Can CBT make a meaningful contribution in the treatment of schizophrenia, bipolar disorder and severe personality disorders?
Cognitive behavioural therapy (CBT) for psychosis focuses on altering the thoughts, emotions, and behaviours of patients by teaching them skills to challenge and modify beliefs about delusions and hallucinations, to engage in experimental reality testing, and to develop better coping strategies for the management of hallucinations. The goals of these interventions are to decrease the conviction of delusional beliefs, and hence their severity, and to promote more effective coping and reductions in distress. This essay will attempt to assess the contribution of CBT to each of the disorders in turn by discussing reviews on efficacy, long term effects, compliance and cost, and then compare the outcome of CBT with alternative form of drug and therapy treatments.
Schizophrenia usually involves a dramatic disturbance in thoughts and feelings and results in behaviour that may seem odd to other people. Some people hear voices, others see things which are not there, or feel they are being persecuted. Some people only experience one episode of psychosis and some recover from schizophrenia. Over the past ten years the use of CBT for treating schizophrenia has been extensively studied. Much informative research has been conducted using the empirical approach of meta-analysis, which allows one summarizing the results of multiple studies.
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Turkington, Kingdon & Chadwick (2003) found that CBT has been has been effective in treating the positive and negative symptoms of schizophrenia. They note that residual symptoms have mostly improved after adult patients received an average of 20 sessions over 9 months, but are cautious in offering CBT to treat ‘first-episode schizophrenia, acute relapse, forensic patients with psychosis or those with co-morbidity such as substance misuse, personality disorder or learning disability, nor for psychosis in adolescence and old age' as these areas have not been adequately investigated. This shows that CBT has started to make a positive contribution to treating schizophrenia but vast amounts of research need to be conducted before its safe to use in all cases, which currently limits its contribution to treatments.
Their findings are useful for the assessment of CBT, as not all studies have commented on the difference in positive symptoms after treatment. The question of whether CBT was found to be significantly beneficial because of its own merits or merely therapist contact, still remains, a factor which could have confounded the results. The study also doesn't inform us about the benefits of CBT compared to other therapies, which is necessary for a thorough investigation.
Rector and Beck (2001) note that the effect of CBT on the secondary aspects of schizophrenia, such as anxiety or depression has not been investigated. This is a weakness in CBT efficacy research, because affective states have been round to maintain schizophrenic symptoms and constitute a risk of relapse and suicide, Siris (1995), so effects of CBT on these states undoubtedly should be addressed. One report on this has come from Senksy et al (2000) who found patient depression levels to be greatly reduced after CBT treatment.
CBT has been found to be useful not just in treating patients, but in insuring they continue with their long term medication. This was found by Kemp et al (1996, 1998). This could have a huge impact on the treatment of schizophrenia because there is a problem of low compliance with all existing treatments for schizophrenia so even if this is a side affect of CBT, it's still useful. However it may not be economically validated to have CBT for this reason alone.
All this research is futile if CBT would be too expensive to administer on a large scale. Healey, Knapp, Astin, Beecham, Kemp, Kirov & David (1998) found CBT to be cost effective compared to other treatments, and Kuipers and colleagues (1998) have pointed to the cost-effectiveness of CBT for schizophrenia in the context of the socialized National Health Service, all evidence supporting CBT to be a practical form of treatment. Turkington et al (2002) found to be effective in realistic community settings as well as more tightly controlled randomized trails and appear to translate to clinical practice.
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A new study by Valmaggia, Van Der Gaag, Tarrier, Pijnenborg, Slooff (2005) suggests that cognitive behavioural therapy may not be as effective as previously documented in treating schizophrenia. They argue that CBT is only effective in treating the positive symptoms of schizophrenia. The initial post-treatment assessment showed that patients had improved in terms of auditory hallucinations and how aware they were of their illness, and the study documents that CBT does help while in treatment, but improvements faded after an initial 6 month period. Clearly this needs to be further investigated.
Dickerson (2000) compared CBT with other non-specific psychology interventions in 20 studies and found the effects of CBT to be of lower significance when controlled for therapy time. Although previous research has shown CBT to be affective compared to routine care, more research is needed to compare it to other therapies.
There is now strong evidence and clinical support for the implementation of CBT as part of the standard management of patients with residual symptoms of schizophrenia. Antipsychotic drugs have undesirable side affects which may be the cause of low compliance rate (Healy et al, 1998). CBT offers an alternative approach which allows for the personal growth of patients as well as illness management. Further investigation into the efficacy of CBT is still required, as well as impact on relapse rates and quality of life. The results of Valmaggia et al (2005) still needs to be addressed to ensure that CBT has positive long term affects and that it works on both positive and negative symptoms.
Bipolar disorder, previously known as manic-depressive illness, and is most commonly diagnosed in persons between 18 and 24 years of age. It's characterized by moods that swing between two opposite poles. People who suffer from this disorder experience episodes of depression and periods of mania (with exaggerated euphoria, irritability, or both). Bipolar disorder is frequently associated with co-morbid conditions including substance abuse and anxiety disorders. Although chemical imbalances in the brain are a key component of bipolar disorder, it is said to be a complex condition that involves a mixture of factors, which could be reflected in appropriate treatment.
Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. Cognitive behavioural therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviours associated with the illness. It was recently thought by Winter (1994) that bipolar disorder patients were incompatible with individual psychotherapies due to concerns that uncontrolled manic or psychotic disorders with associated impulsive, disruptive or uncooperative behaviours were incompatible with ration discussion, self assessment and learning.
Cochran (1984) investigated the efficacy of routine care when supplemented by CBT in treating bipolar disorder in 14 randomly selected patients, compared to 14 patients just receiving routine care. He assessed patients after 3 and 6 months and found CBT-treated patients to have lower rates of medication non-adherence and lower rates of hospitalization compared to controls. Zaretsky, Segal, Gemar (1999) evaluated the effects of CBT combined with medication and just medication, following CBT patients sustained a 64% reduction in measures of depressive symptoms, how ever improvements in dysfunctional thinking proved insignificant.
Lam, Bright, Jones, Hayward, Schuck, Chisolm et al (2001) recently compared 12 patients who received CBT and routine care to 11 patients who received routine care alone, both for 6 months. They found at the end of the 12 month follow up period, patients receiving CBT to report “fewer recurrent episodes, greater affective stability and improved overall functioning and better compliance with prescribed medication.” The studies brought down do show a mix of findings. On the whole they indicate CBT to have a significant improvement on treatment compliance by the patient but not on all aspects of patient well being.
This was reflected in a summary of recent psychotherapy treatment by Blagys and Hilsenroth (2002) who found the relationship between CBT and patient outcome has yielded discrepant results. While some authors have demonstrated a favourable relationship between specific CB processes and patient improvement (Feeley, DeRubeis, Gelfand, 1999; Tang and DeRubeis, 1999; Tang and Whisman, 1993) whilst other researchers have reported a lack of (or negative) relationship between specific CBT interventions and outcome.
This essay needs to address whether CBT specifically performed any better then the other psychotherapies mentioned in order to understand its contribution to treatment. Sullivan (2005) comments that psychotherapy by itself regardless of whether its cognitive, behavioural, or psychodynamic, has not been proven effective in the treatment of bipolar affective disorder.He attributes this to the fact that bipolar is of biochemical etiology, requiring the use of medication to stabilize the basic mood disorder. Sullivan (2005) notes that there is often unsatisfactory response to medication alone. That's why psychotherapy is a useful adjunctive treatment and helps bipolar sufferers to understand their illness and the stresses of their everyday lives that may trigger an episode. It will also help restore lost self esteem and teach ways to prevent relapses.
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However, Shwartz and Frank (2001) found psychotherapy to be marginally favoured over antidepressant medication as a strategy in treating bipolar disorder. They claim that with the exception of CBT, there are no descriptions of psychotherapies employed specifically for the treatment of bipolar depression.
Even so, lithium is considered first line of treatment as its effective for 60-67% of patients. It does come with considerable side affects which could be a factor in the 75% non compliant over a year, which predicts rehospitalisation and suicidality. Many reports (Baldessarini, Tondo, 1998; Maj, Pirozzi, Magliano, Bartoli, 1998) have highlighted other disadvantages in the lithium treatment. They found patients to have low tolerance, to report unsatisfactory outcomes in clinical settings and the early recurrence of bipolar after rapid discontinuation.
Severe Personality Disorder
Personality disorders are chronic psychological disorders, which exist on a continuum so they can be mild to more severe in terms of how pervasive and to what extent a person exhibits the features of a particular personality disorder. There are ten different types of personality disorders that exist, which all have various emphases on several distinct psychological features. These include disturbances in self-image, the ability to have successful interpersonal relationships, appropriateness of range of emotion, ways of perceiving themselves, others, and the world; and difficulty possessing proper impulse control. These disturbances come together to create a pervasive pattern of behavior and inner experience that is quite different to what is considered ‘normal'.
Fisher & Bentley (1996) conducted a small study comparing the “disease and-recovery model” and CBT to each other and with a no treatment control on patients with severe personality disorders. Treatments were 3 times a week over 12 weeks. Within the inpatient sample, the study found no significant changes, with the exception of social and family relations. In the outpatient sample, the change was significantly greater in both treatment groups when compared to the control group. However it was found that patients also benefited significantly more from the CBT based group on measures of alcohol use, social and family relations and psychological functioning.
Alden & Capreol (1993) carried out a randomised study of three different cognitive-based group
treatments for avoidant personality disorders with differing types of interpersonal problems. They concluded that the kinds of interpersonal problems experienced by patients affect their response to different types of treatment and that the specific pattern of interpersonal difficulties should be routinely taken into consideration when patients are being allocated to different treatments. The authors did caution against making assumptions about the findings because of the retrospective nature of the study and the selected nature of the sample, which may mean that results may not replicate to other samples of antisocial personality disorder.
Dolan and Coid (1993) concluded that there was only limited evidence for the long-term efficacy of CBT programmes alone for treating psychopathic disorders in adults although Valliant and Antonowicz (1991) notes that some change was seen after completion of young offenders programme, for patients whose personality disorder status was not specified. Cohen and Filipczak (1971) did not find improvement after CBT treatment to be maintained over the long term.
Stein (1992) reviewed drug treatment literature for severe personality disorders and concluded that small doses of neuroleptics might be beneficial for those with BPD and schizotypal personality disorder. However this is yet to be directly compared with CBT in a controlled study. Dolan and Coid (1993) also noted that carbamazepine had been shown to improve the patient's impulse control irrespective of the personality disorder diagnosis. They suggested its use should be targeted at specific symptoms and behaviours rather than prescribed as a general treatment for any specific personality disorder.
In a Home Office review of treatments for severe personality disorder conducted by Warren et al (2003), they identified 40 studies of CBT, and said they there was little evidence of the efficacy of CBT with either psychopathic or anti-social personality disordered patients or for those with other PD diagnoses held within high security. The authors note that some evidence is available in non-secure and community settings suggesting that CBT can reduce levels of self-harm in women with BPD. Additionally some reduction in alcohol abuse has been demonstrated following outpatient CBT for those with anti-social personality disorder.
However the vast majority of these were studies of women in outpatient settings so evidence can't be generalised to all situations. Most of the CBT were of short-term treatments aimed at a specific aspect of behaviour or attitude (such as aggression, self-harming or social skills) and which do not claim to treat the core disorder of personality.
It appears that there are too few studies on each type of personality disorder to make a meaningful analysis of the effectiveness of CBT on each. This may stem from inadequate scales of measurement and improvement of personality disorders. The evidence that was cited in this essay is still inconsistent, and has many methodological flaws, so conclusions can not yet be made. It seems that they most recent review of the Home Office by Warren et al (2003) has gone into much depth reviewing past literature, so the best I can do is follow the same line of thought that CBT has little of limited efficacy in treated severe personality disorders.
The general conclusion for this essay is that CBT seems to have made a meaningful contribution mostly in the treatment of schizophrenia but also in the treatment of bipolar disorder. From a literature review it is evident that much more research is required especially with regards to the long term effect of CBT and comparisons with other psychosocial treatments. It is also evident that both these disorders are treated most effectively when used alongside drug treatments. Rosenhan and Seligman (1995) found Depression best treated with CBT, electro convulsive therapy and medicated drugs, whilst they found to be schizophrenia best treated with drugs and family intervention therapy.
In relation to severe personality disorder there is little evidence to suggest the effectiveness of CBT, but this might change with third wave variations that could be tailored for each condition. It is suggested that each therapy works best with a particular set of problems which is why it's hard to compare the effectiveness of CBT on the different variations of personality disorders.
Wampold (2001) found the variance of effectiveness of treatment is more due to therapist than it is due to treatment and comments that “a person with a need of psychotherapy should seek the most competent therapist possible without regard for various therapies”. In general CBT has started to make a meaningful contribution in the treatment of Schizophrenia and Depression, but the evidence is less compelling in the case for severe personality disorders.