Cognitive-Behavioural Therapy for First Episodes of Psychosis: A Case Report on the Application of a Multicomponent Treatment Protocol in Italy

Abstract

Objectives: Although pharmacotherapy with antipsychotic medication is an effective intervention for early psychosis (EP), drop out from treatment and relapse rates appear still relatively high. In the last decade, there is growing interest in Cognitive-Behavioural Therapy (CBT) as early intervention for EP. Some studies suggest that CBT may be an effective adjuvant to pharmacotherapy to reduce risk of development of chronic psychosis in individuals who experienced first episodes. Symptoms of depression and social anxiety are very common among patients experiencing first episode psychosis, thus impairing quality of life and functioning. This aspect may create a negative vicious cycle, that may reinforce feelings of learned helplessness and hopelessness with regard to psychosis diagnosis, thus increasing vulnerability to relapse in further episodes. However, there is little knowledge on the use of CBT to target both reoccurrence of psychotic episodes and symptoms of depression and social anxiety secondary to first psychotic episodes. The current case report presents the administration of a modular CBT semi-manualized intervention to a young patient to enhance prevention of psychosis and target symptoms of social anxiety and depression following first psychotic episodes. Methods: Treatment consisted in 21 individual weekly sessions, delivered in an outpatient setting, involving two phases. The first one targeted prevention of psychotic episodes. Case formulation was developed according to cognitive behavioural model of psychosis. Psychoeducation on early signs and vulnerability factors of relapse in psychotic episodes was delivered in order to promote patient’s self-monitoring and insight on positive symptoms prodromes. The second treatment phase targeted symptoms of depression and social anxiety. Homework based on behavioural activation were assigned in order to address depressive symptoms, and cognitive restructuring was used to normalize dysfunctional beliefs. A social skills and assertiveness training was used to target social anxiety. CBT treatment was delivered in combination with medication. Clinical interviews were conducted at pre-, immediate post-treatment, and at 5-month-follow-up, to evaluate reoccurrence of psychotic episodes, and changes in depression, social anxiety, and functioning. Results: As observed by clinical interviews, the patient did not experience further relapse in psychotic episodes. In addition, it was observed a reduction in depressive symptoms and social anxiety through the increase of the number of daily activities, social relations, work and academic engagement. Conclusions: Important limitations of the study are discussed. Future research using large randomized controlled trials with longer follow-up assessments should evaluate the effectiveness of CBT to target depressive symptoms and social anxiety for patients with EP.