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Generic CBT model

  1. Physical symptoms
  2. Thoughts/mental process
  3. Behaviours
  • These three things interact to form your emotional wellbeing
    • Note that the interaction of thoughts, feelings and behaviours leads to social isolation that keeps the cycle going by affirming your beliefs
    • CBT treats internalising conditions quite well through targeting this triad. NNT=2
  • Studies typically follow up for the 6-12 month period. Effects seem to last, and the functional improvements are clear as well.

Depression case


  • I feel so bad. What is wrong with me? I’m useless. Everything is too hard. I can’t do anything right.
  • No‐one cares for me.


  • Stay at home, lie on couch all day, drink a bottle of wine, don’t answer the phone , watch TV until very late at night


  • Tired, irritable, sad, bored, restless, tearful, tense, sick in the stomach, achy

Panic case


  • What if I panic? I couldn’t cope‐ I’d have some kind of breakdown and run mad! Or I’d faint and hit my head


  • Drink water, sit down or hold onto things, take Xanax, avoid going out alone, avoid anything too distressing/emotional


  • Heart racing, tense, shaky, fast breathing, butterflies in the stomach, dizzy, faint, disorientated

In time you become desensitised to the feelings of anxiety, so they become worse. People avoid what they fear again and again until the fear is so big it is overwhelming.

There is a fundamental misinterpretation of the symptoms so there is a fear of the fear - catastrophic interpretation (e.g. 'I'm having a heart attack').

  • The symptoms are fight or flight response: people become afraid of the changes that are evolutionarily designed to help them (e.g. escape from a tiger).

Health anxiety

  • ‘I check in with my GP whenever I get new symptoms. Sometimes she can’t see me straight away, so I hop on the Net to find out what could be going on. There are so many possibilities, but I worry it’s cancer. Doctors miss things all the time. My wife checks my tummy for lumps every week. I monitor my digestion as much as I can; I’ve heard the signs can be so subtle. I often have a headache and feel dizzy and nauseous. You really have to watch for signs and symptoms.’
  • Using the model, explain how the anxiety is maintained.
    • Interpreting symptoms in catastrophic way
    • When you're worried about the symptoms you check more
    • When you check more you find more symptoms (or look them up on the internet)
    • When you find more symptoms, you interpret them in a catastrophic way
    • The cycle continues, leading to more anxiety and fuelling the preoccupation


  • ‘I often feel stressed, tense, and scattered in my thinking. I work as long as it takes to get things right, even if that means late nights and no weekends. I have to keep checking I haven’t made errors... things take me so long... sometimes I miss deadlines. If my work is not 100%, it is worthless and means I have let myself and everyone else down. I can always do better. Sometimes, it all just seems too hard and I put things off until the last minute... at least then when I fail, I can say I didn’t try my hardest. I can be the best, if I just work hard enough.’
  • Using the model, explain how the anxiety is maintained.
    • Pulling all-nighters, not having weekends: no time off, harder to concentrate, put more pressure on themselves
    • Self-fulfilling prophecy: procrastination leads to poor performance.

OCD example

Managing physical symptoms

  • What skills could help patients manage their physical symptoms of anxiety and depression?
    • Controlled breathing and meditation (panicking causes hyperventilation and triggers feelings similar to panic attack)
    • More exercise - use up adrenaline and other stimulators of the sympathetic nervous system
    • Relaxation training
    • Meditation
    • Medications (SSRIs; not benzos. Benzos don't teach people how to cope with the sensations because you're detached from your thoughts/feelings).

Managing cognitive symptoms

  • Thoughts <--> Behaviour <--> Physical symptoms
  • Aim is not to help people get rid of the anxiety (which is normal), it's about learning to manage the feelings so it doesn't lead to distress or interfering with your daily life
    • Fix unhelpful thinking patterns
  • Cognitive restructuring (3 E’s):
    1. Elicit unhelpful feelings (patients aren't always aware of what they're thinking about)
    2. Explore thinking patterns
    3. Evaluate how helpful/realistic these thinking patterns are, and develop more productive feelings

Cognitive distortions

Burns 1989 We all engage in these sorts of thinking from time to time. People with mood (affective) disorders engage in these thinking patterns too often.

  • All‐or‐nothing thinking
  • Overgeneralisation
  • Discounting the positives
  • Jumping to conclusions
  • Mind reading
  • Emotional Reasoning
  • Labelling
  • Magnifying/Minimisation
  • Making “Should” statements

Elicit... Explore... Evaluate

  • What’s the evidence? For & against
  • Is there an alternative explanation?
  • What’s the effect of thinking this way?
  • What’s most realistic?
  • What can you do about it?
  • How would you view this in 5 years time?
  • What would you tell a good friend in the same situation?
    • Most likely be a lot more positive and helpful. More friendly to others than to ourselves.
  • Convince people that they are interesting and have good things to talk about - less uninteresting to others than they initially perceived.

Thought record

  • Get them to re-evaluate their automatic thoughts based on evidence and they'll come up with an alternative response that is more healthy.


  • Testing automatic thoughts with thought records
  • Elicit areas of their life where they were interested and interesting
    • Ask them if they think that's an interesting topic if they were listening to what other people were saying
    • Entice them to admit that they HAVE interesting things to say and try to DELETE their biases that "if I say it, it's not interesting".

Other approaches to cognitive change

  • Surveys
  • Pie charts
  • Cost‐benefit analysis

All aim to bring in new information to support alternative perspective


  • Social Phobia
    • Sampled 10 people each
      • If you noticed someone blushing, what would you make of that?


  • “They are just being nice. I still believe they notice my blushing & think I’m inadequate”
  • Decided on questions
    • Do you think it is strange for a man to blush?
    • Do you think someone over the age of 30 should have grown out of blushing?
    • Do you think blushing is a sign of inadequacy?
    • If someone appeared very nervous while talking to you, would you think badly of them?
    • Would you think they’re too much hard work & avoid them in future?
  • Learning: “I guess others are less judgemental than I thought. People don’t

seem to think so badly about blushing. ”

Possible explanations for a headache

  • Hypochondriac - show them all the different possible causes for their ailment and they will see that their belief is low-probability

Cost‐benefit analysis

Reoccurring worry “I shall be always be alone..”.

  • Challenge the problem thinking
  • Advantages and disadvantages of continuing to dwell on the problem
Advantages Disadvantages
  • Protects me from getting hurt
  • Feel sad and hopeless
  • Keeps my depression going
  • It means I don't get out and meet people (self fulfilling prophecy)
  • Lack confidence and self esteem
  • I don't come across as well to others
  • Strategy provides resilience - yes they've had negative experiences in the past, but they need to learn how to appraise their negative feelings and get rid of unhelpful thinking patterns and behaviours so they can become productive and achieve their goals.

Managing behavioural symptoms

  • Courage is being scared to death... and saddling up anyway
  • A + B = C
  • Situation + Beliefs and thoughts = Consequences
  • e.g. Sitting in a car + Believing you're going to crash = You're gonna have a bad time
    • So change B, and you'll affect the consequences (C) and your future environment (A). Your improved A will produce a positive feedback loop that means you'll have a good time.
  • Avoidance doesn't stop the problem, it just causes recurring anxiety in the future when you're faced with the problem again.
    • By facing the problem, your anxiety level gradually reduces for that situation
    • Then, learning that you can deal with problems means your anxiety level when faced with a new problem is lower, and you bringing the peak back down faster due to experience.
  • Slide 1 = avoid/escape. Slide 2= CBT. Slide 3 = long-term effect of CBT in many different situations.

Exposure needs to be

  • Targeted to the fear stimulus
  • Repeated
  • Prolonged
  • Graded

Specific Phobia

  • 1. Say the word spider and write it on paper (20)
  • 2. Look at pictures spiders on paper (30)
  • 3. Put pictures of spiders on paper around the house (45)
  • 4. Look at photos of spiders on computer (60)
  • 5. Look at dead spider in jar (80)
  • 6. Look at dead spider on table (90)
  • 7. Touch/ discard dead spiders at home (95)
  • 8. Look at spider found at home (95)
  • 9. Catch and release (or kill) spider found at home (100)

Specific phobia

  • 1. Stop checking doors and windows at night (30)
  • 2. Do the gardening with Darren (50 )
  • 3. Stop looking at ceiling corners when enter a room (50)
  • 4. Walk around the block at night- no Darren (60)
  • 5. Darren stops checking cupboards and rooms (65)
  • 6. Leave bedroom window open all night-no checking (70)
  • 7. Hang clothes out at night- Darren not home (80)
  • 8. Do the gardening- no Darren (85)
  • 9. Do the Spit to Manly walk (95)
  • 10. Go to Shakespeare in the Park (100)

Body Dysmorphic Disorder

  • ‘I get so worried about the skin on my face... the blemishes, bumps, redness. Everyone can see‐ it’s disgusting and so embarrassing. I have to wear make‐up all the time... even at the gym. I can’t go swimming because of it. I rely on scarves, hats, and pulling my hair over my face... I just can’t get these worries out of my mind. Then there’s the checking‐ mirrors, shop windows, car doors. I avoid going out if I don’t look 100%‐ it can take me ages to get ready. I know I need to stop picking at my skin, but I am just trying to get it smooth. I seem to spend a fortune on skin care products.’
  • Design a possible Stepladder for this patient with BDD
  1. Stop checking face; just look at your WHOLE self in the mirror (don't check just your face)
  2. Stop picking at face
  3. Limit amount of makeup you put on
  4. Get rid of covers/avoidance behaviours, be more comfortable with face in public

Additional resources