Lecture 1: cognitive and behavioral interventions
Exposure therapy
Theoretical background
An important theory that lies underneath exposure therapy is classical conditioning. Classical
conditioning is a type of learning in which a stimulus acquires the capacity to evoke a reflexive
response that was originally evoked by a different stimulus. E.g., Pavlov’s dogs: Before
conditioning the unconditioned stimulus, food, gives an unconditioned response, salvation. In
this same situation the neutral stimulus, a tuning fork, gives a non conditioned response, no
salvation. During conditioning this neutral stimulus is combined with the unconditioned
stimulus resulting in the condition stimulus, tuning fork, provoking the conditioned response,
salvation, without the food.
Think about John Watson and the casus of little Albert. After conditioning little albert, the sight
of the rat made him scream; after a while Albert began to show similar terrified behaviours to
Watson’s face. The fear evoked by the white furry rat had generalized to other white furry
things like Watson’s beard. This fear and fears in general can be maintained. We’ve learned
that classical conditioning can lead to the onset of pathological fear. The process of operant
conditioning (Skinner’s cat) is needed to explain the maintenance of fear. Keep in mind that
classic conditioning is mainly the analysis of meaning, while operant conditioning can be linked
to the function analysis. The interaction between classical conditioning and operant
conditioning can be explained by the two-factor model of Mowrer. In the beginning you are
anxious because you’ve experienced an interaction that provoked anxiety: the fear of dogs. The
fear response acts as stimulus and motivates you to avoid a dog. This will maintain the fear
factor, while you do not fact check your internal schema about dogs. The avoidance of
something that fears you can be explained with avoidance learning. Avoidance learning shows
us that their neutral signals that existed before the traumatic experience can be a warning signal
and thus you want to avoid what comes next. In the model of Mowrer this means that when you
see a dog, you will avoid this dog, then there is no possibility that the dog will bite you.
Emotional processing therapy (EPT)
These early learning accounts were expanded by integrating Lang’s concept of the fear
structure to create a comprehensive model for understanding pathological anxiety. This fear
structure is an anxiety memory in which representations of stimuli, responses, and meanings
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,are stored together. In anxiety disorders, these stimulus representations are linked to danger and
give strong responses in the patient. For example, you can have a fear structure about a man,
which is blond and has a gun. All these factors combined results into an alerted signal that
signals danger. However, in anxiety, just one of these factors can already result into the altered
danger signal. Therefore, with therapy you want to correct the fear structure. Which means that
only a gun will provoke the danger signal and not blonde males. To change this fear structure,
you need to activate it, which means that the patient needs to re-experience the anxiety. The
consisting fear structure needs to be challenged by giving new information that is incompatible
with the old information. This means that you want to connect the blond man with other (safe)
structures and only the gun with danger. Keep in mind that the old fear structure never leaves
a person’s mind; the new structure is only stronger than the old fear structure.
Exposure therapy
Exposure therapy purposefully generates anxiety by exposing an individual repeatedly to the
fear-provoking stimuli. The absence of repeated aversive outcomes leads to extinction through
inhibitory learning. Extinction is the lowering of the alerted feeling while exposing themselves
to the danger situation over and over again. You learn that anxiety fades away over time by
being exposed to it. In the pre-exposure (before therapy) the link between the CS + UCS and
fear is called the excitatory memory effect. The inhibitory memory effect is the
disconnection of the CS and the UCS through exposure. Which means that the old structure
keeps existing, and both these constructions have a retrieval competition. There are three types
of exposure:
1. In vivo exposure: Exposure to external feared stimuli
2. In vitro exposure/imaginal exposure: Exposure to imaginal stimuli
3. Interoceptive exposure: Exposure to physical (internal) stimuli
You can use exposure therapy in different situations: specific phobias, panic disorders, social
anxiety disorder, generalized anxiety disorder, obsessive compulsive disorder, PTSD. Thus,
focussing on trauma, OCD related disorders and all anxiety disorders.
Procedural variations
There are different ways to perform these exposures. There is a massed versus spaced exposure
(between sessions). They give answer to the question: Must exposure therapy be conducted at
its max length (daily basis , as long as possible). The pro massed (max. number of sessions in
as short time as possible) exposure therapy has quick improvement and enhances motivation,
however there is less opportunity for avoidance. The pro spaced exposure therapy has a lesser
return of fear and is more acceptable and practical to most patients. In current practice the
exposure therapy is pro spaced (while you only have 1 hour for each session).
Another variation answers the question: should exposure therapy be as intense as possible or
gradual? One practice, called flooding, exposes the person to the most anxiety producing
stimulus. This kind of variation results in a quicker result. The other practice, called graduated
exposure, begins with the least fearful stimulus. This kind of variation results into less drop-
out and non-compliance than flooding. Meaning again that the current practice is the exposure
focussing on what patients prefer: graduated exposure.
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,A third variation answers to the question: Should the patient be distracted during the exposure
or have their attention focussed on the trigger? Distraction can be used to regulate levels of
anxiety that are too high, which has a positive effect on the short term. However, it also acts as
cognitive avoidance, while it hampers anxiety activation and habituation to the stimulus.
Therefore, it has a negative effect on the long term when compered to attention focussed
exposure therapy. Attention has a long-term effect that is favourable to the effects of distracted
exposure.
A fourth variation tries to answer the question: is the aid of another person necessary to
successful exposure therapy? In general therapist or spouse-aided exposure therapy are
somewhat more effective than self-directed exposure therapy. In practice it is used mixed,
while they involve others in the first phase of exposure therapy, but later on it is more self-
directed.
The last variation tries to answer the question is exposure in vivo (real life) just as effective as
in vitro (in imagination). In general, in vivo is more effective than in vitro. Every therapy should
include in vivo exposure at some point. Imaginal exposure is used to motivate patient to start
in vivo exposure and in case of exposure to special stimuli (e.g., reexperiences in PTSD: you
don’t go back to a war zone with a client...). Keep in mind that virtual reality is used more and
more often to expose patients to their fears; it feels real, but it is not real.
Examples
Watch the video if you want to see an in vivo exposure of spiders. It’s not that interesting if you
saw the videos of the BTS workgroup about exposure and the inhibiting drug. The only
interesting thing is that you as a therapist try to raise the level of anxiety of your client during
the in vivo exposure. Try to invoke it as much as possible. Furthermore, it is wise to let the
client make a list (either with photos or words) and let them rank it from 0 – 100 ; where 0 is
no harm and 100 is causing serious anxiety. Then you can use this to structure the graduate
therapy.
Research issues
There are some new insights on extinction. Extinction in general does not equal unlearning:
pavlovian associations are forever (and can therefore be re-evoked). The extinctions can be
enhanced by inhibitory learning (occasional exposure of other connections lowers the strength
of the fear structure; aka finding a new response). Also, habituation (fear reduction during
exposure) is not necessary for therapeutic change.
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,Different strategies for enhancing inhibitory learning
Strategy Description
Expectancy violation Design exposure to violate specific expectations
Deepened extinction Present two cues during the same exposure after condition initial
extinction with at least one of them
Reinforced extinction Occasionally present the US during exposure (face your fears
Variability Vary stimuli and context
Remove safety behaviours Decrease the use of safety signals and behaviours
Attentional focus Maintain attention on the target CS during exposure
Affect labelling Encourage the clients to describe their emotional experience
during exposure
Mental Use a cue present during extinction or imaginal reinstate previous
reinstatement/retrieval cues successful exposures
Cognitive restructuring (key of CBT)
Theoretical background
Cognitive models of psychopathology propose that problems in human behaviour and emotion
are often the consequence of biases, distortions or inadequacies in the interpretation or
evaluation of life events. The role of thinking is empathized as influencing behaviour and
emotions. Whereas, the cause of these biases can be biological, the result of socialization, or
negative life events.
Albert Ellis is one of the originators of the cognitive revolution, which opposes radical
behaviourism. He developed the rational emotive therapy. His work is influenced by
Korzybski, who claimed that human knowledge is limited by our language. His work is also
influenced by Stoicism.
Rational emotive therapy
The rational emotive therapy is an important precursor to Beck’s work. Pathology and sickness
are due to irrational beliefs of the individual. Terms that come back often are should-statements,
awfulizing, and low frustration tolerance. He always questioned should statements (I should
finish my work before eating) in order to see if they really must do it. Awfulizing is when
someone claims that it is awful or terrible to do. Of course, Ellis also examined these thoughts.
And he was the first to introduce the low frustration tolerance: People cannot cope properly
with adverse events. Ellis also created the ABC model, see below. It differs from CBT, while
CBT focusses on behaviours in combination with beliefs.
C. D. E.
A. B.
The emotional Disputations to Effective new
Activating Beliefs about
consequence challenge beliefs replace
event or event or
irrational the irration
adversity adversity
beliefs ones
Figure 1:ABC model
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,Beck’s Cognitive model
Aaron Beck claimed that depressed and anxious individuals have a typical distortion in their
thinking. Themes of loss and failure in dreams instead of the ‘inward anger’. These are so-
called negative automatic thoughts, which are: Spontaneous, mood congruent, seem
plausible, and often go unexamined. These negative automatic thoughts are based on a core
belief (e.g., “I am worthless”, “I am weak” or “I am a failure). Core beliefs are fundamental
thoughts about oneself. They have different characteristics, listed below. These core beliefs are
well researched and are often called attribution bias.
- Do not reflect reality of human experience
- Rigid, overgeneralizing, extreme
- Impair realization of personal goals
- Breaking of rules results in extreme emotions
- Almost immune for correction by experience
The extended cognitive model explains that a situation triggers a certain automatic thought (or
cognitive distortion) which is based on intermediate beliefs. Such as your attitude, assumptions
and rules (see table below). These three together form your core belief about something and
results into a certain thought. This thought then triggers a certain emotion.
Figure 2: Extended cognitive model
If we transfer the model from figure 2 to a table with an example it will look like this:
Core belief I’m inadequate
Intermediate belief Attitudes Its terrible to be inadequate
Assumptions Pos If I work hard, I can do okay
Neg If I don’t work hard, I’ll fail
Rules I should always do my best
I should be great at everything I do
Automatic thoughts I can’t do this
when depressed
This is too hard
I’ll never learn this
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, Figure 3: Beck’s Cognitive model of depression
It all starts with an experience at some point of your life that results into a formation of core
beliefs and dysfunctional assumptions. A critical incident confirms your core belief and
therefore activate your assumptions. This in turn, activates your negative automatic thoughts
and result into symptoms of depression.
Cognitive restructuring
Cognitive restructuring is a form of therapy that tries to change your cognitive model. The goal
of therapy is first to increase awareness of the dysfunctional cognitive structures that results in
biased information processing. Then to challenge or test this and ultimately change it. It all
starts with identifying, monitoring and categorizing automatic thoughts.
Basic cognitive model
The idea is that for some people it is nice to see a cake “I would like that cake”, other people
see the same cake and ask themselves “What is in it?” “Is it free?” etc. The same situation can
lead to other experiences and emotions withing different people. Therefore, the goal of CBT is
to find out why people react to a certain stimulus different then others. E.g., You hear an
unexpected noise in house during the night and you can think automatically: it’s a burglar or
it’s a cat. Which either result into anxiety or irritation.
One way to find this automatic thought is to ask: “What was going through your mind just
then?”. This can be done in a few different ways based on the preference of the client: describing
in word, use imagination to describe the situation in detail and have the patient role play a
specific interaction.
Cognitive distortions / errors of logic
- All or nothing / dichotomous thinking: if I’m not a total success, I’m a failure
- Fortune telling ill be so upset, I won’t be able to function at all
- Disqualifying or discounting the positive: I did that project well, but that doesn’t mean
I’m competent. I just got lucky
- Emotional reasoning: I am feeling jealous so my partner must be unfaithful
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, - Mindreading: I know for sure that he will reject these invitations
- Overgeneralization: she yelled at me. So, she’s always telling at me. She must not like
me.
Questioning automatic thoughts / dysfunctional schema’s
1. Examining the cost and benefits of thoughts
2. Defining the terms: what does it mean to not trust someone in comparison to others. Set
up a cognitive continuum. And ask the client to fill in people in their life from e.g., not
at all trustworthy to completely trustworthy.
3. Examining the evidence for and against thoughts: use a pro- con list
4. Using vertical descent: asking what would happen if their negative thought was true
5. Engaging in a rational role play against the belief
6. Using the double standard technique
7. Setting up behavioral experiments tot test the beliefs
a. Formulate original, probably, dysfunctional assumptions and rate credibility
b. Formulate a realistic and functional alternative and rate credibility
c. Design a suitable behavioral experiment
d. Describe how the results would look like with the original and the alternative
assumption
e. Execute the experiment
f. Describe the outcome of the experiment in concrete terms
g. Which conclusion can you draw on the basis of this experiment with respect to
the credibility of the original and alternative assumption?
8. Developing more adaptive thoughts and strategies
Examples
If you fail for the practice exam: look at the example in the slides and try to examine it yourself.
Research issues
1. Does addition of cognitive restructuring to other ingredients of CBT (behavioral
activation or something else) result in a better outcome?
2. Do other treatment interventions also result in cognitive restructuring?
3. Is cognitive restructuring necessary for affective relief or behavioral change?
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, Lecture 2: Activity scheduling and cognitive restructuring in medically
unexplained physical symptoms (MUPS)
Part I. Medically Unexplained Physical Symptoms
Background
A physical symptom is a bodily sensation that is perceived as unpleasant, painful, or worrisome.
Between 80 – 90% of the general population experiences 1 or 2 physical complaints per week, nut these
complaints are mostly stress related and transient (=people will not go to a doctor for these complaints).
Only in ¼ of the cases these symptoms become chronic and 1/3 of physical symptoms remain medically
unexplained (diagnosed as MUPS).
Somatoform disorders
Somatoform disorders (DSM-IV) are a heterogenous group of psychiatric disorders that are
characterized by enduring bodily complaints and symptoms that are due to organic disfunction or
disease. These patients perceive a wide range of severe symptoms, which cause permanent worry and
distress. They excessively seek medical help and reassurance but have difficulties accepting the non-
pathological results of these medical examinations. This definition lays focus on the fact that the
symptoms have to be medically unexplained.
Somatic symptom and related disorders (DSM V) share a common feature: The prominence of
somatic symptoms associated with significant distress and impairment or fear of serious illness in the
absence of somatic symptoms. This definition lays focus on the distress and impairment of an individual.
CBT model of MUPS
The classical CBT model of emotional distress proposed by Beck distinguishes between predisposing
(vulnerabilities), precipitating (triggers) and perpetuating (maintaining factors: cognitive, behavioral,
affective and physiological) factors. The CBT model for MPS is in line with this structure and the three
P’s. See the model below. The most important part about this model is that predisposing and
precipitating factors have an interaction with each other (see later on)
Figure 4: CBT model for MUPS by Deary
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,Development of MUPS
Predisposing factors
First, we start with explaining some predisposing factors, which are factors that put someone at risk of
developing a problem. If we look at personality, there are two different factors that contribute. First
neuroticism/negative affectivity: a stable lifelong tendency to experience negative affect rendering
people more vulnerable for experiencing emotional and physical complaints (aka; predisposition to
somatopsychic distress). Second, alexithymia: which is that one is not able to distinguish between
physical sensations and emotions; they have a difficulty to recognize and label emotions.
Secondly, early experiences of adversity have an influence on getting MUPS. Childhood experiences
of paternal illness (the exact underlying mechanism for this is unclear, however keep it in mind!) /
Vicariously learned illness behavior plays a role (they learn from their parents that stress is coped with
by portraying it physically: copy behavior). Also think about physical or sexual abuse in childhood
(trauma). Thirdly, some core beliefs / schemas lay underneath MUPS. The most important ones are:
“Always perform perfectly” or “Never show any weakness”.
Precipitating factors
Precipitating factors can be roughly translated as triggers. It is about stress in a broad way: physical,
life events and chronic stress. Physical stress can be infections, accidents, or surgery. Another stressor
can be life events (also named; acute stressors) such as illness or death of a partner. And the last stressor
can be chronic stress (also: minor stressors) from home, work, study...
Interaction between predisposing and precipitating
Precipitation factors trigger the development of a symptom/complaints in people who are more
predisposed (read: vulnerable) for developing such symptoms. E.g., a person high on neuroticism that
is confronted with a life-threatening disease of a good friend or a person that as a child was confronted
with a sick father and is involved in a car accident.
Maintenance and aggravation of symptoms
Perpetuating factors are factors that maintain or aggravate symptoms. These can be physiological
processes, cognitive processes, emotional/affective factors, behaviors, and social factors.
Dimension Factor
Cognition Attention
Attribution
Beliefs about symptoms (now/future)
Beliefs about relation symptoms and activity
Behaviors Avoidance behaviors (avoidance of symptoms)
Overriding the body’s signal to stop or slow down
Emotions Anxiety
Dysphoric mood/ clinical depression
Social factors Social support (or lack thereof): helping someone with their work when
one has a headache maintains the symptoms (reinforcement).
Verbal and non-verbal responses of others
Explanation (or lack thereof)
Physiological HPA-axis
Sensitization: pain threshold starts decreasing
Figure 5: Most common maintenance and aggravation factors
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, For attention there can either be selective attention to bodily processes, while attention
intensifies physical symptoms; distraction ameliorates physical symptoms or somatosensory
amplification, which is the tendency to focus on bodily sensations as serious and threatening.
For attributions, somatic illness attributions predict increased symptom experience and illness
behaviors (e.g., consulting the MD). Also, psychological or mixed somatic and psychological
attributions predict better symptom outcomes. Furthermore, a person can have different kind of
beliefs and thoughts. In general, they can be catastrophizing or have catastrophic beliefs
about symptoms that are related to an increased symptom experience. They can also have
beliefs about the relationship between symptom and activity (harmful effects of activity, e.g.,
“walking will increase the pain that I feel”). All these cognitions then lead to behavior which
can be avoidance of the activity that increases the symptoms, overriding/not listening to the
signs of your body, or dysfunctional coping behaviors such as medication use and alcohol
abuse.
Cognitive behavior therapy for MUPS
The treatment focuses on the perpetuating factors, but some of the predisposing factors may
also function as perpetuating factors. For e.g., think about personality, core beliefs of an
individual (e.g., negative affectivity or neuroticism). Thoughts about bodily sensations are
influenced by mood, emotions, bodily processes (such as tension and or arousal), and behavior
(such as avoidance of physical and social activities). This then leads to a reinforcement of the
bodily sensation, which results into a vicious circle in which thoughts play a crucial role (see
the schema below). The goal of CBT is to break this vicious circle. If by now this is not clear
for you, I recommend watching the case description of Anne starting at 31:59
Figure 6: Vicious circle of MUPS (start at thoughts)
Effectiveness of CBT for MUPS
There is still a lot of debate going on about the effectiveness of CBT for MUPS. According to
one study there is a moderate beneficial effect of CBT, but interventions differ in terms of
content, method of delivery, and target patient group. Another study claims that CBT reduces
somatic symptoms. The effects are durable, but there are substantial differences in treatment
components and in effects between studies.
Since there are so many differences in treatment and patient groups it is unclear what the actual
mechanisms of change are and what the most effective components of treatment are.
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