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University of Dhamar

Definition of CBT
Cognitive Therapy is a system of psychotherapy that attempts to reduce excessive emotional reactions and self-defeating behaviours, by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions • * Focused form of psychotherapy based on a model suggesting that psychiatric/psychological disorders involve dysfunctional thinking • The way an individual feels and behaves in influenced by the way s/he structures his experiences • Modifying dysfunctional thinking provides improvements in symptoms and modifying dysfunctional beliefs that underlie dysfunctional thinking leads to more durable improvement • Therapy is driven by a cognitive conceptualization and uses

Environment Body Psych: Cognition Emotions Behaviou r

INPUT Brain receives input from sense organs and filters out irrelevant data; also called “perception” PROCESSING Brain sorts, organizes, stores, compares, categorizes, foresees, plans, formulates using the incoming information (thinking) OUTPUT Brain controls and produces output as a verbal statement or other behavior that is hopefully an adaptive response to the original input

• Meanings we take from what happens around us or within us (words or images) • Happen spontaneously in response to situation • Brief, frequent, habitual – often not heard • Do not arise from reasoning • No logical sequence • Plausible and taken as obviously true, especially when emotions are strong • Hard to turn off • May be hard to articulate

Automatic thoughts

• Cognitive distortions: Errors in interpretation that involve faulty content of thoughts and can be associated with changes in mood and behavior • Cognitive deficits: Information processing operations that are missing or working poorly

Cognitive distortions
• Jumping to conclusion without supporting evidence (arbitrary inference) • Holding unrealistic EXPECTATIONS for a given situation
Expecting self, others or situation to be perfect Pessimism: expecting things to always go wrong Dichotomous thinking (“black and white” or “all or nothing” thinking) Emotional reasoning Distorting the MAGNITUDE of a situation: – Selective abstraction – Catastrophizing, Magnifying – Overgeneralizing – – – –

– Labelling--You identify with your shortcomings.
• Making the wrong ATTRIBUTION for a situation:
– Assuming the wrong intent for another person’s actions – Assuming the wrong locus of control in a given event

– Personalization (Excess responsibility) or blaming others

Cognitive Deficits
– Problems with sensory perception – Inability to filter out irrelevant stimuli – Problems attending to relevant stimuli

– – – – – – – Problems comparing information Incorrect labeling or categorizing stimuli Poor memory capacity or retrieval Slow processing speed Problems following a sequence Problems with foresight or planning Inability to use internal language or “self-talk”

Schemas (Core believes)
• “stable cognitive patterns” that actively “screen, code, categorize, and evaluate stimuli” in our environment. • Those hypothetical organizing structures that guide our processing of the overwhelming number of stimuli that impinge on our senses at any given moment.

Early Experiences


Cognitive Model
Beck (1979)

Core Beliefs & Assumptions Critical Incident

Negative Automatic Thoughts (NATS)

Behaviour Physical symptoms


• SZP is: - Frequently associated with impairments of cognition, emotion, volition, behavior, somatic, educational and socioeconomic functioning - Prodromal, Acute, Residual and Remission phases, - Comorbidity: Anxiety disorders, depressive disorders, substance abuse - Biologically determined and psychotherapy was thought to has no benefit and could be harmful - NICE (2002) - ‘Psychological interventions should play a key role in the treatment of schizophrenia. The best evidence is for CBT and Family Intervention (FI)’ - Currently, NICE Guidelines (2003) recommended CBT as a treatment modality for SZP - based on rigorous metaanalysis of ‘high-quality’ RCTs (20)


Clinical Model
• Diathesis-Stress Model (Vulnerability-Stress) • Vulnerability (predisposing factors): 4) Biological factors: hereditary, constitutional or acquired 5) Psychological factors: constitutional or acquired eg: cognitive deficits or maladaptive schemas 6) Social factors * Stress: Precipitating factors (physical, psychological, social) • Symptoms are normal responses to abnormal situations • Psychotic symptoms are the extremes in a continuum of psychological experience * Maintaining factors (physical, psychological, social)

Clinical Model
Bio-psychosocial vulnerability Trigger Biopsychosocial Stressor Emotional Changes Cognitive Anomalous experience

Appraisal of experience as external

Positive symptoms

Maintaining factors

• To reduce the distress and disability caused by symptoms • To improve mood and self-esteem • To improve social-functioning • To reduce psychotic symptoms • To reduce the risk of further relapse • To enhance early identification and prevention

Aim of CBT for SZP

Overview of a typical course of therapy
• Assessment: wider picture, measures • therapeutic relationship • Formulation (ongoing): precipitating factors, maintaining factors, predisposing factors, problem analysis, sharing model, rationale for treatment • Problem list & prioritise (identify specific problem) • Action plan and Goals for therapy (SMART)

- Course of therapy - cont
• Psycho-education • Collaboratively construct a model that makes symptoms and distress understandable and explainable • Develop an alternative, non-psychotic model of experiences that is acceptable and non-stigmatizing • Develop a plausible ‘biases-in-psychological-processing’ explanation of experiences • Connect up seemingly unconnected factors - beliefs, life events, emotions, thoughts, behaviors and symptoms • Normalize the psychotic experience (you are not alone) • Installation of hope

CBT of Hallucinations
• Identify the type of hallucination • Explore associated environment, cognition, emotions, somatic symptoms and behavior • Psycho-education and Normalizing experience • Change the situation • Use behavioral techniques: - Change behavioral responses - Behav. Exps - Exposure • Cognitive techniques

CBT of Delusion
- Direct confrontation should be avoided - Think about the psychological need of the patient - Encourage development of arguments against beliefs by patients - Focus not on the belief but on the evidence for it - Discuss the belief as an assumption not as a fact - Discuss evidence, Cognitive distortions - Alternative explanations - Behavioral Exps

and finally…

It can be done !