Think CBT Conditions Specific Formulations

Disorder specific models
• 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
© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com

A vicious circle model of phobic anxiety
Situational
Trigger
Physiological Behavioural Subjective

Heart thumping Running away “I might fall”
Sweating “freezing” “This is terrible”
Trembling etc. Shouting for help etc. Fear, embarrassment etc.
Symptoms
Reactions
Physiological Behavioural Subjective

Heart thumping Avoidance, withdrawing “I can’t cope”
etc. from demanding or “I must get out”
Fatigue pleasurable activities Lowered confidence worry,
frustration, fear

A cognitive-behavioural model for the maintenance of specific phobias
Vomiting is unbearably awful and
terrible for me
Avoidance
Encountering the phobic object / situation
Pre-attentive
activation
Catastrophic Autonomic
beliefs arousal
High
degree of
conviction Escape or safety behaviour
The catastrophe does not occur and anxiety Prevents

reactions dissipate disconfirmation
Conclusion drawn: The escape / safety

behaviour prevent the catastrophe
The catastrophic belief is confirmed
The phobia remains unchanged

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01732 808 626 www.thinkcbt.com
A model of the development and maintenance of specific phobias
Development
Biological preparedness, disposition, developmental stage, culture, experience (classical
conditioning, vicarious learning), memories/images, beliefs
Assumptions
With increased vulnerability to
Trigger
Frightening object or situation
Anxious Cognitions
(thoughts and images concerning stimulus)
OVERESTIMATING THREAT AND CONSEQUENCES/ UNDERESTIMATING COPING AND

Hyper vigilance
RESCUE
about physical
symptoms
Anxious mood Physiological symptoms
Increasingly anxious cognitions about Anxious cognitions about symptoms

external triggers (fear of fear)
Safety behaviours Safety behaviours

(related to anxious thoughts about external (related to fear of fear)
trigger)
Secondary cognitions From Chapter 8 of Oxford Guide to

Behavioural Experiments in
Cognitive Behaviour Therapy (Kirk
© Think CBT Ltd info@thinkcbt.com Depression, hopelessness, loss of confidence, low self-esteem & Rouf)
Cognitive model of social phobia
[Clarks and Wells (1995) and Wells and Clark (1997)]
Social Situation
Activates assumptions
a
Perceived social danger
(negative automatic thoughts)
Processing of Self as a Social

Object
Safety Somatic & cognitive

behaviours symptoms

Wells, A., 1997. Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide.
Chichester: John Wiley & Sons Ltd.
Cognitive cycle of fear for panic disorder
Biological Stressful
Vulnerability Events
Alarm reaction
Tachycardia, dyspnea,
chest pain,
depersonalisation etc.
Catastrophic thoughts
F “Oh, oh, oh..”
“I’m gonna die, pass
Increase in anxiety
Increase in symptoms
E out”
“Fall down, going crazy”
A
R Conduct
Running away, escaping
Hyper surveillance
Avoidance
Anticipatory Anxiety
A cognitive model of OCD
(Wells 1997, p.242)
Trigger
Activates
Meta-Beliefs
Appraisal of
Intrusion
Belief about
rituals
Behavioural
Emotion
Response

Cognitive Model of OCD (Salkovskis)
Intrusive thoughts, images, urges, doubts Attention and
Neutralising
reasoning biases
actions (rituals,
(looking for
reassurances etc.)
trouble)
Misinterpretation of
significance of intrusions –
responsibility for actions
Counterproductive “safety” strategies Mood Changes

(though suppression, impossible criteria, (distress, anxiety,
avoidance etc.) depression)

5 Part Cognitive Behavioural Therapy Model
Environment
Thoughts
Behaviours Emotions
Physical

Cognitive Conceptualisation Diagram
(Judith Beck, 1993)
Relevant Childhood Data
Core Belief(s)
Conditional Assumptions/Beliefs/Rules
Compensatory Strategies
Situation 1 Situation 2 Situation 3
Automatic Thought Automatic Thought Automatic Thought
Meaning of the A.T. Meaning of the A.T. Meaning of the A.T.
Emotion Emotion Emotion
Behaviour Behaviour Behaviour

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
Cognitive Anxiety Behaviour

Selective Attention Depression Reassurance Seeking
Rumination Anger
Self-Focus Avoidance
Thinking Errors Bodily checking
safety / prevention
Physiological Changes
e.g Increased Arousal
Bodily Sensations
01732 808 626 www.thinkcbt.com Sleep Disturbance
How did “the problem” develop?
What made me
vulnerable in the first
place? Triggers for the most
recent episode
“The problem”
Things that keep “the problem” going

(These might include things that I do
to control the problem)
Positive things that

I’ve got going for me

“The Vicious Flower” Cognitive Model of OCD (Salkovskis, Forrester & Richards, 1998)
Early Experiences Critical Incidents

Making you vulnerable to OCD What started the OCD off
Activates
Assumptions, General Beliefs

E.G Not preventing disaster is as bad as making it happen
Better safe than sorry
Intrusive Thoughts, Images,

Urges, Doubts
Attention and
Neutralising Actions
Reasoning Biases
Rituals, reassurance,
Looking for
mental argument
trouble
Misinterpretations of
significance of intrusions
– responsibility for
action
Counterproductive
Mood Changes
“Safety” Strategies
Distress, anxiety,
Thought suppression,
depression
impossible criteria

Depression Model
(Beck 1967, 1976)
Early Experiences
Core Beliefs and Assumptions
Critical Incident
Assumptions Activated
Symptoms of Depression
Behavioural Motivational Affective Cognitive Somatic

Depression (Westbrook, Kennerley & Kirk, 2007)
Increased Depressed
hopelessness Mood
Loss of Negative thinking &

pleasure & More Negative Physical symptoms
achievement view of self such as fatigue, poor
concentration etc.
Reduced
Activity
Nothing
Changes
Reduced
coping &
problem-
solving
Anxiety Maintenance
(Westbrook, Kennerley & Kirk, 2007)
1. Perceived threat:
Internal or
Exaggerated and/or
external event
inappropriate
4. Fear remains intact: 2. Client’s best

the alarming belief is attempt to protect
unchanged him/herself from
threat
3. Strategy gives short-

term relief, but fails to
challenge the anxiety-
related belief

Morrey, 2010
1. Automatic
Negative thinking
2. Ruminations
3. Motivation and self-
and Physical attacking
symptoms Depression
Mode
Negative view
of self, world
and future
4. Unhelpful 5. Mood /
behaviours emotion
6. Withdrawal
and avoidance

DEPRESSION
Cognitive-Behavioural Model of Body Dysmorphic Disorder (Veale, 2001)
Trigger
(e.g. reflection)
Mirror-checking and
selective attention
Negative appraisal Processing of

Mirror checking of internal body self as an
image aesthetic object
Avoidance and
Rumination on
safety
Mood ugliness or
behaviours to
(depression & “defectiveness”
change or
disgust) and comparison
camouflage
to ideal
appearance © Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com
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 cope

Helpful Unhelpful
What maintains the problem now

Thoughts
Physical sensations Emotions
Behaviours
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 Cultural

Factors
Precipitating Factors,
including Biological Factors
Exacerbating & maintaining factors

Post Natal Depression
Depression and other

emotions
Anxiety, Anger, Sadness
Mediational Cognitive Behaviour / Coping

Factors Strategies
Negative Automatic Thoughts Lethargy, Indecision, Social
Poor parenting self-efficacy Withdrawal, Martial Conflict,
(mediational = appraisal process) 01732 808 626 www.thinkcbt.com Difficulty dealing with infant
Diagnosis / symptoms
Formative influences
Situation / interpersonal
issues
Biological, genetic and Working Treatment

medical factors hypothesis Plan
Strengths / assets
Typical automatic thoughts,

emotions and behaviours
Underlying schemas

“Vicious Flower” Generic conceptualisation
(Salkovskis, Warwick and Deal 2003)
Anxiety
Worry Images
Processes
Threat
Physical
Appraisal Memories
Sensations
Meaning
Safety Selective
Behaviours Attention
Events,
Stimuli,
Situations
Clark’s cognitive model of panic with maintenance
cycles added (adapted from Clark, 1986)
INTERNAL / EXTERAL TRIGGER
PERCIEVED THREAT
ANXIETY
(Emotions)
MISINTERPREATION PHYSICAL / COGNITIVE

SYMPTOMS
AVOIDANCE AND SAFETY

BEHAVIOURS
(Including Selective Attention)
A cognitive Model of GAD (Wells, 1995)
Trigger
Positive meta-beliefs
activated (Strategy
Selection)
Type 1 Worry
Negative meta- beliefs

activated
Type 2 Worry
Behaviour Emotion
(Meta-worry)
Thought control
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
What if..?
Positive beliefs
Mood about worry Life
State Events
Worry
Negative
Cognitive
problem Anxiety
avoidance
orientation
Demoralization
© Think CBT Ltd info@thinkcbt.com Exhaustion
Low Self-Esteem: A Map of the territory
(Fennell, 1999)
(Early) Experience
Events, relationships, living conditions which have implications for ideas about the self
How Low Self-esteem Develops

The Bottom Line
Assessment of worth/ value as a person
Conclusions about the self, based on experience: this is the kind of person I am
Rules for living

Guidelines, policies or strategies for getting by, given the truth of the Bottom Line
Standards against which self-worth can be measured
Trigger Situations
Situations in which the Rules for Living are, or may be, broken
Activation of the Bottom Line
What keeps Low Self-

Depression
esteem Going
Negative
Predictions
Anxiety
Self-critical thoughts Unhelpful behaviour
© Think CBT Ltd info@thinkcbt.com Confirmation of the Bottom Line

Based on Wells 1997, adapted by Stopa
Social Situation
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?
Thoughts
4. When you are afraid (feared event) will happened

what happens to your attention? Do you become more
3. As you became
self-conscious? As you focus on yourself, what do you
anxious, and
notice? Do you have an image of how you feel you are
thought that
coming across? What does that look like?
(feared event)
might happen, did 2. When you
you do anything to thought (feared
try to prevent it event) might
from happening? happen, what did
Did you do Self-focus you notice
anything to try to happening in your
prevent people body? (Suggest
from noticing? symptoms of
5. As you did (safety 6. As you noticed anxiety)
behaviours) did that yourself becoming more
make you focus more or anxious, what effect did
Safety less attention on that have on your
Behaviours yourself? attention? Anxiety
Symptoms
© Think CBT Ltd info@thinkcbt.com 7. When you did (safety behaviours)
01732 808 626 www.thinkcbt.com what effect did that have on your anxiety?
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 Cognitive

Prior Experiences/ Beliefs/ Coping Influences Processing
State of individual during Trauma
Negative Appraisal of
Nature of Trauma Memory
Trauma and / or its Sequleae
P
Matching E
Triggers R
S
I
S
Current Threat T
Intrusions E
N
Arousal Symptoms T
Strong Emotions
P
T
S
Strategies Intended to Control Threat / Symptoms D
Arrows indicate the following relationships:

Influences = Leads to = Prevents change in =

A cognitive-behavioural model for the maintenance of specific phobias
Various objects / situations are perceived as
potentially harmful
Avoidance
Encountering the phobic object / situation
Pre-attentive
activation
Catastrophic Autonomic
beliefs arousal
High
degree of
conviction Escape or safety behaviour
The catastrophe does not occur and anxiety Prevents

reactions dissipate disconfirmation
Conclusion drawn: The escape / safety

behaviour prevent the catastrophe
The catastrophic belief is confirmed

01732 808 626 www.thinkcbt.com The phobia remains unchanged
Maintaining Cycles
• Safety Behaviours (e.g. OCD client)

Maintaining Cycles
• Reduced activity (depressed client)

Maintaining Cycles
• Perfectionism (e.g. depressed client)

Maintaining Cycles
• Catastrophic Misinterpretation (e.g. panic
client)

Maintaining Cycles
• Scanning/hypervigilence (e.g. health anxiety
client)

Maintaining Cycles
• Escape/avoidance (e.g. social anxiety)

Maintaining Cycles
• Fear of fear (e.g. GAD client)

Maintaining Cycles
• Performance Anxiety

Maintaining Cycles
• Self-fulfilling prophecies

‘Vicious Flower’ model
(Salkovskis, Warwick & Deale, 2003)
Images
Emotion
Memories
Worry Threat Appraisal/ Selective

Processes Meaning Attention
Physical
Sensations Safety Seeking
Behaviours
Events, stimuli, situations
‘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
Anxiety; ‘weirdo’. Ignored. Told
panic I had staring eyes.
Mocked
Rumination; thinking
over past events Focus on self & how
(what went wrong) People think I am
I appear. Ignore any
and rehearsing weird; I will end up friendly remarks from
future ones (what to rejected and alone others (‘just being kind’)
say, etc)
Hold arms down to hide

Sweating, sweat; avoid eye contact.
restlessness, Avoid parties or stay in
shaky hands kitchen out of the way &
leave early. Cross road to
Parties, social occasions, avoid people. Look at road.
memories of social events Keep eyes semi-closed
6 Cycles Maintenance Model – A ‘Vicious
Flower’ for Depression (Moorey, 2010)
1. Automatic
negative thinking
6. Motivation
and physical 2. Ruminations &
symptoms self attacking
Depression
Mode
Negative view
of self, world
& future
5. Unhelpful 3. Mood/emotion
behaviours
4. Withdrawal
and avoidance
Longitudinal Formulation
Depression:
Early experience
Core beliefs/assumptions
Critical Incident(s)
Activation of beliefs/ assumptions
Negative Automatic Thoughts (NATs)

Feelings Physical
Behaviour
Depression:
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
Anxiety: Learning Experience
Generic cognitive theory

Danger Schemas Formed of anxiety disorder
Ref: Wells, A. (2007)

Cognitive Therapy of
Critical Incident Anxiety Disorders.
Chichester: John Wiley &
Sons
Schema Activated
Anxiety Symptoms
Behavioural Responses
Cognitive Biases

Highly anxious mother: not allowed
Anxiety: Learning Experience out alone until age 16; fear of
abduction, etc)
Generic cognitive theory of anxiety
disorder, Wells, A. (2007) Cognitive The world is dangerous; people will
Therapy of Anxiety Disorders. Danger Schemas Formed harm me; I am vulnerable; worrying
Chichester: John Wiley & Sons keeps me safe
Critical Incident Neighbour’s house burgled
The world is dangerous

Schema Activated (& I am vulnerable)
I will be next; I need to get more locks;

I need to have the police’s number Negative Automatic Thoughts
handy; what if it happens when I’m
alone at night?
Heart pounding; rapid breathing;
Anxiety Symptoms sweating; restless; racing thoughts;
rumination
Plan escape routes & location of
weapons; check locks frequently; have Behavioural Responses
mobile by bed; buy alarm system
Selective abstraction (neighbour’s
Cognitive Biases house less secure)
Catastrophising

Think CBT Conditions Specific Formulations

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Disorder specific models

• Panic (Clark, 1986)

See also Core CBT Competencies list for

© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com

Physiological Behavioural Subjective

Physiological Behavioural Subjective

© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com

The catastrophe does not occur and anxiety Prevents

Conclusion drawn: The escape / safety

The catastrophic belief is confirmed

The phobia remains unchanged

OVERESTIMATING THREAT AND CONSEQUENCES/ UNDERESTIMATING COPING AND

Increasingly anxious cognitions about Anxious cognitions about symptoms

Safety behaviours Safety behaviours

Secondary cognitions From Chapter 8 of Oxford Guide to

Processing of Self as a Social

Safety Somatic & cognitive

© Think CBT Ltd info@thinkcbt.com

© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com

Counterproductive “safety” strategies Mood Changes

© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com

© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com

Relevant Childhood Data

Situation 1 Situation 2 Situation 3

Automatic Thought Automatic Thought Automatic Thought

Meaning of the A.T. Meaning of the A.T. Meaning of the A.T.

Emotion Emotion Emotion

Behaviour Behaviour Behaviour

Dysfunctional Schemas Formed

Negative Automatic Thoughts

Cognitive Anxiety Behaviour

Things that keep “the problem” going

Positive things that

© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com

Early Experiences Critical Incidents

Assumptions, General Beliefs

Intrusive Thoughts, Images,

© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com

Core Beliefs and Assumptions

Negative Automatic Thoughts

Behavioural Motivational Affective Cognitive Somatic

Loss of Negative thinking &

4. Fear remains intact: 2. Client’s best

3. Strategy gives short-

© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com

© Think CBT Ltd info@thinkcbt.com

Negative appraisal Processing of

Core Beliefs – about myself, others and the world

Rules I live by…

What triggered the problem

What helps me cope

What maintains the problem now

Vulnerability Factors Cultural

Exacerbating & maintaining factors

Depression and other

Mediational Cognitive Behaviour / Coping

Biological, genetic and Working Treatment

Typical automatic thoughts,

© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com

MISINTERPREATION PHYSICAL / COGNITIVE

AVOIDANCE AND SAFETY

Negative meta- beliefs