17th Sep 2004 journal presentation
Cognitive therapy for command hallucinations
Peter Trower
Max Birchwood
Alan Meaden
Sarah Byrne
Angela Nelson
Kerry Ross BJP 2004,184, 312 – 320
17th Sep 2004 journal presentation
Command hallucinations
Distressing hallucinatory experience which commands the patient to do certain acts
Suicide, violent acts, self harm commonWho obeys (31% comply)? Who resists?High risk symptomRelatively common (53% median
prevalence)
17th Sep 2004 journal presentation
Common findings
Hospitalisation does not have any effect on people who comply to the commands
Cognitive Rx appropriate(Birchwood 2000)
The voices of the patients had social rank superiority than the hearers
17th Sep 2004 journal presentation
Principles of cognitive therapy
Social rank theory-Gilbert, Derby 1992 The social rank theory of
psychopathology suggests that with the evolution of social hierarchies various psychobiological mechanisms became attuned to the success or failure in conflict situations. Specifically, subordinates and those who have lost status are at greater risk of pathology than winners and those of higher status.
17th Sep 2004 journal presentation
Principles of cognitive therapy
Voices had social rank superiority
Authors developed CTCH program
‘Reducing the perceived power of voices’Powerless commanders
17th Sep 2004 journal presentation
Hypothesis
CTCH group would show a lower level of compliance & appeasement behaviour with increase in resistance.Secondary outcome:
‘Lower conviction in power and social rank of voices’
17th Sep 2004 journal presentation
Resistance
Compliance
Appeasement behaviour
Conviction of power
Distress
Depression
Frequency, loudness
content
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Method
Birmingham, Solihull, sand well & w.midlands unit for offenders
38 patients Inclusion criteria: ICD-10 , schiz, 6 months
of command hallucinations. Recent h/o commands, harm to self and
others and forensic Exclude: alcohol & addictive disorders
17th Sep 2004 journal presentation
Design of the trial
Single blind , intention to treat randomised control trial
Sep –2000 to July – 2002 Interview, consent & eligibility CTCH group Vs TAU
C.B.Treatment group Vs treatment as usual group
17th Sep 2004 journal presentation
Procedure
Computerised randomisation Research associate - blind to
allocation at baseline and post testing
Post tests after 6 months and 12 months follow-up
Power calculations: 23 in each group , power of 0.9 , =0.05
17th Sep 2004 journal presentation
Measures
Cognition:The Cognitive Assessment Schedule (CAS; Chadwick & Birchwood, 1995) is a measure of the individual’s feelings and behaviour
Beliefs About Voices Questionnaire measures key beliefs about auditory hallucinations ‘engagement’ and ‘resistance’
17th Sep 2004 journal presentation
Measures
Voice Compliance Scaleobserver-rated scale to measure the frequency of command
hallucinations and level of compliance/resistance with each
identified command. 1.neither appeasement or compliance 2.symbolic appeasement, Harmless commands 3.appeasement , preparatory gestures 4.partial compliance , with at least one severe command 5.full compliance
17th Sep 2004 journal presentation
Measures
Voice Power Differential scalemeasures the perceived relative power differential between
voice and voice hearer. Each is rated on a five-point scale
Omniscience Scalevoice hearer’s beliefs about the knowledge of their voice
regarding personal information.
PANSS, PSYRATS,CDSS
‘Birchwoood : CAS,BAVQ,VPDS,OS
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TREATMENT AS USUAL
TAUThis was delivered by community mental health teams 18 categories of service and admissions
OP,CPN,DAY CARE, SW,SUPPORTED ACCOMODATION, SUPPORT WORKER,CDT,PROBATION OFFICER,OT,PSYCHOLOGIST,RESPITE,HOME TREATMENT,ART Rx,VOICES GROUP,ECT,ADMISSIONS,GUARDIANSHIP
17th Sep 2004 journal presentation
CTCH GROUP
The key foci of the assessment, formulation and intervention :
• that the voice has absolute power and control• that the client must comply or appease, or be severely punished• the identity of the voice (e.g. the Devil)• and the meaning attached to the voice experience
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CTCH Know How?
Collaborative empiricism,Socratic dialogue Challenge power beliefs
Behavioural tests to undermine Gain disconfirming evidence
Build alternative beliefs in their power and status If possible explore origin of schema Protocol by M.B & P.T, administered by
psychologist and supervised by team
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Medication : cpz equivlaents at 6 & 12 months of trial
Statistical analysis:
Generalized Linear Interactive Modelling Program (GLIM) in the Statistical Package for the Social Science for Windows, version 10
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Sample description – consort
17th Sep 2004 journal presentation
Types of commands
2 or more Kill self-25, kill others-13,harm self-12, harm others-14 Innocuous commands High risk of compliance
79% compliance 37% appeased 76% expressed fear about voices
High compliance rate = recent compliance as inclusion criteria
5 persons cautioned due to behaviour linked to hearing voices.(GBH,theft,common assault, attempt to kill in the last 3 years)
17th Sep 2004 journal presentation
Commands &Compliance
Kill self: 12 /13 Stab yourself,slash your wrists,hang yourself, gas yourself
9 attempted, 1 completed / 7 collecting tabs, taking blades to bath Kill others: 6 / 7
Cut her throat,kill therapist,kill your husband and wife, go and kill someone
4 attempted / 3 arming themselves with bats, axe tin foil guns Harm self: 9 / 3
Cut yourself, burn yourself, go in to the road9 harmed - cutting swallowing / 3 wound picking, standing on kerb
Harm others: 8 / 6 Touch your children, kick them, beat the person up
7 hit others / 2 touching,, mild hitting – covert appeasement
17th Sep 2004 journal presentation
Clinical &Demographic patterns
36.635.1
1014
86
0
5
10
15
20
25
30
35
40
age male female
ctch
tau
17th Sep 2004 journal presentation
Psychopathology
20.4
13.4
8.8 10
0
5
10
15
20
25
duration of
voices
duration of
commands
CTCH
TAU
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Psychopathology
4
0
6
11
55
12
12
100
2468
1012
ctch
tau
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Scores
21.920.8 20.8
21.5
36.335.9
05
10152025303540
panss+
panss-
gen.psypath
ctch
tau
17th Sep 2004 journal presentation
Impact of CTCH-Compliance
4.8
3.13.4
0
1
2
3
4
5
ctch
tau
Both: p<0.0001Ctch –6mth: p<0.036
Ctch –12: p<0.001
V.C.SCORES
17th Sep 2004 journal presentation
Drug’s role??
T.A.U
C.T.C.H
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Beliefs / topography / distress
POWERvpd
MALEVOLENCEbavq
OMNISCIENCEbacq
DISTRESSpsyrats
FRQUENCYpsyrats
LOUDNESSpsyrats
NEGATIVE CONTENTpsyrats
DEPRESSIONcdss
CONTROLpsyrats
17th Sep 2004 journal presentation
+ Impact of CTCH
0
5
10
15
20
25
30
cbt-bcbt-6
cbt-12
tau-btau-6
tau-12
power
omnisc ience
control
17th Sep 2004 journal presentation
power and compliance
Covariate analysis to prove power of voices influences compliance
V.P.D
Pre-rx
Compliance scores
Post –rx
Compliance scores
Post rx complianceNormal & intervention
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Distress & depression
0
2
4
6
8
10
12
14
cbt-
6
cbt-
12
tau-
6
tau-
12
distress
depression
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Topography of voices -outcome
00.5
11.5
22.5
33.5
4
cbt-bcbt12tau-btau-12
frequency
- content
loudness
17th Sep 2004 journal presentation
Correlations??? Correlations between voice compliance, distress, power
and omniscience of disobedience
17th Sep 2004 journal presentation
Psychotic SymptomsPsychotic Symptoms
PANSS+PANSS+PANSS-PANSS-
G.PSYPATHG.PSYPATH
CBTCBT1212
CBTCBT66
T.A.UT.A.U66
T.A.UT.A.U1212
PANSS+PANSS+
T.A.U 12T.A.U 12PANSS-PANSS-
G.PSYPATHG.PSYPATH
P<0.001
FOLLOW UP AT 6 & 12 MONTHS
17th Sep 2004 journal presentation
HALLUCINATIONSHALLUCINATIONS
DELUSIONSDELUSIONSANXIETYANXIETYTENSIONTENSION
GUILTGUILTVOLITION PROBLEMSVOLITION PROBLEMS
ATTENTION PROBLEMSATTENTION PROBLEMS
PANSS+ & MEDSPANSS+ & MEDS
17th Sep 2004 journal presentation
Reduction in compliance
CTCH+ TAU : Reduces distress, prevents depression worsening Reduces risk of compliance
12 months clinical impact of CBT significant Risk factors for compliance reduced significantly
Percived power of voices Omniscience Controllability Need to appease
17th Sep 2004 journal presentation
Change in beliefs
CBT is more effective in delusional beliefs No effect in primary psychotic experience
Auditory hallucinations and any of its elements Negative content
Reduction of Panss + is modest & consistent Due to changes in delusional convictions, BUT NOT
experience
17th Sep 2004 journal presentation
Validity
Not a straightforward concept Should be measured not only by self reports : case managers,
key workers and relatives Extarneous factors:
Medication Use of services Halo effect – no change in voices??? Drugs also reduced compliance to commands TAU participants were under medicated?? – both groups >BNF
limits Non-specific aspects of therapy
17th Sep 2004 journal presentation
Qualitative feedback
I know now that the voices can’t hurt me – I feel that I am in control now. I still hear the voices but they are not as powerful.’
‘all the techniques that she [S.B.] taught me; not only have the voices disappeared, but I am sleeping and eating properly now’
17th Sep 2004 journal presentation
Limits
Small sample size
Need for multi-centre experience
Too imprecise
Need for specific questions
Strong
55 % participation
27% dropout
Positive outcome