Class 3 Flashcards
CBT is as good or better than medication for
depression (especially mild to moderate) all anxiety disorders (Axis I) Obsessive Compulsive Disorder (OCD) Social Anxiety Disorder PTSD Generalized Anxiety Disorder (GAD) Panic Disorder Simple Phobia (Hypochondriasis)
CBT is effective in major mental disorder:
in combination with medications
severe or treatment resistant depression
in psychotic disorders (schizophrenia)
bipolar disorders
CBT is effective in major mental disorder:
in multimodal approaches
addictions
eating disorders
chronic pain
CBT Model
thoughts influence emotion and behaviour
behaviour influences thought and emotions
in CBT, patients are taught to detect and modify inner thoughts and change behaviour to reduce distress and promote well-being
Features of CBT
problem focused & goal-oriented
present & future focus
each session involves practical steps to improve mood and solve specific life problems
homework between sessions essential to achieve goals
time-limited
sessions structured
collaborative
People do well in CBT if they:
identify what they are thinking, feeling in session without undue defensiveness
express and have showed by their life stories that they take responsibility for change in their difficulties
are willing to do homework between sessions
People don’t do well in CBT if they
subscribe to another model of change (meds, exploration of childhood issues, talk)
expect change to come from outside of themselves
can’t stay on topic, avoid getting to the heart of the matter (avoidance, excessive talking etc)
CBT and Depression (behave, thinking, emo)
Behaviour: reduced activity level increased unrewarding behaviours (eg. TV) unrewarding interpersonal interactions Thinking : negative triad: I’m a loser (self) Things will never get better (future) People demand too much of me (world) Emotional: emotional withdrawal, neg affectivity
Targets of Intervention in CBT for Depression
Behavioural:
increase pleasurable, rewarding activity
change interpersonal behaviour
Cognitive:
identification of cognitive distortions
changing negative thoughts
(identifying and modifying underlying schemas)
Session Structure
Set agenda What like to accomplish today? How fit in with therapy goals? Prioritize. Mood check, medication compliance Review learning since last session HW review New ideas and skills Setting of new HW Feedback on today’s session What will you take away from today’s session? How do you think the session went? Anything you would have preferred? etc.
Behavioural Activation Principles
people get depressed when their lives provide too few rewards, and too many problems
tendency is then to pull away from routine, and further disrupt their lives
BA not just about doing more, but rather figuring out what would be most helpful, and what small manageable steps could be taken
Start with Self-Monitoring
fill out activity schedule between sessions
see relationships between behaviour, context & mood
identify “reinforcers” of avoidance
e.g. procrastination – avoids stress of doing unpleasant task
e.g. support of wife when avoids something, overeating
Activity Scheduling
based on behavioural analysis of monitoring help patient plan activities in upcoming week goal to reduce avoidance, increase pleasure, mood areas to increase: personally rewarding activities self-care small duties involvement with family & friends SMART
Graded Task Assignment
goal not necessarily to accomplish all parts of the activity, but to increase activation & disrupt avoidance
Counter hopelessness by
breaking each task into small, manageable steps
each step should be reinforcing/rewarding
challenge cognitive (thinking) blocks to progress
encourage self-reward to attempts
redefine success realistically
How do Depressed People Think?
Negative Triad (content of what they think)
The future
Themselves
The world
Cognitive Distortions (how they think)
See things in extreme terms, don’t take all aspects of a situation into consideration
Cognitive Biases in CBT
Confirmatory bias
Black/white thinking: if you don’t get an A you’re stupid
Selective abstraction: selecting what u pay att to
Discounting the +: anyone can do it
Overgeneralizing:
Fortune telling
Catastrophizing
Externalizing bias: it’s not your fault
Jumping to conclusions
Labeling: my boss is a bitch
Mind reading
Shoulds & musts
Personalizing: takes everything personally
Magnification/ minimization
Emotional reasoning: feel some way so it’s the truth
Why Identify Cognitive Biases?
Because distorted thinking fuels depressed mood
Because distorted thinking is often unrealistic & unfair to you and others
Correcting distortions can make thinking more realistic and less depressive
Thinking – 3 different levels
Automatic Thoughts
Assumptions/ Rules for Living
Core beliefs
Automatic Thoughts
situation-specific
automatic flow of thoughts all day long
He thinks I’m an idiot. Uh, oh, here comes a panic attack again. What if this is cancer? They’re laughing at me. People should be more careful!
Maladaptive Assumptions
Rules for living
Negative core beliefs
- often absolute, “black-white”
- deeply held beliefs about the self or others
Using a Thought Record to work with Negative Automatic Thoughts
Select a moment in time where the patient’s mood shifted
Examine this event or moment in detail
Using a thought record, elicit and record :
relevant automatic thoughts
associated emotions/ physiologic sensations
consequent behaviours
Use the thought record to explain the CBT model
Thought Record
Situation, automatic thoughts, emo, behaviour, alternate thoughts
Working with a Thought Record
Explain the CBT Model:
Thoughts affect how we feel and what we do. In CBT we help people feel better by changing what they think and also what they do. If we look at your thought record, we see:
The situation was….
You thought to yourself……
You felt ……..
So you did……
As a result, you……..
Identify thoughts with cognitive distortions
Consider more realistic, balanced thoughts
Considering Alternate Thoughts
Choose an important negative thought:
Would most people agree with this thought? If not, what other thoughts might they have?
What would I say to a friend in the same situation?
Is there information I am missing? If so, how can I get it?
What will happen if I continue to think this way?
Is it useful to think this way? Is there a more useful, encouraging way of thinking?
If the same situation occured again, what would happen if you considered this alternate thought? Would you have felt differently? What would you have done differently?
Practicing Alternate Thoughts
In future situations, practice “realistic thinking”
In situations where you notice your mood going down, are you having depressive thoughts?
Is there a cognitive distortion?
Is there a more realistic or useful way of thinking?
Problem Solving Treatment for Primary Care effective in
depression (= antidepressants) in primary care,
depression and mild cognitive dysfunction in older adults
depression in medically ill, cancer pts
Working with Problems
I. Problem orientation
II. Problem solving
Improving Problem Orientation
1.Recognize a problem before it is too late
use negative affect as cues that a problem exists
“Stop & Think!”
2.See problems as a normal part of life
3.See problems as opportunities rather than threats
Improving Problem Solving
Problem definition and goal setting (“SMART”): focus on changing yourself, not others, one problem at a time
don’t waste time on problems that can’t be solved
Generation of solutions: consider doing nothing
Choice of preferred solutions
Implementation of preferred solutions
Evaluation
Relapse Prevention for Depression
Watch for early warning signs sleep changes, appetite, social isolation Coping strategies talking to someone taking meds as prescribed stress reduction scheduling positive activities correct negative thinking Contact health care professionals if problems re-occur
Stimulus Control for Insomnia Rationale
goal: reverse conditioned arousal & strengthen bed as a cue for sleep
bed has been paired with arousal & negative emotions -> want to “unlearn” this association and restore bed as a cue for sleep
this is an unconscious process, so NOT THE PATIENT’S FAULT
if pair bed repeatedly with drowsiness and relaxation, new association is formed
Stimulus Control Instructions for the Patient
“Stimulus Control” will strengthen your bed as a cue for going to sleep by ensuring that you will be in bed only when asleep or very sleepy. Follow these five steps:
Go to bed when you are sleepy (not just fatigued)
Get out of bed if you are unable to sleep after 20 minutes, and go back to bed only when you are sleepy.
Use your bed only for sleep (or sex).
Wake up at same time each day, and get up within 15 minutes.
Do not nap.
Stimulus Control Tips
If you “feel” that sleep not going to happen, or you get frustrated, get out of bed.
Don’t watch the clock.
Return to bed only when sleepy.
Don’t “Try to sleep”. Forcing sleep is counterproductive.
Remember: “Falling asleep is effortless.”
The Nature of Anxiety
Thinking:
Overestimates danger (probability, cost)
Underestimates their capacity to cope
Underestimates possibility of rescue
Behaviour :
Avoidance
Safety behaviours e.g. cell phone, companions, meds
Control, Rigidity
Emotion:
More intense affect, emotional dysregulation, avoidance
CBT of Anxiety
Change thinking threat estimation coping capacity Change behaviour exposure most important single intervention reduce avoidance, safety behaviours Facilitate emotional processing
Types of Exposure
In Vivo: exposure to “real” stimuli in real world
Interoceptive: exposure to physical sensations
Imaginal
Principles of Exposure
length of exposure not dependent on decline of fear
stay in situation “until you have learned what you need to learn, and sometimes that means learning you can tolerate fear”
more important than length of each exposure is repetition of exposure to see reduction of anxiety over time
progress is best measured by level of anxiety experienced the next time patient encounters phobic situation
after acute treatment, intermittent exposure “booster” leads to less return of fear
Brief Exposure Instructions with Panic Attacks
What you have had is a panic attack.
This is not a physical or psychiatric disorder.
Panic attacks are unpleasant but not dangerous.
The most effective way to reduce the fear is to face the situation where the attack occurred
Go back to the situation as soon as possible, and stay there until the anxiety goes away.
First Exposure Plan
What am I testing out? (specific) ____________
How am I testing it out? (condition, context, duration) ___
What am I throwing out? (safety behaviours)_______
How will I stay with it? (attention to aversive stimulus) ___
How will I combine it? (n/a in first exposure)______
Put together, what is my plan:
_____________________________________________
Monitoring Form: Consolidating Learning
Immediately before practice:
How likely is what I am worried about will occur?____ (0-100%)
What is my current level of anxiety? _____(0-100%)
Immediately after practice:
What is my anxiety now? _____(0-100%)
What was the peak anxiety level? _____
Did what I worried about occur? Y/N
How do I know?_______________
What did I expect to happen? What actually happened? Was that a surprise? ______________
If I repeated the same exposure, how likely is it that what I was worried about will occur this time? ______ (0-100%)
Subsequent Exposures: Generalization
Exposure to multiple stimuli, different contexts, durations
In same trial “combine”
Add a second excitatory cue during exposure to first, as anxiety is lowering
This enhances learning in the long term
Include occasional negative outcomes
E.g. panic attack, social rejection
Also better for long term learning
Tips for Health Care Professionals with Anxious Pts
Principle of treatment – only facing anxiety without safety behaviours can make it better
Sick leaves to avoid anxiety at work countertherapeutic
Special arrangements for patients to tolerate anxious situations may reinforce anxiety (safety behaviours)
e.g. modifications at work to avoid the scene of an accident, or a person, or a night shift
