Cognitive Behaviour Therapy (CBT) Gerhard Ohrband - ULIM University, Moldova 4th lecture Etiological concepts 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 etiological concepts in CBT in comparison to other therapy schools theoretical framework classical conditioning operant conditioning social learning theory two-factor theory cognitive theories etiology of selected psychological disorders

S-O-R-C-K model SituationOrganismResponseContingencyConditioning

A bio-psycho-social model of psychological disorders Biological factors Psychological factors Social Factors Increased vulnerability Non-adaptive behaviour Chronic psychological disorder Stressful life-events reinforcement

Classical Conditioning Basic components of the classical conditioning procedure. Prior to conditioning, the UCS but not the CS elicits a response (the UCR). During conditioning, the CS is presented in conjunction with the UCS. Once the conditioning is completed, the CS alone elicits a response (the CR).

Acquisition and extinction of a conditional response

Timing of CS and UCS in classical conditioning

Classical conditioning

Operant conditioning Reinforcement, punishment and extinction produced by the onset, omission or termination of appetitive or aversive stimuli. The upward-pointing arrows indicate the occurrence of a response.

Generalised Anxiety Disorder (GAD) Excessive worry about all matters relating to the individual’s life: health, money, work, relationships and so on. DSM-IV: worries most be present on most days and will have occurred over a period of at least six months The anxious individual finds it difficult to control the worry and shows at least three symptoms out of the following: restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension and sleep disturbance Around 12 % of anxiety disorders are GAD

Borkovec’s model (1994) GAD arises from the individual’s drive to set and anticipate a set of goals that are desirable The anxiety arises when a history of a frustrated failure to achieve affects the perception of cues associated with these goals Anxiety is reflected in the individual’s need to anticipate possible outcomes, for fear of failing or not achieving

Eysenck’s model Worry or anxiety serves as an ‘alarm function’ which brings information concerning threat- related stimuli into awareness Worry acts as a behaviour that will prepare an individual for future behaviour It prompts the individual to anticipate future situations and their solutions

Gray’s model Similar mechanism as in Eysenck’s model, but tied to neurophysiology and certain brain systems Anxiety is evoked by signals of punishment, lack of reward, novel stimuli and innate fear stimuli The individual detects such threats by means of a behavioural inhibition system (BIS) which also generates anxiety BIS helps the organism (Gray’s theory applies to humans and other animals) to evaluate the threat-content of a stimulus or event Neuroanatomical and neurochemical interaction between a number of brain regions The BIS is thought to be represented by the septum and hippocampal formation

Two-factor model (Andrews) Individuals exhibit a vulnerability to anxiety owing to 1. High trait anxiety and 2. Poor coping skills. There is a strong correlation between neuroticism and almost all major anxiety disorders Loss of control

Information-processing models Individuals high in trait anxiety and those suffering GAD exhibit attentional biases Significantly biased towards responding to threat- or anxiety-related material Anxious people are more vigilant when reacting to threatening faces than to non- threatening (Bradley et al., 1999) Measurement of attentional bias: most common are the dot probe, the emotional Stroop and the interpretation of ambiguous sentences

Dot probe The dot probe task involves the presentation of two words, one above the other, on a computer monitor. Individuals are asked to read aloud the word at the top This word is either neutral or is an anxiety- or threat- related word. After a short pause, the individual is presented with either another pair of words or a dot where the top or bottom word appeared The individual has to press a key when such a dot appears Latencies are shorter for anxiety-related words in GAD patients (MacLeod et al., 1986; Matthews et al., 1990)

Post-traumatic stress disorder (PTSD) Horowitz’s model (1979, 1986): Trauma-related information is processed because of a mechanism called completion tendency. Completion tendency: need for new information to be integrated into existing patterns of thought and memory

Power and Dalgleish (1997) Stunned reaction to the traumatic event Experience of information overload as the individual realises the enormity of the trauma as it ‘sinks in’. Such information cannot be accommodated by existing mental schemata Defence mechanism such as denial and numbing are a means of coping with this lack of accommodation Completion tendency, however, insists on keeping the memory of the event alive through flashbacks and nightmares Anxiety results from the vacillation between these two processes: defence mechanisms and completion tendency

Questions Why do only some individuals develop PTSD? Why is PTSD delayed in some individuals?

Janoff-Bulman’s cognitive appraisal theory In PTSD the individual’s beliefs about the world have been shattered The individual is assumed to view themselves as personally invulnerable, that the world is meaningful and comprehensible, and that the individual views themselves positively These assumptions provide the bedrock of our life and give it structure This structure is shattered by the traumatic event which gives rise to PTSD

Obsessive-compulsive disorder Can be understood in terms of defence mechanisms Obsessions serve as devices to occupy the mind and displace painful thoughts

Infallibility model Sarason and Sarason, 1993: persons with obsessive-compulsive disorder believe that they should be competent at all times Avoid criticism at all costs Worry about being punished by others for behaviour that is less than perfect Engagement in checking behaviour to reduce the anxiety caused by fear of being perceived by others as incompetent or to avoid others’ criticism that they have done something less than perfectly If painful, anxiety-producing thoughts become frequent, and if turning to alternative patterns of thought reduces anxiety, then the principle of reinforcement predicts that the person will turn to these patterns more frequently.

Literature Horowitz, M.J. (1986). Stress Response Syndromes (2 nd edition). Northvale, NJ: Jason Aronson Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York: Free Press. Sarason, I. and Sarason, B. (1993). Abnormal Psychology: The problem of maladaptive behavior (7 th edition). Englewood Cliffs, NJ: Prentice Hall.

Journals American Journal of Psychiatry Annals of Psychiatry Archives of General Psychiatry Behaviour Research and Therapy British Journal of Clinical Psychology British Journal of Psychiatry Clinical Psychology and Psychotherapy Cognitive Neuropsychiatry Current Opinion in Psychiatry Journal of Abnormal Psychology Journal of Clinical Psychology Journal of Psychotherapy Practice and Research Psychotherapy

Internet resources documents/lit_cah.htm documents/lit_cah.htm A link to a collection of full-text articles on mental health t_Behaviour_Relationships/Clinical/ t_Behaviour_Relationships/Clinical/ A collection of links about mental health/clinical psychology A collection of links on mental health resources