Depression & Anxiety Disorders: Cognitive Behavioural Models, Assessment & Treatment

Defining Depression and Anxiety Disorders

Mood Disorders

  • Mood disorders are a group of diagnoses characterized by a disturbance in a person's mood as the main underlying feature.
  • There are two main groups: depressive disorders and bipolar disorders, differentiated by the presence or absence of manic or hypomanic episodes.

Major Depressive Disorder (DSM-5)

  • Diagnostic criteria include five or more of the following symptoms present during the same two-week period, representing a change from previous functioning; at least one symptom must be either depressed mood or loss of interest or pleasure:
    • Depressed mood most of the day, nearly every day (e.g., feeling sad, empty, hopeless)
    • Markedly diminished interest or pleasure in all or almost all activities most of the day, nearly every day
    • Significant weight loss (when not dieting) or weight gain
    • Insomnia or hypersomnia nearly every day
    • Psychomotor agitation or retardation nearly every day
    • Fatigue or loss of energy nearly every day
    • Feelings of worthlessness or excessive or inappropriate guilt
    • Diminished ability to think or concentrate or indecisiveness nearly every day
    • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan
  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Bipolar and Related Disorders

  • Include Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder, Substance/Medication-Induced Bipolar and Related Disorder, Bipolar and Related Disorder Due to Another Medical Condition, Other Specified Bipolar and Related Disorder, and Unspecified Bipolar and Related Disorder.
  • During depressive periods ("the lows"), symptoms include sadness, loss of energy, feelings of hopelessness or worthlessness, loss of enjoyment, difficulty concentrating, uncontrollable crying, difficulty making decisions, irritability, increased need for sleep, changes in appetite, and thoughts of death or suicide.
  • Symptoms of mania ("the highs") include excessive happiness, sudden changes from joy to irritability, restlessness, rapid speech and poor concentration, increased energy and less need for sleep, high sex drive, tendency to make grand plans, poor judgment, drug and alcohol abuse, and increased impulsivity.

Anxiety Disorders

  • Anxiety is a normal response to stress or danger, such as feeling fearful when confronted by an angry stranger, or unease during exams or job interviews.
  • The anxiety response is a normal, vital reaction to threat, involving freeze, fight, or flight responses.
  • Anxiety is an adaptive response to real threat/danger, while fear is the emotional response to real or perceived imminent threat. Anxiety is anticipation of future threat.
  • Anxiety disorders involve excessive fear and anxiety, and related behavioral disturbances, out of proportion to objective danger, resulting in significant distress and/or interference in core areas of functioning.
  • Anxiety disorders occur because people believe situations to be more dangerous than they really are.
    • Four components:
      • Physical: activation of sympathetic nervous system and hormonal system (fight-or-flight)
      • Cognitive: unrealistic thoughts (exaggerated danger, fear losing control)
      • Emotional: terror, panic, irritability
      • Behavioral: coping (e.g., avoidance)

Commonly Occurring Anxiety Disorders (DSM-5)

  • Specific Phobia
  • Social Anxiety Disorder (Social Phobia)
  • Panic Disorder
  • Agoraphobia
  • Generalized Anxiety Disorder
  • Separation Anxiety Disorder

Other Anxiety-Related Disorders

  • Trauma and stressor-related disorders: Post-traumatic stress disorder (PTSD)
  • Obsessive-compulsive and related disorders: Obsessive-compulsive disorder (OCD)

Specific Anxiety Disorders

  • Specific Phobia: Marked fear or anxiety about a specific object or situation. For example, fear of snakes, heights, or flying.

Panic Attacks & Panic Disorder (DSM-5)

  • Panic Attack: An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, during which time four (or more) of the following symptoms occur:
    • Palpitations, pounding heart, or accelerated heart rate
    • Sweating
    • Trembling or shaking
    • Sensations of shortness of breath or smothering
    • Feeling of choking
    • Chest pain or discomfort
    • Nausea or abdominal distress
    • Feeling dizzy, unsteady, lightheaded, or faint
    • Chills or heat sensations
    • Numbness or tingling sensations
    • Derealization (feelings of unreality) or depersonalization (being detached from oneself)
    • Fear of losing control or “going crazy”
    • Fear of dying

Agoraphobia

  • Anxiety about being in situations from which escape is difficult or embarrassing, or in which help might not be available in the event of panic or panic-like symptoms (e.g., far from home, crowds, travel).
  • Situations are avoided or cause great anxiety, or need a companion.
  • Not better accounted for by another disorder.
  • Diagnoses: Panic disorder without agoraphobia, Panic disorder with agoraphobia, Agoraphobia without a history of panic disorder

Social Anxiety Disorder(DSM-5)

  • Marked fear or anxiety about one or more social situations in which the individual is exposed to scrutiny by others. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated.
    • Main Features:
      • Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others (e.g., social interactions, being observed, performing in front of others).
      • The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
      • The social situations almost always provoke fear or anxiety.
      • The social situations are avoided or endured with intense fear or anxiety.
      • The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
      • The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Generalized Anxiety Disorder (DSM-5)

  • Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
  • The person finds it difficult to control the worry.
    • Associated with three (or more) of the following six symptoms in adults or 1 of the following in children (with at least some symptoms having been present for more days than not for the past 6 months):
      • Restlessness, feeling keyed up or on edge.
      • Being easily fatigued.
      • Difficulty concentrating or mind going blank.
      • Irritability.
      • Muscle tension.
      • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
    • The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
    • The disturbance is not attributable to the physiological effects of a substance.
    • The disturbance is not better explained by another mental disorder.

Obsessive-Compulsive Disorder (DSM-5)

  • Obsessions: Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive, unwanted, and that in most individuals cause marked anxiety or distress.
    • The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some thought or action (i.e., by performing a compulsion).
  • Compulsions: Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
    • The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation. However, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
  • The obsessions or compulsions are time consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Post-Traumatic Stress Disorder (PTSD) (DSM-5)

  • Criterion A (one required): Exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence via:
    • Directly experiencing the event(s)
    • Witnessing, in person, the event occurring to others
    • Learning that a relative or close friend was exposed to a violent or accidental trauma
    • Repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders, professionals repeatedly exposed to details of child abuse)
  • Criterion B: Presence of one or more of the following intrusive symptoms associated with the event(s):
    • Recurrent, involuntary, intrusive distressing memories associated with the event
    • Recurrent distressing dreams relating to the event
    • Dissociative reactions (e.g., flashbacks) in which the person feels or reacts as if the event was recurring
    • Intense or prolonged psychological distress after exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event
    • Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event
  • Criterion C: Persistent avoidance of stimuli associated with the traumatic event as evidenced by one or both of the following:
    • Avoidance of, or efforts to avoid, distressing memories, thoughts, or feelings associated with the trauma
    • Avoidance of, or efforts to avoid, external reminders that arouse distressing memories, thoughts, or feelings related to the trauma
  • Criterion D: Negative alterations in cognitions and mood associated with the trauma, as evidenced by two of the following:
    • Inability to recall an important aspect of the trauma
    • Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
    • Persistent distorted cognitions about the cause or consequences of the event leading to blame of self/others
    • Persistent negative emotional state (e.g., fear, horror, anger, shame)
    • Markedly diminished interest or participation in significant activities
    • Feelings of detachment or estrangement from others
    • Persistent inability to experience positive emotions
  • Criterion E: Marked alterations in arousal and reactivity associated with the event, as evidenced by two of the following:
    • Irritable behavior or angry outbursts
    • Reckless or self-destructive behavior
    • Hypervigilance
    • Exaggerated startle response
    • Problems with concentration
    • Sleep disturbance
  • Criterion F: Duration of the disturbance longer than 1 month
  • Criterion G: Causes clinically significant distress or impairment in functioning
  • Criterion H: Not attributable to the effects of a substance or medical condition

Cognitive-Behavioral Models of Psychological Disorders

Behavioral Approach

  • Behaviour Therapy: Symptoms of psychopathology result from learned reactions to life experiences and that dysfunctional behavior can be acquired through learning.
  • Core principles:
    • Classical conditioning (CC): learning association between two stimuli; conditioned stimulus predicts occurrence of unconditioned stimulus.
    • Operant conditioning (OC): learning a specific behaviour/response where behaviour leads to rewarding or reinforcing consequences.
      • Positive reinforcement: behaviour leads to introduction of desirable stimulus
      • Negative reinforcement: behaviour leads to removal of aversive stimulus
      • Punishment: behaviour leads to introduction of aversive stimulus

Cognitive Approach

  • Psychological problems are associated with negative thoughts and beliefs, information processing biases, and dysfunctional ways of thinking.
  • Albert Ellis and Aaron Beck pioneered this approach
  • Psychopathology results from individuals developing irrational beliefs, dysfunctional ways of thinking, and biased information processing.
  • Emotions and behaviour are strongly influenced by cognitions (thoughts, beliefs, interpretations).
  • Event – not necessarily directly lead to a particular emotion – people react differently; depends on interpretation

Cognitive Principle:

  • How we feel is influenced by how we think.
    Event \rightarrow Cognition \rightarrow Emotion

Cognitive-Behavioral Approaches

  • Linking cognitive and behavioral concepts and approaches
  • Key concept: behavioral responses, as well as biased attentional processes – can serve to inadvertently maintain unhelpful beliefs – prevent disconfirmation of inaccurate beliefs; strengthen beliefs; magnify beliefs.
  • Developing alternative perspectives can reduce distress and perspective change can be achieved by verbal and behavioural methods.
  • CBT Principles
  • The behavioral principle: behavior is crucial in maintaining or changing psychological states. Changing what you do is a powerful way of changing thoughts and emotions.
  • The ‘here and now principle’: the main focus of therapy is on what is happening in the present and the processes which may be maintaining the problem.
  • The ‘interacting systems’ principle: problems are thought of as interactions between various systems; within CBT these are commonly cognition, affect, physiology, behaviour and environment.
  • The ‘Empirical’ principle: it is important to evaluate CBT theory and therapy.
  • The ‘Rational’ principle: the explanations for one’s feelings and behaviours lie in one’s thinking. Therefore irrationality is the source of psychological problems.

Levels of Cognition

  1. Automatic thoughts
  2. Intermediate beliefs: attitudes, rules, assumptions about self / world
  3. Core beliefs: Basic beliefs about ourselves, others, the world

Common Thinking Errors/Biases

  • All or nothing
  • Exaggerated standards/expectations
  • Catastrophizing
  • Selective attention to the negative/threat
  • Over-generalizing
  • Dismissing the positive
  • Magnifying/minimizing
  • Jumping to conclusions
  • Emotional reasoning
  • Personalizing
  • Internalizing/externalizing

Role of Avoidance and Safety Behaviors

  • Behavior is a core factor in maintaining or changing psychological beliefs and states.
  • Avoidance behaviors: complete avoidance of situation; escape; in situation safety behaviours.
  • Safety behaviors: intended to protect people from threat or prevent harm - may reduce anxiety in the short term but have unintended consequence of maintaining anxiety in the longer term
  • Attentional processes: scanning; biased attention/hypervigilance for threat

Generic CBT Model of Problem Development and Maintenance

Experiences \rightarrow Beliefs and assumptions \rightarrow Critical incidents \rightarrow Cognitions: Thoughts and beliefs \rightarrow Affect: Emotional states \rightarrow Behaviours \rightarrow Physical/Bodily states

Cognitive-Behavioral Models of Depression

  • Longitudinal Model of Depression
    Early Experience \rightarrow Core Beliefs \rightarrow Rules and Assumptions \rightarrow Critical Incident(s) \rightarrow Beliefs Activated \rightarrow Negative Automatic Thoughts \rightarrow Feelings, behaviours, physiology

Beck's Cognitive Triad

  • Negative views about oneself: "I'm worthless and inadequate"
  • Negative views about the world: "Everyone is against me because I'm worthless"
  • Negative views about the future: "I'll NEVER be good at anything"

Maintaining Cycles: Depression and Reduced Activity

Depressed mood \rightarrow Negative Thoughts \rightarrow Loss of Positive Rewards \rightarrow Reduced activity

Behavioral Models of Depression

  • Vicious and positive cycles of activity leading to feeling low or better, respectively.

Vicious Flower for Depression

  • Depression Mode: motivation and physical symptoms, unhelpful behaviours, withdrawal and avoidance, ruminations and self attacking, mood/emotion

Cognitive-Behavioral Models of Anxiety

Cognitive Models of anxiety

  • Assumption that situation is causing anxiety but actually our appraisal of situation is key