1. COGNITIVE BEHAVIORAL THERAPY Ann Olincy, M.D. Associate Professor of Psychiatry

2. Uses of Cognitive Behavioral Therapy (CBT)  Any disorder with distortions in thinking or dysfunctional behavior –Anxiety disorders  Post traumatic stress disorder  Panic disorder  Obsessive/compulsive disorder –Depression –Schizophrenia –Personality disorders

3. First Step: Learning  Begin with education about the illness –Symptoms –Causes  Heredity  Childhood circumstances  Stress  Triggers  Brain chemicals  Medical conditions

4. Second step: Identify Things That Maintain The Thoughts/Behaviors  Avoidance  Self talk-what you say in your mind  Mistaken beliefs-thoughts about yourself and your life  Withheld feelings-anger, frustration, sadness  Lack of assertiveness

5. Second step: Identify Things That Maintain The Thoughts/Behaviors  Lack of self-nurturing skills  Muscle tension  Stimulants or other diet factors  High stress lifestyle  Lack of sense of purpose

6. Third Step: Identify Things That May Help In Recovery  Physical –Medical (medications) –Relaxation –Nutrition/diet  Emotional –Express suppressed feelings  Behavioral –Confront the things you avoid

7. Third Step: Identify Things That May Help In Recovery  Mental –Counter negative self-talk  Interpersonal –Build strong, supportive relationships  Whole level –Improve self esteem

8. Third Step: Identify Things That May Help In Recovery  Mental –Counter negative self-talk  Interpersonal –Build strong, supportive relationships  Whole level –Improve self esteem

9. Third Step: Identify Things That May Help In Recovery  Existential/spiritual –Find a broad purpose or direction in their life that gives a person meaning  Take responsibility for your problems  Examining motivations for illness and overcoming secondary gains  Willingness to take risks –Make a commitment to change

10. Fourth Step: Learn How to Cope  Deflate the danger-face symptoms don’t run from them  Coping statements –”This feeling isn’t comfortable but I can handle it.” – “This isn’t the worst thing that could happen.” –“This will pass.” –“These are just thoughts-not reality.” –“Nothing serious is going to happen to me.”

11. Fourth Step: Learn How to Cope  Explore the antecedents and identify preliminary signs to preempt a full blown episode  Do something that requires focused concentration to draw your attention from the uncomfortable feelings

12. Fourth Step: Learn How to Cope  Express your emotions  Practice thought stopping-shout “stop it” or if others are around, visualize a stop sign  Relaxation

13. Relaxation Benefits  Decrease heart rate, respiratory rate, blood pressure, muscle tension, metabolic rate, oxygen consumption, analytical thinking  Increase energy and productivity, concentration and memory

14. Relaxation Benefits  Decrease insomnia and fatigue  Decrease psychosomatic disorders  Increase self-confidence  Increase availability of feelings

15. Relaxation Techniques  Abdominal breathing  Progressive muscle relaxation  Visualizing a peaceful scene  Meditation  Guided imagery  Biofeedback  Sensory deprivation  Physical exercise

16. Fifth Step: Behaviors- Desensitization  Imagery desensitization –Unlearning the connection between emotion and particular situation –Visualize yourself in the situation that is disturbing and then practice relaxation –Hierarchical-pick the least disturbing that you can tolerate and work up to the most disturbing when these are conquered

17. Desensitization  Real-life desensitization –Put yourself in a real situation that is disturbing and practice tolerating the feelings –Set goals for recovery –Use a support person at the beginning –Be aware of elements that make you anxious

18. Desensitization  Real-life desensitization –Be willing to take risks –Be willing to tolerate discomfort –Avoid flooding (overexposure with lack of control over your emotions) –Plan for contingencies-things do go wrong

19. Desensitization  Real life –Trust your own pace –Reward yourself for small successes –Use positive coping statements –Expect and know how to handle setbacks –Be prepared to experience strong emotions

20. Sixth Step: Cognitions-Self-talk  Automatic and subtle  One image or word contains scores of memories, thoughts, associations  Can be irrational but sounds like the truth  Are learned  Perpetuates avoidance

21. Types of Self-talk  Worrier –Imagines the worst case scenario, overestimates the bad, creates images of catastrophe –“What if…”  Critic –Points out flaws, limits, –“You stupid…”

22. Types of Self-talk  Victim –Helpless, hopeless, something inherently wrong –“I can’t…” –“I’ll never be able to…”  Perfectionist –Efforts not good enough, intolerant of mistakes or setbacks –“I should…” –“I must…”

23. Cognitive Distortions  Filtering –Focus on the negative aspect of a situation –Worthless, hopeless, pointless, stupid, failure, dangerous, unfair  Emotional reasoning –Judge illogically only on basis of own feelings  Should statements –Should, must, have to

24. Types Of Unrealistic Thinking- Cognitive Distortions  Overestimating odds of negative outcome  Catastrophizing –Terrible, insufferable, catastrophic  Over generalizing –One bad experience will repeat itself –Never, always, all, every, none, no one, nobody, everyone, everything

25. Mistaken Beliefs  I’m powerless  Life is a struggle  If I take a risk I’ll fail  I should always look and act good no matter how I feel  If I worry enough this problem will get better

26. Mistaken Beliefs  I can’t cope with difficult situations  The outside world is dangerous  My needs don’t matter  I’m worthless  I’m unlovable

27. Challenging Mistaken Beliefs  What is the evidence for the belief?  Is this invariably or always true?  Does this look at the whole picture?  Does this promote well-being?  Did I choose this belief on my own?

28. Positive Counterstatements  The worrier –“So what”  The critic –“I’m ok the way I am” –“I accept and believe in myself”  The victim –“It’s never too late to change”  The perfectionist –“It’s ok to make mistakes”

29. Positive Counterstatements  Write down and rehearse  Examine the evidence –What are the odds of this really happening? –Is this always true? –What is the worst that could happen? –Am I looking at the whole picture? –Am I fully objective?

30. Daily Record of Dysfunctional Thoughts DateSituationEmotions Automatic Thoughts Rational Response Outcome Describe: Actual event leading to unpleasant emotion Specify emotion Write automatic thought that preceded emotion Write rational response to automatic thought Re-rate belief in automatic thought 0-100 Stream of thoughts leading to unpleasant emotion Rate degree of emotion 0-100 Rate belief in automatic thoughts 0-100 Rate belief in rational response 0-100 Specify and rate subsequent emotions 0-100