panic (clark, 1986) social phobia (clark & wells, 1995) health anxiety (salkovskis &...

• 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

© Think CBT Ltd. [email protected] 01732 808 626 www.thinkcbt.com



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


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]

01732 808 626 www.thinkcbt.com

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.


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


A cognitive model of OCD(Wells 1997, p.242)

Trigger

Activates Meta-Beliefs

Appraisal ofIntrusion

Belief about rituals

Behavioural Response Emotion


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.)


5 Part Cognitive Behavioural Therapy Model

Environment

Thoughts

Emotions

Physical

Behaviours


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


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


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”


“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


Depression Model (Beck 1967, 1976)

Early Experiences

Core Beliefs and Assumptions

Critical Incident

Assumptions Activated


Symptoms of Depression

Behavioural Motivational Affective Cognitive Somatic© Think CBT Ltd. [email protected]


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


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


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]


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


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


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


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


“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


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]


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


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?


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


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


• 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

Maintaining Cycles


‘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


‘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


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


Longitudinal Formulation

Early experience

Core beliefs/assumptions

Critical Incident(s)

Activation of beliefs/ assumptions

Negative Automatic Thoughts (NATs)

Feelings Physical

Behaviour

Depression:


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:


Longitudinal FormulationAnxiety: Learning Experience

Danger Schemas Formed

Critical Incident

Schema Activated


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


Longitudinal FormulationAnxiety:

Danger Schemas Formed

Critical Incident

Schema Activated


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


panic (clark, 1986) social phobia (clark & wells, 1995) health anxiety (salkovskis &...

Documents

cognitive cycle of fear

cognitivebehavioural

anxious thoughts

terrible fear

social phobia clark

social situation

fear of fear hyper vigilance

unchanged think cbt