Cognitive Behaviour Therapy (CBT) Gerhard Ohrband - ULIM University, Moldova 2 nd lecture Diagnostics in CBT

Course Structure 1. Introduction: What is CBT? What are differences and similarities with other therapy schools? 2. Diagnostics in CBT 3. Classification of Psychological Disorders (ICD- 10, DSM-IV), Clinical Psychology (Etiology, prevalence, comorbidity and symptoms) 4. Etiological concepts in CBT: learning theories (classical and operant conditioning, vicarious learning, Mowrer’s Two-factor theory) 5. Systematic desensitization: in-vivo exposure and imaginatory 6. Aversion training: overt and covert

Course Structure 7. Response prevention: treating obsessive-compulsive disorder (OCD) 8. Social skills training: anger management, assertiveness training 9. Rational-emotive Therapy (RET) 10. Beck’s Cognitive Therapy for depression 11. Marital and Sex Therapy 12. Trauma Therapy: Expressive writing, work with affirmations, visualizations; working with victims of crimes, accidents and other difficult life-events 13. Relaxation techniques: yoga, meditation, Alexander technique, Feldenkrais 14. CBT at school: helping children with autism, hyperactivity, social phobia, social adjustment problems, learning difficulties and antisocial behaviour. 15. CBT in treating addiction and substance abuse

Content diagnostic concepts (S-O-R-C-K model) quality standards in psychological testing (objectivity, reliability, validity) assessment techniques (diaries, rating scales, questionnaires, clinical interviews, behavioural observation, psychophysical measurements) developing a therapy contract evaluating therapy success classifying mental disorders

S-O-R-C-K model SituationOrganismResponseContingencyConditioning

Quality standards in Psychological Testing objectivity reliability validity norm/reference groups acceptability availability costs

Types of validity and reliability Predictive validity Concurrent validity Construct validity Content validity Face validity Parallel reliability Test-retest reliability Split-half reliability

Assessment Techniques questionnaires rating scales (self or other) projective tests behaviour observation experiments diaries clinical interviews

Diary TimeSituationFeelingsResponse Consequences

Group work: fill in a hypothetical diary TimeSituationFeelingsResponse Consequences

Classification of disorders DSM-IV: Diagnostic and Statistical Manual (of Mental Disorders) IV by the American Psychiatric Association ICD-10: International Classification of Diseases 10 by the World Health Organization the two more alike than different (Andrews et. al., 1999)

DSM-IV Five axes: Axis I:Major clinical syndromes Axis II: Personality disorders Axis III: Physical disorders Axis IV: severity of experienced stress (usually within the last year) Axis V:overall level of psychological, social or occupational functioning, on a 100-point global assessment of functioning (GAF) scale, with 100 representing the absence or near absence of impaired functioning, 50 representing serious problems in functioning, and 10 representing impairment that may result in injury to the individual or others

DSM-IV Example: Axis I:Alcohol dependance Axis II:Antisocial personality disorder Axis III:Alcoholic cirrhosis of the liver Axis IV:Severe – divorce, loss of job Axis V:GAF evaluation = 30 (a very serious impairment of functioning

DSM-IV Axis I – Major clinical syndromes Disorders usually first appearing in infancy, childhood or adolescence Delirium, dementia, amnestic and other cognitive disorders Psychoactive substance abuse disorders Schizophrenia and other psychotic disorders Mood disorders Anxiety disorders Somatoform disorders Factitious disorders Dissociative disorders Sexual and sex identity disorders Eating disorders

DSM-IV Factitious disorders: fake mental disorders, such as Munchhausen syndrome, in which the individual is frequently hospitalised because of their claims of illness Dissociative disorders: loss of personal identity and changes in normal consciousness, including amnesia and multiple personality disorder, in which there exists two or more independently functioning personality systems

Some problems with DSM-IV classification Although the DSM-IV is the most widely used classification system for mental disorders, it is not without its problems DSM-IV tends to be more consistent with the medical perspective on mental disorders Questionable reliability

Dangers in classifying mental disorders No classification is likely to be perfect No two people with the same diagnosis will behave in exactly the same Yet once people are labelled, they are likely to be perceived as having all the characteristics assumed to accompany that label Their behaviour will probably be perceived selectively and interpreted in terms of the diagnosis

Experiment: Langer and Abelson, 1974 A group of psychoanalysts were shown a videotape of a young man who was being interviewed Half of the psychoanalysts were told that the man was job applicant, while the other half were told that he was a patient Although both groups of clinicians watched the same man exhibiting the same behaviour, those who were told that he was patient rated him as being more disturbed, that is less well adjusted

Ever-expanding size of DSM-IV Wakefield, 2001: ‘the most ridiculed aspect of DSM classification system is its ever-expanding size.’ Each new addition of the manual brings with it a new classification of a behaviour as a mental illness Some view this enlargement as enlightenment Others see the expansion as over-inclusive, overeager and as inappropriately labelling odd or eccentric behaviour as deviant or as an illness without sufficient scientific evidence for doing so (Houts and Follette, 1998) New disorders are invented, according to critics, and previously accepted behaviours are labelled as disorders.

Houts (2001): examples of behaviours inappropriately classed as mental disorder Sleep disorders Frotteurism (touching or rubbing up against another in a sexual way without consent) Kleptomania (compulsive theft) Dyscaculia (a disorder of mathematical thinking) Pathological gambling Voyeurism Also: the ‘wastebasket’ category of ‘sexual disorder not otherwise specified’ which represents exactly what it says: any sexual behaviour considered deviant by a psychiatrist that does not meet the criteria of the other disorders.

Discussion Points What are the advantages and disadvantages of classifying psychological disorders? Could you think of developing other systems for classification? Is mental disorder better characterised as being one end of a continuum, the other being mentally stable and healthy?

Literature Andrews, G., Slade, T., and Peters, L. (1999). Classification in psychiatry: ICD 10 versus DSM-IV. British Journal of Psychiatry, 174, 3-5. Langer, E.J. and Abelson, R.P. (1974). A patient by any other name … Clinician group difference in labeling bias. Journal of Consulting and Clinical Psychology, 42, 4-9. Wakefield, J.C. (2001). The myth of DSM’s invention of new categories of disorder: Hout’s diagnostic discontinuity thesis disconfirmed. Behaviour Research and Therapy, 39,