رفتاردرمانی شناختی برای جلوگیری از انطباق مضر با توهم فرمان (فرمان): یک مطالعه کنترل شده تصادفی

Schizophrenia affects 0·8% of the UK population, usually starts in young adults, and, in some cases, leads to persistent disability.1 Individuals with this illness have a high risk of suicide (8%) and deliberate self-harm and, although the risk is small, they are more likely to perpetrate aggression than are those without schizophrenia.2 Individuals acting on delusions, including commanding voices, are a cause for concern at societal and political levels because members of the public are at risk of apparently random acts of violence, even when the perpetrators are well supported by services. These concerns are shown in national policy documents—eg, the UK national mental health strategy aims to reduce avoidable harm to self or others.3 Although drug and other treatments have improved, nearly 50% of individuals will have treatment-resistant symptoms or symptoms arising from non-adherence to drug regimens.4 and 5 Auditory hallucinations are some of the most prominent and distressing of the treatment-resistant symptoms, and command hallucinations are the most high risk of these.6 Shawyer and colleagues6 reported a median 53% prevalence of command hallucinations in adult participants with psychiatric disorders; 48% of these participants said the commands stipulated harmful or dangerous actions, rising to 69% for participants in medium secure units.7 However, the link between the presence of command hallucinations and harm to self or others is not straightforward. In the MaCarthur study,8 no association was reported between the presence of delusions or command hallucinations and violence. Thoughts about violence, however, were a strong predictor of violence 6 months later. Our cognitive model of voices has clarified that it is not only the level of activity of voices, or indeed their content, that drives affect and behaviour, but also the nature of the relationship with the personified voice.9, 10 and 11 We showed that compliance or appeasement behaviour can occur when the hearer believes the voice to have malevolent intent, and crucially to have the power to deliver the threat.9 These findings have been independently replicated in a forensic population.12 This theoretical framework informed the development of a cognitive behaviour therapy: cognitive therapy for command hallucinations, which was designed to weaken and challenge beliefs about the power of voices, enabling the individual to break free of the need to comply or appease and thereby reduce harmful compliance behaviour and distress.13 and 14 This therapeutic model was developed because of a major gap in the evidence base. Although cognitive behaviour therapy is recommended by the UK's National Institute for Health and Care Excellence15 to reduce overall symptom severity, the guidance notes that there is insufficient evidence for voice compliance and frequency and inconsistent evidence for any direct effect on delusions. We tested the model in a proof-of-principle trial16 in a group at high risk of compliance with commands because of recent (<9 months) harmful compliance or appeasement. This operational definition of risk was associated with a 39% rate of recurrence of harmful compliance within 12 months in the control group; in people receiving the therapy, the rate of compliance dropped to 14%, equivalent to an effect size of 1·1. This drop was accompanied by a reduction in the perceived power of the voice; there was a reduction in delusional distress and depression, but this was not maintained at 12 months' follow-up. Crucially, as expected, no change was noted in the frequency or intensity of voices, but only in the (power) relation with them. The results of a similar trial by Shawyer and colleagues17 of a different therapy based on acceptance of voices by “cultivating the capacity to just notice voices and associated thoughts rather than believe and act on them” showed no effect on compliance or other outcomes. However, this study had a low base rate of compliance. The aim in the COMMAND trial was to assess the acceptability, effectiveness, and cost-effectiveness of cognitive therapy for command hallucinations. The primary hypothesis was that in participants with command hallucinations who have recently acted on the voices and are therefore at high risk of doing so again cognitive therapy for command hallucinations would increase resistance and thereby reduce the level of further harmful compliance behaviour and the associated risk. Secondary hypotheses were that the perceived power of the persecuting voice would be reduced, which would act as the mediator of change in compliance; there would be no changes in the frequency or topography of voices; and cognitive therapy for command hallucinations would reduce delusional distress and depression.

Schizophrenia affects 0·8% of the UK population, usually starts in young adults, and, in some cases, leads to persistent disability.1 Individuals with this illness have a high risk of suicide (8%) and deliberate self-harm and, although the risk is small, they are more likely to perpetrate aggression than are those without schizophrenia.2 Individuals acting on delusions, including commanding voices, are a cause for concern at societal and political levels because members of the public are at risk of apparently random acts of violence, even when the perpetrators are well supported by services. These concerns are shown in national policy documents—eg, the UK national mental health strategy aims to reduce avoidable harm to self or others.3 Although drug and other treatments have improved, nearly 50% of individuals will have treatment-resistant symptoms or symptoms arising from non-adherence to drug regimens.4 and 5 Auditory hallucinations are some of the most prominent and distressing of the treatment-resistant symptoms, and command hallucinations are the most high risk of these.6 Shawyer and colleagues6 reported a median 53% prevalence of command hallucinations in adult participants with psychiatric disorders; 48% of these participants said the commands stipulated harmful or dangerous actions, rising to 69% for participants in medium secure units.7 However, the link between the presence of command hallucinations and harm to self or others is not straightforward. In the MaCarthur study,8 no association was reported between the presence of delusions or command hallucinations and violence. Thoughts about violence, however, were a strong predictor of violence 6 months later. Our cognitive model of voices has clarified that it is not only the level of activity of voices, or indeed their content, that drives affect and behaviour, but also the nature of the relationship with the personified voice.9, 10 and 11 We showed that compliance or appeasement behaviour can occur when the hearer believes the voice to have malevolent intent, and crucially to have the power to deliver the threat.9 These findings have been independently replicated in a forensic population.12 This theoretical framework informed the development of a cognitive behaviour therapy: cognitive therapy for command hallucinations, which was designed to weaken and challenge beliefs about the power of voices, enabling the individual to break free of the need to comply or appease and thereby reduce harmful compliance behaviour and distress.13 and 14 This therapeutic model was developed because of a major gap in the evidence base. Although cognitive behaviour therapy is recommended by the UK's National Institute for Health and Care Excellence15 to reduce overall symptom severity, the guidance notes that there is insufficient evidence for voice compliance and frequency and inconsistent evidence for any direct effect on delusions. We tested the model in a proof-of-principle trial16 in a group at high risk of compliance with commands because of recent (<9 months) harmful compliance or appeasement. This operational definition of risk was associated with a 39% rate of recurrence of harmful compliance within 12 months in the control group; in people receiving the therapy, the rate of compliance dropped to 14%, equivalent to an effect size of 1·1. This drop was accompanied by a reduction in the perceived power of the voice; there was a reduction in delusional distress and depression, but this was not maintained at 12 months' follow-up. Crucially, as expected, no change was noted in the frequency or intensity of voices, but only in the (power) relation with them. The results of a similar trial by Shawyer and colleagues17 of a different therapy based on acceptance of voices by “cultivating the capacity to just notice voices and associated thoughts rather than believe and act on them” showed no effect on compliance or other outcomes. However, this study had a low base rate of compliance. The aim in the COMMAND trial was to assess the acceptability, effectiveness, and cost-effectiveness of cognitive therapy for command hallucinations. The primary hypothesis was that in participants with command hallucinations who have recently acted on the voices and are therefore at high risk of doing so again cognitive therapy for command hallucinations would increase resistance and thereby reduce the level of further harmful compliance behaviour and the associated risk. Secondary hypotheses were that the perceived power of the persecuting voice would be reduced, which would act as the mediator of change in compliance; there would be no changes in the frequency or topography of voices; and cognitive therapy for command hallucinations would reduce delusional distress and depression.

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