Cognitive Behavior Therapy in First-Episode Psychosis With a Focus on Depression, Anxiety, and Self-Esteem

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1 CBPRA-00471; No of Pages 12: 4C Cognitive and Behavioral Practice xx (2013) xxx-xxx Cognitive Behavior Therapy in First-Episode Psychosis With a Focus on Depression, Anxiety, and Self-Esteem Nasrettin Sönmez, Oslo University Hospital and University of Oslo Roger Hagen, Norwegian University of Science and Technology, Trondheim Ole A. Andreassen and Kristin Lie Romm, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo Marit Grande and Lene Hunnicke Jensen, Oslo University Hospital Anthony P. Morrison, Prestwich Hospital, Manchester Ingrid Melle and Jan I. Røssberg, Oslo University Hospital and University of Oslo Although several reviews show that cognitive behavioral therapy (CBT) is an effective treatment for patients with chronic psychosis, the effects of CBT on patients with a first-episode psychosis are less clear. Patients undergoing a first-episode psychosis are unique in that not only are they struggling with the symptoms of the disease, but also the realization of the diagnosis. Understanding how the disease will impact their lives with respect to changes in social goals, roles, and status can also lead to depression, anxiety and low self-esteem. The main aim of the present study is to describe two clinical cases in order to demonstrate the application of CBT in first-episode psychosis patients in an early stage of their psychosis. The two cases are individuals who were in an ongoing CBT trial for first-episode psychosis patients with symptoms of social anxiety, depression, and low self-esteem. Individual case formulations based on these symptoms were developed. Psychoeducation, normalizing, evaluation of negative automatic thoughts and dysfunctional schematic beliefs, and focusing on the negative consequences of safety behavior were the main treatment targets in attempting to improve the patients symptoms and functioning. Both patients showed improvement in depressive symptoms, self-esteem, and general functioning. The cases described suggest that treatment designed to target depression, anxiety, and self-esteem in patients with first-episode psychosis could have potential beneficial effects; specific studies of this approach are recommended. A CCORDING to current treatment guidelines (National Institute for Health and Clinical Excellence, 2009), it is of importance to establish comprehensive treatment programs combining pharmacological and psychosocial interventions for patients with first-episode psychosis. Such programs have demonstrated improvement in prognosis and promoted recovery and social/occupational functioning (Craig et al., 2004; Garety et al., 2006; Hegelstad et al., 2012; Jeppesen et al., 2005; McGorry, Killackey, & Yung, 2008; Thorup et al., 2005). Cognitive behavioral therapy (CBT) for psychosis has received increased interest over the last decade. Several reviews show that CBT is an effective treatment for patients with chronic psychosis with regard to improvement of hallucinations, delusions, negative symptoms, recovery, Keywords: cognitive behavioral therapy; first-episode psychosis; depression; anxiety; low self-esteem /13/xxx-xxx$1.00/ Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved. depressive symptoms, social anxiety, insight, and number of relapses (Bustillo, Lauriello, Horan, & Keith, 2001; Gould, Mueser, Bolton, Mays, & Goff, 2001; Haddock, Morrison, Hopkins, Lewis, & Tarrier, 1998; Rector & Beck, 2001; Tarrier, 2005; Tarrier & Wykes, 2004; Turkington, Dudley, Warman, & Beck, 2004; Wykes, Steel, Everitt, & Tarrier, 2008; Zimmermann, Favrod, Trieu, & Pomini, 2005). Several national guidelines also recommend CBT as a routine treatment for patients with a psychotic disorder (Lehman et al., 2004). However, most of the existing CBT studies have been performed on samples of patients with a long-established diagnosis of schizophrenia/psychotic disorder. Relatively few studies have been performed among patients in the early stages of a first-episode psychosis. This is significant as the needs and goals of a patient with a first-episode psychosis may be quite different from a patient with a long history of psychosis and involvement with mental health services. First-episode psychosis patients, besides experiencing hallucinations and delusions, often also suffer from "emotional dysfunction." Emotional dysfunction has been described in the literature as symptoms of depression,

2 2 Sönmez et al. anxiety, and reduced self-esteem. The emotional sequelae associated with receiving a chronic mental illness diagnosis has also been underexamined in the literature for those who are newly diagnosed and experiencing a first episode of psychosis. The importance of emotional dysfunction in first-episode psychosis is reflected by the fact that studies show the highest prevalence rate of suicide and suicidal behavior the first year after the start of treatment (Barrett et al., 2010; Melle et al., 2006; Verdoux et al., 2001). Similarly, people experiencing a first-episode psychosis are likely to experience significant levels of internalized stigma (Brohan, Gauci, Sartorius, & Thornicroft, 2011) anddifficulty adjusting to the labels or diagnoses that are given to them. Such emotional processes may be an important target for treatment intervention in first episode psychosis (Birchwood, 2003; Birchwood and Trower, 2006; Morrison, 2009a). In line with this, Haddock and Lewis (2005) describe the importance of developing treatments that are specific to the different phases of psychotic illness. Specific treatment is especially important in first-episode psychosis as symptoms can change rapidly at this stage, and also because this early stage of the disorder can result in major changes in the patient s life. Rather than applying treatment that is standard across all stages of psychotic illness, treatment programs for first-episode psychosis patients need to be individually tailored to meet the specific needs of each patient. To our knowledge, eight randomized clinical trials (RCT) have examined the effect of CBT on patients with a first-episode psychosis (Edwards et al., 2006; Fowler et al., 2009; Haddock et al., 1999; Jackson et al., 2008; Jolley et al., 2003; Lewis et al., 2002; Power et al., 2003; Tarrier et al., 2004). In four of these studies, the main aim was to reduce positive psychotic symptoms (Haddock et al., 1999; Jolley et al., 2003; Lewis et al., 2002; Tarrier et al., 2004), while the other four studies aimed specifically to reduce suicidality, cannabis use, posttraumatic symptoms and improve social recovery among first-episode psychosis patients, respectively (Edwards et al., 2006; Fowler et al., 2009; Jackson et al., 2008; Power et al., 2003). There is a tendency that studies targeting specific symptoms show better outcome results than studies targeting general psychotic symptoms. Fowler and colleagues reported important benefits among patients with nonaffective psychosis who had social recovery problems, while Jackson et al. proved that CBT is an effective method in helping people adopt to the traumatic aspects of a first-episode psychosis. Power and colleagues showed that CBT is effective in the management of suicide ideation. In a review focusing on CBT and first-episode psychosis, Morrison concludes that there is only modest support for the evidence of the effectiveness of CBT for patients with first-episode psychosis and that the evaluated studies have flaws both in study design and with regard to the extent that the treatment approach and intended goals are relevant to the concerns of patients with first-episode psychosis (Morrison, 2009b). Furthermore, studies examining the effect of CBT for patients with a first-episode psychosis should target specific difficulties for this group of patients, such as depression, anxiety, low self-esteem, PTSD, and a reduction of distress and problematic behavior associated with positive psychotic symptoms. Few of the aforementioned first-episode psychosis studies have specifically targeted problems related to emotional dysfunction. There has been an increased interest in the role of emotions or emotional dysfunction in psychosis during the last decade. The term emotional dysfunction is used interchangeably with symptoms of mood and anxiety disorders, including PTSD, negative schematic beliefs, and reduced self-esteem. According to Birchwood (2003), Birchwood and Trower (2006), and Morrison (2009a), CBT for patients with a first-episode psychosis should aim at developing a case formulation based on the patient s emotional dysfunction, as these problems are common in patients with first-episode psychosis and are related to the development, and the maintenance, of positive (e.g., hallucinations and delusions) and negative (e.g., flat affect and apathy) symptoms. Depression in schizophrenia has a prevalence rate varying between 7% and 75% and is associated with poor outcome, frequent relapse, rehospitalization, and increased suicidality (Caldwell & Gottesman, 1990; Heila et al., 1997; Herz & Lamberti, 1995; Romm et al., 2010; Roy, Thompson, & Kennedy, 1983). The rate of social anxiety disorder in the first year following a first episode of psychosis has been reported to be between 43% and 50% (Cosoff & Hafner, 1998; Pallanti, Quercioli, & Hollander, 2004; Romm et al., 2012). Low self-esteem in individuals with psychotic disorder is also common and may be related to poor clinical outcomes (Barrowclough et al., 2003; Bowins & Shugar, 1998; Romm et al., 2011). Self-esteem is a complex concept comprising appraisal of self-worth based on personal achievements and the anticipated evaluation of others. In psychotic disorders low self-esteem has been implicated both in the development of delusions and the maintenance of psychotic symptoms (Bentall, Corcoran, Howard, Blackwood, & Kinderman, 2001; Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001). Smith et al. (2006) found that low mood, low self-esteem, and negative schematic beliefs can contribute to the development of symptoms of psychosis. Thus, there is a strong case to be made for provision of CBT for patients with first-episode psychosis that focuses on emotional dysfunction in addition to positive symptoms (Birchwood & Trower, 2006). We aim to demonstrate that CBT focusing on different aspects of emotional dysfunction can be a helpful intervention for patients with first-episode psychosis. Two case studies are included.

3 CBT for First-Episode Psychosis 3 Method Participants The two cases presented in this paper are part of a structured pilot program of CBT for emotional dysfunction (e.g., depressive symptoms, social anxiety, and self-esteem) in patients with first-episode psychosis at our university clinic. Materials and Procedure The patients were offered 26 sessions of therapy during a 6-month period and the same therapist treated both cases. The study was approved by the regional research ethics committee. Clinical assessment was carried out by trained psychiatrists and clinical psychologists. Diagnosis was based on the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I) (2004). Symptom level was measured with the Structural Clinical Interview of the Positive and Negative Symptom Scale (SCI-PANSS; Kay, Fiszbein, & Opler, 1987), and the Global Assessment of Functioning Scale (GAF; Jones, Thornicroft, Coffey, & Dunn, 1995) split version (Pedersen, Hagtvet, & Karterud, 2007). Severity of depressive symptoms was assessed using the Calgary Depression Scale for Schizophrenia (CDSS; Addington, Addington, & Schissel, 1990). The CDSS was specifically developed to assess depression in schizophrenia and prevent overlap with negative and extrapyramidal symptoms. Self-esteem was measured using the Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1989). This is a 10-item self-administered questionnaire answered on a 4-point Likert scale, ranging from strongly disagree to strongly agree. A higher score indicates better self-esteem. Two different raters assessed the patients on clinical measures at baseline and at the end of therapy. In order to protect patient anonymity, a number of essential details have been altered in these two case studies. All case reports were anonymized. Written informed consent was given by the two patients described. Case I: Self-Esteem and Depression Background Jonathan is a 27-year-old man with a family history of schizophrenia (mother). He had few friends during childhood and was bullied at school. The other children made jokes about him, but they did not physically abuse him. His psychotic symptoms started when he was 25 years old. The duration of untreated psychosis was 2 years. He started to hear voices that said negative things about him. The voices were unfamiliar to him. After approximately 2 months of hearing voices, he began to experience thoughts of being controlled by the devil. He was admitted to hospital and received antipsychotic medication (Aripiprazol). While an in-patient he received a diagnosis of paranoid schizophrenia. Aripiprazol was effective in reducing his psychotic symptoms, and Jonathan was considered nonpsychotic after a month at the hospital. He lived with his mother during therapy. He was referred to CBT due to low self-esteem and several depressive episodes that occurred before, during, and after the psychotic episode. Engagement In the first session the therapist informed Jonathan about the basic principles of CBT and explained how psychotic symptoms often develop based on the stressvulnerability model (Zubin & Spring, 1977). The importance of active participation and collaboration was emphasized early in the therapy by explaining the importance of homework and developing a problem list and goals for the forthcoming sessions. A particular effort was made to clarify Jonathan's own expectations of the therapy. Problem List and Goals The next step in the treatment process was to make a problem list. As homework, Jonathan made a list of what he thought were the most important aspects of his illness to work with, both during and between therapy sessions. With the help of the therapist, the following list was created: low self-esteem, depression/suicidality, and lack of motivation. Jonathan related his lack of self-esteem to his avoidant behavior in social settings. As Jonathan planned to start studying at the university 2 months after the start of therapy, he and the therapist agreed to focus on how he could manage to follow the schedule at the university. Case Formulation The case formulation developed by Morrison (2001) is displayed in Figure 1. This case formulation is applicable for use by both patients with a first-episode psychosis and therapists. In order to develop a case formulation, Jonathan and the therapist explored a specific stressful situation during the previous week. The formulation aimed to clarify how his thoughts and feelings might be affected by his assumptions about himself, others, and the world. The role of his early experiences and earlier life events in shaping such assumptions was also investigated and included in the case formulation. A friend s question about what Jonathan thought about psychology served as a concrete situation for an ABC formulation. This question generated a thought that others could read signs from Jonathan s face, and therefore could see that he went to a psychologist for treatment. These thoughts triggered a schematic belief that he is boring, different, and ugly, and as a consequence of having these thoughts he became anxious, sad, and paranoid. His reaction to this line of thinking was to withdraw from social situations in order to avoid these unpleasant thoughts and feelings. The case formulation is displayed in Figure 2.

4 4 Sönmez et al. What happened? (Event/intrusion) How I make sense of it Beliefs about yourself and others Life experiences What do you do when this happens? How does it make you feel? Figure 1. Case formulation as described by Morrison (2001). From The Interpretation of Intrusions in Psychosis: An Integrative Cognitive Approach to Hallucinations and Delusions, by A. P. Morrison, 2001, Behavioral and Cognitive Psychotherapy, 29, p Adapted with permission of the author. A friend asks, What do you think about psychology? Do I have a sign on me that says goes to a psychologist? I am boring, different and ugly Mother with schizophrenia, bullied at school Don t socialize Be quiet Sad, paranoid anxious Figure 2. A Case Formulation for Jonathan

5 CBT for First-Episode Psychosis 5 Course of Treatment A situation similar to that described above occurred at a school party where a schoolmate asked him, Is everything ok? Drawing on the ABC formulation: (A) he interpreted this remark as indicating that his schoolmate could see that something was wrong with him and that he was unwell and different from his schoolmates; (B) he started feeling angry, frustrated, and forced into a corner; (C) the next step in therapy was to help Jonathan come up with alternative explanations for his negative thoughts (Table 1). After creating an ABC formulation, the therapist used Socratic questioning to see if there were other ways to interpret and understand the situation. To what extent Jonathan believed in the different interpretations was rated on a scale from 0 (not at all) to100(totally right). After Socratic questioning, his interpretations (Is it something wrong with me? What is wrong with me? Do they think that I am not well? Am I different?), at first rated at 70, were reduced to a rating of 20. As a result of Socratic questioning and an analysis of the situation, Jonathan came up with new and more realistic interpretations: It is kind of my friend to ask and She demonstrates that she cares. He then rated his confidence in these new interpretations of the situations as 80. These alternative interpretations made Jonathan happier and more relaxed. The CBT strategies described above were used repeatedly in therapy and Jonathan gradually began to apply them as part of his homework. As a consequence of this he gained more self-confidence and felt less depressed. Lack of motivation was another item on Jonathan s problem list. He felt that he lacked motivation to do things that he felt everyone else could do, such as visiting friends or going shopping. In order to get an overview of his daily activities, Jonathan was asked to write down all his activities the following week and rate how enjoyable the experiences were with a score from 0 to 100. The assessment of Jonathan s homework in the next session demonstrated that Jonathan in fact was quite active. In particular, he spent time with friends nearly every day, an activity that he rated high on the satisfaction scale. After reviewing this homework exercise he stated, I can now see that I am actually much more active in participating in different activities than I thought I was. The last phase of therapy focused predominantly on Jonathan s schematic beliefs. His basic assumptions were that he was ugly and that no one possibly could like him. Together with the therapist, Jonathan evaluated the evidence for and against this belief. According to Jonathan, the evidence supporting this assumption was: I have no sense of humor, I speak little and I do not come up with anything smart to say, I lack spontaneity and social intelligence. The following line of Socratic questioning was used to challenge these assumptions: What is the advantage of thinking like this? How many people have said that this is the way you are? Will you ever get the right answer concerning these questions and, if so, will you ever trust the answers? According to Jonathan, a close friend described him as interesting, kind, empathetic, polite, open, and positive. Many other friends and family members had also described him in such a way. No one had described him as boring and ugly. He then realized that there were no advantages to thinking in such a way. He also realized that there was no evidence supporting such negative assumptions about himself. As a consequence of this new way of thinking, Jonathan believed less in his negative description of himself and his self-esteem increased. He started to realize that his appraisal of himself did not correspond with other people s viewsof him. This made it easier for him to speak with other people and talk in class at the university. These interventions are illustrated in the transcript from a session in the middle of the therapy (Session 16): THERAPIST (T): You have very often stated that you have no sense of humor, lack spontaneity and social intelligence, and that you are boring and ugly. How many people have actually said that directly to you? JONATHAN (J): Hmmm I am not sure. I don t think anyone actually has said it to me directly No, nobody has.... It is just the way it is. T: But how would one of your friends or your mother describe you? J: I am not sure I think my mother would describe me as interesting, polite, open and positive T: And your closest friends? J: Pretty much the same way, I think. Table 1 An ABCDE Formulation A B C D E A schoolmate asks at a party Is everything ok? Is something wrong with me? What is it about me that shows that everything is not ok? They think that I am unwell. Am I different? Angry, frustrated, forced into a corner. So nice that she is asking. She demonstrates that she cares. Happy, important, well.

6 6 Sönmez et al. T: So how come you don t believe them? J: It s just a fact something I feel strongly inside. I feel that I am boring and lack social intelligence. I have nothing to speak with other people about. Nobody can possibly like me. I am boring and ugly. T: Yes, but nobody has, in your entire life, described you like that. Nobody has ever directly said to you that you are boring and ugly. Do you remember that we talked about different core beliefs that people have and how these beliefs are ideas we have about ourselves? They are not necessarily true or false but we are certainly affected by them. J: Yes I remember. T: Fine. What about if I said that you have no reason to believe that you are boring, ugly, lack spontaneity, and actually most people, including myself, see you as a positive and interesting person. What would you think about that? J: That wouldn t change my opinion about myself. You are paid to say things that cheer me up.... T: What if we went out of the office and I asked my colleagues? J: They wouldn t know. They know nothing about me. T: But if they did? J: They would probably say the same things as you. They are probably all paid to cheer people up. T: If we ask 100 people about how you are, and all described you the way your mother and friends did, would you believe them or would you still think so negatively about yourself? J: I am not sure. Probably... People always say nice things to each other. They want to be polite and don t say negative things about each other. T: Okay. So in fact this is a question that has no correct answer It is impossible to find out whether it is true or false? J: Yes, I think so. T: How come? And how do you think we should deal with that? What if you, say about ten years from now, got an answer you really trusted? The true answer and that answer was in fact more in line with how your mother and friends describe you. What about the fact that you are going to have these negative assumptions about yourself in ten years and then you discover that you really have been thinking wrongly about yourself for no reason at all? J: I see your point, but what if, in fact, I am right that I really am boring and ugly with no social competence? T: Yeah What about that? The worst scenario would be that you would have been satisfied with yourself in all the ten years. I think that would make you more satisfied and less depressed. If it should be correct, ten years from now, that you are a bad and socially incompetent person, then you at least probably would have energy to handle and deal with it. J: There is actually no way I can get the correct answer to this question. You are probably right... The last four sessions in therapy focused on relapse prevention. Jonathan was afraid of a relapse and a resultant hospitalization. The final sessions therefore focused on early warning signals for a psychotic relapse, and also the fact that an increase in symptoms over a short period did not necessarily mean that he would need to be admitted to hospital. Results Case I: Self-Esteem and Depression At the end of treatment (24 sessions), Jonathan showed a major improvement in both his symptoms and functioning. This is illustrated by the split version of the GAF scores used in the present study. At the start of treatment, the GAF symptom score was rated as 47, which increased to 72 by the end of therapy. The GAF functioning score increased from 46 to 70. This constitutes a 25% improvement in functioning and symptoms. During therapy Jonathan s depressive symptoms improved gradually; his suicidal thoughts disappeared, he became more optimistic about the future, had more positive thoughts about himself, was less disappointed about himself, and began to enjoy the company of other people. This considerable improvement in depressive symptoms is illustrated by a decrease from 8 to 2 in the total CDSS score. Consequently, according to the usual cutoff score of the CDSS (CDSS 6), he was no longer depressed at the end of therapy. Self-esteem, as measured by the RSES, improved from 22 to 28 during the intervention. This

7 CBT for First-Episode Psychosis 7 constitutes a 20% increase. Jonathan described a considerable change in his view of himself. At the end of the therapy he was more satisfied with himself and thought that he had a lot of good qualities. He no longer felt ashamed of himself or that everyone else was better than him. Perhaps most importantly, he was no longer afraid of appearing stupid in the presence of other people. Jonathan said that during therapy he had learned to generate more realistic assumptions about himself. He was more relaxed in challenging situations and had learned strategies of dealing with different problems in life. The main outcome measures are illustrated in Figures 4 and 5. The PANSS scores further illustrate the improvement in his symptomatology. The total PANSS scores decreased from 48 to 32. Jonathan was scored with a low total PANSS score at the beginning of therapy and, although there was a decrease in total PANSS score, it was not significant (20% decrease). Concerning the specific PANSS subscales, the PANSS positive symptoms subscale scores decreased from 11 to 8 during treatment, and the PANSS negative subscale scores decreased from 11 to 7. The general psychopathology score on the PANSS decreased from 26 to 17. However, Jonathan s main problem was not the positive psychotic symptoms. Like many other patients with a first-episode psychosis, he rapidly recovered from positive psychotic symptoms after receiving antipsychotic medications, but still struggled with depressive symptoms and low self-esteem. Case II: Anxiety and Depression Background Ann is a 23-year-old woman. She has a brother with schizophrenia. Ann received a diagnosis of unspecified psychosis. She worked as a teacher in primary school. Her psychotic symptoms consisted of auditory hallucinations and somatic delusions. She heard what she described as mumbling and annoying voices. She could not describe what the voices said and they did not seem to come from a specific person. Furthermore, when she looked at herself in the mirror she saw her body changing. She was afraid that she was losing control of her mind and that she was going mad. She refused to use antipsychotic medication. Engagement Engagement with therapy was an important target of the first sessions. Ann had the understanding of her psychosis that something wrong was going on in her mind. Psychoeducation about the different forms of psychotic symptoms was given. In the first phase of therapy an emphasis was put on normalization. Information about the fact that both hallucinations and delusional ideas are frequently experienced by healthy, normal people made her less anxious about her symptoms. Education about situations that often initiate positive psychotic symptoms, such as drug abuse, grief, traumatic events and fever, made her even more relaxed concerning her own experiences. This normalization process was probably of major importance in enabling Ann to engage in therapy. The normalizing process is illustrated in the transcript from the second session: THERAPIST (T): You said the first time we met that you were afraid of going mad and the reason was the fact that you heard voices that no one else did. What kind of voices/sounds were they? ANN (A): It was just some mumbling. They were not really voices... although it sounded like a scream or something. I was terrified. T: Okay, and you started to fear that you were going mad and that you were unable to be with your friends, go to work and concentrate. You panicked and you said that you were more depressed when you thought that you were going mad and unable to function? A: Yes. I was terrified. Especially the first time I experienced this. Now, I am actually more depressed than anxious. T: Do you have any idea about how common it is to hear voices? Do you know, or have you heard about, other people who sometimes have heard voices or sounds? A: No. I have not heard about other people experiencing things like this. Except that I know that the people who hear voices are totally crazy. They are often admitted to hospitals and are not able to function at all. No work and no family or children. T: That s actually not the entire truth.... Actually, many people experience hearing voices or sounds and they are not at all totally crazy. A lot of famous people have actually heard voices. You have probably heard about Gandhi and Anthony Hopkins? A: Yes. Of course I have heard about them. Did they really hear voices? T: Yes, they did, and if you ask people on the street many would say that they sometimes have heard sounds or voices that people standing close to them could not hear. It is actually very common. It is especially common after grief and sorrow and after using drugs.

8 8 Sönmez et al. A: That s interesting. I now remember that one of my friends from high school had a grandmother who heard voices after her husband died. She became better after a while, I think.... T: Yes, she probably did. It is actually quite common in different stressful situations to hear voices. Like you As you told me in the last session, you have gone through some quite stressful periods lately.... Problem List and Goals For homework after the third session, Ann had to write down what kind of problems she wanted to work with in therapy in order of importance. She considered the anxiety she experienced in certain situations as being the most problematic issue. Second on her list were her depressive symptoms, and third were intrusive thoughts (e.g., What if I harm the children at school? ). Case Formulation A specific situation that Ann had recently experienced as disturbing was chosen for the construction of the case formulation. The situation (A) involved Ann sitting at home by herself listening to music. She suddenly had a thought that she was losing her mind and would become mad. She assumed that the world was crazy and that she was evil. These thoughts were followed by an assumption that something was wrong with her (B). She became very anxious, and handled her fear with the use of safety behaviors such as sitting quietly and breathing deeply (C). The case formulation is illustrated in Figure 3. Course of Treatment Clark s (1986) model of panic disorder was used to formulate the fear/anxiousness Ann was experiencing in different situations. For example, listening to music triggered feelings of panic, fear, anxiety, and nervousness. The thoughts she had were that something dangerous is happening to me and I am going mad. The bodily reaction she experienced when having these thoughts was a feeling of being unwell, restless, and overwhelmed. Ann tried to cope with these situations by talking to herself and instructing herself to breathe calmly and think about something else, but these instructions were not helpful in coping with the emotional consequences of the situation. The therapist drew the panic circle on the white-board and explained it in detail to Ann, including examples of safety behavior and an explanation of how such behaviors increase anxiety. One of the safety behaviors Ann used when she experienced anxiety was that she stayed at home, which made it impossible for her to work. The therapist encouraged Ann to start working again. After a closer look at the case formulation she understood that her safety behaviors made her situation worse. After 2 weeks in therapy she returned to work and the symptoms of nervousness and anxiety became less troublesome, although she occasionally still had the thought, What if I am going mad? Alone at home, listening to music I am losing my mind. I am going mad The world is crazy. I am evil. There is something wrong with me. Brother with schizophrenia Sit calmly Breathe deeply Anxious, fear Figure 3. A Case Formulation for Ann

9 CBT for First-Episode Psychosis 9 Psychoeducation and Socratic questioning made this thought less stressful for her. The therapist asked such questions as, What do you mean by going mad? and Are these thoughts really dangerous? Focusing on her fear helped Ann to reduce the fear and anxiety that had been very stressful for her. However, the fear was to some extent replaced by depression. In order to address this issue in therapy, the content of Ann s depressive thoughts was identified. She stated that she felt alone, different, not interested in other people, not able to be herself, having differing values than others, and feeling something heavy in herself which she described as a big lump. As a consequence of experiencing these negative thoughts, the focus on the following sessions was on Ann s depression. However, she said that there were some advantages to having these depressive thoughts, and that she was not quite sure if she wanted to get rid of them. She thought that she would become less reflective, less empathetic, and stupid, but also happier and more sociable if she were to stop having these depressive thoughts. As a homework exercise she was asked to write down pros and cons for her assumptions, and to what extent she wanted to work with this in the therapy. She concluded that she wanted to address this problem in therapy, and the forthcoming sessions were mainly focused on the pros and cons for having depressive symptoms. According to Ann, the use of Socratic questioning helped her to see that there was no reason to believe that getting rid of her depression would make her less reflective, less empathetic, and less intellectually deep. The final sessions focused on relapse prevention and means of preventing the use of safety behaviors as a strategy for getting rid of unwanted thoughts and feelings. Ann reported feeling better at the end of therapy (21 sessions) with regard to symptoms and functioning. She was working regularly as an assistant in a primary school and planned to start studying at the university the following semester. Ann was mostly troubled with anxiety and depression, while at the start of therapy she had a relatively normal level of functioning and self-esteem. Her improvement is illustrated in her GAF symptom scores, which increased from 57 to 70 (13 %), and her GAF function score, which increased from 68 to 73 during treatment (5%). Ann s anxiety and fear of losing control resolved quickly after psychoeducation and normalizing procedures of her symptoms. Furthermore, she improved by focusing on the negative consequences of her safety behavior (breathing deeply, sitting quietly, and not going to work). Of primary importance concerning her improvement was the fact that she went back to work only 2 weeks after starting treatment. Ann was considerably depressed at the start of treatment. She had no suicidal thoughts but was pessimistic about the future, felt that she was a failure and was disappointed about herself. She had also lost her interest in other people and easily became tired. These depressive symptoms disappeared during treatment, which is illustrated by the CDSS score. Ann scored considerably lower on the CDSS, with a decrease from 8 at the start of treatment to 1 at the end of treatment. Her self-esteem was quite high at the start of treatment with a score of 30 on the RSES, which increased to 32 by the end of treatment. The main outcome measures are illustrated in Figures 4 and 5. The PANSS positive symptoms subscale score decreased from 13 to 11, and the negative subscale decreased from 9 to 7 from the start to the end of treatment. Although she receive no antipsychotic medication, the general psychopathology subscale reduced from 25 to 18. As with Jonathan, the focus in therapy was not aimed at reducing positive psychotic symptoms. Discussion Treatment programs for first-episode psychosis patients need to be individually tailored in order to meet the unique and specific needs of each patient. This individualization should be a general rule for every therapy, but is especially crucial for first-episode psychosis patients because this patient group has a wide variation in symptoms, problems, and goals. As illustrated in the two cases described in the present paper, Jonathan struggled mostly with depressive symptoms, low self-esteem, lack of motivation, and reduced social functioning, and Ann mostly with anxiety, depression, intrusive thoughts, and auditory hallucinations (mumbling voices). Consequently, the CBT interventions in the two cases were quite different. The effectiveness of CBT in the treatment of different psychiatric disorders, including chronic psychosis and schizophrenia, has been demonstrated (Turkington et al., 2004; Wykes et al., 2008; Zimmermann et al., 2005). As the treatment of first-episode psychosis patients is usually focused on hallucinations and delusions, which respond quickly to antipsychotic medication, it has been difficult Start of therapy End of therapy GAF Symptoms GAF Function GAF Symptoms GAF function Case I Case II Figure 4. GAF Symptoms and Function Before and After Treatment for the Two Cases

10 10 Sönmez et al. Depressive symptoms Self esteem Start of treatment 20 Start of therapy End of treatment End of therapy CDSS CDSS Self esteem Self esteem Case I Case II Case I Case II Figure 5. Depressive Symptoms and Self-Esteem for the Two Cases Before and After Treatment to demonstrate the efficacy of CBT alone. However, emotional dysfunction is prevalent in patients with firstepisode psychosis. Depressive symptoms, social anxiety, and low self-esteem have major consequences for these patients functioning and quality of life, and therefore should be dealt with specifically within therapy. Few studies examining the efficacy of CBT for patients with psychotic disorders have specifically targeted emotional dysfunction and used this as the primary outcome measure. However, a secondary effect of targeting hallucinations and delusions with CBT has been shown to be less depressive symptoms in patients with chronic psychosis (Gilbert et al., 2001; Trower et al., 2004). The problems Jonathan presented in therapy are characteristic for patients with a first-episode psychosis. He responded quickly to antipsychotic medication and the positive psychotic symptoms were no longer problematic for him. After this treatment, his predominant symptoms were depressive symptoms, low self-esteem, and reduced social functioning. In therapy, the therapist and Jonathan worked with his core beliefs that he was stupid, ugly, and that nobody possibly could like him. A more realistic view of himself was probably the main reason for the improvement both in symptom and social functioning. Ann reported some auditory hallucinations (mumbling voices) when she began therapy. She refused to take antipsychotic medications and stated that her hallucinations were very weak and were experienced as being quite unproblematic for her, but made her afraid of losing her mind. The use of psychoeducation and normalizing procedures related to these voices helped and reduced her worry of losing her mind and becoming mad. As a result of treating the anxiety symptoms by reducing safety behavior and explaining bodily misinterpretations, her anxiety symptoms disappeared and were no longer a problem for her. As a consequence of no longer being so anxious, the mumbling voices also faded away. It seems that focusing on her anxiety, fear of losing control, and depressive symptoms also decreased her positive psychotic symptoms (mumbling voices). This was most likely due to the fact that targeting these symptoms made her less distressed and, consequently, less bothered by her positive psychotic symptoms. As some studies suggest, one could speculate whether emotional dysfunction is an underlying factor that can cause, or worsen, positive psychotic symptoms (Gumley et al., 2006; Smith et al., 2006). Consequently, treating such symptoms would be followed by a reduction in hallucinations and delusions. Existing models of psychosis, which are based on the emotional literature (Morrison, 1998, 2001) are, as these two cases illustrate, appropriate for this kind of work. However, it is debatable whether more specific models targeting panic, social anxiety, and low self-esteem would be more fit for purpose. The existing models of psychosis based on emotional dysfunction are certainly more generalizable to other presenting problems that frequently appear among first-episode psychosis patients, including hallucinations and delusions. On the other hand, the specific models might be more effective for specific difficulties. It could be argued that forthcoming studies should aim at specifically focusing on social anxiety, depression, or self-esteem, respectively, in first-episode psychosis patients. However, as studies have shown, these problems are closely related in patients with psychosis, and in clinical practice need to be targeted together under the heading of emotional dysfunction. The present study has several limitations. It is an uncontrolled case study and therefore other factors may have contributed to the observed improvement of symptoms (e.g., medication and time). However, one of the

11 CBT for First-Episode Psychosis 11 patients refused medication and still improved. A randomized controlled trial examining the effect of CBT in emotional dysfunction among first-episode psychosis patients is needed and is under way. We propose that individually tailored CBT, focusing on depression, anxiety, and low self-esteem, would be effective in the treatment of first-episode psychosis patients, as has been suggested previously (Birchwood & Trower, 2006; Morrison, 2009a, 2009b). The two cases presented in this study demonstrate that CBT is applicable and acceptable to first-episode psychosis patients and that individually adjusted case formulations are essential for planning and designing therapy. This necessitates a continuous updating of case formulation and the patient s problem list in order to satisfy the patient s specific needs in different phases of the therapy. References Addington, D., Addington, J., & Schissel, B. (1990). A depression rating scale for schizophrenics. 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Canadian Journal of Psychiatry, 43, Brohan, E., Gauci, D., Sartorius, N., & Thornicroft, G. (2011). Self-stigma, empowerment and perceived discrimination among people with bipolar disorder or depression in 13 European countries: The GAMIAN-Europe study. Journal of Affective Disorders, 129, Bustillo, J., Lauriello, J., Horan, W., & Keith, S. (2001). The psychosocial treatment of schizophrenia: An update. American Journal of Psychiatry, 158, Caldwell, C. B., & Gottesman, I. I. (1990). Schizophrenics kill themselves too: A review of risk factors for suicide. Schizophrenia Bulletin, 16, Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, Cosoff, S. J., & Hafner, R. J. (1998). The prevalence of comorbid anxiety in schizophrenia, schizoaffective disorder and bipolar disorder. Australian and New Zealand Journal of Psychiatry, 32, Craig, T. K., Garety, P. A., Power, P., Rahaman, N., Colbert, S., Fornells-Ambrojo, M., & Dunn, G. (2004). The Lambeth Early Onset (LEO) Team: Randomised controlled trial of the effectiveness of specialised care for early psychosis. BMC Psychiatry, 6, 329. Edwards, J., Elkins, K., Hinton, M., Harrigan, S. M., Donovan, K., Athanasopoulos, O., & McGorry, P. (2006). Randomized controlled trial of a cannabis-focused intervention for young people with firstepisode psychosis. Acta Psychiatrica Scandinavica, 114, Fowler, D., Hodgekins, J., Painter, M., Reilly, T., Crane, C., Macmillan, I., et al. (2009). Cognitive behaviour therapy for improving social recovery in psychosis: A report from the ISREP MRC Trial Platform Study (Improving Social Recovery in Early Psychosis). Psychological Medicine, 39, Garety, P. A., Craig, T. K., Dunn, G., Fornells-Ambrojo, M., Colbert, S., Rahaman, N., Power, P. (2006). Specialised care for early psychosis: Symptoms, social functioning and patient satisfaction randomised controlled trial. British Journal of Psychiatry, 188, Garety, P. A., Kuipers, E., Fowler, D., Freeman, D., & Bebbington, P. E. (2001). A cognitive model of the positive symptoms of psychosis. Psychological Medicine, 31, Gilbert, P., Birchwood, M., Gilbert, J., Trower, P., Hay, J., Murray, B., Miles, J. (2001). An exploration of evolved mental mechanisms for dominant and subordinate behaviour in relation to auditory hallucinations in schizophrenia and critical thoughts in depression. Psychological Medicine, 31(6), Gould, R. A., Mueser, K. T., Bolton, E., Mays, V., & Goff, D. (2001). Cognitive therapy for psychosis in schizophrenia: An effect size analysis. Schizophrenia Research, 48, Gumley,A.F.,Karatzias,A.F.,Power,K.F.,Reilly,J.F.,McNay, L. F., & O'Grady, M. (2006). Early intervention for relapse in schizophrenia: Impact of cognitive behavioural therapy on negative beliefs about psychosis and self-esteem. British Journal of Clinical Psychology, 45, Haddock, G., & Lewis, S. (2005). Psychological interventions in early psychosis. 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American Journal of Psychiatry, 154, Herz, M. I., & Lamberti, J. S. (1995). Prodromal symptoms and relapse prevention in schizophrenia. Schizophrenia Bulletin, 21, Jackson, H. J., McGorry, P. D., Killackey, E., Bendall, S., Allott, K., Dudgeon, P., Harrigan, S. (2008). Acute-phase and 1-year follow-up results of a randomized controlled trial of CBT versus Befriending for first-episode psychosis: The ACE project. Psychological Medicine, 38, Jeppesen, P., Petersen, L., Thorup, A., Abel, M. B., Oehlenschlaeger, J., Christensen, T. O., Nordentoft, M. (2005). Integrated treatment of first-episode psychosis: effect of treatment on family burden: OPUS trial. British Journal of Psychiatry, Suppl 48, Jolley, S., Garety, P., Craig, T., Dunn, G., White, J., & Aitken, M. (2003). Cognitive therapy in early psychosis: A pilot randomized controlled trial. Behavioural and Cognitive Psychotherapy, 31, Jones, S. H., Thornicroft, G., Coffey, M., & Dunn, G. (1995). 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