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Effect of body-oriented psychological therapy on negative symptoms in schizophrenia: a randomized controlled trial

Psychological Medicine, 2006, 36, 669–678.
Effect of body-oriented psychological therapy on negative symptoms in schizophrenia : a randomized F R A N K R O¨ H R I C H T 1* A N D S T E F A N P R I E B E 2 1 Consultant Psychiatrist, Honorary Senior Lecturer, Unit for Social & Community Psychiatry, Newham Centre for Mental Health ; 2 Professor of Social and Community Psychiatry, Barts and the London School of Medicine, Queen Mary, University of London Background. In order to improve the treatment of medication-resistant negative symptoms inschizophrenia, new interventions are needed. Neuropsychological considerations and older reportsin the literature point towards a potential benefit of body-oriented psychological therapy (BPT).
This is the first randomized controlled trial specifically designed to test the effectiveness ofmanualized BPT on negative symptoms in chronic schizophrenia.
Method. Out-patients with DSM-IV continuous schizophrenia were randomly allocated to eitherBPT (n=24) or supportive counseling (SC, n=21). Both therapies were administered in smallgroups in addition to treatment as usual (20 sessions over 10 weeks). Changes in negative symptomscores on the Positive and Negative Symptom Scale (PANSS) between baseline, post-treatment and4-month follow-up were taken as primary outcome criteria in an intention-to-treat analysis.
Results. Patients receiving BPT attended more sessions and had significantly lower negativesymptom scores after treatment (PANSS negative, blunted affect, motor retardation). The differ-ences held true at 4-month follow-up. Other aspects of psychopathology and subjective qualityof life did not change significantly in either group. Treatment satisfaction and ratings of thetherapeutic relationship were similar in both groups.
Conclusions. BPT may be an effective treatment for negative symptoms in patients with chronicschizophrenia. The findings should merit further trials with larger sample sizes and detailed studiesto explore the therapeutic mechanisms involved.
treatment-resistant (Arango et al. 2004), andthere is a need to develop new, effective strat- Despite improvements in antipsychotic treat- egies to treat patients with negative symptoms ment schizophrenia patients often experience persistent symptoms and full remission is infre- quent (Sheitman & Lieberman, 1998). Andrews oriented psychotherapy (BPT), also referred and co-workers concluded (2003) that current to in the literature as ‘ body psychotherapy ’ interventions avert only 13 % of the burden of (Staunton, 2002 ; Totton, 2003), may be worth schizophrenia. Primary negative symptoms and studying in this context : positive reports in the deficit syndrome appear to be particularly the literature on body-oriented interventionsin schizophrenia, and neuropsychological con-siderations.
* Address for correspondence : Dr Frank Ro¨hricht, Academic BPT refers back to a long tradition of body- Unit, Newham Centre for Mental Health, London E13 8SP, UK.
oriented interventions in psychiatry. At the beginning of the twentieth century the psycho- It is against this background that the first analysts Ferenczi and Reich were experimenting author of this paper defined a treatment manual with non-verbal, body-oriented interventions for BPT with schizophrenia patients suffering to overcome perceived limitations of psycho- from persistent negative symptoms. We report analytic practice. The earliest trials influenced here the first randomized controlled trial of BPT for patients with schizophrenia in recent Californian dance therapist Schoop. She started history. The trial tested the hypothesis that BPT to work with hospitalized schizophrenia patients is effective in reducing negative symptoms in 1959, and her ‘ body-ego technique ’ aimed in out-patients with schizophrenia. To control to focus patients’ attention ‘ on body posture for the influence of non-specific attention and and movement … body-ego boundaries … and structured group activities BPT was compared reality contact and experience in movement ’ (May et al. 1963 ; Goertzel et al. 1965). A trialshowed a significant improvement in patients treated with the technique, compared withcontrols, especially in affective contact, motility and general functioning (Goertzel et al. 1965).
The study was conducted in East London, UK.
Four further controlled studies – three of Patients were recruited by referrals from com- munity mental health services. The study was oriented interventions with non-specific atten- approved by the North East London Strategic tion, music therapy or fitness training (Goertzel Health Authority Ethics Committee and written et al. 1965 ; Darby, 1970 ; Nitsun et al. 1974 ; informed consent was obtained from all patients Seruya, 1977). These studies were all conducted before 1980 and have serious methodological We applied the following selection criteria : shortcomings, such as vaguely defined outcome age 20–55 years ; an established diagnosis criteria, no systematic assessment of psycho- of schizophrenia according to DSM-IV, with pathology, no recording of medication, and at least two episodes with acute psychotic no intention-to-treat analysis. Nevertheless, the symptoms ; time since last in-patient treatment results suggest favorable effects of the exper- more than 1 month (currently out-patient) ; imental treatments on a variety of outcome suffering from persistent symptoms of schizo- variables, including some indicators of negative phrenia for at least 6 months with a high degree of negative symptoms at baseline, i.e. Positive The approach of body-oriented interventions is based on phenomenological findings (Priebe score ‘ Negative ’ o20 and/or one of the & Ro¨hricht, 2001 ; Ro¨hricht & Priebe, 2002) and the assumption that movement and emotional ‘ motor retardation ’ or ‘ blunted affect ’) o6 experiences are biologically and experientially (6=severe); stable medication prior to entering associated. This is supported by close anatom- the study. Exclusion criteria were : evidence of ical and functional links between the limbic organic brain disease ; severe or chronic physical system, particularly the extended amygdala, illness ; and substance misuse as primary diag- and the basal ganglia. It is also emphasized by nosis. An experienced psychiatrist, blind to the Trimble’s observation on how ‘ movement and allocated treatment, carried out all screening, emotion are linked in common speech (hence baseline and outcome assessments ; the rater ‘‘ a moving experience ’’) ’ (1997 : 114).
was trained in the use of assessment instru- Two primary negative symptoms in particular ments. All patients referred to the project were lend themselves to body-oriented interventions : offered an appointment for a screening inter- emotional withdrawal/affective blunting and view to establish whether selection criteria were motor retardation. Given their non-cognitive met. Suitable patients were then further assessed nature, they might be best targeted through (details below) within the same interview.
non-verbal methods, combining sensory aware- Eligible patients were randomly allocated to one of the two treatment conditions (BPT or SC, both in addition to treatment as usual) Body-oriented psychological therapy in schizophrenia following the opening of a sealed envelope by (2) to refocus cognitive and emotional aware- the project co-ordinator, who had no involve- ment in data collection or assessments. This was co-ordination and orientation in space) ; carried out in blocks : once a sufficient number (3) to stimulate activity and emotional respon- of patients had been recruited to the study to fill one treatment group in each condition, the (4) to promote exploration of self-potentials, recruited patients were randomly allocated.
focusing on body strength and capability,experiencing the body as a source of creativity, reliability, pleasure and self- All patients in both treatment arms received psychological group treatments in addition to (5) to modify dysfunctional self-perception ; the usual care provided by community psychi- atric services (TAU). Treatment plans were not substantially altered during the trial period.
In both conditions, BPT and SC, the group size was limited to a maximum of eight patients, andthe aim was to provide 20 sessions of 60–90 BPT was delivered within a format of defined minutes each over a period of 10 weeks.
sections as follows (intervention examples given The therapists providing treatment in the study were otherwise not involved in the patients’ (A) Opening circle : checking in : ‘ How do you care. A part-time dance movement therapist feel, how does your body feel (i.e. warm, cold, conducted BPT. Two nurse therapists, also with tense, floppy) ? Describe your level of energy ; previous training and experience in provid- where is the centre of your body-awareness ? ’ ing psychological therapies for schizophrenia Sitting in a circle on the floor and engaging in patients, delivered SC. All therapists had many simple warm-up activities and communication years’ experience of working with patients tasks with props such as soft balls, balloons suffering from schizophrenia and attended specific training sessions before the trial. Later (B) Warm up section : standing in a circle, they received three supervision sessions each continuation of warm-up using different body to ensure adherence to the given treatment parts and different qualities of movement, e.g.
manual (on the basis of written records of each swings, stretches, jumps. Grounding, body- centering and body awareness techniques/exercises and movements, focusing on basic Body-oriented psychological therapy (BPT) physiological functions such as breathing and Different schools of body-oriented psycho- pulsation. Travelling movements including dif- therapeutic interventions have developed, but ferent kinds of walks in different directions, at various authors acknowledge the underlying different speeds and with different qualities, e.g.
coherence and substantial overlap in the applied brisk, purposeful walk in contrast to lethargic intervention strategies (e.g. Guimon, 1997 ; walk as well as crawling, jumping, turning ; Staunton, 2002 ; Totton, 2003). The treatment exploring the dimensions of space within and manual used in this study was defined (by the first author) based on the available evidence and aimed to integrate different techniques (e.g.
immediate vicinity from small to big and in all Krietsch & Heuer, 1997 ; Scharfetter, 1999) three dimensions ; demarcating own boundaries into a clinically focused and syndrome-specific with props, e.g. rope. Identifying a partner, method (for full description see Ro¨hricht, 2000).
defining demarcation of own boundaries in The protocol of the manual was designed to copying each others’ movements ; leading andfollowing from a stationary position and then travelling with the purpose of exploring the body-ego as consistent, self-evident and active ; exploring emotionally equivalent movements, i.e. stamping, stroking, hiding away, defending.
total sample of 40–60 patients would provide Creating body image sculptures on paper or in 55 % power of detecting an effect size of 0.6, partners and comparing internal with external and 81 % power for an effect size of 0.8 with a two-tailed significance level of 0.05 (Cohen, group circle. Group mirroring with each par-ticipant having an opportunity to initiate Primary and secondary outcome assessments movement phrases in the group based either Patients were assessed prior to and at the end of treatment as well as after a 4-month follow- rhythmic music, or with a concrete theme like up period. The work of the therapists and the different sports themes, or related to feelings/ assessing researcher were kept strictly separate opposites. Creating group sculptures. Reflecting in order to ensure blindness of the assessor, on how this feels : ‘ Can you engage in these and patients were requested not to reveal any movement exercises ? ’, ‘ Do you feel stress/ details of their treatment during post-treatment assessments up to the end of the follow-up interview, when qualitative data was collected.
(E) Closing circle : reflecting on group experi- ences, energy levels, re-focusing on self with was the level of negative symptoms as rated on simple body-oriented exercises such as self- the corresponding subscale of the PANSS (Kay et al. 1987). We specifically assessed changesin ‘ affective blunting ’ and ‘ decreased spon- taneous movement ’ (psychomotor retardation), Basic principles of the method are described because these symptoms are regarded as ‘ core elsewhere (Tarrier et al. 1993 ; Valmaggia et al.
negative symptoms ’ (Liddle, 2000) of chronic 2005). In this study, the therapist focused schizophrenia. Since negative symptoms may on individual difficulties and corresponding be secondary to extrapyramidal side-effects of problem-solving strategies regarding the core antipsychotic medication, these were recorded negative symptoms. The therapist initially facilitated a safe and supportive atmosphere Symptom Scale (EPS ; Simpson & Angus, 1970).
amongst group participants ; in the next step Antipsychotic medication was documented as patients were given the opportunity to talk chlorpromazine-equivalent (Atkins et al. 1997 ; about specific difficulties in relation to lack of BMA, 2003) at all three points in order to assess motivation, difficulties initiating activities, and lack of emotional responsiveness ; the group then engaged in discussing their experiences, positive and PANSS general), and subjective trying to identify the impact of the symptoms quality of life (SQOL) were assessed at three on their lives and possible contributing factors time-points as secondary outcome measures.
to the problems ; this was followed by the The Manchester Short Assessment of Quality therapists’ emphasis on examples of good prac- of Life (MANSA ; Priebe et al. 1999) was used tice, i.e. well established coping strategies, as to assess SQOL (providing a mean score of well as creative attempts to identify possible satisfaction ratings in 12 life domains, each solutions related to individual difficulties, fol- ranging on a Likert scale of 1=‘could not be lowed by verbal closure, integrating the different worse ’ to 7=‘ could not be better ’).
Patients’ satisfaction with treatment was measured post-treatment and at follow-up on the Client’s Assessment of Treatment Scale In this exploratory trial, the power calculation (CAT ; Priebe et al. 1995), comprising seven was based on the aim to detect a moderate to 11-point rating scales ranging from 0=extreme large effect size, comparable to effects in pub- negative answer to 10=extreme positive answer lished trials on other forms of psychotherapy for on different aspects of treatment. At follow-up persistent symptoms of schizophrenia (Kuipers the same scale was administered to assess retro- et al. 1997 ; Durham et al. 2003). A trial with a spective satisfaction with treatment.
Body-oriented psychological therapy in schizophrenia We also assessed the quality of the thera- total, four groups of patients were treated in peutic relationship after treatment and at each condition. The detailed flow diagram is follow-up as a non-specific and potentially mediating factor. Patients rated the Helping Demographic and clinical characteristics of Alliance Scale (HAS ; Priebe & Gruyters, 1993), the study sample (n=45) are shown in Table 1.
which consists of five Likert-type items. The None of the variables showed significant ratings are summarized, with higher scores statistical difference between the two groups.
indicating a better quality of the relationship.
The sample consisted mainly of middle-aged,single, unemployed individuals, and partici- pants had a long history of mental illness.
All data were analyzed using the Statistical The two groups differed significantly with Package for the Social Sciences version 10.1. for Windows (SPSS Inc., Chicago, IL, USA).
sessions attended : BPT (n=11.3, S.D.=6.0); SC (n=4.5, S.D.=4.8); t=4.0, df=43, p<0.001.
to-treat basis. Differences in negative symptom Dosages of antipsychotic medication as well scores between the experimental intervention as extrapyramidal symptom scale scores did and control groups were tested using analysis not differ significantly between the two groups of covariance (ANCOVA), with baseline scores as covariates. ANCOVA was also conductedon the mean of satisfaction ratings in the Mean scores of the psychopathology outcome corresponding baseline scores as a covariate.
Another analysis examined the proportion of to follow-up are shown in Table 3. The two patients in each treatment group who showed groups showed no significant differences in an improvement between baseline and post- psychopathological scores at baseline.
treatment of 25 % or greater in negativesymptom scores.
Changes of negative symptom severity from Changes of medication during participation in the trial were recorded as both changes in Controlling for baseline scores, the ANCOVA mean daily equivalents of chlorpromazine and of patients’ negative symptom scores showed changes from typical to atypical antipsychotics.
a significant effect of the experimental inter- In order to examine the impact of dosage of vention : patients treated with BPT had signifi- antipsychotic medication and extrapyramidal cantly lower symptom scores after treatment (PANSS negative : F=5.0, p=0.031; blunted analysis of variance was repeated with the affect : F=10.8, p=0.002 ; motor retardation : medication and the EPS scale total score as negative : F=7.0, pf0.015; blunted affect: covariates. Furthermore it was intended to F=5.6, p=0.026 ; motor retardation : F=7.7, analyze the data based on group allocation as follows : no change of medication, change The number of patients with symptom reduc- from typical to typical antipsychotic, change tion of 20 % or more (range 20–46 %) from from typical to atypical antipsychotic. Patients’ baseline score was significantly higher in the relationship were analyzed using t tests.
versus n=4/21 %). When repeating ANCOVAwith chlorpromazine-equivalents of antipsy-chotic medication and the EPS scale total score as additional covariates, the results of the analyses were not substantially affected by these A total of 67 patients were referred for inclusion covariates. Thus, differences in treatment effects in the study, 55 of whom fulfilled the inclusion on negative symptoms were not influenced by criteria. Of these, 45 consented and were extrapyramidal side-effects or level of antipsy- randomized to the treatment conditions. In chotic medication as measured in this trial.
Not meeting inclusion criteria (n = 12) Withdrawal from assessment (n = 10) Allocated to body psychotherapy (n = 24) Allocated to supportive counseling (n = 21) Received allocated intervention (n = 22) Received allocated intervention (n = 14) (n = 2 did not receive allocated intervention because they (n = 7 did not receive allocated intervention because they Assessed at end of treatment phase (n = 23) Assessed at end of treatment phase (n = 19) Patients’ assessment of treatment was broadly baseline to post-treatment occurred only in positive : the mean CAT score did not differ be- tween groups after treatment (BPT : mean=6.8, allowing for analysis of variance as intended.
S.D.=2.0 ; SC : mean=6.4, S.D.=1.9) and at A case-by-case analysis showed that in four follow-up (BPT : mean=7.3, S.D.=1.9 ; SC: mean=6.7, S.D.=1.8). Equally, patients’ ratings to another atypical antipsychotic, two patients of the therapeutic relationship was generally were changed from typical to atypical anti- appreciative and did not differ between groups psychotic, and one patient from atypical to after treatment (BPT : mean=7.2, S.D.=1.9; typical antipsychotic. These changes were not SC : mean=6.6, S.D.=1.8) and at follow-up associated with more or less favorable treatment (BPT : mean=7.1, S.D.=2.1 ; SC : mean=7.1, (PANSS positive, general, and total) as well as SQOL scores did not differ significantly, either BPT was administered without worsening of positive, florid psychotic symptoms. It was more Body-oriented psychological therapy in schizophrenia mazine-equivalent) and extrapyramidal symptomscale scores Chlorpromazine-equivalents of antipsychotic medication BPT, Body-oriented psychological therapy ; SC, supportive coun- BPT, Body-oriented psychological therapy ; SC, supportive coun- There was a high drop-out rate in the control group. Some of the clinical improvement maytherefore be attributed to better treatmentadherence in the experimental group and non- effective in improving persistent and medi- specific effects of more attention and activities.
cation-resistant primary negative symptoms However, we did not find a difference in indi- than SC, when given in addition to treatment as cators of non-specific effects between the two groups in an intention-to-treat analysis. Also, The findings did not suggest an influence the better adherence of patients to BPT shows a of potentially confounding factors, i.e. anti- relatively good acceptance of the experimental psychotic medication, extrapyramidal symp- treatment, which may be regarded as a positive toms, improvement of positive symptoms, on effect of BPT itself and facilitate its use in the different treatment effect in the two groups.
Both groups showed similar treatment satisfac-tion and ratings of therapeutic relationships.
The effect of BPT, therefore, cannot be ex- plained by non-specific effects as reflected in treatment satisfaction and the quality of the efficacy of atypical antipsychotics on negative therapeutic relationship. Applying the criterion symptoms (reviews Leucht et al. 1999 ; Mo¨ller, of 20 % reduction on symptom scale scores as 2000 ; Chakos et al. 2001), the results of this a measure of clinically significant change (as study appear encouraging. A review of Chakos suggested by Rector et al. 2003), a significantly et al. (2001) found effects of clozapine, olanz- higher number of patients in the BPT group apine or risperidone on negative symptoms (50 %) achieved this degree of response to the with an improvement of between 3 % and 15 %, i.e. lower than the mean reduction of 20–25 % inthis study. Volavka et al. (2002) directly com- pared clozapine, olanzapine, risperidone and This was an exploratory trial with a small haloperidol in the treatment of chronic schizo- sample size. A single therapist administered phenia. Only in patients treated with clozapine BPT, and it remains unclear whether the effect was a significant improvement in negative can be replicated across different therapists symptoms identified after 8 weeks – comparable and in other samples and settings. However, the manualization should help to reduce variation cognitive-behavioural therapy (CBT) targeting Clinical outcome measures (ANCOVAs, adjusted for baseline score) PANSS, Positive and Negative Symptom Scale ; MANSA, Manchester Short Assessment of Quality of Life ; BPT, Body-oriented psycho- logical therapy ; SC, supportive counseling.
negative symptoms in schizophrenia (Tarrier, the baseline scores for negative symptoms were 2005). Rector & Beck (2001) identified three significantly lower than in our study. In various studies with medium to large treatment effects trials (Tarrier et al. 1993 ; Sensky et al. 2000 ; Tarrier et al. 2000) CBT has been associated with routine care or supportive therapy. Sensky with lower drop-out rates than the control et al. (2000) reported a significant improvement conditions, as has BPT in our study.
There is currently no evidence suggesting that other non-pharmacological therapies (family which was sustained after 9 months only in the interventions, social skills training, cognitive CBT group. Rector et al. (2003) remarked that remediation, psychoeducation, assertive com- these changes might have been secondary to munity treatment) have consistent effects on changes in positive and/or depressive symp- negative symptoms in schizophrenia (Bustillo toms, a concern that does not apply to the et al. 2001 ; Pilling et al. 2002 ; Turkington et al.
findings of this study. In their own study, Rector et al. (2003) found that 61 % of patients withpersistent symptoms receiving CBT were re-garded as treatment ‘ responders ’ compared with 31 % in ‘ enriched treatment as usual ’, and In this exploratory trial of BPT we targeted a the effects were not attributable to changes in highly selective patient group with marked and positive symptoms and/or depression. However, Body-oriented psychological therapy in schizophrenia schizophrenia. BPT was accepted by patients Durham, R. C., Guthrie, M., Morton, R. V., Reid, D. A., Treliving, and associated with a favorable effect. The effect L. R., Fowler, D. & MacDonald, R. R. (2003). Tayside-Fife clinicaltrial of cognitive-behavioural therapy for medication-resistant size was substantial and at least as high as psychotic symptoms. Results to 3-month follow-up. British those reported in the literature for antipsychotic Journal of Psychiatry 182, 303–311.
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