Matcheri S Keshavan MD Harvard Medical School, and University of Pittsburgh

1. Psychotherapy in Psychotic disorders: Principles and practice of Personal therapy Matcheri S Keshavan MD Harvard Medical School, and University of Pittsburgh NIMH MH 60902, 92440 and 105596; Disclosures: Sunovion, Otsuka

2. Psychosocial treatments in schizophrenia: a historical overview Disorder relevant interventions SST Personal therapy Tandon, Nasrallah and Keshavan Schiz Res 2010

3. Effects of psychotherapy in schizophrenia: II. Comparative outcome of two forms of treatment.Gunderson et al Schiz Bull 1984;10(4):564-98. Psychoanalytic therapy is largely ineffective

4. Major role therapy: -Psychotherapy (if used alone) is ineffective Hogarty et al 1974

5. Family therapy reduces relapse rates

6. Multi-family therapy is effective in maintaining remission McFarlane et al 1995

7. Psychoeducation may prevent relapse

8. Key aspects of schizophrenia relevant for personal therapy: Schizophrenia is.. • A disease of Brain Development • A disease of risk and diathesis (Zubin: Environmental stress- Biological vulnerability model) • A disease of stages • A disease of affect as well as cognition.

9. Schizophrenia is related to the normal pruning of gray matter going haywire

10. Gray matter loss might heighten stress responsivity (Zubin)

11. Schizophrenia is a Cognitive and an affective disorder • Pervasive cognitive deficits • Speed • Memory • Attention • Reasoning • Tact • Synthesis • Affect(the “affective paradox”) • Decreased expression • Increased arousal • Impaired regulation

12. Affective symptoms (40-50 %) Depression Anxiety Stress induced relapses Cognitive (80-90%) Working memory Selective attention Positive symptoms (40-50 %) Hallucinations Delusions Loose associations Functional Impairment Cognitive impairment Strongly predicts Functional outcome Negative symptoms (60-70 %) Avolition Anhedonia Anergia Asociality Alogia

13. Schizophrenia is a disorder of stages Recovery Prodromal Transitional Premorbid Psychotic Premorbid alterations Decline begins in prodrome Post-illness onset Functional decline Psychosis Typically begins in adolescence Psychosis is actually a “late”stage of schizophrenia!

14. Psychological aspects of schizophrenia vary with the phase of the illness and can be prevented/minimized. Prevention/early intervention Stabilization/ relapse prevention Remediation Integration Personal therapy Recovery Prodromal Transitional Premorbid Psychotic Psychosis Denial/ non-compliance Stress sensitivity, Depression/ anxiety Social incompetence Cognitive impairment

15. Psychoanalytic Reality-adaptive therapy (Gunderson), Major role therapy (Hogarty) Psychoeducation (Dixon) Family psychoeducation (Leff) Social skills training (Liberman) Cognitive Behavioral treatments Personal therapy (Hogarty) Cognitive enhancement therapy Hogarty, Flesher, Eack, Keshavan Faulty defenses, regression to earlier developmental stages Early case management and supportiive help Increasing illness awareness Primary environmental stress modification Correcting maladaptive behavioral excesses or deficits Correcting faulty cognitive schemata Recognition, self monitoring and adaptive control of psychotic prodromes Systematic rebuilding of cognitive and social cognitive abilities Toward second- generation, disorder-relevant Psychotherapies for schizophrenia Keshavan and Eack, 2014. in: Treatment of Psychiatric Disorders, Gabbard G. Ed. American Psychiatric Press.

16. Psychotherapeutic interventions in schizophrenia: effect sizes in meta-analyses .

17. Key principles of Enriched supportive therapy (Personal therapy) • Integrated composite of CBT, psychoeducation and basic social skills training principles • Disorder relevant practice principles • Gradual staging of interventions • Centrality of affect dys-regulation

18. Hogarty et al 1995

19. Personal therapy Goals: Phase 1 (3-6 months): • Illness education • Goal setting and progression • Internal coping • Basic stress avoidance skills Hogarty et al 1995

20. Psychoeducation • Schizophrenia as a “no-fault” brain disorder • Tailored to individual’s illness stage and ability to process • Correcting mis-information (e.g. that it is a split-mind disorder, that it is incurable, etc) • Initially provided in a formal educational workshop followed by individual sessions • Teaching pathophysiology (e.g. dopamine imbalance) as connected to treatments (e.g. antipsychotic medications) • Emphasis on risk- liability models (e.g. asthma, high blood pressure) • Some repetition is good; emphasize interaction

21. Resumption of daily tasks • Goal setting: Start from basic steps ( Focus on self care personal hygeine, nutrition, sleep) • Set up reasonable goals: “Internal yardstick” approach • Expectations to be adjusted to clinical state • Connect small goals to larger, long term goals • Expect set-backs; “ one step back and 2 steps forward rule) How do I measure Up to myself, then and now? How do I measure Up to them?

22. Internal Coping • Understanding schizophrenia as an environmentally sensitive psychobiological illness • Identification of what patient means by “distress”, in his own words • Identifying the interpersonal context or life event with which he/she associates this distress • Identification of internal cues of affect dys-regulation (prodromal signs) • Identification of patient’s existing autoprotective strategies to cope with stress (helpful as well as unhelpful) • Stress avoidance skills: Reinforcing prosocial statements; “one thing at a time”

23. Early or Warning Signs of Psychosis Social Sensitivity and irritability when touched by others Refusal to touch persons or objects; wearing gloves, etc. Severe deterioration of social relationships Dropping out of activities - or out of life in general Social withdrawal, isolation, and reclusive Unexpected aggression Suspiciousness  Emotional Inappropriate laughter Inability to cry, or excessive crying Feelings of depression and anxiety Inability to express joy Euphoric mood Personality Reckless behaviours that are out of character Significantly prolonged drops in motivation or speech Shift in basic personality. • Behavioral • Strange posturing • Odd or bizarre behavior • Excessive writing without meaning • Cutting oneself; threats of self-mutilation • Deterioration of personal hygiene • Hyperactivity or inactivityStaring • Agitation • Sleep disturbances • Drug or alcohol abuse (This may be a coping mechanism: self-medicating) • Thinking and Speech • “Things seem changed in some way” • Rapid speech that is difficult to interrupt • Irrational statements • Preoccupation with religion or occult • Peculiar use of words or odd language • Unusual sensitivity to stimuli (noise, light, colours, textures) • Memory problems • Severe distractibility  Herz and Melville 1985

24. Reinforcing adaptive auto-protective strategies • Passive distraction (e.g. radio or TV) • Active distraction (reading, writing) • Change in environment (e.g. going for a walk) • Supportive contact (calling family, friends) • Exercise • Calling therapist Adaptive Maladaptive • Alcohol/ drugs • Excessive sleep • Smoking • Social withdrawal • Excessive praying • Self-protective measures (e.g. sleeping with a weapon)

25. Basic stress avoidance skills • Role restructuring (e.g. reduce class load, cut down on extracurricular activities • Conflict avoidance • Avoiding behaviors that evince negative reactions from others • Taking breaks • Positive assertions • Complements • Positive self statements Role play and Homework for all above goals

26. Personal therapy: stages (contd) • Phase II (intermediate; 7- 18 months) • Continued psychoeducation (goal: self- awareness; recognition of prodromal signs of relapse • Acquisition of adaptive techniques: Relaxation training; guided imagery/ music; active distraction techniques; basic conflict resolution skills Hogarty et al 1995

27. Intermediate phase of PT: Goals • Maintenance and enhancement of clinical stability • Managing comorbidity- depression, anxiety, substance abuse • Minimizing side effects • Achieving minimal effective dose • Monitoring and addressing suicidality • Personalized crafting of psychoeducation • 20-30 minute interactive sessions on cues of distress, incremental conflict avoidance skills, concepts of disability and adjustment to it • Increasing resumption of responsibilities within home • Adjustment to disability

28. Resumption of household responsibilities • Go with patient’s own choice • Simple, relevant, feasible, compatible with clinical state • Avoid unreasonable expectations • Consider cooperative sharing with another family member • Progressive increase in complexity • Consider timing (maximize at times of highest enegy) • Revisit stress- vulnerability model regularly

29. Adjustment to disability • Exclusive strengths based approach may be counterproductive • Address denial, “Flight to normalcy” • Learning what to say and not say about one’s illness

30. Other techniques • Deep breathing and simple relaxation • Visual imagery • Criticism management

31. PT advanced phase (Interfaces and overlaps with Cognitive enhancement therapy19- 36 months) • Psychoeducation with a greater emphasis placed on the refined assessment of genuine, individual prodromes. • Addressing social and cognitive deficits, “one step at a time” • Managing Criticism, an assessment of its validity, learning a repertoire of verbal and behavioral responses designed to lessen the other person's intensity and to enhance the patient's social perception and negotiation skills • Advanced internal coping strategies include progressive relaxation training, which is designed to reduce autonomic arousal. • Independent application of various PT strategies in differing social contexts,

33. Conclusions • Schizophrenia is a developmental disorder of affect, behavior and cognition • Schizophrenia sequentially evolves with prodromal and psychotic phases Characterized by psychosis and affective dysregulation, followed by a transitional phase with recurrent relapses before finally a stable, chronic phase sets in, primarily with cognitive and negative symptoms • Treatment is best tailored to the aspects of illness prominently manifesting at the specific phases of the illness • Personal therapy is designed as a compehensive, step-wise approach to early phases of schizophrenia, involving psychoeducation, stress management and development of coping skills, setting a stage for rehabilitative approaches such as cognitive remediation