Symptom - Specific Group Therapy for Inpatients with Schizophre n i a

The efficacy of cognitive interventions was compared to standard treatment in medicated chronic schizophrenic inpatients. Clinical symptoms of 25 patients were assessed using the Positive and Negative Syndrome Scale (PANSS). Problem symptoms were matched to appropriate treatment groups including: ‘attitudes’ (simple introductory cognitive concepts), positive symptoms, negative symptoms, attention, affective regulation, substance abuse and ‘boundaries’. Patients received 3-5 sessions of group per week (total of 50-100 sessions), then were reassessed on the PANSS. Compared to the control group of 23 patients, whose PANSS scores did not change from the baseline, patients receiving cognitive interventions showed a 22% decrease (from 83 to 65) in total symptom severity on the PANSS over 6 months. The improvement occurred for the positive, negative and general symptom scales of the PANSS, as well as for 4 out of 5 factors: negative symptoms, dysphoric mood, activation and autistic preoccupation, but not for positive symptoms. The results suggest that the program is effective for medicated inpatients with symptoms in the mild to moderate range on the PANSS. It is essential, however, to confirm these findings with a rigorously controlled experimental study, as well as to include patients with symptoms outside the mild-moderate range. Schizophrenia is a severe neuropsychiatric condition (Shelley et al., 1996, 1999). Although its exact etiopathology remains unknown, it is now recognized that pharmacotherapy is necSymptom-Specific Group Therapy for Inpatients with Schizophre n i a Einstein Quarterly Journal of Biology and Medicine (2001) 18:21-28 Cognitive Interventions in Schizophrenia 22 One criticism of CBT in schizophrenia has been that evaluations are mainly case studies and uncontrolled trials. Several controlled trials have now been published on the use of CBT for schizophrenia (Kuipers et al., 1997), as a means of improving treatment adherence (Lecompte and Pelc, 1996; Kemp et al., 1996), as an adjunctive treatment for inpatients admitted for short-term treatment (Drury et al., 1996) and for psychotic symptoms unresponsive to medication (Kuipers et al., 1997; Tarrier et al., 1993; 1998). Tarrier et al. (1998), for example, conducted a randomized controlled trial of intensive CBT. Patients were randomly allocated to an intensive CBT group (20 hours over 10 weeks in which patients were taught coping strategy enhancement, problem solving and techniques for relapse reduction), to a supportive counseling group (in which patients were given the same number of sessions of standard non-cognitive therapy), or to a routine care only group. Assessments on the Brief Psychiatric Rating Scale (BPRS) showed a significant decrease in the severity (p=0.006) and number (p=0.009) of positive symptoms shown by patients receiving CBT. Supportive counseling was effective but to a far lesser extent. Another recent large-scale, well-controlled study has been the London-East Anglia randomized controlled trial of CBT for psychosis (Kuipers et al., 1997). Patients in the study were randomly allocated to either a CBT or a routine care condition. The CBT consisted of weekly treatment sessions aimed at improving coping strategies or developing new ones, modifying beliefs about delusions, hallucinations and dysfunctional schemas and management of social disability and relapse. Results indicated that, following a 9 month treatment period, the CBT group showed a 25% reduction in symptom severity on the BPRS, compared to the control group, who received only routine clinical care with no significant change in BPRS score (p=0.009) (Kuipers et al., 1997; Garety et al., 1997). Improvements in the CBT group were maintained 18 months after baseline (Kuipers et al., 1998), and several predictors for a good treatment response (cognitive flexibility and number of recent admissions) have been found (Garety et al., 1997). These findings suggest that CBT may be a specific and costeffective intervention in medication-resistant psychosis. Two other studies have also provided follow-up data on the efficacy of CBT (Kemp et al., 1998, Sensky et al., 2000). The results of these studies have been considered promising in the American Psychiatric Association guidelines (1997). For example, Sensky et al. (2000) demonstrated that both CBT and supportive therapy led to significant reductions in positive and negative symptoms and depression. But at 9-month follow-up, only the CBT group continued to improve. Given these promising developments, several programs have incorporated CBT techniques into their treatment of schizophrenic patients. These programs include Cognitive-Behavioral Educational Program for Schizophrenic Patients (CB/EPS) (Gallagher and Nazarian, 1996), coping strategy enhancement (CSE) (Tarrier et al., 1998), problem solving (PS) (Tarrier et al., 1998), Integrated Psychological Therapy (ITP) (Brenner et al., 1994) and Personal Therapy (Hogarty et al., 1991, 1995). With the increasing recognition of the need and potential benefit of techniques such as CBT, skills training, psycho-education and group therapy, we designed and implemented a symptomspecific cognitive-behavioral group treatment program on an inpatient ward of the Bronx Psychiatric Center (BPC). This was intended as an adjunctive form of treatment to the standard pharmacotherapy and other routine treatments received by patients of the hospital. Clearly, many excellent programs have been developed to address different aspects of schizophrenia and its treatment. One shortcoming of most previous programs has been that they are general, addressing mental illness broadly, rather than targeting the symptoms of schizophrenia specifically. Another is that schizophrenia presents with many profiles; some patients show predominantly positive symptoms, others mainly negative symptoms, still others have primarily attention problems or affective dysregulation, and some are mixed. Thus, we reasoned, it would be therapeutically advantageous to develop flexible programs that consist of a number of units or treatment modules that, in various combinations, can be tailored and applied to different symptom profiles. The ongoing task of treatment for schizophrenia is the design of programs that are symptom-specific and have the flexibility to address all the different symptom profiles of schizophrenia. These were the two major goals of our program design. To this end, we employed the Positive and Negative Syndrome Scale (PANSS) (Kay, et al., 1992) for both symptom assessment and the design of the different treatment units of the program that addressed each of the symptom clusters. The PANSS was developed and standardized for typological and dimensional assessment of the symptoms of schizophrenia (Kay et al., 1992). It is a 30-item, 7-point scale that measures the severity of symptom dimensions of schizophrenia based on a s e m i s t r u c t u red clinical interview and other informational sources. It has been widely employed in both clinical and research settings (Opler et al., 1994; Herman et al., 2000). The conceptual framework for the PANSS derives from the work of C row (1980a; 1980b) and Andreasen and Olsen (1982). Specifically, positive symptoms are viewed as active, disruptive processes, including delusions and hallucinations, that are superimposed on a normal mental state while negative symptoms are viewed as the absence of normal functions, including blunted affect and emotional withdrawal. The PANSS generates scores on three scales: positive symptoms (7 items), negative symptoms (7 items), and general psychopathology symptoms (16 items). Factor analytic studies have shown that the PANSS can be broken down into 5 factors: negative, positive, activation, dysphoric mood and autistic preoccupation (White et al., 1997). 23 Einstein Quarterly Journal of Biology and Medicine Innovative features of our program included: 1. Patients were assessed on symptom severity preand post-treatment using the PANSS (Kay et al., 1987; 1992; Opler and Ramirez, 1998). 2. Groups were designed to target and address specific symptom clusters of schizophrenia as identified by the PANSS—positive symptoms, negative symptoms, activation, dysphoria and preoccupation—and to teach patients coping strategies. 3. A group format was used to allow as many patients as possible to benefit. All interventions were delivered to groups of inpatients with schizophrenia. 4. The program used a specific type of cognitive-behavioral therapy: Rational Emotive Behavior Therapy (REBT) (Ellis, 1962), simplified and adapted for use with this type of severely mentally ill population. The program also used techniques modified from REBT group therapy (Ellis, 1997). These included cognitive techniques (such as psychoeducation, collaborative challenging of dysfunctional cognitions, learning coping statements), emotive techniques (such as role playing, humor and encouragement) and behavioral techniques (such as skills training and use of reinforcement). 5. The program incorporated additional treatment techniques (psychoeducation, skills training, social cognition and cognitive rehabilitation) that have been found to be useful and effective in targeting and treating symptoms of schizophrenia. We hypothesized that symptom severity as indexed by the PANSS would not differ between the 2 groups pre-treatment, but that the 2 groups would differ on PANSS scores post-treatment and on pre to post change scores. In addition, as both groups received similar pharmacological treatment and routine clinical care, but differed only with respect to the cognitive treatment program, differential changes in symptom severity were hypothesized to be attributable to the program.