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Newsletter for October 2008


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Cognitive Behavioral Therapy (CBT) in treating Depression,

General Anxiety and Bipolar Disorder

                   (excerpted from (

Cognitive Behavioral Therapy
(CBT) is an umbrella-term for psychotherapies that deal with cognitions, assumptions, beliefs, evaluations and behaviors, with the aim of influencing emotions and behaviors that relate to maladaptive and dysfunctional appraisal of events. The general approach, developed out of behavior modification, Cognitive Therapy and Rational Emotive Behavior Therapy, has become widely used to treat various kinds of psychopathology, including mood disorders and anxiety disorders. The particular therapeutic techniques vary within the different approaches of CBT according to the particular kind of problem issues, but commonly may include keeping a diary of significant events and associated feelings, thoughts and behaviors; questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; and trying out new ways of behaving and reacting. Relaxation, mindfulness and distraction techniques are also commonly included. CBT is widely accepted as an evidence- and empiricism-based, cost-effective psychotherapy for many disorders and psychological problems. It is sometimes used with groups of people as well as individuals, and the techniques are also commonly adapted for self-help manuals and, increasingly, for self-help software packages.

One of the objectives of CBT typically is to identify and monitor thoughts, assumptions, beliefs and behaviors that are related and accompanied to debilitating negative emotions and to identify those which are dysfunctional, inaccurate, or simply unhelpful. This is done in an effort to in a wide array of different methodologies replace or transcend them with more realistic and self-helping ways.

An example from cognitive therapy may illustrate this process: Having made a mistake at work, a person may believe, "I'm useless and can't do anything right at work." Strongly believing this, in turn, tends to worsen his mood. The problem may be worsened further if the individual reacts by avoiding activities and then behaviorally confirming his negative belief to himself. As a result, an adaptive response and further constructive consequence becomes unlikely, which reinforces the original belief of being "useless." In therapy, the latter example could be identified as a self-fulfilling prophecy or "problem cycle," and the efforts of the therapist and client would be directed at working together to change it. This is done by addressing the way the client thinks and behaves in response to similar situations and by developing more flexible ways to think and respond, including reducing the avoidance of activities. If, as a result, the client escapes the negative thought patterns and destructive behaviors, the feelings of depression may, over time, be relieved. The client may then become more active, succeed and respond more adaptive more often, and further reduce or cope with his negative feelings.

Cognitive behavioral therapy generally is not an overnight process. Even after patients have learned to recognize when and where their mental processes go awry, it can take months of effort to replace a dysfunctional cognitive-affective-behavioral process or habit with a more reasonable and adaptive one.

The cognitive model especially emphasized in psychiatrist Aaron Beck's cognitive therapy says that a person's core beliefs (often formed in childhood) contribute to "automatic thoughts" that pop up in everyday life in response to situations. Cognitive Therapy practitioners commonly hold that clinical depression is typically associated with negatively biased thinking and dysfunctional thoughts.

Cognitive behavioral therapy is often used in conjunction with mood stabilizing medications to treat conditions like bipolar disorder. Its application in treating schizophrenia along with medication and family therapy is recognized by the NICE guidelines (see below) within the British NHS.


Negative thinking dominates when a person experiences depression. The depressed person can experience negative thoughts as being beyond their control, thereby allowing them to become automatic and self-perpetuating.

Negative thinking can be categorized into a number of common patterns called "cognitive distortions." The cognitive therapist provides techniques to give the client a greater degree of control over negative thinking by correcting these distortions or correcting thinking errors that abet the distortions, in a process called cognitive restructuring.

Causes of depression according to cognitive theory

One etiological theory of depression is the Aaron Beck cognitive theory of depression. His theory is regarded as the most verified psychological theory of depression. His theory states that depressed people think the way they do because their thinking is biased towards negative interpretations. According to Beck’s theory of the etiology of depression, depressed people acquire a negative schema of the world in childhood and adolescence. (Children and adolescents who suffer from depression acquire this negative schema earlier.) Depressed people acquire such schemas through a loss of a parent, rejection of peers, criticism from teachers or parents, the depressive attitude of a parent and other negative events. When the person with such schemas encounters a situation that resembles in some way, even remotely, the conditions in which the original schema was learned, the negative schemas of the person are activated. [6]

Beck also included a negative triad in his theory. A negative triad is made up of the negative schemas and cognitive biases of the person; Beck theorized that depressed individuals make negative evaluations of themselves, the world, and the future. Depressed people, according to this theory, have views such as “I never do a good job,” and "things will never get better." A negative schema helps give rise to the cognitive bias, and the cognitive bias helps fuel the negative schema. This is the negative triad. Also, Beck proposed that depressed people often have the following cognitive biases: arbitrary inference, selective abstraction, overgeneralization, magnification and minimization. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema.[7]

Another cognitive theory of depression is the Hopelessness Theory of depression. This is the latest theory of the helpless/hopeless theories of depression, stating that hopelessness depression is caused by a state of hopelessness. A state of hopelessness develops when the person believes that no good outcomes are possible, only negative ones. The person also feels that he or she has no ability to change the situation to allow for a positive outcome. Stressors (negative life events) are thought to interact with a diathesis (in this case, a predisposing factor to depression) to create a sense of hopelessness.[8]

Some proposed diatheses are attributing negative events to stable and global factors, low self-esteem, and a tendency to believe that negative life events will have severe negative consequences. Such diatheses increase the possibility that a person will experience hopelessness depression.

Attributional style

An approach to depression based upon attribution theory in social psychology is related to the concept of attributional style. First advanced by Lyn Abramson and her colleagues in 1978, this approach argues that depressives have a typical attributional style —they tend to attribute negative events in their lives to stable and global characteristics of themselves.[9] This theory is sometimes known as a revised version of learned helplessness theory.

In 1989, this theory was challenged by Hopelessness Theory.[10] This theory emphasized attributions to global and stable factors, rather than, as in the original model, internal attributions. Hopelessness Theory also emphasizes that beliefs about the consequences of events, and rated importance of events, may be at least as important as causal attributions in understanding why some people react to negative events with clinical depression.

The ABC-model of psychological disturbance and change

A major aid in cognitive therapy is what Albert Ellis calls the ABC-model.[2] In therapy the client and the therapist work through a situational episode a person has a significant disturbed emotional response in relation to. These situations and problems may be used to assess and map more complex and multi-layered problem issues.

  • A - Activating Event or adversity. This represents the situation, that is, the often infered situational and critical event that triggers a significant emotional response.
  • B - Beliefs. This is the evaluative emotional and behavioral beliefs about the adversity the client has in relation to his unique personal likes and dislikes.
  • C - Consequence. This represents the negative disturbed emotions and dysfunctional behaviors related to A and B. The beliefs and assumptions at B are seen as a connecting mediating bridge between the situation and the unhealthy feelings and maladaptive behaviors.

For example, Gina is upset because she fails an important math test. The activating event, A then is that she failed her test and infers that she will not be able to get her degree. The evaluative belief, B about A, is that she believes in her heart and head that she absolutely always must have good grades and succeed or else its awful the end of the world. The Consequence, C, is that Gina tend to feel depressed and thinks may be no use to continue school.

  • Disputing. After a situational episode, beliefs and responses have been identified and assessed, the therapist will often work in wide array of ways with the client in challenging and disputing the dysfunctional beliefs on the basis of evidence from the client's experience. By using many cognitive, emotive and behavioral methods and techniques the client is helped to develop and ingrain more functional and rational beliefs with succeeding healthy and adaptive responses.

From the example above, a therapist may help Gina realize that it is self-defeating and that there is no evidence and does not make sense to believe that she absolutely always must pass her tests and succeed - and that such kind of thing is an absolute horror. Although she normally may want and strongly prefer to pass her tests and succeed, she has alternatives and not doing it would not be the end of the world. If she realizes that not passing her tests, and even have trouble getting her degree is highly unfortunate and sad, but not awful and horrible she will tend to feel sad or frustrated, but not depressed and helpless. The sadness and frustration are then healthy negative emotions because they are more likely to make her to study more effectively or deal with her problems as a reponse.

Effectiveness of CBT with or without drugs

For treatment of anxiety, a meta-analysis of 35 studies[11]shows the psychological method of cognitive behavioral therapy to be more effective in the long term than pharmacologic treatment (drugs such as SSRIs), and while both treatments reduce anxiety, CBT is more effective in reducing depression.

For treatment of depression, a large-scale study in 2000[12] showed substantially higher results of response and remission (73% for combined therapy vs. 48% for either CBT or a particular discontinued antidepressant alone) when a form of cognitive behavior therapy and that particular discontinued anti-depressant drug were combined than when either modality was used alone.

For more general results confirming that CBT alone can provide lower but nonetheless valuable levels of relief from depression, and result in increased ability for the patient to remain in employment, see The Depression Report,[13] which states: 1000people attend up to sixteen weekly sessions one-on-one lasting one hour each, some will drop out but within four months 50 people will have lost their psychiatric symptoms over and above those who would have done so anyway. After recovery, people who suffered from anxiety are unlikely to relapse. . . . So how much depression can a course of CBT relieve, and how much more work will result? One course of CBT is likely to produce 12 extra months free of depression. This means nearly two months more of work.

The American Psychiatric Association Practice Guidelines (April 2000) indicated that among psychotherapeutic approaches, cognitive behavioral therapy and interpersonal psychotherapy had the best-documented efficacy for treatment of major depressive disorder, although they noted that rigorous evaluative studies had not been published.[14]

Effectiveness of CBT for insomnia

Cognitive behavioural therapy has been found to be highly effective in the treatment of insomnia and in reducing benzodiazepine usage. Temazepam, nitrazepam and zopiclone (not a benzodiazepine) are the most frequently prescribed hypnotics in the United Kingdom.

Hypnotic drugs are of poor value for the management of chronic insomnia. It is widely accepted that hypnotic drug usage beyond 4 weeks is undesirable for all age groups of patients. Many continuous sedative hypnotic users exhibit disturbed sleep as a consequence of tolerance but experience worsening rebound or withdrawal insomnia when the dose is reduced too quickly, which compounds the problem of chronic hypnotic drug use. No formal withdrawal programs for benzodiazepines exist with local providers in the United Kingdom.

CBT has been found to be more effective for the long-term management of insomnia than sedative hypnotic drugs. A meta-analysis of published data on psychological treatments for insomnia shows a success rate between 70 and 80%. A large-scale trial utilising cognitive behavioural therapy in chronic users of sedative hypnotics including nitrazepam, temazepam and zopiclone found CBT to be a more effective long-term treatment for chronic insomnia. Persisting improvements in sleep quality, sleep latency, and increased total sleep, as well as improvements in sleep efficiency and significant improvements in vitality and physical and mental health at 3-, 6- and 12-month follow-ups were found in those receiving cognitive behavioural therapy.

A marked reduction in total sedative hypnotic drug use was found in those receiving CBT, with 33% reporting no hypnotic drug use. Age has been found not to be a barrier to successful outcome of CBT.

It was concluded that CBT for the management of chronic insomnia is a flexible, practical, and cost-effective treatment for the treatment of insomnia and that CBT leads to a reduction of benzodiazepine drug intake in a significant number of patients.[15]

CBT with children and adolescents

The use of CBT has been extended to children and adolescents with good results. It is often used to treat depression, anxiety disorders, and symptoms related to trauma and Post Traumatic Stress Disorder. Significant work has been done in this area by Mark Reinecke and his colleagues at Northwestern University in the Clinical Psychology program in Chicago. Paula Barrett and her colleagues have also validated CBT as effective in a group setting for the treatment of youth and child anxiety using the Friends Program she authored. This CBT program has been recognized as best practice for the treatment of anxiety in children by the World Health Organization.Combining the Biofeedback method with the CBT process is very effective. CBT has been used with children and adolescents to treat a variety of conditions with good success.

CBT is also used as a treatment modality for children who have experienced Complex Post Traumatic Stress Disorder, chronic maltreatment, and Post Traumatic Stress Disorder[19]. It would be one component of treatment for children with C-PTSD, along with a variety of other components, which are discussed in the Complex Post Traumatic Stress Disorder article.

Computerized CBT

There are Cognitive-Behavioral therapy sessions in which the user interacts with computer software (either on a PC, or sometimes via a voice-activated phone service), instead of face to face with a therapist. It cannot replace face-to-face therapy, but it can provide an option for patients, especially in light of the fact that there are not always therapists available, or the cost can be prohibitive. Computerized CBT is clinically proven and drug-free. For people who are feeling depressed and withdrawn, the prospect of having to speak to someone about their innermost problems can be off-putting. In this respect, CCBT (especially if delivered online) can be a good option.

Randomized controlled trials have proven its effectiveness, and in February 2006 the UK's National Institute of Health and Clinical Excellence (NICE) recommended that CCBT be made available for use within the NHS across England and Wales, for patients presenting with mild/moderate depression, rather than immediately opting for antidepressant medication.[20]

A new UK government initiative for tackling Mental Health issues[21] has recently been launched by the Care Services Improvement Partnership.[22] This confirms Primary Care Trust (PCT) responsibilities in delivering the NICE Technology Appraisal on CCBT. National Director for Mental Health, Professor Louis Appleby CBE[23] has confirmed that by 31 March 2007 PCTs should have ST Solutions' "FearFighter" and Ultrasis' "Beating the Blues" CCBT products in place and the NICE Guidelines should be met. Some areas have developed, or are trialing, other CCBT products notably Outreach-online[24] developed in-house by the NHS and currently being trialed in North Wales (UK).

In the United States, a Chicago-based company Prevail Health Solutions, LLC is leading the development of computerized Cognitive-Behavioral Therapy. Their products are not yet offered to the general population, but currently there are ongoing clinical trials to determine efficacy in the treatment of several mental health disorders.







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