Key areas of Practice
Depression is so frequent that it has been called ‘the common cold of psychiatry’ (Seligman 1975). The World Health Organisation estimates that by 2020 it will be second only to cardiovascular disease in terms of worldwide burden of ill health (Murray and Lopez 1998). In mild or short-lived forms, depression is an almost universal experience; in more severe forms it can become a crippling disorder. The cognitive model of depression proposes that early loss leads to the formation of enduring cognitive structures, which render the person vulnerable to depression in the event of future losses. Thus, core beliefs derived from early experience (e.g. ‘I am stupid’), together with related conditional assumptions (e.g. ‘If I can maintain a very high standard, people may not notice my stupidity’), predispose a person to depression. Events that evoke core beliefs and contravene underlying assumptions (e.g. a challenging new job) then trigger depression. Once activated, the system colours the process and content of thinking in such a way as to perpetuate low mood and other symptoms of depression. Cognitive therapy first tackles negative thinking (undermining cognitive and behavioural maintenance factors), and then re-evaluates underlying assumptions and beliefs so as to reduce future vulnerability (Beck et al. 1979).
Perfectionism can be a significant clinical problem interfering with a person's functioning in everyday life (Burns, 1980). It is associated with a range of psychopathology, including depression, anxiety and suicidality (Flett & Hewitt, 2002) and has been implicated in the maintenance of eating disorders (Fairburn, Cooper, & Shafran, 2003). Furthermore, perfectionism has been shown to impede the successful treatment of depression (Blatt et al., 1998). Treatment sees perfectionism as the over-dependence of self-evaluation on the determined pursuit of personally demanding, self-imposed, standards in at least one highly salient domain, despite adverse consequences. Such over-dependence means that self-evaluation is extremely vulnerable and failure to meet those standards results in self-criticism and negative self-evaluation. Futhermore, even when goals are met, they are then set higher and higher, which is ultimately self-defeating.
obsessive compulsive disorder
Obsessive-compulsive disorder (OCD) is characterised by recurrent obsessions and/or compulsions. Obsessions are persistent thoughts, images, or impulses which have, at least at some time, been experienced by the sufferer as intrusive and inappropriate, and which cause marked anxiety or distress. Compulsions are repetitive behaviours or mental acts which the person feels driven to perform as a response to obsessions or in relation to rigid rules, and which are intended to reduce distress or the risk of some feared event. There are several cognitive models of OCD. Salkovskis (1985) first proposed that obsessional problems begin with normal intrusive thoughts, and that the difference between these and obsessions lies not in their occurrence or controllability, but in the way in which OCD patients interpret the intrusions - as an indication that they may be responsible for harm or for its prevention.
The term ‘insomnia’ does not refer to the night or two of poor sleep we all have now and then, especially associated with stressful life events. Insomnia is a difficulty of at least one month’s duration involving problems getting to sleep, maintaining sleep, or waking in the morning not feeling restored. Theoretical models of insomnia have specified a role for unhelpful beliefs about sleep (Espie 2001; Harvey 2002; Lundh 1998; Perlis et al. 1997). A number of additional cognitive processes are important to the maintenance of insomnia. Specifically, that insomnia is maintained by a cascade of cognitive processes operating at night and during the day. The key cognitive processes that comprise the cascade are worry, monitoring, thoughts/beliefs leading to safety behaviours, and perception of sleep.
Social Anxiety is defined as a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.’ Note that people with social phobia may not actually do anything humiliating or embarrassing; they only have to fear that they will (or think that they have). Their symptoms do not even have to show (though the sweating, blushing, and trembling that plague people who are socially anxious, sometimes do show); they only have to think that they might. The key processes that are target by treatment are self-focused attention, safety seeking, and biases in self-image. These factors have far-reaching cognitive, emotional, and behavioural consequences that link them to the theme of perceived social danger. This theme has two key aspects: concerns about being evaluated negatively by others, or being judged and found wanting, and concerns about not being able to cope with rejection or criticism.
Specific phobia is defined as a persistent fear of an object or situation, exposure to which leads to immediate anxiety and even panic. Anticipatory anxiety is a central feature. Levels of fear are often related to the proximity of the frightening object/situation and appraisals about the ability to escape it. Although sufferers recognise the fear as excessive or unreasonable, they either avoid the object/situation (overtly or covertly) or endure it with dread. Therapy is behavioural in focus, including exposure techniques. This is augmented with a selection of cognitive methods such as ‘emotional processing’ (Rachman 1980; Foa and Kozak 1986), ‘perceived control’ (Rachman et al. 1986), and ‘self-efficacy’ (Barlow 1988).
Generalised anxiety disorder
Generalised anxiety disorder (GAD) is defined as ‘excessive anxiety and worry (apprehensive expectation), usually occurring more days than not, about a number of events or activities’. The disorder is defined in terms of a cognitive process: worry, of a minimum severity level, to distinguish it from normal worry. This worry is perceived as difficult to control, leads to significant distress or impairment, and is associated with a number of anxiety symptoms. The generic cognitive model (e.g. Beck et al., 1985) suggests that anxiety and worry arise when the number of perceived threats outweighs perceived resources (internal and external) for dealing with them. One of the more recent models (Dugas et al., 1998; Ladouceur et al., 2000), suggests that people with GAD are intolerant of uncertainty. They are reluctant to give threatening material their full attention and, therefore, despite having the appropriate skills, are slow to initiate the process of problem solving. Instead they appear to catastrophise at length, and to anticipate the consequences of something going wrong.
bipolar affective disorder
Bipolar affective disorders are characterised by recurring episodes of mania and depression, interspersed with periods of well-being. The American Psychiatric Association defines an episode of mania as a persistently elevated, expansive, or irritable mood lasting at least a week. It is accompanied by at least three of the following symptoms: inflated self-esteem or grandiosity (which can reach delusional proportions), decreased need for sleep, pressure of speech or flight of ideas, distractibility, increased involvement in goal-directed activities, and excessive involvement in pleasurable (but potentially reckless) activities. The cognitive model (incorporating biological vulnerability factors) acknowledges a role for medication as well as a role for stress management, by promoting active coping. In particular, patients can learn effective ways to regulate their sleep, eating, and other patterns of activity, thereby compensating for their hypothesised inherited predisposition. Both medication and behavioural interventions (such as activity scheduling) can be employed during the early stages to prevent relapse into mania or depression.
panic disorder & agorapobia
A panic attack is defined as a sudden increase in anxiety, accompanied by symptoms such as palpitations, breathlessness, and dizziness. The term panic disorder is reserved for individuals with recurrent panic attacks, some of which are unexpected. Agoraphobia is defined as anxiety about being in places or situations from which escape might be difficult or embarrassing in the event of a panic attack or panic-like symptoms. There are several models of treatment, the best known being the approach described by Clark (1986). This model suggests that people who suffer from panic attacks do so because they have a relatively enduring tendency to misinterpret bodily sensations (particularly anxiety symptoms) as indicative of an imminent physical or mental catastrophe. Safety behaviours and selective attention maintain the disorder (Clark 1999). Cognitive therapy aims to remove this tendency to misinterpret symptoms and instil a more accepting and confident mindset.
post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) as a response to a profoundly distressing event, involving re-experiencing, avoidance, numbing, and symptoms of hyper-arousal. To be deemed traumatic, the event may involve threatened or actual death, or serious injury to the self or others. The person's response can involve intense fear, helplessness, or horror. Key models suggest that PTSD arises if a person processes a traumatic event and/or its consequences so as to generate a sense of current, serious threat. Treatment goals therefor are to process trauma memories fully and thus reduce re-experiencing, identify and amend unhelpful appraisals which maintain the sense of ongoing threat, and to drop safety behaviours.
Self-esteem is a term used in psychology to reflect a person's overall emotional evaluation of his or her own worth. It is a judgement of oneself as well as an attitude toward the self. Self-esteem encompasses beliefs (for example, "I am competent", "I am worthy") and emotions such as triumph, despair, pride and shame. Smith & Mackie define it by saying "The self-concept is what we think about the self; self-esteem, is the positive or negative evaluations of the self, as in how we feel about it." At every stage of treatment, behavioural experiments are crucial, ensuring that belief change does not remain an intellectual exercise but is grounded in direct experience and the transformation of emotion.
Health anxiety is characterised by fears of having a serious illness either now or in the future. It causes a great deal of distress, both to the patient and to those trying to help. Patients believe that they have serious health problems that are not receiving appropriate diagnosis or treatment. The result is numerous consultations and high use of resources. Medical staff often find it difficult to know how to help, leading them to repeatedly reassure the patient and request further, medically unnecessary investigations. This only serves to intensify the patient’s anxiety, reinforcing thoughts such as ‘My GP wouldn’t have suggested an investigation if she didn’t think there was something wrong’. Treatment recognises how people with health anxiety perceive their bodily reactions and appearance, and medical information, as more dangerous than they actually are. Together with this perception of threat comes the belief that the individual is unable to cope with the threat and its perceived course. Targets include exaggerated beliefs, arbitrary inference, and selective attention that can result in a confirmatory bias and lead to patients selectively noticing and remembering information that is consistent with their negative beliefs about illness.