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17 th 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

CBT for Command Hallucinations

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Journal Presentation in 2007, made by JP Rajendran

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Page 1: CBT for Command Hallucinations

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

Page 2: CBT for Command Hallucinations

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)

Page 3: CBT for Command Hallucinations

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

Page 4: CBT for Command Hallucinations

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.

Page 5: CBT for Command Hallucinations

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

Page 6: CBT for Command Hallucinations

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’

Page 7: CBT for Command Hallucinations

17th Sep 2004 journal presentation

Resistance

Compliance

Appeasement behaviour

Conviction of power

Distress

Depression

Frequency, loudness

content

Page 8: CBT for Command Hallucinations

17th Sep 2004 journal presentation

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

Page 9: CBT for Command Hallucinations

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

Page 10: CBT for Command Hallucinations

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

Page 11: CBT for Command Hallucinations

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’

Page 12: CBT for Command Hallucinations

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

Page 13: CBT for Command Hallucinations

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

Page 14: CBT for Command Hallucinations

17th Sep 2004 journal presentation

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

Page 15: CBT for Command Hallucinations

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

Page 16: CBT for Command Hallucinations

17th Sep 2004 journal presentation

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

Page 17: CBT for Command Hallucinations

17th Sep 2004 journal presentation

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

Page 18: CBT for Command Hallucinations

17th Sep 2004 journal presentation

Sample description – consort

Page 19: CBT for Command Hallucinations

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)

Page 20: CBT for Command Hallucinations

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

Page 21: CBT for Command Hallucinations

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

Page 22: CBT for Command Hallucinations

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

Page 23: CBT for Command Hallucinations

17th Sep 2004 journal presentation

Psychopathology

4

0

6

11

55

12

12

100

2468

1012

ctch

tau

Page 24: CBT for Command Hallucinations

17th Sep 2004 journal presentation

Scores

21.920.8 20.8

21.5

36.335.9

05

10152025303540

panss+

panss-

gen.psypath

ctch

tau

Page 25: CBT for Command Hallucinations

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

Page 26: CBT for Command Hallucinations

17th Sep 2004 journal presentation

Drug’s role??

T.A.U

C.T.C.H

Page 27: CBT for Command Hallucinations

17th Sep 2004 journal presentation

Beliefs / topography / distress

POWERvpd

MALEVOLENCEbavq

OMNISCIENCEbacq

DISTRESSpsyrats

FRQUENCYpsyrats

LOUDNESSpsyrats

NEGATIVE CONTENTpsyrats

DEPRESSIONcdss

CONTROLpsyrats

Page 28: CBT for Command Hallucinations

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

Page 29: CBT for Command Hallucinations

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

Page 30: CBT for Command Hallucinations

17th Sep 2004 journal presentation

Distress & depression

0

2

4

6

8

10

12

14

cbt-

6

cbt-

12

tau-

6

tau-

12

distress

depression

Page 31: CBT for Command Hallucinations

17th Sep 2004 journal presentation

Topography of voices -outcome

00.5

11.5

22.5

33.5

4

cbt-bcbt12tau-btau-12

frequency

- content

loudness

Page 32: CBT for Command Hallucinations

17th Sep 2004 journal presentation

Correlations??? Correlations between voice compliance, distress, power

and omniscience of disobedience

Page 33: CBT for Command Hallucinations

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

Page 34: CBT for Command Hallucinations

17th Sep 2004 journal presentation

HALLUCINATIONSHALLUCINATIONS

DELUSIONSDELUSIONSANXIETYANXIETYTENSIONTENSION

GUILTGUILTVOLITION PROBLEMSVOLITION PROBLEMS

ATTENTION PROBLEMSATTENTION PROBLEMS

PANSS+ & MEDSPANSS+ & MEDS

Page 35: CBT for Command Hallucinations

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

Page 36: CBT for Command Hallucinations

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

Page 37: CBT for Command Hallucinations

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

Page 38: CBT for Command Hallucinations

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’

Page 39: CBT for Command Hallucinations

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