panic (clark, 1986) social phobia (clark & wells, 1995) health anxiety (salkovskis &...
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• Panic (Clark, 1986)• Social Phobia (Clark & Wells, 1995)• Health Anxiety (Salkovskis & Warwick, 1986)• OCD (Salkovskis, 1994)• GAD (Wells, 1997)• PTSD (Ehlers & Clark, 2000)• Depression (Beck, 1967)
See also Core CBT Competencies list for recommended models:
http://www.ucl.ac.uk/clinical-psychology/CORE/CBT_Competences/CBT_Competences_Map.pdf
Disorder specific models
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A vicious circle model of phobic anxietySituational Trigger
PhysiologicalHeart thumping
SweatingTrembling etc.
BehaviouralRunning away
“freezing” Shouting for help etc.
Subjective“I might fall”
“This is terrible”Fear, embarrassment etc.
Symptoms
Reactions
PhysiologicalHeart thumping
etc.Fatigue
BehaviouralAvoidance, withdrawing
from demanding or pleasurable activities
Subjective“I can’t cope”
“I must get out”Lowered confidence worry,
frustration, fear
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A cognitive-behavioural model for the maintenance of specific phobiasVomiting is unbearably awful and
terrible for me
AvoidanceEncountering the phobic object / situation
Catastrophic beliefs
Autonomic arousal
Pre-attentive activation
High degree of conviction Escape or safety behaviour
Prevents disconfirmation
The catastrophe does not occur and anxiety reactions dissipate
Conclusion drawn: The escape / safety behaviour prevent the catastrophe
The catastrophic belief is confirmed
The phobia remains unchanged© Think CBT Ltd. [email protected] 01732 808 626 www.thinkcbt.com
A model of the development and maintenance of specific phobiasDevelopment
Biological preparedness, disposition, developmental stage, culture, experience (classical conditioning, vicarious learning), memories/images, beliefs
AssumptionsWith increased vulnerability to
TriggerFrightening object or situation
Anxious Cognitions(thoughts and images concerning stimulus)
OVERESTIMATING THREAT AND CONSEQUENCES/ UNDERESTIMATING COPING AND RESCUE
Anxious mood
Increasingly anxious cognitions about external triggers
Safety behaviours(related to anxious thoughts about external
trigger)
Physiological symptoms
Anxious cognitions about symptoms(fear of fear)
Safety behaviours(related to fear of fear)
Hyper vigilance about physical
symptoms
Secondary cognitions
Depression, hopelessness, loss of confidence, low self-esteem
From Chapter 8 of Oxford Guide to Behavioural Experiments in Cognitive Behaviour Therapy (Kirk & Rouf)© Think CBT Ltd. [email protected]
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Cognitive model of social phobia [Clarks and Wells (1995) and Wells and Clark (1997)]
Social Situation
Activates assumptions
Perceived social danger(negative automatic thoughts)
Processing of Self as a Social Object
Safety behaviours
a
Somatic & cognitive symptoms
Wells, A., 1997. Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide.Chichester: John Wiley & Sons Ltd.
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Cognitive cycle of fear for panic disorderBiological
Vulnerability
Alarm reaction Tachycardia, dyspnea,
chest pain, depersonalisation etc.
Stressful Events
Catastrophic thoughts“Oh, oh, oh..”
“I’m gonna die, pass out”
“Fall down, going crazy”
ConductRunning away, escaping
Hyper surveillanceAvoidance
Anticipatory Anxiety
Increase in anxietyIncrease in symptoms
FEAR
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A cognitive model of OCD(Wells 1997, p.242)
Trigger
Activates Meta-Beliefs
Appraisal ofIntrusion
Belief about rituals
Behavioural Response Emotion
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Cognitive Model of OCD (Salkovskis)
Intrusive thoughts, images, urges, doubts
Misinterpretation of significance of intrusions –
responsibility for actions
Neutralising actions (rituals,
reassurances etc.)
Attention and reasoning biases
(looking for trouble)
Mood Changes (distress, anxiety,
depression)
Counterproductive “safety” strategies (though suppression, impossible criteria,
avoidance etc.)
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5 Part Cognitive Behavioural Therapy Model
Environment
Thoughts
Emotions
Physical
Behaviours
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Cognitive Conceptualisation Diagram (Judith Beck, 1993)
Relevant Childhood Data
Core Belief(s)
Conditional Assumptions/Beliefs/Rules
Compensatory Strategies
Situation 1
Behaviour
Automatic Thought
Meaning of the A.T.
Emotion
Situation 2
Behaviour
Automatic Thought
Meaning of the A.T.
Emotion
Situation 3
Behaviour
Automatic Thought
Meaning of the A.T.
Emotion
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A Cognitive Model of Hypochondriasis (Adapted from Salkovskis, 1989; Warwick and Salkovskis, 1990)
Previous Experience
Dysfunctional Schemas Formed
Critical Incident
Activates Schemas
Negative Automatic Thoughts
CognitiveSelective Attention
RuminationSelf-Focus
Thinking Errors
AnxietyDepression
Anger
BehaviourReassurance Seeking
AvoidanceBodily checking
safety / preventionPhysiological Changese.g Increased Arousal
Bodily SensationsSleep Disturbance
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How did “the problem” develop?What made me
vulnerable in the first place? Triggers for the most
recent episode
Positive things that I’ve got going for me
Things that keep “the problem” going(These might include things that I do
to control the problem)
“The problem”
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“The Vicious Flower” Cognitive Model of OCD (Salkovskis, Forrester & Richards, 1998)
Early ExperiencesMaking you vulnerable to OCD
Critical IncidentsWhat started the OCD off
Activates
Assumptions, General BeliefsE.G Not preventing disaster is as bad as making it happen
Better safe than sorry
Intrusive Thoughts, Images, Urges, Doubts
Misinterpretations of significance of intrusions
– responsibility for action
Attention and Reasoning Biases
Looking for trouble
Mood ChangesDistress, anxiety,
depression
Counterproductive “Safety” Strategies
Thought suppression, impossible criteria
Neutralising ActionsRituals, reassurance,
mental argument
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Depression Model (Beck 1967, 1976)
Early Experiences
Core Beliefs and Assumptions
Critical Incident
Assumptions Activated
Negative Automatic Thoughts
Symptoms of Depression
Behavioural Motivational Affective Cognitive Somatic© Think CBT Ltd. [email protected]
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Depression (Westbrook, Kennerley & Kirk, 2007)
Depressed Mood
Negative thinking & Physical symptoms
such as fatigue, poor concentration etc.
More Negative view of self
Nothing Changes
Loss of pleasure &
achievement
Reduced coping & problem-
solving
Reduced Activity
Increased hopelessness
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Anxiety Maintenance (Westbrook, Kennerley & Kirk, 2007)
Internal or external event
1. Perceived threat:Exaggerated and/or inappropriate
2. Client’s best attempt to protect him/herself from threat
3. Strategy gives short-term relief, but fails to challenge the anxiety-related belief
4. Fear remains intact: the alarming belief is unchanged
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Morrey, 2010
Depression Mode
Negative view of self, world
and future
1. Automatic Negative thinking
2. Ruminations and self- attacking
3. Motivation and Physical symptoms
4. Unhelpful behaviours
5. Mood / emotion
6. Withdrawal and avoidance
DEPRESSION© Think CBT Ltd. [email protected]
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Cognitive-Behavioural Model of Body Dysmorphic Disorder (Veale, 2001)
Trigger(e.g. reflection)
Processing of self as an
aesthetic object
Negative appraisal of internal body
image
Mirror-checking and selective attention
Mood (depression &
disgust)
Rumination on ugliness or
“defectiveness” and comparison
to ideal
Avoidance and safety
behaviours to change or
camouflage appearance
Mirror checking
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What made me vulnerable in the first place
Core Beliefs – about myself, others and the world
Rules I live by…Helpful Unhelpful
Current Problem
What triggered the problem
What helps me copeHelpful Unhelpful
What maintains the problem nowThoughts
Physical sensations EmotionsBehaviours
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Cognitive Model of Postnatal Depression[Milgrom A., Martin P.R., Negri L.M (1999) Treating Postnatal Depression: A psychological Approach for
Health Care Professionals. Wiley. Chichester. Adapted from Beck’s Cognitive Model of Depression (1979)]
Vulnerability Factors
Precipitating Factors, including Biological Factors
Cultural Factors
Post Natal Depression
Depression and other emotions
Anxiety, Anger, Sadness
Mediational Cognitive Factors
Negative Automatic ThoughtsPoor parenting self-efficacy(mediational = appraisal process)
Behaviour / Coping Strategies
Lethargy, Indecision, Social Withdrawal, Martial Conflict,Difficulty dealing with infant
Exacerbating & maintaining factors
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Diagnosis / symptoms
Formative influences
Situation / interpersonal issues
Biological, genetic and medical factors
Strengths / assets
Typical automatic thoughts, emotions and behaviours
Underlying schemas
Working hypothesis
Treatment Plan
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“Vicious Flower” Generic conceptualisation (Salkovskis, Warwick and Deal 2003)
Threat Appraisal Meaning
Anxiety
Images
Memories
SelectiveAttention
Worry Processes
PhysicalSensations
SafetyBehaviours
Events, Stimuli,
Situations© Think CBT Ltd. [email protected] 01732 808 626 www.thinkcbt.com
Clark’s cognitive model of panic with maintenance cycles added (adapted from Clark, 1986)
INTERNAL / EXTERAL TRIGGER
PERCIEVED THREAT
ANXIETY(Emotions)
PHYSICAL / COGNITIVE SYMPTOMS
MISINTERPREATION
AVOIDANCE AND SAFETY BEHAVIOURS
(Including Selective Attention)© Think CBT Ltd. [email protected] 01732 808 626 www.thinkcbt.com
A cognitive Model of GAD (Wells, 1995)
Trigger
Positive meta-beliefs activated (Strategy
Selection)
Type 1 Worry
Negative meta- beliefs activated
Type 2 Worry (Meta-worry)
Behaviour
Thought control
Emotion
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Cognitive-behavioural model of generalized anxiety disorder[From Dugas, M.J., Gagnon, F., Ladoucer, R. & Freeston, M.H. (1998) Generalized Anxiety Disorder: A
preliminary test of a conceptual model. Behaviour Research and Therapy, 36, 215-226]
Situation
Life Events
Mood State
What if..?
Positive beliefs about worry
Worry
AnxietyNegative problem
orientation
Cognitive avoidance
Demoralization Exhaustion© Think CBT Ltd. [email protected]
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Low Self-Esteem: A Map of the territory (Fennell, 1999)
(Early) ExperienceEvents, relationships, living conditions which have implications for ideas about the self
The Bottom LineAssessment of worth/ value as a person
Conclusions about the self, based on experience: this is the kind of person I am
Rules for livingGuidelines, policies or strategies for getting by, given the truth of the Bottom Line
Standards against which self-worth can be measured
Trigger SituationsSituations in which the Rules for Living are, or may be, broken
Activation of the Bottom Line
Negative Predictions
Unhelpful behaviour
Confirmation of the Bottom Line
Self-critical thoughts
Depression
Anxiety
How
Low
Sel
f-es
teem
Dev
elop
sW
hat k
eeps
Low
Sel
f-es
teem
Goi
ng
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Based on Wells 1997, adapted by Stopa
Social Situation
Thoughts
1. What went through your mind at that time? What was the worst you thought could happen? What did you think
people would notice / think about you? What would that mean/ what would be so bad about that?
Anxiety Symptoms
2. When you thought (feared
event) might happen, what did
you notice happening in your
body? (Suggest symptoms of
anxiety)
Safety Behaviours
3. As you became anxious, and thought that
(feared event) might happen, did you do anything to
try to prevent it from happening?
Did you do anything to try to prevent people from noticing?
Self-focus
4. When you are afraid (feared event) will happened what happens to your attention? Do you become more self-conscious? As you focus on yourself, what do you notice? Do you have an image of how you feel you are
coming across? What does that look like?
5. As you did (safety behaviours) did that
make you focus more or less attention on
yourself?
6. As you noticed yourself becoming more anxious, what effect did
that have on your attention?
7. When you did (safety behaviours)what effect did that have on your anxiety?
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Arrows indicate the following relationships:Influences = Leads to = Prevents change in =
A. Ehlers., D.M Clarke. (2000) A Cognitive Model of posttraumatic stress disorder. Behaviour Research and Therapy 38, p. 319-345
Characteristics of trauma / Sequelae Prior Experiences/ Beliefs/ Coping
State of individual Influences
Cognitive Processing
during Trauma
Nature of Trauma Memory Negative Appraisal of Trauma and / or its Sequleae
Current ThreatIntrusions
Arousal SymptomsStrong Emotions
Matching Triggers
Strategies Intended to Control Threat / Symptoms
PERSISTENT
PTSD
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A cognitive-behavioural model for the maintenance of specific phobiasVarious objects / situations are perceived as
potentially harmful
AvoidanceEncountering the phobic object / situation
Catastrophic beliefs
Autonomic arousal
Pre-attentive activation
High degree of conviction Escape or safety behaviour
Prevents disconfirmation
The catastrophe does not occur and anxiety reactions dissipate
Conclusion drawn: The escape / safety behaviour prevent the catastrophe
The catastrophic belief is confirmed
The phobia remains unchanged© Think CBT Ltd. [email protected] 01732 808 626 www.thinkcbt.com
• Safety Behaviours (e.g. OCD client)
Maintaining Cycles
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• Reduced activity (depressed client)
Maintaining Cycles
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• Perfectionism (e.g. depressed client)
Maintaining Cycles
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• Catastrophic Misinterpretation (e.g. panic client)
Maintaining Cycles
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• Scanning/hypervigilence (e.g. health anxiety client)
Maintaining Cycles
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• Escape/avoidance (e.g. social anxiety)
Maintaining Cycles
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• Fear of fear (e.g. GAD client)
Maintaining Cycles
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• Performance Anxiety
Maintaining Cycles
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• Self-fulfilling prophecies
Maintaining Cycles
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‘Vicious Flower’ model(Salkovskis, Warwick & Deale, 2003)
Images
Threat Appraisal/Meaning
Memories
Selective Attention
Safety Seeking Behaviours
Events, stimuli, situations
Physical Sensations
Worry Processes
Emotion
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‘Vicious Flower’ model(Salkovskis, Warwick & Deale)
Standing in the corner at party, looking odd, wild staring eyes,
drenched in sweat. People laughing and pointing School – called
‘weirdo’. Ignored. Told I had staring eyes.
Mocked
Focus on self & howI appear. Ignore any
friendly remarks fromothers (‘just being kind’)
Hold arms down to hide sweat; avoid eye contact. Avoid parties or stay in kitchen out of the way & leave early. Cross road to avoid people. Look at road. Keep eyes semi-closed
Parties, social occasions, memories of social events
Sweating, restlessness, shaky hands
Rumination; thinking over past events
(what went wrong) and rehearsing
future ones (what to say, etc)
Anxiety; panic
People think I am weird; I will end up rejected and alone
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Depression Mode
Negative view of self, world
& future
6 Cycles Maintenance Model – A ‘Vicious Flower’ for Depression (Moorey, 2010)
6. Motivation and physical symptoms
5. Unhelpful behaviours
4. Withdrawal and avoidance
1. Automatic negative thinking
2. Ruminations & self attacking
3. Mood/emotion
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Longitudinal Formulation
Early experience
Core beliefs/assumptions
Critical Incident(s)
Activation of beliefs/ assumptions
Negative Automatic Thoughts (NATs)
Feelings Physical
Behaviour
Depression:
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Longitudinal Formulation
Deprived of affection; Lack of attention vs. siblings
There’s something wrong with me; I’m unlovable
Break up of relationship
Activation of beliefs/ assumptions
I’m unlovable, If I get into relationship it goes wrong
Upset Lethargic, heavy
Withdraw
Depression:
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Longitudinal FormulationAnxiety: Learning Experience
Danger Schemas Formed
Critical Incident
Schema Activated
Negative Automatic Thoughts
Anxiety Symptoms
Behavioural Responses
Generic cognitive theory of anxiety disorder Ref: Wells, A. (2007) Cognitive Therapy of Anxiety Disorders. Chichester: John Wiley & Sons
Cognitive Biases
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Longitudinal FormulationAnxiety:
Danger Schemas Formed
Critical Incident
Schema Activated
Negative Automatic Thoughts
Anxiety Symptoms
Behavioural Responses
Generic cognitive theory of anxiety disorder, Wells, A. (2007) Cognitive Therapy of Anxiety Disorders. Chichester: John Wiley & Sons
Cognitive Biases
Highly anxious mother: not allowed out alone until age 16; fear of
abduction, etc)Learning Experience
The world is dangerous; people will harm me; I am vulnerable; worrying
keeps me safe
Neighbour’s house burgled
The world is dangerous(& I am vulnerable)
I will be next; I need to get more locks; I need to have the police’s number handy; what if it happens when I’m
alone at night?Heart pounding; rapid breathing;
sweating; restless; racing thoughts; rumination
Plan escape routes & location of weapons; check locks frequently; have
mobile by bed; buy alarm systemSelective abstraction (neighbour’s
house less secure)Catastrophising
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