Neural changes following cognitive behaviour therapy for psychosis: a longitudinal study

A growing body of evidence demonstrates that persistent positive symptoms, particularly delusions, can be improved by cognitive behaviour therapy for psychosis. Heightened perception and processing of threat are believed to constitute the genesis of delusions. The present study aimed to examine functional brain changes following cognitive behaviour therapy for psychosis. The study involved 56 outpatients with one or more persistent positive distressing symptoms of schizophrenia. Twenty-eight patients receiving cognitive behaviour therapy for psychosis for 6–8 months in addition to their usual treatment were matched with 28 patients receiving treatment as usual. Patients’ symptoms were assessed by a rater blind to treatment group, and they underwent functional magnetic resonance imaging during an affect processing task at baseline and end of treatment follow-up. The two groups were comparable at baseline in terms of clinical and demographic parameters and neural and behavioural responses to facial and control stimuli. The cognitive behaviour therapy for psychosis with treatment-as-usual group (22 subjects) showed significant clinical improvement compared with the treatment-as-usual group (16 subjects), which showed no change at follow-up. The cognitive behaviour therapy for psychosis with treatment-as-usual group, but not the treatment-as-usual group, showed decreased activation of the inferior frontal, insula, thalamus, putamen and occipital areas to fearful and angry expressions at treatment follow-up compared with baseline. Reduction of functional magnetic resonance imaging response during angry expressions correlated directly with symptom improvement. This study provides the first evidence that cognitive behaviour therapy for psychosis attenuates brain responses to threatening stimuli and suggests that cognitive behaviour therapy for psychosis may mediate symptom reduction by promoting processing of threats in a less distressing way

Association between a longer duration of illness, age and lower frontal lobe grey matter volume in schizophrenia

The frontal lobe has an extended maturation period and may be vulnerable to the long-term effects of schizophrenia. We tested this hypothesis by studying the relationship between duration of illness (DoI), grey matter (GM) and cerebro-spinal fluid (CSF) volume across the whole brain. Sixty-four patients with schizophrenia and 25 healthy controls underwent structural MRI scanning and neuropsychological assessment. We performed regression analyses in patients to examine the relationship between DoI and GM and CSF volumes across the whole brain, and correlations in controls between age and GM or CSF volume of the regions where GM or CSF volumes were associated with DoI in patients. Correlations were also performed between GM volume in the regions associated with DoI and neuropsychological performance. A longer DoI was associated with lower GM volume in the left dorsomedial prefrontal cortex (PFC), right middle frontal cortex, left fusiform gyrus (FG) and left cerebellum (lobule III). Additionally, age was inversely associated with GM volume in the left dorsomedial PFC in patients, and in the left FG and CSF excess near the left cerebellum in healthy controls. Greater GM volume in the left dorsomedial PFC was associated with better working memory, attention and psychomotor speed in patients. Our findings suggest that the right middle frontal cortex is particularly vulnerable to the long-term effect of schizophrenia illness whereas the dorsomedial PFC, FG and cerebellum are affected by both a long DoI and aging. The effect of illness chronicity on GM volume in the left dorsomedial PFC may be extended to brain structure–neuropsychological function relationships

Beyond Dopamine: Functional MRI Predictors of Responsiveness to Cognitive Behaviour Therapy for Psychosis

Despite the favourable effects of antipsychotics on positive symptoms of schizophrenia, many patients continue to suffer from distressing symptoms. Additional benefits of cognitive behaviour therapy for psychosis (CBTp) have been reported for approximately 50% of such patients. Given the role of left hemisphere-based language processes in responsiveness to CBT for depression, and language pathway abnormalities in psychosis, this study examined whether pre-therapy brain activity during a verbal monitoring task predicts CBTp responsiveness in schizophrenia. Fifty-two outpatients, stable on antipsychotics with at least one persistent distressing positive symptom and wishing to receive CBTp adjunctive to their treatment-as-usual, and 20 healthy participants underwent fMRI during monitoring of self- and externally-generated (normal and distorted) speech. Subsequently, 26 patients received CBTp for 6–8 months adjunctive to their treatment-as-usual (CBTp + TAU, 20 completers), and 26 continued with their treatment-as-usual (TAU-alone, 18 completers). Symptoms were assessed (blindly) at entry and follow-up. The CBTp + TAU and TAU-alone groups had comparable demographic characteristics, performance and baseline symptoms. Only the CBTp + TAU group showed improved symptoms at follow-up. CBTp responsiveness was associated with (i) greater left inferior frontal gyrus (IFG) activity during accurate monitoring, especially of own voice, (ii) less inferior parietal deactivation with own, relative to others’, voice, and (iii) less medial prefrontal deactivation and greater thalamic and precuneus activation during monitoring of distorted, relative to undistorted, voices. CBTp + TAU patients, on average, displayed left IFG and thalamic hypo-activation (<healthy participants). The findings implicate language processing (IFG), attention (thalamus), insight and self-awareness (medial prefrontal and parietal cortices) in CBTp responsiveness in schizophrenia

Orbitofrontal cortex, emotional decision-making and response to cognitive behavioural therapy for psychosis

Grey matter volume (GMV) in the orbitofrontal cortex (OFC) may relate to better response to cognitive behavioural therapy for psychosis (CBTp) because of the region's role in emotional decision-making and cognitive flexibility. This study aimed to determine the relation between pre-therapy OFC GMV or asymmetry and CBTp responsiveness and emotional decision-making as measured by the Iowa Gambling Task (IGT). Thirty patients received CBTp + standard care (CBTp+SC; 25 completers) for 6-8 months. All patients (before receiving CBTp) and 25 healthy participants underwent structural magnetic resonance imaging and performed the IGT. Patients' symptoms were assessed before and after therapy. Pre-therapy OFC GMV, measured using a region-of-interest approach, and IGT performance, measured as overall learning, attention to reward, memory for past outcomes and choice consistency, were comparable between patient and healthy groups. In the CBTp+SC group, greater OFC GMV was correlated with positive symptom improvement, specifically hallucinations and persecution. Greater rightward OFC asymmetry correlated with improvement in several negative and general psychopathology symptoms. Greater left OFC GMV was associated with lower IGT attention to reward. The findings suggest that greater OFC volume and rightward asymmetry, which maintain the OFC's function in emotional decision-making and cognitive flexibility, are beneficial for CBTp responsiveness

Preservation and compensation: The functional neuroanatomy of insight and working memory in schizophrenia

Background: Poor insight in schizophrenia has been theorised to reflect a cognitive deficit that is secondary to brain abnormalities, localized in the brain regions that are implicated in higher order cognitive functions, including working memory (WM). This study investigated WM-related neural substrates of preserved and poor insight in schizophrenia. Method: Forty stable schizophrenia outpatients, 20 with preserved and 20 with poor insight (usable data obtained from 18 preserved and 14 poor insight patients), and 20 healthy participants underwent functional magnetic resonance imaging (fMRI) during a parametric 'n-back' task. The three groups were preselected to match on age, education and predicted IQ, and the two patient groups to have distinct insight levels. Performance and fMRI data were analysed to determine how groups of patients with preserved and poor insight differed from each other, and from healthy participants. Results: Poor insight patients showed lower performance accuracy, relative to healthy participants (p. = 0.01) and preserved insight patients (p. = 0.08); the two patient groups were comparable on symptoms and medication. Preserved insight patients, relative to poor insight patients, showed greater activity most consistently in the precuneus and cerebellum (both bilateral) during WM; they also showed greater activity than healthy participants in the inferior-superior frontal gyrus and cerebellum (bilateral). Group differences in brain activity did not co-vary significantly with performance accuracy. Conclusions: The precuneus and cerebellum function contribute to preserved insight in schizophrenia. Preserved insight as well as normal-range WM capacity in schizophrenia sub-groups may be achieved via compensatory neural activity in the frontal cortex and cerebellum. © 2013 Elsevier B.V.Wellcome Trust, UK; NIHR Birmingham and Black Country CLAHRC, UK; Biomedical Research Centre for Mental Health at the Institute of Psychiatry, King's College London; South London and Maudsley NHS Foundation Trust, UK

Is there a role for music therapy in the recovery approach in mental health?

The recovery approach in mental health care emphasises the importance of the service user leading a fulfilling, meaningful life beyond the limitations of illness or symptomatology. This approach to care is increasingly included as a central part of mental health policy and service provision in a number of countries including the UK and Ireland, to address the needs of people who have severe and enduring mental disorders. It is an autonomous, holistic and empowering way of working with individuals as they journey towards healing. Fundamental to this model is the relationship fostered between service users and health professionals. The recovery philosophy of care mirrors some of the core principles of music therapy, including the importance of the therapeutic relationship and the possibilities for change and growth within this. This paper explores the congruence between music therapy and the recovery approach by providing: (1) An overview of current published evidence for music therapy in mental health care. (2) A discussion of this psycho-social creative arts therapy intervention within the specialized area of recovery in psychiatry, and (3) case vignettes to illustrate the application of this philosophy in music therapy work within a recovery service

Is there a role for music therapy in the recovery approach in mental health?

The recovery approach in mental health care emphasises the importance of the service user leading a fulfilling, meaningful life beyond the limitations of illness or symptomatology. This approach to care is increasingly included as a central part of mental health policy and service provision in a number of countries including the UK and Ireland, to address the needs of people who have severe and enduring mental disorders. It is an autonomous, holistic and empowering way of working with individuals as they journey towards healing. Fundamental to this model is the relationship fostered between service users and health professionals. The recovery philosophy of care mirrors some of the core principles of music therapy, including the importance of the therapeutic relationship and the possibilities for change and growth within this. This paper explores the congruence between music therapy and the recovery approach by providing: (1) An overview of current published evidence for music therapy in mental health care. (2) A discussion of this psycho-social creative arts therapy intervention within the specialized area of recovery in psychiatry, and (3) case vignettes to illustrate the application of this philosophy in music therapy work within a recovery service

The self or the voice? Relative contributions of self-esteem and voice appraisal in persistent auditory hallucinations

Background Persistent auditory hallucinations are common, disabling and difficult to treat. Cognitive behavioural therapy is recommended in their treatment though there is limited empirical evidence of the role of cognitive factors in the formation and persistence of voices. Low self-esteem is thought to play a causal and maintaining role in a range of clinical disorders, particularly depression, which is prevalent and disabling in schizophrenia. It was hypothesized that low self-esteem is prominent in, and contributes to, depression in voice hearers. Methods Beliefs about persistent auditory hallucinations were investigated in 82 patients using the Beliefs About Voices Questionnaire - revised in a cross-sectional design. Self-esteem and depression were assessed using standardized measures. Results Depression and low self-esteem were prominent as were beliefs about the omnipotence and malevolence of auditory hallucinations. Beliefs about the uncontrollability and dominance of auditory hallucinations and low self-esteem were significantly correlated with depression. Low self-esteem did not mediate the effect of beliefs about auditory hallucinations- both acted independently to contribute to depression in this sample of patients with schizophrenia and persistent auditory hallucinations. Conclusions Low self-esteem is of fundamental importance to the understanding of affective disturbance in voice hearers. Therapeutic interventions need to address both the appraisal of self and hallucinations in schizophrenia. Measures which ameliorate low self-esteem can be expected to improve depressed mood in this patient group. Further elucidation of the mechanisms involved can strengthen existing models of positive psychotic symptoms and provide targets for more effective treatments

Coping styles predict responsiveness to cognitive behaviour therapy in psychosis

The study aimed to determine the clinical and neuropsychological predictors of responsiveness to cognitive behavioural therapy for psychosis (CBTp). Sixty patients with schizophrenia or schizoaffective disorder and 25 healthy individuals took part in the study. Thirty patients (25 protocol completers) received CBTp in addition to standard care (SC); 30 patients (18 protocol completers) received SC only. All patients were assessed on symptoms using the Positive and Negative Syndrome Scale (PANSS) and clinical and neuropsychological function before and after CBTp. Symptoms and self-esteem improved to a greater extent in the CBTp + SC than SC control group. Greater pre-therapy coping ability and the self-reflectiveness dimension of cognitive insight at baseline predicted improvement in symptoms in the CBTp + SC group, but not the SC control group, explaining up to 21% of the variance in symptom improvement. Pre-therapy neuropsychological function, duration of illness, clinical insight and gender did not predict CBTp responsiveness. Being able to have a range of coping strategies and reflect on one's experiences while refraining from overconfidence in one's interpretations before therapy is conducive to better CBTp responsiveness