Cognitive-Behavioral Therapy Class -2007

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CBT class –spring 2007

Class 26/2/2007

Q) how do you know the therapy is working?

A)

Evidence-Based Practice

• knowledge in the field
• client and his needs
• therapist and his needs

-many times, we choose approach based on gut-feeling

àCBT is an approach which was proven scientifically

àgot to look up how CBT was studied on specific issue that client brings up

Why is CBT popular

-in CBT you can measure success. In others, you can’t measure success

-more people involved =b/c insurance limits the # of measures

-cheaper = shorter therapy

-sees client as equal àpass on info to client

Historical path:

Psychodynamicàhumanisticàbehaviorism [50s ->wanted the success of therapy measured]àCBT

Radical behaviorism

-skinner: we can only look at behavior since we can’t see anything else. Also, they thought that therapy should be cheaper

-skinner: there is no emotions/personality àeverything is a product of surrounding/context = we need to see everything. Whatever we don’t see – doesn’t exist

-clean behavioral = works on people with things like dementia/autism/etc = when you definitely can’t talk about anything

-diagnosis is most of the work here “functional analysis”

Functional analysis: ABC

Antecedents – 2^nd stage = see why he does it [radical behaviorists: you got to observe – can’t ask him] – this is done in hypothesis fashion

Behaviors-1^st stage = you got to identify very clearly and specifically what the problem

Consequences -3^rd stage= why he continues doing so – benefits? – this is done in hypothesis fashion

• positive reinforcement –give something positive [change consequences] to change b/h
• negative reinforcement –take away something negative

àboth increase b/h

• punishment: don’t deal with motive/leaves bad taste = work less

àdecrease b/c

-each person is diff – so you got to do functional analysis for each person separately

-if you change the consequences, you change the behavior

How do you collect info in functional analysis?

-we want to see which b/h is problematic = does it fit situation/too much/too little/intensity of b/h

Kinds of observation:

• ask people in patient’s surrounding
• benefits: cheap/24 hours
• downside: lack of training/incorrect reports/sometimes atual surrounding create the problem
• professional observer [external]
• benefit: objective/professional
• downside: expensive/could infl. Patient’s b/h

• self-monitoring: probably not in radical behaviorism
• analogous monitoring: in similar situations –i.e. in things like phobias àmight use simulators

Principles emphasized in Self-Monitoring

• be specific – on focusing the patient on what to look
• i.e. in diet:
• number of calories
• kinds of foods
• number of meals
• drinks
• note: very specific measures

• got to make a chart w/ patient about what to do:
• what behaviors
• when
• where
• w/ whom
• decide who fills the chart, and when:
• with the event
• afterwards – at night

-studies show that people who do the homework succeed better in therapy

Cbt:

-you need to diagnose in order to see how to go about treating the patient

Class – 12/3/07

-radical behaviorists do not do interviews – only observe

-you have to teach people h. to do their observations: i.e. choose when a good time to observe is. Usually, most comfortable thing for client is to do retrospective observation

-part of preparation is to speak about possible obstacles in filling out the observation

àa main problem is practice and maintaining the observations – you have to make sure that they know exactly what to do

àanother observation is physiological measures

Tripartite model of Behavior:

• Physiological
• Behavioral
• Subjective

-there is often a gap b/w the diff. measures, and this could also be an opening for work

Functional analysis:

-when we want to make change in client, we have to see what we want to change

àso, first question is

1. what is the wanted alternative?
2. can the client put up with the alternative?
3. what obstructed client from doing so?

Ways to do so, behavioristically

1. antecedent manipulation: bringing client into the situation differently – i.e. if kid had a hard time in supermarket – give her a toy
2. extinction: we stop reinforcing the behavior: i.e. we stop giving her the junk-food that makes girl go wacko in supermarket
3. differential reinforcement of other behaviors: you reinforced the preferred b/g and not reinforce the unwanted b/h –i.e. give the child her wanted junk-food from the super, but when she does the right b/h and not wrong b/h

criticism of clean behaviorism:

• doesn’t solve beyond the symptoms
• doesn’t deal the general problem
• makes person mechanical – the b/h see this as a strength
• everyone can do the job – so the therapeutic relation isn’t important - the b/h see this as a strength
• his is manipulation of the therapist [it is more clearly seen that psychodynamic b/h]
• ignores past of client – CBT says that this is not true!!!

2 trends in CBT studies:

1. efficacy studies - needed in order to prove that a therapy works
• randomized control trial (RCT)
• always has a control – high control over what happends in study. The participants are set to clear criteria. There is a guide book àinternal validity
• Downside: not natural setting of clients. It is done ‘sterility’ as in a lab. In reality, there is no guide book
2. effectiveness studies - doesn’t speak about which works – not filtered population, or # of meetings. There is no control here, but there is external validity [except you don’t really know what you are generalizing]
3. dissemination studies: try to take effectiveness studies and generalize it to natural contextual settings

Cognitive-behavioral unit

4 interacting elements of treatment:

1. behavioral
2. physiological
3. affect
4. cognitions/thoughts

-change in one infl. All the rest

First thing: as a therapist: try to map out where client is w/I the 4 elements [above]

àalso need to explain to the client why we’re doing this –that each infl. Each other

-so mapping out means to put into the specific clauses in right places – i.e. “I feel everyone hates me” is not an emotion but a thought

19/3/2007

-in CBT, the diagnosis is of the essence – it dictates how to treat

Major depression

5 out of 9 symptoms in 2 weeks

1. subjective sadness or lack of interest –this symptom has to be there

then 4 out of 8

2. loss or gain of weight
3. sleep disturbance
4. irritable or slow b/h
5. tiredness/lack of energy
6. shame
7. perceived lack of value
8. lower concentration/thinking
9. thought of death or suicide

ways to find out depression

questionnaires:

1. beck depression inventory: BDI
2. CESD
3. geriatric depression scare

àonly shows symptoms

clinical interviews:

1. structured clinical interview for DSM-4 –SCID – considered the definitive set

àfor diagnosis, need also professional evaluation than open interview

Beck

-started off as psychoanalysit, but then decided that:

1. thought
2. Cognitive
3. Affect
4. Physiological

The cognitive triangle – imp. for dev. Of depression

1. negative view of self
2. negative view of surrounding
3. negative view of future

-people w/ depression seem to make cognitive mistakes

Mistakes: based on primary schemes that are not adapive/self-talk is negative

1. all-or-nothing
2. selective search [to substantiate their claim]
3. mind-reading
4. catastophization
5. maximization or minimalization

schemes:

• stable ways of thought that develop in childhood and remain through life

àin depressives, the maladaptive schemes are caused by lack of fit b/c temperament and family setting.

• b/c those schemes are so primary, we’re often not aware of them
• people generally don’t change them
• they are stable over time, b/c they are so deep
• in pathology, the schemes are maladaptive

conceptualization of using schemes to understand patient

1. childhood experiences
2. schemes – i.e. world is against me
3. ways of coping – i.e., extreme b/h

--until now – things learnt in past

--now: in present:

• situation 1:
• automatic though
• emotion
• behavior:
• situation 2
• automatic thought
• emotion
• behavior

-in CBT therapy – speaks s about here and new and only later do they speak about background schemes

-process:

• decide what is the proceedings in the session
• events of past week
• homework – working on the technique discussed – b/c:
• the real problems are not in the session but in the real world
• Helps implicate the stuff learnt – also in Long term
• Gives info as to what happens to client in outside world
• Proves to be essential to success of therapy
• Need to discuss possible obstacles
• Need to give g/w that person can do
• new technique taught to client [+explanation/rational for why it is done]
• summary
• mutual feedback

behavioral activation

-depressives tend to have few positive events and many negative events [behavioral approach] àartificially get them to have positive activities àkick-starts therapy

-there are lists out there of things that

-many people know intuitively that we also need to have fun, but the depressives don’t

26/3/2007

-thought journal:

• this helps test thoughts
• Make them more adaptive
• Not used when thought is correct
• Important to differentiate b/w thought and emotion despite phrasing of client
• Try to understand the issue that the client brings

-after taking alternative thought into account, see the new score of the emotion

Stages of therapy:

-at first reduce symptoms

1. b/h activation
2. try to seek evidence for a certain assumption vs. contradictory b/h
3. seeing relevance of the issue – i.e. what does it matter to you if X thinks something of you –socrantic question: questioning the validity of the assumptions.
4. thinking more rational – i.e. think in words and not amorphically

-if it is hard to verbalize something, mental acting out or role playing

In later stages:

• you can start working on schemes and not specific symptoms – to avoid relapse
• to ado preventative therapy
• link b/w past event sand correct schemes – how did person come to have current schemes
• there are “dominant schemes” tests
• the schemes dictate specific automatic thoughts. It is self-feeding =it only allows evidence supporting

Jeff Young – common schemes

1. abandonment – i.e. borderline
2. Mistrust and abuse
3. Scheme of dependency
4. Vulnerability – always await a disaster
5. Emotional deprivation
6. Social isolation
7. Defectiveness: something is inherently wrong with me/I am a failure
8. Subjugation – give up your needs for others
9. High standards which are impossible to rech
10. Entitlement

-they start in childhood, but stay around for the long run

Questions to find the depressive schemas – w/ answers ranking 1-5

1. I cling to close people b/c I fear they will leave me
2. I worry that close people will find someone else to love
3. I usually check what are the motivations of others/don’t easily trust people
4. I can’t put down my defenses t/w others, so they won’t hurt me
5. I worry about dangers more than others
6. I worry that me or my family will lose $
7. I don’t succeed in dealing independently w/ my problems
8. I am same as my parents in problems
9. I have no one to care or worry about me
10. people never listened to my needs/no empathy
11. I do not fit
12. I am boring/dry
13. If someone knew my real self w/ all my problems, no one will like me
14. Shame of myself
15. I am not as intelligent as others
16. Inadequate
17. I have no choice but to answer others’ needs – so they won’t reject me
18. People see me as one who does more for others and too little for me
19. I try to do my best/no compromise/I have to be #1
20. There are so many things that I have to do, that I have no time to rest or enjoy life
21. I feel I can’t go through regular norms
22. I can’t get myself into routine to finish a task/control my emotions

-the above questions –each 2 parallel to each of young’s category – keep the highest score

Changing schemes:

-after identifying the scheme, find evidence for the schemata and for its alternative

àsame as automatic thought – just here, it s underlying assumptions

-i.e. I am always a failure vs. I also succeed/I can fail w/o being a failure

Class was off for a while b/c of Passover and the retarded student strike

Class 14/5/2007

Anxiety –intro

-anxiety is adaptive in its basis

-best when it is in the middle – not to high, but not too low

àthis is the first piece of info of those who come to CBT for it. To try to get rid of it is not only maladaptive, but also increases anxiety

-fight/freeze/flight reactions are based on anxiety – it is evolutionary

-to explain that to an anxiety-filled patient (who hates his anxiety) us somewhat relieving

• w/o anxiety = low motivation
• too much anxiety = over-freezing

development

-anxiety can develop from real events/dangers in surroundings or even perceived danger

Stages:

Stage 1: it can developed through conditioning

• event = anxiety

Stage 2: operant conditioning = avoiding place of event lessens the anxiety

• place (stimulus) = anxiety

life-span

-w/ time, anxiety is reduces – after some 20-30 minutes

àeven when exposed to chronic stimulus

àthe body reduces anxiety automatically b/c it can’t deal w/ it chronically

-people wrongly attribute it to the successful avoidance and not the automatic biological reduction of anxiety

àyou don’t need the avoidance of stimulus for anxiety to reduce but the wrong attribution actually maintains the anxiety

Explanation of anxiety

Social learning: = modeling =learning to have anxiety through seeing others’ anxiety

Biology: anxiety runs in some families

Evolutional: anxiety’s basis is adaptational in its basis

DSM axis:

• axis 1: acute problems = anxiety is here
• axis 2: personality/retardation
• axis 3: health problems contributing to problem
• axis 4: psychosocial situation influencing problem [i.e. recent divorce, etc…]
• axis 5: general assessment of functioning

21/5/2007

-review of last class – and movie

28/5/2007

How does anxiety develop

Cognitive-behavioral approach: it is not inborn but contextual learning.

A) Conditioning:

stages

1. Classical conditioning b/w stressor and neutral effect. The problem gets increased by generalization processes
2. Operant conditioning: person learns that avoidance reduces the anxiety learnt in Classical conditioning –maladaptive link: escape = reduced anxiety
3. Nature of anxiety: after 20-30 minutes, it gets reduced/ thus they think that anxiety got reduced b/c of avoidance, and not b/c of is withering nature

B) social learning approach:

-if I see others b/h in a certain way, I do it too

C) biological

-anxiety disorders have some biological/genetic component

-anxiety has an evolutionary basis – if you pass on the message to the client, it will calm him

Anxiety disorders

1. panic disorder
2. social phobia
3. simple phobia
4. General anxiety disorder
5. PTSD –post traumatic stress-disorder
6. OCD –obsessive-compulsive

Except OCD, most victims of anxiety are women

Identification and diagnosis

• subjectively, anxiety is felt
• I.e. clinical interview/questionnaires [i.e. State trait anxiety inventory – sees diff. b/w chronic and trait/beck anxiety inventory/ anxiety disorders interview schedule – allows us to see if and which anxiety disorder that the guy has]
• self-monitoring – i.e. journal is kept by patient -of where/how/context

• physiological measures: sympathetic system is running on high gears running the fight-or-flight mechanism
• electromyography [i.e. lie detector –based on muscle tension] –good for biofeedback
• electro-dermal – measures h.m. electric conduction is in the body. Measured through sweat.
• Blood flow
• Heartbeat
• behavior: observations: stuttering, tics, sweats, tone, shaking, etc…
• behavioral avoidance test: put the stressful stimuli in room
• role playing

-those measures can show person that “It is not that bad as you think –you are not going to die!!”

Panic disorder

1. panic attack must be present, w/o a forewarning. It is limited to 15-20 minutes and include:
1. high heartbeat
2. numbness of hands”
3. shortness of breath
4. over sweating
5. hot or cold sweats
6. failing
7. derealization
8. chest pain
9. choking
10. fear of loss of control
11. fear of death
2. for it to be a panic disorder, the panic attacks must be repeating and unexpected. For at least 1 month w/ following results:
1. constant fear of repeated panic attacks
2. fear of results of the panic
3. behavioral change
4. avoidance of places where subjectively, person can’t get help or escape [agoraphobia]

explanation

-how people interpret the physiological symptoms infl. the development of panic attack:

àit is a self-feeding loop =

• physiological arousal+ awareness of themlàinterpretationàmore physiological arousal

Panic attack people’s dominant ways of thinking

• catastrophic thinking
• sense of loss of control
• lack of reevaluation of states

therapy

• info: is most important first step: that his symptoms aren’t really a catastrophe as he thinks àgot to use his subjective interpretation
• alternative interpretations to symptoms
• physiological change – i.e. äøôéä –relaxation techniques – got to find our what the client sees is best for his relaxation. But you have to teach him them when he is calm – can’t teach him when he’s stressed out

Techniques:

1. progressive muscle relaxation: teach the diff. b/w tension states and more relaxed states, and teach how to relax the [16 groups of] muscles. With time, reduce # of groupings -8, 4 grouping and then all of body [cute recall – use a cue to remind you to be relaxed]
2. in-vivo imagery – the main idea here is to walk patient through imagination of the stressful event [use a sense – i.e. sight, or preferably most if not all– ]
3. breathing -hyperventilation causes sympathetic symptoms – so teach him diaphragm breathing
4. behavioral – introspective exposure – expose person to internal feelings [expose the client to the internal/physiological stimulus] – teach bad link b/w feelings and anxiety-inducing interpretations. So, in therapy room, therapist helps set feelings similar to panic attack inducer, and work on their interpretation – show that you can induce those feelings in a safe place – to prove that they aren’t really the horrible things that they seem àgood for panic attacks
5. graded stimulus exposure: make a list of increasingly “scary” situations, and expose him gradually to increasingly anxiety-provoking stimulus. When exposed, the client notes the level of anxiety at each point. The point is trying to induce habituation. After some 20-30 minutes, the anxiety is over. With repeated episodes, the anxiety baseline is reduced. Stages: at first, rank all the stressful situations and make them into a graded list. You got to work on the easy ones. Ones the easy ones become un-stressful, the hierarchy gets changed, so you to remake the anxiety-situation list. Sometimes, exposure in mind is easier than real exposure -80-100% success rate/also Long Term effects were reported

4/6/2006

Generalized anxiety disorder – GAD

• extreme anxiety over many things for most of the day for at least 6 months.
• Hard for client to control the anxiety
• Has to be across many situations
• Beyond what other people reasonably feel
• Sense of loss of control
• Not accountable by other diagnosis [i.e. specific anxiety/phobia]
• At least 3 out of 6 symptoms
• Tension stress
• Tiredness
• Concentration problems
• Anger
• Muscle tension
• Sleep problems

-people w/ GAD often think that their actual worrying prevents a big problems and this is one cognitive thing that has to be worked on

Cognitive distortion

• tend to give high probabilities of something bad happening
• the situations are not controlable/manageable/solvable
• ruminative kinds of thinking –jump from one bad possibility to its possible offshoot ànever get a chance to calm down

-here, they give catastrophic meaning not to physiological [panic disorder] but to external things

Questionnaires for GAD

• Beck anxiety inventory
• State rate anxiety inventory
• Such questionnaires look at symptoms. Often, they are given each few sessions to see diff. in symptoms

-of al anxiety disorders, CBT is less useful for GAD b/c it is an all-encompassing, personality type of thing

Kinds of questions in the clinical interview: - to see specifity of anxiety

• is it hard for you to stop worrying?
• Do your worries disturb your other activities?
• Do you worry about things that others don’t?
• Do you still worry even after the thing is over?

Important tools in therapy for anxiety:

• in all anxiety disorders – start by explaining how anxiety is evolutionary/adaptive in it basis
• in beginning speak about the patient’s anxiety and expectations of the therapist
• journal is a useful tool for homework

levels of anxiety:

• emotions: stress/anxiety
• behaviors: irritability
• physiological: sleep-disturbances/stress
• thoughts: repeated worrying that are uncontrollable

Journal

-have to remind the client that their automatic thoughts are assumptions, despite the high stakes they put on it.

-we try to get people to have more accurate/adaptive assumptions about world [and not the more pleasant assumption]

Thought stopping:

-when bothering thought comes around, the person allows them on for a bit, and then he stops it with something that distracts. This technique is not very useful

Worry exposure: -çùéôä ìçøãä

-similar to other exposures –except here is exposure is in the mind. So first there is a calming exercise, them making a list of hierarchy of worrying thoughts. Here, you need to teach the client how to imagine in a self-convincing way [i.e. get the person speaking about the anxiety-provoking thing]. Here, to, you don’t want person to get exposed to overly high anxiety – so we start off w/ lower anxiety thing. This anxiety-episode is thought about and spoken about for 30-40 minutes w/o letting him run away from it. Eventually, habituation kicks in.

Problems:

• over-anxiety
• distraction
• we give the homework even after the anxiety is over
• hard for client to be imaginative [which is necessary for in-mind exposure]

11/6/2007

Relaxation techniques – cont.

Time management

-people overwhelmed by many tasks/hard for them to say no/can’t give others tasks/takes all responsibility to themselves

• teach people how to give responsibility to others

àjournal can help to teach alternatives to “Only I should do all of this”

àcognitive restructuring

• teach assertiveness – how to say no when needed
• role playing
• teach priorities/going through calendar to see what is most imp. to do when

problem solving

-teach them to be more systematic in solving their problem:

àthose people see the general problem but not specifics of it and thus can’t think of steps to deal w/ the problem

GAD Characteristics

• most of the GAD symptoms are parallel to depression symptoms – except the dominant affect. And thus many GAD people also suffer from depression
• In GAD, the anxiety is ego-syntonic. Thus they believe in the cause-and-effect of the anxiety
• GAD is not only acute problem but even on the personality level

Social phobia

Criteria:

1. persistent fear of exposure to unknown people or evaluations of others. The person fears that he will act in a way which will embarrass him
2. This causes anxiety or even panic attack
3. The person knows that his fears are too extreme and illogical [note: illogical = ego-dystonic]
4. The person avoids the situation or enters it w/ great anxiety
5. Disturbs his daily life
6. For people over 18 – it has to be for over 6 months

Characteristics

• there is a diff. b/w performance and social kinds of this phobia
• the key thing here is the fear of others’ evaluations
• being shy is not social phobia – b/c shyness is very specific and social phobic is more general
• Social phobia is diff. from panic attacks. If the key issue is the others evaluation and not the actual panic
• Under-evaluate their strengths
• awareness of their physical reactions and think others are too
• over-evaluate others’ social abilities

Social Phobia goes w/:

• GAD
• Dysthemia
• Depression
• Simple phobia
• Alcoholism
• Avoidant Personality Disorder [just in the personality disorder, their anxiety in social situations is bigger]

Social phobia questionnaires

• Social Avoidance and Distress Scale
• Fear of Negative evaluations
• Social phobia and anxiety Inventory

Social phobia –examples of questionnaire questions:

• how much are you scared to meet/speak to strangers
• how scared are you to use public washrooms
• to enter a room full of others
• look into a stranger’s eyes
• public speaking

-role playing is another way to diagnose Social phobia. During the role playing, the client reports SUD [subjective units of distress]

Etiology

• fear that world is dangerous, where locus of ‘danger’ is social
• focus on past failures and not on successes
• want to make good impression on others but are not sure that they will succeed
• low Self-esteem and low expectations that they’ll succeed
• real or perceived low social skills

cognitive-Behavioral Group Therapy (CBGT)

• CBGT is ideal for social phobia
• Group is a forum for social learning - Learn diff. techniques in socially safe place
• Allows for testing of bad cognitions and alternatives. The mere fact that there is a group gives the therapy strengths – learning from groups of equals/feedbacks from others/can see others w/ similar problems, but from a prespective – even better than a journal done by individual therapy
• ideal: 5-7 people. You want some homogeneity in anxiety levels – not too extreme gaps
• man and women leaders – to further increase “social situations”
• you have to build group correctly w/ right client makeup
• first meeting: when you want to put a person into a group, you have to explain to them what it is and what it involves [i.e. what CBT is about/group is about/contract/build hierarchies [also ranked by SUD] – but in the group, can’t work on everyone’s SUDs, so at each meeting, work on one member’s SUD and others will work at theirs at home –got to work on a lower level of anxiety thing first
• defenses: lowering eyes/sitting in back of class. You can find out the client’s defenses and work on gradually lowering them

Other techniques

Social skills training: teach [i.e. through role-playing] how to acquire more social skills

Cognitive restructuring: change in the connections that the person is making

In-vivo exposure: to reduce the anxiety

Note:

• best to not get personality disorder people into the group
• if the person has depression – deal w/ it before the social disorder
• if the social skills are overly lacking – first work on that b/f the group for social phobia
• preferably, no medications b/f the group b/f the key thing is to deal w/ the interaction b/w the person and anxiety
• long-term effect -75% get better

Exam:

-multiple choice

-until what we learnt

-50 questions

-don’t remember by heart the questionnaires, but you should be able to identify them and connect it to its disorder

Class 18/6/2007

CBT for depressions - movie

-activity scheduling

ài.e. focus on small chunks of [problem] activities – i.e. going to school/problem days or times àpopular: pleasurable/social activities or actual therapy’s homework

Guidelines:

1. give the client a rational
2. Socratic questioning – get him to logically get to alternative activity
3. Start where client is at and not where he wants to be
4. Be specific and concrete – no abstract or diffuse thing w/ no specific time slot
5. Foresee and plan around obstacles

-Depressives are given activities which do not cost money

OCD – obsessive compulsive disorder

Obsessions: thoughts/impulses/fantasies which are experienced as intrusion and cause emotional stress

àat least some of the time, the client has to identify them as his own and not forced onto him for him not to be psychotic

Compulsive: overt or covert behaviors which repeat/ those behaviors are meant to reduce the anxiety caused by the obsessions. They are not realistically related to the obsessions and they are exaggerated.

Common themes:

• counting
• washing
• cleanliness
• symmetry
• rituals

obsessive themes behind compulsive b/h

• constant rechecking -fear of external harm
• cleanliness – I am polluted
• counting: undoing things – magical thinking

model

-external or internal trigger àobsessive thoughtsàinterpretation [either thought-action fusion or excessive responsibility] àinternal [or external] trigger

-homosexuals obsessed w/ religion – try to undo homosexuality through religion

àthey do not separate thought from actions

-external trigger: gay parade àinternal intruding thoughts [homosexual fantasies]àthought interpretation: that is not allowed àcompensatory [compulsive] b/h

98% -will have compulsive [compensatory] b/h. if no compensatory b/h – the anxiety will be high

Obsessions w/o compulsions are even worse – since they do not have anything to reduce their anxieties

àthe level which people believe in their obsessions influence their prognosis [as long as not w/I context of schizophrenia

-OCD starts around 13-15 and in early 20s for women. It starts small and tends to grow/

-in about 1/3 of cases, it starts in childhood, and antibiotics help –since it usually is based on a brain infection

-OCD is related to serotonin, and SSRI also help this

Behavioral model of OCD

-wrong conditioning was done –i.e. a neutral stimulus is paired accidentally w/ anxiety and thus the response to neutral stimulus is done to reduce the anxiety

Problem: b/c of the intrusiveness of obsessions, it is impossible to avoid so many stimuli involved w/ them, and thus the compulsions b/c decreasingly effective

Cognitive model:

-exaggerated expectations of negative situations: i.e. I will die if I don’t wash my hands

àbased on the obsessions, there exaggerated responsibility and thus a great guilt and they try to undo them w/ the compulsions –since their perception is that there is no other way out!

25/6/2007

Comorbility w/ OCD

-symptom is ego-dystonic

• turret
• separation anxiety
• tics
• anorexia
• depression
• trichotlymania – tearing out hair
• panic disorder

Differential diagnosis [in CBT, diagnosis is important

à[i.e. hard to control drives and not over-control of OCD – when the symptom is ego-syntonic

• gambling
• kleptomania

There is a view –that psychosis and OCD are 2 ends of an awareness axis

• psychosis

àwhen aware of weak logical causality and can question it = OCD

àwhen unable to question and think that they have to do something because it is the right thing to do =psychosis

àthe approach mentioned later in class is not meant for those closer to the psychosis side of this axis

àanother difference b/w schizophrenia and OCD = OCS are generally functioning while schizophrenics are totally unfunctioning

àanother way: organization of thought

• depression vs. OCD
• the OCD treatment is bad for the Depressives
• commonality is the ruminating of the depressives

• OCD and Obsessive-compulsive personality disorder (OCPD)
• Less questioning of obsessions/less anxiety in the OCPD
• Therapy: OCPD = deal w/ schemes vs. OCD = deal w/ beliefs

OCD questionnaire:

• Y-BOCS -this questionnaire maps out the obsessive themes and compulsive themes

example

Exposure and response prevention –type of therapy à make a hierarchy of events or thoughts which cause anxiety – you expose the ones to those 4 (out of 10) – yet we prevent the client from doing the compulsive thought

àyou prove to the client that the anxiety gets reduced despite him not reacting the compulsion èshow him that the link b/w compulsive act and reduction of anxiety are not link

-recommendation: do not make this overly intensive – several hours a day

Less [but somewhat] effective techniques:

• relaxation
• cognitive restructuring

Factors hindering OCD therapy

• lower motivation to change [b/w of fears of exposure to the things most scary to them]
• when anxiety is too high [perhaps exposure has to be mental first] – sometimes, medication is needed in the beginning
• secondary gains of the OCD = won’t want to change the OCD
• deal w/ benefits of letting go of OCD

• therapist’s OCD or uncomforts– i.e. if therapist has to hold hand of client for 20 minutes as part of exposure – therapist might not be OCD but he also has limits of comforts which might hinder the exposure
• boredom = of repetition of exposures
• therapist’s frustration of not understanding the complexity of compulsion

-exposure and response prevention -90% recovery rate = very successful! Even long after end of therapy – vs. medication which the OCD returns w/ ending the medication taking

-next class – PTSD

July 2/2007

PTSD –post-traumatic stress disorder

Criteria;

1. exposure to traumatic event w/ 2 factors
1. experienced or witnessed in event or events w/ death or injury [or risk of them], or threat to body
2. his reaction is hopelessness or fear
2. the traumatic even is re-experienced in following ways:
1. annoying, repetitive memories of the event
2. dreams of the event
3. feeling that event is repeating [flashbacks/delusions/hallucinations]
4. psychological distress related to internal or external stimuli that remind of an aspect of the event
5. physiological reactivity as a result of those external/internal stimuli which remind of the event
3. chronic avoidance symptoms of stimuli which remind of the trauma, as expressed in 3 or more of:
1. attempts to avoid thoughts/talks of the trauma
2. attempts to avoid activities/places/people who remind of the trauma
3. inability to remember main elements of the event
4. avoiding activities
5. dissociated feeling from others
6. smaller rage of emotions
7. feelings of grim future
4. chronic symptoms of over-arousal, as expressed in 2 or more of the following:
1. harder to fall asleep
2. irritability
3. concentration difficulties
4. ãøéëåú
5. Exaggerated startle response
5. the problem is over a month long
6. the problem creates a significant problem or is debilitating/disturbs function
7. if the symptoms are less than 3 months, then it is acute – if more than 3 months, then it is chronic. Delayed onset – if the symptoms com on 6 or more months afterwards. Is less than a months, it is called “acute stress disorder” [the significance of the difference is the prognosis]

-the prognosis is diff. b/c it is expected to process a hard event. If the processing gets stuck, and he is stuck in those processing symptoms, then the prognosis is worse

Acute stress disorder

1. exposure to traumatic event w/ 2 factors
1. experienced or witnessed in event or events w/ death or injury [or risk of them], or threat to body
2. his reaction is hopelessness or fear
2. dissociative symptoms during and after event (at least 3)
1. subjective feeling of numbing/detachment or lack of emotion
2. reduction of awareness of surrounding
3. derealization
4. depersonalization
5. forgetfulness – dessociative amnesia – forgetting significant parts of traumatic events
3. traumatic event is re-experiances in one or more of following ways:
1. repeated visions of event
2. repeated thoughts
3. dreams
4. illusions
5. flashbacks
6. sense of reliving experience
7. irritability if things reminding of the event
4. avoidance of stimuli which remind of the trauma
5. anxiety or overarousal symptoms w/ or after the event
1. concentration problems
2. sleep problems
3. irritability
4. anger spurs
5. Sudden fear or anxiety
6. Over-arousal
7. Somatic symptoms: hyperventilation/muscular tensions
8. Compulsively repetitive thoughts/and those dealing w/ the events
9. Sleep problems
10. Motoric irritability [i.e. shaking leg all the time]
11. Hopeless
12. Avoidance of social relationships
6. Disturbs functions and discomfort [as in any disturbace]
7. More than 2 days but less than 4 weeks. It is supposed to start w/I 4 weeks of the events

Models explaining stress disorders

Horovitz:

-psychodynamic/CBT combination

-the ability of people to deal w/ stress is to have a scheme –or make one up

àdenial and other mechanisms try to avoid us from building schemes unacceptable to us.

ài.e. a woman doesn’t want to have a scheme for surviving a rape – so she avoids processing it àbut it comes back to haunt her [thus you have the 3 symptom categories: avoidance/repetitive/physiological] – so there is an attempt to process as well as to avoid it

Biological model

-exposure to event which is uncontrollable – same reaction as animals who has learnt hopelessness

àin those uncontrollable trauma, noradrenalin goes down and remains down [causes flatness of affect/anhedonia]. Also, the body automatically releases opiates [natural pain killers]. After the event, they are low in the body levels, and yet the person gets addicted to the opiates – and the natural amount is not enough for the addicted, so the victim keeps on looking for other events which triggered high levels of opiods [that’s also why the turn to other “painkillers”, i.e. alcohol]

Learning theory

Classical conditioning: every stimuli associated w/ event through classical conditioning to create similar reactions to those of the original reaction – w/ time, there is generalization

Operational conditioning: the learnt aversion to avoid the aversive [secondary] stimulus

Kinds of trauma along the time/boundaries axis

Focus trauma: those traumas which the event is clear and has clear time boundaries.

Complex trauma: when the trauma is chronic and traumas are built on layers and layers of traumas over traumas – i.e. abused women – can no longer put a definite time capsule on it

Developmental trauma: when traumas started at young age – so the developmental effects of it are pervasive

àthose categories influence the kind of therapy done

àthe clearer defined trauma, the easier it is to treat

Diagnosis

-ask about the event – many PTSD people do not make the link b/w the symptoms and the event. When you ask about the event, you got to do it carefully not to overwhelm the emotional capacity of the person

Therapy

1. stress inoculation training: -meichenbaum – helps deal w/ fears by teaching hem ways of coping
1. stage 1 -give info about trauma and anxiety
2. speak about the link b/w thought/emotion/physical cycles and explain coping techniques [got to explain their logic b/f actually using them

Coping techniques

-give at least 2 ways of coping for the 3 cycles

àgive examples/play them out àfor example, teach muscle relaxation for the physical symptoms/though stoppers for cognitive elements, or naming them and then offering alternative thoughts/behavioral: role playing for avoidance, or exposure and resolution of conflict w/ the painful stimuli

àfirst practice them in non-stress situations

Most successful treatment: prolonged exposure

Prolonged exposure -PE– edna foee

• Prolonged exposure first ask the client to report the traumatic event.
• At first, let him chose the # of details he can bring up and deal w/, and w/ time, asking for more details – rebuild the memory of the experience àand then rebuild the story w/o things like guilt over not helping others/etc…
• Clients can record and listen to the therapy at home to habituate to the story
• Kind of like introceptive exposure [vs. in-vivo exposure]

• in-vivo exposure – 2^nd step – works on the avoidance part of the PTSD – i.e. chose the 4-level anxiety experience out of his anxiety list – and not letting him run away for 30-40 minutes until anxiety goes down anyways

Prolonged exposure – is very successful for trauma disorders

Class – 9/7/2007

Dialectical-behavioral therapy -DBT – good for borderlines, suicidals, drugs, eating disorders

-Marsha Lineham – develops this

-the history of CBT: pure behavioralàCBTàDBT

-in DBT

-there is an element of acceptance here – like in eastern religions – accepting what you can not change

Borderline personality disorder

Personality disorder: a constant scheme of thoughts/behaviors/emotions/relations/drive control which is pathological. Needs to have some basis from b/f 18

Borderline:

• 11% of outpatients, 19% of inpatients are BPD
• 1/3 of those diagnosed also have BPD
• 74% are women
• 70-75% have self-injury history – 9-10% succeed in suicide

Symptoms: 5/9 symptoms:

1. attempts to avoid separation
2. social relations which are very dramatic: go b/w love and hate
3. report identity confusion
4. impulsivity/drugs/uncontrolled driving/sex
5. self-destructive b/h – i.e. suicidal/cut wrists
6. emotional instability - everything is very extreme
7. chronic sense of emptiness
8. anger and inability to deal w/ it
9. paranoid thoughts and sense of not belonging

DBT: sees BPD as biosocial development

biology

• biological side: inability to deal w/ strong emotional – i.e. high arousal to stimuli, including emotions
• high emotional reactivity
• hard to return to calm afterwards

social surroundings:

• invalidating surroundings
• i.e. sexual exploitation of the BPD person as a kid. As a result, they never learnt to name their emotions – since they were negated from early on.
• So they look at surroundings b/c they learnt never to trust themselves [“you’re not anger” is something they were told, and way too often]
• So she learns that only extreme actions cause surrounding to relate to her feelings

DBT Therapy process

• Individual – mostly supportive
• group therapy – to learn specific tools to deal w/ life’s stresses
• telephone service therapy for times of distress
• support groups for therapists: borderline’s therapists b/c somewhat borderline so they too need some therapy [principle: need to work in staff group in order to treat the BPD]

-DBT: combination b/w CBT and eastern religions’ forms of acceptance of what you cannot change

• dialectics of opposites – change what you can and accept what you cannot change

àeverything has good and bad

stages of therapy:

• preparation for therapy and agree to mutual work
• clear borders- i.e. what is suicidal b/h, what is an emergency which requires calling the hotline, # of phone-calls a day, # of meeting a week – those boundaries are not artificial but based on what is reasonable. When those boundaries are set, they need to be expressed explicitly and in 1^st person “I won’t have phone calls on the weekend” and not: “it is not acceptable to this organization that…”
• diagnostic interview, explanations of the therapy, identifying the behaviors
• express the goals of the therapy – i.e. tackling maladaptive b/h
• first stage of actual therapy: focuses on behaviors of self-inflicting damage/suicide/behaviors which are obstacles for the therapy – his stage could last a year or more!!!
• also teach what dialectic thinking is – the middle path/integration of good/bad ànot only use intellect or emotion but integrate the two

skills taught include:

• mindfulness skills: [mindfulness based therapy] – teach the person how to be aware of emotions, w/o reaction or judgmental/meditation
• distress tolerance: 1^st stage is to name the [in this case, negative] emotion [vs. surroundings], view those emotions w/o trying to throw hem away
• self-management skills: i.e. realistic expectations, functional analysis [see how their situations/crisis come around], behavioral schemes to change b/h
• problem solving techniques: i.e. functional analysis

-the therapist of BPD has to keep the balance b/w support/acceptance one hand and help them change on the other hand. It is always easy to turn to try to change but w/o the supportive element, the therapy will be invalidating too

• second stage of therapy: moving from present to past – seeing how past events influence current b/h. they patient has to be stable enough in order to touch those tough memories. When the past is touched, you have to deal w/ PTSD aspects of those traumatic experiences – at this stage, there is parallelism to trauma therapy: i.e. exposure to those traumatic memories –usually complex/developmental trauma
• also deal w/ self-blame cognitions
• deal w/ wavering b/w denial and intrusions of traumatic memories
• last stage: building self-esteem and self-respect, accepting self, including my behaviors and emotions

-the DBT is very effective for such patients

End of course!!!!!!