Psychiatry Lecture: Cognitive Behaviour Therapy (CBT) - an overview

0:02 welcome to this presentation this will be a lecture on cognitive behavior therapy CBT we'll first look at the rationale for CBT we will briefly look at the history of development of CBT we will focus on the use of CBT in depression and anxiety disorders at the end we will go through

0:47 five multiple choice questions some information about myself I'm a consultant psychiatrist based in Chennai which is a city in Southern India I have worked for many years in the United Kingdom so what is CBT CBT is a type of

1:35 psychotherapy CBT stands for cognitive behavior therapy cognition refers to thoughts Behavior refers to actions what is the rationale for CBT one's cognition and one's Behavior can have an influence on one's mood negative

2:20 cognitions and maladaptive behaviors can lead to depressed mode therefore by identifying and correcting negative cognitions and maladaptive behaviors the depressed mod can be improved so this is the rational for CBT Aon Beck is generally considered the pioneer of CBT he was a professor of Psychiatry at the University of Pennsylvania in the

3:10 US he initially developed cognitive therapy for treating depression this therapy was subsequently expanded to include behavioral components and became cognitive beh behavioral therapy since then CBT has been used successfully for a range of disorders including depression either on its own or in combination with psychotropic medication

4:02 this is Aaron Beck we will now look at the use of CBT in clinical practice CBT is a Time limited therapy usually between 12 and 16 sessions the number of sessions s is typically desided in advance sessions take place once a week each session lasts for about 50 minutes the goals of treatment are

4:49 clearly identified at the beginning of therapy once therapy starts the patient's progress is regularly monitored during therapy in CBT the patient is an active participant the patient is generally given homework tasks to complete in between sessions rating scales are usually used

5:37 at the beginning of therapy and also at the end of therapy to assess Effectiveness or otherwise of the therapy in CBT the focus is on on the here and now the focus is not on the origin of the problem the main objective of CBT is to help the patient use practical cognitive and behavioral strategies to

6:24 overcome their problem in this slide I have highlighted some differences between cognitive behavior therapy and exploratory Psychotherapy by exploratory Psychotherapy we include psychoanalysis psycho dnamic Psychotherapy Etc so if you want you can pause at this point and go through this Slide the initial assessment is

7:13 important it should include description of current difficulties realistic goals of treatments treatment need to be identified the treatment rationale should be explained to the patient you need to establish whether the patient would be willing to work in a CBT model clearly explain the structure and purpose of the treatment sessions if suitable you can then start treatment so each treatment session should

7:58 have a clear structure you should agree on an agenda for the session review the progress since the previous session review homework tasks given to the patient at the last session and inquire whether there were any difficulties in doing them discuss in detail a specific problem or difficulty that the patient is experiencing devise specific strategies to address that problem give homework tasks with clear instructions and get feedback from the

8:45 patient and ensure that the patient has understood we will now look look at CBT in depression the aim is to overcome negative cognitions and unhelpful behaviors that serve to maintain the depression examples of negative cognitions can be I am worthless it is all my fault I will never get better examples of unhelpful behaviors

9:31 include social withdrawal avoiding activities staying in bed for long periods in this slide I have listed three key terms that are used in CBT in depression dysfunctional assumptions negative automatic thoughts cognitive distortions dysfunctional assumptions are extreme and inflexible opinions that people form about themselves and about the world people's early life experiences

10:19 influence what dysfunctional assumptions they develop examples of dysfunctional assumptions if I am not perfect I cannot be happy if I don't succeed in everything I do I'm a failure dysfunctional assumptions remain latent until there is a critical stressful event when they then lead to negative automatic thoughts

11:05 negative automatic thoughts are called so because they are negative that is they have negative themes and they are automatic these thoughts keep popping in one's mind the content of negative automatic thoughts tends to be related to the dysfunctional assumptions that precede them examples of negative automatic thoughts I will never be happy I will always be a failure negative automatic thoughts then make the depression worse

12:00 cognitive distortions are errors in thinking that are commonly seen in depression these cognitive distortions serve to maintain depression CBT aims to identify such cognitive distortions and helps the patient to correct them this process is called cognitive restructuring in this slide I have listed some types of cognitive distortions All or Nothing thinking

12:47 jumping to conclusions magnification minimization over generalization and disqualifying the positive we will look at them one by one all or nothing thinking refers to thinking in absolute rather than in relative terms words such as always never everything nothing these words words characterize All or Nothing

13:34 thinking let us look at an example a person applies for a promotion at work he does not get promoted while another colleague does he then concludes I will never get promoted or I am always a failure jumping to conclusions refers to coming to negative conclusions with insufficient evidence there are two types the first one is mind reading for example at work a colleague

14:20 does not smile back the person then concludes he no longer likes me the second type is fortune telling the person fails his driving test the first attempt he then concludes that he will never pass the driving test magnification and minimization the person with this cognitive distortion tends to magnify his his or her mistakes while minimizing any positive achievements

15:08 example magnification the person fails to meet a deadline at work by just one day he feels very guilty about this minimization the same person succeeds in meeting a deadline at work several days in advance he however dismisses it feeling that he was just lucky and therefore deserves no credit in over generalization the person makes sweeping

15:54 generalizations from an isolated example the patient prepares dinner for friends apart from one item all the others come out very well however the person generalizes from the one poor item and concludes I am a terrible cook disqualifying the positive in this the patient dismisses any good attribute of oneself and you can use the same example as in the previous cognitive

16:41 distortion over generalization we will now look at the CBT techniques used in depression cognitive strategy include identifying and challenging negative automatic thoughts distraction techniques behavioral strategies include monitoring activities on Mastery and pleasure scheduling activities and graded task

17:27 assignment in order to to identify negative automatic thoughts the patient is asked to maintain a record of negative thoughts that keep popping into their mind these negative thoughts usually involve one of the following three themes about oneself such as I am worthless about the world and others no one cares for me and about the future future there is no hope for me once the negative thoughts are identified the patient is advised to

18:13 challenge them to establish how true they are in reality by repeatedly doing this exercise the patient would be able to see the link between low mood and negative automatic thoughts and between challenging the negative automatic thoughts and Improvement in mood in this slide I have given an example of a record of negative automatic thoughts so in this situation the patient's manager makes a

19:01 harsh criticism at work as a result the patient gets the negative automatic thought I am always a failure and at this point the rating of depression is almost maximum 95% out of a total of 100% the patient then rationally challenges the negative automatic thought I have succeeded many times previously this criticism by the manager is more a reflection of bullying on his part than a failure on my part even if I had made a mistake I will use this as a

19:47 learning experience because everyone makes mistakes and then the depression level Falls to 40% so this is an exercise that the patient is asked to do regularly distraction techniques are useful when one is extremely distressed because of symptoms of depression or anxiety by distracting oneself from depressive and anxiety thoughts the patient can reduce the acute severity of these symptoms they are useful in the short term while

20:33 the patient is learning other CBT techniques examples of distraction techniques include focusing on an object doing some mental exercises thinking about pleasant memories and fantasy sensory awareness and doing some absorbing activities in focusing on an object the

21:19 patient is taught how to focus attention on an object for example the patient is ask to look at an object nearby such as a wall clock and asked to mentally answer several simple questions such as what is its location how big is it what is its color what is it made of what time is it showing Etc examples of mental exercises include subtracting back from 1,000 so you subtract for example six

22:05 sequentially thinking of objects beginning with a certain letter of the alphabet so the patient is asked to think about past pleasant memories or possible future fantasies examples thinking about a previous holiday that the patient had enjoyed or what they would do if they win a large amount in the lottery in depression especially if it is severe it might be difficult for the patient to recall or contemplate about anything positive

22:59 indulging in some activities that can distract the patient can be helpful for example doing a cross word or a Sudoko puzle listening to music or watching a favorite program on television sometimes any physical activity such as cooking cleaning ironing Etc can be helpful again if the depression is significant due to reduced mental concentration and increased physical tiredness the patient may find doing these activities

23:46 difficult behavioral strategies include monitoring activities scheduling activities graded task assignment the patient is initially asked to keep a record of all the activities that they do on a daily basis the patient is then asked to rate each activity on a scale of 1 to 10 based on the following Mastery how well did you do the activity and pleasure how much enjoyment did you get while doing this

24:35 activity this would be an example of a record of activities if you want you can pause at this point and spend some time looking at the slide this monitoring record of activities that the patient does every day helps to counter negative thoughts such as I don't do anything even if I do something I don't do it well I don't do anything that gives me pleasure because the record of activities would show that the patient is actually doing certain things and

25:22 there are certain things that the patient does well and there are certain things that give the patient patient pleasure the next step is scheduling activities the previous task would give an idea of the kind of activities that the patient is able to do and also able to enjoy the next step is for the patient to plan each day in advance preferably on an hour by hour basis the number of activities should however be realistic considering the severity of the patient's

26:10 depression the patient is asked to include activities that day enjoy planning in advance helps the patient have a greater sense of control and it also helps to avoid the patient have to repeatedly make decisions during the day the next step is graded task assignment if the patient is unable to do a particular task in one go he is advised to break such a task into

26:56 smaller more manageable steps this grading helps to overcome procrastination negative cognitions such as it is too much for me and hopelessness I can never do this we will now move on to CBT for anxiety disorders CBT has been shown to be effective in a range of anxiety disorders including panic disorder

27:42 phobias obsessive compulsive disorder generalized anxiety disorder we will go through some of the important features of each anxiety disorder panic disorder is characterized by episodic paroxysmal anxiety the anxiety attacks come out of the blue in panic disorder there are both cognitive symptoms example fear of fainting fear of dying Etc

28:28 as well as physical symptoms such as palpitations sweating trembling Etc Panic symptoms can also occur in phobic disorders in response to exposure to the feared stimulus this slide highlights the relationship between physical SYM symtoms and associated cognitions in panic disorder So Physical symptom like palpitations may be associated with the fear I'm having a heart attack I'm going to die the physical symptom of

29:14 breathlessness might lead to the fear I'm going to suffocate feeling dizzy might lead to the fear I'm going to faint phobia is an anxiety disorder in which symptoms occur when the person is exposed to the feared stimulus depending on the stimulus there are different types of phobias simple or specific phobia aerophobia social phobia are common types of phobias

30:03 in simple or specific phobia the anxiety symptoms do not occur in the absence of the feared stimulus examples include fear of spiders Heights enclosed spaces Etc in aerophobia the patient has a fear of crowded places or traveling alone or leaving home in severe cases the agrop obic patient becomes totally F

30:55 bound social phobia is also called social anxiety disorder in this condition the anxiety symptoms manifest in social situations such as attending social events such as parties public speaking or sometimes even eating in public as in restaurants in anxiety disorders such as panic and phobias the behavioral response of the patient to overcome the anxiety is usually one of the following

31:42 two avoidance and Escape so if the patient knows which situation triggers the anxiety he or she may avoid that situation or if the patient develops anxiety in a particular situation they try to leave that situation so that would be Escape CBT aims to change such maladaptive behaviors and helps the patient deal with the anxiety so avoidance and Escape May provide short-term relief of anxiety but in the long run they reinforce the anxiety

32:29 obsessive compulsive disorder is a disorder characterized by obsessions and compulsions obsessions are repetitive intrusive unpleasant thoughts that keep coming up in the mind despite the patient attempts to resist the thoughts so they are different from the negative automatic thoughts that we saw earlier obsessions are characterized by the patient attempts to resist the thoughts whereas this resistance is not seen in the case of negative automatic thoughts compulsions are repetitive behaviors that are done in order to

33:16 reduce the anxiety associated with the obsessions so examples of obsessions include fear of contamination fear for On's safety or the safety of others close to the person such as children need for Symmetry and examples of compulsions include repeated hand washing repeated checking and arranging

34:03 generalized anxiety disorder is an anxiety disorder in which the patient feels tense or on edge most of the time the anxiety in generalized anxiety disorder is referred to as free floating in contrast to the out of the blue anxiety that is seen in panic disorder Associated symptoms in Gad include muscle tension being FID Restless insomnia headache fatigue difficulty concentrating

34:48 Etc we'll now look at some CBT techniques used in anxiety disorders relaxation exercises exposure and response prevention distraction techniques identifying anxiety inducing thoughts and finding Alternatives there are several techniques of relaxation the main technique used in CBT is applied relaxation exercise which includes several

35:34 stages these relaxation exercises should be regularly practiced so that they can be used in real life anxiety inducing situations the first stage is called the progressive muscular relaxation in this the body is divided into a series of large muscle groups and each group is first tensed and then relaxed by alternating between tension and relaxation the patient is taught to distinguish between these two

36:24 states initially the relaxation EX exercises are taught by the therapist during the sessions the patient then practices them when he is in non-stressful situations example while sitting in a chair at home in due course the patient is able to use these techniques in those situations that induce anxiety or when symptoms of anxiety have actually started in exposure and response prevention the patient is exposed to the feared

37:10 stimulus thereby overcoming avoidance this stimulus would induce anxiety but the patient is prevented from showing their habitual maladaptive response which would which would have been escaped sking from the stimulus the patient is advised a few general principles regarding anxiety symptoms that however distressing these anxiety symptoms are they will neither kill you nor will they last forever in other words if you are patient the symptoms would eventually

37:56 subside the exposure to the feared stimulus is usually done in a graded manner hence the term graded exposure Studies have shown that CBT is effective in other disorders apart from depression and anxiety disorders such as eating disorders including bulimia nervosa nonorganic Sleep disorders such as insomnia and nonorganic sexual

38:45 disorders in addition CBT in combination with other treatments usually psychotropic medication has been shown to improve outcome in psychotic disorders such as schizophrenia bipolar affective disorder alcohol and substance misuse disorders and personality disorders such as borderline personality disorder CBT is an effective treatment that has revolutionized the management of depression and anxiety

39:31 disorders in CBT the patient is an active participant in therapy and is not just a passive recipient of treatment given by a professional in psychiatric practice CBT techniques are usually used in combination with medication in order to try to improve outcome we have now come to the end of the lecture but before we finish we will go through five mcqs question one CBT is not

40:16 indicated as monotherapy for which of the following disorders by monotherapy we mean the soul treatment so for which of the following disorders is CBT not indicated as monotherapy is it a depression B OCD or C schizophrenia if you want you can pause and select your choice the correct answer is schizophrenia in depression and OCD especially for mild to moderate depression and OCD CBT can be used on its own whereas in

41:02 schizophrenia antic psychotic medication is the first line treatment while CBT can be used alongside medication for some patients question two CBT was pioneered by if you want you can pause now and choose your choice and the answer is B Aaron Beck Sigman Freud pioneered psychoanalysis while Marsha lenihan developed dialectical behavior therapy or DBT compared to psychodynamic

41:48 Psychotherapy which of the following is true regarding CBT if you want you can pause now and choose your choice and the correct answer is a CBT gives little importance to unconscious processes total duration of CBT is longer is not correct because CBT is time limited usually 12 to 16 weeks whereas psychodynamic Psychotherapy can extend for up to several years and IND ual sessions in CBT are for 50 minutes generally which is the same for psycho

42:35 dnamic Psychotherapy also question four exposure and response prevention is a CBT strategy used for a Mania B depression or C phobias you can pause and select your answer the correct answer is phobias so exposure and response prevention is used for anxiety disorders such as phobias the final question in CBT for depression All or Nothing thinking is an example of a dysfunctional assumptions B cognitive distortions C

43:20 negative automatic thoughts you can pause now and select your option the cor answer is B cognitive distortions these three concepts are closely related but they are distinct so I suggest that you go through that section of the lecture where I discuss these Concepts again for greater Clarity and we have now come to the end of this presentation hope you found the lecture useful thank you for watching