Cognitive Behavioral Therapy for negative symptoms (CBT-n) in

psychotic disorders: A pilot study

Anton B.P. Staring
a,
*
, Mary-Ann B. ter Huurne
b
, Mark van der Gaag
c, d
a
Altrecht Psychiatric Institute, ABC-straat 8, 3512 PX Utrecht, The Netherlands
b
Mediant Psychiatric Institute, Laan van Driene 101, 7552 EN Hengelo, The Netherlands
c
Parnassia Psychiatric Institute, Oude Haagweg 357, 2552 ES The Hague, The Netherlands
d
VU University and EMGO Institute for Health and Care Research, Van Boechorststraat 1, 1081 BT Amsterdam, The Netherlands
a r t i c l e i n f o
Article history:
Received 1 September 2012
Received in revised form
21 January 2013
Accepted 23 January 2013
Keywords:
Psychosis
Schizophrenia
Cognitive therapy
CBT
Negative symptoms
Self-stigma
a b s t r a c t
Background and objectives: The treatment of negative symptoms in schizophrenia is a major challenge for
mental health care. One randomized controlled trial found that cognitive therapy for low-functioning
patients reduced avolition and improved functioning, using an average of 50.5 treatment sessions over
the course of 18 months. The aim of our current pilot study was to evaluate whether 20 sessions of
Cognitive Behavioral Therapy for negative symptoms (CBT-n) would reduce negative symptoms within 6
months. Also, we wanted to test the cognitive model of negative symptoms by analyzing whether
a reduction in dysfunctional beliefs mediated the effects on negative symptoms.
Method: In an open trial 21 adult outpatients with a schizophrenia spectrum disorder with negative
symptoms received an average of 17.5 sessions of CBT-n. At baseline and end-of-treatment, we assessed
negative symptoms (PANSS) and dysfunctional beliefs about cognitive abilities, performance, emotional
experience, and social exclusion. Bootstrap analysis tested mediation.
Results: The dropout rate was 14% (three participants). Intention-to-treat analyses showed a within group
effect size of 1.26 on negative symptoms (t 6.16, j Sig 0.000). Bootstrap analysis showed that
dysfunctional beliefs partially mediated the change.
Limitations: The uncontrolled design induced efcacy biases. Also, the sample was relatively small, and
there were no follow-up assessments.
Conclusions: CBT-n may be effective in reducing negative symptoms. Also, patients reported fewer
dysfunctional beliefs about their cognitive abilities, performance, emotional experience, and social
exclusion, and this reduction partially mediated the change in negative symptoms. The reductions were
clinically important. However, larger and controlled trials are needed.
2013 Elsevier Ltd. All rights reserved.
1. Introduction
1.1. Negative symptoms
Negative symptoms of psychotic disorders include avolition,
affective attening, social withdrawal, anhedonia, and poverty of
speech. A review demonstrates that these symptoms are strong
predictors of poor long-termprognosis (Lang, Ksters, Lang, Becker,
& Jger, 2012). They are clearly associated with low levels of
functioning (r 0.42), which is not the case for positive symptoms
(Ventura, Hellemann, Thames, Koellner, & Nuechterlein, 2009).
Even though negative symptoms are often regarded as stable
aspects of psychotic disorders such as schizophrenia, not changing
much or otherwise worsening over time, there is recent evidence
that both at affect and social functioning show important changes
during the course of ten years after a rst psychotic episode,
slowly deteriorating or improving for different patient subgroups
(Evensen et al., 2012). This installs hope for change and targeted
interventions. However, the treatment of negative symptoms in
schizophrenia is still a major challenge for mental health care.
Second generation antipsychotic medications produce only mod-
erate effects on negative symptoms (Leucht, Arbter, Engel, Kissling,
& Davis, 2009), and an exacerbation of negative symptoms due to
antipsychotics has also been reported (Artaloytia et al., 2006). More
effective treatments are needed.
* Corresponding author. Tel.: 31 (0) 6 815 99 505.
E-mail addresses: tonnie@backwash.org, t.staring@altrecht.nl (A.B.P. Staring),
mary-ann.huurne@mentrum.nl (M.-A.B. ter Huurne), m.vander.gaag@vu.nl
(M. van der Gaag).
Contents lists available at SciVerse ScienceDirect
Journal of Behavior Therapy and
Experimental Psychiatry
j ournal homepage: www. el sevi er. com/ l ocat e/ j bt ep
0005-7916/$ e see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jbtep.2013.01.004
J. Behav. Ther. & Exp. Psychiat. 44 (2013) 300e306
1.2. Cognitive Behavioral Therapy (CBT) for negative symptoms
In the US, a randomized controlled trial with 60 patients was
conducted to assess the efcacy of a program for low-functioning
patients with neurocognitive impairments and negative symp-
toms (Grant, Huh, Perivoliotis, Stolar, & Beck, 2012). The program
was based on recent evidence that defeatist performance attitudes
(e.g. if you cannot do something well, there is little point in doing it
at all) correlate with negative symptoms (Beck, Grant, Huh,
Perivoliotis, & Chang, 2011; Couture, Blanchard, & Bennett, 2011)
and partially mediate the relationship between neurocognitive
performance and negative symptoms (Grant & Beck, 2009). This
means that patients beliefs about their neurocognitive impair-
ments are important in determining the extent to which these
impairments lead to withdrawal and inactivity. Also, in three
studies, using experience sampling methods, there was no evi-
dence for a decit in the experience of pleasure in patients with
psychotic disorders e rather, there were strong negative expec-
tancies of experiencing pleasure (low anticipatory pleasure: I will
not be able to enjoy this) (Gard, Kring, Gard, Horan, & Green, 2007;
Oorschot et al., 2011). These beliefs predicted low social activity
levels (Oorschot et al., 2011). Another study found that asocial be-
liefs (e.g. having close friends is not as important as most people
say) were predictive of lowsocial functioning one year later, rather
than the other way around (Grant & Beck, 2010).
This body of research implicates that low expectations for
pleasure and performance may strongly affect negative symptoms.
Grant et al. (2012) used cognitive therapy (CT) to correct dysfunc-
tional beliefs about pleasure, cognitive abilities, performance and
social functioning. Techniques included goal-setting, behavioral
experiments, activity scheduling, and more. Several accommoda-
tions were used to work around neurocognitive impairments. The
CT-group received 18 months of individual treatment. CT was found
to be superior in reducing avolition/apathy and improving levels of
functioning. However, other negative symptoms did not improve
signicantly, such as affective attening, alogia, and anhedonia-
asociality. Also, the treatment duration was long: an average of
50.5 sessions.
Another recent and large randomized controlled trial compared
a shorter version of CBT for negative symptoms (average 16.6 ses-
sions) with cognitive remediation in 198 patients (Klingberg et al.,
2011). Treatment consisted of case formulation based on a cognitive
model, goal setting, discussion of cognitive processes, homework
assignments, and role-play. Patients received two out of ve
available treatment modules that target negative symptoms. The
aim was to reduce generalized expectancy of failure (defeatist be-
liefs) and improve social cognitive skills like emotion detection and
expression. The CBT treatment, in comparison to the trial of Grant
et al. (2012), had a greater focus on training of cognition and
behavior, and a somewhat smaller focus on cognitive therapy for
dysfunctional beliefs. Results showed moderate improvements in
negative symptoms in both groups, but no signicant benet for
CBT.
Although other studies of psychosocial interventions have been
conducted, they rarely targeted negative symptoms as their pri-
mary outcome. There have been three small but promising trials on
peer support groups (Castelein et al., 2008), music therapy (Gold,
Solli, Krger, & Lie, 2009), and body-oriented psychosocial ther-
apy (Rhricht & Priebe, 2006). Also, CBT for the positive symptoms
of psychotic disorders has been found to decrease negative symp-
toms: an average effect size of 0.44 (Wykes, Steel, Everitt, & Tarrier,
2008). Less paranoia and less fear for distressing voices may lead to
less withdrawal and more experience of pleasure. This illustrates
the well known multifactorial nature of negative symptoms: posi-
tive symptoms, anxiety, depression, and other symptom clusters
may exacerbate negative symptoms. Interventions that target those
factors therefore exert some effect on the negative symptoms as
well. For example, antidepressant medications are known to
decrease negative symptoms in schizophrenia (Singh, Singh, Kar, &
Chan, 2010). However, treatment of the more primary negative
symptoms remains a major challenge (Buckley & Stahl, 2007;
Kirkpatrick, Fenton, Carpenter, & Marder, 2006). Antipsychotics and
family interventions are unsatisfactory in this regard (Mkinen,
Miettunen, Isohanni, & Koponen, 2008). The trial of Grant et al.
(2012) is one of the most promising. More research is needed to
conrm to what extent specic CBT for negative symptoms may
reduce these symptoms as well as dysfunctional beliefs, and to
evaluate whether it can be achieved in fewer sessions than 50.
1.3. Aims of the study
Based on recent literature, we constructed a Dutch treatment
manual of Cognitive Behavioral Therapy for negative symptoms
(CBT-n) (Staring & Van den Berg, 2010; Staring & Van der Gaag,
2010). The aim of this uncontrolled pilot study was to test: (a)
whether the treatment manual is useful for therapists; (b) whether
CBT-n may be effective in reducing negative symptoms for patients
with a schizophrenia spectrum disorder, using a maximum of 20
treatment sessions in six months; and (c) whether a reduction in
dysfunctional beliefs mediates the effect on negative symptoms.
Findings within this pilot study will be used as preparation for
a large RCT.
2. Materials and methods
2.1. Study design
An open pilot trial in which negative symptoms were treated
with CBT-n in participants with a schizophrenia spectrum disorder,
with a maximum of 20 treatment sessions.
2.2. Setting
Participants were outpatients from nine psychiatric institutions
in The Netherlands: Altrecht Psychiatric Institute, Mediant Psychi-
atric Institute, Parnassia Psychiatric Institute, Mental Health Care
Drenthe, Mental Health Care Breburg, Mental Health Care Noord-
Holland Noord, Rivierduinen Psychiatric Institute, GGNet, and
Reinier van Arkel Group.
2.3. Participants
Inclusion criteria were:
1. A chart diagnosis of schizophrenia spectrum disorder;
2. At least some negative symptoms (at least three PANSS neg-
ative symptom items scoring a 3 or higher, bringing the total
score of the PANSS negative syndrome to at least 13) about
which the patient expressed dissatisfaction.
Exclusion criteria were:
1. Younger than eighteen years of age;
2. No mastery of the Dutch language;
3. Negative symptoms as a consequence of positive symptoms
(e.g. withdrawal due to paranoid delusions). This was assessed
within the initial information session by the therapist. He/she
asked the patient about the reasons for social withdrawal, low
activity levels, low pleasure experience levels, etc., and explic-
itly asked whether voices or certain psychotic fears play a role
A.B.P. Staring et al. / J. Behav. Ther. & Exp. Psychiat. 44 (2013) 300e306 301
or not. Positive symptoms as such were not an exclusion cri-
terion; only whenthey were considered to be the primarycause
of the negative symptoms, in which case CBT-p or another type
of intervention for positive symptoms was called for.
2.4. Procedure
After referral to this study, information was given verbally as
well as in writing, and written informed consent was obtained.
After that, baseline measurements were administered (T0). Par-
ticipants were then treated with weekly sessions of 45 min ac-
cording to the CBT-n manual, with a maximum of 20 sessions.
Treatment as usual (e.g. case management) was also continued.
Therapists worked in the same team as the case managers and kept
in touch about progress. Measurements were administered again at
the end-of-treatment (T1). In total, thirteen therapists participated
in the study. All therapists were health and clinical psychologists
with experience in CBT for psychosis. Ten had at least a two-year
post-doctoral clinical specialization. The therapists received
a one-day training in the CBT-n manual. Treatment integrity mea-
surements were not collected. The rst author did keep in touch
with all therapists about progress and gave consultation for the
various phases of the treatment for each participant.
The Medical Ethics Committee of the University Medical Center
of Utrecht approved the study protocol (METC-protocol number:
11-228/C, date 10-06-2011).
2.5. Cognitive Behavioral Therapy for negative symptoms (CBT-n)
The treatment manual was based on the work of Grant and col-
leagues (Grant et al., 2012; Perivoliotis & Cather, 2009), but adapted
here and there, e.g. in order to make distinctions between various
dysfunctional beliefs andto further t the model withinsights about
self-stigma, perceived discrimination and social exclusion, mourn-
ing over experienced losses, and states of demoralization. This is
based onsome recent literature. For example, ina recent study using
time budget to concisely measure activity levels, perceived dis-
crimination, within a measure of stigma appraisals, was found to be
associatedwithreducedactivity(Moriarty, Jolley, Callanan, &Garety,
2012). Patients withpsychosis epossiblyas a consequence of insight
into neurocognitive impairments and of the experienced losses due
to psychotic episodes and hospital admissions e may be vulnerable
for internalizing some highly stigmatizing beliefs about their illness
and for sliding into a state of demoralization. Indeed, assessing 145
outpatients, it was found that high insight combined with high self-
stigma predicted levels of demoralization in patients with psychotic
disorders (Cavelti, Kvrgic, Beck, Rsch, & Vauth, 2011). This is in line
with other studies that have found that a combination of good
insight together with stigmatizing illness appraisals renders a pa-
tient at risk for highlevels of hopelessness as well as lowself-esteem
and low quality of life (Lysaker, Roe, & Yanos, 2007; Staring, Van der
Gaag, Van den Berge, Duivenvoorden, & Mulder, 2009). Based on
this, as well as onthe work of Grant et al., we constructed a cognitive
model of negative symptoms (Fig. 1).
The treatment manual started with a structured interview in
order to make an individual case formulation based on the model in
Fig. 1. A patients individual goals were assessed, and psycho-
education about neurocognitive impairments and dysfunctional
attitudes was provided. General activity scheduling and registra-
tions were applied, and signicant others were informed about the
treatment rationale. When the rst treatment goal had been cho-
sen, the case formulation provided insight into possible obstacles.
Dysfunctional beliefs and avoidance behaviors that stood in the
way of the goal constituted the targets of CBT-techniques, e.g.
cognitive restructuring and roleplay. Behavioral experiments and
other cognitive methods took place within the treatment sessions
as much as possible. Typical dysfunctional beliefs that were tar-
geted included: I got damaged by my psychotic episode and I cannot
enjoy things anymore, I have no energy at all and when I start
working again, even for a few hours, I will get a psychotic breakdown,
Negative self-image,
self-stigmatization,
expectation of social
exclusion
Reduced
emotional
competencies
Reduced
Reduced
behavioral
competencies
cognitive
competencies
Setbacks,
internal and
external loss-
experiences
(e.g. identity,
capacities,
education,
work,
relationships)
Negative expectations
about cognitive capacities, e.g. memory,
concentration, energy levels
Negative expectations
about agency, performance and
social skills
Negative expectations
about the ability to enjoy and
experience positive emotions
Primary interpretation: Impairment:
Secondary
interpretation:
Avoidance:
Withdrawal, less expression,
inactivity, defeatist attitude,
thought and emotion suppression
Psychoses
Fig. 1. Cognitive model of negative symptoms (Staring & Van der Gaag, 2010). On the left side, impairments are included that may be present in a psychotic disorder and that are
considered unchangeable using CBT. The psychotic episodes, setbacks, and experienced losses are summarized in the upper mid section of the gure; they have taken place in the
past and constitute no target for change. The current problems are summarized in the right and lower sides of the model. These are dysfunctional beliefs that are often characterized
by all-or-nothing polarization as well as by a connection with avoidance behavior.
A.B.P. Staring et al. / J. Behav. Ther. & Exp. Psychiat. 44 (2013) 300e306 302
or I am unable to concentrate and memorize anything new, and
therefore unable to study again. Visual aids, text-messages, imagery,
and the help of signicant others were used to work around neu-
rocognitive impairments. In order to promote a sense of personal
efcacy as much as possible, each failure of the patient to execute
a new behavior was interpreted to be the therapists fault by
insufcient preparation or setting the goals too high. They
responded with sentences like: This is my fault, I did not prepare you
enough for this step. Therapists were instructed to repeatedly get
this message across, as authentically as they were able to. The idea
is that small successes are highly needed for the patient to expe-
rience a sense of hope and personal efcacy. Little failures are
threats that patients may interpret as evidence for negative beliefs
about performance. Patients do not learn from failure and perform
better after errorless learning (Pope & Kern, 2006). However,
therapists were always careful to not install unrealistic beliefs or
goals. Finally, several techniques were used to keep the patient
attending the sessions, e.g. watching entertaining youtube-movies
during the rst part of the session.
2.6. Measurements
2.6.1. Primary outcome
The negative syndrome of the Positive And Negative Syndrome
Scale (PANSS) (Kay, Fiszbein, & Opler, 1987) was used to assess
negative symptoms. It consists of 7 items and produces a total score
ranging from 7 (minimum) to 49 (maximum).
2.6.2. Mediator: dysfunctional beliefs
We intended to measure typical dysfunctional beliefs that con-
stitute the targets of CBT-n, in order to assess whether these would
mediate an effect on negative symptoms. However, no existing scale
ts these beliefs accurately. Although the Dysfunctional Attitudes
Scale e Defeatist Performance Attitude (DAS-DPA) (Weissman,
1978) correlated with negative symptoms in the aforementioned
studies, many of its items reect other attitudes than the perfor-
mance expectancies that constitute the beliefs in the model of Fig. 1,
and some of the beliefs we wanted to measure (e.g. low expec-
tancies about pleasure, energy or concentration) are not included in
this scale. We therefore selected specic items from a range of
existing scales that seemed useful: the Beck Depression Inventory
second edition (BDI-2) (Beck, Steer, Ball, &Ranieri, 1996; Beck, Steer,
& Brown, 1996; Beck, Steer, & Garbin, 1988), the Beck Hopelessness
Scale (BHS) (Beck, Weissman, Lester, & Trexler, 1974), the Dysfunc-
tional Attitudes Scale e Defeatist Performance Attitude (DAS-DPA)
(Weissman, 1978), and the Internalized Stigma of Mental Illness
(ISMI) scale (Ritsher, Otilingam, & Grajales, 2003).
Reasoning from the model in Fig. 1, the selected items should
reect dysfunctional beliefs about cognitive abilities, (social) per-
formance, and the ability to experience positive emotions. Also, we
planned to measure beliefs about social exclusion and internalized
stigma.
(1) Dysfunctional beliefs about cognitive abilities: BDI-13 (indici-
siveness), BDI-15 (subjective loss of energy), BDI-19 (subjective
concentration difculty), and BDI-20 (experienced tiredness or
fatigue).
(2) Dysfunctional beliefs about (social) performance: BHS-2 (I
might as well give up because theres nothing I can do to
make things better for myself), BHS-6 inverted (In the future
I expect to succeed in what concerns me most), DAS-DPA-6
(If I fail at my work, then I am a failure as a person), DAS-
DPA-14 (If I ask a question, it makes me look inferior),
DAS-DPA-15 (I cannot trust other people because they might
be cruel to me).
(3) Dysfunctional beliefs about experiencing pleasure and positive
emotions: BDI-4 (subjective loss of pleasure), BDI-10 (crying too
much or cannot cry), BDI-12 (loss of interest), BDI-21 (loss of
interest in sex), BHS-17 (It is very unlikely that I will get any
real satisfaction in the future).
Based on standardized item-scores (to equal their weights),
these 14 items were summed to constitute a score that reects the
primary beliefs in the model of Fig. 1. Cronbachs alpha of this
measure was 0.719, indicating an acceptable internal consistency.
(4) Beliefs about social exclusion and internalized stigma: ISMI
total score.
The ISMI contains 29 items rated on a four-point Likert-type
scale, ranging from 1 (strongly agree) to 4 (strongly disagree).
It contains ve subscales: alienation, stereotype endorsement,
perceived discrimination, social withdrawal, and stigma resist-
ance. For this study, ISMI total scores were used, in which higher
scores indicate more internalized stigma as well as more expe-
rienced or expected social exclusion. The measure has high
internal consistency and testeretest reliability. Construct and
concurrent validity were supported by comparisons with other
measures.
The ISMI total score as well as the sum of the selected 14 items
were both standardized (transformed into z-scores). These two
scales were then added up to constitute a total measure of the
dysfunctional beliefs that were the main target of CBT-n. Higher
scores indicated more dysfunctional beliefs, with an average score
of zero at baseline.
2.7. Statistical analyses
Descriptive statistics were produced to describe the de-
mographic characteristics and baseline variables of the total
sample. Paired samples t-tests for means were performed to
determine the statistical signicance of the changes in scores on
the primary outcome as well as the mediating measure. Effect sizes
were used as indicators of clinical relevance of the observed
changes (Cohen, 1992). We also performed a regression-analysis,
in which it was checked whether a change in negative symptoms
would still be signicant when depression scores were controlled
for.
Deeper understanding is gained when we comprehend the
process that causes the effect. A variable is a mediating variable if
it (to a certain extent) accounts for the association between the
therapy and symptom reduction. Perfect or complete mediation
refers to an absence of treatment effect when the mediator has
been controlled for. When the treatment effect is reduced by
a non-trivial amount, but not to zero, partial mediation has
occurred (Baron & Kenny, 1986). To demonstrate mediation, the
causal steps strategy should be applied (Fig. 2). This means that
several results must be ascertained: (1) an effect of treatment on
B A
M
C'
Y
C
Y X
X
Fig. 2. Path models of the total effect of treatment on symptoms (upper gure) and
mediated effects of treatment on symptoms (lower gure). C is the total effect of
treatment X on symptoms Y. C
0
is the direct effect of treatment X on symptoms Y with
the effects of mediator M partialled out. A is the effect of treatment X on mediator M
and B is the effect of mediator M on symptoms Y.
A.B.P. Staring et al. / J. Behav. Ther. & Exp. Psychiat. 44 (2013) 300e306 303
symptoms (C path); (2) an effect of treatment on the mediator (A
path); (3) an effect of the mediator on symptoms (B path); and (4)
the effect of treatment on symptoms without the indirect effect of
the moderator must be non-trivially reduced or absent (C
0
path).
In order to analyze whether dysfunctional beliefs mediated the
treatment effects on negative symptoms, we used the bootstrap
method that can handle non-parametric data and relatively small
sample sizes (Preacher & Hayes, 2008). The algorithm and syntax
for SPSS 18 are available on the Internet (Hayes, 2011). In our
uncontrolled design, however, all changes and mediations must
be interpreted with caution, as time effects are not necessarily due
to the treatment.
3. Results
3.1. Participants
A total of 34 patients, who met the criteria of the study, were
asked to participate. Eight refused. The remaining 26 patients
wanted to participate, but two did not enroll because of a physical
illness that required hospital treatment, two missed out on the
participation deadline, and one patient started another exper-
imental treatment. Twenty-one patients enrolled in the study, and
they constitute the participants sample for the intention-to-treat
analyses.
Three patients prematurely stopped treatment. Two of them
stopped halfway due to low motivation. Another patient got too
depressedtocontinue. All threewere available for T1-measurements
and so we had no missing data for the intention-to-treat analyses.
Eighteen patients completed the treatment (Table 1).
3.2. Treatment execution
On average 17.5 sessions of CBT-n were provided to each
participant. Although most patients seemed to benet from the
therapy, the pace of progress varied considerably. Some therapists
noted that, when they continued the treatment program after the
end-of-treatment measurement (T1) and beyond the maximum
of 20 sessions, patients would continue to benet in terms of
improved functioning and fewer negative symptoms. It thus seems
that some patients may accomplish more treatment gains if CBT-n
would be extended. Therapists also described that change in beliefs
and attitudes would come rst, followed by successful behavioral
activation.
In two cases, delusions turned out to be an obstacle for the
patient to engage in desired activities. Their positive symptoms
stood in the way of escaping withdrawal. One patient reported the
fear e after working with this goal for various sessions e that if he
would start socializing, his mother would read his thoughts and
disapprove. And one patient was afraid to return to horse riding,
because they might still be out to get him. Despite the exclusion
criterion of positive symptoms causing withdrawal, we had been
unable to see this beforehand. These patients were kept in treat-
ment and CBT-techniques were used to work on the positive
symptoms. After doing so, at least one of them was able to engage
in more constructive activity.
Therapists generally found that the treatment manual was clear
and concise. However, some therapists were struggling with the
distinction between actual neurocognitive impairments and the
patients beliefs about these impairments. Behavioral experiments
for testing beliefs in goal-specic situations (e.g. I want to study
this book for college, but my memory does not work), rather than
using neurocognitive test-batteries, often proved satisfactory in
solving this issue.
3.3. Outcome
The pre- to posttreatment results are shown in Table 2. The
improvement on the primary outcome measure was highly signif-
icant and clinically relevant. The effect size and PANSS-scores
indicate an important reduction of negative symptoms during the
course of treatment.
In order to control for depression, we performed a stepwise
regression-analysis to predict negative symptom levels, in which
we rst entered depression (BDI-2) as the independent variable,
and time point (either baseline or end of treatment) in the second
block. This analysis showed that the change in negative symptoms
was not explained by a change in depression scores, as the effects of
depression in the regression analysis were non-signicant (t 1.07
j p 0.291) and the changes achieved during the treatment period
remained signicant (t 2.96 j p 0.005).
3.4. Mediation of dysfunctional beliefs
Specic results of the mediation analysis are presented in
Table 3. The total mediator model was signicant F(2, 39) 11.838,
p 0.0001. The total explained variance (R
2
) was 38%. The adjusted
R
2
was 35%. Dysfunctional beliefs fullled the criteria for partial
mediation: therapy signicantly affected the mediator (path A), the
mediator signicantly affected negative symptoms (B), the direct
effect of therapy on negative symptoms reduced when corrected
for dysfunctional beliefs (path C
0
is less strong than path C), and the
bootstrap indirect effects were signicant. In short, the reduction of
dysfunctional beliefs partially mediated the reduction in negative
symptoms, although not completely.
4. Discussion
4.1. Outcome
The dropout rate was 14% (three out of twenty-one patients),
indicating that CBT for negative symptoms was an acceptable
treatment for these patients. This dropout rate is similar to other
psychosocial interventions for psychotic disorders (Villeneuve,
Table 1
Demographic characteristics of participants.
Frequency (n 21)
Mean age 40.6 years (range 22e58)
Sex Male 14
Female 7
Living status Alone, independently 19
In sheltered living 1
With parents 1
Ethnicity Dutch (western) 17
Non-western Immigrant 4
Psychotic disorder Schizophrenia 17
Schizoaffective disorder 1
Schizophreniform disorder 1
Psychotic disorder NOS 2
Mean duration of
psychotic disorder
13.0 years (range 1e26)
Substance abuse Alcohol abuse 4
Medication First generation antipsychotic 7
Second generation antipsychotic 14
A.B.P. Staring et al. / J. Behav. Ther. & Exp. Psychiat. 44 (2013) 300e306 304
Potvin, Lesage, & Nicole, 2010). This is positive in our view, given
the likelihood that patients with negative symptoms may be dif-
cult to motivate to fully complete their treatments.
A large within-group effect size was found on the PANSS
negative syndrome, changing from an average of 20.2 to 14.1,
indicating that CBT-n ts its purpose: to decrease negative
symptoms. The changes were clinically important and may surpass
the effects of other treatment methods for negative symptoms.
The Klinberg et al. (2011) study, for example, found the PANSS
negative syndrome score only changing from an average of 18.9 to
16.1 (in their article they mention the average item-scores of 2.7
and 2.3). And the controlled trial on body-oriented psychosocial
therapy (Rhricht & Priebe, 2006) found the PANSS negative syn-
drome changing from an average of 23.4 to 18.2. To conrm the
effectiveness of CBT-n, however, larger and controlled trials are
needed.
Also, we found a large effect size on our measure of dysfunc-
tional beliefs, which indicates that CBT-n may effectively target the
beliefs of our cognitive model. Furthermore, a reduction in these
beliefs partially mediated the change in negative symptoms. This
nding is evidence for their clinical importance and it supports our
cognitive model of negative symptoms. The mechanism of change
in negative symptoms is in part explained by the reduction
of dysfunctional beliefs. Also, however, a signicant part of the
change in negative symptoms was unexplained by dysfunctional
beliefs. This part of the effect may for example be more associated
with the goal-setting and behavioral activation components of the
treatment.
Patients appraised their illnesses in a less stigmatizing way and
became more hopeful for the future. Besides relevant as a mecha-
nism for reducing negative symptoms, this improvement is also
important in itself. Other studies on psychosocial interventions that
target self-stigma, for example, have mostly produced small to
medium effects (Mittal, Sullivan, Chekuri, Allee, & Corrigan, 2012).
4.2. CBT-n manual
Based on the ndings we learned that although 20 treatment
sessions may accomplish important improvements for most pa-
tients, the therapy should probably be allowed to extend its dura-
tion when needed.
It was difcult to exclude patients that experience negative
symptoms as a consequence of delusions. We may sometimes fail to
detect positive symptoms up until the time that a patient is actively
engaged to achieve goals. It is desirable that CBT-techniques for
positive symptoms are available when needed.
4.3. Limitations
This was an uncontrolled study. Therefore the efcacy ndings
are biased. Patients may have improved over the course of the
study by self-initiated change or because other treatments were
helpful. The lack of a control group means that this effect was not
controlled for.
Second, also as a consequence of the uncontrolled design,
measurements were not blind. We mostly used self-report mea-
surements, and patients were fully aware that they had received an
active treatment for their negative symptoms. This may have
caused efcacy to be overestimated.
Third, about 25% of the patients that we initially asked to par-
ticipate refused. Some of them did not want to participate in a sci-
entic project, whereas others seemed unwilling to work on their
negative symptoms. This is a problem, as the negative symptoms
themselves may in part be the cause of these patients refusing
participation. Although we used various strategies to facilitate
participation, we were unable to engage 25% of the patients at the
start.
Fourth, we did not formally measure treatment integrity.
The therapists did ll in a form every therapy session, and
the rst author monitored the therapists adherence to the
manual.
Finally, there was no follow-up assessment, making it impos-
sible to determine whether treatment gain was maintained over
time.
Randomized controlled trials with sufcient statistical power
will need to be performed in order to conrm or refute our results.
4.4. Conclusions
CBT-n seemed effective in reducing negative symptoms. The
changes were partially explained by a reduction in dysfunctional
beliefs about cognitive abilities, performance, emotional experi-
ence, self-stigma, and social exclusion. The changes were clinically
important.
Limitations of this study include the uncontrolled design. Ef-
cacy was probably overestimated. Also, the patient sample was
relatively small, and we performed no follow-up measurements.
Larger and better designed trials are needed.
Declaration of interest
None. No special funding was used and no conicts of interest
exist with regard to this study.
Table 3
Results of mediation analysis on negative symptoms (PANSS) with bootstrapping.
Direct and total effects p-values Bootstrap indirect effects 95% condence interval (A*B path)
A B C(
0
) Lower limit Upper limit
Total treatment effect (without mediation) 0.000 (C)
Dysfunctional beliefs as mediator 0.004 0.028 0.007 (C
0
) 0.285 3.669
C, total effect of treatment (time) on negative symptoms; A, effect of treatment on the mediator dysfunctional beliefs; B, effect of dysfunctional beliefs on negative symptoms;
C
0
effect of treatment on negative symptoms without the indirect effect of the mediator dysfunctional beliefs; A*B path, bootstrap results for the indirect effect; lower and
upper limits of condence interval for test of mediation with 5.000 bootstrap re-samples and bias correction.
Table 2
Paired samples t-test statistics for the mean changes between baseline and end-of-treatment. Intention-to-treat analysis (n 21).
Baseline mean (sd) End-of-treatment mean (sd) t (2-tailed) p Effect size Cohens d
PANSS negative syndrome 20.2 (4.3) 14.1 (5.3) 6.16 0.000 1.26
Dysfunctional beliefs 0.00 (1.68) 1.51 (1.50) 3.84 0.001 0.95
PANSS: positive and negative syndrome scales.
A.B.P. Staring et al. / J. Behav. Ther. & Exp. Psychiat. 44 (2013) 300e306 305
Acknowledgments
We would like to acknowledge the contributions by the thera-
pists of this study: Rob van Grunsven, Chris van Oeveren, Kwok
Wong (Altrecht Psychiatric Institute), Anouk Nienhuis, Mary-Ann
ter Huurne, Peter van Veen (Mediant Psychiatric Institute), Clau-
dia Berwers (Parnassia Psychiatric Institute), Roxanne Valk (Mental
Health Care Drenthe), Marije Quadackers (Mental Health Care
Breburg), Heleen Begheijn (Mental Health Care NoordHolland
Noord), Matty Geurink (Rivierduinen Psychiatric Institute), Fabian
Shug (GGNet), and Bas van Oosterhout (Reinier van Arkel Group).
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