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Thursday , 10/03/13 - 7:10

LAS VEGAS—Cognitive-behavioral therapy (CBT) for psychotic symptoms is about giving patients the skills to evaluate beliefs rather than directly confronting patients’ delusions, according to a presentation by Douglas Noordsy, MD, Associate Professor of Psychiatry at Dartmouth University in Hanover, New Hampshire.

Although psychosis typically is treated with antipsychotic medications, psychotic symptoms persist in approximately 25% to 40% of patients with schizophrenia, which makes CBT an important treatment option.

Research shows that CBT may help improve outcomes for some patients with schizophrenia, is more effective than usual care, and is at least as effective as supportive therapy. CBT is an evidence-based strategy based on the premise that people’s thoughts shape their personality and behaviors, and that they can choose how to spend their mental time. “You are what you think,” said Dr. Noordsy.   

Dr. Noordsy discussed the stages of CBT for psychosis at the 26th Annual U.S. Psychiatric and Mental Health Congress.

Engaging, Coping, and Normalizing

Dr. Noordsy cautions patients that CBT is hard work, analogous to carving a riverbed from a canyon, a path for new thoughts to flow. “It’s not easy for people. I’ve found that people with the greatest distress about their symptoms have the greatest success with CBT,” he said.

Thus, patients with symptoms of grandiosity might not be motivated to make changes, while patients who are frightened by their thoughts may be more interested in modifying thought processes.

Clinicians should begin by engaging patients in a nonjudgmental manner, taking care to avoid confronting them about delusional beliefs. “Therapy is not all about you deciding which beliefs are accurate, it’s about giving patients the skills to decide what things are reality-based,” said Dr. Noordsy.

When patients ask if you believe their story, he suggests responding, “It’s not about what I believe. It’s about understanding your experience.”

Clinicians need to conduct detailed behavioral analysis of the onset of the behavior and resulting chain of events, including consequences that are relevant to the patient and might motivate change.

Once the clinician and patient have established open, honest communication, the clinician can introduce simple interventions that reduce the impact of psychotic symptoms and confer immediate relief. Patients might be asked to exercise, socialize, and learn relaxation and distraction techniques, sometimes as simple as using earbuds to play music and take the focus off voices.

Although patients may benefit from attempting to actively stop intrusive thoughts, they might have more success with mindfulness strategies that help them focus attention on their breath or the environment rather than on symptoms.

Patients should be encouraged to view distractions as a typical part of life for all people. “Try to help people feel less alone and less stressed by their symptoms,” said Dr. Noordsy.

To assist with this process, clinicians can educate patients about the frequency of psychotic-like experiences in the general population and explain how these experiences are similar to dreaming, a normal life experience. Patients also may learn distancing techniques that reinforce the idea that although they might not control the voices they hear, they can control whether they attend to them.

Other distancing strategies include understanding that words cannot hurt them and learning to shift from experiencing symptoms as real to experiencing them as a symptom. According to Dr. Noordsy, a patent might learn to say “Oh, there’s those voices again. That comes from my auditory cortex.”

A Shared Endeavor

However, although some patients may eventually interpret psychosis as an illness, others still believe their psychotic symptoms are the result of special powers or a conspiracy. The clinician and patient must act as partners in understanding the patient’s perspective and level of insight into the illness.

The goal is to help the patient move from a loose jumble of ideas to clear conceptualization of the condition. “It’s the patient’s therapy. I’m not going to say they’re wrong,” said Dr. Noordsy.

In cases in which the patient’s understanding remains delusional-based, Dr. Noordsy will work on cognitive restructuring that starts with the assumption that the patient experiences, for example, alien visitations. He will purposely avoid calling the experience a symptom and will instead examine how aliens get in the way of the patient’s goals.

Together, the patient and clinician will work together to systematically evaluate evidence associated with the psychotic symptoms. The clinician might delve into alternative explanations for the symptoms and examine whether anything predicted by the symptoms has happened.

“Help the person take their belief and test it out,” said Dr. Noordsy.

In Dr. Noordsy’s experience, patients may benefit from testing their beliefs using a simple grid that outlines the experience in question. The patient would report on details of the situation in question, evidence supporting their beliefs, any automatic thoughts, and other possible explanations for the experience.

As therapy progresses, the patient should be encouraged to pragmatically question the value of certain beliefs and whether they have been helpful or harmful in life.

Integration Into Care

Even if clinicians do not have time for a full CBT session during the office visit, they could embed CBT principles into routine care, Dr. Noordsy noted.

All clinicians can benefit from listening for evidence of psychotic thought, identifying automatic thoughts, asking clarifying questions, showing genuine curiosity, and adopting a side-by-side therapeutic stance. Such a partnership might start by using the patient’s terminology and understanding the patient’s beliefs without endorsing them.

“Shift the paradigm away from believing versus not believing, because that’s what’s getting the person into trouble. It’s about evaluating evidence and thinking about reinforcement, too,” said Dr. Noordsy. He added, “Be mindful of reinforcing a person’s ability to view themselves as having power in the relationship.”

—Lauren LeBano