Secondary Schizophrenia (162 page)

in manic states, for example, are unlikely to think of it
3. Sleep Scheduling. Sleep time is restricted to
as insomnia and may not see it as a problem. As with
gradually bring hours of sleep more in line with
substance abuse, motivational interviewing
[19]
may
normal parameters. Patients are initially

be needed in some cases where treatment is volun-instructed to go to bed when they usually are
tary, in order to gain engagement in a sleep-related
getting to sleep, and to rise at a certain time,
intervention. In bipolar patients, case study evidence
regardless of how much sleep they had. Naps

suggests that interventions to reset circadian rhythms
during the day are eliminated to ensure fatigue is
and provide greater sleep duration (extended bed rest
experienced during the evening. The time to bed
and darkness)
[76]
may prove helpful. Some strategies
is gradually brought forward, until an acceptable
in standard insomnia treatment (e.g., relaxation or
sleep routine is established.

meditation to reduce arousal, and progressive changes
4. Cognitive Therapy. Dysfunctional beliefs and
412

to sleep schedules) should in principle have some
attitudes about the patient’s insomnia are

Chapter 33 – Nonpharmacological interventions in secondary schizophrenia

challenged, using Socratic questioning and

events and situations that precipitate and

behavioral experiments.

perpetuate the symptoms.

5. Paradoxical Intention. Patients with sleep
2. Problem solving is employed to develop strategies
initiation insomnia may be instructed to remain
to address the contributing factors.

passively awake and avoid any effort to fall asleep.

3. Cognitive restructuring or cognitive therapy
This therapy addresses the activating effects of
involves identifying the misattributions or

excessive efforts to go to sleep.

distortions related to the symptom and helping
6. Sleep Hygiene Therapy. Another popular strategy
the patient to challenge and reappraise these
in multicomponent treatments that requires

through verbal challenge and evidence testing.

further support before recommendation as a

Behavioral experiments are also used to test the
stand-alone intervention is Sleep Hygiene Therapy.

validity of the beliefs.

Patients are educated about lifestyle factors that
4. Relapse prevention. Idiosyncratic triggers and
may exacerbate insomnia, such as diet and

early warning signs of relapse are identified, and
exercise. Recommendations are also made to

plans are developed to address them.

avoid sleep-incompatible behaviors such as

caffeine use or exercise in the hours before

CBT can also be applied to medication adherence
[85].

bedtime.

Although psychoeducation alone is relatively ineffective at producing significant changes in medication
adherence in most studies
[86]
, there is evidence that
Management of psychotic symptoms

motivational interviewing
[87]
and cueing techniques
and their sequelae

[88, 89]
can significantly raise adherence.

Although pharmacological treatments will likely
Social Skills Training (SST), a variety of CBT,
always hold the front line in the management of
addresses the fact that psychosis is commonly asso-psychosis, there are limitations to the benefits and
ciated with diminished social competence, which in
improvements that can be achieved from phar-

turn contributes to family conflict, social isolation, and
macological intervention alone. Many patients are
work disability
[90].
SST aims to enhance communica-noncompliant with medication, and despite advances
tion and social coping skills, using education and prob-in pharmacotherapies, some continue to have symp-lem solving, modeling, repetitive practice, corrective
toms despite high levels of adherence. Nor does
feedback, positive reinforcement, and in vivo home-medication directly address the social and functional
work assignments
[81,
91].
Targeted skills are indi-impact of the psychosis. Given these limitations, there
vidually tailored, but may include training in accu-has been substantial recent interest in the develop-rate perception of emotions and intentions expressed
ment of psychological interventions to address the
by others; expressing emotions, intentions, or desires;
symptoms and consequences of psychosis. Extensive
and basic conversational skills
[91].
There is evidence
research has been conducted and has been subject to
of generalization to the natural environment and an
multiple reviews and meta-analysis [e.g.
77, 78, 79,

impact on functioning, provided that generalization is
80, 81].
Overall, current evidence supports the use of
specifically addressed in the program
[90, 91, 92, 93
cf.

a range of psychological interventions, in comparison
94].

with a control intervention.

CBTs require cognitive capabilities (including pro-Cognitive Behavioral Therapies (CBTs) are the lead-cessing speed, attention span, working memory, and
ing nonpharmacological approaches to positive symp-verbal learning) that are negatively affected by psy-toms, and currently yield moderate effect sizes on
chosis
[95],
and methods to address these deficits may
symptom severity
[81]
. Although there is no univer-be necessary to maximize the impact of psychological
sally accepted CBT, treatments typically share some
interventions
[91].
Whereas the severity and enduring
common elements
[79, 82, 83, 84],
including:
nature of cognitive deficits may not be as pronounced
in secondary psychosis, cognitive dysfunction is likely
1. Psychoeducation about symptoms and diagnosis
to be experienced when the person is highly symp-allows development of insight into the disorder.

tomatic, and may be ongoing if the secondary psy-The relationship between thoughts and behaviors
chosis does not remit. In either case, treatments may
413

is explained and leads into identification of the
need to be adapted in cases of cognitive deficit, with
Treatment – Section 5

short sessions, simpler sentence construction, greater
substance use, insomnia, or other problems. Research
repetition and more frequent summaries, and explicit
into this question is required.

training for generalization.

Cognitive Remediation attempts to address ongo-Implications for clinical practice
ing cognitive deficits. Several programs for cognitive
Where patients with secondary psychoses are suffering
remediation have been developed
[96],
but generally
from ongoing positive symptoms, social skill, or cog-involve increasingly demanding paper-and-pencil or
nitive deficits, or one or more members of the patient’s
computerized tasks with corrective feedback, scaffold-household display critical attitudes or intrusive behav-ing, and errorless learning techniques to teach specific
ior toward the patient, the respective psychological
skills, and development of strategies to compensate
strategies should be considered.

for deficits (making lists, posting reminders). Recent
meta-analyses tend to find small-to moderate-effect
Summary and conclusions

sizes from these strategies on a range of cognitive outcomes
[81]
, together with a moderate translation to
Most causes of secondary psychosis constitute cerebral
social functioning [cf.
94].

insults that are not directly accessible to psychological
Family Intervention addresses the risks for symp-intervention. Two exceptions, discussed in the current
tomatic relapse that are associated with negative or
chapter, are psychoactive substance use and insom-overly intrusive interactions with family members
[97]

nia. Psychological interventions for concurrent sub-and engages families in provision of appropriate sup-stance misuse and psychosis are having a significantly
port. Interventions with households that would other-greater impact on substance use (and in some studies,
wise present a high risk of relapse result in significantly
on symptoms and functioning) than are control inter-reduced rates of patient relapse and rehospitalization
ventions, although effects on average are weaker in
and greater compliance with medication
[81].
Family
longer-term follow-up. Insomnia has had little atten-interventions typically involve psychoeducation, com-tion in people with established psychosis, but the cur-munication training, goal setting, and problem solving
rent data suggests that the same strategies that have
[81,
98].

been effective in the general population will also work
Only one study was identified that examined the
in this context. There have not as yet been controlled
impact of family intervention and CBT for psychotic
trials on averting potential psychosis using either a
symptoms in people with substance use and psychosis
substance use or insomnia intervention, although sub-

[32]
. Because the study combined these strategies with
stance use is addressed in multicomponent studies on
other interventions including motivational interview-early episodes of psychosis
[38, 50, 51].
There is evi-ing, it is not clear what contribution to the study’s
dence to support a range of psychological interven-impact was provided by these components.

tions for the symptoms and sequelae of psychosis, and
many of these are likely to be applicable to people
with secondary psychoses, particularly where ongo-Suggestions for future research
ing symptoms or psychological deficits are present.

It is not currently clear whether these psycholog-There is, however, substantial opportunity to increase
ical interventions improve the outcomes of people
the generalization of trained skills and their impact on
with psychoses that are triggered or maintained by
overall functioning.

414

Chapter 33 – Nonpharmacological interventions in secondary schizophrenia

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