1 Psychotherapy in Psychotic disorders: Principles and practice of Personal therapy Matcheri S Keshavan MD Harvard Medical School, and University of Pittsburgh NIMH MH 60902, and ; Disclosures: Sunovion, Otsuka

2 Psychosocial treatments in schizophrenia: a historical overviewDisorder relevant interventions SST Personal therapy Tandon, Nasrallah and Keshavan Schiz Res 2010

3 Psychoanalytic therapy is largely ineffectiveEffects of psychotherapy in schizophrenia: II. Comparative outcome of two forms of treatment. Gunderson et al Schiz Bull 1984;10(4): Psychoanalytic therapy is largely ineffective

4 Major role therapy: -Psychotherapy (if used alone) is ineffectiveHogarty et al 1974

5 Family therapy reduces relapse rates

6 Multi-family therapy is effective in maintaining remissionMcFarlane et al 1995

7 Psychoeducation may prevent relapse

8 Key aspects of schizophrenia relevant for personal therapy: Schizophrenia is..A disease of Brain Development A disease of risk and diathesis (Zubin: Environmental stress- Biological vulnerability model) A disease of stages A disease of affect as well as cognition.

9 Schizophrenia is related to the normal pruning of gray matter going haywire

10 Gray matter loss might heighten stress responsivity (Zubin)

11 Schizophrenia is a Cognitive and an affective disorderPervasive cognitive deficits Speed Memory Attention Reasoning Tact Synthesis Affect (the “affective paradox”) Decreased expression Increased arousal Impaired regulation

12 Stress induced relapsesAffective symptoms (40-50 %) Depression Anxiety Stress induced relapses Cognitive (80-90%) Working memory Selective attention Positive symptoms (40-50 %) Hallucinations Delusions Loose associations Functional Impairment Cognitive impairment Strongly predicts Functional outcome Negative symptoms (60-70 %) Avolition Anhedonia Anergia Asociality Alogia

13 Schizophrenia is a disorder of stagesRecovery Prodromal Transitional Premorbid Psychotic Premorbid alterations Decline begins in prodrome Post-illness onset Functional decline Psychosis Typically begins in adolescence Psychosis is actually a “late” stage of schizophrenia!

14 Denial/ non-compliancePsychological aspects of schizophrenia vary with the phase of the illness and can be prevented/minimized. Prevention/early intervention Stabilization/ relapse prevention Remediation Integration Personal therapy Recovery Prodromal Transitional Premorbid Psychotic Psychosis Denial/ non-compliance Stress sensitivity, Depression/ anxiety Social incompetence Cognitive impairment

15 Keshavan and Eack, 2014. in: Treatment of Psychiatric Toward second- generation, disorder-relevant Psychotherapies for schizophrenia Psychoanalytic Reality-adaptive therapy (Gunderson), Major role therapy (Hogarty) Psychoeducation (Dixon) Family psychoeducation (Leff) Social skills training (Liberman) Cognitive Behavioral treatments Personal therapy (Hogarty) Cognitive enhancement therapy Hogarty, Flesher, Eack, Keshavan Faulty defenses, regression to earlier developmental stages Early case management and supportiive help Increasing illness awareness Primary environmental stress modification Correcting maladaptive behavioral excesses or deficits Correcting faulty cognitive schemata Recognition, self monitoring and adaptive control of psychotic prodromes Systematic rebuilding of cognitive and social cognitive abilities Keshavan and Eack, in: Treatment of Psychiatric Disorders, Gabbard G. Ed. American Psychiatric Press.

16 Psychotherapeutic interventions in schizophrenia: effect sizes in meta-analyses . Treatment modality Most commonly reported outcome variable Effect size (Hedge’s g) References Psychoeducation Relapse (2 years) .Moderate Pharo, Pilling, Pischall-Waltz Lincoln Cognitive Behavior Therapy (CBT) Positive symptoms Relapse rates Tarrier, Zimmerman, Lynch Family psychoeducation Relapse Pfammater et al 2006 Social skills training Skill acquisition Community functioning .Moderate- High Benton and Schroeder, Corrigan Kurtz and Mueser

17 Key principles of Enriched supportive therapy (Personal therapy)Integrated composite of CBT, psychoeducation and basic social skills training principles Disorder relevant practice principles Gradual staging of interventions Centrality of affect dys-regulation

18 Hogarty et al 1995

19 Personal therapy Goals: Phase 1 (3-6 months):Illness education Goal setting and progression Internal coping Basic stress avoidance skills Hogarty et al 1995

20 Psychoeducation Schizophrenia as a “no-fault” brain disorderTailored to individual’s illness stage and ability to process Correcting mis-information (e.g. that it is a split-mind disorder, that it is incurable, etc) Initially provided in a formal educational workshop followed by individual sessions Teaching pathophysiology (e.g. dopamine imbalance) as connected to treatments (e.g. antipsychotic medications) Emphasis on risk- liability models (e.g. asthma, high blood pressure) Some repetition is good; emphasize interaction

21 Resumption of daily tasksGoal setting: Start from basic steps ( Focus on self care personal hygeine, nutrition, sleep) Set up reasonable goals: “Internal yardstick” approach Expectations to be adjusted to clinical state Connect small goals to larger, long term goals Expect set-backs; “ one step back and 2 steps forward rule) How do I measure Up to myself, then and now? How do I measure Up to them?

22 Internal Coping Understanding schizophrenia as an environmentally sensitive psychobiological illness Identification of what patient means by “distress”, in his own words Identifying the interpersonal context or life event with which he/she associates this distress Identification of internal cues of affect dys-regulation (prodromal signs) Identification of patient’s existing autoprotective strategies to cope with stress (helpful as well as unhelpful) Stress avoidance skills: Reinforcing prosocial statements; “one thing at a time”

23 Early or Warning Signs of PsychosisBehavioral Strange posturing Odd or bizarre behavior Excessive writing without meaning Cutting oneself; threats of self-mutilation Deterioration of personal hygiene Hyperactivity or inactivityStaring Agitation Sleep disturbances Drug or alcohol abuse (This may be a coping mechanism: self-medicating) Thinking and Speech “Things seem changed in some way” Rapid speech that is difficult to interrupt Irrational statements Preoccupation with religion or occult Peculiar use of words or odd language Unusual sensitivity to stimuli (noise, light, colours, textures) Memory problems Severe distractibility  Social Sensitivity and irritability when touched by others Refusal to touch persons or objects; wearing gloves, etc. Severe deterioration of social relationships Dropping out of activities - or out of life in general Social withdrawal, isolation, and reclusive Unexpected aggression Suspiciousness  Emotional Inappropriate laughter Inability to cry, or excessive crying Feelings of depression and anxiety Inability to express joy Euphoric mood Personality Reckless behaviours that are out of character Significantly prolonged drops in motivation or speech Shift in basic personality. Herz and Melville 1985

24 Reinforcing adaptive auto-protective strategiesMaladaptive Passive distraction (e.g. radio or TV) Active distraction (reading, writing) Change in environment (e.g. going for a walk) Supportive contact (calling family, friends) Exercise Calling therapist Alcohol/ drugs Excessive sleep Smoking Social withdrawal Excessive praying Self-protective measures (e.g. sleeping with a weapon)

25 Basic stress avoidance skillsRole restructuring (e.g. reduce class load, cut down on extracurricular activities Conflict avoidance Avoiding behaviors that evince negative reactions from others Taking breaks Positive assertions Complements Positive self statements Role play and Homework for all above goals

26 Personal therapy: stages (contd)Phase II (intermediate; months) Continued psychoeducation (goal: self- awareness; recognition of prodromal signs of relapse Acquisition of adaptive techniques: Relaxation training; guided imagery/ music; active distraction techniques; basic conflict resolution skills Hogarty et al 1995

27 Intermediate phase of PT: GoalsMaintenance and enhancement of clinical stability Managing comorbidity- depression, anxiety, substance abuse Minimizing side effects Achieving minimal effective dose Monitoring and addressing suicidality Personalized crafting of psychoeducation 20-30 minute interactive sessions on cues of distress, incremental conflict avoidance skills, concepts of disability and adjustment to it Increasing resumption of responsibilities within home Adjustment to disability

28 Resumption of household responsibilitiesGo with patient’s own choice Simple, relevant, feasible, compatible with clinical state Avoid unreasonable expectations Consider cooperative sharing with another family member Progressive increase in complexity Consider timing (maximize at times of highest enegy) Revisit stress- vulnerability model regularly

29 Adjustment to disabilityExclusive strengths based approach may be counterproductive Address denial, “Flight to normalcy” Learning what to say and not say about one’s illness

30 Other techniques Deep breathing and simple relaxation Visual imageryCriticism management

31 PT advanced phase (Interfaces and overlaps with Cognitive enhancement therapy 19- 36 months)Psychoeducation with a greater emphasis placed on the refined assessment of genuine, individual prodromes. Addressing social and cognitive deficits, “one step at a time” Managing Criticism, an assessment of its validity, learning a repertoire of verbal and behavioral responses designed to lessen the other person's intensity and to enhance the patient's social perception and negotiation skills Advanced internal coping strategies include progressive relaxation training, which is designed to reduce autonomic arousal. Independent application of various PT strategies in differing social contexts,

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33 Conclusions Schizophrenia is a developmental disorder of affect, behavior and cognition Schizophrenia sequentially evolves with prodromal and psychotic phases Characterized by psychosis and affective dysregulation, followed by a transitional phase with recurrent relapses before finally a stable, chronic phase sets in, primarily with cognitive and negative symptoms Treatment is best tailored to the aspects of illness prominently manifesting at the specific phases of the illness Personal therapy is designed as a compehensive, step-wise approach to early phases of schizophrenia, involving psychoeducation, stress management and development of coping skills, setting a stage for rehabilitative approaches such as cognitive remediation