Clinical Practice Guidelines for Cognitive Behavioral Therapy for Psychotic Disorders

Abstract

INTRODUCTION The International Classification of Diseases (ICDs) – 10th Edition – as well as the most recent 11th edition of the ICD include schizophrenia, persistent delusional disorders, acute and transient psychotic disorders (ATPDs), schizoaffective disorder, schizotypal disorders, and others under the broad rubric of psychotic disorders.[12] Psychotic disorders are considered as a severe mental illness and almost all psychotic disorders (except ATPD) have a chronic course, characterized by severe impairment in cognitions, affect, and behavior. It has been well researched that despite adequate trials of available pharmacological treatments, a substantial proportion of patients (25%–50%) with psychotic disorders, particularly schizophrenia, continue to experience persistent hallucinations, delusions, emotional withdrawal, and depressive symptoms.[345] Moreover, about 5%–10% of patients with schizophrenia do not show any benefit from any antipsychotic medications.[6] Persistence of psychotic symptoms can be disabling and distressing to the patients, can lead to the development of depression, and poses a high risk of suicide.[78910] To deal with these difficult and persistence psychotic symptoms in patients with psychotic disorders, various nonpharmacological psychological treatment strategies have been developed. Cognitive behavioral therapy for psychosis (CBTp) is one such treatment option which has been developed for patients with psychotic disorders since 1952.[11] Over the last 20 years, significant research interest has grown in CBTp interventions and the existing literature suggests it to be quite effective in patients with psychotic disorders in reducing positive and negative symptoms and depressive symptoms, increasing adherence to treatment, and improving insight.[121314151617] Almost all the recent treatment guidelines of schizophrenia suggest specific recommendations to include CBT for the treatment of persistent psychotic symptoms.[18192021] The clinical practice guidelines for schizophrenia of the Indian Psychiatry Society have also suggested CBT for psychosis in some situations.[20] The aim of this document is to provide a framework and guidance for a comprehensive assessment and evaluation for CBTp, formulate a treatment plan, and practice CBTp interventions (as applicable to the patient). Initially, we discuss the available evidence for CBTp in different clinical scenarios in patients with psychosis and then discuss the indications and assessment, formulation of a treatment plan, and execution of the same. These guidelines can be used in any treatment settings, but will require modifications as per the treatment setting and the needs of the patients. These recommendations are primarily meant for adult patients with psychotic disorders. It is expected that the psychiatrists will have a basic understanding of the various cognitive models of psychotic symptoms (delusions and hallucinations) and negative symptoms as these are essential to carry out the CBTp interventions. A detailed description of these cognitive models is beyond the scope of this document and interested clinicians can refresh their knowledge by going through the descriptions of available models.[2223242526272829] EFFICACY/EFFECTIVENESS OF COGNITIVE BEHAVIORAL THERAPY FOR PSYCHOSIS CBTp has been evaluated in different studies in different clinical scenarios in patients with psychotic disorders and those at risk of developing psychosis. Chronic phase of schizophrenia Most of the available efficacy/effectiveness studies have been conducted on patients with treatment-resistant psychotic symptoms during the chronic phase of psychotic illness (usually schizophrenia). The meta-analyses of studies focusing on resistant positive and negative symptoms in patients with chronic schizophrenia suggest that there is moderate-to-good effect size for positive symptoms and low effect size for negative symptoms [Table 1].[15173031323334] On the basis of the existing literature, CBTp can be recommended in patients with chronic schizophrenia/psychosis as an adjunct to antipsychotic medications.Table 1: Meta-analyses of studies on cognitive behavioral therapy for psychosis in patients with psychosisClozapine-resistant schizophrenia Only one randomized controlled trial (FOCUS-RCT) has evaluated the role of CBTp as an effective augmentation strategy in patients with clozapine-resistant schizophrenia (CRS).[36] This RCT compared patients with chronic-resistant schizophrenia assigned to both CBTp and treatment as usual (TAU) (n = 242) and compared with TAU alone (n = 245). The assessors were blind to the interventional arms. At the end point (i.e., 9 months), CBTp led to significant improvement in symptoms, but at 21-month follow-up, CBTp did not show a lasting effect on total symptoms, when compared with TAU. Further, the study did not support the recommendation to routinely offer CBTp to all patients who meet criteria for CRS, and CBTp was not found to be a cost-effective intervention in patients with CRS.[36] Based on the limited data on CBTp interventions in patients with CRS, CBTp is not recommended for routine use. However, it can be used in some special cases (such as patients with distressing auditory hallucinations, those not willing for electroconvulsive therapy [ECT], or in whom ECT is contraindicated). Prepsychotic phase (prodromal phase/ultra-high risk for psychosis/at-risk mental state There is preliminary evidence to suggest that CBTp interventions may prevent or delay transition to psychosis in ultra-high-risk patients and those who are at-risk mental state (ARMS). It is also found to be quite cost-effective.[373839] A new CBTp protocol specifically targeted at cognitive biases in ultra-high risk/ARMS patients has been developed, and it has been found to be quite efficacious in reducing subclinical psychotic symptoms in these patients.[40] However, based on the limited existing literature and lack of robust evidence to favor CBTp in this group of population, currently, CBTp cannot be routinely recommended, though it can be a reliable and logical treatment option in these patients.[4142] First-episode psychosis Several studies have evaluated the effectiveness of psychological interventions in patients with early psychosis/ first-episode psychosis. These studies have mostly based on CBTp interventions and/or cognitive remediation therapy (CRT). Few studies have found CBTp to be effective over routine care alone or supportive counseling in speeding remission from acute symptoms[43] and in the reduction of substance use (cannabis use).[44] Considering these findings, CBTp interventions can be useful in patients with first-episode psychosis when used as an adjunct to routine pharmacological therapy and can aid in the improvement of symptoms, medication adherence, improving self-esteem, and developing insight about the illness, with no potential risks or disadvantages.[45] However, these studies are limited by small sample sizes and difficulty in blinding. Due to this, meta-analyses of studies on CBTp and CRT in first-episode psychosis patients have been grossly inconclusive because of the high heterogeneity of interventions used in the studies and outcome measures; therefore, the authors failed to draw any definite inferences or make any recommendations.[4647] Further studies are needed before advocating CBTp routinely to all patients with first-episode psychosis. Acute phase of schizophrenia The benefits of CBTp during an acute psychotic episode are difficult to study and have been investigated in only a handful of studies. The studies which have investigated the efficacy of CBTp during acute phase of psychosis (i.e., CBTp vs. TAU) have shown variable results ranging from significant improvement to no statistically significant differences.[484950] However, long-term follow-up of these patients fails to show any beneficial effect of CBTp, if carried out during the acute phase.[50] Further, there is lack of good-quality RCTs (blinded and with proper raters) to recommend CBTp during acute psychotic episode. However, the National Institute for Health and Clinical Excellence guidelines suggest that CBTp can be started during the acute phase,[21] although there is lack of consensus opinion about the same. Cognitive behavioral therapy for psychosis for patients with schizophrenia not taking antipsychotic drugs One exploratory trial (n = 37) which assessed the role of CBTp in patients with schizophrenia who are not willing to take antipsychotics, suggested CBTp to be an acceptable and effective treatment in such patients with significant beneficial effects noted on total Positive and Negative Symptom Scale for Schizophrenia (PANSS) scores.[51] However, the study sample was small to make any specific recommendations. Accordingly, based on the current level of evidence, it can be said that CBTp may be primarily used in patients with chronic schizophrenia with residual symptoms as an augmentation strategy. It can also be considered in prodromal phase, patients at high risk of developing psychosis, those with a history of poor medication compliance, and patients with first-episode psychosis. Use of CBTp in the acute phase should only be considered based on the level of patient's cooperation and other feasibility issues [Table 2].Table 2: Clinical situation for the use of cognitive behavioral therapy for psychosis in patients with psychotic disordersCOGNITIVE BEHAVIORAL THERAPY FOR PSYCHOSIS IN THE INDIAN CONTEXT Although there is sufficient evidence from across the world to suggest that CBT can be a suitable augmenting strategy in certain difficult-to-treat cases, studies from Indian scenario are lacking. A thorough search literature on Indian studies on CBTp revealed only three studies till date. These include one open-label study,[52] one case series of three patients with CRS,[53] and a case report describing a 31-year-old male with paranoid schizophrenia on 250-mg/day clozapine, yet, had treatment-resistant delusions related to “internet” controlling him who was treated with several sessions of CBTp with good response to CBTp.[54] The open-label study included 51 patients with schizophrenia/schizoaffective disorder, all of whom were provided a structured CBTp intervention program (included intensive psychoeducation, behavioral analysis, activity monitoring and scheduling, assertiveness training, relaxation, distraction techniques, in-vitro systematic desensitization, exposure and response prevention, stress inoculation and skills training, and cognitive restructuring), which resulted in marked improvement in overall adjustment, with significant decrease in the intensity of psychotic symptoms immediately after the completion of CBTp intervention, and the gains achieved were retained at 9-month follow-up assessment.[52] This study also suggested that family members developed positive regard for their patients after the psycho-education sessions in which they were included. The case series of three patients with CRS in whom CBTp techniques were used as adjunctive treatment suggests that it is useful in clozapine nonresponders with refractory-positive psychotic symptoms.[53] Limited literature from India could be due to: (1) lack of awareness and knowledge about CBT techniques for psychosis; (2) lack of training about CBTp when compared to CBT techniques for depression; (3) as CBTp requires longer time investment on part of the treating mental health professionals, such therapy may not be feasible in every case; (4) low cognitive sophistication in Indian patients having different cultural background and literacy (rural–urban, educated – literate or illiterate); (5) feasibility issues such as difficulty in adhering to regular follow-up, as patients are often dependent on the caregivers’ difficulty on part of the caregivers to invest that much amount of time for therapy sessions, financial issues, distance, etc.; (6) lack of availability of culturally adapted CBTp manuals not developed with regard to the Indian context; (7) low publication rates – it is possible that CBTp is practiced by many clinicians in India, but usually people do not write about their experience of using the same; and (8) lack of acceptance of manuscript reporting CBTp from the Indian context. INDICATIONS AND GOALS FOR COGNITIVE BEHAVIORAL THERAPY FOR PSYCHOSIS CBTp can be used in patients with persistent psychotic symptoms, who have not responded completely to the ongoing medications or when the symptoms are not severe enough in the prodromal phase of illness to warrant the use of antipsychotic medications. Table 1 outlines the usual indications for CBTp. The basic goal of CBTp is to improve the understanding and insight about the psychotic experiences and to cope with the same so that the associated distress and dysfunction is minimized [Table 3 and Figure 1].Table 3: Indications of cognitive behavioral therapy for psychosis interventionsFigure 1: Indications for cognitive behavioral therapy for psychosisASSESSMENT AND EVALUATION Based on the indications, a comprehensive and thorough assessment of the patient is required for CBTp. Usually, assessment can be classified as general assessment and symptom-specific assessment. The general assessment includes collection of information from the patient and his/her caregiver about the type of current symptoms and their severity, response to medications, impact of these symptoms on the patient's functioning in different areas, and strategies used by the patient to cope up with them [Table 4]. All relevant biological, psychological, and social factors that may have contributed to the onset of illness, premorbid functioning, comorbid psychiatric illnesses (anxiety disorders, depression, substance abuse disorders, etc.), and comorbid medical illnesses should be assessed. Efforts should be made to assess for comorbid depression and anxiety which may be acting as barriers to engage in activities. Studies have demonstrated that patients with negative symptoms may have comorbid anxiety symptoms (not diagnosable any anxiety disorder per se), experience somatic symptoms and feelings of helplessness, and have a negative self-image.[5859] Further, apathy and withdrawal symptoms can be because of avoidance developed in order to prevent the positive symptoms and their consequences such as fear/anxiety. Effects of medication (sedation and extrapyramidal symptoms) should also be taken into account as possible reasons for inactivity and social withdrawal.Table 4: Assessment and evaluation for cognitive behavioral therapy for psychosisPatient's motivation for undergoing CBTp interventions is also an essential aspect which needs to be assessed. Often, the patients are reluctant to remain engaged in such type of therapies, therefore all possible efforts should be made to enhance the motivation, which may take few sessions. It is also important to assess the psychological sophistication of the patient so as to modulate the manner in which instructions are to be passed on or to be explained. Intelligence quotient (IQ) and neurocognitions may need to be assessed too, though not routinely recommended as a definite requisite for CBTp interventions. Studies have demonstrated that those with significant cognitive deficits or with mild range of intellectual disability (as per IQ score) can also be undertaken for therapy, but the therapy process has to be modulated and simplified based on the level of understanding, i.e., from cognitive techniques to more of behavioral techniques/instructions.[60] A detailed and proper functional analysis of the patient's behavior is to be done as a part of assessment for CBTp. It includes how time is being spent on a daily basis, particular hobbies and activities one like to which one to do well and from one like to do but had been to reasons for not to do the and activities which his/her family members to do more assessment includes the of This can be done by the patient to the of the on a However, if it is to use Scale and for which can be used are about Cognitive Assessment Assessment of insight is an part of CBTp. It should usually be done through a proper clinical with the of of symptoms, various assessment can also be used for the assessment of such as for Scale to the of from and and Cognitive It is also to include the caregivers in the assessment process to have a understanding about the level of with psychotic symptoms, avoidance and medication adherence, The assessment needs to be an ongoing process and to the of the illness, it may take a time to the assessment. the therapy some of the such as and need to be assessed at various so as to the over the of the It also the to the of the ongoing strategies and the strategies on the need and A thorough assessment also in the in CBTp, i.e., includes and developing a with the patient with the Indian on the type of the symptoms for CBTp, caregivers can also be in assessment and engaged in the treatment, as they an part of the treatment, as they are often in and monitoring the patient at the patient to the treating and the financial of Table and Figure the basic of assessment for 2: for assessment and evaluation for cognitive behavioral therapy for psychosis A COGNITIVE BEHAVIORAL THERAPY FOR PSYCHOSIS THERAPY of CBTp about treatment indications for CBTp techniques to be and to be and caregivers should be the part and of the needs to be as per the needs of the patient and based on the feasibility Cognitive sophistication of the patient is also essential to the techniques for CBT interventions. Based on the assessment, a CBT psychological case formulation and case should be CBT provide an of a has and are the factors for the of the same. It also the intervention and potential that It is a based on the information during assessment and may during the of The formulation needs to be based on the experiences of However, it be that CBTp is an adjunct treatment and not a for of treatment The basic of a treatment setting for CBTp interventions is to provide CBTp sessions in the setting and feasible setting as per the needs of the patient and CBTp interventions can be carried out as an treatment in regular follow-up or can be in and as an the of psychiatric in India, and indications for care in patients with psychotic disorders being acute of psychosis or acute psychosis, CBTp interventions should be carried out on an However, care can be considered based on the needs and the OF COGNITIVE BEHAVIORAL THERAPY FOR PSYCHOSIS The general of CBTp are to that of the general and usual of These are a and developing a includes the for therapy and the of therapy, issues related to therapy, and of sessions. of should be patient's and being should be and a is one of the most important in CBTp, as patients with psychosis are often with their experiences in a context. A as a to engage the patient in the CBT The should and but should not or to with a experience in the sessions, no how the may the patient to remain then the should it and should not to the patient into behavior or of the patient may to be but the should and should or to activity which can patient's should be such as to positive or should be made as it can the All possible efforts should be made to the of the OF COGNITIVE BEHAVIORAL THERAPY FOR PSYCHOSIS the assessment and of the the basic of CBTp include psychoeducation, cognitive therapy, behavioral training, and strategies [Table the cognitive therapy and behavioral training the of of cognitive behavioral therapy for AND OF COGNITIVE BEHAVIORAL THERAPY FOR PSYCHOSIS The of CBTp is almost to the of CBT for depression and It is an and intervention usually lasting for in an The sessions are on the development of developing a with the of the psychotic and The role of is (1) to the symptoms of the (2) to an of and (3) to do a assessment of symptoms and to treatment (4) to the patient about the role of stress and effect on his/her and (5) to by the A CBTp is in Table sessions are usually and exploratory any on clinical is to be sessions by in the and for from the patient over the However, it is to be that there should be more with regard to therapy in patients with psychosis as compared to patients with of a cognitive behavioral therapy for psychosis FOR delusions The CBTp techniques used for resistant and persistent delusions in psychotic patients are on reducing the and of the delusions [Table Over the of therapy, the should the patient about the cognitive biases and and out behavioral Cognitive behavioral therapy for psychosis techniques for persistent COGNITIVE AND BEHAVIORAL FOR with persistent usually report various auditory ranging from of or type of auditory The CBT techniques are developed to the distress out of such [Table The time to these strategies and to them from to and also on patient's motivation and cognitive support and a good in the of the Cognitive behavioral therapy for psychosis techniques for persistent COGNITIVE AND BEHAVIORAL FOR CBTp techniques for patients with schizophrenia with negative symptoms have been with The cognitive and behavioral strategies usually for the of negative symptoms are to strategies used in These include (1) of (2) and techniques, (3) activity scheduling, (4) (5) social skills training, and (6) assertiveness training These techniques are required to be to the level of and cooperation of the reasons for inactivity and motivation for routine activities should be carried out and at can be with for specific activity undertaken by the behavioral can be carried out to the and to in such patients. with comorbid depressive and anxiety symptoms, different cognitive and behavioral strategies should be used for OF AND the therapy the patient may show improvement or no significant case of no significant other of symptoms should be such as comorbid and poor case of improvement and the that the therapy is to the should the of sessions, improvement is and should be The patient should be the of of sessions. The patient should be the option to meet the in then a and then at longer This prevent the patient from being dependent on the the follow-up sessions should be carried out so as to the gains achieved and the improvement and cognitive so achieved is retained or case of early of strategies such as more intensive more sessions, and the of and them should be done The detailed of CBTp interventions is shown in 3: of CBTp IN COGNITIVE BEHAVIORAL THERAPY FOR PSYCHOSIS new of CBTp have been developed in the recent These are (1) and Cognitive and (4) the of these new of CBTp interventions is being techniques of CBTp such as intervention and through have also been suggested with good These of techniques to be beneficial to those patients who therapy sessions and offer new to the beyond mental health However, the of these CBTp interventions are that these are interventions and they lack the basic essential However, these CBTp interventions are at the level and evaluation is required before advocating and these in the Indian support and of interest There are no of

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