Cognitive Therapy cognitive therapy for prevention
and treatment of psychosis:
a research update and clinical workshop
Tony Morrison
Division of Clinical Psychology, University of
Manchester
& Psychosis Research Unit, GMWMHT
Objectives
• Outline UHR and Psychosis
• Cognitive approach to understanding psychosis
• Application of CT to people with distressing
psychotic experiences (UHR, FEP and beyond)
• Formulation
• Normalisation
• Strategies for common difficulties
• Case illustrations, exercises, videos
• Evidence base
Psychosis ‘prodrome’
• A period of months to years prior to the
onset of Psychosis (assessed retrospectively)
• Progressive symptoms/signs
•
•
•
•
Mood
Thinking
Behaviour
Cognitive functions
• Reduction in ability to function
Onset of psychosis
First
psychotic Build up
symptom
Prodrome
Emergence
of
psychosis
Why is early detection important?
• If psychosis is detected early, many problems can be
prevented and functioning can be restored.
• The earlier the problems are treated, the greater the
chance of a successful recovery.
• Onset is often in a critical stage of a young person’s life.
Adolescents and young adults are just starting to develop
their own identity, form lasting relationships, and make
plans for the future.
• People are help seeking and distressed.
Ultra High Risk Criteria
Original PACE criteria (Yung et al. 1996)
 Age between 14 and 30 years
AND
 Family history of DSM-IV psychotic disorder and reduction on
GAF scale of ≥ 30
AND/OR
 Attenuated symptoms, occurring several times during the
week for at least one week
AND/OR
 Brief, limited or intermittent psychotic symptoms (BLIPS) for
less than one week and resolving spontaneously
Modified criteria now assessed using CAARMS
Identification Study at PACE
Yung et al 1998 British Journal of Psychiatry
25
40% made
transition at six
months, 50% at
one year
20
Number
not
psychotic
15
10
5
0
0 1 2 3 4 5 6
Months of assessment
Intervention Study at PACE:
The prevention of psychosis
McGorry et al 2002 Archives of General Psychiatry
40 %
35 %
30 %
% making transition
to psychosis
25 %
Needs based Tx
20 %
Specific
interventions
15 %
10 %
5%
0%
6
12
Months
PRIME Study: Olanzapine versus placebo
McGlashan et al. 2006 American Journal of Psychiatry
40
35
30
37.9
25
20
16.1
15
10
5
0
Transition %
20
18
16
14
12
10
8
6
4
2
0
*
19
Olanzapine
Placebo
1
Average
Weight Gain lb
Early Detection: Problems
• Ethics of interventions in pre-psychotic phase
• Solution:
– employ interventions with minimal risks / side effects
– employ interventions that will be useful to those who
will never become psychotic
– informed choice
• Balancing the costs and benefits of treatment must be
weighted in some way according to the ratio of people
actually helped to those unnecessarily treated
• Psychosis is not necessarily dreadful
• Prediction not very accurate (e.g. 60% false positives)
• Side effects of medication (and can be fatal)
– atypicals commonly produce weight gain and sexual dysfunction;
diabetes; cardiovascular problems
• Effects of medication on developing brain unknown
Caveats
• Distressing psychosis
• Indisputable that antipsychotics help some
people a great deal
• Not anti-antipsychotics, but anti overreliance (or exclusive reliance) on
antipsychotics and lack of patient choice
Antipsychotics Oversold?
• “Risperidone may well help people with
schizophrenia, but the data in this review are
unconvincing. People with schizophrenia or their
advocates may want to lobby regulatory
authorities to insist on better studies being
available before wide release of a compound
with the subsequent beguiling advertising.
People given risperidone may wish to negotiate
on length of prescription, ask about adverse
effects, and help generate better evidence than
currently exists.” (Rattehalli et al., 2010, p.18).
Aripiprazole 10mg/day or 30mg/day Versus
Placebo: PANSS Change in acute psychosis
Antipsychotic-Induced Weight Gain in Chronic and FirstEpisode Psychotic Disorders:
A Systematic Critical Reappraisal
20
Chronic RCT
FEP
Chronic RCT
3 kg
15
4 kg
kg 10
12 kg
5
0
12
24
Months
36
Alvarez-Jimenez et al; CNS Drugs, 2008
48
The British Journal of Psychiatry 2010
196, 116–121. doi: 10.1192/bjp.bp.109.067512
Twenty-five year mortality of a community
cohort with schizophrenia
Steve Brown, Miranda Kim, Clemence Mitchell and Hazel
Inskip
Conclusions
People with schizophrenia have a mortality risk that is two to three times
that of the general population. Most of the extra deaths are from natural
causes.
The apparent increase in cardiovascular mortality relative to the general
population should be of concern to anyone with an interest in mental health.
The most clinically useful intervention is probably to try to help people with
schizophrenia stop smoking, to promote exercise and to facilitate effective
health screening
.