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
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The effect of coffee and caffeine consumption on serum lipids in rats.N. Rakicioglu, G. Pekcan and A. Cevik. International Journal of Food Sciences and Nutrition 49.6 (Nov 1998): p441(1). (3575 words) Abstract: Coronary heart disease research confirms that coffee alone is not a significant risk factor. Laboratory rats were fed controlled diets with varying levels of coffee, caffeine