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'''In children or adolescents''', CBT is an effective part of treatment plans for: anxiety disorders;<ref name=SeligmanLD>{{cite journal |author=Seligman LD, Ollendick TH |title=Cognitive-behavioral therapy for anxiety disorders in youth |journal=Child Adolesc Psychiatr Clin N Am |volume=20 |issue=2 |pages=217–38 |year=2011 |month=April |pmid=21440852 |pmc=3091167 |doi=10.1016/j.chc.2011.01.003}}</ref> [[body dysmorphic disorder]];<ref name=PhillipsKA>{{cite journal |author=Phillips KA, Rogers J |title=Cognitive-behavioral therapy for youth with body dysmorphic disorder: current status and future directions |journal=Child Adolesc Psychiatr Clin N Am |volume=20 |issue=2 |pages=287–304 |year=2011 |month=April |pmid=21440856 |pmc=3070293 |doi=10.1016/j.chc.2011.01.004 }}</ref> depression and [[Suicidal ideation|suicidality]];<ref name=SpiritoA> {{cite journal |author=Spirito A, Esposito-Smythers C, Wolff J, Uhl K |title=Cognitive-behavioral therapy for adolescent depression and suicidality |journal=Child Adolesc Psychiatr Clin N Am |volume=20 |issue=2 |pages=191–204 |year=2011 |month=April |pmid=21440850 |pmc=3073681 |doi=10.1016/j.chc.2011.01.012 }}</ref> eating disorders and [[obesity]];<ref name=WilfleyDE>{{cite journal |author=Wilfley DE, Kolko RP, Kass AE |title=Cognitive-behavioral therapy for weight management and eating disorders in children and adolescents |journal=Child Adolesc Psychiatr Clin N Am |volume=20 |issue=2 |pages=271–85 |year=2011 |month=April |pmid=21440855 |pmc=3065663 |doi=10.1016/j.chc.2011.01.002 }}</ref> [[obsessive–compulsive disorder]];<ref name= BoileauB> {{cite journal |author=Boileau B |title=A review of obsessive-compulsive disorder in children and adolescents |journal=Dialogues Clin Neurosci |volume=13 |issue=4 |pages=401–11 |year=2011 |pmid=22275846 |pmc=3263388}}</ref> [[posttraumatic stress disorder]];<ref name=KowalikJ> {{cite journal |author=Kowalik J, Weller J, Venter J, Drachman D |title=Cognitive behavioral therapy for the treatment of pediatric posttraumatic stress disorder: a review and meta-analysis |journal=J Behav Ther Exp Psychiatry |volume=42 |issue=3 |pages=405–13 |year=2011 |month=September |pmid=21458405 |doi=10.1016/j.jbtep.2011.02.002 |url=}}</ref> and [[tic disorder]]s, [[trichotillomania]], and other repetitive behavior disorders.<ref name=FlessnerCA>{{cite journal |author=Flessner CA |title=Cognitive-behavioral therapy for childhood repetitive behavior disorders: tic disorders and trichotillomania |journal=Child Adolesc Psychiatr Clin N Am |volume=20 |issue=2 |pages=319–28 |year=2011 |month=April |pmid=21440858 |pmc=3074180 |doi=10.1016/j.chc.2011.01.007}}</ref>
'''In children or adolescents''', CBT is an effective part of treatment plans for: anxiety disorders;<ref name=SeligmanLD>{{cite journal |author=Seligman LD, Ollendick TH |title=Cognitive-behavioral therapy for anxiety disorders in youth |journal=Child Adolesc Psychiatr Clin N Am |volume=20 |issue=2 |pages=217–38 |year=2011 |month=April |pmid=21440852 |pmc=3091167 |doi=10.1016/j.chc.2011.01.003}}</ref> [[body dysmorphic disorder]];<ref name=PhillipsKA>{{cite journal |author=Phillips KA, Rogers J |title=Cognitive-behavioral therapy for youth with body dysmorphic disorder: current status and future directions |journal=Child Adolesc Psychiatr Clin N Am |volume=20 |issue=2 |pages=287–304 |year=2011 |month=April |pmid=21440856 |pmc=3070293 |doi=10.1016/j.chc.2011.01.004 }}</ref> depression and [[Suicidal ideation|suicidality]];<ref name=SpiritoA> {{cite journal |author=Spirito A, Esposito-Smythers C, Wolff J, Uhl K |title=Cognitive-behavioral therapy for adolescent depression and suicidality |journal=Child Adolesc Psychiatr Clin N Am |volume=20 |issue=2 |pages=191–204 |year=2011 |month=April |pmid=21440850 |pmc=3073681 |doi=10.1016/j.chc.2011.01.012 }}</ref> eating disorders and [[obesity]];<ref name=WilfleyDE>{{cite journal |author=Wilfley DE, Kolko RP, Kass AE |title=Cognitive-behavioral therapy for weight management and eating disorders in children and adolescents |journal=Child Adolesc Psychiatr Clin N Am |volume=20 |issue=2 |pages=271–85 |year=2011 |month=April |pmid=21440855 |pmc=3065663 |doi=10.1016/j.chc.2011.01.002 }}</ref> [[obsessive–compulsive disorder]];<ref name= BoileauB> {{cite journal |author=Boileau B |title=A review of obsessive-compulsive disorder in children and adolescents |journal=Dialogues Clin Neurosci |volume=13 |issue=4 |pages=401–11 |year=2011 |pmid=22275846 |pmc=3263388}}</ref> [[posttraumatic stress disorder]];<ref name=KowalikJ> {{cite journal |author=Kowalik J, Weller J, Venter J, Drachman D |title=Cognitive behavioral therapy for the treatment of pediatric posttraumatic stress disorder: a review and meta-analysis |journal=J Behav Ther Exp Psychiatry |volume=42 |issue=3 |pages=405–13 |year=2011 |month=September |pmid=21458405 |doi=10.1016/j.jbtep.2011.02.002 |url=}}</ref> and [[tic disorder]]s, [[trichotillomania]], and other repetitive behavior disorders.<ref name=FlessnerCA>{{cite journal |author=Flessner CA |title=Cognitive-behavioral therapy for childhood repetitive behavior disorders: tic disorders and trichotillomania |journal=Child Adolesc Psychiatr Clin N Am |volume=20 |issue=2 |pages=319–28 |year=2011 |month=April |pmid=21440858 |pmc=3074180 |doi=10.1016/j.chc.2011.01.007}}</ref>


'''Emerging evidence''' suggests a role for CBT in the treatment of [[attention deficit hyperactivity disorder]] (ADHD),<ref name=KnouseLE >{{cite journal |author=Knouse LE, Safren SA |title=Current status of cognitive behavioral therapy for adult attention-deficit hyperactivity disorder |journal=Psychiatr. Clin. North Am. |volume=33 |issue=3 |pages=497–509 |year=2010 |month=September |pmid=20599129 |pmc=2909688 |doi=10.1016/j.psc.2010.04.001 }}</ref> [[hypochondriasis]]<ref>[http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006520.pub2/abstract Cochrane]</ref> and [[bipolar disorder]],<ref name=daCostaRT>{{cite journal |author=da Costa RT, Rangé BP, Malagris LE, Sardinha A, de Carvalho MR, Nardi AE |title=Cognitive-behavioral therapy for bipolar disorder |journal=Expert Rev Neurother |volume=10 |issue=7 |pages=1089–99 |year=2010 |month=July |pmid=20586690 |doi=10.1586/ern.10.75 |url=}}</ref> but more study is needed. CBT has been studied as an aid in the treatment of anxiety associated with [[stuttering]].<ref>{{cite journal |author=Reddy RP, Sharma MP, Shivashankar N |title=Cognitive behavior therapy for stuttering: a case series |journal=Indian J Psychol Med |volume=32 |issue=1 |pages=49–53 |year=2010 |month=January |pmid=21799560 |pmc=3137813 |doi=10.4103/0253-7176.70533 }}</ref>
'''Emerging evidence''' suggests a role for CBT in the treatment of [[attention deficit hyperactivity disorder]] (ADHD),<ref name=KnouseLE >{{cite journal |author=Knouse LE, Safren SA |title=Current status of cognitive behavioral therapy for adult attention-deficit hyperactivity disorder |journal=Psychiatr. Clin. North Am. |volume=33 |issue=3 |pages=497–509 |year=2010 |month=September |pmid=20599129 |pmc=2909688 |doi=10.1016/j.psc.2010.04.001 }}</ref> [[hypochondriasis]],<ref>{{cite journal |author=Thomson AB, Page LA |title=Psychotherapies for hypochondriasis |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD006520 |year=2007 |pmid=17943915 |doi=10.1002/14651858.CD006520.pub2 }}</ref> and [[bipolar disorder]],<ref name=daCostaRT>{{cite journal |author=da Costa RT, Rangé BP, Malagris LE, Sardinha A, de Carvalho MR, Nardi AE |title=Cognitive-behavioral therapy for bipolar disorder |journal=Expert Rev Neurother |volume=10 |issue=7 |pages=1089–99 |year=2010 |month=July |pmid=20586690 |doi=10.1586/ern.10.75 |url=}}</ref> but more study is needed. CBT has been studied as an aid in the treatment of anxiety associated with [[stuttering]].<ref>{{cite journal |author=Reddy RP, Sharma MP, Shivashankar N |title=Cognitive behavior therapy for stuttering: a case series |journal=Indian J Psychol Med |volume=32 |issue=1 |pages=49–53 |year=2010 |month=January |pmid=21799560 |pmc=3137813 |doi=10.4103/0253-7176.70533 }}</ref>


'''Ineffective''': a Cochrane review found no evidence that CBT was effective for [[tinnitus]], although there was an effect on management of associated depression and quality of life.<ref>[http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005233.pub3/abstract Cochrane]</ref>
'''Ineffective''': a Cochrane review found no evidence that CBT was effective for [[tinnitus]], although there was an effect on management of associated depression and quality of life.<ref>[http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005233.pub3/abstract Cochrane]</ref>

Revision as of 19:35, 21 April 2012

Cognitive behavioral therapy
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Cognitive behavioral therapy (CBT) is a psychotherapeutic approach: a talking therapy that addresses dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic process. The name refers to behavior therapy, cognitive therapy, and to therapy based upon a combination of basic behavioral and cognitive research.

CBT is effective for the treatment of a variety of conditions, including mood, anxiety, personality, eating, substance abuse, tic, and psychotic disorders. Many CBT treatment programs for specific disorders have been evaluated for efficacy; the health-care trend of evidence-based treatment, where specific treatments for symptom-based diagnoses are recommended, has favored CBT over other approaches such as psychodynamic treatments.[1]

CBT was primarily developed through an integration of behavior therapy with cognitive therapy. While rooted in rather different theories, these two traditions found common ground in focusing on the "here and now", and on alleviating symptoms.[2]

Description

The premise of cognitive behavioral therapy is that changing maladaptive thinking leads to change in affect and behavior.[3] Therapists or computer-based programs use CBT techniques to help individuals challenge their patterns and beliefs and replace "errors in thinking such as overgeneralizing, magnifying negatives, minimizing positives and catastrophizing" with "more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behavior".[3] CBT helps individuals replace "maladaptive ... coping skills, cognitions, emotions and behaviors with more adaptive ones",[4] by challenging an individual's way of thinking and the way that he or she reacts to certain habits or behaviors.[5]

According to Gathcel et al (2008), CBT has six phases:

1. assessment, 2. reconceptualization, 3. skills acquisition, 4. skills consolidation and application training, 5. generalization and maintenance, and 6. post-treatment assessment follow-up. ... The reconceptualization phase makes up much of the "cognitive" portion of CBT.[4]

There are different protocols for delivering cognitive behavioral therapy, but there are important similarities among the protocols;[6] and use of the term CBT may refer to different interventions: "self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting".[4] Treatment is sometimes manualized, with specific technique-driven brief, direct, and time-limited treatments for specific psychological disorders. CBT is used in individual therapy as well as group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are more cognitive oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (in vivo exposure therapy). Other interventions combine both (e.g. imaginal exposure therapy).[7]

Cognitive behavioral therapy most closely allies with the scientist–practitioner model, in which clinical practice and research is informed by a scientific perspective, clear operationalization of the problem, an emphasis on measurement (and measurable changes in cognition and behavior) and measurable goal-attainment. These goals are often met through "homework" assignments in which the patient and the therapist will work together to craft an assignment to complete before the next session.[8] The completion of these assignments - which can be as simple as a person suffering from depression attending some kind of social event - shows a dedication and desire to change.[8] The therapists can then logically gauge the next step of treatment based on how thoroughly the patient completes the assignment.[8] Effective cognitive behavioral therapy is dependent on a therapeutic alliance between the health care practitioner and the person seeking assistance. Unlike many other forms of therapy, the patient is very involved.[8] For example, an anxious patient may be asked to talk to a stranger as a homework assignment but if that is too difficult, he or she can work out an easier assignment first before working up to talking to a stranger.[8] The therapist needs to be flexible and willing to listen to the patient rather than acting as an authority figure.[8]

Specific applications

CBT has been applied within clinical and non-clinical environments and has been successfully used as a treatment for many disorders, personality conditions and behavioral problems. [9] A systematic review of CBT in depression and anxiety disorders concluded, "CBT delivered in primary care, especially including computer- or Internet-based self-help programs, is potentially more effective than usual care and could be delivered effectively by primary care therapists."[10] CBT has been used with children and adolescents to treat a variety of conditions.

In adults, CBT has been shown to have a role in the treatment plans for: anxiety disorders;[11] depression;[12] eating disorders;[13] chronic low back pain;[4] personality disorders;[14] psychosis and [15] schizophrenia;[16] substance use disorders;[17] and adjustment, depression and anxiety associated with fibromyalgia,[3] and with post-spinal cord injury.[18]

In children or adolescents, CBT is an effective part of treatment plans for: anxiety disorders;[19] body dysmorphic disorder;[20] depression and suicidality;[21] eating disorders and obesity;[22] obsessive–compulsive disorder;[23] posttraumatic stress disorder;[24] and tic disorders, trichotillomania, and other repetitive behavior disorders.[25]

Emerging evidence suggests a role for CBT in the treatment of attention deficit hyperactivity disorder (ADHD),[26] hypochondriasis,[27] and bipolar disorder,[28] but more study is needed. CBT has been studied as an aid in the treatment of anxiety associated with stuttering.[29]

Ineffective: a Cochrane review found no evidence that CBT was effective for tinnitus, although there was an effect on management of associated depression and quality of life.[30]

In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) recommends CBT in the treatment plans for a number of mental health difficulties, including posttraumatic stress disorder, obsessive–compulsive disorder (OCD), bulimia nervosa, and clinical depression.

Anxiety disorders

CBT has been shown to be effective in the treatment of generalized anxiety disorder, and possibly more effective than pharmacological treatments in the long term.[31]

A basic concept in some CBT treatments of anxiety disorders is in vivo exposure—a gradual exposure to the actual, feared stimulus. This treatment is based on the theory that the fear response has been classically conditioned and that avoidance negatively reinforces and maintains that fear. This "two-factor" model is often credited to O. Hobart Mowrer.[32][page needed] Through exposure to the stimulus, this conditioning can be unlearned; this is referred to as extinction and habituation.

Schizophrenia, psychosis and mood disorders

Cognitive behavioral therapy has been shown as an effective treatment for clinical depression.[12] 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.[33] One etiological theory of depression is Aaron T. Beck's cognitive theory of depression. His theory states that depressed people think the way they do because their thinking is biased towards negative interpretations. According to this theory, depressed people acquire a negative schema of the world in childhood and adolescence as an effect of stressful life events, and the negative schmeats is activated later in life when the person encounters similar situations.[34]

Beck also described a negative cognitive triad, made up of the negative schemata 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", "It is impossible to have a good day", 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, over-generalization, magnification and minimization. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema.[34]

In long-term psychoses, CBT is used to complement medication and is adapted to meet individual needs. Interventions particularly related to these conditions include exploring reality testing, changing delusions and hallucinations, examining factors which precipitate relapse and lastly managing relapses.[15] Several meta-analyses have shown CBT effective in schizophrenia[35][16] and the American Psychiatric Association includes CBT in its schizophrenia guideline as an evidence-based treatment. There is also some limited evidence of effectiveness for CBT in bipolar disorder[28] and severe depression.[36]

A 2010 meta-analysis found that no trial employing both blinding and psychological placebo showed CBT to be effective in schizophrenia or bipolar disorder, and the effect was small in major depressive disorder. They also found evidence lacking that CBT was effective in preventing relapses in bipolar disorder.[37] Evidence that severe depression is mediated by CBT is lacking, and anti-depressant medications are still viewed as more effective than CBT,[12] although success with CBT for depression was observed beginning in the 1990s.[38]

Computer-based therapy

Computerized Cognitive Behavioral Therapy (CCBT) is described by NICE (2006) as a "generic term for delivering CBT via an interactive computer interface delivered by a personal computer, internet or interactive voice response system", [39] instead of face-to-face with a therapist. While it cannot replace face-to-face therapy, this 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.

Randomized controlled trials have proven its effectiveness in treating depression and anxiety disorders[10] and in February 2006 NICE recommended that CCBT be made available for use within the NHS across England and Wales, for patients presenting with mild to moderate depression, rather than immediately opting for antidepressant medication.[39] The 2009 NICE guideline recognised that there are likely to be a number of computerised CBT products that are useful to patients. They have therefore removed the endorsement of any specific product.[40]

History

Behavior therapy roots

Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly Stoicism.[41][page needed] For example, Aaron T. Beck's original treatment manual for depression states, "The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers".[42] The modern roots of CBT can be traced to the development of behavior therapy in the early 20th century, the development of cognitive therapy in the 1960s, and the subsequent merging of the two. Behavior therapeutical approaches appeared as early as 1924,[2] with Mary Cover Jones' work on the unlearning of fears in children.[43] In 1937 Abraham Low developed cognitive training techniques for patient aftercare following psychiatric hospitalization.[44][45][46][47]

It was during the period 1950 to 1970 that behavioral therapy became widely utilized, with researchers in the United States, the United Kingdom and South Africa who were inspired by the behaviorist learning theory of Ivan Pavlov, John B. Watson and Clark L. Hull.[2] In Britain, this work was mostly focused on the neurotic disorders through the work of Joseph Wolpe, who applied the findings of animal experiments to his method of systematic desensitization,[48] the precursor to today's fear reduction techniques.[2] British psychologist Hans Eysenck, inspired by the writings of Karl Popper, criticized psychoanalysis in arguing that "if you get rid of the symptoms, you get rid of the neurosis",[49][page needed] and presented behavior therapy as a constructive alternative.[2][50] In the United States, psychologists were applying the radical behaviorism of B. F. Skinner to clinical use. Much of this work was concentrated towards severe, chronic psychiatric disorders, such as psychotic behavior[51][page needed] and autism.[2][52]

Other roots

Although the early behavioral approaches were successful in many of the neurotic disorders, they had little success in treating depression.[2] Behaviorism was also losing in popularity due to the so-called "cognitive revolution". The therapeutic approaches of Albert Ellis and Aaron T. Beck gained popularity among behavior therapists, despite the earlier behaviorist rejection of "mentalistic" concepts like thoughts and cognitions. Both these systems included behavioral elements and interventions and primarily concentrated on problems in the present. Albert Ellis's system, originated in the early 1950s, was first called rational therapy, and can arguably be called one of the first forms of cognitive behavioral therapy. It was partly founded as a reaction against popular psychotherapeutic theories at the time, mainly psychoanalysis.[53][page needed] Beck, inspired by Albert Ellis, developed cognitive therapy in the 1960s.[citation needed] Beck describes his therapeutic approach as originating in a realization he made while conducting free association with patients in the context of classical psychoanalysis—he noted that patients had not been reporting certain thoughts at the fringe of consciousness, thoughts which often preceded intense emotional reactions; this realization led Beck to begin viewing emotional reactions as resulting from cognitions, rather than understanding emotion within the abstract psychoanalytic framework.[54] He named these cognitions "automatic thoughts" because he believed that people were not necessarily aware that the cognitions existed, but that they could identify that the thoughts when questioned.[8] Beck believed that pushing his clients to identify these automatic thoughts was integral to overcoming a particular difficulty.[8]

In initial studies, cognitive therapy was often contrasted with behavioral treatments to see which was most effective. During the 1980s and 1990s, cognitive and behavioral techniques were merged into cognitive behavioral therapy. Pivotal to this merging was the successful development of treatments for panic disorder by David M. Clark in the UK and David H. Barlow in the US.[2]

Concurrently with the contributions of Ellis and Beck, starting in the late 1950s and continuing through the 1970s, Arnold A. Lazarus developed what was arguably the first form of broad-spectrum cognitive behavioral therapy.[citation needed] He later broadened the focus of behavioral treatment to incorporate cognitive aspects.[55][page needed] Lazarus, seeking to optimize therapy's effectiveness and effect durable treatment, cognitive and behavioral methods, developed a new form of therapy called multimodal therapy, based on CBT, but also including physical sensations (as distinct from emotional states), visual images (as distinct from language-based thinking), interpersonal relationships, and biological factors.[citation needed]

Samuel Yochelson and Stanton Samenow pioneered the idea[original research?] that cognitive behavioral approaches can be used successfully with a criminal population.[56]

See also

References

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  20. ^ Phillips KA, Rogers J (2011). "Cognitive-behavioral therapy for youth with body dysmorphic disorder: current status and future directions". Child Adolesc Psychiatr Clin N Am. 20 (2): 287–304. doi:10.1016/j.chc.2011.01.004. PMC 3070293. PMID 21440856. {{cite journal}}: Unknown parameter |month= ignored (help)
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Further reading

  • Butler G, Fennell M, and Hackmann A. (2008). Cognitive-Behavioral Therapy for Anxiety Disorders. New York: The Guilford Press. ISBN 978-1-60623-869-1
  • Dattilio FM, Freeman A. (Eds.) (2007). Cognitive-Behavioral Strategies in Crisis Intervention (3rd ed.). New York: The Guilford Press. ISBN 978-1-60623-648-2
  • Willson R, Branch R. (2006). Cognitive Behavioural Therapy for Dummies. ISBN 978-0-470-01838-5

External links

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