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Disorder specific models

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1 Disorder specific models
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: © Think CBT Ltd.

2 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 © Think CBT Ltd.

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

4 A model of the development and maintenance of specific phobias
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 Hyper vigilance about physical symptoms Anxious mood Physiological symptoms Increasingly anxious cognitions about external triggers Anxious cognitions about symptoms (fear of fear) Safety behaviours (related to anxious thoughts about external trigger) Safety behaviours (related to fear of fear) Secondary cognitions From Chapter 8 of Oxford Guide to Behavioural Experiments in Cognitive Behaviour Therapy (Kirk & Rouf) © Think CBT Ltd. Depression, hopelessness, loss of confidence, low self-esteem

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

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

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

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

9 5 Part Cognitive Behavioural Therapy Model
Environment Thoughts Emotions Behaviours Physical © Think CBT Ltd.

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

11 Negative Automatic Thoughts Physiological Changes
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 © Think CBT Ltd.

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

13 “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 Neutralising Actions Rituals, reassurance, mental argument Attention and Reasoning Biases Looking for trouble Misinterpretations of significance of intrusions – responsibility for action Counterproductive “Safety” Strategies Thought suppression, impossible criteria Mood Changes Distress, anxiety, depression © Think CBT Ltd.

14 Depression Model (Beck 1967, 1976)
Early Experiences Core Beliefs and Assumptions Critical Incident Assumptions Activated Negative Automatic Thoughts Symptoms of Depression Behavioural Motivational Affective Cognitive Somatic © Think CBT Ltd.

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

16 Anxiety Maintenance (Westbrook, Kennerley & Kirk, 2007)
1. Perceived threat: Exaggerated and/or inappropriate Internal or external event 4. Fear remains intact: the alarming belief is unchanged 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 © Think CBT Ltd.

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

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

19 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 © Think CBT Ltd.

20 Cognitive Model of Postnatal Depression [Milgrom A. , Martin P. R
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 Cultural Factors Precipitating Factors, including Biological Factors Post Natal Depression Exacerbating & maintaining factors Depression and other emotions Anxiety, Anger, Sadness Mediational Cognitive Factors Negative Automatic Thoughts Poor parenting self-efficacy (mediational = appraisal process) Behaviour / Coping Strategies Lethargy, Indecision, Social Withdrawal, Martial Conflict, Difficulty dealing with infant © Think CBT Ltd.

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

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

23 Clark’s cognitive model of panic with maintenance cycles added (adapted from Clark, 1986)

24 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 Emotion Thought control © Think CBT Ltd.

25 Positive beliefs about worry
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, ] Situation What if..? Positive beliefs about worry Worry Mood State Life Events Negative problem orientation Cognitive avoidance Anxiety Demoralization Exhaustion © Think CBT Ltd.

26 Low Self-Esteem: A Map of the territory (Fennell, 1999)
(Early) Experience Events, relationships, living conditions which have implications for ideas about the self The Bottom Line Assessment of worth/ value as a person Conclusions about the self, based on experience: this is the kind of person I am How Low Self-esteem Develops Rules for living Guidelines, policies or strategies for getting by, given the truth of the Bottom Line Standards against which self-worth can be measured Trigger Situations Situations in which the Rules for Living are, or may be, broken Activation of the Bottom Line Depression Negative Predictions What keeps Low Self-esteem Going Anxiety Self-critical thoughts Unhelpful behaviour © Think CBT Ltd. Confirmation of the Bottom Line

27 Based on Wells 1997, adapted by Stopa
Social Situation 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? Thoughts 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? 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? 2. When you thought (feared event) might happen, what did you notice happening in your body? (Suggest symptoms of anxiety) Self-focus 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? Safety Behaviours Anxiety Symptoms © Think CBT Ltd. 7. When you did (safety behaviours) what effect did that have on your anxiety?

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

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

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

31 Maintaining Cycles Reduced activity (depressed client)
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) © Think CBT Ltd.

32 Maintaining Cycles Perfectionism (e.g. depressed client)
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’) © Think CBT Ltd.

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

34 Maintaining Cycles Scanning/hypervigilence (e.g. health anxiety client) 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’ © Think CBT Ltd.

35 Maintaining Cycles Escape/avoidance (e.g. social anxiety)
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) © Think CBT Ltd.

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

37 Maintaining Cycles Performance Anxiety
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’ © Think CBT Ltd.

38 Maintaining Cycles Self-fulfilling prophecies
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 © Think CBT Ltd.

39 ‘Vicious Flower’ model (Salkovskis, Warwick & Deale, 2003)
Images Emotion Memories Worry Processes Threat Appraisal/ Meaning Selective Attention Allows you to integrate core concern and the different processes that this drives (engine & cogs) Physical Sensations Safety Seeking Behaviours Events, stimuli, situations © Think CBT Ltd.

40 ‘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 Anxiety; panic Rumination; thinking over past events (what went wrong) and rehearsing future ones (what to say, etc) People think I am weird; I will end up rejected and alone 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 Sweating, restlessness, shaky hands Parties, social occasions, memories of social events © Think CBT Ltd.

41 6 Cycles Maintenance Model – A ‘Vicious Flower’ for Depression (Moorey, 2010)
1. Automatic negative thinking 6. Motivation and physical symptoms 2. Ruminations & self attacking Depression Mode Negative view of self, world & future More helpful across a range of situations, as opposed to each 5 areas model being better suited to a specific situation 5. Unhelpful behaviours 3. Mood/emotion 4. Withdrawal and avoidance © Think CBT Ltd.

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

43 Longitudinal Formulation
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 © Think CBT Ltd.

44 Longitudinal Formulation
Anxiety: Learning Experience Generic cognitive theory of anxiety disorder Ref: Wells, A. (2007) Cognitive Therapy of Anxiety Disorders. Chichester: John Wiley & Sons Danger Schemas Formed Critical Incident Schema Activated Negative Automatic Thoughts Anxiety Symptoms Behavioural Responses Cognitive Biases © Think CBT Ltd.

45 Longitudinal Formulation
Highly anxious mother: not allowed out alone until age 16; fear of abduction, etc) Anxiety: Learning Experience Generic cognitive theory of anxiety disorder, Wells, A. (2007) Cognitive Therapy of Anxiety Disorders. Chichester: John Wiley & Sons The world is dangerous; people will harm me; I am vulnerable; worrying keeps me safe Danger Schemas Formed Critical Incident Neighbour’s house burgled The world is dangerous (& I am vulnerable) Schema Activated 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? Negative Automatic Thoughts Heart pounding; rapid breathing; sweating; restless; racing thoughts; rumination Anxiety Symptoms Plan escape routes & location of weapons; check locks frequently; have mobile by bed; buy alarm system Behavioural Responses Selective abstraction (neighbour’s house less secure) Catastrophising Cognitive Biases © Think CBT Ltd.

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