Lecture 4 Notes: Cognitive Behavioral Therapy

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Stoicism and Cognitive-Behavioral Therapy

  • Stoicism: "If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment."
  • "Very little is needed to make a happy life; it is all within yourself in your way of thinking."

Lecture Overview

This week's lecture is divided into sections:

  • Section 1: Depression: Biological Approaches

    • Genetics
    • Neurochemistry
    • Default Mode Network

  • Section 2: Depression: Psychological Approaches

    • Cognitive Behavioral Therapy (CBT)
    • History
    • Aaron Beck
    • Life Influences
    • CBT: Empirical Evidence

  • Section 3: Clinical Psychology: Career Options

Section 1: Depression - Biological Approaches

Topics to be covered:

  • Genetics
  • Neurochemistry
  • Default Mode Network

Learning outcomes:

  • Outline contributing factors to vulnerability to depression.
  • Appreciate that different therapies might work through common means.

DSM-5: Depressive Disorders

Types of depressive disorders according to DSM-5:

  • Disruptive Mood Dysregulation Disorder
  • Major Depressive Disorder
  • Persistent Depressive Disorder (Dysthymia)
  • Premenstrual Dysphoric Disorder
  • Substance/Medication-Induced Depressive Disorder
  • Depressive Disorder Due to Another Medical Condition
  • Other Specified Depressive Disorder
  • Unspecified Depressive Disorder

DSM-5: Major Depressive Disorder Criteria

Criterion A: 5 or more symptoms, with at least one of them being either depressed mood or diminished interest/pleasure.

Symptoms include:

  1. Depressed mood [emotional] (e.g., feels sad, empty, hopeless).
  2. Diminished interest or pleasure in activities [motivational].
  3. Significant weight loss or weight gain.
  4. Insomnia or hypersomnia [Gillin et al. (1979): terminal insomnia].
  5. Psychomotor agitation or retardation [behavioral symptoms].
  6. Fatigue or loss of energy.
  7. Feelings of worthlessness or excessive or inappropriate guilt.
  8. Diminished ability to think or concentrate [cf. Zullow (1984): rumination on possible negative consequences of an action, which is key to the maintenance of Major Depressive Disorder].
  9. Thoughts of death or suicide.

Mullins and Lewis (2017): Subphenotyping of the nine core symptoms of depression indicates that almost 1500 symptom combinations can fulfill the diagnostic criteria, and two patients with a diagnosis of MDD may not have a single symptom in common.

Depression: Genetic Factors

  • Kessler et al. (2003): Depression is common, with a lifetime prevalence of around 10-16%.
  • Kendler et al. (2006): Twin study of over 42,000 twins showed depression is moderately heritable at around 38%.
  • Flint and Kendler (2014): Major review of candidate genes for depression. Many possibilities exist, but most are only weakly associated with depression.

Depression: Gut Bacteria

  • Maes et al. (2008): Depressed individuals have higher levels of blood antibodies to a marker for infectious gut bacteria.
    • Increased translocation of gram-negative bacteria (leaky gut) plays a role in the inflammatory pathophysiology of depression.
  • Qin et al. (2022): 20% increased risk of depression per standard deviation rise in gut concentrations of Morganella.

Depression: Serotonin

  • Serotonin is related to the raphé and related nuclei.

Serotonin: Emotional Effects of Depletion

  • Delgado et al. (1999): Previously depressed patients given a tryptophan-free diet for 2 days. Over half showed a significant increase in depressive symptoms.

Serotonin: Emotional Effects of Depletion - Factors

  • Booji et al. (2002): Literature review showed that a range of intervening factors heavily influence the impact of serotonin depletion, including the number of prior episodes of depression.

Antidepressants: Treatment Effectiveness

  • Geddes et al. (2003): Meta-analysis of 31 antidepressant clinical studies showed they helped prevent relapse, even after just 1-2 months’ treatment.

Depression Treatment: Antidepressants

  • Yatham et al. (1999): Study showed the effects of successful antidepressant treatment (desipramine) on brain serotonin function, indicating a probable increased serotonin function in the medial frontal gyrus.

Mindfulness & Default Mode Network

  • Brain regions involved in the Default Mode Network (DMN) include:
    • Prefrontal cortical regions
    • Cingulate/Insula regions
    • Medial Prefrontal Cortex
    • Posterior Cingulate Cortex
    • Angular gyrus

DMN-Amygdala Connectivity and Depression

  • Posner et al. (2013):
    • The severity of depressed participants’ depression ratings correlated with the levels of activity detected between the posterior cingulate cortex (a key component of the DMN) and the amygdala.
    • DMN-amygdala connectivity correlated with depression rating.

Antidepressants & DMN Activity

  • Posner et al. (2013):
    • Treatment with the antidepressant drug Duloxetine reduced activity within the DMN in depressed patients to normal levels.

CBT & DMN

  • Rubin-Falcone et al. (2018):
    • 14 sessions of cognitive behavioral therapy reduced negative feelings to presentations of bad memories that depressed participants had previously listed.
    • CBT also reduced the neural response in DMN-related regions, including the subgenual cingulate cortex and medial prefrontal cortex.

Section 2: Depression - Psychological Approaches

Topics to be covered:

  • Cognitive Behavioral Therapy (CBT)
    • History
    • Aaron Beck
    • Life Influences
    • CBT: Empirical Evidence

Learning outcomes:

  • Outline cognitive underpinnings of CBT.
  • Give an account of the history and scientific basis for CBT.

Roots of CBT: Stoicism

  • Zeno of Citium (c. 334 – c. 262 BC):
    • Founder of the Stoic school of philosophy.
    • Began teaching in 301 BC.
    • Destructive emotions result from errors of judgment.
    • People should choose to maintain a will (reason, called prohairesis) that is in accordance with nature.
  • Emperor Marcus Aurelius (161-180 A.D.):
    • Follower of Stoicism.
    • "If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment."
    • Your ‘estimate’ will be subjective: it could be positive – or negative!

Aaron Temkin Beck

  • Aaron Temkin Beck (July 18, 1921 - November 1, 2021)

Aaron Beck: Birth and Early Life

  • Born on July 18, 1921, in East Side, Providence, Rhode Island, USA.
  • Youngest of 5 children.
  • Father, Harry Beck, was a printer; mother, Elizabeth Temkin, was a seamstress and store clerk.
  • Early life marked by loss of an older brother and sister in the ‘flu epidemic post-WWI, and his mother became chronically depressed.
  • Mendlowicz et al. (2022): These events may well have influenced Beck’s later interests and career.
  • 1946: Completed medical degree and started at Cushing Veterans Administration Hospital in Framingham, Massachusetts, initially adopting the psychoanalytic approach.
  • Believed strongly in experimental research.
  • Rosner (2015): “…what most distinguishes Beck from the psychoanalysts was his fierce allegiance to experimental science.”
  • Hoffman et al (2012): “CBT refers to a class of interventions that share the basic premise that mental disorders and psychological distress are maintained by cognitive factors."

Depression Treatment: Cognitive Behavioral Therapy

  • Beck (1967, 1991): People develop depression directly as a result of negative cognitions, i.e., negative thinking directly leads to depression.
    • Maladaptive attitudes / negative schemas
    • Begin in childhood, e.g., belief that self-worth or parental affection depends upon success in school.
    • May ‘lie dormant’ until a particularly adverse event is experienced.
    • The Cognitive Triad
    • Once reactivated, negative schemas cause 3 types of negative thinking:
      • Negative thoughts about oneself, e.g., “I am inadequate and worthless.”
      • Negative thoughts about the current situation.
      • Negative thoughts about the future, e.g., “There is no hope for the future, things will never improve.”

Attributional Style: Negative Thinking

  • Metalsky, Seligman et al. (1982): New students were tested for attributional style and asked what exam grade later in the year they would consider a failure.
    • “…the more internal or global students' attributional styles for negative outcomes were…the more severe their depressive mood reactions to the…receipt of a low midterm grade…students who were extremely external or specific in their attributional styles for negative outcomes…actually were invulnerable to depressive mood reactions upon receipt of the low midterm grade.“ (p. 615)
  • Negative attributional style and inclination to ‘learned helplessness’ may be an important predictor of vulnerability to depression through adverse life events.

Positive Thinking or Learned Optimism

  • Seligman (1991, 2011): Identified most pessimistic 25% of Princeton student entrants and allocated them either to control or 16 hours of learned-optimism workshops.
    • 32% of controls experienced a significant episode of depression, compared to only 22% of those who’d taken the workshops.

Depression Treatment: Cognitive Behavioral Therapy 2

  • Errors in logic maintain the cognitive triad, e.g.
    • Arbitrary inference: Negative conclusions from little or even contradictory evidence, e.g., if glanced at in the street, assumes “They must think I’m really stupid.”
    • Selective abstraction: Inappropriate focus on negative aspects of a generally positive situation, e.g., at a dinner that otherwise went very well, a single clatter of a fork is taken to indicate a disastrous night.
    • Overgeneralization: A single negative event is taken to apply at all times/places, e.g., following the dinner above, a person might conclude “I’m always absolutely hopeless at socializing.”
  • Automatic thoughts:
    • “I always mess things up.”
    • “I always say the wrong thing.”
    • “I’m a burden on my friends.”
    • “They don’t really like me at all.”

Selective Abstraction

  • Bradley and Matthews (1983): Controls vs. depressed participants presented with words and told they either related to an unfamiliar or familiar person, or themselves.
    • Depressed participants recalled fewer positive words and more negative words specifically when words related to themselves.
    • Error in logic: Selective abstraction

Arbitrary Inference

  • Leppänen et al (2004):
    • Happy, sad, or neutral faces briefly shown to controls or depressed participants.
    • Depressed participants specifically interpreted neutral (ambiguous) faces as sad (negative) ones.

Cognitive Behavioral Therapy: Treatment Phases

  • Castonguay et al. (2018): Four main phases:
    • 1. Behavioral Component: Increasing activities and mood: schedule of activities drawn up, participation in which is expected to improve mood, though not remove depressive thinking.
    • 2. Identifying, then challenging negative thoughts, errors in logic: patients taught to recognize and record negative thoughts and tendencies to interpret events negatively.
    • 3. Identifying, then challenging underlying maladaptive attitudes/negative schemas: fundamental maladaptive attitudes explored and challenged.
    • 4. Coping strategies generated to deal with possible depressive episodes after completion of treatment.

First Empirical Study of CBT

  • Rush, Beck et al (1977): First empirical study of CBT, with a second, antidepressant group (imipramine, a ‘tricyclic’ antidepressant).
    • 12 weeks treatment in each case, 20 sessions of CBT.
    • Fairly small initial study: CBT, n=19; Drug, n=22.
    • However, 8 drug dropouts, just one CBT dropout.

CBT: Improved Depression Ratings Maintained

  • Rush, Beck et al (1977):
    • Continued to monitor participants depression scores for 6 months following the end of treatment.
    • CBT’s advantage over imipramine treatment was robustly maintained throughout this time.

Cognitive Behavioral Therapy: Long-Term Follow-Up

  • Hollon et al (2005):
    • Cognitive behavioral therapy (CT) most effective in reducing relapse over the long term, compared with antidepressants (ADM).

CBT vs. Drug Treatment

  • Blackburn et al. (1981): Large follow-up study with 64 participants completing the study.
    • Three groups: CBT, Drug (amitriptyline or clomipramine: tricyclic antidepressants), or CBT/Drug together.
    • 20 weeks treatment, mostly 1 CBT session/week.
    • Drugs least effective, combination treatment most effective.

CBT Applications

  • Mendlowicz et al. 2022: “Cognitive therapy was found to be effective for treating panic disorder and agoraphobia, social phobia, OCD, PTSD, insomnia, and eating disorders.
  • CBT has now become the most commonly practiced and extensively researched form of psychotherapy in the world.

Beck Institute

  • Two years after retiring from the University of Pennsylvania (1992), Beck and his daughter, Dr. Judith Beck, founded the nonprofit Beck Institute for Cognitive Behavior Therapy.
  • Mendlowicz et al 2022: the Beck Institute has trained more than 28,000 health and mental health professionals from 130 countries through both in-person and online programs.
  • On November 1, 2021, Dr. Aaron T. Beck passed away peacefully at the age of 100 in his home in Pennsylvania, surrounded by his family.

Section 3: Clinical Psychology - Career Options

Topics to be covered:

  • Clinical Psychology: Career Options

Learning outcomes:

  • Appreciate the key role of cognitive behavioral therapy in a clinical psychologist’s repertoire.
  • Relate the two main routes to becoming a clinical psychologist.

Clinical Psychologist: Work Settings

  • Health and social care settings (e.g., hospitals, health centers, community mental health teams, Child and Adolescent Mental Health Services (CAMHS), and social services).
  • Usually employed by the NHS in the UK, but may be in private practice.
  • Often as part of a team with other health professionals and practitioners.

Clinical Psychologist: Qualification

  • Firstly, do a BPS-accredited degree.
  • Then, apply for a Doctorate Course; there are two main routes:
    • Via the Clearing House for Postgraduate Training Courses in Clinical Psychology for courses nationally.
    • Directly through the University of Hull.
  • Register with the Health and Care Professions Council (HCPC) and perhaps also become a Chartered Member of the BPS.

Bangor University – North Wales Clinical Psychology Programme

  • Course: 3 years.
  • Accredited by the BPS and approved by the HCPC.
  • Entry Requirements:
    • 2:1 is required with an average for final year module marks of 60% or higher.
    • At least one year of relevant paid clinical/research experience is required.
  • Top-listed approach: Cognitive Behavioral Therapy.
  • Residence: You need to be eligible for home fees status.
  • Placements:
    • Most placements are located in Betsi Cadwaladr University Health Board and stretch from Wrexham to Pwllheli, and Holyhead to Dolgellau.
    • Due to the challenges of public transport in rural areas and the extensive travel distances, having access to your own transport will be required.

University of Hull: Clinical Psychology Doctorate

  • Course: 3 years, accredited by the BPS and approved by the HCPC.
  • Entry requirements:
    • Clinical Modules in the Final Year of your degree, and at least a 2.1 Degree result.
    • ”Applicants are not required to have lengthy pre-training clinical experience. However, we do expect to see evidence of commitment to clinical psychology, such as voluntary work or other experience with vulnerable people.”
  • Top-listed approach: CBT (Advanced module title: Clinical Psychology & Applications of Cognitive Behavioral Therapy).
  • Advantages:
    • Employed by the NHS as a trainee clinical psychologist, so get paid a salary and fees paid.
    • Fast-track entry: Straight from Uni.
  • Disadvantages:
    • Very competitive, only a minority who apply for clinical modules in final year go to Hull.

Doctorate Funding and Eligibility

  • Hull:
    • As the Doctorate is funded by the NHS, to apply you must be from the UK or have the right to work in the UK under the EU settlement scheme (EUSS) without restriction.
  • Bangor:
    • Not able to consider you if you qualify for overseas fee status.