CBT

CBT developed by

Aaron T beck, MD

CBT developed to

treat depression

CBT was developed in the

1960s

theory of CBT

promotes active problem solving in order to modify dysfunctional thinking and behavior, grounded in cognitive model

current use of CBT

adapted to treat a variety of psychosomatic conditions (anxiety, substance abuse, body dysmorphic disorder, chronic pain)

CBT uses relationship between

situation, behavior, thought, emotion

behaviors are made of

thoughts, perceptions, and feelings

healthy thoughts lead to

healthy feelings and behaviors

negative thoughts lead to

self-destructive feelings and behaviors

types of CBT

• Acceptance & commitment therapy (ACT)

• Dialectical behavior therapy (DBT)

• Exposure & Responsive Prevention (ERP)

• Rational Emotional behavior therapy (REBT)

Key constructs of CBT

• cognitive distortions

• core beliefs

• automatic thoughts

• behavioral patterns

• emotional regulation

• problem-solving skills

• psychoeducation

CBT Techniques

• Cognitive restructuring

• graded exposure

• behavioral activation

• successive approximation

• journaling

• guided discovery

• behavioral experiments

• ID’ing the problem

• Relaxation

• Role Playing

• Mindfulness

Aspects of cognitive restructuring

• ID the upsetting situation

• ID the strongest feelings the situation brings about (name the emotion)

• Ask questions about the thoughts behind those feelings

• Evaluate and break down those thoughts

• make an objective decision about accuracy of thought

Graded exposure

slowly introducing anxiety inducing activities or situations into life for measured periods of time

goal of graded exposure

to unlearn negative though processes, lessen induced reactions, and teaching pts

Behavioral activation

ID and engage in activities that bring joy and a sense of accomplishment despite low motivation

aspects of behavioral activation

understanding the cycle, increasing positive reinforcement, activity scheduling, ID barriers

successive approximation

breaking up overwhelming tasks into smaller, more achievable steps (confidence booster)

purpose of therapeutic journaling

recognize patterns, process emotions, track progress

Guided discovery aspects

active process, reflective questions, evidence evaluation, cognitive reframing, behavioral insight, perspective shift

cognitive reframing

challenge unhelpful thoughts and expand perspectives

behavioral insight

differentiate fear-driven behaviors from reality

ID the problem aspects

action-oriented process, structured problem-solving, broad relevance, sequential and non-judgmental

Purpose of relaxation strategies

promote relaxation, calmness, and reduction of pain, anxiety, stress, or anger

Goals of relaxation strategies

recognize triggers, apply coping skills and de-escalate the body’s stress response

relaxation techniques

deep breathing, progressive muscle relaxation, and guided imagery

Role playing aspects

skill practice, preparation, scenario rehearsal

Chronic pain biopsychosocial model components

biological, psychological, social

biological components of pain

medical dx, co-morbidities, medical management, genetic factors, altered neurotransmitter function, changes in pain receptors, cortical reorganization

psychological components of pain

negative affect, pain cognitions, catastrophizing, answer-seeking, self-efficacy

social components of pain

environmental stressors, interpersonal relationships, social support/isolation, cultural factors, previous experiences

Solicitives

can perpetuate the cycle

punishing

judgement from others, negative interactions with support network

PTs are not very accurate at allocating pts into

risk stratification groups or ID’ing psychological factors

PTs self-reported competence in managing pts was lowest when

pts R/O higher distress

chronic pain cycle

chronic pain, decreased activity, negative emotions, avoidance withdrawal, distress disability, back to chronic pain

CBT is/is not effective for chronic pain

IS

Early CBT for chronic back pain resulted in

less pain, better QOL, etc. at 5 year follow up

CBT compared to customary tx had

effect on pain, disability, mood, and catastrophizing

long term effects of CBT were superior to… in TMJ disorder

general education for reported pain and improved function in

few studies available comparing use of CBT compared to

other active treatments

several factors may moderate CBT efficacy

coping strategies, treatment expectations, severity of pathology, age, educational level

Goals of CBT for chronic pain

• decrease negative impact of pain

• improve physical and emotional functioning

• increase use of effective coping skills

• decrease pain intensity

Some CBT treatment elements for chronic pain

cognitive restructuring, graded exposure, activity pacing, pleasant activity scheduling, stress management, sleep hygiene

Ways to assess knowledge/beliefs

Pain catastrophizing scale, Fear avoidance beliefs questionnaire, neurophysiology of pain questionnaire

ways of cognitive restructuring

recognition and evaluation of automatic, maladaptive thought processes, substitution with adaptive cognitive responses, education on pain, neurophysiology of pain (explain pain)

Graded exposure is designed to address

fear avoidance behaviors contributing to the chronic pain cycle

activity pacing involves deliberate scheduling of

both activity and rest periods

Pleasant activity scheduling can help to

boost mood and self-esteem, serve as pain distraction, may increase socialization, enhances attention and concentration skills, provides direction and purpose, gives something to look forward to

External stressors

environmental, social, organizational

Internal stressors to reduce

lifestyle choices, negative self-talk, personality traits

relaxation techniques

diaphragmatic breathing, progressive muscle relaxation, guided imagery, meditation, yoga, tai-chi

current use of CBT in PT

activity pacing, pleasant activity scheduling

Barriers to CBT in PT

training, reimbursement, productivity