of individuals with psychotic disorders. METHODS: Attendees of a 1-day (N=168) and a 4-day (N=29) Psychosis REACH training were surveyed at three timepoints: pretraining, posttraining, and 4-month follow-up. Longitudinal changes across the full sample were evaluated by paired-sample t tests or a one-way repeated-measures analysis of variance (ANOVA). Two-way mixed ANOVAs were conducted with training condition, time, and the training condition × time interactions entered into the model. RESULTS: Reductions were noted in self-perceived depression, anxiety, negative aspects of the caregiving experience, and expressed emotion. Trainees also showed more prosocial attitudes toward psychosis immediately and at 4 months after the training. CONCLUSIONS: This evaluation of the launch of Psychosis REACH in the United States suggests that the training can improve the mental health, attitudinal, and relational outcomes of family and caregivers of individuals with psychosis. Given the dearth of CBTp and family interventions for psychosis in mental health services in the United States, short-term, intensive training that supplements clinical services has intuitive appeal as a means of surmounting the barriers that have plagued family interventions.

Targeting dissociation using cognitive behavioural therapy in voice hearers with psychosis and a history of interpersonal trauma: A case series.

OBJECTIVES: Previous studies have suggested that dissociation might represent an important mechanism in the maintenance of auditory verbal hallucinations (i.e., voices) in people who have a history of traumatic life experiences. This study investigated whether a cognitive behavioural therapy (CBT) intervention for psychosis augmented with techniques specifically targeting dissociative symptoms could improve both dissociation and auditory hallucination severity in a sample of voice hearers with psychosis and a history of interpersonal trauma (e.g., exposure to sexual, physical, and/or emotional abuse). DESIGN: Case series. METHODS: A total of 19 service users with psychosis were offered up to 24 therapy sessions over a 6-month intervention window. Participants were assessed four times over a 12-month period using measures of dissociation, psychotic symptoms severity, and additional secondary mental-health and recovery measures. RESULTS: Sixteen participants engaged in the intervention and were included in last-observation-carried-forward analyses. Dropout rates were in line with those of other CBT for psychosis trials (26.3%). Repeated measures ANOVAs revealed large and significant improvements in dissociation (drm  = 1.23) and hallucination severity (drm  = 1.09) by the end of treatment; treatment gains were maintained 6 months following the end of therapy. Large and statistically significant gains were also observed on measures of post-traumatic symptoms, delusion severity, emotional distress, and perceived recovery from psychosis. CONCLUSIONS: The findings of this case series suggest that the reduction of dissociation represents a valuable and acceptable treatment target for clients with auditory verbal hallucinations and a trauma history. Future clinical trials might benefit from considering targeting dissociative experiences as part of psychological interventions for distressing voices. PRACTITIONER POINTS: Practitioners should consider the role of dissociation when assessing and formulating the difficulties of voice hearers with a history of trauma. Techniques to reduce dissociation can be feasibly integrated within psychological interventions for voices. Voice hearers with histories of trauma can benefit from psychological interventions aimed at reducing dissociation.

Ageism in first episode psychosis.

OBJECTIVE: To consider the characteristics of first episode psychosis in older adults in a county in North East England. METHOD/DESIGN: The present study used a naturalistic design to compare individuals aged 65 years and over with those under 65, with a first episode psychosis. Data were collected on demographics, diagnosis at presentation and hospital admissions in the first year. RESULTS: Almost a quarter of all patients were aged 65 years or older. The older group were admitted later on after presentation, but with longer average hospital stays (p < 0.01), compared to the younger group, with no difference in the use of the Mental Health Act. Late onset schizophrenia (40-59 years) and very late onset schizophrenia-like psychosis (60 + years) formed a considerable proportion of patients. CONCLUSIONS: There is a substantial proportion of older people with first episode psychosis, with a significant use of hospital bed days. There are large gaps in services for this group who often do not have the same access to those offered to younger people, e.g. Assertive Outreach or crisis teams, access to Clozapine and CBT. Ageism exists in all forms; the elderly are doubly disadvantaged in view of their age and mental illness.In view of the Age Discrimination Act (2006) the elderly functionally ill group of patients should be entitled to the same level of care and equal access to services as younger people. More attention and interventions need to be focused on this overlooked group.

What are the essential ingredients of a CBT case conceptualization for voices and delusions in schizophrenia spectrum disorders? A study of expert consensus.

Evidence supports the use of cognitive behavioural therapy (CBT) for the treatment of patients with schizophrenia spectrum disorders. A case conceptualization (CC) (or case formulation) is seen as the keystone of CBT in terms of making sense of a patient's difficulties, to guide and inform such treatment. Despite the importance placed on CC there is no known consensus amongst experts as to the essential ingredients involved in this fundamental process. This study used the Delphi method to establish expert consensus for the essential components of a CC when working to treat auditory hallucinations (voices), and persecutory delusions. An international panel of 78 CBT for psychosis (CBTp) experts from 12 different countries participated in the main stage of this study. This 3-stage process involved producing and rating statements that addressed key areas of CC in terms of: presenting issues, predisposing, precipitating, perpetuating and protective factors. One presenting issue and 6 perpetuating factors were endorsed as essential by >80% of the expert panel. The exact same items were endorsed for both voices, and persecutory delusions. The findings are unique in that a large panel of international experts reached consensus that case conceptualizations (CCs) should be parsimonious and focused on the perpetuating (maintaining) factors to facilitate change. Overall, the proposed recommendations should lead to core guidance for the process of developing CCs, and improvements in training for clinicians that conceptualize voices, and persecutory delusions in CBT for schizophrenia spectrum disorders.

Improving patient flow in acute psychiatric wards: enhanced bed management and trusted assessment.

AIMS AND METHOD: In three localities in a mental health trust in England, an enhanced bed management team was established to improve patient flow and reduce out-of-area placements. Trusted assessments were provided to support risk management and conflict resolution. Two measures of flow were compared before and after the team was established. RESULTS: The trusted assessment recommendation was for discharge in 70% of cases. The number of out-of-area placements was significantly reduced (P < 0.05), saving £616 876 over a 12-month period. Patient flow was significantly improved in one of the three localities as measured by patients/bed/6-month period (P < 0.05). In one of the other localities increased use of trusted assessment input and reduced numbers of patients being transferred in are recommended to improve flow. CLINICAL IMPLICATIONS: Mental health trusts should consider the establishment of an enhanced bed management team, including trusted assessment, as a safe and cost-effective approach to improving patient flow and reducing the need for out-of-area placement.