COGNITIVE BEHAVIOUR THERAPY: COGNITIVE BEHAVIOUR THERAPY dr . B . shailaja 23 – March - 2011 Plan of Presentation: Plan of Presentation History The Cognitive Model The Behavioral Model Cognitive & Behavioral Treatment strategies Formulation of Treatment 3/23/2011 2 PSYCHOTHERAPY: PSYCHOTHERAPY Psychotherapy is the systematic use of a human relationship for therapeutic purposes of alleviating emotional distress by effecting enduring changes in a patients Thinking , Feelings and Behaviour . ( Strupp , 1986 ) The mutual engagement of the patient and psychotherapist both cognitively & Emotionally , is the foundation for effective psychotherapeutic work. 3/23/2011 3 COGNITIVE BEHAVIOUR THERAPY: COGNITIVE BEHAVIOUR THERAPY CBT-type of re educative therapy. CT- a system of psychotherapy based on theories of pathological information processing in mental disorders. Mainly directed at modifying distorted or maladaptive cognitions & related behavioral dysfunction . Focused and problem oriented . Emphasizes psycho education Deliberate efforts at readjustment & goal modification-with or with out insight in to cons. conflicts. 3/23/2011 4 History :: History : Concepts of Greek Stoic philosophers ,Taoism and Buddism . Epictetus, Greek philosopher. Observed that people are not disturbed by things that happen but by the view they take of things that happen. Proposed by Aaron T.Beck -early 1960s. Struck by retroflexed hostility of psychoanalytical theory & observations-negatively biased constructions of self and environment . COGNITIVE THERAPY FOR DEPRESSION -1979 later to others. 3/23/2011 5 PowerPoint Presentation: ENCHRIDION-ideas or thoughts are controlling factor for emotional lives. Modern philosophers-conscious ideas & meanings attached to events-source of actions. Phenomenological approach to philosophy -Kant ,jaspers , Binswanger,& others influenced C.T. Adler ,Honey .Alexander & Sullivan-perceptions of self & conscious experience. 3/23/2011 6 PowerPoint Presentation: Kell ’ s theory of personal constructs and developmental psychology –schemas . Ellis rational emotive therapy- promulgate CT. Wright & Thase – combining CT & phar. Therapy. Review of Evolution of CT- Beck in 1993- fulfill criteria for a system of psychotherapy. 3/23/2011 7 CRITERIA FOR A SYSTEM OF PSYCHOTHERAPY: CRITERIA FOR A SYSTEM OF PSYCHOTHERAPY A comprehensive theory. Empirical support for the theory. An operationalized therapy based on theoretical principles. Empirical evidence for effectiveness of the psychotherapy. 3/23/2011 8 the cognitive model : the cognitive model Characteristic errors in information processing in psychiatric disorders and alterations in thought process are closely link to emotional reactions and dysfunctional behaviour patterns – Beck. E.g.. the negative cognitive triad of self , world ,& future . Over estimation of danger – anxiety . Cog . Model –NOT presume cog. Path.-cause of specific syndromes ; other factors involved in etiology. 3/23/2011 9 PowerPoint Presentation: 3/23/2011 10 THOUGHT EMOTION BEHAVIOR the cognitive model PowerPoint Presentation: 3/23/2011 11 PowerPoint Presentation: 3/23/2011 12 PowerPoint Presentation: 3/23/2011 13 WORKING MODEL FOR CT: WORKING MODEL FOR CT 3/23/2011 14 The Cognitive Model: The Cognitive Model Core Beliefs Assumptions Compensatory/coping strategies Situation Automatic thoughts/images Reaction (emotional/behavioral physiological) MODEL FOR INF.PROCESSING: MODEL FOR INF.PROCESSING 3/23/2011 16 Activation of Relevant schema Perception of event Altered information Processing Automatic thoughts Behavioral symptoms Emotional Symptoms PowerPoint Presentation: 3/23/2011 17 Situation : A Classmate brushes past me in the library without saying “hello “ . I am unlovable I Need her approval to feel worthwhile She Doesn ’t like me Emotion : Sad , Depressed , Hopeless Levels of dysfunctional cognition: Levels of dysfunctional cognition Beck & colleagues – 2 major levels a. automatic thought s . b. schemas . Automatic thoughts – cognitions that occur rapidly in a situation or recalling an event . - not subjected to rational analysis and based on erroneous logic . 3/23/2011 18 PowerPoint Presentation: 3/23/2011 19 Automatic Negative Thoughts Schemas Cognitive errors PowerPoint Presentation: Faulty logic – cognitive errors-translate between ANT and SCHEMAS COG. Errors during affective arousal – narrow attention simplify info .processing & intensify beh .responses . 3/23/2011 20 Cognitive errors: Cognitive errors Selective abstraction (mental filter ) Arbitrary inference Absolute thinking (all or none thinking) Maximizing & minimizing Personalization Over generalization Catastrophic thinking Selective negative focus Jumping to conclusions 3/23/2011 21 Schemas : Schemas Def : Are deeper cognitive structures that contain the basic rules for screening, filtering & coding inf. from environment. Develop through childhood experiences & formative influences. ( Bowlby 1985 ) Play adaptive role in assimilation of data & decision making. In psy . disorders-clusters of maladaptive schemas-resulting in dysphoric mood & ineffective or self defeating behavior. 3/23/2011 22 SCHEMAS: SCHEMAS Types : 1.simple 2.intermediary. 3.corebeliefs (D .A . Clark). Maladaptive schemas-lie dormant; triggered by stress. Newly emerged schemas influences-superficial level of cog .functioning.-episodic dis In chronic conditions-consistent schemas – which are resistant to change . 3/23/2011 23 Proposed maladaptive schemas: Proposed maladaptive schemas Dependence Subjugation- lack of individuation Vulnerability to harm/ illness Fear of losing self -control 3/23/2011 24 Autonomy Proposed maladaptive schemas: Proposed maladaptive schemas 3/23/2011 25 CONNECTEDNESS Emotional deprivation Abandonment – Loss Mistrust Social Isolation/ Alienation Proposed maladaptive schemas : Proposed maladaptive schemas 3/23/2011 26 WORTHINESS Defectiveness – Unlovability Social undesirability Incompetence – failure Guilt- Punishment Shame- embarrassment Proposed maladaptive schemas: Proposed maladaptive schemas 3/23/2011 27 LIMITS &STANDARDS Unrelenting Standards Entitlement PowerPoint Presentation: 3/23/2011 28 Relatively stable structures which guides the ways in which we mold data into cognitions activated by certain situations Key assumptions about ourselves our experiences and our future - Underlying our ATs Rapid , Surface level thoughts that directly influence emotions without necessarily being aware PowerPoint Presentation: 3/23/2011 29 I'm Unlovable She Doesn ’t like me I Need her approval to feel worthwhile Situation : A Classmate brushes past me in the library without saying “hello “ . Emotion : Sad , Depressed , Hopeless Behavior model: Behavior model Based on learning theories. in classical conditioning (Ivan Pavlov) – CS paired with UCS – UCR In operant conditioning ( B. F . Skinner ) –in a stimulus situation a response is followed by favorable or unfavorable consequences. in observational learning (Albert Bandura) – an observer attends to a model’s behavior and its consequences . 3/23/2011 30 Behavior model: Behavior model Behavior therapies involve the application of learning principles to direct efforts to change mal adaptive behaviors . They are based on certain assumptions – 1. it is assumed that behavior is a product of learning . 2. it is assumed that what has been learned can be unlearned . 3/23/2011 31 Chain of events: Chain of events 3/23/2011 32 Stimulus Organism Response Contingency Cognitive & Behavioral Treatment strategies: Cognitive & Behavioral Treatment strategies Collaborative empiricism Psycho education Cognitive techniques Identifying & modifying AT. Identifying & modifying SCHEMAS. Behavioral Techniques 3/23/2011 33 Collaborative empiricism: Collaborative empiricism Therapeutic stance of-high collaboration &scientific attitude in testing Cognitions. & behaviors. Function like an investigative team to develop hypothesis about cog .& beh . patterns ,examine data , & explore alternate ways of cog .& beh . Individual differences are important. Therapist general attitude influences…&non specific variables like…….. Adjust therapist activity level to match severity of illness &phase of treatment. 3/23/2011 34 Psychoeducation : Psychoeducation Major goal –to teach pts new way of thinking & behaving to resolve current & future problems. Explains basic concepts ,socializing to CT. Reading assignments & computer programs also enhance. 3/23/2011 35 PowerPoint Presentation: Obtain accurate assessment of validity cog. &efficacy behavior . Coping strategies for real losses &actual deficits. Encourage self –monitoring &self help. Regular feed back &customize interventions. Managing transference. 3/23/2011 36 Cognitive techniques: Cognitive techniques Identifying & modifying AT. Identifying & modifying SCHEMAS. 3/23/2011 37 AUTOMATIC THOUGHTS….: AUTOMATIC THOUGHTS…. Socratic questioning Use of mood shifts to demonstrate in vivo Imagery exercises Role-play Thought recording Examining the evidence Generating alternatives Decatastrophizing Reattribution Cognitive rehearsal 3/23/2011 38 PowerPoint Presentation: 3/23/2011 39 PowerPoint Presentation: 3/23/2011 40 THOUGHT CHANGE RECORD: THOUGHT CHANGE RECORD 3/23/2011 41 Identifying & modifying schemas: Identifying & modifying schemas Socratic questioning Imagery & role playing Thought recording Identifying repetitive AT Psycho education Listing schemas in therapy note book Examining evidence Listing advantages & disadvantages Generating alternatives Cognitive rehearsal. 3/23/2011 42 BEHAVIOURAL TECHNIQUES: BEHAVIOURAL TECHNIQUES Usually integrated with cog. Restructuring. Behavioral therapy - greater emphasis in early phase. Used - 1.to change dysfunctional behavior. -2.reducing troubling symptoms. -3.assist in identification & modification of Mal adaptive cognitions. 3/23/2011 43 Behavioral procedures: Behavioral procedures Activity scheduling Graded task assignments Mastery & pleasure exercises Breathing control Contingency contracting and Behavioral exchange Desensitization & Relaxation Training Exposure & Flooding 3/23/2011 44 PowerPoint Presentation: Participant Modeling / Contact Desensitization Social skills training – Role playing , Modeling , Role reversal , Behavioral rehearsal , Specific Practice Assignments . Assertiveness training Thought stopping & Distraction Self monitoring Coping cards 3/23/2011 45 Formulation of Treatment: Formulation of Treatment Indications & Contraindications Issues of gender ,race and ethnicity Case formulation Structuring therapy Phases of treatment Outcome assessment Efficacy in various disorders 3/23/2011 46 PowerPoint Presentation: 3/23/2011 47 INDICATIONS & Contraindications: INDICATIONS & Contraindications Selection of pts : no contra indications. Usually not attempted in organic brain disease. Indications: primary treatment for Axis I disorders; MDD , Dysthymia ,panic disorder , social phobia , OCD , PTSD , GAD , Bulimia nervosa. Adjunctive in- bipolar , schizophrenia Incorporating coping skills in substance abuse , personality disorders. Modified CBT-AXIS II disorders. 3/23/2011 48 Issues of gender ,race and ethnicity: Issues of gender ,race and ethnicity Equally effective in all . Individual differences should be respected Therapists with special skills for selected pts. 3/23/2011 49 PowerPoint Presentation: 3/23/2011 50 Preparation of patient: Preparation of patient Active participants in tryout new strategies To do home work Out come monitored & may be altered Focused on symptoms & time limited Incorporation of therapy into day today life 3/23/2011 51 Structuring therapy: Structuring therapy Preparing therapy agenda by therapist & pt. Usually 2-4 items per each session Over whelming problems in to workable segments. Constructive feed back to provide significant opportunities for change. Decision to deviate from agenda-made by both. Assign home work to link sessions together . 3/23/2011 52 Phases of treatment: Phases of treatment 3 phase process – 1.initial phase . a. Clinical assessment. b. case formulation. c. Establishment of therapeutic relationship. d. socialization e. psycho education f. introduction to Treatment procedures. 2. middle stage :sequential application and mastery of CBT- ends with desired out come 3/23/2011 53 Continuation & maintenance CBT: Continuation & maintenance CBT Acute phase CT. C-CT. C-CT focuses on – biological domain, -psycho social -cognitive. Thase & co workers have studied . 3/23/2011 54 PowerPoint Presentation: 3.Final phase:- prep. for termination -frequency – reduced . -transfer from therapist to pt. -focuses on relapse prevention Anticipation of future stressors Identi . Of prodromal symptoms Self help procedures. Est. guidelines for return 3/23/2011 55 Intensity & duration of treatment : Intensity & duration of treatment OP. CBT- 1 or 2 /wk , for severe cases 3-daily. pharmacotherapy & Computer Assisted Therapy with CBT- can reduce sessions to every other week / 20-25 min sessions reduces . Good therapeutic relationship Frequently held cession. In most cases - 3-6 months Unsuccessful therapy - 12-16wks /OP Not to be terminated – achieve sym .relief At least 2-3 /alt wk before termination 3/23/2011 56 predictors for out come: predictors for out come Chronicity & severity of symptoms- poorer response. High levels cognitive dysfunction in depression –good response. Good pre morbid history-suitable for CT. Above average intelligence- not a predictor. Simplified procedures for sub normal intelligence. Flexible approach for pts needs. 3/23/2011 57 Out come assessment : Out come assessment Therapist administered scales – 1.Hamilton Anxiety Rating Scale. 2. Hamilton Depression Rating Scale. 3.Yale Brown Obsessive Compulsive Scale Self report assessment : 1 . Beck Depression Inventory. 2 . Fear Survey Schedule . 3 . Fear Questionnaire . 4 . Hopkins Symptoms Check List . These scales administered Before and during treatment. 3/23/2011 58 PowerPoint Presentation: The Dysfunctional Attitude Scale. Attributional Style Questionnaire. Automatic Thoughts Questionnaire……to evaluate distorted cognitions. High residual sym.-risk of relapse. High score of Hopelessness scale- risk of suicide. 3/23/2011 59 Augmentation of therapy : Augmentation of therapy To add drugs Often combines both forms from the beginning. pharmacological stabilisation before CBT-some axis 1. Both used in combination - clear lines Severe refractory cases may benefit from combine therapies Inc. frequency of visit, switching emphasis involving spouse or family members . Computer augmentation 3/23/2011 60 D-cycloserine(DCS) and CBT: D- cycloserine (DCS) and CBT DCS is effective in augmenting CBTs that incorporate exposure and desensitization tech in several anxiety disorders ( Panic, Social Anxiety and Specific phobia.) Wilhelm and colleagues used DCS to augment CBT in the treatment of OCD. In the study they concluded that DCS group had a sig. improvement compared to placebo group at mid-treatment. DCS had an effect on OCD symptoms after 5 CBT sessions suggests that it may be a useful augmentation strategy for OCD. 3/23/2011 61 PowerPoint Presentation: In all the OCD studies difference between the DCS and placebo groups were found when DCS administered 1 to 2 hrs before therapy sessions, but not when administered 4 hrs before. Animal studies concluded that DCS more effective when given immediately before or even after extinction exercises. Its one of the solid foundation of fear extinction. DCS seems to be effective at low doses(50 mg) and has no more side effects. 3/23/2011 62 Efficacy in depression: Efficacy in depression Acute treatment phase studies : Metanalyses of numerous studies – CT equals to or superior over others . Dobson 1989 , Gaffan et al 1995 ,Robinson et al 1990,Elkin et al 1989,95, DeRubeis et al 2005,Miller et al 2005 ,Thase et al 1991- support the above. 3/23/2011 63 Efficacy in depression: Efficacy in depression Long term studies :over 1-2 yrs of follow up- lower risk of relapse . Kovacs et al 1981 ,Black burn et al 1981,Unive. of Pennsylvania, Holan et al 2005, Fave et al 1996,2004,jarrett et al 2001- reduces relapse from 47% -29%. Jarrett et al 2001 examined C –phase CT & confirmed at risk pts for relapse & demonstrated the efficacy in protection. Fully remitted pts –no benefit . 3/23/2011 64 PowerPoint Presentation: 3/23/2011 65 Evans et . Al. 1992 Efficacy in OCD: Efficacy in OCD Effective & frequently used for OCD. Response Rates 50-70% ( Emmelkamp & Beans 1991 ) Behavior Strategies take Precedence over cognitive interventions with Exposure & Response prevention ( Emmelkamp & Beans 1991 ) 3/23/2011 66 Efficacy in anxiety disorders: Efficacy in anxiety disorders Most authours recommended both cog. & beh.measures -Barlow Cerney1988; Beck et al. 1985a. D.M.Clark et al.1985-behavioural measures –useful in panic disorders . and greater reductions in anxiety , catastrophic cognitions &frequency pf panic attacks. Uncontrolled study at university of Pensylvania , j.g beck et al.1994;Craske et al.1995;Heldt et al.2006; have supported the above . 3/23/2011 67 PowerPoint Presentation: In GAD-studies of Hollon &Beck1994,Power et al.1990,Butler et al.1991,University of Pennsylvania ,Davidson et al.2004,D.M.Clark et al.2003, & Stangier et al.2003 support efficacy. In PTSD –Mc Donagh et al.2005 , Foa et al 2005(n=171), Kubany et al .2004 , Bisson et al 2004 support superiority of CT 3/23/2011 68 In eating disorders: In eating disorders Agras et al 1992,2000;Bnasiak t al.2005 ; Carter et al.2003;Cooper et al.1996,Fairburn et al.1991,1993,1995;……have supported. Reduces binge behaviors from 73% to93% &complete remission in51%-84% of cases. CT&IPT were superior to beh . therapy; CT most effective in modifying extreme dieting, emesis ,dysfunctional attitudes(Fairburn et al) CT superior over IPT ( Agras )&along with drugs than drugs alone . 3/23/2011 69 In psychosis: In psychosis Reported to reduce symptoms of sciz .( Garety et al.1994;Tarrier et al.1993) Metaanalysis of 14 invest. Completed between 19940-2004-suggested sign. Adjunctive procedure. Drury et al.1996-improvement of positive sym. &reduced time for recovery 3/23/2011 70 Bipolar disorder: Bipolar disorder Few randomized controlled studies SCOTT et al 2001 (n=42),Lam et al 2003(n=103),Ball et al 2006-decrease in relapse rate Suggested booster sessions or maintenance therapy. 3/23/2011 71 Others….: Others…. Personality disorders Substance abuse 3/23/2011 72 Acceptance and Commitment Therapy: Acceptance and Commitment Therapy ACT is rather an reformulation of Skinnerian radical behaviorism. Mainly hints at the basic premise of the causative interplay between cognitions, behaviors and emotions. Although different from CBT, similar by techniques known as acceptance , cognition delusion , being present , self as context, values and committed actions. 3/23/2011 73 PowerPoint Presentation: Major aspect is the notion of acceptance. Method: By encouraging patients to embrace negative thoughts and feelings, such as pain and anxiety, pain and guilt rather than attempting to change and eliminate them, patients begin to learn that acceptance can be more important alternative to experience avoidance. By meta analysis ACT for a range of mental disorders and physical problems like anxiety, depression , psychosis and smoking cessation 3/23/2011 74 PowerPoint Presentation: 3/23/2011 75 PowerPoint Presentation: TEXT BOOK OF PSYCHIATRY BY TASMAN 2 nd EDITION CTP IX EDITION OXFORD TEXT BOOK OF PSYCHIATRY 2 nd EDITION A.P.P TEXT BOOK OF CLINICAL PSYCHIATRY 4 th EDITION Psychiatric clinics of North America , vol 33, CBT MEDSCAPE References THANK YOU…..: THANK YOU…..