EBT Lecture 3 + 4

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lhoyman
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153067
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EBT Lecture 3 + 4
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2012-05-09 13:55:00
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CBT dep bipolar PTSD
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EBT Lecture 3 + 4
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  1. Obessions
    like having many false alarms over the course of the day
  2. OCD cognitive formulation
    • doubt=dangerous
    • certainty=absolute safety

    rituals and complusions are directed at reducing doubt and increasing certainty
  3. OCD cog, formulation-5 assumptions
    • „Thinking of an action is the same as performing it (thought-action fusion)
    • „Failing to prevent harm is the same or the moral equivalent to causing harm
    • „Responsibility for harm is not diminished by extenuating circumstances
    • „Failing to ritualize in response to an idea about harm constitutes an actual intention to harm
    • „One should always exercise control over one’s thoughts
  4. OCD integrated model-Clark
    • development/onset
    • maintenance and exacberation
  5. integrated model-development/onset
    function of classical cond, cog, modeling and transmission of info
  6. integrated model-maintenance and exacerbation
    • neg. reinforcemtn (operant cond)
    • hypersensitivity to cues associated with obs and comps ( classical cond)
    • appraisals that have to do w/ harm and responsibility
  7. OCD
    • routines help establish a sense of control
    • when sense of control is threatened or thwarted, high levels of arousal occur
    • referred to as paradox of mental control
  8. tx for OCD (1)
    • „Provide psychoeducation
    • „Demonstrate understanding of sxs
    • „Help pt distinguish between their thoughts and OCD
    • „Discuss cost of compulsions and avoidance
    • „Explain course of TX including eventual exposure
    • „Begin with self-monitoring
  9. tx for OCD (2)
    • „Use facilitative strategies (e.g. cognitive techniques)
    • „Establish exposure hierarchy
    • „In session graduated exposure
    • „Out of session HW exposure
    • „Identify and modify Underlying Assumptions and Core Beliefs
    • „Relapse Prevention
  10. treating thought and action fusion
    • link bw thoughts and action is INDIRECT
    • there are numerous factors that determine whether or not you carry out an action
  11. behavioral experiments (OCD)
    • try to lose control
    • telling something out loud in waiting room
    • singing at bus stop
    • jumping up down wildly in public
  12. counting obsessions and compulsions
    • gradually reduce number of times an action is performed
    • change the way the counting is done
    • substitute something else for the counting (list colors, months of the years)
    • be sure to vary the subsitution
    • count to the wrong number
  13. make the rules conditional rather than absolute
    • might instead of will
    • I might contract AIDS if I touch someone VS I will contract AIDS if I touch someone
  14. faciltitative strategies for OCD
    • counting obsessions and compulsions
    • make rules conditional rather than absolute
    • rituals-break the rules
    • handling reassurance seeking
  15. rituals-break the OCD rules
    • delay ritual
    • shorten ritual
    • do ritual differently
    • do ritual more slowly
  16. handling reassurance seeking
    • have blocks of time for reasurrance seeking and no checking times
    • write answer on cardhave reassurance seeking coupons
    • reinforce for not seeking reassurance
    • after the reassuring q's
    • ask in wrong
    • backward
    • sing it
    • make it nonsensical-are martians invading today?
  17. exposure record
    • time
    • distress level
    • thoughts, images, feelings or urges

    conckusion-what happened to distress over time? what made it go down?
  18. cognitive therapy for panic
    • main prob is way ppl process signals within body (interoceptive exposure)
    • basic aim is to modify the misinterpreation of physical sensations
  19. overview of panic
    • 1. education
    • learn the model
    • 2. teaching specific coping strategies
    • 3. repeated exposure
  20. symptom, process and streatgy table (padesky)
    Symptom-->beh/emo/cog process-->intervention strategy
  21. Symptom-panic table
    • pts observation of physical/mental changes
    • overarousal of ANS
    • attention glued to subjective physiological feelings and catastrophic feelings
    • attribution to danger
    • overwhelming escape behavior
  22. beh/emo/cog processes-panic table
    • preoccupation
    • hypervigilance
    • emotional activation
    • attentional focus
    • catastrophizing
    • overgeneralization
    • avoidance
  23. Intervention strategy-panic table
    • psychoeducation
    • relaxation
    • refocusing
    • cognitive restructuring
    • graduated exposure
  24. pts observation of physical/mental changes-panic
    • precoocupation
    • hypervigilance
    • -->psychoeducation
  25. overarousal of ANS-panic
    emotional activation-->relaxation
  26. attention glue to subj physiological and catastrophic feelings-panic
    attentional focus-->refocusing
  27. attribution to danger-panic
    • catastrophizing
    • overgeneralization
    • -->cog. restructuring
  28. overwhelming escape beh-panic
    avoidance-->graduated exposure
  29. level of arousal and intervention
    padesky-level of sx arousal-->type of intervention

    • low
    • moderaste
    • high
  30. low level of sx arousal-panic
    • psychoeducation
    • environmental clean up (decrease caffeine intake, time management)
    • relaxation training
  31. moderate level of sx arousal-panic
    cog. restructuring
  32. high level of sx arousal-panic
    • attention refocus (early in tx)
    • exposure (later in tx)
  33. psychoeducation-panic
    • clinician reads and reviews info
    • ex.coping w/panic diary
    • go over verbally
    • give pt copy and assign them the task of mindfully reading it
  34. self monitoring-panic
    • self report. clinician rater, structured interviews, structured instruments
    • daily thought records
    • SUDs ratings and hierarchies
    • panic diaries
    • mood diaries
  35. panic diary
    • date
    • time began and ended
    • where did it occur
    • who was present
    • how did you cope
    • check all sx that apply...
    • what went through your mind?
  36. attentional refocus-panic
    • what happes if you have a bug bite and you keep noticing how much it itches?
    • what happens when your attention is distracted away?
  37. refocusing techniques-panic
    • „Read a paragraph backwards
    • „Count change in pockets
    • „Do different math problems
    • „Sensory grounding techniques (e.g. grab arms of chairs and feel its firmness)
    • „Name every US President since 1850
    • „Name All US States in Alphabetical Order
    • „If entertainment fan, 6 degree separation from Kevin Bacon
    • „Sports Fan: World Series, Superbowl Champs from 1980
    • „Count number of ppl with some color hair, eyes, wearing a particular article of clothing
  38. beh interventions-panic
    • relaxation
    • deep breathing
    • breathing control
    • environmental clean up
    • time mgmt
  39. cog restructuring/coping cards-panic
    • although scary, panic sx are not dangerous
    • what i am experiencing is normal
    • anxiety is alike a wave-it will pass
    • stay in the present
    • pay attention to breathing and slow it down
    • panic can only go so far
    • i can make myself more anxious by my thoughts
    • it is not true that my mind and body can only take so much
    • the more i try to control panic attacks, the worse the panic gets
  40. rational analysis-panic
    • reattribution
    • test of evidence
    • testing out misinterpretation in imagery
    • ex. not getting enough oxygen on plane
    • look around, is anyone else gasing for air? are the air masks out?
  41. interoceptive exposure
    • purpose is to disrupt or weake associations bw specific body cues and panic reactions
    • decrease the hyperventilation response
    • decrease fear avoidance response
  42. consult with physician for panic induction for these conditions...
    • „Cardiovascular disease
    • „Hypertension
    • „Respiratorydisease
    • „Metabolic/hormonal disorder
    • „Epilepsy
    • „Pregnancy
    • „Psychosis
    • „Intellectual Disability
    • „Elderly
  43. contraindications for panic induction
    • any medical or physical condition where the induction may lead to serious physical consequences
    • consult with physician to see if pt is medically clearned for the approach
  44. types of panic induction
    • imagery
    • overbreathing
    • shake head from side to side
    • run in place
    • spin in a chair
    • breathe through narrow straw
    • hold breath
    • turn up heat in room
  45. panic induction steps
    • 1. pt fills out panic diary or sensation checklist
    • 2. "we're going to do an anxeiyty experiment together..."
    • 3. you may experience neg sensations but it is important to keep going as long as possible
    • 4. fill out sensation check list again
  46. panic induction protocol qs
    • cheerlead pt
    • how are you feleing now?
    • how was this similar/diff from a regular panic attack?
    • what thoughts ran through your head during experiment?
    • what conclusions can you make about the exp?
    • what does it say about your level of control?
  47. flashbacks
    • involuntary
    • consist of sensory impressions rather than thought
    • pts feel as if they are reliving them/experiencing them right now
  48. intentional recall
    • voluntary
    • involves an appraisal process
    • VS. flashbacks in PTSD
  49. types of PTSD exposure
    • imaginal (narrative)
    • in session
    • virtual reality
  50. cog processing therapy-PTSD
    • integrates elements of cog, beg, narrative and existential therapies
    • by writing detailed acct in graduated fashion it creates a tolerable dose of awareness and exposure
    • by writing/drawing, pts gain a sense of mastery, ascribe meaning to an incomprehensible event
    • reptetitive writing and processing facititates habituation
    • integrates existential by heling ppl find their meaning in survival-very empowering approach
  51. common goals of CBT for PTSD
    • remember and accept what happened by not avoiding memories and accompanying emotions
    • allow self to feel natural emotions and let them run their courses so the memory can be put away without strong feelings attached
    • balance beliefs that had been disrupted or reinforced
  52. why cog, processing works
    • connects previously fragmented and isolated parts of memory
    • promotes psychological integration
    • propels discrimination bw "then" and "now" moments
    • verbal, deliberate recall is reinforced while sensory involuntary experiences fade into background
    • talking and writing about trauma is a systematic, graduated, and mindful way that decreases blood pressure, muscle tension and GSR
  53. psychoeducational intro-PTSD
    „You‘ve been trying to cope with memories of the trauma by pushing them away, and its certainly okay to try that, but it hasn’t worked well enough for you , so we need to try something different. The fact that these thoughts keep coming back and bothering you tells me that there’s some unfinished business here, and you need to finish up so you can put the trauma behind you. The way to do this is for us to deal with these memories together. I’ll help you go over and over what happened until we wear these memories and they no longer have any power over you because you have taken control over them.”
  54. tips for processing the trauma narrative
    • detailed acct should be doone
    • should be delivered in tolerable doses
    • offer support during process
    • -if pt can survive the trauma, they survive the process
    • coach the pt to stay in the first person, present time orientation
    • stay alert to the inherent appraisal process
    • -note the appraisals, self blame, survivors fuily
    • note and reinforce coping
  55. meta analysis of comparative studies of tx of dep
    • compared: CT, no ndirective supportive, beh activation, psychodynamic, problem solving, IPT, social skills training
    • all went through at least 5 RCTs
    • no appraoch is most efficaious
    • IPT a little more, supportive a little less
  56. CBT
    dysfunctional thoughts-->current beh and future functioning
  57. nondirective supportive (SUP)
    • unstructured, empathy, reflect emotions
    • Rogers
  58. behavioral activation (BA)
    • B of CBT
    • acivity scheduling
    • increase pos. reinforcement
  59. psychodynamic (DYN)
    increase insight as to how past conflucts impact current life
  60. problem solving (PST)
    problem + solving=resolution
  61. interpersonl (IPT)
    brief, structures, interpersonal deficits only
  62. social skills training (SST)
    build/maintain relationships, assertiveness
  63. conceptualizing depression-CBT
    • Beck's negative cognitive triad
    • pessimistic thoughts about self, others/world, future
    • Beck Depression Inventory
  64. CBT Case Formulation
    • identifying info
    • chief complaint
    • problem list
    • hypothesized mechanism
    • relation of mechanism to problems
    • precipitants of current probs
    • origins of central prob
    • tx plan
    • predicted obstacles to tx
  65. core tenants of CBT
    • time limited and goal oriented
    • patient is active collaborator
    • goal is ind. functioning
    • cog conceptualization model
    • model of emotion
  66. CBT structured sessions
    • update, mood check, summary of last session, review pt goals
    • review hw
    • set session agenda
    • discuss agenda
    • assign new hw
    • summary/feedback
  67. cognitive conceptualization diagram-CBT
    • relevant childhood data-->core beliefs-->conditional assumptions/rules-->compensatory strategies
    • Situation 1-->automatic thoughts-->meaning of the AT-->emo-->beh
  68. core beliefs and schemas
    • develop early
    • deeper level cognition
    • rigid
    • predict and shape automatic thoughts
  69. automatic thoughts
    • maladaptive automatic thoughts block goals and increase emo pain
    • alternative thoughts may help reach goals and dec emo pain
  70. 4 steps to conquer automatic thoughts
    • 1. identifying
    • introducing distortions, thought records in session
    • 2. tracking
    • HW-ID thoughts related to neg emotions
    • 3. evaluating
    • pros and cons, function, evidence for/against
    • 4. creative alternatives
    • reducing disortions, consider realistic options
  71. list of maladaptive thought patterns
    • catastrophizing
    • filtering
    • personalizing
    • over generalizing
    • polarizing
    • emotionalizing
  72. catastrophizing
    always anticipating the worst possible outcome to occur
  73. filtering
    exaggerating the neg and minimizing the pos aspects of an experience
  74. personalizing
    automatically accepting blame when something bad occurs even when you had nothing to do with the cause of the neg event
  75. over generalizing
    viewing isolated trubling events as evidence that all following events will become troubled
  76. emotionalizing
    allowing feelings about an event to override logical eval of the events that occured during the event
  77. polarizing
    viewing situations in black or white (all good or all bad) terms rather than looking for shades of gray
  78. evaluating maladaptive thoughts
    • 1. what is the evidence? for/against?
    • 2. is there an alternative explanation?
    • 3. what is the worst that could happen? could I live through it? what is the best that cuould happen? which outcome is more realistic?
    • 4. what should I do about it?
    • 5. what advice would I give a friend in the same situation?
  79. CBT behavioral assessment and intervention
    • track behaviors/activities
    • introduce activity scheduling
    • increase mastery experiences
    • role play
    • relaxation
  80. CBT tx termination
    • review tx
    • assessment of goals
    • anticipate obstacles
    • create a plan for obstacles
    • booster sessions
  81. CBT considerations
    as efficacious as meds

    • client preference, willingness
    • culture, SES, life circumstances
    • integrative vs pure approach
  82. goald for tx-bipolar
    • education
    • prevention
    • sx severity
    • mechanisms and etiology
    • maintenance
  83. self mgmt-bipolar
    • maintaining welness
    • mania
    • depression
    • suicidality
    • family and work
  84. risk factors to maintaining wellness-bipolar
    • stressful life changes
    • substance abuse
    • sleep deprivation
    • interpersonal probs
    • medication inconsistency
  85. protective factors in maintaining wellness-bipolar
    • monitoring mood and triggers
    • day and night routines
    • social support
    • regular tx
  86. mania
    • controlling severity and limiting damage...
    • know prodromal sx
    • prevantative measures
    • plan and contract detailing prevention procedures
    • support: family/social and tx provider
  87. depression-bipolar
    • awareness of signs and sx
    • pleasurable activities/beg act
    • cog restructuring
  88. suicidal thoughts-bipolar
    • risk factors
    • decrease access increase support systems
    • reasons for living inventory
    • prevention plan
  89. sucidality risk factors-bipolar
    • SUD
    • short illness period
    • severe anxiety
    • impulsive
    • previous attempts
    • family suicide
    • recent stressful event
    • isolated
    • no access to tx
  90. family and work-bipolar
    • possible probs=neg emo reaction, overprotectiveness, intimacy
    • solutions=education, comm skills, problem solving

    • work=advantages and disadvantages of disclosing illness
    • accomodation

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