رفتار درمان شناختی فردی در درمان توهم و هذیان ها: بررسی

The limitations of biochemical treatments in reducing the severity of hallucinations and delusions has led to an increased interest in the investigation of psychological treatments for these symptoms. These investigations have spanned the last 4 decades and have covered a range of psychological approaches from psychoanalytically oriented psychotherapy to behavioral approaches. More recently, findings that some psychotherapies are not effective treatments for psychosis and that cognitive-behavior therapy can be an effective treatment for neurotic disorders have led to increasing interest in the investigation of the effectiveness of cognitive-behavior therapy for psychosis. This review describes and evaluates the research on the cognitive-behavioral treatment of hallucinations and delusions and describes the cognitive models from which the treatments have developed. The conclusion is that, on the whole, the literature provides fairly strong evidence for the efficacy of cognitive-behavioral approaches in the management of chronic psychotic disorders and associated symptoms, although there are a number of areas where further development is necessary. THE USUAL FIRST-LINE TREATMENT for patients with psychotic symptoms such as hallucinations and delusions is neuroleptic medication. The finding that this type of medication was effective in the treatment of psychosis during the 1950s (Delay, Deniker, & Harl, 1952) brought about important developments in the care and management of people with schizophrenia (e.g., by reducing positive symptoms during acute crises and preventing subsequent relapse rates). Despite this, neuroleptic medication has some limitations with regard to its efficacy on psychotic symptoms. For example, a substantial number of patients will continue to experience persistent and distressing hallucinations and delusions or will be subject to periodic relapse of these symptoms despite appropriate doses of neuroleptic medication. Although the introduction of atypical neuroleptics has gone some way to improve outcome for neuroleptic nonresponders, medication still does not provide full remission for large numbers of patients. The discovery of drug therapies that will completely eradicate the occurrence or relapse of psychotic symptoms has remained elusive since the 1950s when chlorpromazine (a drug still in use in the United Kingdom today) was first introduced as a possible treatment for psychosis.

The range of cognitive-behavioral approaches used in the treatment of psychosis is diverse, and there have been changes in the emphasis and type of interventions over time, with development from solely behavioral approaches to a recent emphasis on modifying cognitive processes. Whether these changes have led to greater improvements in treatment outcome is, as yet, unclear although more contemporary cognitive-behavioral treatments appear to have greater generalization over time. Nevertheless, as many researchers have evaluated comprehensive combination treatment packages, the single essential elements of cognitive-behavioral treatments have not been evaluated, and much research is necessary to indicate what are the effective elements of treatment and which strategies are most effective at remedying particular symptoms. In addition, there are few large controlled studies demonstrating their efficacy in relation to a comparable control group, although several funded trials are ongoing in the United Kingdom. Further research is also necessary to establish cognitive-behavioral techniques as an effective management strategy either as a stand-alone treatment or in conjunction with traditional medical approaches to management. In addition, most of the cognitive-behavior and behavior therapy research on schizophrenia has been performed with patients in a residual phase of the disorder, in conjunction with a stabilizing antipsychotic drug regimen rather than newly diagnosed or acute patients. However, rigorous procedures to determine stability in the residual phase are often not performed or not reported. In many cases, a psychosocial treatment is indicated because drugs have failed to resolve symptoms or other problems adequately. Positive symptoms (hallucinations, delusions, thought disorder, etc.) usually show the most definitive response to antipsychotic drugs and are in that sense more associated with the acute phase. However, sometimes they persist despite pharmacological treatment. This suggests that the meaning of “residual phase” and “optimal medication” is different for different patients. As a result, the implications for the probable success of cognitive-behavior therapy, given the variability in individual differences in symptom stability, duration, configuration, and response to medication, are as yet unclear. Despite the predominance of research on drug-refractory patients in the residual state, there is some evidence that cognitive-behavioral interventions may also facilitate recovery from acute psychosis. Drury, Birchwood, Cochrane, and Macmillan 1996a and Drury, Birchwood, Cochrane, and Macmillan 1996b targeted acutely ill hospitalized psychotic patients, some of whom were experiencing their first episode of psychosis. In this study, cognitive-behavior therapy was used to improve and speed time to recovery. Patients allocated to the cognitive-behavior therapy condition received intensive individual sessions plus family support and education sessions. This was compared with a nonspecific control group that received recreational activity and a group that received routine hospital care. Sixty-five percent of the cognitive-behavior therapy group achieved full symptomatic recovery by 12 weeks compared with 40% of the controls. The mean time to recovery and time in hospital were reduced by 48% and 54%, respectively, for the cognitive-behavior therapy group compared with the recreational control group, which showed no advantage over routine care. The first two authors are currently carrying out a similar but much larger multicenter study designed to target acutely psychotic patients during an early episode of their illness. This study (the SOCRATES study) will assess the effectiveness of providing intensive cognitive-behavior therapy plus routine hospital care compared with hospital care alone in terms of levels of psychopathology, distress, and time to recovery from the index episode and will examine whether this treatment provides any protection against subsequent relapse (Lewis, Tarrier, Haddock, Bentall, & Kinderman, 1995). There are several conflicts to resolve if these promising beginnings are to fulfill their therapeutic potential. It is clear that pragmatic trials of sufficient size are required to demonstrate what treatment works best with which patient and under which conditions, but it is also necessary to agree on a common currency in terms of outcome. For example, what are the most important outcomes by which it is necessary to demonstrate a treatment effect in any trial involving schizophrenia. This lack of agreement is highlighted by the debate on whether to concentrate on individual symptoms alone, on a range of symptoms and dysfunctions, or on the putative underlying mechanisms. This in turn reflects different explanatory models held by researchers in the area, and communication among researchers is needed to yield an integrated model of psychosis. A related issue is the investigation of the processes involved in therapeutic change. Rigorously designed studies are needed to elucidate which therapeutic processes are responsible for which therapeutic changes and whether these are changes in cognitive deficits, actual changes in the phenomenology of symptoms, changes in beliefs, or arousal reduction. A greater integration of theory and practice is required to further develop psychological treatment in psychosis. Finally, keeping independent assessors of outcome blind to the treatment condition can be problematic, especially when comparing cognitive-behavior therapy to routine care, because patients may disclose information regarding the treatment they are receiving. It is less of a problem when comparing different types of cognitive-behavior therapy or a placebo intervention, but care is required to ensure that assessments are carried out with the same rigor that would be expected in a pharmacological study. The use of “active” psychological treatments also raises issues of treatment quality and fidelity. There are practical difficulties involved in delivering the required “dose” of treatment of a required quality with appropriate patient adherence. Differing priorities of therapist and patient may mean that a patient may view his or her positive symptoms as low priority compared with other symptoms, medication side effects, disabilities, and social deprivations. Similarly, a congenial interaction with a therapist may be a more attractive aspect of a therapeutic contact than the active therapy itself, with a resulting decrease in time spent on actual therapy. These may all signify that the amount and quality of therapeutic input of cognitive-behavior therapy may vary considerably within a treatment group with a corresponding effect on outcome. Future trials will need to assess treatment credibility and what was actually done in therapy and relate this to outcome.Tarrier Beckett Harwood Baker Yusupoff Ugarteburu 1993 and Tarrier Sharpe Beckett Harwood Baker Yusupoff 1993