Narrative Review Medicine ®

The application of cognitive behavioral therapy in

patients with schizophrenia
A review
Feifei Xu, PhDa , Hang Zhang, PhDb,*

Abstract
The aim of this review is to explore the clinical nursing application of cognitive behavioral therapy (CBT) in patients with schizophrenia.
A literature search was conducted using the CINAHL and MEDLINE databases. The database search occurred during the month
of December 2022. This article comprehensively summarizes the theoretical basis of CBT in improving schizophrenia in clinical
nursing, its application in managing symptoms and improving social function, as well as research progress in this field. There are
still inconsistencies in the research results on CBT, but overall, psychological intervention combined with drug treatment is more
effective than conventional treatment alone. If social function training can be added at the same time, it is believed that it will have
better effects on clinical treatment and can maintain long-lasting effectiveness. Only in this way can patients truly understand and
recognize the disease, improve treatment compliance, and ultimately achieve the goal of improving prognosis and quality of life.
Abbreviations: CAT = cognitive adaptation training, CBT = cognitive behavioral therapy, ST = support therapy.
Keywords: cognitive behavioral therapy, negative symptom, positive symptom, schizophrenia, social function

1. Introduction intervention methods, the results showed that CBT produced

statistically significant improvements in total symptoms by the
Schizophrenia is a prevalent mental illness affecting 0.3% to end of treatment. Thus, a combination of medication and psy-
0.7% of the population throughout their lifetime. It typically chotherapy is likely to produce better clinical outcomes for
manifests in young adults and is marked by disturbances in patients with schizophrenia.[8]
perception, cognition, emotions, and behavior, as well as a
lack of coordination in mental activities,[1] such as positive
symptoms, negative symptoms, and cognitive impairment.[2]
2. Methods
The illness has a prolonged course and can cause a decline in
mental activity, which can significantly affect the daily lives 2.1. Aim
of patients. This places a heavy burden on both patients and
The aim of this review is to explore the clinical nursing appli-
their families.[3] Antipsychotic medication is currently the
cation of CBT in patients with schizophrenia. This article
most commonly used clinical treatment for schizophrenia.[4]
comprehensively summarizes the theoretical basis of CBT in
However, it is important to consider the significant side effects
improving schizophrenia in clinical nursing, its application
of such medication, as well as the stigma associated with
in managing symptoms and improving social function, as
mental illness and the negative impact of long-term medica-
well as research progress in this field. In addition, this article
tion on patient compliance[5] Therefore, it is crucial to find
emphasizes future research directions and potential issues that
a better treatment for schizophrenia. Research suggests that
should be considered when using CBT as a treatment plan for
relying solely on medication therapy may not be optimal for
schizophrenia.
treating schizophrenia.[6] In fact, treatment with antipsychotic
drugs has been linked to changes in brain volume in patients
with this condition. Specifically, the volume of gray matter in
schizophrenic patients tends to decrease over time, while the 2.2. Searching strategy
volume of the lateral ventricle increases. Furthermore, some A literature search was conducted using the CINAHL and
of these neuroanatomical changes may be associated with MEDLINE databases. The database search occurred during
the use of antipsychotic drugs.[7] Ap M et al focus on patients the month of December 2022. A search was conducted using
taking olanzapine as the research object and using cognitive the key terms, “Schizophrenia” AND “CBT OR Cognitive
behavioral therapy (CBT) and conventional treatment as behavioral therapy.” MeSH terms were used in the MEDLINE

The authors have no funding and conflicts of interest to disclose.
Data sharing not applicable to this article as no datasets were generated or
analyzed during the current study.
This review did not require ethical approval.
a
School of Psychology, Zhejiang Normal University, Jin Hua, China, b School of
Humanities and International Education Exchange, Anhui University of Chinese
Medicine, HeFei, China.
*Correspondence: Hang Zhang, Anhui University of Chinese Medicine, HeFei,
230012, China (e-mail: zhanghang.psy@gmail.com).
Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
How to cite this article: Xu F, Zhang H. The application of cognitive behavioral
therapy in patients with schizophrenia: A review. Medicine 2023;102:32(e34827).
Received: 7 July 2023 / Received in final form: 27 July 2023 / Accepted: 28 July
2023
http://dx.doi.org/10.1097/MD.0000000000034827

1
Xu and Zhang • Medicine (2023) 102:32Medicine
search, and CINAHL Headings were used when searching
CINAHL when available. The search limiters included the fol-
lowing: “English language” and “peer-reviewed.” No time limit
was set.
3. Results
3.1. The therapeutic effect of CBT on different symptoms
of schizophrenia
Previous research has discovered that many early-stage psychi-
atric patients may acquire drug resistance throughout treat-
ment, particularly after 12 weeks of complete treatment, with
approximately 20% of patients still having significant residual
positive symptoms.[9] The effectiveness of traditional treatments
for schizophrenia is limited. However, studies have shown that
CBT is a more effective long-term treatment option compared
to conventional treatments.[10] Rector and Beck concluded that
CBT plus routine care (pharmacotherapy and case management)
led to substantial pretreatment-posttreatment improvements in
positive symptoms, negative symptoms, and total symptoms.
Patients receiving only routine care did much less. Alternative
psychosocial interventions, such as supportive therapy or
befriending, produced intermediate.[11] Patients who undergo
CBT experience improvements in overall symptoms, positive
symptoms, and social function.[12] After receiving mental health
services for the first time, psychiatric patients often experience
a continuous period of symptom relief, with almost half of
them recovering.[13] The preferred method of psychotherapy is
CBT. CBT helps individuals to evaluate, challenge, and change
their irrational beliefs, leading to a change in their behavior.[10]
Initially, Aaron Beck used CBT in 1952 to treat delusional
symptoms in patients with paranoid schizophrenia.[14] After
decades of development, CBT has made significant progress in
the study of schizophrenia, with studies showing that combin-
ing CBT with medication is more effective in reducing positive
psychotic symptoms than medication alone.[15] CBT should be
the first psychosocial intervention to be considered in the long-
term treatment of patients with schizophrenia.[16] However, CBT
encompasses various therapeutic techniques, but different stud-
ies may use different techniques during the treatment process,
due to difficulties with recruitment, the sample size is too small,
resulting in inconsistent research results. This issue needs to be
taken seriously in future research.[17,18] Additionally, research-
ers may have varying levels of expertise, which can result in
inconsistent findings in the study of schizophrenia. In terms of
neurobiology, improvement in psychotic symptoms was pre-
dicted by neural responses to threat-related influences across
sensorimotor and frontal limbic areas, whereas improvement in
affective symptoms was predicted by neural responses to fear-
ful faces only and pro-social influences across sensorimotor and
frontal areas. These findings suggest that CBT is most likely to
improve psychiatric and affective symptoms in those who sup-
port more threatening assessments and emotionally congruent
processing biases, respectively, which are explored and redefined
as part of the treatment.[19] An MRI study showed that cognitive
behavior therapy showed decreased activation of the inferior
frontal, insula, thalamus, putamen and occipital areas to fearful
and angry expressions at treatment follow-up compared with
baseline.[20] The purpose of this article is to explore the theoret-
ical basis of CBT for treating schizophrenia, as well as its cur-
rent research status on the symptoms and social functioning of
schizophrenia. It also proposes new ideas for future research on
CBT in schizophrenia.
Schizophrenia is a complex clinical syndrome characterized by
a variety of symptom clusters. It is a multifactorial disease that
presents with both positive and negative symptoms.[21] Positive
symptoms include hallucinations, delusions, excitement, bizarre
behavior, and obvious thought association abnormalities.[22]
Negative symptoms include speechlessness, attention deficit,
2
emotional retardation, apathy, and social withdrawal.[23] With
in-depth research on patients with schizophrenia, cognitive dys-
function is also an important core symptom of schizophrenia,
and is a major cause of disability in schizophrenia patients,[24]
and it is pointed out that cognitive dysfunction appears before
symptoms.[25] Schizophrenia shows a variety of neurocognitive
impairments, including memory, working memory, executive
function, attention, and processing speed.[26] Cognitive dysfunc-
tion is closely linked to symptoms and can persist even after
psychotic symptoms have subsided. The improvement of cog-
nitive function is strongly correlated with the effectiveness of
treatment.[27] For example, hallucinations are further related
to increased suffering (evaluated as malicious, powerful, famil-
iar voices; individuals disagree and refuse the voices), delu-
sions, pessimistic thinking, low self-esteem, negative emotions,
and cognitive impairment (executive dysfunction, tendency to
draw conclusions, and inability), ultimately leading to diffi-
culty in understanding others’ psychological states.[28] Patients
with severe negative symptoms will have impaired social and
occupational functioning, which may cause a vicious cycle and
reduce the ability of patients to learn from mistakes, ultimately
exacerbating cognitive dysfunction.[29] These studies indicate
that cognitive function is closely related to psychotic symptoms,
furthermore, after standard treatment with antipsychotic drugs,
the cognitive function of patients with schizophrenia cannot be
completely improved and may require adjuvant treatments.[30]
So, during the treatment process, not only symptoms should be
treated, but corresponding treatment plans should also be taken
for cognitive function improvement. Related studies have shown
that CBT can improve patients’ cognitive function through cog-
nitive regulation, thereby promoting symptom improvement.[31]
Research has shown that the close association between symp-
toms of mental illness and cognitive function has led to CBT
being used as an adjunctive therapy for schizophrenia and other
mental illnesses in clinical research and practice.[32,33] The treat-
ment process for positive symptoms involves thoroughly evalu-
ating the patient symptoms,[34] gradually establishing a negative
relationship between cognition and experience of mental illness,
questioning the evidence of automatic thinking and inference
using Socratic methods,[35] guiding the search for alternative
explanations for voices, suspicious and delusional ideas, correct-
ing cognitive distortions, and encouraging the adoption of more
logical thinking and rational responses.[36] The core principle is
to challenge beliefs about content, identity, and power related to
voices, with the goal of empowering patients and strengthening
their self-control over their behavior (e.g., respect for voices).[37]
Cognitive-behavioral interventions for negative symptoms aim
to change unreasonable beliefs that have a significant impact on
symptoms (negative beliefs about social belonging and perfor-
mance, erroneous judgments of one own ability, low expecta-
tions of happiness and success, and negative beliefs activated by
positive symptoms).[38] Research has shown that CBT improves
psychiatric symptoms, disease prognosis, and quality of life
through cognitive intervention, and the treatment effect persists
for 3 months after treatment ends.[39]
Although the frequency and quality of cognitive interven-
tion techniques used in CBT have different effects on symptom
improvement, the overall effect is better than that of traditional
therapies. However, the mechanism of action of these tech-
niques, such as brain mechanisms, Physiological changes, is still
unclear. Further analysis of the mechanism of action of CBT
would be extremely important for improving the prognosis and
quality of life of individuals with schizophrenia.
3.2. Positive symptoms
CBT can be applied as an augmentation to antipsychotic
medication. The success of CBT depends on the reduction of
catastrophic appraisals, thereby reducing the concurrent anx-
iety and distress. CBT aims at reducing the emotional distress
Xu and Zhang • Medicine (2023) 102:32www.md-journal.com
associated with auditory hallucinations, CBT enhances personal
coping strategies, enabling patients to manage symptoms and
daily stress more effectively.[40,41] However, in a study on audi-
tory hallucinations in schizophrenia. A study used CBT and
Cognitive Adaptation Training (CAT) - a method that provides
compensatory strategies and environmental support for patients
- to intervene in 2 groups of patients respectively. The results
showed that the improvement of auditory hallucinations in the
CBT group was not as good as that in the CAT group, and the
social function improvement in the CBT group was also poorer
than that in the CAT group. Compared with previous research,
the difference was significant. The reason for this result may
be that the average educational level of the patients recruited
was too low, and they could not agree with the examiner in
understanding CBT,[12] indicating that the patient educational
background is also a factor affecting the treatment effect.[42]
Moreover, delusions, a positive symptom, may be directly based
on negative views of the self.
Freeman used CBT therapy to modify negative beliefs in
patients with schizophrenia and found significant improve-
ments in patients mental health, positive self-beliefs, negative
social comparison, and self-esteem after treatment. Meanwhile,
the degree of paranoid delusions in patients decreased signifi-
cantly compared to before treatment, whereas patients in the
control group who received conventional treatment did not
show this improvement.[43] This indicates that the effects of CBT
therapy are multifaceted and can be reflected in patients’ daily
lives. In order to test the replicability of the research results,
the researchers conducted a comparison between 20 sessions
of CBT intervention and a control group. The results showed
significant decreases in scores on the Positive Symptom Scale
and Delusion Scale, and in the follow-up after 12 months, the
intervention effects of the CBT group were still present. This
also suggests that the cognitive intervention of CBT has a signif-
icant impact on symptom improvement, and cognitive changes
can maintain symptom improvement for a long time period.[44]
In addition, another form of psychotherapy, support therapy
(ST), is also commonly used in Western clinical studies. In vari-
ous studies, these 2 therapies have similarities and can both pro-
duce good results for patients. To compare the efficacy of these
2 therapies, Chinese scholars used CBT and ST in combination
with medication to improve the psychopathology and insight of
schizophrenic patients. In the long term, CBT was significantly
superior to ST in terms of overall symptoms, positive symptoms,
and social functioning of schizophrenic patients.[45] This suggests
that different backgrounds and populations may be the reasons
for bias, ultimately leading to heterogeneous results. The above
studies indicate that CBT therapy also has certain requirements
for patients themselves, such as comprehension and self-control,
as well as cultural background, all of which can affect the final
treatment effect. Results of psychological interventions may be
inconsistent in different cultural backgrounds, which suggests
that in future research, treatment techniques suitable for their
ethnic group should be developed based on cultural back-
grounds in order to achieve the best results.
3.3. Negative symptoms
The characteristics of negative symptoms include emotional
deficits or reductions, as well as social and behavioral impair-
ments. They are considered one of the core symptoms of schizo-
phrenia and are also one of the most important predictors of
its quality of life and functional outcomes.[46] In addition, nega-
tive symptoms may be transient or a side effect of antipsychotic
medication.[47,48] Treating negative symptoms of schizophre-
nia presents a significant challenge for mental health care. So
researchers need to pay attention to drug side effects in their
studies and try to adjust the number of treatments to make the
intervention outweigh the drug side effects as much as possible.
3
A randomized controlled trial found that conducting 20 ses-
sions of CBT within a 6-month period was effective in reducing
negative symptoms in patients with schizophrenia. Additionally,
improvements in cognitive abilities, daily functioning, emo-
tional experiences, and maladaptive social beliefs indirectly led
to changes in negative symptoms.[49] The change in cognition
promotes symptom recovery, which is also supported by rele-
vant research in recent years. However, there is still relatively
little research on negative symptoms in clinical settings, and
only through large-sample randomized controlled experiments
can the effectiveness of CBT be truly clarified.[50] If the nega-
tive symptoms of psychotic patients are not resolved for a long
time, they may be transformed into other mental illnesses such
as depression,[51] causing significant damage to their lives and
social functioning.
Polese et al conducted a systematic analysis of studies on
CBT interventions for patients with schizophrenia over the past
decade and found that the efficacy of CBT in treating general psy-
chopathological and positive symptoms was relatively clear, but
its efficacy in treating negative symptoms remained unclear.[50]
This may be due to the lack of focus on negative symptoms in
previous studies and the lower level of patient engagement in
CBT interventions, which can lead to poor treatment outcomes.
However, some studies have found that group therapy can
significantly increase patient engagement and have therapeu-
tic effects. In the future, combining CBT with group therapy
or social psychological interventions may improve abnormal
attitudes and enhance treatment outcomes.[52] Some studies
have also found significant correlations between schizophrenic
patients’ abnormal attitudes and beliefs, negative symptoms,
and social functioning.[53] CBT can target patients’ negative atti-
tudes and beliefs centered around failure to treat their negative
symptoms and functional impairments.[9] Although the CBT
approach is heterogeneous, numerous randomized controlled
trials have found that combining CBT with standard treatments
(including medication) can reduce psychiatric symptoms such as
depression and negative symptoms.[54]
To promote the application of CBT therapy, many researchers
have begun to integrate it with cognitive-behavioral social skills
training, which is a comprehensive psychological intervention
technique that combines CBT and problem-solving techniques
to improve negative symptoms and functional impairment in
patients with schizophrenia. Studies have shown that this inte-
grated technique can achieve better therapeutic outcomes than
single-drug therapy or CBT alone.[55] This indicates that the use
of CBT alone has limitations, whereas CBT in combination
with drug therapy or other psychological treatment techniques
can produce better results than conventional treatment. Future
research can focus on integrating CBT with more techniques
such as group therapy and social interventions to enhance the
final therapeutic outcomes.
3.4. Social function
CBT has been proven to be a promising additive treatment
method. They have been proven to improve social adaptation
and quality of life, reduce symptoms of mental illness and related
pain.[56] Inducing and reducing apathy in social attitudes during
treatment may be beneficial for patients with schizophrenia. It
can also bring better social functions.[57] Patients with schizo-
phrenia face obstacles in interpersonal communication and
vocational abilities, which seriously affect their social function-
ing and quality of life, leading to the persistence of the disease.
Researchers selected early-stage patients with non-emotional
mental illness for intervention by comparing CBT with conven-
tional treatment and found that CBT can shorten hospitaliza-
tion time and improve general social function. In non-emotional
mental illness patients with impaired social function, CBT has
important benefits and significant improvements in symptoms
Xu and Zhang • Medicine (2023) 102:32Medicine
and emotional states.[58] However, A meta-analysis suggests that
CBT can have a certain effect on social function and quality of
life, but its effects are not long-lasting. Improving function is a
long-term goal, and drugs are difficult to play a major role, mul-
tiple joint interventions are needed to achieve better results.[59]
In summary, there are still inconsistencies in the research
results on CBT, but overall, psychological intervention com-
bined with drug treatment is more effective than conventional
treatment alone. If social function training can be added at the
same time, it is believed that it will have better effects on clinical
treatment and can maintain long-lasting effectiveness. Only in
this way can patients truly understand and recognize the dis-
ease, improve treatment compliance, and ultimately achieve the
goal of improving prognosis and quality of life.
4. Future research directions
A study consisting of 36 randomized controlled trials involv-
ing 3542 patients with schizophrenia compared and analyzed
various indicators such as relapse, readmission, mental state,
mortality, social function, and quality of life between CBT and
other psychosocial therapies. The results showed no significant
differences between CBT and other therapies, and the effective-
ness of CBT could not be conclusively determined. This could
be attributed to flaws in experimental design.[60] The clinical effi-
cacy of CBT is commendable, however, schizophrenia is still one
of the main causes of disability worldwide. Current research on
CBT interventions in schizophrenia mostly focus on symptom-
atic recovery, that is, on mental functions, as a primary treatment
target.[61] Although symptom reduction is undeniably important
in schizophrenia it is less clear the extent to which traditional
and “third wave” CBT interventions address the whole scope of
disabilities experienced by people with lived experience of schizo-
phrenia. Considering service users definitions of recovery it is also
important to explore, whether current CBT interventions focus
on recovery and what is their impact on disability domains.
In the future, we can start from the treatment plan and find a
rigorous research approach to ensure the consistency of research
results and provide more evidence for the clinical application of
CBT.
Such results may be due to CBT being a commonly used
adjunctive therapy in clinical settings. If a safe and stable thera-
peutic alliance cannot be formed with patients during treatment,
it may result in poor patient compliance, leading to inadequate
treatment efficacy. Therefore, prior to the study, sufficient con-
tact should be made with the patients so that they can have a
full understanding of the therapy, followed by further interven-
tion. CBT primarily relies on the skills of the main examiner,
and different interventions by different examiners may lead to
different results for patients. Therefore, rigorous CBT training
for examiners is necessary, followed by strictly following the
intervention plan to intervene with patients. In the future, stan-
dardized treatment in research has great potential for clinical
studies. Personalized CBT techniques should be used for differ-
ent types of schizophrenia patients to achieve consistent effects.
Future studies can try to study patients with a single subtype of
schizophrenia and combine brain electrical activity and imaging
techniques to explore the mechanism of action of CBT, provid-
ing more beneficial evidence for the joint use of computer tech-
nology or behavioral training methods in the future.
At present, there is a significant gap in both professional
psychological interventionists and effective intervention plans
in China. Although there are a large number of psychiatrists
in China, there are still very few medical workers special-
ized in psychological therapy for the treatment of schizo-
phrenia. So introducing effective interventions from abroad
has important practical significance. CBT therapy has been
widely applied abroad, but it is still relatively less involved in
domestic research, and there is still a significant gap between
4
domestic researchers and professionalization in treatment
technology. On the one hand, referring to existing therapeu-
tic research in the West and combining it with domestic cul-
ture, we have developed CBT technology that belongs to our
own country, cultivating more psychotherapy talents. On the
other hand, in the future, existing intervention plans can be
improved as much as possible from the perspectives of curric-
ulum design, content arrangement, etc, in order to strengthen
the intervention effect and increase patient participation, so as
to maximize the effectiveness of CBT. Internationally, CBT has
achieved good clinical results, but there is still a need to pay
attention to the issue of combining multiple technologies for
intervention based on individual differences. At the same time,
traditional CBT interventions address more disability domains
than “third wave” therapies, however, both approaches focus
mostly on mental functions that reflect schizophrenia psy-
chopathology there are also few interventions that focus on
recovery. These results indicate that CBT interventions going
beyond symptom reduction are still needed. Recovery-focused
CBT interventions seem to be a promising treatment approach
as they target disability from a broader perspective including
activity and participation domains.
Author contributions
Conceptualization: Feifei Xu, Hang Zhang.
Data curation: Hang Zhang.
Formal analysis: Hang Zhang.
Funding acquisition: Feifei Xu.
Project administration: Feifei Xu, Hang Zhang.
Resources: Feifei Xu.
Supervision: Hang Zhang.
Visualization: Feifei Xu, Hang Zhang.
Writing – original draft: Feifei Xu, Hang Zhang.
Writing – review & editing: Feifei Xu, Hang Zhang.
References
[1] Ma L, Rolls ET, Liu X, et al. Multi-scale analysis of schizophre-
nia risk genes, brain structure, and clinical symptoms reveals inte-
grative clues for subtyping schizophrenia patients. J Mol Cell Biol.
2019;11:678–87.
[2] Bucci P, Galderisi S, Mucci A, et al. Premorbid academic and social func-
tioning in patients with schizophrenia and its associations with nega-
tive symptoms and cognition. Acta Psychiatr Scand. 2018;138:253–66.
[3] Bowie CR, Harvey PD. Cognitive deficits and functional outcome in
schizophrenia. Neuropsychiatr Dis Treat. 2006;2:531–6.
[4] Jääskeläinen E, Juola P, Hirvonen N, et al. A systematic review
and meta-analysis of recovery in schizophrenia. Schizophr Bull.
2013;39:1296–306.
[5] Misdrahi D, Tessier A, Husky M, et al. Evaluation of adherence patterns
in schizophrenia using electronic monitoring (MEMS®): a six-month
post-discharge prospective study. Schizophr Res. 2018;193:114–8.
[6] Turkington D, Dudley R, Warman DM, et al. Cognitive-behavioral
therapy for schizophrenia: a review. J Psychiatr Pract. 2004;10:5–16.
[7] Fusar-Poli P, Smieskova R, Kempton MJ, et al. Progressive brain changes
in schizophrenia related to antipsychotic treatment? A meta-analysis of
longitudinal MRI studies. Neurosci Biobehav Rev. 2013;37:1680–91.
[8] Morrison AP, Pyle M, Gumley A, et al. Cognitive behavioural therapy
in clozapine-resistant schizophrenia (FOCUS): an assessor-blinded,
randomised controlled trial. Lancet Psychiatry. 2018;5:633–43.
[9] Grant PM, Huh GA, Perivoliotis D, et al. Randomized trial to evalu-
ate the efficacy of cognitive therapy for low-functioning patients with
schizophrenia. Arch Gen Psychiatry. 2012;69:121–7.
[10] Butler AC, Chapman JE, Forman EM, et al. The empirical status of
cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol
Rev. 2006;26:17–31.
[11] Rector NA, Beck AT. Cognitive behavioral therapy for schizophrenia:
an empirical review. J Nerv Ment Dis. 2001;189:278–87.
[12] Velligan DI, Tai S, Roberts DL, et al. A randomized controlled trial
comparing cognitive behavior therapy, cognitive adaptation training,
their combination and treatment as usual in chronic schizophrenia.
Schizophr Bull. 2015;41:597–603.
Xu and Zhang • Medicine (2023) 102:32www.md-journal.com
[13] Morgan C, Lappin J, Heslin M, et al. Reappraising the long-term course
and outcome of psychotic disorders: the AESOP-10 study. Psychol
Med. 2014;44:2713–26.
[14] Patmore J, Meddaoui B, Feldman H. Cultural considerations for treat-
ing hispanic patients with eating disorders: a case study illustrating the
effectiveness of CBT in reducing bulimia nervosa symptoms in a Latina
patient. J Clin Psychol. 2019;75:2006–21.
[15] Halperin S, Nathan P, Drummond P, et al. A cognitive-behavioural,
group-based intervention for social anxiety in schizophrenia. Aust N Z
J Psychiatry. 2000;34:809–13.
[16] Bighelli I, Rodolico A, García-Mieres H, et al. Psychosocial and psy-
chological interventions for relapse prevention in schizophrenia: a
systematic review and network meta-analysis. Lancet Psychiatry.
2021;8:969–80.
[17] Simblett S, Birch J, Matcham F, et al. A Systematic review and
meta-analysis of e-mental health interventions to treat symptoms of
posttraumatic stress. JMIR Ment Health. 2017;4:e14.
[18] Sönmez N, Romm KL, Østefjells T, et al. Cognitive behavior therapy
in early psychosis with a focus on depression and low self-esteem: a
randomized controlled trial. Compr Psychiatry. 2020;97:152157.
[19] Tolmeijer E, Kumari V, Peters E, et al. Using fMRI and machine learn-
ing to predict symptom improvement following cognitive behavioural
therapy for psychosis. NeuroImage. 2018;20:1053–61.
[20] Kumari V, Fannon D, Peters ER, et al. Neural changes following cog-
nitive behaviour therapy for psychosis: a longitudinal study. Brain.
2011;134:2396–407.
[21] Tan AS, Chew QH, Sim K. Cerebral white matter changes in deficit
and non-deficit subtypes of schizophrenia. J Neural Transm (Vienna).
2020;127:1073–9.
[22] Nordgaard J, Henriksen MG, Berge J, et al. First-rank symptoms and
self-disorders in schizophrenia. Schizophr Res. 2019;210:306–7.
[23] Crow TJ. Molecular pathology of schizophrenia: more than one disease
process? Br Med J. 1980;280:66–8.
[24] Hambsch B, Keyworth H, Lind J, et al. Chronic nicotine improves
short-term memory selectively in a G72 mouse model of schizophrenia.
Br J Pharmacol. 2014;171:1758–71.
[25] Tripathi A, Kar SK, Shukla R. Cognitive deficits in schizophrenia:
understanding the biological correlates and remediation strategies. Clin
Psychopharmacol Neurosci. 2018;16:7–17.
[26] Schaefer J, Giangrande E, Weinberger DR, et al. The global cognitive
impairment in schizophrenia: consistent over decades and around the
world. Schizophr Res. 2013;150:42–50.
[27] Irani F, Kalkstein S, Moberg EA, et al. Neuropsychological performance
in older patients with schizophrenia: a meta-analysis of cross-sectional
and longitudinal studies. Schizophr Bull. 2011;37:1318–26.
[28] Bentall RP, Rowse G, Shryane N, et al. The cognitive and affective
structure of paranoid delusions: a transdiagnostic investigation of
patients with schizophrenia spectrum disorders and depression. Arch
Gen Psychiatry. 2009;66:236–47.
[29] Lincoln TM, Mehl S, Kesting M-L, et al. Negative symptoms and social
cognition: identifying targets for psychological interventions. Schizophr
Bull. 2011;37(Suppl 2):S23–32.
[30] Swartz MS, Perkins DO, Stroup TS, et al. Effects of antipsychotic med-
ications on psychosocial functioning in patients with chronic schizo-
phrenia: findings from the NIMH CATIE study. Am J Psychiatry.
2007;164:428–36.
[31] Kukla M, Bell MD, Lysaker PH. A randomized controlled trial examining
a cognitive behavioral therapy intervention enhanced with cognitive reme-
diation to improve work and neurocognition outcomes among persons
with schizophrenia spectrum disorders. Schizophr Res. 2018;197:400–6.
[32] Watanabe N, Hunot V, Omori IM, et al. Psychotherapy for depression
among children and adolescents: a systematic review. Acta Psychiatr
Scand. 2007;116:84–95.
[33] Calear AL, Christensen H. Systematic review of school-based pre-
vention and early intervention programs for depression. J Adolesc.
2010;33:429–38.
[34] Jonas KG, Lencz T, Li K, et al. Schizophrenia polygenic risk score and 20-year
course of illness in psychotic disorders. Transl Psychiatry. 2019;9:300.
[35] Braun JD, Strunk DR, Sasso KE, et al. Therapist use of socratic ques-
tioning predicts session-to-session symptom change in cognitive ther-
apy for depression. Behav Res Ther. 2015;70:32–7.
[36] Thomas N, Hayward M, Peters E, et al. Psychological therapies for
auditory hallucinations (voices): current status and key directions for
future research. Schizophr Bull. 2014;40(Suppl 4):S202–12.
[37] Morrison AP. A manualised treatment protocol to guide delivery of
evidence-based cognitive therapy for people with distressing psychosis:
learning from clinical trials. Psychosis. 2017;9:271–81.
[38] Luther L, Salyers MP, Firmin RL, et al. Additional support for the cog-
nitive model of schizophrenia: evidence of elevated defeatist beliefs in
schizotypy. Compr Psychiatry. 2016;68:40–7.
[39] Mortan Sevi O, Tekinsav Sutcu S, Yesilyurt S, et al. Comparison of
the effectiveness of two cognitive-behavioral group therapy programs
for schizophrenia: results of a short-term randomized control trial.
Community Ment Health J. 2020;56:222–8.
[40] Sommer IEC, Slotema CW, Daskalakis ZJ, et al. The treatment of
hallucinations in schizophrenia spectrum disorders. Schizophr Bull.
2012;38:704–14.
[41] Jauhar S, Laws KR, McKenna PJ. CBT for schizophrenia: a critical
viewpoint. Psychol Med. 2019;49:1233–6.
[42] Lee SH, Song KJ, Shin SD, et al. The Relationship between clinical
outcome in subarachnoidal hemorrhage patients with emergency
medical service usage and interhospital transfer. J Korean Med Sci.
2015;30:1889–95.
[43] Freeman D, Pugh K, Dunn G, et al. An early Phase II randomised con-
trolled trial testing the effect on persecutory delusions of using CBT
to reduce negative cognitions about the self: the potential benefits of
enhancing self confidence. Schizophr Res. 2014;160:186–92.
[44] Kråkvik B, Gråwe RW, Hagen R, et al. Cognitive behaviour therapy for
psychotic symptoms: a randomized controlled effectiveness trial. Behav
Cogn Psychother. 2013;41:511–24.
[45] Li Z-J, Guo Z-H, Wang N, et al. Cognitive-behavioural therapy for
patients with schizophrenia: a multicentre randomized controlled trial
in Beijing, China. Psychol Med. 2015;45:1893–905.
[46] Green MF. Impact of cognitive and social cognitive impairment on
functional outcomes in patients with schizophrenia. J Clin Psychiatry.
2016;77(Suppl 2):8–11.
[47] Carpenter WT, Heinrichs DW, Wagman AM. Deficit and non-
deficit forms of schizophrenia: the concept. Am J Psychiatry.
1988;145:578–83.
[48] Kirschner M, Aleman A, Kaiser S. Secondary negative symptoms - a
review of mechanisms, assessment and treatment. Schizophr Res.
2017;186:29–38.
[49] Staring ABP, Ter Huurne M-AB, van der Gaag M. Cognitive behavioral
therapy for negative symptoms (CBT-n) in psychotic disorders: a pilot
study. J Behav Ther Exp Psychiatry. 2013;44:300–6.
[50] Polese D, Fornaro M, Palermo M, et al. Treatment-resistant to anti-
psychotics: a resistance to everything? psychotherapy in treat-
ment-resistant schizophrenia and nonaffective psychosis: a 25-year
systematic review and exploratory meta-analysis. Front Psychiatry.
2019;10:210.
[51] Fusar-Poli P, Borgwardt S, Bechdolf A, et al. The psychosis high-risk
state: a comprehensive state-of-the-art review. JAMA Psychiatry.
2013;70:107–20.
[52] Lawrence R, Bradshaw T, Mairs H. Group cognitive behavioural ther-
apy for schizophrenia: a systematic review of the literature. J Psychiatr
Ment Health Nurs. 2006;13:673–81.
[53] Quinlan T, Roesch S, Granholm E. The role of dysfunctional attitudes
in models of negative symptoms and functioning in schizophrenia.
Schizophr Res. 2014;157:182–9.
[54] Burns AMN, Erickson DH, Brenner CA. Cognitive-behavioral therapy
for medication-resistant psychosis: a meta-analytic review. Psychiatr
Serv. 2014;65:874–80.
[55] Granholm E, Holden J, Worley M. Improvement in negative symptoms
and functioning in cognitive-behavioral social skills training for schizo-
phrenia: mediation by defeatist performance attitudes and asocial
beliefs. Schizophr Bull. 2018;44:653–61.
[56] Abdel-Baki A, Nicole L. [Schizophrenia and cognitive behavioral psy-
chotherapy]. Can J Psychiatry. 2001;46:511–21.
[57] Le TP, Holden JL, Link PC, et al. Neurocognitive and theory of mind
deficits and poor social competence in schizophrenia: the moderating
role of social disinterest attitudes. Psychiatry Res. 2018;270:459–66.
[58] Fowler D, Hodgekins J, Painter M, et al. Cognitive behaviour therapy
for improving social recovery in psychosis: a report from the ISREP
MRC trial platform study (improving social recovery in early psycho-
sis). Psychol Med. 2009;39:1627–36.
[59] Laws KR, Darlington N, Kondel TK, et al. Cognitive behavioural ther-
apy for schizophrenia - outcomes for functioning, distress and quality
of life: a meta-analysis. BMC Psychol. 2018;6:32.
[60] Jones C, Hacker D, Cormac I, et al. Cognitive behavioral therapy plus
standard care versus standard care plus other psychosocial treatments
for people with schizophrenia. Schizophr Bull. 2019;45:284–6.
[61] Nowak I, Sabariego C, Świtaj P, et al. Disability and recovery in schizo-
phrenia: a systematic review of cognitive behavioral therapy interven-
tions. BMC Psychiatry. 2016;16:228.