CBT Disorder Specific Clinical Handbook

CBT Disorder Specific Clinical Handbook v10

Contents

Introduction. 3

Depression. 3

DSM Diagnosis. 3

Demographics. 3

Disorder specific assessment requirements. 3

Conceptualisations. 4

Treatment. 7

Beckian approach. 7

Martell approach. 10

Safran\Sega. 13

Anxiety. 15

Perfectionism.. 15

Panic Disorder. 17

Characteristics of panic attacks. 17

Conceptualisations. 18

Treatment options. 20

Specific Phobia. 22

Development. 22

Symptoms. 22

Conceptualisation. 22

Treatment. 23

Notes. 23

GAD.. 24

Introduction. 24

Diagnosis. 24

Dugas. 24

Notes. 27

Social phobia. 28

Wells. 28

Notes. 31

OCD.. 32

Diagnosis. 32

Veale and Wilson. 32

Salkovskis. 35

Conceptualisations. 36

Treatment. 36

PTSD.. 38

Ehlers Clark. 38

Health Anxiety\Somatic problems. 40

Salkovskis. 40

Wilson and Veale (Overcoming Health Anxiety). 43

Self Esteem.. 44

Introduction. 44

Concepts. 45

Conceptualisation. 45

Treatment. 45

Anger. 47

Introduction. 47

Concepts. 47

Assessment/Treatment. 47

Conceptualisation. 48

Client Behaviour

Introduction

This is a working document to store CBT approaches to specific disorders and to be a quick reference prior to seeing a new presentation you haven’t seen for a while.

Depression

DSM Diagnosis

Broadly

1.       Anhedonia

2.       Low mood

3.       Lowered activity

4.       Poor concentration

5.       Thoughts of worthlessness

6.       Loss of energy

Demographics

·         15-20% suffer from depression in any one year

·         Affects twice as many women than men

·         More likely in lower social classes, with no job or formal qualifications

Disorder specific assessment requirements

·         Suicide assessment is paramount

·         Alcohol\benzodiazepine\opiate use, i.e. any depressant drug use

·         Co-morbidity is high, social phobia can be prominent, but so much else depression as outcome of many anxiety disorders

·         With depression there is a sense something is missing\lost. What type of thing is missing? The stronger the depression the more essential that the something lost is to the existence of the person, the more hopeless the stronger the feeling that they will not get it back. The more essential to a person’s existence that which is lost, then the less identity they have and the less they think they are valued by other people and loveable.

o   Indeed you may take it that through relation with the primary care giver, peers and society what it means to be them is developed, through attribute, achievement, attitude and capability. When these are lost then depression ensues, as they lose value and see themselves as not loveable. So another question might be in time, how you find out that what is lost is valuable to you, how can you get it back or replace it

o   Our current society values individual competitive success, i.e. more successful than at many different areas, and this could well be one of the things that is lost, or unattained

·         Strengths, assets and values

o   Whilst it does depend how you treat, building on strengths and assets, or using values can be critical, as it’s easier to build on the functional than change the dysfunctional

Conceptualisations

1.       J Beck

2.       Martell

3.       Morrey

4.       Westbrook, Kennerley

The choice of conceptualisation comes both from what your client presents and also how you see them.

Beck

So choosing the Beck formulation takes you down a predominantly cognitive path. The big deal I guess with Beck is that you can look at when rules are broken and early experiences.

Martell

Using the Martell conceptualisation would take you down a more behavioural route.  It’s nice because it looks at behaviour in context, so behaviour doesn’t have a fixed meaning but how it operates in that person’s life at that time.

Morrey

With Morrey I guess this conceptualisation gives you the opportunity to see which aspect of the depression is the most significant so you can choose with the client what to start working on. Whilst the model he gives is just a vicious flower and doesn’t contain low activity levels, I guess you could add that in. I guess again that you could start with Morrey to give an indicator of are cognitive\behavioural problems to the fore, and then on the basis of that choose to get more detail with Beck or Martell.

Westbrook

 Now Westbrook is quite handy again at quite a high level as it gives all the aspects of depression and makes the relationship between them, so possibly a more powerful model than Morrey. Again you would wonder if this could be a useful initial conceptualisation and then to get more focussed with Beck\Martell.

J Beck :

Martell:

Morrey

Westbrook, Kennerley

Treatment

Beckian approach

Base concept, depression is maintained through dysfunctional thinking. Remember though thinking is both the propositional kind and imaginal. An image is a thought, so when people imagine things they are thinking. The image might point into the future, so is imagination, or to the past, which is memory.

NATS

·         Start with NATS as they’re easiest to challenge

o   Ensure client is psycho-educated, i.e. NAT=>emotion

o   Ensure client can spot their NAT’s and its consequence emotion

o   Techniques to elicit

§  When client has shift in emotion

§  Clients problematic event

§  Use imagery or role play, if you are talking about past events and not getting NATs

o   Things to watch out for

§  Watch out you don’t get interpretations of the situation, e.g. I think I was denying my feelings, but try and get the hot thought

§  Don’t get hooked on trivial NAT’s but look for the hot one that really explains the emotion

§  If you get an embedded expression, e.g. I couldn’t get myself to start doing it then translate it into a direct proposition:  I can’t do this

§  Change questions, or exclamations into propositions, e.g. Uh oh= I have too much to do or Will I pass the test? => I might fail

o   Evaluating

§  Only work on those that have

·         Big affect

·         Highly dysfunctional

·         Are strongly believed

·         Commonly occur

o   Working on

§  Use a Thought record and

·         Identify hot thought

·         Key emotion, look for the primary not the secondary if possible, e.g. I was sad, then I was angry that I was sad

·         Identify cognitive errors

·         Question the utility of the thoughts

·         Question the veracity of the thoughts

·         Get client to use them, practice them until they began to use the technique quite naturally in their thinking

§  Use simpler thought challenging techniques using 3^rd parties

·         What would a compassionate person say of what happened?

·         What would you say if a friend was in a similar position

·         Have there been people in your life that would have seen this situation differently

·         Would everyone interpret this situation in this way?

§  Think longitudinally

·         Where do you think you learnt to interpret your behaviour like this

Intermediate Beliefs

·         Identifying

o   Provide the first part of the assumption and get the client to fill the rest, so if you are lazy then..

o   Use a downward arrow technique, e.g. what does that mean to you

o   Look for themes in NATS and say you seem to be operating to a rule, can you see what it is?

·         Evaluating

o   If a client holds an intermediate belief strongly and its dysfunctional then work on it, otherwise don’t

·         Working on

o   Psycho-educate about how beliefs are learnt, indeed this should drop out of your Beckian conceptualisation

o   Change the intermediate belief into a conditional assumption, it’s easier to test and work on

o   Specific techniques

§  Advantages\disadvantages, ensure  you get more disadvantages

§  Behavioural experiments to test belief

§  If the belief is black and white, either I’m 100% or I’m a failure use a continuum

§  If a client believes that their intermediate belief is dysfunctional but still acts on it, do a rational\emotional role play, where they start playing the emotional part of their mind and you play the rational, then you swop.

§  You can use other people as a reference point. Would you recommend your rules to others, are there other people you respect who break your rules

§  Generate a new belief

·         Formulating a new belief, look to find a way to get more of the advantages and less of the disadvantages into a new belief

·         Act as if the new rule is true see the outcomes

Core Beliefs

Beck sees core beliefs as to be about self-competence, lovability, which not everyone does, e.g. see Martell for interpersonal ones and you would have to ask about the world and others.

·         Identifying

o   Use a downward arrow

o   Common themes in NATS and IB’s

·         Evaluating

o   Psycho-educate, using the prejudice metaphor, the learning history ideas

·         Treatment

o   Generate a new functional belief

o   Use core belief worksheets, to find evidence to challenge the old and support the new core belief

o   Use extreme comparison, so find someone who is an extreme version of your core belief, are you like them

o   Historical test. When did you learn this CB? Then reframe it.

o   Restructure early memories, use reliving plus a reference from the present, get the client to play their six year old and answer from that point, then ask the adult client to explain to the child client how to handle the situation

Beck also introduces a number of other techniques that doesn’t fit directly with the rationale of its dodgy thinking that maintains depression but she says are equally important:

·         Enhance problem solving orientation and skills

·         Activity monitoring and scheduling which connects the client with more positive reinforcing activities

·         Distraction and refocussing on the task in hand, which reduces worry\rumination

·         Relaxation, although be aware of the paradoxical arousal effect where becoming more relaxed can make a client more anxious and nervous

·         Coping cards, i.e. challenge rules and CB’s. On one side put the NAT/IB/CB and on the other the rational response

·         Graded exposure, i.e. shape the required behaviour and achieve one step at a time

·         Role playing: practice skills or try out new ones

·         Responsibility pie

·         Positive data log

Beck also mentions imagery

·         Some clients are more amenable to imaginal intervention than cognitive, clues to this would be having distressing images, rather than distressing thoughts, or when you run into cognitive roadblocks.

Working with images

·         Normalise their occurrence, they are just another way to think

·         Finish out images, distressing images usually stop at the worst point, take them through to a safe place.

·         Jumping ahead in time. So they have some anxiety, get them to jump ahead in time to a point where they have done the thing, e.g. I’m trying to write a paper, get them to imagine having completed the paper and what that’s like

·         Coping in the image: difficult image, get them to imagine coping in the image, or introduce someone into the image to help them cope

·         Changing the image: difficult image, horrible ending, get them to imagine a better image.

·         Reality testing the image: effectively to a DTR on it.

·         Repeating the image: with an exaggerated image but non catastrophic, get them to repeat the image and it may well reduce, so asking a teacher for help and they get angry

·         Image stopping: when you have the image, imagine a red traffic light and scream to yourself stop

·         Image substitution: create a pleasant image, then if you have the unpleasant image, then substitute the pleasant one

·         You might want to induce an image to rehearse coping techniques

·         Distancing: so they’re having a hard time now, what do you think this time will look like next month, year, in ten years’ time

Martell approach

Depression Concept

Depression is caused by the short term coping strategies maintaining depression through reducing the ability to experience positive reward from the environment.

Treatment concept

What you need to do is to get the client to experience positive reward from their environment and to decrease avoidance behaviours, and to replace them with problem solving.

Ten Core principles

1.       The key to changing how people feel is helping them change what they do

2.       Changes in life can lead to depression and short term coping strategies that may keep people stuck over time

3.       The clues to figuring out what will be antidepressant for a particular client lie in what precedes and what follows the client’s important behaviours, i.e. functional analysis

4.       Structure and schedule activities that follow a plan, not a mood

5.       Changes will be easier when starting small

6.       Emphasise activities that are naturally rewarding

7.       Act as a coach

8.       Emphasise a problem solving empirical approach and recognise that all results are useful

9.       Don’t just talk, do!

10.   Troubleshoot possible and actual barriers to activation

Techniques

1.       Psycho-educate client to the relationship between behaviour and emotion

2.       Encourage a scientific attitude to the work, to find out what works and what doesn’t.  Set up the task of discovering behavioural anti-depressants, bit like Indiana Jones hunting for treasure

3.       Establish client values, or the kind of week they would like, or things they used to do when they weren’t depressed.

4.       Psycho-educate in terms of conceptualisation i.e. Feeling down=>do nothing=>no reward=>feeling down etc. to feeling down=> do something=>feel better. At this point you talk about acting towards a plan not a mood.

5.       Do activity monitoring

a.       Get them to specify using adjectives or activities the kind of week they would have for it to be rewarding, i.e. meaningful, having value to them, before they monitor

b.      Get them to record what they do, how they feel, and if there was something that they should have been doing instead, i.e. things they were avoiding

6.       Get the activity monitor sheet back

a.       Get them to grade each day, and to grade the week against their criteria

b.      Get them to look at things that helped them towards their desired week, and things that took them away from it

c.       Look for the antecedents to positive and negative behaviour, such that it can be maintained or changed.

d.      Look for any patterns, e.g. when I’ve been on Facebook for hours I then can’t sleep, or don’t fancy going out in the evening

7.       Do activity scheduling

a.       Get them to plan events, to help them to move towards their goals. Ensure they are small enough to be achievable, and timed on a certain day.

8.       Troubleshooting

a.       Didn’t achieve task. What were the antecedents? How can we change these? Were the task chosen important enough? Did they predict a bad outcome, could we act like a scientist and try, the guy who invented the light bulb made thousands of mistakes before he invented the light bulb, should he have stopped when it went wrong the first time? Was the task too big, then shape it.  How have they remembered to do, achieved difficult things before, what can we learn. If thoughts get in the way, don’t necessarily challenge them directly but look to replace with another behaviour. Find out what the antecedents to thinking this way are and change them. If a client ruminates, try getting them to switch attention to a task and pay attention to it in minute detail, see how that impacts their rumination levels. As you trouble shoot, use ABC analysis to psycho-educate the client, if they start using this then things will get better for them.

9.       Contextualism

a.       Remember what is rewarding for you may not be for them. Remember reward is contextual, so winning one race might be rewarding winning 10 races less so.

10.   Avoidance

a.       Psycho-educate to the maintenance aspect of it

                                                               i.      Repetition of avoidance makes problem seem more insurmountable, i.e.  the problem is so bad, I’ve had to avoid it 10 times..

                                                             ii.      Avoidance  is negatively reinforcing and  doesn’t provide any pleasure

b.      Look at problem orientation

c.       It is the increase effort to do a standard task that can be aversive, and conceivably the self-criticism which is painful, if it doesn’t work. So the negative reinforcement can be against the effort made, and self-criticism. So if you can reduce the need for effort via shaping and to treat any outcome as feedback then this can help.

d.      The cognitive impairment of depression can make problem solving harder, so it is worth noticing this to normalise and also offer support to work through the problem

e.      ACTION: Assess the function of behaviour, Choose an action,  Integrate the behaviour into a routine, Observe the results, Never give up

f.        TRAP/TRAC Trigger response avoidant pattern, Trigger response Adaptive Coping

11.   Rumination

a.       Treatment

                                                               i.      Look at consequences of ruminating

                                                             ii.      Use a worry tree and problem solve if appropriate

                                                            iii.      Refocus on the task at hand

                                                           iv.      Refocus on the present moment, i.e. mindfulness describe what’s happening without judgement

                                                             v.      Meditation

                                                           vi.      Distract oneself: replace with positive image

12.   Tips

a.       To do activity monitoring if they can’t do a week, do a day, or a few hours of every day, again shape the task to get something that is manageable. If there’s problems use an ABC analysis to understand why. So look at the antecedent, to the behaviour that led to the consequence of not doing what you wanted.

b.      Do behavioural experiments. Many clients say I’m not motivated to do something, then test if motivation is easier to sustain once you are doing something. Motivation is readiness, willingness and able. So you could test how important is the task, how able do you feel to do it. To enhance willingness, look at ambivalence, create dissonance. To increase confidence, then evocative smart questions, first steps, obstacles. Confidence ruler, reviewing past successes, review personal strengths and support, hypothetical successful change, when you look back, what did you think enabled you to make this change

c.       Look for any behaviour or event that perpetually derails behaviour

d.      Look for avoidance patterns in activity monitoring

e.      As they start to activate, build the new behaviour into a habit, part of a daily routine, i.e. integrate. Routine can be an antidote to depression, it can also help the new behaviour to be assimilated into the clients life

f.        Sometimes talking about problems can be a way to passively avoid doing anything about them

g.       When you set up the activity schedule get the client to think about what they most want to do and what the most need to do, and maybe think of some shaped goals towards that

h.      Look at the clients coping style, avoidance or boom and bust, and look to pitch the activity schedule somewhere between the two, nudge the pain

Safran\Segal

The Safran Segal approach is that depression can be a valid response to interpersonal difficulties. They challenge the Beckian notion that dysfunctional ideas is the root of their problem, as their interpersonal style produces interactions that justify these ideas. They also challenge behavioural interaction, in that the core problem they have is their interpersonal style which is what limits their behavioural repertoire and prevents them building close interpersonal relationships.  The approach then would be instead of using behavioural activation, would be to use the therapeutic relationship, to investigate this. They also cite interpersonal schema as things to be on the look out to construct. These are slightly more involved than the self-esteem style of Beckian core beliefs. So the idea is that during their formative years when they interact with their care givers then they develop ways they find can keep interpersonal relationships and threaten them. Both of these can become problematic. So for instance if being angry gets attention, then they can develop pleasing people, or being clever as a response to establish interpersonal relation. Likewise if being sad or angry can threaten interpersonal relationships again they will provoke anxiety if they arise and will be emotions that are disallowed.

Safran and Segal also show emotions are learnt, where there is matching with the primary care giver. So a child is happy, the mum responds with happiness the child has happiness validated and understands it. Likewise if there isn’t the response, say with anger or sadness, then the child won’t understand it.

The impacts of this could be that sadness is considered a threat to interpersonal relationship, so if it is felt, another emotion, or behaviour may be put on the top of it to conceal it, e.g. humour, anger, or keeping busy. This leads to a difficulty in interpersonal relationships as closeness is harder when only a certain range of emotions are shown. Again if certain types of behaviour, pleasing people, being hurt, or maybe angry has been ways that have secured interpersonal relationships.

So there are schemas, such as I am stupid, but if I show myself to be clever then people will accept me. These are acted on but they were learnt in a specific family dynamic and are not applicable to all people, who it will distance. There is generally a relationship involved in the action that come out of interpersonally orientated action. So if someone thinks that being passive is a way to get the relationship they want then then the other is pulled towards activity, or if being hurt is the approach, then looking after is the response.  

In summary then emotions are essentially inter-relational, client is passive draws you to active. The client has difficulty inter-personally their style has caused the depressive cognitions. So what you need to do is:

1.       Notice what emotions are not allowed in session

2.       Notice what emotions and behaviours are elicited by the client in session in the therapist, if they are detrimental they may well be things that are generally elicited in people. You need to check this out by asking the client what is going on for them at the moment, how they feel and what they are thinking, and to establish whether or not they behave like this more generally

The aim then of therapy is to make a client aware of his interpersonal style and to find out its functional and dysfunctional elements. This may well include emotions that the client doesn’t allow themselves to feel. This may well include an interpersonal schema which it may be useful to elucidate and to find out when and why they learnt this.

Anxiety

Perfectionism

Definition

Defined as setting high standards which are pursued despite problems created whilst following them plus having self-worth being dependent with achievement of these standards.

Symptoms

Procrastination

·                           doing things at the last moment means there a good reason why it’s not perfect

·                           Doing something you could do less than perfectly is anxiety provoking

·                           Putting off something that is going to take an awful lot effort to do because of the standards that may be achieved.

Avoidance

·                           avoiding things that can’t be done to the standard that is required

·                           avoiding taking any extra responsibility of more tasks that have to be done to a certain standard

Performance checking

·                           repeated checking to see\ reassurance seeking to see: if the task is up to standard

·                           Comparing ourselves with other to see if our task is up to standard

Areas that perfectionism can be applied to

1. Career
2. Social
3. Weight\shape
4. Sport

The continuum of perfectionism ranges between the three factors

1. Standards
2. Outcomes
3. Level of self-esteem that is based on performance levels

and the level of distress that is caused in relation to these three variables

Maintainers of perfectionism

1. Secondary gain of the rewards achieved when the high standards are met
2. Socially held beliefs of the importance of hard work and high standards
3. Socially held beliefs of you are what you do or own

Model

Model explanation:

1. Early Experience
1. E.g.: On the basis of early experiences, e.g. only receiving praise for achieving certain standards
2. Self-worth overly dependent on striving and achievement
1. E.g.: Beliefs are created around if I don’t achieve then I have low value
3. Inflexible standards
1. For example: I should always put everything I have into something, either something is right or its wrong
4. Cognitive bias
1. E.g.: Only notice what is wrong with something rather than what is right
5. Performance related behaviour
1. E.g.: work all night to get task done.
6. Temporarily meets standards
1. This can lead to the standards not being seen to be demanding enough and the standards get changed into the unreachable
7. Fails to meet standards\avoids meeting standards
1. Both of these result in self-criticism and can result in either increasing the importance of the targets or an increasing of the standards to reduce the feelings of low self-worth.

Perfectionism, or relentless achievement seems to fit very much into our current culture that values competitive individual success.

Maintaining beliefs

1. If I lower my standards then
1. I will let myself go
2. I will become lazy
3. I won’t get praise
4. I will not achieve\progress
5. I will be average

Treatment

1. Do an advantages\disadvantages for changing\staying same
2. Early experience: establish where perfectionism was learnt, and what’s at stake: If I do something perfectly then. If I don’t
3. Do a consequences on 1 years’ time on perfectionist areas
4. Do a values sheet in varies areas of life
1. What do you want to be?
2. What do you want to achieve?
5. Identify area of perfectionism, associated  and behaviours
6. Perfection monitoring
1. Use the form from Overcoming perfectionism book on page 93
7. Psycho-education
1. The 80\20 rule
2. Efficiency diminishing on the effort increase
8. Surveys
1. Test beliefs
9. Modify beliefs
10. Behavioural experiments as to whether modified beliefs produce desired outcome
11. Moving from rigid rules\beliefs to flexible ones
1. CBA of the belief
2. What would the future mean if you hold such a belief
3. Behavioural experiments test drive the new belief
12. Reducing self-criticism
1. Conceptualise, find out what early experiences  contribute to it
2. Monitor
3. Look at functional outcome
4. Treat

                                                               i.      Cognitively restructure

1.       Would you speak to a friend like that?

                                                             ii.      Use compassionate voice

                                                            iii.      Compassionate letter to a friend

Panic Disorder

Characteristics of panic attacks

Panic attacks are described as rapid escalations of anxiety where there are at least four of the 13 symptoms from the DSM categorisation, these four or more have to escalate within a ten minute period to be classified as a panic attack.  These symptoms include palpitations, derealisation, sweating and shaking.  Panics can either be situational, i.e. cued or spontaneous.  Hmm I would argue about spontaneous ones here, they are triggered by something and if you see them as spontaneous you probably can’t work out the trigger!

Panic Disorder:

·         Where there panic attacks are spontaneous

·         Where there is fear of having a panic attack that has a dysfunctional outcome

Conceptualisations

1.       Wells

2.       Clark

Wells

The Wells model sees there are two dysfunctional interpretations, the first one is the interpretation of the triggers which provokes anxiety, the second one is the interpretation of the symptoms of anxiety, which escalates the anxiety. He also sees the safety behaviours as maintaining the interpretation of anxiety and keeping the upward cycle of anxiety going.  Maintenance is also by selective attention, to the sensation that is feared, e.g. palpitations, and by focussing on them you can enhance them. Avoidance also of the initial trigger or of the symptoms of anxiety can prevent disconfirmation of the two dysfunctional interpretations.

Clark

The Clark model is identical to Wells. His take on it is panic is experience of imminent disaster caused by the misinterpretation of bodily sensations. If panic attacks have happened regularly then a state of apprehension can be created, an on-edgeness, whose hyper-vigilance, can scan, and create abnormal physical sensations, which then operate as a trigger to the panic cycle.  Avoidance then maintains the dysfunctional belief that panic will always arise in certain situations and that if it does arise that the client can’t cope with it. Clients can often think as there was no obvious antecedent to the attack, therefore it must be due to something serious, therefore finding antecedents can be directly therapeutic. To assess what you need to do is to get typical symptoms and typical situations.  So get the modulators and avoidance behaviours and get what the significant other makes of the panic attacks, and how the client understands them, where do they come from. It’s important to get the latter answer as the patient may have therapy interfering beliefs.

Treatment options

Wells

1.       Firstly formulate

a.       Find triggers: what are the situations in which you have a panic attack, what is the first thing you notice

b.      Find interpretation of trigger: what is the worst that you think can happen on seeing\experiencing the trigger

c.       Find safety behaviours: what are the things that you do to keep yourself safe if you think you’re having a panic attack

d.      Find the misinterpretation of the physical sensations of panic, or the cognitive

2.       Psycho-educate              

a.       Paired associates task to show thinking can cause anxiety

b.      Fainting only happens with low blood pressure

c.       Body focus can give you weird sensations

d.      Why don’t soldiers go mad they must have very high levels of anxiety

3.       Reattribution

a.       Cognitively restructure the primary and secondary misinterpretation

4.       Behavioural experiment

a.       Do a panic induction to get them to test out their beliefs that they will go mad etc.

b.      Do a panic induction to habituate to the feelings of panic

c.       Get them to stare at a spot to give floaters and visual disturbance

5.       Exposure

a.       If they have a fear of what might happen if they fell over, and people would fuss, then do a behavioural experiment to test this out

6.       Graded exposure

a.       Get them to do a graded task hierarchy to expose them to progressively increasing levels of anxiety provoking situations

Clark

1.       Can be useful to do activity monitoring, to link together behaviour and anxiety. It could be that the client has too much to do and they have no time to relax and therefore have high resting levels of anxiety.

2.       Relaxation: studies show it easier to access positive thoughts when relaxed. Relaxation can be difficult with panic clients as it can get them to focus on bodily sensations. Relaxation can be difficult as it makes some clients feel out of control.

Hyper ventilation

When you over breathe, you breathe quickly and shallowly. Don’t panic authors and overcoming panic argue that when you do this, you exhale too much carbon dioxide and you don’t take in enough oxygen, which helps provides the symptoms? Now I have read elsewhere but can’t find it at the moment, the argument that what happens is that you breathe too quickly to process the oxygen so that you are over oxygenated, which I suppose is the same as carbon dioxide depleted. But the not enough oxygen argument goes on with Cabat Zinn in MBSR to argue that you can faint from over breathing, which I don’t think you can, and goes against the panic = high blood pressure, and fainting needs low blood pressure. Anyway when I find the reference hopefully will update here, or maybe they are saying the same thing but Cabat Zinn is wrong…

Specific Phobia

A phobia is fear that is always felt in the face of some object/situation that is not dangerous. Patients when in a safe place would dismiss their fears as irrational but when confronted by the object would believe them very much. There are three types of phobia, simple (spiders), social and agoraphobia. In agoraphobia closeness to the feared object is as bad as the distance from the safety object.

Development

Especially common in the under 6 year olds, but generally goes at that point.  Phobias are almost exclusively on prepared fear objects. Generally they rarely come from a critical incident but rather build up over time. People are responsive to building up these fears during times of high stress. Most phobias start around the teenage years.

Symptoms

Physically they can be similar to if you’ve almost been run down by a car. The response is in the flight or freeze response. Behaviourally there is avoidance, or running away. Subjectively the response might be I’m going to lose control, people will see at the anticipation phase, and I can’t cope in the exposure phase etc.

Conceptualisation

This comes from the Hawton\Salkovskis\Kirk book, although I don’t know what its origins are.

So the formulation works in two parts, there is the trigger, see the spider get the symptoms, and then the reaction. The reaction to the symptoms might happen first, so I think I can’t cope, I avoid. But the standard thing is see the spider, get a freeze response, think this is terrible, then feeling fatigue, wanting to get away, and then thinking I can’t cope.

Treatment

This is going to be after psycho-education, exposure and response prevention, that’s pretty much it. Phobia is a fear of fear issue. As they don’t see it as rational, then cognitive restructuring isn’t going to do much good, unless it’s when the fear is activated.

Notes

Could do with some more information on treatment, although phobia seems to be a rare presentation.

Do also look at the treatment resistant anxiety section. Rollo May amongst others argues that specific phobias are a way to deal with more difficult anxiety, when you’re involved in a conflict that threatens something essential to you. It’s an impossible situation, but it’s easier to deal with if you substitute a simple phobia for it. So whilst following the above exposural treatment protocol is the safest, i.e. Occam’s razor way to go, if it doesn’t work, do look to when it started and if it took the pressure off an impossible situation.

GAD

Introduction.

There are three main models, Wells, Dugas, and Borkovec. The keys differences are:

1.       Wells: Type 2 worries

2.       Dugas: Intolerance of uncertainty

3.       Borkovec: Worrying as cognitive avoidance

I would also add, as I heard Gillian Butler talk, who argued that the domains that are worried about by GAD are significant. Standardly there are only certain areas that people have GAD symptoms over, e.g. how they are seen by others, or the success of their children.  So you would want to know why they think they can’t cope with a problem in these areas that they can in others. The answer to which is that it’s probably a combination to be, it’s vital to my personality and I have built up the idea of myself, through certain experiences that I can’t cope in these areas.

You might also notice that within the GAD presentation there is a desire to have complete control over something that may go wrong. Now to desire complete control would suggest that they feel powerless and out of control either in this area, or they are using this are to substitute what they are actually anxious about. But for this have a look at the treatment resistant section.

Diagnosis

For 6 months:

1.       Excessive worry about a number of events or situations occurring more days than not

2.       Worry is difficult to control

3.       3 or more of the following symptoms

a.       Restless

b.      Easily fatigued

c.       Difficulty concentrating

d.      Irritability

e.      Muscle tension

f.        Sleep difficulties

4.       The content of worries do not relate exclusively to Axis 1 disorders

5.       The worry causes significant impact on functioning

Dugas

Presentation

·         Clients live in the future, tend not to enjoy the present

·         Worries about a number of different things, almost everything in their life

·         Worries about more minor matters than the non-clinical worriers

·         Worries tend to be about more remote or unlikely things

·         Clients may be calm on presentation but go into excessive detail when talking about their worries.

·         Clients may not use the word worrying, their worry is an attempt to control all future eventualities, so they might talk about control

Concepts

Four main features

1.       Intolerance of uncertainty

2.       Positive beliefs about worry

3.       Negative problem orientation

4.       Cognitive avoidance

Intolerance of uncertainty

Negative beliefs about uncertainty and its implications. If there is a very small possibility that something can happen, then a GAD client will worry about how they can deal with it.  GAD clients seem to require absolute certainty. So an intolerance of uncertainty could also be seen as a need for absolute certainty.  This makes cognitive restructuring of the content of GAD almost impossible.

Positive beliefs about worry

Five main beliefs:

1.       Worrying:

a.       Can prevent or minimize negative outcomes

b.      Is a positive action for finding a solution

c.       Increases motivation to get things done

d.      Can prevent bad things happening

e.      Shows I care and am a responsible person

Negative Problem orientation

·         Problems are threatening (I won’t get it right)

·         I haven’t got the skills to fix problems

·         I’ve failed to fix problems before

Cognitive Avoidance

Two categories of

1.       Automatic strategies

2.       Voluntary strategies

Automatic

Borkovec shows that worrying dampens threatening cognitive content and physiological arousal.  It also dampens affect laden images.  So the GAD client will to suppress their fear response using worrying, they may well do it in an automatic way so as soon as something is seen that could be fearful, then worrying automatically kicks in to dampen the feared fear response. Thus worrying avoids the problem.

Voluntary

When there is a conscious thought, such as I could get cancer, then worrying kicks in this, provides the same cognitive avoidance but in a voluntary manner.

Conceptualisation

Treatment

1.       Monitoring Worry

a.       Trigger, Type of worry (current problem or hypothetical), Content of worry, length of worry, mood before and after

2.       Evaluate

a.       Beliefs about uncertainty

3.       Psychoeducation

a.       Worry as an intolerance of uncertainty. Certainty is impossible.

4.       ERP to uncertainty

a.       Not treble checking emails

b.      Don’t tightly plan do things on a whim

c.       Not filling every hour of the day

d.      Increase spontaneity

e.      Deliberately miss the last bus home

f.        Go to a shop without a shopping list

g.       Say yes to the first invite from a friend

5.       Re-evaluate the usefulness of worry

a.       So challenge the positive beliefs about worry, but note that it is the excessiveness of worry that causes the problems.

6.       Problem solving training

a.       Define the problem

b.      Generate solutions

c.       Evaluate solutions

d.      Choose

e.      Implement

f.        Evaluate              

7.       Re-evaluate negative problem orientation

a.       Cognitively restructure beliefs

b.      Show vicious avoidant circle that is maintained

8.       Imaginal Exposure

a.       Problem solving isn’t appropriate for things that have not happened. Before doing this it needs some selling. So you are frightened of something happening, so you worry, but this doesn’t stop you being frightened it actually increases your fear as you can’t do anything about it, so what happens you worry some more.  So what the model is you react to fear by using worry that increases the fear, but suppose we could get you to not react so strongly to fear, so that you didn’t need to worry.

Notes

TODO: I need to do Berkovec

Social phobia

Wells

Concepts

Social phobics live in fear of negative evaluation from others, which will result from some form of failed performance. It will be a socially judged performance (e.g. performing on stage) or could be just socially (e.g. at work, or at a party). The socially phobic person believes this failed social performance will lead to rejection and loss of self-worth. So a bad thing is going to happen, and this bad thing is going to lead to a rejection.

The social phobic has a negative self-concept and high levels of self-focus and this maintains their anxiety.  Social phobics have preoccupations with self-image, evaluation of others and performance. This leads to an increase in anxiety and a decrease in performance.  The socially phobic sees their performance inadequacy will make them embarrassed and that others will judge them as crazy, weak or stupid and will then reject them. The socially phobic fears both the view that others hold of them, and also the view they hold of themselves.

Conceptualisation

Central to the model is that social phobics never encounter situations to disconfirm their beliefs. The social phobic desperately wants to give a good impression, they think that a strong social performance will provide acceptance but they think they are incapable of doing so.

As the social phobic experiences anxiety, this then becomes a sign of danger and confirms their negative beliefs that created the initial anxiety. Social phobics are hypersensitive to their somatic responses as they can be visible to others and are signs of their inadequate social performance.

A social phobic’s attention to themselves detracts their attention to the other, who they see as the persecutor and them the centre of attention, the helpless one. Social phobics operate on a self-generated perception of how others see them, and act on that. This self-generated image is usually based on their feelings, so they feel bad, therefore they think they must look bad. Their safety behaviours then tries to counteract this perception but unfortunately makes their anxiety worse and interfere with social relation\performance. Some safety behaviours can make the social phobic appear unfriendly so can detract from social engagement. The non-occurrence of catastrophe in social situations is put down to safety behaviours.

There is an anticipatory phase where there is worry about the social situation. Safety behaviours can be seen rehearsing what to say etc. Anxiety can be significant here and has a significant impact when the social situation is reached. It is during the anticipatory phase that the negative self-image gets activated.  Then you get the exposure phase when the social situation is engaged with, then afterwards there is the post event processing, when social performance will be analysed, but because no feedback is sought from other people there, it merely reinforces worst fears. This is dealt with better in Hawton and Salkovskis. In the post mortem there is selective abstraction that maintains the negative self-image, and the negative thoughts about performance.

When in the exposure situation, attention shifts to the self, which is done from an observer perspective. This image is derived from interoceptive information, i.e. I feel bad I look bad.

It is not just that the feared thing can happen to the social phobic i.e. being rejected or stared at, but the meaning they make out of it, i.e. it’s a catastrophe. There is also a distorted sense of the other where the social phobic thinks everyone will see them.

The NATs the social phobic have are for instance, “I will tremble”. To work with these you need to find what the meaning of them is, i.e. I will tremble, and everyone will see, will think I’m crazy and reject me.

Cognitive Structure

Core beliefs: I’m boring

Intermediate beliefs: if people think I’m anxious they will think I’m incompetent. If people think I’m boring they will reject me. I am not socially competent

Rigid rules: I must not show any anxiety.

Treatment

Early Experience\Meaning

As you conceptualise then what can be useful apart from what keeps it going is, is to find out the main threat. Let’s say it will be I will be socially isolated and unloved. Now is this something they fear happening because it has happened before to them, or they have seen it happen to someone else, or they imagine it could happen to them.

Focus

Important to establish what the most significant time is for them, before a social invite, during or after. It could also be the times when they are avoiding social contact.

Socialisation

Look at how when they enter a social situation they perceive it as dangerous (they could be humiliated) and look to protect themselves from it.  However their anxiety that they feel because they think the situation is dangerous, is also used to prove the situation is dangerous. Their anxiety also produces safety behaviours (e.g. self-attentional focus), that combined with their anxiety makes social engagement harder, and therefore something of a self-fulfilling prophecy.  Their safety behaviours also increases their anxiety which again makes the situation more dangerous, and calls for their safety behaviours to be increased or for them to leave the situation.

So in terms of socialisation, firstly you have the thought “If I’m socially inadequate then I will be rejected and this will be awful”, secondly you have the safety behaviours and thirdly you have self-image.

So the socialisation is firstly to see the issue is of anxiety. So you enter a situation and you feel anxious as there is a threat there, you seek to prevent what you are frightened of happening, so you use your safety behaviours.  What is the effect of the safety behaviours on your performance and on your anxiety? When your anxiety increases what do you do in a social situation, does that create a vicious cycle? Does your safety behaviour have an impact on the catastrophic NAT that creates anxiety in the first place, does the safety behaviour save it from coming true, so implicitly validate it?

Treatment

1.       Elucidate the NATS

2.       Elucidate the somatic responses, find out how visible they think they are and how many people saw them

3.       Elucidate the core –beliefs, intermediate beliefs and negative automatic thoughts

4.       Elucidate the self-image

5.       Elucidate the safety behaviours (do you conceal your symptoms, how do you keep yourself safe), the avoidance, anticipatory and post mortem behaviours

6.       Do the conceptualisation

7.       Elucidate longitudinal data, was there a critical incident for themselves or another of social rejection

8.       You could well go back to the conceptualisation and operationalize it, so it will be terrible if I sweat people will think I’m stupid. How many people in the room? How terrible will it be

9.       Look at the relation between the NAT, the self-image and the safety behaviour, they will all go together.

10.   Socialise to the role of anxiety in the model

11.   Test the effect of doing safety behaviours, so do it in session and then in vivo

12.   Test the effect of self-focussed attention. Do it in session and then in vivo.

a.        Does it increase symptoms, does it increase anxiety, and does it mean we could find out that the NAT isn’t true.

13.   Cognitively restructure the core beliefs, intermediate beliefs and NATS.

a.       Firstly where’s the evidence

b.      Secondly what’s the catastrophe, could you manage it

c.       Thirdly what’s the counter evidence

d.      Aim to generate rational responses

e.      You can use a social balance sheet, i.e. internal evidence, external evidence and counter evidence

f.        Look at thinking errors

g.       Use interrogating the environment, so how could we tell if they think you’re boring

14.   Look at the self-image, how do you know this is what you look like, where does this image come from, look at its relation to the beliefs and the unpleasant feeling.

a.       You could provoke the symptoms with a video camera

15.   Look at the relation between felt sense, self-image and what the others see.

16.   Modifying self-processing

a.       Get client to do a presentation to you and get them to say how they think their symptoms will look\sound

b.      Video\audio tape and get them to judge it against that, and use a survey

17.   Overcoming avoidance

a.       Sell the vicious cycle

                                                               i.      I think it will be bad, I avoid, I feel relief. Next time, I have avoided it 10 times, so I guess it must be really bad, the fear goes up, as does the avoidance.

b.      Graded task hierarchy

18.   Increase bandwidth (social phobics operate in the safe zone of their rigid rules)

a.       Test increasing the bandwidth

                                                               i.      Take a rule and break it

19.   Test alternative behaviours rather than overcompensations, i.e. if I think I’m boring will try and tell jokes

Notes

1.       Need to do the Hawton\Salkovskis

OCD

Diagnosis

How do you tell if you have a client presenting with symptoms of OCD?

Firstly check you have a dystonic thought. It is important to check that it is dystonic as if it isn’t you may have someone who wants to carry out their thoughts and is using you to get permission. Secondly if you have related mechanisms that are used to reduce the anxiety of this thought, so checking, washing for example. To have repetitive behaviour which looks like a compulsion may well not be OCD. A client who has been raped, may repeatedly clean themselves. They do this to manage their emotions from the rape. However there is no dystonic thought, so you would be treating the trauma first.

Thirdly look at the onset and experiences around that time. If there was a highly anxiety provoking situation then the “OCD” ritual might be a substitute for this. OCD model has threat and control, so can function as a substitute for feeling helpless.

Veale and Wilson

Introduction/Concepts

Most common OCD subtype is contamination, then ensuring harm doesn’t come to property, e.g. checking, then symmetry, then TAF. All OCD behaviours are about harm, either preventing harm happening to self or others, or ensuring that I don’t do harm to self or others.  With contamination\checking\symmetry then I’m protecting from harm, with TAF I’m protecting from doing harm.

There is also the theme of responsibility: Checking is to respond to the awfulness if I was responsible for being burgled.  Symmetry sees high level of responsibility for the awfulness if something happened to my loved ones, and possibly a negative problem orientation.

With compulsion then the criteria for stopping is emotional, although it could be argued with contamination then it is logical certainty, or when I have no more doubts.  This is as opposed to the objective standards people without OCD have.

Maintainers

Safety seeking behaviour= this is finding out that you don’t need to do your compulsion to be safe, E.g. compulsive washing.

Avoidance where you find out that you don’t need to avoid situations to be safe, for instance symmetry people.

Magical Thinking the belief that you can think something and make something happen

The key aspect with maintenance is that the safety behaviours focus the mind on the fear repeatedly. This makes it seem more likely and therefore needing to be protected against. The more the focus on the feared harm there is, the more likely it becomes and the more awful as the feared event is dwelled on, therefore the certainty criteria that is needed to ensure you are safe.

Vicious circles

Certainty= the harder that you try to be certain about something then you merely increase the levels of doubts you have to rule them out. But all this does is increase your ability to doubt, which means you feel less certain and you continue trying to get certainty by fixing your doubts. Thus you have a vicious circle.

Safety behaviours

These are to protect you from the feared thing happening. But the more effort you put into safety behaviours, the more likely you think the feared thing will happen and therefore the more effort you put into safety behaviours.

Avoidance

The more you avoid your feared object, the more attention you put on it, the more likely it is that you think it could happen

If you believe the intrusions are the problem then you need to neutralise them. If you believe intrusions are normal then your attempts to neutralise them are the problem.

General Conceptualisation

What is the feared event?

What is the intrusion?

What is the compulsion?

What is the criteria for finishing compulsion?

What are the other behaviours, given the existence of the feared event?

Avoidance, reassurance seeking, worry etc.

Beliefs pertinent to subtype: Magical thinking, thinking something is a bad as doing it, I must therefore be bad

Early experiences to explain core concepts

With any of the early experiences find out is the OCD behaviour a substitute for a previous anxious scene. With their anxiety are they trying to stop something that has happened before or they imagine happening.

Contamination

Core to this is that I/or loved ones am vulnerable to getting ill, and if I\they got seriously ill it would be catastrophic, find out why this is. Early experience of someone being ill that was felt as overwhelming, or imagined awfulness is someone, e.g. child became ill.

I have to be highly certain that I have protected myself from harm. Emotional as opposed to rational criteria are used here to establish how much precaution should be taken to protecting from harm. Theory A is I have to protect myself from germs that could give me a serious illness. Theory B is I am worried about serious illness, and my compulsions reduce my worry. Again notice the theme of certainty. A desire for certainty often is the solution to a feeling of helplessness and anxiety.

Checking

Core to this is that I don’t trust my abilities, functional and memory, and that if I was responsible for something bad happening this would be catastrophic. Early experiences of being untrustworthy, blamed or of how bad it would be if something bad happened, and it could.

 Emotional as opposed to rational criteria are used here to establish how much precaution should be taken to protecting from harm. Theory A is I have a bad memory and can’t be trusted. Theory B is I am worried about being responsible and my compulsions reduce this fear. Certainty criteria again seen here generally, of I must be certain I have turned off the light.  Again notice certainty as a solution to a feeling of helplessness and anxiety.

Symmetry

Core to this is magical representational action and how catastrophic it would be if something bad happened to my loved ones and how I am responsible for stopping this. Early experience of wanting to be able to have an impact on something and feeling powerless, so resorting to magic to help.

Theory A is I can affect my loved ones by doing representational actions. Theory B is I am worried about bad things happening to my loved ones, and my compulsions reduce this worry

TAF

Core to this is how thoughts are more than thoughts and about how catastrophic it would be if I wasn’t a really good person.  Early experience of being told off for thoughts, fear of being bad, importance of being good and not thinking bad thoughts, certainly some strong moral rules have been here.

Here compulsions are not so much to the fore, or not necessarily. You more see safety behaviours and avoidance.  Theory A is I’m a bad person, and need to ensure I protect others from myself.

Treatment

1. Conceptualise
2. Create Theory A Theory B and get % belief. Use this through treatment to capture evidence for each side
3. Establish the core maintaining aspect
1. Contamination
1. Certainty
2. Checking
1. Awfulness of being irresponsible and being blamed
3. Symmetry
1. Awfulness of something happening to kids, responsibility and magical action
4. TAF
1. Awfulness of being bad, significance of thoughts
4. Monitor the behaviours (use variations to support theory A or theory B
1. Contamination=Theory A, I must do all I can to protect myself from germs to stop myself getting a serious illness. Theory B I am very worried about getting a serious illness, and the effort to make sure I protect myself is maintaining the problem
2. Checking= Theory A I am not to be trusted to shut the door, and my memory is suspect, therefore I must repeatedly check the door. Theory B I am really worried if I was responsible for us being broken in, my efforts to make certain maintains the problem
3. Symmetry=Theory A I am responsible for stopping harm happening to my loved ones, which I can do, by magical action. Theory B, I am really worried if something happened to my loved ones, and my use of magical action, maintains this worry.
4. TAF=Theory A It’s likely that I’m a bad person, and I must avoid having bad thoughts, and being out of control.  Theory B I’m really worried that I might be a bad person, and trying to remain in control and avoid bad thoughts is maintaining the problem.
5. Prepare for exposure
1. Establish general level of anxiety about harm coming, increase safety behaviours to see if it affects anxiety levels
2. Psycho-educate about safety behaviours
3. Look to find out what determines how long they do their compulsions and psycho-educate about the difference between an emotional                  
4. Psycho-educate to anxiety and false alarms and what might happen if you are exposed and you do not respond as you usually do
5. Teach attentional focussing techniques (could become a new safety behaviour)
6. Establish what is important to them about overcoming OCD, have this present in some way when exposure is done.
7. Expose (this should be on the core maintaining aspect)

Salkovskis

Concepts

OCD is understood as something really awful could happen, that I am responsible for and that I can prevent. Through the use of the compulsions there is the belief that it is prevented. This awful thing is indicated in a thought. 

Because of the enormity of the “something awful” that could happen great effort needs to be put into stopping this happening. Sometimes high levels of certainty are required to ensure this doesn’t happen.

The trap of OCD is that you never find out how improbable the something is that doesn’t happen, you never find out that you could cope with it. Again the compulsions repeat the idea that it is awful and probable and you can’t cope. The search for certainty can be self-defeating as the more you check, the less you trust your memory.  As soon as you doubt yourself in this way, then you can start to doubt other aspects of your life and OCD behaviour can generalise.

The problem with OCD is one of anxiety. There is an intrusive thought that produces anxiety due to the meaning attributed to that intrusion. The compulsion in the short term reduces this anxiety but keeps it going in the long run. Working with clients this is the first piece of psycho-education you need. Without this I think it’s going to be difficult to work. As soon as you get this theory A, theory B you can do vicious flowers, behavioural experiments, and you can change the way the client thinks about their problem. Instead of seeing it as a problem with the content they point to, e.g. contamination, something bad happening etc., it gets moved to an anxiety management technique.

Conceptualisations

Treatment

1.       Conceptualisation

a.       Develop that it is the interpretation of the thought that is the problem

b.      Ensure you get what would be so bad if they don’t do their compulsion, i.e. core beliefs. Also think about the responsibility angle and see if something goes there

c.       Look to bring out fear of uncertainty

d.      Look to develop that idea that they are treating this as an incredibly important problem, which can help you understand it. The awfulness felt by clients is so bad that they want to make this amount of effort

2.       Theory A and Theory B

a.       This is vital for treatment.  The difference being Theory A=there is danger, theory Br you are worried about danger. So where’s the evidence, how should you behave to improve this problem, what does this mean for the future and what does this say about me as person

3.       Show how safety behaviours are self-defeating

4.       Taking the Risk

                                                               i.      Here you aim to get the client to test out theory B find out if it is true but this takes some courage and hopefully the theory A and B work will show the advantages and disadvantages. If not then use the insurance salesman, i.e. comes to your door either 50 for the basics or 100,000 for everything. What would you do? Go for the lower cost as it’s unlikely to happen. OCD is like a seedy insurance salesman, it is a very high cost against very low probability

                                                             ii.      Do an advantages and disadvantages of being obsessional and anti-obsessional

                                                            iii.      The risks you want to take are

1.       Start living your life according to theory B

2.       Challenge your beliefs that you are responsible for something bad happening

3.       Don’t avoid anything

4.       Stop all safety behaviours

5.       Start finding out how the world really works.

                                                           iv.      Use the analogy of the builders mate and the wall, and lead into the three choice obsessional, non-obsessional(theory b), or anti obsessional (challenge theory A)

                                                             v.      Set up behavioural experiments that are either non obsessional or anti obsessional. Support anti obsessional with the analogy of soldiers training for war.     

b.      Tackling Responsibility beliefs

                                                               i.      Use a continuum, with extreme examples, then examples of known people then put the client on. Ask what would happen if they don’t do their compulsions, how much would it change their position

PTSD

Ehlers Clark

Concepts

People with PTSD have the experience of trauma which is not a time limited event (i.e. which ended) that has global implications for the future that indicates danger. This danger can be external, i.e. the world is a dangerous place, or internal, I am not capable of doing the things that are important to me. The reason these beliefs can be constructed is there can be a prior vulnerability to these beliefs before the trauma, and then the trauma both confirms and accentuates them.

PTSD is characterised by the sense of current threat. This has to do with the cognitive processing during the trauma. When there is a sense of the self being overwhelmed the amygdala part of the brain is responsible for encoding memory. The amygdala doesn’t encode situationally, i.e. in a time, in a place. This leads to recall being by data driven triggers such as sounds, sights, smells that are related to the original memory. So you get data driven triggers to intrusions that seem like they are happening now, as there is no situational memory. What also contributes to this sense of current threat is the overgeneralisation of the cognitions learnt from the trauma. So the client might learn that this exceptional event is more frequent than it is and the world is a bad and dangerous place and men are not to be trusted.

The sequelae of the trauma are intrusions, mood swings, emotional numbing and lack of concentration. That the client has these symptoms can also lead to the client interpreting them as indicators about dysfunction with themselves. I’m going mad, I can’t cope etc. This when mixed with the negative appraisals of the trauma can be highly debilitating and can lead to changes of behaviours. These can be avoidance of places that trigger intrusions or safety behaviours that keep themselves safe. Both of these then maintain their dysfunctional appraisals.

The predominant emotions around PTSD can be:

1.       Fear/Anxiety: e.g. nowhere is safe, leading to anger about this being unfair

2.       Shame: I enjoyed him doing that, I’m disgusting

3.       Sadness: That accident means that my life will never be the same again

Some of the safety behaviours are:

1.       Suppress thought

2.       Suppress emotions

3.       Avoid the place it happened

4.       Checking things are safe

5.       Ruminate

6.       Give up seeing friends

7.       Give up pleasant activities

8.       Stay up very late, to avoid nightmares

9.       Avoid anything that could be stressful

Conceptualisation

Treatment

1.       Produce the conceptualisation

2.       Psycho-educate about PTSD and trauma

3.       Relive and rescript

a.       Identify hotspots: restructure

b.      Rescript the unpleasant image, update with new information, roll forward to a safe place, introduce helping figures

c.       Identify triggers and discriminate then from now

4.       Behavioural experiments on the effects of safety behaviours

Health Anxiety\Somatic problems

Salkovskis

Concepts

You may well meet clients who sees CBT as a last resort, they have tried medical treatment, but haven’t got “cured”. They may believe they have a physical problem but no one is treating them seriously. So the first port of call is to treat them seriously.  Their difficulties are real, its causes and treatment is unknown.  One concept that could be useful is instead of just have a cognitive triangle add in the body to make it a square, and show how physiology is changed by emotions and how physiology changes emotions, they have a bi-directional relationship. You do not want to rule out somatic causes but then you want to look at the psychological aspects of it. There could be some physical stuff going on, but then there could be some psychological stuff going on.  Indeed you could argue that all physical sensation is modulated by the brains interpretation (see Moseley and Butler)

Clients generally believe their problems are physically caused.  Client’s base exaggerated beliefs on observations of physical aspects. These beliefs are that their physical symptoms show that something bad will happen to them, impairment, illness or death. The emotional reactions to this are anxiety that it may happen, or it is preventable and depression when they think it really will happen.

Reaction to this belief of oncoming danger is cognitive, emotional and behavioural and can both impair the persons functioning and maintain the problem.

Categories

3 types

1.       Problems with an observable disturbance of bodily functioning e.g. IBS

2.       Problems of perceived disturbance or excessive reaction to bodily symptoms

3.       A mixture of the above two

Physical\Psychological correlates

1.       Anxiety disorders

a.       Insomnia

b.      IBS

c.       Headaches

2.       Depression

a.       Loss of appetite

b.      Panic attacks

c.       Cardiac symptoms

Conceptualisation

Maintaining Factors

1.       Increased physiological arousal. Given there is a perceived danger there is physiological arousal which can be misinterpreted as a sign that there is a somatic problem.

2.       Focus of attention. The area which is thought to be the locus of the problem may have a lot of attention put on it, which can enhance the sensations either physical or perceptually.

3.       Avoidant behaviours

a.       Clients are anxious about threats which are posed by internal stimuli. These can be enhanced by external sources, e.g. reading about things in the paper. This can in turn generate avoidant behaviour, i.e. never exercise due to fear of heart attack. The more the behaviour is avoided the more strength gets added to the belief, I could die of a heart attack through exertion.  Both avoidant behaviours and safety behaviours all reduce anxiety short term but perpetuate it in the long term

4.       Beliefs and misinterpretation of signs. Ambiguous information is seen malignly, an itch means malaria, a doctor saying, I don’t think you have anything wrong with you, leads to the idea that there could be as he wasn’t certain.

a.       Thinking errors: there is a confirmatory bias, where evidence that supports the negative belief is remembered and that which contradicts it is forgotten

Socialising

A client presents and may be resentful to seeing a therapist thinking they have a physical problem not a psychological one. This needs addressing.  So firstly find out what their thoughts are about seeing you secondly say that at the moment you don’t know what the problem is , or problems are but what we can do is to see if there is any psychological component, which if we treat can make an improvement for you. How much is psychological and how much physical we don’t know but we can test this and get to find out some more about it.

Assessment

What are the symptoms, what do they mean to you? Look at thoughts\emotions and behaviours that relate to this. Look at avoidance too and ask what the worst that could have happened had you have done them.  What you also need to find out is the key variables:

1.       Problem incidents

a.       Related behaviours, including safety and avoidance

b.      Related beliefs

c.       Related emotions

d.      Medication taken

2.       Early experience: is fear of bad health something that is an imaginal problem, or that has happened and they are trying to prevent happening again

3.       They generally seek high levels of certainty than people who don’t suffer, do they have equal and opposite higher levels of helplessness. Is so why?

Treatment

Underlying principles

1.       Aim  to help identify what the problem is rather what the problem  is not

2.       Acknowledge symptoms emotional and physical do exist

3.       Distinguish relevant, irrelevant and repetitive information and avoid reassuring with the latter

4.       Stay collaborative, don’t end up in a physical vs. psychological battle

5.       Don’t discount clients beliefs rather find the evidence that supports them and collaboratively look at those

6.       Use frequent summaries to ensure that new ideas are not discounted using the confirmatory bias thinking error

1.       Monitoring

a.       Monitor the frequency of the key variables

b.      Aim here really to get an ABC analysis

2.       Engagement in treatment

a.       Look at the conceptualisation and see what the relation between thoughts, emotions and behaviours is

3.       Reduce medication (in consultation with doctor)

a.       Taking medication when you haven’t a disorder can increase anxiety as it increases attention that you have a disorder

4.       Dietary and lifestyle

a.       More exercise

b.      Better diet

c.       Less caffeine, alcohol and cigarettes

5.       Cognitive restructure

a.       Use probability approach, i.e., how many people in a city, how many have a headache, how many refer to the doctor

b.      Look at the beliefs, the lump means I have cancer, and how strongly it is believed.  Relate the strength of the beliefs to different contexts, e.g. checking the lump and not checking the lump. Beliefs should be challenged when they are at their strongest

6.       Behaviours

a.       Look at the relationship between the symptoms and when you pay attention to them and when you don’t, do they increase, have you got an intelligent disease

7.       Psycho-educate

a.       Pain understanding and being not purely physical could be useful see Explain Pain by Moseley and Butler

Wilson and Veale (Overcoming Health Anxiety)

Stages:

1.       Assess

a.       Early experiences

                                                               i.      Experience around illness

                                                             ii.      Experiences around people protecting themselves from illness

b.      What are the triggers to worrying about health anxiety

c.       What behaviours do you have to keep yourself safe

d.      What do you avoid because of health problems

e.      What is your fear of having a serious health problem, what do you think would happen, what makes you think you couldn’t cope with it.

f.        What are your health based Intermediate Beliefs, that underlie each behaviour

                                                               i.      Checking can prevent me from having a health problem

                                                             ii.      I’m likely to have a health problem

g.       What is your current preoccupation with health, i.e. how much time do you put on it, how sensitive to news articles, to sensations in your body etc., how has the preoccupation changed over the years

2.       Establish Theory A and Theory B

a.       Theory A I have a medical problem

b.      Theory B I am anxious about having a medical problem and through trying to become less worried about it I am keeping the worry going

3.       Conceptualise (you could do a vicious flower with preoccupation with health at the centre or :)

a.       Do a functional analysis (have at the top both the preoccupation with health anxiety and I have a problem with my health, i.e. Theory a and b)

                                                               i.      Find a bump

                                                             ii.      Have a thought

                                                            iii.      Get anxious

                                                           iv.      Get physiological response which can provide more evidence

                                                             v.      Do something to feel absolutely certain there is no problem

                                                           vi.      Reduce anxiety

b.      List all the triggers, in a box on the diagram of the functional analysis above.

c.       List all the behaviours, in a box on the diagram of the functional analysis above

d.      Establish what the short and long term impact of the behaviours is

                                                               i.      This results in what the point of these behaviours is and gives us a treatment option already, draw this on the conceptualisation

4.       Treatment

a.       Theory A/B

                                                               i.      Establish what you would need to do if theory A  or B is true

                                                             ii.      Rate theory A and Theory B

                                                            iii.      What is the back ground to supporting theory A\B

                                                           iv.      How much do you believe theory a/b.

                                                             v.      What gives us evidence to support theory A or theory B

b.      Testing effects of various behaviours to prove short\term long term effect

c.       Managing the triggers

                                                               i.      Exposure to triggers without response prevention

                                                             ii.      Finding body abnormality

1.       Do the thumb test

2.       Establish beliefs about abnormality and health

a.       Challenge, do nice recommendation, should everyone operate this standard

3.       Try reducing checking to a tenth of what you do at the moment and see the impact of how many abnormalities you find

                                                            iii.      Thoughts

1.       Challenge

2.       Mindfulness

3.       Best\worst\most likely case

d.      Managing behaviours

                                                               i.      Increase the behaviour see if it decreases anxiety or provokes it

                                                             ii.      Deal with Worry (CBA, worry time, decatastrophise)

                                                            iii.      Socratically question criteria for certainty and its affect (You can never prove, with absolute certainty that something isn’t the case)

e.      General

                                                               i.      Self-focussed attention

1.       Do the self-attention focus monitoring to see the effect then do the treatment

Self Esteem

Introduction

Self-esteem is a funny one. It combines depressive and anxious difficulties and is held together by a negative core-belief about the value of yourself. So I’m unlovable, ugly, incompetent, a loser etc.  Whilst one approach to this might be to invert the core belief, so I’m beautiful, clever, a winner etc., but then I guess another would be move outside the valuation of self. The base core belief is only a problem seemingly as it means something about the person’s ability to fulfil their needs in the world. So I’m incompetent, therefore I won’t be able to look after my needs and I won’t have friends or a lover as no-one will respect me. It seems the core belief needs caching out in terms of what this means about them. Implicitly within the model it’s here within the intermediate beliefs but I do think it needs to be spelt out clearly with a client to understand what this means to them.  I would also add that given individual competitive success is a very common value in our society (see Rollo May Concept of anxiety for more on this.)

Concepts

The maintenance cycle of self-esteem is a negative view of self, leads to a negative bias in perception, a negative cognitive interpretive bias and a negative memory bias.  The things that “protect” the client from their feared bottom of line of for instance I’m not good enough, are to have rules for living, such as I must always achieve high standards in whatever I do. Whilst this can cause problems in themselves, whenever you get a rule break then you will activate the bottom line.

Once the bottom line is activated then the client’s makes anxious predictions of what will go wrong. This can lead to avoidance, safety behaviours, worry, all things that you can see in the social phobia model impacting performance and maintaining the anxiety.

When the bottom line is confirmed, then you will see self-criticism and a depressive cycle.

Conceptualisation

Treatment

Well it depends where in the cycle they are depressive or anxious but assuming anxious then

1.       Challenge anxious predictions

a.       Overestimating something bad will happen and I won’t be able to cope

b.      Monitor them, understand what makes them believable,  then cognitively restructure

c.       Generate alternative beliefs, and identify what’s the worst that can happen and what the best is

d.      Test them out

2.       Identify safety behaviours

a.       On the basis of the anxious predictions what are the things you do to keep yourself safe.

b.      Monitor safety behaviours and find out if they help

c.       Do behavioural experiments to test their efficacy

3.       Self-criticism

a.       Monitor how often and how it makes you feel

b.      Psycho-educate, if you someone told you over again the same thing, would you start to believe it, would you believe it even more if it was someone very close to you? But just because you’re told it, does it make it true?

c.       Do an ABC on self-criticism, what are its consequences? What are the advantages and disadvantages of it? Is it true, are there other ways to look at the evidence. Do you notice the triggers for self-criticism, is it when you are down? What makes self-critical thoughts more believable? Where did you learn self-criticism? Have you been criticised in anyways similar to your self-criticism, was it useful?

d.      Introduce cognitive, memory, perceptual biases and how they help keep depression around. Identify thinking errors

e.      Operationalize self-critical thoughts, e.g. I’m such a loser, then cognitively restructure individual self-critical thoughts. Maybe draw on the biases and errors mentioned above. Maybe use a continuum to counter any black\white self-descriptions.

f.        Introduce positive data logs and the notion of discounting

g.       Do behavioural activation as when things are going better you don’t criticise yourself

4.       Rules

a.       Get the major rule that is going on for the client then work through the changing the rules form which

                                                               i.      Establishes its impact

                                                             ii.      Knows it’s in operation because..

                                                            iii.      Realise it’s understandable because..

                                                           iv.      Realise its costs and benefits

                                                             v.      Knows where it was learnt from and why

                                                           vi.      Develops a more realistic rule

b.      On the generation of a new rule then test drive it

                                                               i.      Know how you will tell it’s in operation

                                                             ii.      Monitor its use

5.       Bottom line

a.       Do a longitudinal analysis to know how you learnt it

b.      Weaken the old one with cognitive restructuring and a continuum if appropriate

c.       Identify a new one and its attributes

d.      Keep a log of all times you see evidence of the new one

e.      Look at evidence for old belief, reframe and restructure this

f.        Do behavioural experiments, of how you would act if the new belief was true

Anger

Introduction

This section taken from the overcoming anger and irritability book.

Concepts

Think of the leaky bucket. Anger can build up by things getting added to the bucket, and also can leak. When the bucket overflows that signals an angry outburst.

Assessment/Treatment

1.       Longitudinal

a.       When did you notice having a problem with your anger

b.      Did you know many angry people as you were growing up

2.       Identify the triggers, and what level of anger they create

3.       Identify the internal and external inhibitions that modify your responses to anger

4.       Monitor the number of times you feel angry, their levels and your response per week and their consequence

5.       Conceptualise a specific situation into trigger, appraisal, anger level, inhibition and response

6.       Monitor using the smaller conceptualisation to get good detail of trigger, appraisal, inhibition and responses

7.       Conceptualise using the moods and what their determiners are

8.       Make a comparison of how things seem when in a good and bad mood

9.       Do a longitudinal analysis on the key beliefs

10.   Start cognitive restructuring appraisals

11.   Introduce thinking errors, and notice  which ones pop up

12.   Introduce cognitive restructuring forms for angry situations for homework

13.   Exposure to anger inducing situations

Conceptualisation

Client Behaviours
Wind tunnel client behaviour
Definitions:
Speaks quickly, moves from topic to topic (kitchen sinking), speaks for long periods of time, moves off topic before one topic has been dealt with
Effects:
Listener can’t respond there’s too much
Speaker feels overwhelmed.
No one can deal with any one of the topics as they connect to all the others so you can’t problem solve
Possible causes and maintaining factors:
Client has a desire to fix everything and a desire that their therapist helps them do this.
Client responds to anxiety by doing things more quickly, speaking, acting etc. When one problem is engaged with then this reminds them of another and they move onto this.
Client doesn’t start one problem as this would mean they are not attending to all the others.
Client is concerned that starting with one problem might mean they might not achieve it (LSE\perfectionism)
Client is concerned that tackling one problem they won’t know what will happen (intolerance of uncertainty)
Interventions
Notice the wind tunnel is happening and reflect back to client.  Check in with them the effects of it, emotionally and behaviourally on them, if this leads to more wind tunnelling let them know how it is for them. Ask them if we shouldn’t pick an area to start with and maybe what makes it difficult for them to do it.
Traps
If you are concerned about being a good enough therapist you might try to solve all their problems and be complicit with them