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

Prodrome

First psychotic symptom

Build up

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 CriteriaOriginal 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 ≥ 30AND/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 PACEYung et al 1998 British Journal of Psychiatry

0

5

10

15

20

25

0 1 2 3 4 5 6Months of assessment

Number notpsychotic

40% made transition at sixmonths, 50% atone year

Intervention Study at PACE:The prevention of psychosis

McGorry et al 2002 Archives of General Psychiatry

0 %

5 %

10 %

15 %

20 %

25 %

30 %

35 %

40 %

6 12

Needs based Tx

Specificinterventions

Months

% making transitionto psychosis

PRIME Study: Olanzapine versus placeboMcGlashan et al. 2006 American Journal of Psychiatry

19

102468

101214161820

AverageWeight Gain lb

Olanzapine

Placebo

16.1

37.9

05

10152025303540

Transition %

*

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 over-

reliance (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

kg

Months 12 24 0 4836

Chronic RCT Chronic RCT

10

5

20

15

12 kg

4 kg

3 kg

Alvarez-Jimenez et al; CNS Drugs, 2008

Antipsychotic-Induced Weight Gain in Chronic and First-Episode Psychotic Disorders: A Systematic Critical Reappraisal

FEP

The British Journal of Psychiatry 2010 196, 116–121. doi: 10.1192/bjp.bp.109.067512Twenty-five year mortality of a community

cohort with schizophreniaSteve Brown, Miranda Kim, Clemence Mitchell and Hazel

InskipConclusionsPeople 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.