Management of comorbid anxiety states in the clinical pattern of endogenous mental diseases of the schizophrenic spectrum

An important aspect is also the analysis of significant external environmental and psychological internal factors that affect the characteristics of the formation of certain behavioral strategies and their transformation in the course of the disease. The obtained data will contribute to the understanding of psychodynamic mechanisms in each specific case, which is important in choosing adequate psychotherapeutic correction and rehabilitation measures.

When using CBT approaches to work with psychotic patients, work aimed at assimilating the skills of acceptance and management of productive symptoms by patients is of great importance.

At the same time, therapy does not aim to facilitate the elimination of symptoms. It seeks to restructure the old voices assessments and delusions and generate new alternatives that do not cause the same distress as the patient's past cognitive interpretations. In this case, treatment should be considered as effective if there is a decrease in the patient's emotional distress as a result of therapy [6], as well as the “improved social outcome” - “greater social involvement and effectiveness” [24].

Current research and randomized controlled trials show that CBT should be implemented in a way that is acceptable to patients, which will enhance their ability to adapt to disease and work to improve their quality of life [8]. CBT in endogenous mental diseases of the schizophrenic spectrum should be developed relying on the basic “classical” principles:

1. Cooperation. Joint development of a common, conceptualization, understandable for the patient, which will form his/her ideas about the origins and mechanisms that provoke anxiety states and maintain side psychotic symptoms.

2. Normalization. Support and acceptance without judgment can reduce the experiences of shame or stigma that are often associated with anxiety and psychosis.

3. Orientation of the patient to accept psychotic symptoms.

The treatment protocol can be broken down into four main stages (Table).

The main stages of the protocol for psychotherapeutic support

The presented format displays the chronological order of the stages of therapy but is not strictly prescriptive. Displacement or intersection of stages in the process of therapeutic intervention is obvious for clinical practice. In addition, options for the inclusion of additional stages to solve related problems that may arise in the course of therapy are not excluded.

The treatment plan is a required part of CBT. It allows us to outline the structure and scope of psychotherapeutic assistance for a specific patient, to carry out the management of a clinical case and to track the effectiveness of psychotherapeutic assistance.

Planning psychotherapy for people with schizophrenia requires careful research and attention to areas such as the patient's psychological and psychosocial problems.

The psychotherapist may face a number of problems that will significantly interfere with therapy. Such problems include ambivalent or negative attitudes towards therapy, rapid fatiguability during a session, deviations from the subject, or, on the contrary, excessive concentration on something.

Working through the feelings and emotions of the therapist can become a problem as well. Establishing a collaborative partnership is an essential part of CBT and it aims to develop in the patient a sense of striving for a common goal during the psychotherapeutic process.

Reestablishing a sense of subjectivity and intersubjectivity in the patient can be facilitated by involving the patient in telling his/her life story. It is this kind of patient support, which consists in the independent discovery of objective reality, that is the basic principle in CBT. The here and now principle, applied in CBT, encourages the expression of existing feelings and experiences, helping to restore the connection between the person and the actual situation. Thus, the use of a narrative approach can enhance the ability of patients with schizophrenia to restore the lost unity between emotions and interpersonal situations, and therefore, restore a basic sense of self and oneself in relationships with others.

Patient motivation is another significant factor that can affect the effectiveness of CBT. Therefore, it is extremely important to take into account the patient's subjective complaints regarding his/her feelings, as well as the problems and goals of therapy.

Analyzing the research data on the effectiveness of CBT in anxiety states in schizophrenic patients, it can be concluded that the expediency of introducing structured short-term therapeutic programs is obvious [3, 7, 20]. Despite the recognition of the scientific validity and evidence-based effectiveness of using these programs, they have not yet received a widespread application in Ukraine. Therefore, analysis of the experience in implementation and application of programs in other countries and the gradual introduction into practice of CBT protocols and in endogenous mental disorders of the schizophrenic spectrum are the promising directions of research.

Conclusions

The results of the study demonstrate that CBT is an effective method for the treatment of patients with chronic psychosis, and the issue of the effectiveness of CBT in working with patients with the first psychotic episode is the least studied. Patients who underwent the first psychotic episode represent a special group, since they have to fight not only with the symptoms of the disease, but also negatively perceive the recently diagnosed disease. A complete or incomplete understanding of how the disease will now affect their lives can also lead to depression, anxiety, and low self-esteem.

Thus, we can conclude that psychological education, normalization, assessment of negative automatic thoughts and dysfunctional deep beliefs, as well as focusing on the negative consequences of destructive behavior, whose implementation is possible with CBT methods, should be included in the goals of helping mentally ill people, including to relieve symptoms and improve their quality of life.

Programs for the management and care of patients with a first psychotic episode must be tailored to suit the unique and specific needs of each patient. This individualization should be the general rule for every therapy, but it is especially important for patients in this group, which has a wide range of symptoms, problems and goals. In this context, one can encounter such problems as manifestations of depressive symptoms, low self-esteem, lack of motivation, decreased social functioning, anxiety, obsessive thoughts, etc. Thus, with certain adherence to the protocols and rules for using CBT methods, the intervention in each individual case will be different.

At this stage of the research, the authors were interested primarily in the analysis of their own studies and existing clinical observations from other scholars to build a conceptual model. At the next stages, it is planned to empirically test it to answer questions that require further attention, structuring and personalization of psychotherapeutic programs, identifying the features of working with certain types of productive and negative symptoms, as well as introducing short-term protocols, which will contribute to effective patient follow-up.

References

1. Achim A.M., Maziade M., Raymond E., Olivier D., Merette C., Roy M.A. (2011). How prevalent are anxiety disorders in schizophrenia? A meta-analysis and critical review on a significant association. Schizophrenia Bulletin. Vol. 37, issue. 4, pp. 811 - 821. https://doi. org/ 10.1093/schbul/sbp148

2. Aikawa, S., Kobayashi, H., Nemoto, T., Matsuo, S., Wada, Y., Mamiya, N., Mizuno, M. (2018). Social anxiety and risk factors in patients with schizophrenia: Relationship with duration of untreated psychosis. Psychiatry Research. Vol. 263, pp. 94 - 100. https://doi.org/10.1016/j.psychres.2018.02.038

3. Alvarez-Astorga, A., Sotelo, E., Lubeiro, A., deLuis, R., Gomez Pilar, J., Becoechea, B., & Molina, V. (2019). Social cognition in psychosis: Predictors and effects of META-cognitive training. Progress in Neuro - Psycho pharmacology and Biological Psychiatry. https://doi.org/10.1016/j,pnpbp.2019.109672

4. Baer, L. H., Shah, J. L., & Lepage, M. (2019). Anxiety in you that clinical high riskfor psychosis: A case study and conceptual model. Schizophrenia Research. https://doi.org/10.1016/j.schres.2019.01.006

5. Bernardo M., Bioque M., Cabrera B., Lobo A., Gonzalez-Pinto A., Pina L., et al. (2017). Modelling gene-environment interaction in first episodes of psychosis. Schizophrenia Research. https://doi.org/10.1016/j.schres.2017.01.058

6. Birchwood, M., Trower P. (2006). The future of cognitive-behavioural therapy for psychosis: not a quasi-neuroleptic. British Journal Psychiatry. Vol. 188, issue 2, pp. 107 - 108. https://doi.org/10.1192/bjp.bp.105.014985

7. Bosanac, P., Castle, D. (2015). How should we manage anxiety in patients with schizophrenia? Australasian Psychiatry. Vol. 23, issue. 4, pp. 374 - 377. https://doi.org/10.1177/1039856215588207

8. Brabban, A., Byrne, R., Longden, E., Morrison, A. (2017). The importance of human relationships, ethics and recovery-orientated values in the delivery of CBT for people with psychosis. Psychosis. Vol. 9, issue 2, p. 157 - 166. https://doi.org/10.1080/17522439.2016.1259648

9. Buckley P, Miller BJ, Lehrer DS, et al. (2009). Psychiatric comorbidities and schizophrenia. Schizophrenia Bulletin. Vol. 35, issue. 2, pp. 383 - 402. https://doi.org/ 10.1093/schbul/sbn135

10. Buonocore, M., Bosia, M., Bechi, M., Spangaro, M., Cavedoni, S., Cocchi, F. et al. (2017). Targeting anxiety to improve quality of life in patients with schizophrenia. European Psychiatry. Vol. 45, pp. 129 - 135 https://doi.org/10.1016/_j.eurpsy.2017.06.014

11. Christopher Frueh, B., Grubaugh, A. L., Cusack, K. J., Kimble, M. O., Elhai, J. D., &Knapp, R. G. (2009). Exposure-based cognitive-behavioral treatment of PTSD in adults with schizophrenia or schizoaffective disorder: A pilot study. Journal of Anxiety Disorders. Vol. 23, issue 5, pp. 665 - 675. https://doi.org/10.1016/_j.janxdis.2009.02.005

12. Freeman, D., Waller, H., Harpur-Lewis, R., et al. (2015). Urbanicity, persecutory delusions, and clinical intervention. Behavioural and Cognitive Psychotherapy. Vol. 43, Issue. 1, pp. 42 - 51 http://dx.doi.org/10.1017/S1352465813000660

13. Halperin, S., Nathan, P., Drummond, P., &Castle, D. (2000). A Cognitive-Behavioural, Group-Based Intervention for Social Anxiety in Schizophrenia. Australian & New Zealand Journal of Psychiatry. Vol. 3, Issue 5, pp. 809 - 813. https://doi.org/10.1080/j.1440-1614.2000.00820.x

14. Hartley S, Barrowclough C, Haddock G. (2013). Anxiety and depression in psychosis: A systematic review of associations with positive psychotic symptoms. Acta Psychiatrica Scandinavica. Vol. 128, issue 5, pp. 327-346. https://doi.org/10.1111/acps.12080

15. Huppert, J. D., Kivity, Y., Barlow, D. H., Gorman, J. M., Shear, M. K., &Woods, S. W. (2014). Therapist effects and the outcome - alliance correlation in cognitive behavioral therapy for panic disorder with agoraphobia. Behaviour Research and Therapy, Vol. 52, pp. 26 - 34. https://doi: 10.1016/j,brat.2013.11.001

16. Kingsep, P., Nathan, P., &Castle, D. (2003). Cognitive behavioural group treatment for social anxiety in schizophrenia. Schizophrenia Research. Vol. 63, Issue 1 - 2, pp. 121 - 129. https://doi.org/10.1016/s0920-9964(02)00376-6

17. Korczak, A., & Styla, R. (2021). Anxiety and executive functions relationships in schizophrenia: A meta-analysis. Personality and Individual Differences. Vol. 177, 110643. https://doi,org/10.1016/j.paid.2021.110643

18. Lysaker, P. H., Davis, L. W., Lightfoot, J., Hunter, N., & Stasburger, A. (2005). Association of neurocognition, anxiety, positive and negative symptoms with coping preference in schizophrenia spectrum disorders. Schizophrenia Research. Vol. 80, issue 2-3, pp. 163 - 171. https://doi:10.1016/j.schres.2005.07.005

19. Nemoto, T., Uchino, T., Aikawa, S., Matsuo, S., Mamiya, N., Shibasaki, Y., Mizuno, M. (2020). Impact of changes in social anxiety on social functioning and quality of life in outpatients with schizophrenia: A naturalistic longitudinal study. Journal of Psychiatric Research. Vol. 131, pp. 15-21. https://doi.org/10.1016/jjpsychires.2020.08.

20. Opoka, S. M., & Lincoln, T. M. (2017). The Effect of Cognitive Behavioral Interventions on Depression and Anxiety Symptoms in Patients with Schizophrenia Spectrum Disorders. Psychiatric Clinics of North America. Vol. 40, issue. 4, pp. 641 - 659. https://doi.org/10.1016Zj.psc.2017.08.005

21. Szalisznyo, K., Silverstein, D., &Toth, J. (2019). Dynamics in schizo-obsessive spectrum disorders: a computational approach. Journal of Theoretical Biology. https://doi.Org/10.1016/j.jtbi.2019.01.038

22. Temmingh, H., & Stein, D. J. (2015). Anxiety in Patients with Schizophrenia: Epidemiology and Management. CNS Drugs. Vol. 29, issue. 10, pp. 819 - 832. https://doi.org/10.1007/s40263-015-0282-7

23. Tibbo P, Swainson J, Chue P, LeMelledo JM. (2003). Prevalence and relationship to delusions and hallucinations of anxiety disorders in schizophrenia. Depress Anxiety. Vol. 17, issue. 2, pp. 65 - 72. https://doi.org/10.1002/da.10083

24. Turkington, D., Kingdon D, Turner T. (2002). Effectiveness of a brief cognitivebehavioural therapy intervention in the treatment of schizophrenia. British Journal Psychiatry. Vol. 180, issue 6. pp. 523-527. https://doi.org/10.1192/bjp.180.6.523

25. Wilson, R. S., Yung, A. R., & Morrison, A. P. (2019). Comorbidity rates of depression and anxiety in first episode psychosis: A systematic review and meta-analysis. Schizophrenia Research. https://doi.org/10.1016/j.schres.2019.11.035

Література

1. Achim A.M., Maziade M., Raymond E., Olivier D., Merette C., Roy M.A. (2011). How prevalent are anxiety disorders in schizophrenia? A meta-analysis and critical review on a significant association. Schizophrenia Bulletin. Vol. 37, issue. 4, pp. 811 - 821. https://doi.org/10.1093/schbul/sbp148

2. Aikawa, S., Kobayashi, H., Nemoto, T., Matsuo, S., Wada, Y., Mamiya, N., Mizuno, M. (2018). Social anxiety and risk factors in patients with schizophrenia: Relationship with duration of untreated psychosis. Psychiatry Research. Vol. 263, pp. 94 - 100. https://doi.org/10.1016/j.psychres.2018.02.038

3. Alvarez-Astorga, A., Sotelo, E., Lubeiro, A., deLuis, R., Gomez Pilar, J., Becoechea, B., &Molina, V. (2019). Social cognition in psychosis: Predictors and effects of META-cognitive training. Progress in Neuro - Psycho pharmacology and Biological Psychiatry. https://doi.org/10.1016/j.pnpbp.2019.109672

4. Baer, L. H., Shah, J. L., & Lepage, M. (2019). Anxiety in you that clinical high risk for psychosis: A case study and conceptual model. Schizophrenia Research. https://doi.org/ 10.1016/j.schres.2019.01.006

5. Bernardo M., Bioque M., Cabrera B., Lobo A., Gonzalez-Pinto A., Pina L., et al. (2017). Modelling gene-environment interaction in first episodes of psychosis. Schizophrenia Research. https://doi.org/10.1016/j.schres.2017.01.058

6. Birchwood, M., Trower P. (2006). The future of cognitive-behavioural therapy for psychosis: not a quasi-neuroleptic. British Journal Psychiatry. Vol. 188, issue 2, pp. 107 - 108. https://doi.org/10.1192/bjp.bp.105.014985

7. Bosanac, P., Castle, D. (2015). How should we manage anxiety in patients with schizophrenia? Australasian Psychiatry. Vol. 23, issue. 4, pp. 374 - 377. https://doi.org/10.1177/1039856215588207

8. Brabban, A., Byrne, R., Longden, Е., Morrison, A. (2017). The importance of human relationships, ethics and recovery-orientated values in the delivery of CBT for people with psychosis. Psychosis. Vol. 9, issue 2, p. 157 - 166. https://doi.org/10.1080/17522439.2016.1259648

9. Buckley P, Miller BJ, Lehrer DS, et al. (2009). Psychiatric comorbidities and schizophrenia. Schizophrenia Bulletin. Vol. 35, issue. 2, pp. 383 - 402. https://doi,org/ 10.1093/schbul/sbn135

10. Buonocore, M., Bosia, M., Bechi, M., Spangaro, M., Cavedoni, S., Cocchi, F. et al. (2017). Targeting anxiety to improve quality of life in patients with schizophrenia. European Psychiatry. Vol. 45, pp. 129 - 135 https://doi.org/10.1016/_j.eurpsy.2017.06.014

11. Christopher Frueh, B., Grubaugh, A. L., Cusack, K. J., Kimble, M. O., Elhai, J. D., &Knapp, R. G. (2009). Exposure-based cognitive-behavioral treatment of PTSD in adults with schizophrenia or schizoaffective disorder: A pilot study. Journal of Anxiety Disorders. Vol. 23, issue 5, pp. 665 - 675. https://doi.org/10.1016/_j.janxdis.2009.02.005

12. Freeman, D., Waller, H., Harpur-Lewis, R., et al. (2015). Urbanicity, persecutory delusions, and clinical intervention. Behavioural and Cognitive Psychotherapy. Vol. 43, Issue. 1, pp. 42 - 51 http://dx.doi.org/10.1017/S1352465813000660

13. Halperin, S., Nathan, P., Drummond, P., &Castle, D. (2000). A Cognitive-Behavioural, Group-Based Intervention for Social Anxiety in Schizophrenia. Australian & New Zealand Journal of Psychiatry. Vol. 3, Issue 5, pp. 809 - 813. https://doi.org/10.1080/j.1440-1614.2000.00820.x

14. Hartley S, Barrowclough C, Haddock G. (2013). Anxiety and depression in psychosis: A systematic review of associations with positive psychotic symptoms. Acta Psychiatrica Scandinavica. Vol. 128, issue 5, pp. 327-346. https://doi.org/10.1111/acps.12080

15. Huppert, J. D., Kivity, Y., Barlow, D. H., Gorman, J. M., Shear, M. K., &Woods, S. W. (2014). Therapist effects and the outcome - alliance correlation in cognitive behavioral therapy for panic disorder with agoraphobia. Behaviour Research and Therapy, Vol. 52, pp. 26 - 34. https://doi:10.1016/j,brat.2013.11.001

16. Kingsep, P., Nathan, P., &Castle, D. (2003). Cognitive behavioural group treatment for social anxiety in schizophrenia. Schizophrenia Research. Vol. 63, Issue 1 - 2, pp. 121 - 129. https://doi,org/ 10.1016/s0920-9964(02)00376-6

17. Korczak, A., & Styla, R. (2021). Anxiety and executive functions relationships in schizophrenia: A meta-analysis. Personality and Individual Differences. Vol. 177, 110643. https://doi.org/10.1016/j.paid.2021.110643

18. Lysaker, P. H., Davis, L. W., Lightfoot, J., Hunter, N., & Stasburger, A. (2005). Association of neurocognition, anxiety, positive and negative symptoms with coping preference in schizophrenia spectrum disorders. Schizophrenia Research. Vol. 80, issue 2-3, pp. 163 - 171. https://doi:10.1016/j.schres.2005.07.005

19. Nemoto, T., Uchino, T., Aikawa, S., Matsuo, S., Mamiya, N., Shibasaki, Y., Mizuno, M. (2020). Impact of changes in social anxiety on social functioning and quality of life in outpatients with schizophrenia: A naturalistic longitudinal study. Journal of Psychiatric Research. Vol. 131, pp. 15-21. https://doi.org/10.1016/jjpsychires.2020.08.

20. Opoka, S. M., & Lincoln, T. M. (2017). The Effect of Cognitive Behavioral Interventions on Depression and Anxiety Symptoms in Patients with Schizophrenia Spectrum Disorders. Psychiatric Clinics of North America. Vol. 40, issue. 4, pp. 641 - 659. https://doi.org/10.1016Zj.psc.2017.08.005

21. Szalisznyo, K., Silverstein, D., &Toth, J. (2019). Dynamics in schizo-obsessive spectrum disorders: a computational approach. Journal of Theoretical Biology. https://doi.org/10.1016/jjtbi.2019.01.038

22. Temmingh, H., & Stein, D. J. (2015). Anxiety in Patients with Schizophrenia: Epidemiology and Management. CNS Drugs. Vol. 29, issue. 10, pp. 819 - 832. https://doi,org/10.1007/s40263 -015-0282-7

23. Tibbo P, Swainson J, Chue P, LeMelledo JM. (2003). Prevalence and relationship to delusions and hallucinations of anxiety disorders in schizophrenia. Depress Anxiety. Vol. 17, issue. 2, pp. 65 - 72. https://doi.org/10.1002/da.10083

24. Turkington, D., Kingdon D, Turner T. (2002). Effectiveness of a brief cognitivebehavioural therapy intervention in the treatment of schizophrenia. British Journal Psychiatry. Vol. 180, issue 6. pp. 523-527. https://doi.org/10.1192/bjp.180.6.523

25. Wilson, R. S., Yung, A. R., & Morrison, A. P. (2019). Comorbidity rates of depression and anxiety in first episode psychosis: A systematic review and meta-analysis. Schizophrenia Research. https://doi.org/10.1016/j.schres.2019.11.035

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