Cbtszp

CBT OF SZP

University of Dhamar

Definition of CBT Cognitive Therapy is a system of psychotherapy that attempts to reduce excessive emotional reactions and self-defeating behaviours, by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions • * Focused form of psychotherapy based on a model suggesting that psychiatric/psychological disorders involve dysfunctional thinking • The way an individual feels and behaves in influenced by the way s/he structures his experiences • Modifying dysfunctional thinking provides improvements in symptoms and modifying dysfunctional beliefs that underlie dysfunctional thinking leads to more durable improvement • Therapy is driven by a cognitive conceptualization and uses

Environment Body Psych: Cognition Emotions Behaviou r

COGNITIVE FUNCTION INPUT

PROCESSING

OUTPUT

Brain receives input from sense organs and filters out irrelevant data; also called “perception”

Brain sorts, organizes, stores, compares, categorizes, foresees, plans, formulates using the incoming information (thinking)

Brain controls and produces output as a verbal statement or other behavior that is hopefully an adaptive response to the original input

Automatic thoughts

• Meanings we take from what happens around us or within us (words or images) • Happen spontaneously in response to situation • Brief, frequent, habitual – often not heard • Do not arise from reasoning • No logical sequence • Plausible and taken as obviously true, especially when emotions are strong • Hard to turn off • May be hard to articulate

COGNITIVE DYSFUNCTON • Cognitive distortions: Errors in interpretation that involve faulty content of thoughts and can be associated with changes in mood and behavior • Cognitive deficits: Information processing operations that are missing or working poorly

Cognitive distortions • Jumping to conclusion without supporting evidence (arbitrary inference) • Holding unrealistic EXPECTATIONS for a given situation – – – –

•

Expecting self, others or situation to be perfect Pessimism: expecting things to always go wrong Dichotomous thinking (“black and white” or “all or nothing” thinking) Emotional reasoning Distorting the MAGNITUDE of a situation: – Selective abstraction – Catastrophizing, Magnifying – Overgeneralizing

– Labelling--You identify with your shortcomings. •

Making the wrong ATTRIBUTION for a situation: – Assuming the wrong intent for another person’s actions – Assuming the wrong locus of control in a given event

– Personalization (Excess responsibility) or blaming others

Cognitive Deficits • INPUT: – Problems with sensory perception – Inability to filter out irrelevant stimuli – Problems attending to relevant stimuli

•

PROCESSING: – – – – – – –

Problems comparing information Incorrect labeling or categorizing stimuli Poor memory capacity or retrieval Slow processing speed Problems following a sequence Problems with foresight or planning Inability to use internal language or “self-talk”

Schemas (Core believes) • “stable cognitive patterns” that actively “screen, code, categorize, and evaluate stimuli” in our environment. • Those hypothetical organizing structures that guide our processing of the overwhelming number of stimuli that impinge on our senses at any given moment.

Early Experiences

   

Cognitive Model

Core Beliefs & Assumptions

Beck (1979)

Critical Incident

Negative Automatic Thoughts (NATS)

Behaviour

Feelings Physical symptoms

CBT of SZP

• SZP is: - Frequently associated with impairments of cognition, emotion, volition, behavior, somatic, educational and socioeconomic functioning - Prodromal, Acute, Residual and Remission phases, - Comorbidity: Anxiety disorders, depressive disorders, substance abuse - Biologically determined and psychotherapy was thought to has no benefit and could be harmful - NICE (2002) - ‘Psychological interventions should play a key role in the treatment of schizophrenia. The best evidence is for CBT and Family Intervention (FI)’ - Currently, NICE Guidelines (2003) recommended CBT as a treatment modality for SZP - based on rigorous metaanalysis of ‘high-quality’ RCTs (20)

Clinical Model •

Diathesis-Stress Model (Vulnerability-Stress) • Vulnerability (predisposing factors): 4) Biological factors: hereditary, constitutional or acquired 5) Psychological factors: constitutional or acquired eg: cognitive deficits or maladaptive schemas 6) Social factors * Stress: Precipitating factors (physical, psychological, social) • Symptoms are normal responses to abnormal situations • Psychotic symptoms are the extremes in a continuum of psychological experience * Maintaining factors (physical, psychological, social)

Clinical Model Bio-psychosocial vulnerability

Trigger Biopsychosocial Stressor

Appraisal of experience as external

Emotional Changes

Positive symptoms

Cognitive Anomalous experience

Maintaining factors

Aim of CBT for SZP

• To reduce the distress and disability caused by symptoms • To improve mood and self-esteem • To improve social-functioning • To reduce psychotic symptoms • To reduce the risk of further relapse • To enhance early identification and prevention

Overview of a typical course of therapy • Assessment: wider picture, measures • therapeutic relationship • Formulation (ongoing): precipitating factors, maintaining factors, predisposing factors, problem analysis, sharing model, rationale for treatment • Problem list & prioritise (identify specific problem) • Action plan and Goals for therapy (SMART)

- Course of therapy - cont • Psycho-education • Collaboratively construct a model that makes symptoms and distress understandable and explainable • Develop an alternative, non-psychotic model of experiences that is acceptable and non-stigmatizing • Develop a plausible ‘biases-in-psychological-processing’ explanation of experiences • Connect up seemingly unconnected factors - beliefs, life events, emotions, thoughts, behaviors and symptoms • Normalize the psychotic experience (you are not alone) • Installation of hope

CBT of Hallucinations • Identify the type of hallucination • Explore associated environment, cognition, emotions, somatic symptoms and behavior • Psycho-education and Normalizing experience • Change the situation • Use behavioral techniques: - Change behavioral responses - Behav. Exps - Exposure • Cognitive techniques

CBT of Delusion - Direct confrontation should be avoided - Think about the psychological need of the patient - Encourage development of arguments against beliefs by patients - Focus not on the belief but on the evidence for it - Discuss the belief as an assumption not as a fact - Discuss evidence, Cognitive distortions - Alternative explanations - Behavioral Exps

and finally…

DON’T PANIC It can be done !