Authored by James B McCarthy*
Abstract
Empirical studies of children and adolescents at high-risk for psychosis and those with first episode psychosis include investigations of the associated risk factors, neurobiological correlates and longitudinal trajectories and the use of pharmacological and psychosocial interventions, but few studies compare the impact of different forms of psychotherapy with each other or with multimodal treatment with both psychotherapy and psychotropic medication. There is a scarcity of trials that compare the efficacy and long-term outcome of cognitive behavioral therapy, psychodynamic psychotherapy and family therapy with these vulnerable youth even though evidence has been accumulating about their positive impact with children, adolescents and adults with many psychiatric disorders. Research on first episode psychosis in children and adolescents needs to be enhanced by studies that ascertain the benefits of cognitive behavior therapy, psychodynamic psychotherapy, and family therapy and their role in combined treatment.
Keywords: First episode psychosis; Psychotic disorders; Childhood psychosis; Psychodynamic psychotherapy; CBT; Family therapy; Antipsychotic medication
Introduction
Considerable difficulties occur in doing research with children and adolescents with severe psychiatric disorders, and studies of youth at high-risk for psychosis reveal variable outcomes. Early identification and prevention programs for children and adolescents at risk for psychosis investigate clinical characteristics, family history, and genetic, neurobiological and environmental risk factors while utilizing diverse preventative strategies. Assessments of the factors contributing to the conversion to psychosis indicate some salient predictor variables in first episode psychosis along with heterogeneous developmental trajectories with less than one third of high-risk youth developing persistent psychotic disorders [1]. However, few investigations have compared the impact of different forms of psychotherapy with each other in terms of their influence on the outcomes of children and adolescents who experience a first episode of psychosis even though studies have demonstrated that the combination of psychological and psychopharmacological interventions can have a positive effect on early-onset psychotic disorders [2]. This review aims to emphasize the need for studies that compare the impact of Cognitive Behavior therapy (CBT), psychodynamic psychotherapy and family therapy, and combinations of different forms of psychotherapy with psychopharmacological approaches in the treatment of children and youth who experience a first episode of psychosis.
Practice guidelines point to the importance of psychological therapy for individuals with a first episode of psychosis. Modestly effective results have been shown to derive from combinations of CBT and psychosocial interventions with children at risk for psychosis, but there have been few attempts to study very longterm benefits of CBT for the first episode of a psychotic disorder in childhood [3,4]. Reviews of typically cited databases, such as PubMed, PyschInfo, and Medline, note studies of the predictor variables, the diagnostic stability and the use of antipsychotic medication with first episode psychosis in children, adolescents and adults but an absence of investigations of different forms of psychotherapy with children and young adolescents who experience first episode psychosis [5-8].
The majority of children and adolescents who have brief psychotic symptoms will continue to experience later mental health problems, but most will not develop actual psychotic disorders [9]. One-year outcome studies of children and adolescents at high clinical risk who do develop non-affective psychosis indicate the predictive importance of both positive and negative symptoms and that more than half of the youth continue to be at high-risk while at least 20% develop schizophrenia [10]. The presence of psychotic symptoms is also associated with a greater severity of Major Depressive Disorder and a longer duration of episodes of illness in children and adolescents with Bipolar Disorder [11]. A study of adults with first episode psychosis revealed that for individuals who experience only one episode of psychosis the combination of prompt treatment and social and family support lowers the risk of future episode of psychosis [12]. Even among high-risk children and adolescents who have attenuated symptoms of psychosis, not all will develop a psychotic disorder [13], but there are few prospective studies or randomized trials that compare the potential long-term gains associated with different forms of psychotherapy with very high-risk children and adolescents who develop psychosis.
Case Example
X, a nine-year-old Caucasian girl with deteriorating academic functioning, no prior psychiatric history or mental health treatment and no discernable history of trauma or psychiatric illness in the family, set a fire in her apartment in which a family member was severely burned. She reported that a voice told her to set the fire because the apartment had been invaded by demons and that burning the demons would be the only way to keep her parents and siblings safe from harm.
Research on CBT with First Episode Psychosis
The findings from the influential Child and Adolescent First Episode of Psychosis Study (CAFEPS) indicate that for youth with a first episode of psychosis, aged nine to seventeen, Psychotic Disorder Not Otherwise Specified, Mood Disorder with Psychosis, and Schizophreniform Disorder are the most common diagnoses and that clinical assessments of symptom severity and negative symptoms are the most meaningful predictive outcome indicators [14]. Studies measuring the effect of CBT with individuals with first episode psychosis throughout the lifespan note either effective results when compared with treatment as usual or inconsistent findings [15]. For example, Addington et al. [4] reported no significant improvements with either the use of CBT or treatment as usual [16]. Early literature reviews of first episode psychosis studies revealed that psychosocial therapies, in general, in combination with psychopharmacology and the absence of a diagnosis of schizophrenia are associated with more positive outcomes [17]. More recent systematic reviews of preventative interventions and studies comparing the impact of psychological, psychopharmacological and combined treatments with children, adolescents and young adults with psychosis have found that antipsychotic medications have a modestly beneficial effect on psychotic symptoms and that family therapy in addition to CBT can be useful in delaying the onset of psychotic episodes, but no trials were found that compared psychotherapeutic interventions with youth under the age of eighteen [3,18].
Early investigations of the use of CBT with adults with schizophrenia who experience a first episode of psychosis often found little difference between CBT and supportive psychotherapy, but later studies placed a greater emphasis on the functional adaptations and quality of life issues that are associated with a persistent psychotic disorder [19]. Other early studies of CBT with first episode psychosis in adults showed that CBT has some efficacy in lowering psychotic symptoms and improving the individual’s quality of life but little influence on the reoccurrence of psychotic episodes [20]. Within the last ten years, the use of group CBT treatments with adults with first episode psychosis has been increasingly studied [21] with the caveat that the complexity of the clinical variables, such as comorbidity, and the limitations of the mental health care system can make it difficult to apply group CBT interventions effectively [22]. Gaynor and colleagues [22] reported that outpatient group CBT is more effective than individual CBT with relatively stable adults with first episode psychosis in reducing the presence of negative symptoms [23], while a 2018 investigation of group cohesion in cognitive behavioral group therapy with adults with first episode psychosis revealed that group participation and group cohesion are positively associated with both improved selfesteem and symptom reductions [24].
Studies of group cognitive behavioral therapy with adults with either first episode psychosis or a recent onset of psychosis also point to the value of groups in sustaining symptomatic improvements after there has been a stabilization of the psychotic symptoms [25], but as far as we know similar studies are lacking that assess the overall efficacy and long term outcome of individual or group CBT with children and young adolescents with a first episode of psychosis.
Research on Psychodynamic Psychotherapy with First Episode Psychosis
Psychodynamic psychotherapy, with its emphasis on the developmental roots of the individual’s subjective experience, the nuances of the therapeutic relationship, and scrutiny of therapistpatient mutual influences in transference-countertransference exchanges, has rarely been the subject of empirical studies with individuals who experience a first episode of psychosis. In one of the few prospective studies of psychodynamic psychotherapy with adults with a first episode of Schizophrenia Spectrum Disorder, a multisite, two year-long study was conducted that compared treatment as usual with supportive psychodynamic psychotherapy with a combination of both interventions; the combination of the two had a much stronger association with significant improvements in symptoms and global functioning [26]. Similar studies are lacking with children and young adolescents who are at very high risk for psychosis or are experiencing first episode psychosis.
Since its early origins, psychodynamic psychotherapy has been concerned with the intrapsychic sequalae of trauma as well as the relationship between difficulties in mental functioning and problems in forming and sustaining mental representations of self and others. Recent studies of psychodynamic and integrative psychotherapy approaches have examined such posttraumatic phenomena and object relations deficits as crucial aspects of psychotherapy with individuals who are suffering from early signs of psychosis or persistent psychotic disorders. Investigations of efforts to improve metacognition or metacognitive reflection ability in individuals experiencing early phases of psychosis have also been increasing in number [27,28]. Consumer oriented approaches to individual psychotherapy with people with psychotic disorders similarly emphasize the individual’s understanding and emotional experience of the illness and facilitating openness to accepting support and avenues for empowerment that can enhance social, cognitive and emotional functioning. In addition, psychodynamic approaches with their emphasis on psychological defenses and internalized relationship patterns are well suited for the exploration of adolescents’ and young adults’ concerns about identity, autonomy, intimacy and the experience of the self in the midst of struggles with psychotic illness [29]. There is a very long history of influential theoretical and clinical articles on psychoanalytic approaches to the treatment of childhood psychosis; some of the contributions are consistent with the steadily emerging literature about the relationship between trauma and psychotic symptoms [30]. However, in spite of the voluminous literature on the use of psychodynamic principles in understanding psychotic communication and attachment difficulties, a comprehensive 2017 survey of the growing empirical support for psychodynamic psychotherapy with children and adolescents found no empirical studies of the efficacy of psychodynamic psychotherapy with psychotic children and adolescents [31].
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