Cognitive Therapy for People with a
Schizophrenia Spectrum Diagnosis not
Taking Antipsychotic Medication:
Results From an Open Trial
Thomas Christodoulides, Clinical Psychologist
Early Intervention in Psychosis Service, South of Tyne and Wear
Acknowledgments


Tony Morrison
Douglas Turkington

Melissa Wardle, Helen Spencer, Laura Drage, Paul
French

Rory Byrne

Robert Dudley, Paul Hutton, Victoria Lumley, Alison
Brabban, Pauline Callcott, Nicola Chapman, Sara Tai
Background


NICE (2009): Antipsychotic medication is
recommended as first line of treatment
But many service users choose not to take, or
discontinue pharmacological treatment:
– Lieberman et al (2005) 74% discontinued
their medication within 18 months
– Lacro et al (2002) Estimated rate of
medication non-compliance in Schizophrenia:
40%-50%
Reasons for discontinuing




Moncrieff et al (2009): service users opposed
to taking antipsychotic medication. Why?
Lack of insight
Stigma
Concerns about side effects
–
–
–
–
–
weight gain
Extra pyramidal
Cardiovascular problems (Tandon et al, 2008)
Increased risk of sudden cardiac death (Ray et al, 2009)
Cerebral abnormalities (Ho et al, 2011)
Response to medication

Leucht et al (2009):
– meta analysis
– atypicals > placebos on the PANSS
by only 10 pts (about 5%)
Choice and Empowerment

Owens et al (2008)
– many inpatients retain treatment decision making
capacity

Warner et al (2006)
– Literature review on choice and decision making
– Service users want to be offered more than just
medication

NICE guidelines for Schizophrenia (2009)
– Recommended treatment choice for the individual
– All patients with Schizophrenia should have access
to CBT and family interventions.
CBT with antipsychotic
medication

Pilling et al (2002); Wykes, Steel
& Tarrier (2008)
– Meta analyses
– CBT effective in combination with
antipsychotic medication
CBT in the absence of antipsychotic
medication?


Morrison (1994)
- Single case: CBT achieved significant
reduction in auditory hallucinations.
Morrison (2001)
- Case series: Reported significant
reduction in conviction, frequency, and
distress associated with auditory
hallucinations.
CBT in the absence of antipsychotic
medication?


Christodoulides et al (2008)
Wellcome and Insight trials
– Small number reported as antipsychotic medication
free
– Showed significant improvement on a wide range of
psychometric assessment measures
– Case series: Reduction in positive and negative
symptoms of schizophrenia.
Design

Aim
– To assess the feasibility and effectiveness of CBT for
patients not taking antipsychotics

Dual Site
– North East (Professor Douglas Turkington)
– Manchester (Professor Tony Morrison)


Experienced therapists offering 9 months CBT 25 sessions.
Manualized therapy
– Turkington et al (2009); Morrison et al (2008)


Recruiting from EIP, CMHT, CAMHS
20 participants
Inclusion Criteria:
ICD-10 diagnosis of schizophrenia,
schizo-affective disorder or delusional
disorder
Or 4+ score on the PANSS on
hallucinations or delusions, or 5 on
conceptual disorganization, grandiosity,
or suspiciousness
Age 16-65 years
Exclusion Criteria:
Organic brain disease including dementia, epileptic
psychosis, head injury (impaired cognitive functioning
and with subsequent inability to engage in CBT)
Use of antipsychotic medication in previous 6 months.
Primary diagnosis of drug or alcohol misuse
Impaired intellect severe enough to interfere with
ratings
Receiving acute psychiatric inpatient care at baseline,
(patients must be stable enough to engage in CBT, and
to justify continued absence of antipsychotic
medication).
Previous manualised CBT for psychosis and/or
previous manualised CBT for anxiety/depression
within the last 2 years (those previously exposed to
CBT may be habituated to the model).
Diagnosis

All diagnosis established using
– ICD-10
– Case notes
– Review by a consultant psychiatrist
– Schizophrenia (n =15)
– Schizo-affective disorder (n = 4)
– Delusional disorder (n = 1)
Outcome measures

PANSS – 30 item (0-7)
– semi-structured interview of +ve and –ve
symptoms and psychopathology

PSYRATS
– clinician administered 11 item (0-4)
questionnaire of hallucinations and delusions

Clinically significant change on PANSS
– >50%, >25%, <25%
Outcome measures

PRP – user defined measure of recovery
– 22 item questionnaire

PSP
– Personal and Social Performance Scale
– 100 point single item rating scale




Socially useful activities
Personal and social relationships
Self care
Disturbing and aggressive behaviour
Psychometric Assessment
Schedule:
Therapy Booster sessions
>4 sessions (6 months post therapy)
Therapy (9 months >25 sessions)
Baseline
3 months
Measures
Jan
Feb
6 months
Measures
Mar
Apr
May Jun
9 months
Measures
Jul
Aug Sep
15 months
(Follow-up: 6 months post therapy)
Measures
Oct
Nov Dec
Measures
Jan
Feb
Mar
Apr
Intervention




Maximum 26 sessions
9 months
Beckian CBT
Manual based
– Morrison et al (2004b)
– Kingdon & Turkington (2005)

Model
– Morrison (2001b)
– Normalize and de-catastrophize
– generate and explore alternatives
Results 1
Variable
Pretreatment
Mean (S.D.)
Posttreatment
mean
(S.D.)
t/Wa P
d
95%
CI
PANSS
total
69.55 (11.99)
59.20
(19.52)
3.66
0.0002
0.85
0.321.35
PANSS
Positive
18.75 (4.74)
14.65
(7.37)
2.99
0.0003
0.87
0.451.53
PANSS
Negative
14.60 (5.06)
12.40
(5.58)
3.33
0.001
1.00
0.451.54
Results 1
Variable
Pretreatment
Mean (S.D.)
Posttreatment
mean
(S.D.)
t/Wa P
d
95%
CI
PANSS
total
69.55
(11.99)
59.20
(19.52)
3.66
0.0002
0.85
0.321.35
PANSS
Positive
18.75 (4.74)
14.65
(7.37)
2.99
0.0003
0.87
0.451.53
PANSS
Negative
14.60 (5.06)
12.40
(5.58)
3.33
0.001
1.00
0.451.54
Results 1
Variable
Pretreatment
Mean (S.D.)
Posttreatment
mean
(S.D.)
t/Wa P
d
95%
CI
PANSS
total
69.55 (11.99)
59.20
(19.52)
3.66
0.0002
0.85
0.321.35
PANSS
Positive
18.75 (4.74)
14.65
(7.37)
2.99
0.0003
0.87
0.451.53
PANSS
Negative
14.60 (5.06)
12.40
(5.58)
3.33
0.001
1.00
0.451.54
Results 1
Variable
Pretreatment
Mean (S.D.)
Posttreatment
mean
(S.D.)
t/Wa P
d
95%
CI
PANSS
total
69.55 (11.99)
59.20
(19.52)
3.66
0.000
2
0.85
0.321.35
PANSS
Positive
18.75 (4.74)
14.65
(7.37)
2.99
0.000
3
0.87
0.451.53
PANSS
Negative
14.60 (5.06)
12.40
(5.58)
3.33
0.001
1.00
0.451.54
Results 2
Variable
Pretreatment
Mean (S.D.)
Follow up
(S.D.)
t/Wa P
d
95%
CI
PANSS
total
69.55 (11.99)
54.30 (17.23)
5.63
0.000
1.26
0.661.84
PANSS
Positive
18.75 (4.74)
13.35 (6.11)
3.31
0.0001
1.08
0.511.62
PANSS
Negative
14.60 (5.06)
12.15 (5.41)
2.80
0.0005
0.79
0.271.28
Results 2
Variable
Pretreatment
Mean (S.D.)
Follow up
(S.D.)
t/Wa P
d
95%
CI
PANSS
total
69.55
(11.99)
54.30 (17.23)
5.63
0.000
1.26
0.661.84
PANSS
Positive
18.75 (4.74)
13.35 (6.11)
3.31
0.0001
1.08
0.511.62
PANSS
Negative
14.60 (5.06)
12.15 (5.41)
2.80
0.0005
0.79
0.271.28
Results 2
Variable
Pretreatment
Mean (S.D.)
Follow up
(S.D.)
t/Wa P
d
95%
CI
PANSS
total
69.55 (11.99)
54.30 (17.23)
5.63
0.000
1.26
0.661.84
PANSS
Positive
18.75 (4.74)
13.35 (6.11)
3.31
0.0001
1.08
0.511.62
PANSS
Negative
14.60 (5.06)
12.15 (5.41)
2.80
0.0005
0.79
0.271.28
Results 2
Variable
Pretreatment
Mean (S.D.)
Follow up
(S.D.)
t/Wa P
d
95%
CI
PANSS
total
69.55 (11.99)
54.30 (17.23)
5.63
0.000
1.26
0.661.84
PANSS
Positive
18.75 (4.74)
13.35 (6.11)
3.31
0.000
1
1.08
0.511.62
PANSS
Negative
14.60 (5.06)
12.15 (5.41)
2.80
0.000
5
0.79
0.271.28
Results 3
Variable
Pretreatment
Mean
(S.D.)
Posttreatment
Mean
(S.D.)
t/Wa
P
d
95%
CI
PSYRATS
Hallucinations
19.35
(15.03)
10.80 (13.34)
2.17
0.03
0
0.56
0.841.03
PSRATS
Delusions
14.70
(6.67)
6.45 (7.07)
4.41
0.00
0
0.99
0.441.52
QPR total
48.83
(15.69)
57.22 (18.59)
1.69
0.11
0
0.41
0.090.90
PSP total
47.4 (13.80) 56.45 (18.37)
2.44
0.02
5
0.54
0.071.01
Results 3
Variable
Pretreatment
Mean
(S.D.)
Posttreatment
Mean
(S.D.)
t/Wa
P
d
95%
CI
PSYRATS
Hallucinations
19.35
(15.03)
10.80 (13.34)
2.17
0.03
0
0.56
0.841.03
PSRATS
Delusions
14.70
(6.67)
6.45 (7.07)
4.41
0.00
0
0.99
0.441.52
QPR total
48.83
(15.69)
57.22 (18.59)
1.69
0.11
0
0.41
0.090.90
PSP total
47.4
(13.80)
56.45 (18.37)
2.44
0.02
5
0.54
0.071.01
Results 3
Variable
Pretreatment
Mean
(S.D.)
Posttreatment
Mean
(S.D.)
t/Wa
P
d
95%
CI
PSYRATS
Hallucinations
19.35
(15.03)
10.80
(13.34)
2.17
0.03
0
0.56
0.841.03
PSRATS
Delusions
14.70
(6.67)
6.45 (7.07)
4.41
0.00
0
0.99
0.441.52
QPR total
48.83
(15.69)
57.22
(18.59)
1.69
0.11
0
0.41
0.090.90
PSP total
47.4 (13.80) 56.45
(18.37)
2.44
0.02
5
0.54
0.071.01
Results 3
Variable
Pretreatment
Mean
(S.D.)
Posttreatment
Mean
(S.D.)
t/Wa
P
d
PSYRATS
Hallucinations
19.35
(15.03)
10.80 (13.34)
2.17
0.03 0.56
0
0.841.03
PSRATS
Delusions
14.70
(6.67)
6.45 (7.07)
4.41
0.00 0.99
0
0.441.52
QPR total
48.83
(15.69)
57.22 (18.59)
1.69
0.11 0.41
0
0.090.90
PSP total
47.4 (13.80) 56.45 (18.37)
2.44
0.02 0.54
5
0.071.01
95%
CI
Results 4
Variable
Pretreatment
Mean
(S.D.)
Follow up
Mean
(S.D.)
t/Wa
P
d
95%
CI
PSYRATS
Hallucinations
19.35
(15.03)
9.65
(12.81)
2.70
0.008
0.70
0.201.19
PSRATS
Delusions
14.70
(6.67)
6.40
(6.69)
4.31
0.000
0.98
0.421.15
QPR total
48.83
(15.69)
60.96
(18.80)
2.50
0.024
0.65
0.081.11
PSP total
47.4 (13.80) 66.05
(18.31)
3.99
0.001
0.87
0.341.37
Results 4
Variable
Pretreatment
Mean
(S.D.)
Follow up
Mean
(S.D.)
t/Wa
P
d
95%
CI
PSYRATS
Hallucinations
19.35
(15.03)
9.65
(12.81)
2.70
0.008
0.70
0.201.19
PSRATS
Delusions
14.70
(6.67)
6.40
(6.69)
4.31
0.000
0.98
0.421.15
QPR total
48.83
(15.69)
60.96
(18.80)
2.50
0.024
0.65
0.081.11
PSP total
47.4
(13.80)
66.05
(18.31)
3.99
0.001
0.87
0.341.37
Results 4
Variable
Pretreatment
Mean
(S.D.)
Follow up
Mean
(S.D.)
t/Wa
P
d
95%
CI
PSYRATS
Hallucinations
19.35
(15.03)
9.65
(12.81)
2.70
0.008
0.70
0.201.19
PSRATS
Delusions
14.70
(6.67)
6.40
(6.69)
4.31
0.000
0.98
0.421.15
QPR total
48.83
(15.69)
60.96
(18.80)
2.50
0.024
0.65
0.081.11
PSP total
47.4 (13.80) 66.05
(18.31)
3.99
0.001
0.87
0.341.37
Results 4
Variable
Pretreatment
Mean
(S.D.)
Follow up
Mean
(S.D.)
t/Wa
P
d
95%
CI
PSYRATS
Hallucinations
19.35
(15.03)
9.65
(12.81)
2.70
0.00
8
0.70
0.201.19
PSRATS
Delusions
14.70
(6.67)
6.40
(6.69)
4.31
0.00
0
0.98
0.421.15
QPR total
48.83
(15.69)
60.96
(18.80)
2.50
0.02
4
0.65
0.081.11
PSP total
47.4 (13.80) 66.05
(18.31)
3.99
0.00
1
0.87
0.341.37
Discussion




CBTp without APM is acceptable
Associated with clinically significant
reduction in symptoms post treatment
Maintained at follow up
Associated with clinically significant
improvement in functioning
Methodological
Limitations




Small sample size
Diagnostically heterogeneous sample
Treatment fidelity not formally assessed
Open trial
– No control
– allegiance effects
– Non-blind ratings


Inflated estimates of treatment effects?
Need for RCT replication
Key reference



Morrison, A. P., Hutton, P., Wardle, M.,
Spencer, H., Barratt, S., Brabban, A.,
Callcott, P., Christodoulides, T., Dudley, R.,
French, P., Lumley, V., Tai, S.J. and
Turkington, D. (2011). Cognitive therapy for
people with a schizophrenia spectrum
diagnosis not taking antipsychotic
medication: an exploratory trial.
Psychological Medicine, 1-8.
Email address for correspondence:
anthony.p.morrison@manchester.ac.uk
References




Christodoulides, T., Dudley, R., Brown, S., Turkington, D., &
Beck, A. (2008). Cognitive behaviour therapy in patients with
schizophrenia who are not prescribed antipsychotic
medication: a case series. Psychology and Psychotherapy:
Theory Research and Practice, 81, 199-207.
Ho, B., Andreason, N., Ziebell, S., Pierson, R., Magnotta, V.
(2011). Long term antipsychotic treatment and brain volumes:
a long term longitudinal study of first episode schizophrenia.
Archives of General Psychiatry, 68, 128-137.
Kingdon, D., & Turkington, D. (2005). Cognitive Therapy for
Schizophrenia. Guilford Press: New York
Lacro, J., Dunn, L., Dolder, C. (2002). Prevalence of and risk
factors for medication nonadherence in patients with
schizophrenia: a comprehensive review of recent literature.
Journal of Clinical Psychiatry, 63, 892-909.
References




Leucht, S., Corves, C., Arbter, D., Engel, R., Li, C., Davis, J. (2009).
Second generation versus first generation antipsychotic drugs for
schizophrenia: a meta analysis. Lancet, 373, 31-41.
Lieberman, J., Stroup, T., McEvoy, J., Swatz, m., Rosenheck, R.,
Perkins, D., Keefe, R., Davis, S., Davis, C., Lebowitz, B., Severe, J., &
Hsiao, J. (2005). Effectiveness of antipsychotic drugs in patients with
chronic schizophrenia. New England Journal of Medicine, 353, 1209 –
1223.
Moncrieff, J., Cohen, D., Mason, J. (2009). The subjective experience
of taking antipsychotic medication: a content analysis of internet
data. Acta Psychiatrica Scandinavica, 120, 102-111.
Morrison, A. (1994). Cognitive behaviour therapy for auditory
hallucinations without concurrent medication: a single case.
Behavioural and Cognitive Psychotherapy, 22, 259-264.
References





Morrison, A. (2001b). The interpretations of intrusions in psychosis:
an integrative cognitive approach to hallucinations and delusions.
Behavioural and Cognitive Psychotherapy, 29, 257-276.
Morrison, A., Renton, J., Dunn, H., Williams, S., Bentall, R. (2004b).
Cognitive Therapy for Psychosis: A formulation based Approach.
Brunner-Routledge: London.
NICE (2009). Schizophrenia: Core Interventions in the Treatment
and Management of Schizophrenia in Primary and Secondary care.
National Institute for Clinical Excellence: UK.
Owens, G., Richardson, G., David, a., Szmuckler, G., Hayward, P., &
Hotopf, (2008). Mental capacity to make decisions on treatment in
people admitted to psychiatric hospitals: cross sectional study. British
Medical Journal, 337, 448.
Pilling, S., Bebbington, p., Kuipers, E., Garety, p., Geddes, J.,
Orbach, G., & Morgan, C. (2002). Psychological treatments in
schizophrenia: I. meta analysis of family intervention and cognitive
behaviour therapy. Psychological Medicine, 32, 763-782
References




Ray, W., Chung, C., Murray, K., Hall, K., & Stein, M. (2009). Atypical
antipsychotic drugs and the risk of sudden cardiac death. New
England Journal of Medicine, 360, 225-235.
Tandon, R., Belmaker, R., Gattaz, w., Lopez-Ibor Jr, J., Okasha, A.,
Singh, B., Stein D., Olie, J., Fleischhacker, W., & Moeller, H. (2008).
World Psychiatric association Pharmacopsychiatry section statement
on comparative effectiveness of antipsychotics in the treatment of
schizophrenia. Schizophrenia Research, 100, 20 – 38.
Warner, L., Mariathasan, J., Lawton-Smith S., Samele, C. (2006). A
review of the literature and consultation on choice and decision
making for users and carers of mental health and social care
services. King’s Fund/Sainsbury Centre for Mental Health: London
Wykes, T., Steel, C., & Tarrier, N. (2008). Cognitive behavior therapy
for schizophrenia: effect sizes, clinical models, and methodological
rigor. Schizophrenia Bulletin, 34, 523-537.
A brief case illustration:
Sandy






An 18-year old man who had heard and seen an
invisible figure (‘John’) most of his life.
Did not wish to take medication (and never had).
Beginning to experience a lack of control (obeying
instructions). Distressed and seeking help.
Cognitive therapy involved seeking continual
consent as the experience was valued by the
client.
His initial goals were to increase control. Later
goals were to reduce frequency/duration of visual
and auditory hallucinations down to zero.
Formulation…
TRIGGERS
Causes
Increases
Increases
HOW I FEEL
WHAT I DO
HOW DO I MAKE
SENSE OF THIS?
Leads to
Leads to
Maintains
Sandy:
Intervention

I have no control over this” (100% conviction)
– Advantages & disadvantages analysis of John
– Thought suppression experiment (to examine
whether ‘pushing away’ was helpful)
– Mindful detachment encouraged (just observe
rather than engage – let it come and go)
– Examined whether shouting back was helpful
– Spontaneously stopped obeying John, once the
appraisal of ‘having no control’ decreased.
Sandy:
Intervention

“It means I’m weird” (100% conviction)
– Normalising: Information detailing prevalence of
this and other experiences was given to Sandy
to keep and refer to.
 “I don’t feel alone with it any more”
– Distinction between different / acceptable, and
different / unacceptable discussed.
 “I’m a little bit different but that doesn’t mean
I’m not acceptable
As
W
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(s
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Conviction
Beliefs about John
90%
80%
50%
Week (session)
I have no control
It means I'm weird
100%
Mindful
detachment
70%
60%
40%
Normalising
30%
20%
10%
0%
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(D
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13
W
ee
k
14
W
ee
W
ee
k
16
k
15
(s
es
sio
n
8)
4
3
2
1
20%
k
k
k
k
se
As
30%
W
ee
W
ee
W
ee
W
ee
Conviction
Beliefs about John
Week (session)
People will reject me
It means I haven't grown up
100%
90%
80%
70%
60%
50%
40%
Distinction made between
different/acceptable &
different/unacceptable
10%
0%
As
W
se
ee
ss
k
m
1
en
(s
W
es
ee
t
si
k
on
2
(s
W
es 1)
ee
si
k
on
3
(s
W
es 2)
ee
si
k
on
4
W
(c
an 3)
ee
ce
k
5
lle
(s
W
d)
e
ee
s
si
k
on
6
(s
W
es 4)
ee
si
k
on
7
W
(c
an 5)
ee
ce
k
8
lle
(s
es d)
si
on
6
W
W )
ee
ee
k
k
10
9
(D
W
NA
ee
)
W
k
12 eek
(s
11
es
si
on
7)
W
ee
k
13
W
ee
k
W
14
ee
W
k
16 eek
(s
15
es
si
on
8)
Number of appearances per week
Frequency of John per week
30
25
20
15
10
5
0
Week (session)
As
W
se
ee
ss
k
m
1
en
W
(s
es
t
ee
si
k
on
2
(s
W
es 1)
ee
si
k
on
3
(s
W
es 2)
ee
si
k
on
4
W
(c
an 3)
ee
ce
k
5
lle
W
(s
d)
e
ee
s
si
k
on
6
(s
W
es 4)
ee
si
k
on
7
W
(c
an 5)
ee
ce
k
8
lle
(s
d)
es
si
on
6)
W
W
ee
ee
k
k
9
10
(D
N
W
ee
W A)
k
12 eek
11
(s
es
sio
n
7)
W
ee
k
13
W
ee
k
W
14
ee
W
k
16 eek
15
(s
es
sio
n
8)
Minutes
Average duration of John per week
70
60
50
40
30
20
10
0
Week (session)
Sandy:
Conclusion

Wants to spread remaining 4 sessions out over the
next year. Pleased he can contact us if any
problems in the meantime.
– ‘I’m 99.1% confident I can sort it out on my own’
– ‘I’ll read the information and listen to the therapy tapes’

He perhaps still has some anxiety but encouraging
a ‘so what’ approach to reappearance of
experience.