Schizophr Bull. 2026 Apr 10;52(3):sbag066. doi: 10.1093/schbul/sbag066.
ABSTRACT
BACKGROUND AND HYPOTHESIS: Cognitive models of schizophrenia-spectrum disorders (SSD) posit dysfunctional beliefs and cognitive biases as maintenance mechanisms of positive and negative symptoms. Although cognitive behavioral therapy (CBT) targets these processes, its effects on mechanism-level outcomes remain unclear. This review examined whether CBT modifies dysfunctional beliefs and cognitive biases in SSD using rigorous randomized evidence.
STUDY DESIGN: PRISMA 2020-compliant systematic review and meta-analysis (PROSPERO registered). Primary analyses were restricted to intention-to-treat (ITT) randomized controlled trials (RCTs) in SSD samples, using random-effects models and between-group post-treatment estimates. Pre-post and nonrandomized studies were analyzed separately as secondary evidence. Subgroup and meta-regression analyses were conducted.
STUDY RESULTS: Thirty-three studies met inclusion criteria. Fourteen ITT RCTs contributed to the primary pooled analysis of dysfunctional beliefs, yielding a small but statistically significant effect favoring CBT (g = 0.154, 95% CI, 0.049-0.259). Effects were strongest for delusional conviction (g = 0.450) and self-related schemas (positive-self g = 0.278; negative-self g = 0.298). Voice-related beliefs did not reach statistical significance. Too few RCTs assessed cognitive biases to support primary pooled analyses; exploratory findings suggested small effects for belief inflexibility and no reliable effect for jumping-to-conclusions. Greater reductions in dysfunctional beliefs were associated with greater improvements in positive symptoms across trials.
CONCLUSIONS: CBT produces small but reliable improvements in dysfunctional beliefs in SSD, although effects vary by domains particularly for delusional conviction and self-schemas, supporting their role as modifiable therapeutic targets and plausible mechanisms of change. Effects on cognitive biases remain limited and understudied.
PMID:42104795 | DOI:10.1093/schbul/sbag066
