Fundamentals of CBT

What is CBT?

  • Definition:

    • CBT is a talking therapy that can be conducted individually or in groups.

  • Characteristics:

    • Time limited: Typically consists of 12-16 sessions.

    • Brief: Each session lasts between 50-60 minutes.

    • Structured: Follows a set framework for therapy.

    • Collaborative: Involves working together with the therapist.

    • Problem-oriented: Focuses on addressing specific issues.

  • Uses:

    • Effective for treating a variety of mental health difficulties.

Why CBT?

Conditions Treated with CBT Include:

  • Generalized anxiety disorder

  • Obsessive-compulsive disorder

  • Panic disorder

  • Social phobia

  • Specific phobias

  • Post-traumatic stress disorder

  • Depression

  • Psychosis (in conjunction with antipsychotic medication)

Guidelines related to these conditions can be explored further.

Thought Experiment

  • Imagine you see a friend in town who does not acknowledge you when you call out and wave.

  • Questions to Consider:

    • What thoughts come to mind regarding their lack of acknowledgment?

    • How does this affect your emotions (both emotionally and physically)?

    • How does this impact your behaviour? What actions will you take in response?

Core Principles of CBT (I)

  • Model Components:

    • Cognitions: Thoughts and beliefs that influence emotion.

    • Affect: Emotional states experienced by the individual.

    • Physiology: Bodily states associated with emotional responses.

    • Behaviour: Actions that result from cognitive and emotional processes.

    • Hot Cross Bun Model: A formulation based on Beck's CBT principles, developed by Padesky & Greenberger (1995).

Core Principles of CBT (II)

  • Example of Cognitions and Responses:

    • Thought: “They are ignoring me”

    • Affect: Sad, anxious, or angry feelings

    • Physiology: Bodily states resulting from emotions

    • Behaviour: Choosing to avoid them next time

Core Principles of CBT (III)

  • Alternative Example of Cognitions:

    • Thought: “They didn’t see me”

    • Affect: No change in emotional state

    • Physiology: No change in bodily sensations

    • Behaviour: Plan to say hello next time

The Cognitive Model

  • Core Idea: You feel the way you think

    • The meaning or interpretation attached to an event directly influences the emotional response.

    • Individuals may interpret the same event differently, leading to varying emotional responses.

Case Example (I)

  • Identification Task:

    • Identify elements of the ‘hot cross bun’ model in given scenarios. Look for evidence indicating a lack of functionality in cognition and behaviour.

Case Example (II)

  • Subject: Sinem, a 42-year-old woman experiencing panic attacks.

  • Symptoms: Panic attacks during shopping led to avoidance of local centers and reduced outings.

  • Family Support: Family members go out to manage her anxiety.

Case Example (III)

  • Incident Recall:

    • Sinem recalls a panic attack at a shopping center seemingly occurring out of the blue.

    • Noticed embarrassment after bumping into a shop assistant, leading to feelings of blushing and a racing heart.

    • Became concerned about fainting and took safety measures by sitting down to monitor her heart rate.

DSM-5: Panic Disorder (I)

  • Criteria for Diagnosis:

    1. Recurrent and unexpected panic attacks.

    2. At least one attack has been followed by one month or more of:

    • Persistent concern about additional attacks.

    • Worry about the implications or consequences of the attack.

    • A significant behavioral change related to the panic attacks.

DSM-5: Panic Disorder (II)

  • Definition of Panic Attack:

    • Defined as a period of intense fear or discomfort, with four or more symptoms developing abruptly and reaching a peak within 10 minutes:

    • Palpitations

    • Sweating

    • Trembling or shaking

    • Shortness of breath

    • Feeling of choking

    • Chest pain or discomfort

    • Nausea or abdominal distress

    • Feeling dizzy, unsteady, lightheaded, or faint

    • Derealization (feelings of unreality)

    • Fear of losing control or “going crazy”

    • Fear of dying

    • Paresthesias (numbness/tingling)

Catastrophic Misinterpretation

  • Definition:

    • The tendency to interpret bodily sensations as indicative of impending biological (e.g., death), mental (i.e., insanity), or behavioral (e.g., loss of control) disasters.

  • Examples:

    • “I'm having chest pain; I must be having a heart attack!”

    • “I am shaking; I can't handle this; I'm going to lose control and go crazy!”

Cognitive Model of Panic Disorder (Clark, 1986, I)

  • Common Coping Mechanisms:

    • Extensive safety-seeking and avoidance strategies are prevalent. They are often misguided attempts to prevent an impending disaster, such as a panic attack.

  • Examples of Avoidance:

    • Avoiding crowded spaces due to fear of panic attacks

    • Frequently asking friends to validate physical sensations

    • Carrying a water bottle as a safety measure

    • Taking medication preventively

    • Exiting meetings or social events abruptly when feeling anxious

    • Avoiding exercise due to fear of inducing panic-like symptoms

Cognitive Model of Panic Disorder (Clark, 1986, II)

  • Panic Formulation Breakdown:

    • Trigger: External situation or slight physical sensation, such as a memory of a previous panic attack

    • Emotional Response: Recognizing physical sensations that occur

    • Thoughts (interpretation/beliefs): Developing thoughts associated with the sensations

    • Safety Behaviours: Strategies used to maintain feelings of security, e.g., what can I do to keep myself safe?

Cognitive Model of Panic Disorder (Clark, 1986, III)

  • Example of Panic Formulation:

    • Trigger: Burning face and racing heart

    • Thoughts: “I am going to panic”

    • Feelings: Anxiety and fear

    • Physical Sensations: Breathlessness, light-headedness

    • Interpretation/Beliefs: “I am going to faint or die”

    • Safety Behaviours: Sitting down and monitoring heart rate

Treatment for Panic Disorder

  • Step 2: Treatment for mild to moderate panic disorder

    • Use of facilitated or non-facilitated self-help strategies.

  • Step 3: Treatment for moderate to severe panic disorder

    • Implementing CBT sessions spanning 7 – 14 hours.

    • Use of antidepressants if the disorder is long-standing or if no benefit from psychological intervention has been observed (patient choice).

    • Reference to Clinical guidance on managing generalized anxiety and panic disorder in adults (Clinical guideline [CG113]).

Techniques Used in CBT

  • Key Role of CBT Therapist:

  1. Helping clients identify thoughts negatively impacting feelings and behaviours.

  2. Identifying behaviours affecting thoughts and feelings.

Key Stages of CBT:

  1. Psychoeducation:

    • Education about cognitive explanations for recurring panic attacks.

    • Presenting alternative explanations for panic attacks, creating a rationale for treatment.

    • Sharing cognitive formulation diagrams.

    • Normalizing experiences by providing information about symptoms.

    • Homework assignment involving panic logs.

  2. Cognitive Techniques:

    • Address thoughts like “I am going to die,” “I will pass out,” or “I am having a heart attack.”

    • Introduce conflicting evidence while offering alternative explanations to loosen beliefs for effective behavioural changes.

  3. Behavioural Techniques:

    • Implement planned experiential activities based on observations or experimentation.

    • Aim to test and construct new adaptive beliefs, contributing to cognitive formulation.

Cognitive Techniques

  • Cognitive Techniques Examples:

    • Client beliefs such as:

    • “I am going to die.”

    • “I will pass out.”

    • “I am having a heart attack.”

    • Aim:

    1. Elicit evidence in support of the belief.

    2. Examine that evidence critically.

    3. Elicit evidence against the belief to emerge alternative coping strategies.

Cognitive Techniques Cont.

  • Theory A and Theory B Technique:

    • Theory A: Belief that there will be a heart attack.

    • Theory B: The worry about having a heart attack.

  • Evidence Gathering Exercise Examples:

    • For Theory A: Look for real evidence supporting this belief.

    • For Theory B: Reflect on situations where threats did not materialize and identify alternative actions based on this belief system.

Behavioural Experiments

  • Definition:

    • Planned experiential activities to test existing beliefs and construct new adaptive beliefs.

  • Aims:

    • Validates existing beliefs about oneself and the world.

    • Assists in developing more adaptive beliefs.

    • Enhances cognitive formulation verification (Bennett-Levy et al., 2004).

Behavioural Experiment Record Sheet

  • Components of Record Sheet Include:

    • Date

    • Target cognition(s)

    • Experiment description

    • Prediction(s) of outcomes

    • Actual outcomes

    • Observations and reflections on outcomes regarding original beliefs.

    • Rate belief in cognitions (percentage scale 0-100%).

Example Entry:

  • Cognition Tested:

    • “I feel really unwell; I am going to have a heart attack unless I rest.” (90% belief)

  • Experiment Planned:

    • Go running in the park instead of resting.

  • Outcome Summary:

    • Successfully ran further than expected without health issues, leading to modified belief to 30% on the original anxiety.

Characteristics of CBT

  • Overall Structure:

    • Time-limited (12-16 weeks).

    • Starts with formulation.

    • Involves cognitive and behavioural work in the middle.

    • Concludes with therapy blueprint used for reinforcing gains and relapse prevention.

  • Session Structure:

    • Begins with a collaboratively set agenda.

    • Assessment of mood and discussion of homework tasks.

    • Plans for next homework assignment and session feedback.

Critical Evaluation – Does it Work?

  • Effectiveness Statistics:

    • Response across disorders averaged 49.5% post-treatment and 53.6% at follow-up.

    • IAPT services in the NHS aim for at least a 50% recovery rate after treatment.

Critical Evaluation – Does it Work? (II)

  • Comparative Analysis:

    • CBT and medication found equally effective for treating depression and anxiety according to studies (DeRubeis et al., 2008; Roshanaei-Moghaddam et al., 2011).

    • Suggests diverse treatment options available for patients according to NICE guidelines, especially for moderate to severe panic disorder.

Recap

  1. Introduction to CBT:

    • Recognised treatment methodology as recommended by NICE for various mental health disorders, prevalent in NHS offerings.

  2. Cognitive and Behavioural Techniques:

    • Explained how beliefs shape thoughts and feelings.

  3. CBT Formulation of Panic Cycle and Treatment:

    • Illustrations of CBT panic formulations alongside cognitive and behavioural techniques used in practice.

  4. Critical Evaluation:

    • Discussions on the effectiveness of CBT treatments.

Useful Additional References/Further Reading

  • Bennet-Levy, J., Butler, G., Fennell, M., Hackmann, A., Mueller, M., & Westbrook, D. (Eds) (2004). The Oxford Guide to Behavioural Experiments in Cognitive Therapy. Oxford: Oxford University Press.

  • Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461-470.

  • DeRubeis, R., Siegle, G., & Hollon, S. (2008). Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms. Nat Rev Neurosci, 9, 788–796.

  • Padesky, C., & Greenberger, D. (1995). Clinician’s Guide to Mind Over Mood. New York: Guildford Press.

  • Roshanaei‐Moghaddam, B., Pauly, M.C., Atkins, D.C., Baldwin, S.A., Stein, M.B., & Roy‐Byrne, P. (2011). Relative effects of CBT and pharmacotherapy in depression versus anxiety: is medication somewhat better for depression, and CBT somewhat better for anxiety? Depress. Anxiety, 28, 560-567.