Dickerson (2000) compared CBT with other non-specific psychology interventions in 20 studies and found the effects of CBT to be of lower significance when controlled for therapy time. Although previous research has shown CBT to be affective compared to routine care, more research is needed to compare it to other therapies.
There is now strong evidence and clinical support for the implementation of CBT as part of the standard management of patients with residual symptoms of schizophrenia. Antipsychotic drugs have undesirable side affects which may be the cause of low compliance rate (Healy et al, 1998). CBT offers an alternative approach which allows for the personal growth of patients as well as illness management. Further investigation into the efficacy of CBT is still required, as well as impact on relapse rates and quality of life. The results of Valmaggia et al (2005) still needs to be addressed to ensure that CBT has positive long term affects and that it works on both positive and negative symptoms.
Bipolar Disorder:
Bipolar disorder, previously known as manic-depressive illness, and is most commonly diagnosed in persons between 18 and 24 years of age. It’s characterized by moods that swing between two opposite poles. People who suffer from this disorder experience episodes of depression and periods of mania (with exaggerated euphoria, irritability, or both). Bipolar disorder is frequently associated with co-morbid conditions including substance abuse and anxiety disorders. Although chemical imbalances in the brain are a key component of bipolar disorder, it is said to be a complex condition that involves a mixture of factors, which could be reflected in appropriate treatment.
Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. Cognitive behavioural therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviours associated with the illness. It was recently thought by Winter (1994) that bipolar disorder patients were incompatible with individual psychotherapies due to concerns that uncontrolled manic or psychotic disorders with associated impulsive, disruptive or uncooperative behaviours were incompatible with ration discussion, self assessment and learning.
Cochran (1984) investigated the efficacy of routine care when supplemented by CBT in treating bipolar disorder in 14 randomly selected patients, compared to 14 patients just receiving routine care. He assessed patients after 3 and 6 months and found CBT-treated patients to have lower rates of medication non-adherence and lower rates of hospitalization compared to controls. Zaretsky, Segal, Gemar (1999) evaluated the effects of CBT combined with medication and just medication, following CBT patients sustained a 64% reduction in measures of depressive symptoms, how ever improvements in dysfunctional thinking proved insignificant.
Lam, Bright, Jones, Hayward, Schuck, Chisolm et al (2001) recently compared 12 patients who received CBT and routine care to 11 patients who received routine care alone, both for 6 months. They found at the end of the 12 month follow up period, patients receiving CBT to report “fewer recurrent episodes, greater affective stability and improved overall functioning and better compliance with prescribed medication.” The studies brought down do show a mix of findings. On the whole they indicate CBT to have a significant improvement on treatment compliance by the patient but not on all aspects of patient well being.
This was reflected in a summary of recent psychotherapy treatment by Blagys and Hilsenroth (2002) who found the relationship between CBT and patient outcome has yielded discrepant results. While some authors have demonstrated a favourable relationship between specific CB processes and patient improvement (Feeley, DeRubeis, Gelfand, 1999; Tang and DeRubeis, 1999; Tang and Whisman, 1993) whilst other researchers have reported a lack of (or negative) relationship between specific CBT interventions and outcome.
This essay needs to address whether CBT specifically performed any better then the other psychotherapies mentioned in order to understand its contribution to treatment. Sullivan (2005) comments that psychotherapy by itself regardless of whether its cognitive, behavioural, or psychodynamic, has not been proven effective in the treatment of bipolar affective disorder. He attributes this to the fact that bipolar is of biochemical etiology, requiring the use of medication to stabilize the basic mood disorder. Sullivan (2005) notes that there is often unsatisfactory response to medication alone. That’s why psychotherapy is a useful adjunctive treatment and helps bipolar sufferers to understand their illness and the stresses of their everyday lives that may trigger an episode. It will also help restore lost self esteem and teach ways to prevent relapses.
However, Shwartz and Frank (2001) found psychotherapy to be marginally favoured over antidepressant medication as a strategy in treating bipolar disorder. They claim that with the exception of CBT, there are no descriptions of psychotherapies employed specifically for the treatment of bipolar depression.
Even so, lithium is considered first line of treatment as its effective for 60-67% of patients. It does come with considerable side affects which could be a factor in the 75% non compliant over a year, which predicts rehospitalisation and suicidality. Many reports (Baldessarini, Tondo, 1998; Maj, Pirozzi, Magliano, Bartoli, 1998) have highlighted other disadvantages in the lithium treatment. They found patients to have low tolerance, to report unsatisfactory outcomes in clinical settings and the early recurrence of bipolar after rapid discontinuation.
Severe Personality Disorder
Personality disorders are chronic psychological disorders, which exist on a continuum so they can be mild to more severe in terms of how pervasive and to what extent a person exhibits the features of a particular personality disorder. There are ten different types of personality disorders that exist, which all have various emphases on several distinct psychological features. These include disturbances in self-image, the ability to have successful interpersonal relationships, appropriateness of range of emotion, ways of perceiving themselves, others, and the world; and difficulty possessing proper impulse control. These disturbances come together to create a pervasive pattern of behavior and inner experience that is quite different to what is considered ‘normal’.
Fisher & Bentley (1996) conducted a small study comparing the “disease and-recovery model” and CBT to each other and with a no treatment control on patients with severe personality disorders. Treatments were 3 times a week over 12 weeks. Within the inpatient sample, the study found no significant changes, with the exception of social and family relations. In the outpatient sample, the change was significantly greater in both treatment groups when compared to the control group. However it was found that patients also benefited significantly more from the CBT based group on measures of alcohol use, social and family relations and psychological functioning.
Alden & Capreol (1993) carried out a randomised study of three different cognitive-based group
treatments for avoidant personality disorders with differing types of interpersonal problems. They concluded that the kinds of interpersonal problems experienced by patients affect their response to different types of treatment and that the specific pattern of interpersonal difficulties should be routinely taken into consideration when patients are being allocated to different treatments. The authors did caution against making assumptions about the findings because of the retrospective nature of the study and the selected nature of the sample, which may mean that results may not replicate to other samples of antisocial personality disorder.
Dolan and Coid (1993) concluded that there was only limited evidence for the long-term efficacy of CBT programmes alone for treating psychopathic disorders in adults although Valliant and Antonowicz (1991) notes that some change was seen after completion of young offenders programme, for patients whose personality disorder status was not specified. Cohen and Filipczak (1971) did not find improvement after CBT treatment to be maintained over the long term.
Stein (1992) reviewed drug treatment literature for severe personality disorders and concluded that small doses of neuroleptics might be beneficial for those with BPD and schizotypal personality disorder. However this is yet to be directly compared with CBT in a controlled study. Dolan and Coid (1993) also noted that carbamazepine had been shown to improve the patient’s impulse control irrespective of the personality disorder diagnosis. They suggested its use should be targeted at specific symptoms and behaviours rather than prescribed as a general treatment for any specific personality disorder.
In a Home Office review of treatments for severe personality disorder conducted by Warren et al (2003), they identified 40 studies of CBT, and said they there was little evidence of the efficacy of CBT with either psychopathic or anti-social personality disordered patients or for those with other PD diagnoses held within high security. The authors note that some evidence is available in non-secure and community settings suggesting that CBT can reduce levels of self-harm in women with BPD. Additionally some reduction in alcohol abuse has been demonstrated following outpatient CBT for those with anti-social personality disorder.
However the vast majority of these were studies of women in outpatient settings so evidence can’t be generalised to all situations. Most of the CBT were of short-term treatments aimed at a specific aspect of behaviour or attitude (such as aggression, self-harming or social skills) and which do not claim to treat the core disorder of personality.
It appears that there are too few studies on each type of personality disorder to make a meaningful analysis of the effectiveness of CBT on each. This may stem from inadequate scales of measurement and improvement of personality disorders. The evidence that was cited in this essay is still inconsistent, and has many methodological flaws, so conclusions can not yet be made. It seems that they most recent review of the Home Office by Warren et al (2003) has gone into much depth reviewing past literature, so the best I can do is follow the same line of thought that CBT has little of limited efficacy in treated severe personality disorders.
Conclusion:
The general conclusion for this essay is that CBT seems to have made a meaningful contribution mostly in the treatment of schizophrenia but also in the treatment of bipolar disorder. From a literature review it is evident that much more research is required especially with regards to the long term effect of CBT and comparisons with other psychosocial treatments. It is also evident that both these disorders are treated most effectively when used alongside drug treatments. Rosenhan and Seligman (1995) found Depression best treated with CBT, electro convulsive therapy and medicated drugs, whilst they found to be schizophrenia best treated with drugs and family intervention therapy.
In relation to severe personality disorder there is little evidence to suggest the effectiveness of CBT, but this might change with third wave variations that could be tailored for each condition. It is suggested that each therapy works best with a particular set of problems which is why it’s hard to compare the effectiveness of CBT on the different variations of personality disorders.
Wampold (2001) found the variance of effectiveness of treatment is more due to therapist than it is due to treatment and comments that “a person with a need of psychotherapy should seek the most competent therapist possible without regard for various therapies”. In general CBT has started to make a meaningful contribution in the treatment of Schizophrenia and Depression, but the evidence is less compelling in the case for severe personality disorders.
References:
Alden, L. E. & Capreol, M. J. (1993) Avoidant personality disorder: interpersonal problems as predictors of treatment response. Behavioural Therapy, 24, 357-376.
Baldessarini RJ, Tondo L, Hennen J (1999), Effects of lithium treatment and its discontinuation on suicidal behavior in bipolar manic-depressive disorders. J Clin Pyschiatry 60(suppl 2):77-84.
Blagys, M., & Hilsenroth, M. (2002). Distinctive features of Short-Term Cognitive-Behavioral Psychotherapy: An Empirical Review of the Comparative Psychotherapy Process Literature. Clinical Psychology Review, 22, 671-706.
Cochran, S.D. (1984) Preventing medical non compliances in the outpatient treatment of bipolar affective disorders. The Journal of Consult Clinical Psychology vol 52, pp 873-8.
Cohen, H. L. & Filipczak, J. (1971). A new learning environment: A case for learning. Boston, MA: Authors Cooperative, Inc..
Curry, J, F. (2005). "Specific Psychotherapies for Childhood and Adolescent Depression." Retrieved from Bipolar website:
Dickerson, F. B. (2000) Cognitive behavioural psychotherapy for schizophrenia: a review of recent empirical studies. Schizophrenia Research, 43, 71–90.
Dolan, B. & Coid, J. (1993) Psychopathic and Antisocial Personality Disorders: Treatment and Research Issues. London: Gaskell.
Feeley, M., DeRubeis, R.J. & Gelfand, L.A., (1999). The temporal relation of adherence and alliance to symptom change in cognitive therapy for depression. Journal of Consulting and Clinical Psychology 67, pp. 578–582.
Fisher, M. S., Sr. and K. J. Bentley (1996) Two group therapy models for clients with a dual diagnosis of substance abuse and personality disorder. Psychiatric Services 47(11): 1244-1250.
Healey, Knapp, Astin, Beecham, Kemp, Kirov & David (1998) Cost-effectiveness evaluation of compliance therapy for people with psychosis. The British Journal of Psychiatry 172: 420-424.
Huxley, NA., Parikh, S, V., Baldessarini, R, J. (2000) Effectiveness of psychosocial treatments in bipolar disorder: state of the evidence. Harvard Review of Psychiatry, 8(3): 126-40.
Kemp R, Hayward P, Applewhaite G, Everitt B, David A (1996) Compliance therapy in psychotic patients: Randomized controlled trial. Br Med J 312:345-349.
Kemp R, Kirov G, Everitt B, Hayward P, David A (1998) Randomized controlled trial of compliance therapy: 18-month follow-up. Br J Psychiatry 72:413-419.
Kuipers E, Fowler D, Garety P, Chisholm D, Freeman D, Dunn G, Bebbington P, Hadley C (1998) London-East Anglia randomized controlled trial of cognitive behaviour therapy for psychosis. III: Follow up and economic evaluation at 18 months. Br J Psychiatry 173:61-68.
Lam, Bright, Jones, Hayward, Schuck, Chisolm et al (2001) Cognitive therapy for bipolar illness; pilot stidy of relapse prevention. Cognitive Behaviour Therapy. [in press].
Maj M, Pirozzi R, Magliano L, Bartoli L (1998), Long-term outcome of lithium prophylaxis in bipolar disorder: a 5-year prospective study of 402 patients at a lithium clinic. Am J Psychiatry 155(1):30-35.
Rector, N., Beck, A. (2001). Cognitive Behavioural Therapy for Schizophrenia: An Empirical Review. The journal of nervous and mental disease. Volume 189(5), May 2001, pp 278-287.
Rosenhan, DL, & Seligman, MEP (1995). Abnormal Psychology (3rd Ed.) New York: WW
Sensky T, Turkington D, Kingdon D, Scott JL, Scott J, Siddle R, O'Carroll M, Barnes. (2000). A randomized controlled trial of cognitive-behavioural therapy for persistent symptoms in schizophrenia resistant to medication. Arch Gen Psychiatry 57:165-172.
Swartz HA & Frank E (2001), Psychotherapy for bipolar depression: a phase-specific treatment strategy? Bipolar Disorders 3(1):11-22.
Siris SG (1995) Depression in Schizophrenia. In CL Shriqui, HA Nasrallah (Eds), Contemporary issues in the treatment of schizophrenia. Washington, DC: American Psychiatric Press.
Stein, D. J., D. Simeon, et al. (1995) An open trial of valproate in borderline personality disorder. Journal of Clinical Psychiatry 56(11): 506-10.
Sullivan, C. (2005). Cited in http://www.bipolarworld.net/Treatments/treatment.html
Tang, T.Z. and DeRubeis, R.J., (1999). Reconsidering rapid early response in cognitive–behavioral therapy for depression. Clinical Psychology: Science and Practice 6, pp. 283–288.
Tang, T.Z. and DeRubeis, R.J., (1999). Sudden gains and critical session in cognitive–behavioral therapy for depression. Journal of Consulting and Clinical Psychology 67, pp. 894–904.
Whisman, M.A., (1993). Mediators and moderators in cognitive therapy for depression. Psychological Bulletin 114, pp. 248–265.
Turkington, D. & Kingdon, D. (2000) Cognitive-behavioural techniques for general psychiatrists in the management of patients with psychoses. British Journal of Psychiatry, 177, 101-106.
Turkington, Kingdon & Chadwick (2003) Cognitive-behavioural therapy for schizophrenia: filling the therapeutic vacuum. The British Journal of Psychiatry (2003) 183: 98-99 Retrieved from
Valliant, P. M., & Antonowicz, D. H. (1991). Cognitive behavioural therapy and social skills training improves personality and cognitions in incarcerated offenders. Psychological Reports, 68, 27-33.
Valmaggia, Van Der Gaag, Tarrier, Pijnenborg, Slooff (2005). Cognitive–behavioural therapy for refractory psychotic symptoms of schizophrenia resistant to atypical antipsychotic medication. Randomised controlled trial. The British Journal of Psychiatry, vol 186; 324-330
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods and findings. Mahwah, NJ: Erlbaum.
Warren, F, McGauley, G, Norton, K, Dolan, B., Preedy-Fayers, K., Pickering, A &Geddes, J. (2003) Home office online report on treatments for personality disorder, Retrieved from
Winter, G (1994) Psychotherapy with manic-depressives; problems in interaction between patient and therapist. Group Anal, vol 27, p467-74.
Zaretsky, A., Segal, Z., Gemar, M., (1999). Cognitive therapy for bipolar depression: a pilot study. Canadian Journal of Psychiatry vol 44, p 491-4.
