Thérapie comportementale et cognitive des symptômes négatifs de la schizophrénie. Revue de la question : pratiques actuelles et directions futures

Abstract

Negative symptoms, such as a lack of motivation, anhedonia or poverty of speech, constitute a major difficulty in schizophrenia. Indeed, these symptoms have deleterious effects on quality of life and functional outcome of individuals with schizophrenia. However, although multiple interventions have been the subject of investigation, to date, including pharmacological strategies, brain stimulation, physical activity and psychosocial interventions, none reached the threshold for clinically significant improvement. Therefore the treatment of negative symptoms represents a major challenge for mental health care in schizophrenia. If recent advances in CBT have clearly shown their efficiency on positive symptom and are now recommended as first line treatment for schizophrenia, CBT trials mainly focused on positive symptoms and investigated change in negative symptoms only as a secondary outcome. The aim of this article is to describe and to provide a brief description of the different CBT interventions targeting negative symptoms, the theoretical models on which they are based and empirical evidence highlighting their effectiveness. Of the interventions reviewed, cognitive interventions, behavioral activations and social skills training appear to have the most empirical support. The cognitive approach suggests the role of negative cognitions, or dysfunctional attitudes in the maintenance and exacerbation of behaviors is associated with negative symptoms in schizophrenia (Rector et. al., 2005 ; Beck et. al., 2009). Consequently, cognitive therapy interventions focus primarily on changing generalized beliefs that prevent patients with prominent negative symptoms from goal attainment. Clinical trials showed improvements on apathy, avolition, and functioning but not on anhedonia, blunted affects, and alogia suggesting that cognitive models of negative symptoms would be valid for the dimension avolition but less for the dimension diminished expression. Regarding behavioral interventions, there is now clear evidence that social skills training should be routinely recommended in treatment guidelines for psychological intervention targeting negative symptoms as a whole (Turner et al., 2018). However, its distinct impact on the two main dimensions of negative symptoms is still unknown. Behavioral activation appears particularly promising in the treatment of negative symptoms secondary to depression. Although psychosocial treatments show promise for the treatment of negative symptoms, certain limitations exist, particularly regarding the conceptualization of the different negative symptoms and the lack of integrative psychological models proposed in the literature. However, cognitive and behavioral therapy offer interesting possibilities for the improvement of negative symptomatology, particularly recovery-oriented cognitive therapy, focusing on dysfunctional beliefs, and adaptations to circumvent neurocognitive and engagement difficulties. As recommendations, we emphasize the need for a detailed and integrative functional analysis of each negative symptom before any interventions in order to understand the influence of the different environmental factors and psychological processes. Specific CBT interventions have utility in ameliorating negative symptoms in psychosis but validated and integrative psychological models need to be developed to increase their effectiveness.