Schizophrenia is a very disabling psychiatric illness affecting about 2 to 3 million Americans. Contrary to popular perception, it has nothing to do with a “split personality.” Schizophrenia is a chronic brain disorder involving “positive” and “negative” symptoms. Positive symptoms include hallucinations (hearing voices or seeing visions that aren’t real), delusions (fixed false beliefs), and disorganized thinking or speech. People suffering from active positive symptoms often respond to those symptoms in ways that are obvious to others around them (e.g., agitation, disorganization). Negative symptoms include marked decreases in a person’s social interactions, communication, and motivation, and are associated with cognitive dysfunction, including how a person organizes and retrieves information. Positive symptoms may fluctuate over time; negative symptoms tend to be more chronic and pervasive. Positive symptoms may improve, sometimes dramatically, when a person is treated with antipsychotic medications. Negative symptoms often do not respond to these medications.
These positive and negative symptoms make it difficult for a person with schizophrenia to establish and maintain relationships, work productively, and interact socially. Cost factors can be a barrier in obtaining treatment, and the disordered thinking that is part of this illness may make it difficult for a person to understand that their thinking is abnormal and to follow treatment recommendations. Sometimes, people with schizophrenia abuse street drugs. When substance dependence develops in a person with schizophrenia, effective treatment is even more difficult.
A recent study in the Archives of General Psychiatry by Paul Grant, Aaron Beck, and their colleagues found that a modified version of cognitive-behavioral therapy (CBT), a specific type of talk therapy, can produce clinically significant improvement in patients with schizophrenia. Importantly, significant improvement was seen in certain negative symptoms—apathy/avolition (lack of drive)—as well as in positive symptoms. These results are impressive, especially considering that the participants had been ill for an average of 18 years and suffered from severe symptoms. In this study, study participants were divided into two groups. One group received CBT in addition to “standard treatment,” which included treatment with antipsychotic medications. The other group received standard treatment alone.
CBT has been shown to be effective in a variety of psychiatric illnesses. It uses pragmatic techniques to help a person correct inaccurate or dysfunctional thoughts and emotions by promoting critical comparison of those thoughts with observable facts. For example, if a person believes that he/she is “doing absolutely nothing,” one CBT technique would be to encourage the person to keep a detailed diary of daily activities. The therapist would later review this diary with the patient and facts would be compared to perceptions. Homework assignments would include strategies to increase productive activities.
In the study mentioned above, the researchers focused CBT “on identifying and promoting concrete goals for improving quality of life and reintegration into society.” Therapy sessions utilized a variety of specifically designed activities, and patients were given assignments to complete between sessions (homework). On average, the research patients participated in about 50 sessions over 18 months, each lasting 50 minutes. Although the patients and therapists knew whether the patient was receiving CBT, the members of the research team measuring outcomes were unaware of the participant’s treatment group. In fact, when these researchers were asked to guess which treatment group a person was in, they couldn’t tell, i.e., they were correct only half the time.
In our opinion, this is a very important study because it demonstrates that a specific type of talk therapy can be effective in helping the most difficult symptoms of schizophrenia. While this study requires replication by other investigators, we believe it is likely that CBT techniques help the brain “learn” and that this learning may result in rewiring the brain in a manner that corrects or by-passes brain circuits that are not functioning correctly due to the underlying illness. A key feature of CBT may be its emphasis on refocusing attention from automatic and non-productive negative thoughts to more effective and appropriate ways of thinking and behaving. In effect, this may be a form of cognitive rehabilitation that helps to correct defects in attention and working memory.
Importantly, the need for this type of cognitive restructuring is not unique to schizophrenia; it cuts across psychiatric disorders and may contribute to the effectiveness of CBT in depression, anxiety disorders, and personality disorders, among others. In our view, CBT may alter defects in information processing that are common to a range of psychiatric disorders. There are many types of psychotherapies, but only a few, such as CBT, are supported by evidence from carefully performed research showing that the treatment works better than the important, but non-specific, effects of talking with and listening to a caring therapist.
Utilizing several different treatment approaches in combination can sometimes have additive effects. Some studies have demonstrated that combining CBT with pharmacotherapy (medication treatment) can lead to more improvement than either treatment alone. Whenever possible, the decision to combine treatments should be based on clinical evidence. Far too often, physicians combine a variety of medications without evidence that such combinations do more good than harm. We are optimistic that combining evidence-based talk therapies with evidence-based medication treatments will result in better and longer lasting outcomes. On the other hand, treating a patient with several antidepressants together with several mood stabilizers, antipsychotics, and anti-anxiety agents may do more harm than good.
An advantage of evidenced-based psychotherapies like CBT is that they can be performed by trained individuals who are not physicians. Care of people with severe psychiatric illnesses benefits from teams of mental health professionals that include psychiatrists, psychologists, social workers, and therapists. Such team approaches allow effective treatments to reach more patients in a fiscally responsible manner. We strongly encourage team approaches and believe it is critical for therapists to use the most up-to-date evidenced-based psychotherapies.
This column was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD.