Dr. Neil A. Rector, Ph.D., C.Psych. Director, Mood And ... Internet.pdf · La triade cognitive de Beck . Trois types de pensées négatives présents dans la dépression . ... Anxiety

Dr. Neil A. Rector, Ph.D., C.Psych.

Director, Mood And Anxiety Treatment and Research Program

Director of Research, Thompson Anxiety Disorders Centre

Sunnybrook Health Sciences Centre

Professor, University of Toronto

Affiliate Clinical Scientist, Centre for Addiction and Mental Health

Provide an overview of the cognitive-behavioural conceptualization of psychosis and recent studies testing aspects of the CBTp model

Survol du cadre théorique de la TCC dans le contexte de la psychose

Discuss empirically supported cognitive-behavioral strategies to reduce delusions, hallucinations, and negative symptoms

Techniques et stratégies TCC pour réduire les symptômes positifs et négatifs

Present the CBTp treatment of two cases to highlight the nature and timing of intervention strategies

Deux exemples d’intervention TCC

Open discussion of cases and time for Q & A Discussion de cas cliniques et période de questions

BMJ 2001;323:334-336

Observational Studies

RCTs

Meta-analyses Méta-analyses

Études contrôlées randomisées

Études observationnelles

Opinions d’experts

Études non-analytiques

EMOTIONS THOUGHTS

BEHAVIOUR Comportement

Émotions

Pensées

Event

Behaviour Emotion

Cognitive Appraisal

Théorie cognitive de la dépression

Situation

Comportement

Évaluation cognitive

The cognitive triad encompasses the themes of the cognitive content that is linked to depression.

The cognitive triad consists of

A negative view of the self A negative view of the world A negative view of the future

Beck, 1967

La triade cognitive de Beck

Trois types de pensées négatives présents dans la dépression

Faible estime de soi

Pensées négatives sur le monde

Pensées négatives sur l’avenir

Psychoeducation – Socialization to CBT framework (Psychoéducation – Initiation au cadre de la TCC)

Phase 1: Behavioural Activation Strategies (Stratégies d’activation comportementale)

Phase 2: Cognitive assessment and restructuring exercises (Évaluation cognitive et exercises de restructuration)

Phase 3: Targeting dysfunctional assumptions/core beliefs (Identification des inférences/croyances dysfonctionnelles)

Relapse planning and prevention (Prévention et élaboration d’un plan en cas de rechute)

Beck et al., 1979

Patient responders that terminated CT were significantly less likely to relapse than responders that terminated medications. (TCC plus efficace que la médication pour prévenir les rechutes après le traitement)

The CT group was no more likely to relapse than the patients continuing on medications. (Groupe TCC n’a pas montré plus de rechutes que les patients poursuivant la médication)

0

20

40

60

80

100

CTMeds.Plac.

Hollon et al., 2005 Archives of General Psychiatry

Months following acute treatment

% S

urvi

val

Physical Reactions Thoughts Increased heart rate I’m having a heart attack More shallow breathing Less oxygen to heart and brain Increased heart rate This means I really am Further increases in having a heart attack. I’m physical sensations going to die PANIC

Clarke, 1986

Réactions physiques

Rythme cardiaque ↑

Respiration plus profonde

Moins d’oxygène au cœur et cerveau

Rythme cardiaque ↑

Sensations physiques ↑

Pensées

J’ai une crise cardiaque

Mais j’ai vraiment une crise cardiaque! Je vais mourir

0102030405060

0 1 2 3 4 5

%

CBT+ IMI

IMI alone

CBT+ PBO

CBT alone Pe

rcen

t of P

atie

nts R

elap

sing

With

in 6

Mon

ths

Upper = Intent to follow

Lower=Completers

14/29

10/25

10/25

5/20 5/30

1/26

5/28

2/25

Barlow et al. 2000 JAMA

Disorder Systematic bias in processing information

Depression Negative view of self, experience and future

Hypomania Inflated view of self and future

Anxiety Disorder Sense of physical or psychological danger

Panic Disorder Catastrophic interpretation of bodily/mental experiences

Phobia Sense of danger in specific, avoidable situations

Hysteria Concept of motor or sensory abnormality

Obsession Repeated warning or doubts about safety

Compulsion Rituals to ward off perceived threat

Suicidal behavior Hopelessness and deficiencies in problem solving

Anorexia nervosa Fear of being fat

Hypochondriasis Attribution of serious medical disorder

Beck & Dozois, 2011

Estimated prevalence for comorbidity based on weighted averages from heterogenous studies: (Prévalence estimée des comorbidités)

Buckey et al., 2009, Schizophrenia Bulletin

15% for panic disorder (25% for panic attacks) (Trouble panique)

29% for posttraumatic stress disorder (Stress post-traumatique)

23% for obsessive-compulsive disorder (Trouble obsessionnel-compulsif)

50% for depression

Tested efficacy of CBT in ↓ trauma, depression and low self esteem following a first episode of psychosis (TCC ↓ le trauma, la dépression et la faible estime de soi qui suivent souvent un 1er épisode) n = 66 CRI group had lower levels of post-intervention trauma symptoms and demonstrated greater improvement vs. TAU alone (Le groupe CRI réduit davantage les symptômes que le traitement habituel)

Esp. at 6 months for those with high pre-treatment levels of trauma.

Fig. 2. Mean Scores on the IES (total)

• IES = Impact of Events Scale (Sundin & Horowitz, 2002), self report questionnaire used to measure post traumatic phenomena

• CRI = Cognitive Recovery Intervention; cognitive therapy based recovery intervention

Jackson et al., 2009, Behaviour Research and Therapy

Vulnerability Stressors Schizophrenia

Vulnérabilité Stresseurs Schizophrénie

Constitutional Vulnerability

Neurocognitive Changes

Stressors

Schizophrenia

Vulnérabilité Stresseurs

Changements neurocognitifs

Schizophrénie

1. Thought disorder – Confused (trouble de la pensée – confus)

2. Lack of motivation/apathy (manque de motivation)

3. Overvalued ideation (“Idées surévaluées”)

4. Relapse/Recurring Nature of the Illness – Hopelessness (Rechute, cycle de la maladie – désespoir)

5. Therapist fear of symptoms (crainte des symptômes chez le thérapeute)

6. Therapist beliefs – I can’t be of help (croyances du thérapeute – je ne peux pas l’aider)

"The article that follows is part of the Schizophrenia Bulletin's ongoing First Person Account series. We hope that mental health professionals—the Bulletin's primary audience—will take this opportunity to learn about the issues and difficulties confronted by consumers of mental health care. In addition, we hope that these accounts will give patients and families a better sense of not being alone in confronting the problems that can be anticipated by persons with serious emotional difficulties." —The Editors.

Constitutional Diathesis

Stressors Appraisal Schizophrenia

Stresseurs Évaluation Schizophrénie Diathèse

Man with 7-year Persecution Delusion (Homme avec délire de persécution depuis 7 ans)

28 year-old WWII Veteran (28 ans, vétéran de la 2e guerre)

Treatment focused on: Le traitement ciblait:

Delusional triggers and interpretations (les déclencheurs et interprétations délirantes)

Alternative evidence gathering (identification de preuves alternatives)

Constructing alternative , less distressing interpretations of experiences (élaboration d’interprétations alternatives et plus adaptées)

Linking to past experiences and negative core beliefs (liens avec les expériences passées et les croyances profondes négatives)

Childhood Experiences (Expériences de l’enfance)

Self-conscious in group (malaise dans un groupe – ex: se sentir observé)

Cheating by father and self Core Beliefs (Croyances profondes)

If conspicuous, will be put down Since we cheated, we are vulnerable

Precipitation Demeaned and isolated in the army (Humilié et isolé dans l’armée)

Delusional Misinterpretations (Interprétations délirantes)

FBI observing and following him (FBI l’observe et le suit)

Schemas

Activating Situation

Interpretation

Affect Behaviour

Situation activatrice

Comportement Émotion

1)DELUSIONS (Délires)

2)HALLUCINATIONS

3)NEGATIVE SYMPTOMS (Symptômes négatifs)

4)POOR INSIGHT (Faible “insight”)

Factor Analysis of Delusional Ratings: 1) Delusions of being controlled (Délires de contrôle)

2) Self-significance (grandiose, religious, sinful)

(Grandiosité)

3) Delusions of persecution/paranoia (Délires de persécution / paranoia)

Kimhy et al., 2005

Pervasiveness: How much the patient’s consciousness is controlled by the belief (Omniprésence)

Conviction: How strongly the patient believes (Certitude)

Significance: How important the belief is to the patient (Importance)

Intensity: To what degree the belief displaces more realistic beliefs (Intensité)

Inflexibility and Self-certainty: How impervious the belief is to contradictory evidence, logic or reason (Rigidité de pensée)

Preoccupation Impact on behavior and emotions (Impact sur le comportement et les émotions)

Group General Improvement

Reality-tested Delusions

Type of Delusional Activity

Pervasiveness

Conviction

I (N = 4) Slight No Mixed: Encapsulated and overtly delusional

Unchanged Unchanged

II (N = 2) Moderate No Encapsulated Markedly Reduced

Unchanged

III (N = 2) Marked Yes Nondelusional

Markedly Reduced

Markedly Reduced

Hole, Rush & Beck, 1979

Social Phobia

Axis I: Heightened Suspiciousness

Axis II: Paranoia Delusional

Disorder

Chronic Schizophrenia

Paranoid Delusions

Phobie sociale

Méfiance accrue

Trouble délirant

Délires paranoides

Multidimensional assessment of extreme self and other evaluation: (Évaluation multidimensionnelle de soi et d’autrui)

Negative-self Positive-self Negative-other Positive-other

Predictors of paranoia: (Prédicteurs de la paranoia)

High Negative-other (9% variance) (Forte perception négative des autres) Low Positive-other (4% variance) (Faible perception positive des autres) Anxiety (2%)

No effects for general self-esteem Fowler et al., 2006

“POOR ME!” (Apitoiement) Persecution paranoia Focusing on oneself as hurt – wronged, victimized and persecuted Grandiosity in thinking Angry, confrontational, and vengeful More difficult to treat

e.g., “The professors are trying to hold me back in life. They have sent spies to watch me in the shop where I work.”

“BAD ME!” (Blâme) Punishment paranoia Focusing on oneself as bad – deserving of blame Paranoia regarding others’ negative evaluations Easier to treat

e.g., “I was sitting in my office, thinking about bad things I have done. My phone rang - it was a sign that someone heard my thoughts, and now they know how bad and perverted I am.”

Chadwick, Birchwood, & Trower, 1996

0

10

20

30

40

Positive Negative

Deluded

Kaney and Bentall, 1988

Inte

rnal

ity

People with delusions “jump to conclusions” when making decisions – request less information to make decision (Garety & Freeman, 1999) (Sauter aux conclusions)

Present in those with delusional proneness (Colbert & Peters, 2002) (Biais présents chez les personnes “à risque”)

Elevated in those who have recovered from delusions (Peters et al., 1999) (Biais plus fréquents chez les individus en rémission)

Contributes directly to delusional conviction (Garety et al., 2005) (Biais contribuent au maintien du délire)

Relates to belief inflexibility and failure to generate alternative explanations (Freeman et al., 2004) (Contribuent à la rigidité de la pensée)

Confirmatory Bias: Select evidence that supports their own conclusions Disconfirmation Bias: Rule out the consideration of inconsistent evidence

Delusion Situation/ Antecedent

Belief

Emotional/ Behavior Consequences

Paranoid People heard speaking outside house

“they’ve come to harm me”

Fear/ Escape house

Thought broadcast

Hears man ask for bus ticket just as he was thinking “I need a ticket”

My thoughts are being passed to others

Fear/ Escape

Reference Plane passes overhead

WWIII is starting Anxiety/ Helplessness

Somatic Develops skin rash

I’ve got AIDS Terror/ Hopelessness

Stressors Appraisal Constitutional Diathesis Schizophrenia

Flexibility

1. At times I have misunderstood other people’s attitudes towards me

2. Other people can understand the cause of my unusual experiences better than I can

3. I have jumped to conclusions too fast 4. Some of my experiences that have seemed

very real may have been due to my imagination

12.5

13

13.5

14

14.5

15

15.5

16

Psychotic Disorder No Psychotic Disorder

n = 91 n = 59

t (148) = 2.65, p < .01

Freeman, et al. (2007): 96% of participants had used at least one safety behavior: (96% en ont utilisé au moins 1) Avoidance (78%): (évitement)

Meeting people, being far from home, public transportation In-situation (63%): (en situation:)

Protection: not answering the front door, only going outside accompanied by family member Invisibility: wear a hat or cycle helmet, walk down the street quickly Vigilance: watching people, looking up and down Resistance: “ready to strike out”, “get stressed to warn them not to mess with me”

Escape (35%): (fuite) A person reported having a thought inserted into her head about being attacked, she fled the aerobics class

Compliance (25%): (se conformer, être diplomate)

Trying to make the neighbours like me, being diplomatic with people

Help-seeking (31%): (recherche d’aide)

From family, friends, hospital staff Aggression (24%):

Approaching people and telling them to “get off my back, confronting people

Delusional (6%): Avoidance of masturbation due to fear that someone was going to cut off his testicles

Somatic Vulnerability and Psychosocial Stressors

Negative Representations Attenuated Resources

Impaired Reality Testing Cognitive Biases

Delusion Formation

Safety Behaviors

Confirmatory Bias

Delusional Interpretations

Vulnérabilité somatique et stresseurs psychosociaux

Ressources atténuées

Mauvaise évaluation de la réalité

Perceptions négatives

Biais cognitifs Construction délirante

Comportements de protection

Interprétations délirantes Biais confirmatoire

Psychoeducation and Normalizing (Psychoéducation et normalisation)

Socializing to Cognitive Model (Initiation au modèle cognitif)

Socratic Questioning of Evidence (Questionnement socratique des preuves)

Questioning of Evidence for Paranoid Beliefs (Past and Present) (Remise en question du rationnel des croyances délirantes)

Reducing Maladaptive Behaviours (Réduction des comportements inadaptés)

Addressing Underlying Assumptions/Beliefs (Modifications des croyances profondes)

Focusing on functional outcomes! (Focus sur le fonctionnement)

1)DELUSIONS

2)HALLUCINATIONS

3)NEGATIVE SYMPTOMS

4)POOR INSIGHT

ANTICIPATION PREDICTIONS (POSITIVE) WARNINGS PREDICTIONS (NEGATIVE)

“SHOULD NOTS” PROHIBITIONS “SHOULDS” INJUNCTIONS CRITICISM EVALUATIONS (NEGATIVE)

PRAISE EVALUATIONS (POSITIVE)

COMMENTARY SELF-MONITORING

AUTOMATIC THOUGHT OR VOICE (Pensée automatique)

COGNITIVE PROCESS (Processus cognitif)

Aim is to make less threatening by altering meanings associated with voices (Diminuer l’impression de menace en modifiant les interprétations / significations associées aux voix)

Similar to treatment of delusional beliefs (Semblable au traitement des croyances délirantes)

Target weak beliefs before more rigid beliefs (Cible les croyances plus fragiles avant les plus rigides)

Target escape, avoidance, safety behav’s (Cible entre autres les comportements de fuite et d’évitement)

Goal is for patient to realize voices self-generated and reflect personal concerns (L’objectif est de faire réaliser au patient que les voix sont auto-générées et qu’elles reflètent des inquiétudes personnelles

Identify cues that increase/decrease voices (Identifier des indices qui augmentent /diminuent les voix)

Practice strategies within session (Pratiquer les stratégies apprises durant les séances)

Patient comes to initiate activity in session for short periods then stops (À l’aide d’exercises durant la séance, on aide le patient à réaliser qu’il peut lui-même initier / diminuer /arrêter les voix)

Consider evidence for beliefs about the voice’s control and power (Remettre en question les croyances que les voix ne peuvent être contrôlées et qu’elles sont “toutes puissantes”)

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

Post Follow-up

CBT-RC

ST-RC

-0.6-0.4-0.2

00.20.40.60.8

1

Effect Size

1 3 5 7 9 11 13 15 17 19

Trial Number

Terrier & Wykes, 2004

Jauhar et al., 2014, British Journal of Psychiatry

Fig. 2 Forest plot of studies in the meta-analysis of overall symptoms

Pooled ES for overall symptoms was -0.33 (95% CI -0.47 to -0.19, P<0.001)

n = 80 patients (40 CBTp, 40 waitlist + CBTp after) CBTp sig. ↑ over waitlist for total PANSS score at posttreatment–postwait, F(1, 77) = 12.0, p ≤ .001, ƞ2p = .14. Intent-to-treat postassessment ES in most of the domains were moderate

Lincoln et al., 2012

Trower, P., Birchwood, M., Meaden, A., Byrne, S., Nelson, A., & Ross, K. (2004). Cognitive therapy for command hallucinations: randomized controlled trial. British Journal of Psychiatry, 184, 312-320.

Mea

n Vo

ice

Com

plia

nce

1)DELUSIONS

2)HALLUCINATIONS

3)NEGATIVE SYMPTOMS

4)POOR INSIGHT

Andreasen, 1982

EMOTIONAL WITHDRAWAL (Émoussement affectif / retrait émotionnel)

ANHEDONIA (Anhédonie)

ASOCIALITY (Retrait social, isolement)

PSYCHOMOTOR RETARDATION (Ralentissement psychomoteur)

POOR RAPPORT (Relations interpersonnelles superficielles)

INAPPROPRIATE AFFECT (Affect inapproprié)

ATTENTIONAL IMPAIRMENTS (Déficits attentionnels)

Importance of defeatist performance beliefs (Importance des croyances défaitistes liées à la performance)

Importance of negative expectancy appraisals (Importance des attentes de succès diminuées)

Rector, Beck, & Stolar, 2005

“WHAT’S THE POINT”, (“à quoi bon”)

“WHY SHOULD I BOTHER”, (“pourquoi je m’en ferais avec cela”)

“IT’S TOO MUCH WORK” (“c’est trop de travail”)

“I WON’T ENJOY IT” (“ça ne sera pas l’fun”)

DAS SCALE ITEM (item de l’échelle DAS) r If I fail at my work, then I am a failure as a person. .48** If you cannot do something well, there is little point doing it at all.

.33*

If I fail partly, it is as bad as being a complete failure.

.30*

If a person asks for help, it is a sign of weakness. .35** If I do not do as well as other people it means I am an inferior human being.

.42**

*p<.05 **p<.01 Rector, 2004

Cognitive Impairment Negative Symptoms

Affective Flattening

Avolition / Apathy

Anhedonia / Asociality

.29

DAS Perf. Beliefs

.45* .46*

Grant & Beck, 2009

*p < .05

Déficit cognitif

Croyances liées à la performance

Symptômes négatifs

Émoussement affectif

Apathie / Amotivation

Anhédonie / Retrait social

Social cognition

Defeatist beliefs

Negative symptoms

Functional outcome

(RFS)

Social perception

(PONS)

Theory of mind (TASIT)

Emotion processing (MSCEIT)

Green et al., 2012 Archives of General Psychiatry

0.72 0.72

0.68

0.43 -0.44 0.23 -0.74

Beliefs and motivation Ability Daily Functioning

Perception sociale Théorie de l’esprit Traitement émotionnel

Cognition sociale

Croyances défaitistes

Symptômes négatifs Fonctionnement

0

0.2

0.4

0.6

0.8

1

1.2

Post Follow-up

CTSCRC

Effe

ct S

ize

Rector & Beck, 2001 NUMBER OF STUDIES = 7

Behavioural Self-Monitoring (Auto-supervision des comportements)

Activity Scheduling (Planification de l’horaire des activités)

Pleasure and Mastery Ratings (Cotations du plaisir et des performances)

Graded Task Assignments (Affectation de tâches à difficulté croissante)

Assertiveness Training (Entraînement à l’affirmation de soi)

Schedule meaningful activity (Planifier des activités emballantes)

Set expected pleasure rating (Estimer le niveau de plaisir attendu)

Identify cognitive distortion (Identifier les distorsions cognitives)

Consider alternative evidence (Considérer une hypothèse alternative)

Prepare alternative balanced treatment (Préparer un traitement alternatif équilibré Keep pleasure ratings (Continuer les cotations du plaisir ressenti)

Use feedback to shift low expectations (Utiliser le feedback pour augmenter les attentes d’avoir du plaisir)

Negative symptoms improve when performance beliefs and negative expectancies are directly targeted in treatment (Les symptômes négatifs s’améliorent lorsque le traitement cible les croyances de performance et les attentes négatives)

CT (18 mo) + standard treatment vs. standard treatment alone, n = 60 Showed mean reduction in avolition-apathy but no sig. group differences for other negative symptoms

Grant et al., 2012

Avec cette clientèle, la TCC a montré un effet significatif pour la réduction de l’apathie

BMJ 2001;323:334-336

Observational Studies

RCTs

Meta-analyses Méta-analyses

Études contrôlées randomisées

Études observationnelles

Opinions d’experts

Études non-analytiques

The National Institute for Clinical Excellence (NICE), APA Practice Guidelines, & American Psychological Association Section 12 all recommend CBTp (TCC largement recommandée)

Based on modest-moderate clinical research results

NICE (2009) specifically recommends offering CBT to all people with schizophrenia, during the acute phase or later

Recommended CBT should be delivered on a one-to-one basis over at least 16 planned sessions Also recommended promoting recovery; “offer CBT to assist in promoting recovery in people with persisting positive and negative symptoms and for people in remission”

But there continues serious methodological issues with CBTp research (e.g. heterogeneity of patients, stage of illness, diversity of CBTp)

Hampers definitive conclusions about outcomes associated with CBTp

Hutton & Taylor, 2014, Psychological Medicine

Relative risk (RR) of developing psychosis was reduced by >50% for those receiving CBT at every time point Random effects analysis:

RR at 6 mo = 0.47, p=0.008 (6 RCTs, n=800) 12 mo, RR = 0.45, p=0.001 (6 RCTs, n=800) 18-24 mo, RR = 0.41, p=0.002 (4 RCTs, n=452)