Mood disorders Flashcards
What is the most difficult aspect of treating depression
relapse prevention
Overall CBT process for depression
behavioural activation
introducing the cognitive model
monitoring automatic thoughts
evaluating automatic thoughts
challenging/restructuring automatic thoughts
intermediate beliefs
schemas and core beliefs
Beck’s cognitive model of depression
early experience
dysfunctional assumptions
critical incident
negative automatic thoughts
symptoms (affect each other)
cognitive conceptualisation
relevant childhood data
core beliefs
conditional assumptions, beliefs, rules
compensatory strategies
situation - automatic thought- meaning of automatic thought- emotion - behaviour
2 main CBT core beliefs
central beliefs that maintain the presenting problem
helplessness
unloveability
conditional assumptions, beliefs, rules
assumptions generated to assist in coping with the core belief
e.g. if i am liked by everyone then i am worthwhile
therefore if anyone does not like me i am not worthwhile
compensatory strategies
behaviours performed that assist in coping with core beliefs
used to maintain the positive version of the conditional assumption
negative cognitive triad
self: i am a failure
world: the world sucks, people are trying to take advantage of me
future: things are never going to get better, my life will always be this bad
attributional style for negative events
depressed individuals have a tendency to attribute INTERNAL for negative events and this attribution is STABLE over time as well as GLOBAL across other contexts and situations
key characteristics of CBT
agenda setting
goal focus
cooperative, explicit approach
collaborative empiricism
time limited
directive/skills based
goal setting in CBT should be
realistic
specific rather than general
described in behavioural terms- “what would you be doing if you were happier?”
rationale for behavioural activation
decreased engagement with environment denies opportunity for positive reinforcement
depressed client views day or week as uniformly negative
by increasing activity, chance of positive reinforcement is increased
Lewinsohn’s model of depression:
: thoughts about depression happening in two phases. Explains that being around and listening to an individual experiencing depression can be fatiguing, and cause people to distance themselves from someone who is chronically depressed. People with depression have an interpersonal style that initially elicits sympathy (reinforcing), but eventually people may isolate themselves from the person (affirms depression related core beliefs, alienating)
behavioural activation procedure
Provide the rationale for activity scheduling
Monitor pre-intervention activity levels
Have the patient prepare their environment / significant others for change
Identify potential activities. This can be done using either a broad list of activities, or by providing general areas for the patient to select from.
Compile a list of activities and rank them in order of difficulty.
Organize the activities into a hierarchy.
Monitor and reward progress.
Common problems- behavioural activation
poorly specified schedules or activities
too much, too soon (use a hierarchy)
activities that appear monolithic to the client (break down into smaller, more manageable tasks)
ACTION- dealing with avoidance
assess my behaviour
choose whether to activate/engage in helpful behaviours or continue to avoid the experience
try the behaviour I’ve chosen
Integrate the new behaviour into a regular routine
Observe the outcome of the behaviour
Never give up
demonstrating the importance of cognitions
create an emotion
thought injection
case of dreaming
examples from clients own history
examples where the situation is the same but different beliefs lead to different emotions
overall guideline for depression treatment
goal setting and overview
behavioural activation introduced
automatic thoughts introduced
cognitive distortions introduction
DTR introduced
ATs sessions 5-8
IBs/CBs sessions 9-12
Closing sessions 13-15+
session structure
brief update and mood check
bridge from previous session
agenda setting
homework review
discussion of agenda items (summaries, consolidations, homework setting during session discussions)
final summary and homework tie up
feedback
thought vs belief
thoughts are fleeting
beliefs tend to stick
reframing questions in AT
questions are difficult to challenge and not subject to evaluation of validity
reframe them as statements
content specificity hypothesis
proposes that each emotional state is associated with different automatic thought content
AT that have themes of sadness, loss, deprivation are associated with emotions of sadness, sorrow etc.; AT that have themes of threat, anxiety are associated with emotions of anxiety; AT that have themes of injustrice, retribution, violation, are associated with emotions of anger; AT that have self critical themes are associated with emotions of guilt
cognitive distortions
logical errors made in information processing that lead to dysphoria
help show patterns in types of errors made
cognitive distortion types
all or nothing thinking: black or white categories
overgeneralisation: a single event is seen as part of a never ending pattern
mental filter: pick out one negative aspect and dwell on it excessively
mind reading: making guesses about what other people might be thinking based on inadequate evidence
fortune telling: making guesses about what may happen in future based on inadequate evidence
arbitrary inference/jumping to conclusions: drawing negative conclusions even when no definite facts to support it (types of this are mind reading and fortune telling)
magnification and catastrophisation: exaggerates the importance of something
emotional reasoning: drawing conclusions based on their emotions themselves
should sstatements: comparison of how things actually with how we would like them to be, counterfactual thinking
labelling and mislabelling: instead of describing an error, behaviour or problem, sometimes a person may attribute it to a character flaw in themselves or others
personalisation: seeing yourself as the cause or reason for an event for which you were not fully responsible
six types of socratic questions
clarification
probe assumptions
probe reason and evidence
viewpoints and other perspectives
probe implications and consequences
questions about the question
questions to evaluate ATs
objectivity - what is the evidence, is there an alternative explanation, what is the worst that could happen
utility - what is the effect of believing this, is it useful to achieving my goals
consistency- what would i tell friend in same situation, have there been times i thought differently
Dysfunctional thought record (DTR)
Client identifies automatic thought
clear link drawn between thought and emotion
distortions inherent in the though are recognised
goes through process of evaluating thought
change in belief strength is quantified and highlighted
change in emotional intensity is quantified and highlighted
action planning/solution focus is engaged
when an evaluation of an AT is ineffective
more central ATs left unevaluated
implausible, superficial or inadequate evaluation
not sufficiently expressed the evidence they believe supports the AT
AT itself also a core belief
believes intellectually that AT is distorted but not on an emotional level
discounts the evaluation
aim of behavioural experiments
used as a follow up to verbal discussion of beliefs
aim to gather evidence for or against a belief, try out a new belief, consolidate a new belief
types of behavioural experiments
hypothesis testing: testing theories
discovery: what happens when i do _
active: client is an active participant
observational: client observes without interacting
ideal behavioural experiment is capable of
determining decisively whether a belief is true
types of intermediate beliefs
attitudes: it is intolerable to be disliked
assumptions: so long as everyone likes me im ok, if someone doesnt like me im flawed
rules/operating rules: i should do everything i can to make people like me
compensatory behaviours
intermediate beliefs can be associated with compensatory behaviours, serving a defensive function
six methods of uncovering intermediate beliefs
through identifying that a patient has reported an intermediate belief as an automatic thought
by cueing the patient using the first part of an assumption
through direct enquiry about a patient’s rules or attitudes
using the downward arrow technique
through identifying common themes through the patient’s automatic thoughts
through use of questionnaires
evaluating intermediate beliefs
logical objective evaluation
utility evaluation
consistency of the belief across time person and place
methods for modifying intermediate beliefs
socratic questioning
behavioural experiments
cognitive continuum
rational emotional roleplays
using others as a reference point
acting ‘as if’
cognitive continuum
used to modify beliefs that reflect polarised or dichotomous thinking
recalibration of standards
rational emotive roleplay
define the original belief
have the therapist assume the role of the original belief while the client agrees to take on the role of the new belief
therapist should begin by articulating the original belief, and have the client respond to this with evidence for the more rational belief
continue until the therapist exhausts all lines of argument
particularly useful for clients who feel the need to ‘defend’ their beliefs
using others as a reference point
considering the beliefs of others
aiming to recalibrate one’s own beliefs through considering the viewpoint of others in similar situations
acting ‘as if’
client agrees to a behavioural experiment in which they act ‘as if’ the new belief (not original) were true
schemas v core beliefs
schemas are the cognitive structures within the mind
core beliefs are the content of these cognitive structures
symptom typography reflects
schema content
schema change requires
schema activation
two types of core beliefs
helplessness
unloveability
Young’s schemas
disconnection and rejection: abandonment/instability, mistrust/abuse, emotional deprivation, defectiveness/shame, social isolation/alienation
Impaired autonomy and performance: dependence/incompetence, vulnerability to harm or illness, enmeshment/undeveloped self, failure
impaired limits: entitlement/grandiosity, insufficient self control/self discipline
Other directedness: subjugation, self sacrifice, approval/recognition seeking
Over vigilance and inhibition: negativity/pessimism, emotional inhibition, unrelenting standards/hypercriticalness, punitiveness
knowing when a core belief is uncovered
uncovering associated with strong emotional response
core beliefs tend to be general and asolutistic
tend to be exaggerations
downward arrow
choose salient AT
thought written at top of page and arrow drawn under
asked questions to uncover deeper meaning like what would this mean to you, what would be so bad about, what would be the worst thing about it being true, what would that say about you, why would this be so upsetting
each step down should go from more specific to general and global beliefs
should not response with statement of desire or wishes about how they would like things to be or feelings/emotions
techniques used to modify core beliefs
core belief worksheet
extreme contrasts
developing metaphors
historical tests
restructuring early memories
coping cards
extreme contrasts
ask to compare self with an extreme example of a core belief they report
metaphor/analogy for core beliefs
particularly useful when client can relate it to personal experience
restructuring early memories
The client can be asked to respond to earlier statements said to them in the same fashion as they respond to their own internal beliefs
coping cards
patients can compile coping cards that record key pieces of information for use in distressing situations
Their core belief
Their explanation for how the core belief arose.
Evidence that refutes the core belief
Alternative beliefs or reframed evidence.
