CBT Models disorders.ppt

• Panic (Clark, 1986)
• Social Phobia (Clark & Wells, 1995)
• Health Anxiety (Salkovskis & Warwick, 1986)
• OCD (Salkovskis, 1994)
• GAD (Wells, 1997)
• PTSD (Ehlers & Clark, 2000)
• Depression (Beck, 1967)
See also Core CBT Competencies list for
recommended models:
http://www.ucl.ac.uk/clinical-
psychology/CORE/CBT_Competences/CBT_Competences_Map.pdf
Disorder specific models
© Think CBT Ltd info@thinkcbt.com 01732 808 626 www.thinkcbt.com

A vicious circle model of phobic anxiety
Situational Trigger
Physiological
Heart thumping
Sweating
Trembling etc.
Behavioural
Running away
“freezing”
Shouting for help etc.
Subjective
“I might fall”
“This is terrible”
Fear, embarrassment etc.
Symptoms
Reactions
Physiological
Heart thumping
etc.
Fatigue
Behavioural
Avoidance, withdrawing
from demanding or
pleasurable activities
Subjective
“I can’t cope”
“I must get out”
Lowered confidence worry,
frustration, fear

A cognitive-behavioural model for the maintenance of specific phobias
Vomiting is unbearably awful and
terrible for me
Avoidance
Encountering the phobic object / situation
Catastrophic
beliefs
Autonomic
arousal
Pre-attentive
activation
High
degree of
conviction Escape or safety behaviour
Prevents
disconfirmation
The catastrophe does not occur and anxiety
reactions dissipate
Conclusion drawn: The escape / safety
behaviour prevent the catastrophe
The catastrophic belief is confirmed
The phobia remains unchanged
© Think CBT Ltd info@thinkcbt.com
01732 808 626 www.thinkcbt.com

A model of the development and maintenance of specific phobias
Development
Biological preparedness, disposition, developmental stage, culture, experience (classical
conditioning, vicarious learning), memories/images, beliefs
Assumptions
With increased vulnerability to
Trigger
Frightening object or situation
Anxious Cognitions
(thoughts and images concerning stimulus)
OVERESTIMATING THREAT AND CONSEQUENCES/ UNDERESTIMATING COPING AND RESCUE
Anxious mood
Increasingly anxious cognitions about
external triggers
Safety behaviours
(related to anxious thoughts about external trigger)
Physiological symptoms
Anxious cognitions about symptoms
(fear of fear)
Safety behaviours
(related to fear of fear)
Hyper vigilance
about physical
symptoms
Secondary cognitions
Depression, hopelessness, loss of confidence, low self-esteem
From Chapter 8 of Oxford Guide to
Behavioural Experiments in
Cognitive Behaviour Therapy (Kirk
& Rouf)

Cognitive model of social phobia
[Clarks and Wells (1995) and Wells and Clark (1997)]
Social Situation
Activates assumptions
Perceived social danger
(negative automatic thoughts)
Processing of Self as a Social
Object
Safety behaviours
a
Somatic & cognitive
symptoms
Wells, A., 1997. Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide.
Chichester: John Wiley & Sons Ltd.

Cognitive cycle of fear for panic disorder
Biological
Vulnerability
Alarm reaction
Tachycardia, dyspnea,
chest pain,
depersonalisation etc.
Stressful
Events
Catastrophic thoughts
“Oh, oh, oh..”
“I’m gonna die, pass
out”
“Fall down, going crazy”
Conduct
Running away, escaping
Hyper surveillance
Avoidance
Anticipatory Anxiety
Increase in anxiety
Increase in symptoms
F
E
A
R

A cognitive model of OCD
(Wells 1997, p.242)
Trigger
Activates
Meta-Beliefs
Appraisal of
Intrusion
Belief about
rituals
Behavioural
Response
Emotion

Cognitive Model of OCD (Salkovskis)
Intrusive thoughts, images, urges, doubts
Misinterpretation of
significance of intrusions –
responsibility for actions
Neutralising
actions (rituals,
reassurances etc.)
Attention and
reasoning biases
(looking for
trouble)
Mood Changes
(distress, anxiety,
depression)
Counterproductive “safety” strategies
(though suppression, impossible criteria,
avoidance etc.)

5 Part Cognitive Behavioural Therapy Model
Environment
Thoughts
Emotions
Physical
Behaviours

Cognitive Conceptualisation Diagram
(Judith Beck, 1993)
Relevant Childhood Data
Core Belief(s)
Conditional Assumptions/Beliefs/Rules
Compensatory Strategies
Situation 1
Behaviour
Automatic Thought
Meaning of the A.T.
Emotion
Situation 2
Behaviour
Automatic Thought
Meaning of the A.T.
Emotion
Situation 3
Behaviour
Automatic Thought
Meaning of the A.T.
Emotion

A Cognitive Model of Hypochondriasis
(Adapted from Salkovskis, 1989; Warwick and Salkovskis, 1990)
Previous Experience
Dysfunctional Schemas Formed
Critical Incident
Activates Schemas
Negative Automatic Thoughts
Cognitive
Selective Attention
Rumination
Self-Focus
Thinking Errors
Anxiety
Depression
Anger
Behaviour
Reassurance Seeking
Avoidance
Bodily checking
safety / prevention
Physiological Changes
e.g Increased Arousal
Bodily Sensations
Sleep Disturbance

How did “the problem” develop?
What made me
vulnerable in the first
place? Triggers for the most
recent episode
Positive things that
I’ve got going for me
Things that keep “the problem” going
(These might include things that I do to
control the problem)
“The problem”

“The Vicious Flower” Cognitive Model of OCD (Salkovskis, Forrester & Richards, 1998)
Early Experiences
Making you vulnerable to OCD
Critical Incidents
What started the OCD off
Activates
Assumptions, General Beliefs
E.G Not preventing disaster is as bad as making it happen
Better safe than sorry
Intrusive Thoughts, Images,
Urges, Doubts
Misinterpretations of
significance of intrusions
– responsibility for
action
Attention and
Reasoning Biases
Looking for
trouble
Mood Changes
Distress, anxiety,
depression
Counterproductive
“Safety” Strategies
Thought suppression,
impossible criteria
Neutralising Actions
Rituals, reassurance,
mental argument

Depression Model
(Beck 1967, 1976)
Early Experiences
Core Beliefs and Assumptions
Critical Incident
Assumptions Activated
Symptoms of Depression
Behavioural Motivational Affective Cognitive Somatic

Depression (Westbrook, Kennerley & Kirk, 2007)
Depressed
Mood
Negative thinking &
Physical symptoms
such as fatigue, poor
concentration etc.
More Negative
view of self
Nothing
Changes
Loss of
pleasure &
achievement
Reduced
coping &
problem-
solving
Reduced
Activity
Increased
hopelessness

Anxiety Maintenance
(Westbrook, Kennerley & Kirk, 2007)
Internal or
external event
1. Perceived threat:
Exaggerated and/or
inappropriate
2. Client’s best attempt
to protect him/herself
from threat
3. Strategy gives short-
term relief, but fails to
challenge the anxiety-
related belief
4. Fear remains intact:
the alarming belief is
unchanged

Morrey, 2010
Depression
Mode
Negative view
of self, world
and future
1. Automatic
Negative thinking
2. Ruminations
and self-
attacking
3. Motivation
and Physical
symptoms
4. Unhelpful
behaviours
5. Mood /
emotion
6. Withdrawal
and avoidance
DEPRESSION

Cognitive-Behavioural Model of Body Dysmorphic Disorder (Veale, 2001)
Trigger
(e.g. reflection)
Processing of
self as an
aesthetic object
Negative appraisal
of internal body
image
Mirror-checking and
selective attention
Mood
(depression &
disgust)
Rumination on
ugliness or
“defectiveness”
and comparison
to ideal
Avoidance and
safety
behaviours to
change or
camouflage
appearance
Mirror checking

What made me vulnerable in the first place
Core Beliefs – about myself, others and the world
Rules I live by…
Helpful Unhelpful
Current Problem
What triggered the problem
What helps me cope
Helpful Unhelpful
What maintains the problem now
Thoughts
Physical sensations Emotions
Behaviours

Cognitive Model of Postnatal Depression
[Milgrom A., Martin P.R., Negri L.M (1999) Treating Postnatal Depression: A psychological Approach for
Health Care Professionals. Wiley. Chichester. Adapted from Beck’s Cognitive Model of Depression (1979)]
Vulnerability Factors
Precipitating Factors,
including Biological Factors
Cultural
Factors
Post Natal Depression
Depression and other
emotions
Anxiety, Anger, Sadness
Mediational Cognitive
Factors
Poor parenting self-efficacy
(mediational = appraisal process)
Behaviour / Coping
Strategies
Lethargy, Indecision, Social
Withdrawal, Martial Conflict,
Difficulty dealing with infant
Exacerbating & maintaining factors

Diagnosis / symptoms
Formative influences
Situation / interpersonal
issues
Biological, genetic and
medical factors
Strengths / assets
Typical automatic thoughts,
emotions and behaviours
Underlying schemas
Working
hypothesis
Treatment
Plan

“Vicious Flower” Generic conceptualisation
(Salkovskis, Warwick and Deal 2003)
Threat
Appraisal
Meaning
Anxiety
Images
Memories
Selective
Attention
Worry
Processes
Physical
Sensations
Safety
Behaviours
Events,
Stimuli,
Situations

Clark’s cognitive model of panic with maintenance
cycles added (adapted from Clark, 1986)
INTERNAL / EXTERAL TRIGGER
PERCIEVED THREAT
ANXIETY
(Emotions)
PHYSICAL / COGNITIVE
SYMPTOMS
MISINTERPREATION
AVOIDANCE AND SAFETY
BEHAVIOURS
(Including Selective Attention)

A cognitive Model of GAD (Wells, 1995)
Trigger
Positive meta-beliefs
activated (Strategy
Selection)
Type 1 Worry
Negative meta- beliefs
activated
Type 2 Worry
(Meta-worry)
Behaviour
Thought control
Emotion

Cognitive-behavioural model of generalized anxiety disorder
[From Dugas, M.J., Gagnon, F., Ladoucer, R. & Freeston, M.H. (1998) Generalized Anxiety Disorder: A
preliminary test of a conceptual model. Behaviour Research and Therapy, 36, 215-226]
Situation
Life
Events
Mood
State
What if..?
Positive beliefs
about worry
Worry
Anxiety
Negative
problem
orientation
Cognitive
avoidance
Demoralization
Exhaustion

Low Self-Esteem: A Map of the territory
(Fennell, 1999)
(Early) Experience
Neglect- Teeth, abscess, lump neck, witness to DV, TB, conditional acceptance (physical),
living conditions which have implications for ideas about the self
The Bottom Line
I am worthless (family hate me), I am unlovable, I am unworthy
Rules for living
If I keep secrets, I will be part of the family, If I
Trigger Situations
Negative contact, challenged, negative feedback.
Activation of the Bottom Line
Negative Predictions
Unhelpful behaviour
Confirmation of the Bottom Line
Self-critical thoughts
Depression
Anxiety
/anger/
FIGHT
How
Low
Self-esteem
Develops
What
keeps
Low
Self-
esteem
Going

Based on Wells 1997, adapted by Stopa
Social Situation
Thoughts
1. What went through your mind at that time? What was the
worst you thought could happen? What did you think people
would notice / think about you? What would that mean/
what would be so bad about that?
Anxiety
Symptoms
2. When you
thought (feared
event) might
happen, what did
you notice
happening in your
body? (Suggest
symptoms of
anxiety)
Safety
Behaviours
3. As you became
anxious, and
thought that
(feared event)
might happen, did
you do anything to
try to prevent it
from happening?
Did you do
anything to try to
prevent people
from noticing?
Self-focus
4. When you are afraid (feared event) will happened
what happens to your attention? Do you become more
self-conscious? As you focus on yourself, what do you
notice? Do you have an image of how you feel you are
coming across? What does that look like?
5. As you did (safety
behaviours) did that
make you focus more or
less attention on
yourself?
6. As you noticed
yourself becoming more
anxious, what effect did
that have on your
attention?
7. When you did (safety behaviours)
what effect did that have on your anxiety?

Arrows indicate the following relationships:
Influences = Leads to = Prevents change in =
A. Ehlers., D.M Clarke. (2000) A Cognitive Model of posttraumatic stress disorder.
Behaviour Research and Therapy 38, p. 319-345
Characteristics of trauma / Sequelae
Prior Experiences/ Beliefs/ Coping
State of individual
Influences
Cognitive
Processing
during Trauma
Nature of Trauma Memory
Negative Appraisal of
Trauma and / or its Sequleae
Current Threat
Intrusions
Arousal Symptoms
Strong Emotions
Matching
Triggers
Strategies Intended to Control Threat / Symptoms
P
E
R
S
I
S
T
E
N
T
P
T
S
D

A cognitive-behavioural model for the maintenance of specific phobias
Various objects / situations are perceived as
potentially harmful
Avoidance
Encountering the phobic object / situation
Catastrophic
beliefs
Autonomic
arousal
Pre-attentive
activation
High
degree of
conviction Escape or safety behaviour
Prevents
disconfirmation
The catastrophe does not occur and anxiety
reactions dissipate
Conclusion drawn: The escape / safety
behaviour prevent the catastrophe
The catastrophic belief is confirmed
The phobia remains unchanged

• Safety Behaviours (e.g. OCD client)
Maintaining Cycles
Fear/threat
e.g. house burning down
Safety Behaviour
e.g. repeated checking of
appliances
Failure to disconfirm
threat
(attributed to safety behaviour)

• Reduced activity (depressed client)
Maintaining Cycles
Depressed
mood
Negative Thoughts
(What’s the point?’, ‘I can’t be
bothered with anything’)
Reduced activity
General reduction in
achievement, activity levels,
social withdrawal
Loss of Positive Rewards
(Loss of sense of pleasure/social
contacts)

• Perfectionism (e.g. depressed client)
Maintaining Cycles
Negative self
beliefs
(e.g. I am worthless)
Has high standards
(‘If I don’t get 100%
success in everything I do
I’ve failed’)
Unable to achieve
standards/derive satisfaction
from achievement
(‘Nothing I do is good enough’)

• Catastrophic Misinterpretation (e.g. panic
client)
Maintaining Cycles
Symptoms
e.g. heart racing, chest
tight, breathless
Misinterpretation
‘I’m having a heart attack’
Increased anxiety
Anxiety symptoms
increased

• Scanning/hypervigilence (e.g. health anxiety
client)
Maintaining Cycles
Worry about
illness
e.g. fear of cancer
Scanning/checking
e.g. headaches
Sensations noticed or
produced
Interpreted as confirmation of illness
‘I might have a brain tumour’

• Escape/avoidance (e.g. social anxiety)
Maintaining Cycles
Feared situation
e.g. parties, social
gatherings
Escape/avoidance
e.g. turn down invites, others see
them as dull, where possible, avoid
eye contact/talking to others if have
to go
Failure to change belief
(Client continues to believe boring)

• Fear of fear (e.g. GAD client)
Maintaining Cycles
Anxiety
(any cause)
Aversive anxiety
symptoms
Heart racing, tense, nausea
Anticipatory fear of
becoming anxious
‘I can’t cope with anything’

• Performance Anxiety
Maintaining Cycles
Worry about
performance
e.g. public speaking
Anxiety symptoms
affect performance
e.g. hands shaking, speech
hesitant, dry throat
Apparent confirmation
‘I was right, I’m terrible at public
speaking’

• Self-fulfilling prophecies
Maintaining Cycles
Negative beliefs
about others
(e.g. ‘Other people dislike
me’)
Behaviour changes
towards others
(e.g. appear tense/hostile,
withdrawn)
Behaviour elicits negative
response from others
e.g. others appear uncomfortable, stop social
approaches
Apparent confirmation
of negative
beliefs/predictions

‘Vicious Flower’ model
(Salkovskis, Warwick & Deale, 2003)
Images
Threat Appraisal/
Meaning
Memories
Selective
Attention
Safety Seeking
Behaviours
Events, stimuli, situations
Physical
Sensations
Worry
Processes
Emotion

‘Vicious Flower’ model
(Salkovskis, Warwick & Deale)
Standing in the corner at party,
looking odd, wild staring eyes,
drenched in sweat. People
laughing and pointing School – called
‘weirdo’. Ignored. Told I
had staring eyes.
Mocked
Focus on self & how
I appear. Ignore any
friendly remarks from
others (‘just being kind’)
Hold arms down to hide
sweat; avoid eye contact.
Avoid parties or stay in
kitchen out of the way &
leave early. Cross road to
avoid people. Look at road.
Keep eyes semi-closed
Parties, social occasions,
memories of social events
Sweating,
restlessness,
shaky hands
Rumination; thinking
over past events
(what went wrong)
and rehearsing
future ones (what to
say, etc)
Anxiety;
panic
People think I am
weird; I will end up
rejected and alone

Depression
Mode
Negative view
of self, world
& future
6 Cycles Maintenance Model – A ‘Vicious
Flower’ for Depression (Moorey, 2010)
6. Motivation
and physical
symptoms
5. Unhelpful
behaviours
4. Withdrawal
and avoidance
1. Automatic
negative thinking
2. Ruminations &
self attacking
3. Mood/emotion

Longitudinal Formulation
Early experience
Core beliefs/assumptions
Critical Incident(s)
Activation of beliefs/ assumptions
Negative Automatic Thoughts (NATs)
Feelings Physical
Behaviour
Depression:

Deprived of affection; Lack of attention vs. siblings
There’s something wrong with me; I’m unlovable
Break up of relationship
Activation of beliefs/ assumptions
I’m unlovable, If I get into relationship it goes wrong
Upset Lethargic, heavy
Withdraw
Depression:

Anxiety: Learning Experience
Danger Schemas Formed
Critical Incident
Schema Activated
Anxiety Symptoms
Behavioural Responses
Generic cognitive theory
of anxiety disorder
Ref: Wells, A. (2007)
Cognitive Therapy of
Anxiety Disorders.
Chichester: John Wiley &
Sons
Cognitive Biases

Anxiety:
Danger Schemas Formed
Critical Incident
Schema Activated
Anxiety Symptoms
Behavioural Responses
Generic cognitive theory of anxiety
disorder, Wells, A. (2007) Cognitive
Therapy of Anxiety Disorders.
Chichester: John Wiley & Sons
Cognitive Biases
Highly anxious mother: not allowed
out alone until age 16; fear of
abduction, etc)
Learning Experience
The world is dangerous; people will
harm me; I am vulnerable; worrying
keeps me safe
Neighbour’s house burgled
The world is dangerous
(& I am vulnerable)
I will be next; I need to get more locks;
I need to have the police’s number
handy; what if it happens when I’m
alone at night?
Heart pounding; rapid breathing;
sweating; restless; racing thoughts;
rumination
Plan escape routes & location of
weapons; check locks frequently; have
mobile by bed; buy alarm system
Selective abstraction (neighbour’s
house less secure)
Catastrophising

CBT Models disorders.ppt

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to CBT Models disorders.ppt

Similar to CBT Models disorders.ppt (20)

Recently uploaded

Recently uploaded (20)

CBT Models disorders.ppt

Editor's Notes