Behavioural Activation

This week’s post is about a technique used as part of cognitive behavioural therapy for people with depression. As you probably know already, symptoms of depression include low mood, low self-esteem, feelings of anxiety and helplessness, and having low motivation and interest in activities which they previously enjoyed.

Behavioural activation focuses on the ‘B’ of the CBT model, in this case on the last symptom in particular – the withdrawal from usual activities and friends. For example, they may start to avoid social engagement and ignore invites from friends or make excuses as to why they can’t meet up, whereas before they would have been happy to go. Although in the short term this avoidance causes a temporary relief, such as a lowering of anxiety, it simply reinforces feelings of low mood or low self-esteem. This maintenance of the condition is illustrated by this diagram below:

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Therefore, in order to break this cycle, behavioural activation aims to change the unhelpful behaviours which continue the cycle of low mood. It does this by gradually building up activities that the person can do, which is turn will improve their mood, and lead eventually to them getting back to activities they used to enjoy. This progression is important, as the change in mood is needed before larger behavioural changes can occur.

Key features of Behavioural Activation are as follows (taken from Jacobson et al, 2001):

  • Firstly, the model is presented to patients by their clinician, who explain a bit about it and why it works. This is called a treatment ‘rationale’ and it is important for the patient to feel confident that this will work. A good relationship and trust with the therapist is also important.
  • Developing treatment goals through collaboration between the patient and the therapist – these goals are new behaviours rather than moods or emotions.
  • Analysis of causes and maintenance factors of the depression
  • Graded task assignment – e.g. starting with something small such as walking to the corner shop. This is scheduled in between sessions, and a hierarchy is discussed with the therapist.
  • Establishing a routine, in the hope this results in improved mood.

Ultimately, the aim of Behavioural Activation is to help the patient re-engage and find joy in activities which they have been avoiding. This will raise mood, and therefore help someone recover from depression.

Phobias Part 2 – treatments

This week’s post is the second in a 2 part series about phobias, and will focus on different types of treatment, and what works. If you haven’t already, read part 1 (see here) for more information on types of phobias and possible causes.

If you’r a regular reading of my blog, you may remember that a while back I did a post on Cognitive Behavioural Therapy (CBT) and how that can be used to treat people with phobias. The main principle is to reduce the anxiety felt by encountering the phobia stimulus, be it crowds, flying, or needles. By teaching the patient breathing exercises to help them relax and working to change the thoughts (cognitions) about the phobic stimulus, therapists can help the patient to work towards overcoming their fear. The behavioural part of this technique is gradual exposure to the thing the patient is afraid of, whilst the patient works hard to control their breathing and stay calm. This exposure can help towards changing thoughts which contribute to the phobia such as ‘if I’m in a room with a dog it will bite me’, which in turn reduces fear.

For example, take a look at the diagram below which shows how phobias remain if the fears aren’t challenged. If therapy targets the thoughts, and tests the fear, then it is likely the phobia will be treated successfully.

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Another form of exposure therapy which has been used to treat phobias is known as ‘flooding’. Unlike in CBT, where the individual is gradually exposed to their fear, in this technique they are put straight in the worst situation they could imagine. This uses more behavioural techniques – as the body cannot sustain a physiological stress response for a long period of time, people begin to notice they feel calmer, even though they are in the presence of their fear. An example would be putting someone who was scared of birds in a room full of them! This also enables the individual to confront their worst fear and learn that nothing bad happens when they are in that situation.

Thanks for reading – there won’t be a post next week as I’ve got 2 interviews but I’ll be back the week after!

Obsessive Compulsive Disorder

It’s not unusual for people to say they’re ‘a bit OCD’ when they check they’ve locked the front door, or that they turned appliances off before they go on holiday. However, there is an important distinction between these behaviours and OCD, which can cause significant disruption to sufferer’s lives. OCD is a psychological disorder which affect about 1.2% of the population (ocduk.org), and is characterised by obsessions and compulsions, which cause great distress and are very time consuming.

Obsessions are recurrent and persistent thoughts or images, which cannot be controlled by the individual. They are not just excessive worries about actual problems.

Compulsions are repetitive behaviours carried out by the individual to try to reduce the anxiety caused by the obsessive thought.

However, as illustrated by the figure below, these symptoms cause the distress to continue in a cycle of OCD.

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There are 4 main types of OCD symptoms: washers, orderers, checkers, and hoarders. These factors are stable across time (Mataix-Cole et al, 2002) and are thought to be associated with different genes.

Treatments for OCD:

Pharmacological treatments for OCD include SSRIs (a type of antidepressant) and antipsychotics. Behavioural treatments include exposure therapy, and response prevention – to stop sufferers from performing the compulsive rituals. Foa et al (2005) found that a combination of these therapies was the most effective treatment.

Thank you for reading, and let me know if you would like a more in-depth post about the genes and brain areas implicated in OCD.

CBT: what is it and how does it work?

Cognitive Behavioural Therapy,  or CBT is one of the most well known types of psychological therapy.. But how does it work, and why is it so effective?

CBT was developed from the 1950’s, and came to prominence in the 1980’s. It was based on form of Behavioural Therapy, usually used to treat people with phobias. This was based on the principles of classical conditioning: that a conditioned stimulus, when paired with an unconditioned stimulus, produces a conditioned response. This is illustrated by the classic Pavlov’s dogs experiment, as shown below:

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This process was used a basis for techniques to reduce fear, for example through systematic desentisation – gradually exposing patients to the phobic stimulus in a hierarchy system in order to reduce their fear (e.g. bottom layer of hierarchy: looking at picture of a spider – top layer: holding a spider in your hand). Part of this therapy is to teach the patient to relax during each step, as that prevents anxiety.

CBT builds on the exposure used in behavioural therapy in order to also address the cognitions behind the fear or anxiety. For example, in panic disorder,  patients suffer from recurrent panic attacks which cause intense fear and distress. The cognitive theory of panic disorder (Clark & Wells, 1995) states that panic attacks are brought on by a misinterpretation of physiological symptoms of anxiety such as palpitations or dizziness. The individual interprets these as that they will immediately suffer a physical or mental disaster e.g. a heart attack.

Part of the CBT for patients with panic disorder is exposure – they will go into a crowded place (if this causes panic attacks for them) and record their feelings, in order to discuss with their therapist. However, it has been found that exposure alone is not as effective as if the cognitions which maintain the disorder are not addressed. These are known as safety behaviours (Salkovskis, 1988): for example if a person who has anxiety about crowds and thinks they are going to faint if they are in a crowded place, they might sit down so they don’t faint. The sitting down is the safety behaviour – it prevents people from realising they wouldn’t have fainted from being in a crowd, they think they only reason they didn’t faint was because they took that action. If exposure is paired with strategies to reduce safety behaviours, it is much more effective at reducing panic and anxiety (Salkovskis et al, 1999).

CBT is recommended as the treatment of choice by NICE (the public body which develops treatment guidance for the NHS) for depression and all anxiety disorders – not just panic disorder. In order for it to be effective, Clark et al, 1994 have shown that a ‘cognitive shift’ must occur in patients (a change in their beliefs), or risk of relapse is much higher.

 

Let me know if you’ve got any questions or would like more posts like this – hope you found it interesting!

Hallucinations

This blog post will look at what hallucinations are, what causes them, and what can be do to help people who suffer from them. Normally, we are pretty good at identifying what’s real in the environment, but occasionally this processing is distorted, and people see things which aren’t there. This is a hallucination, and the most common type is auditory.

Causes:

Although they are a symptom of schizophrenia, they can occur in people without the condition, and factors such as drug use, sleep or sensory deprivation or bereavement can make them more likely to occur.

It has been hypothesised that hallucinations are caused by an internal event being misattributed to an external source. For example, internal speech is thought to originate from something external, and so is experienced as hearing a voice. Evidence to support this comes from a study by McGuire et al (1993) who found increased blood flow to Broca’s area during auditory hallucinations – this is an area of the brain involved in language production.

This externalising bias is thought to be caused by impairments in self-monitoring, which means that sufferers do not identify the sense of effort or intention behind their actions. Evidence for this comes from studies such as one carried out by Johns et al (2001), which ask patients to speak words out loud into a microphone. The words are then played back to the individual, some distorted and some in another person’s voice. The patient then has to identify whether or not they spoke the word. This study found that patients with hallucinations were more likely than healthy controls to identify their speech as someone else’s.

Therapy:

One of the most successful ways to treat hallucinations is using cognitive therapy, which involves challenging people’s beliefs about their voices. At first this is done using a hypothetical contradiction, before progressing to directly questioning their beliefs.

A new form of therapy to treat hallucinations has recently been developed, and involves the use of technology. Leff et al (2013) helped patients develop an avatar which resembled the voice their hear, and the patient was encouraged to stand up to the voice. The therapist spoke as the voice, and gradually changed their responses so that the avatar was under the control of the patient. This technique was found to reduce hallucinations more than traditional methods.

However, most of the research has only focused on auditory hallucinations, whereas they can occur in any sensory modality. Therefore, more needs to be done to develop successful therapies for these other types of hallucinations.

 

Thanks for reading!

Social Anxiety Disorder

Do you ever feel shy when talking to people you’ve never met before? Or get nervous before speaking in front of a large audience?
While these emotions are normal, people with Social Anxiety Disorder (or Social Phobia) have a persistent fear of social situations. Often, sufferers believe that they will say or do something embarrassing, such as blush or shake, and so tend to avoid these situations as much as possible.
If social situations cannot be avoided then the sufferer will carry out ‘safety behaviours’ such as wearing thick make up or hiding part of their face with a scarf to hide blushing. However, these actions rarely help and instead contribute to the maintenance of the disorder.

Social Anxiety Disorder is relatively common, with a lifetime prevalence of about 12% (Kessler et al, 2005) and it normally begins in childhood or adolescence. It an extremely persistent disorder if not treated.

The Cognitive Model of Social Anxiety
– developed by Clark & Wells (1995)
– states that people with this disorder have set beliefs about what will happen to them if they perform a certain way
– they therefore monitor their behaviour very closely and turn their attention inwards during social interactions
– this causes them to ignore any evidence from their conversation partner which suggests that they are pleasant to talk to
– sufferers also have extremely distorted self-images: for example when they blush they think their whole face goes bright red, whereas it isn’t at all this obvious.

Social-Anxiety-Disorder-Symptoms-Pie1-e1314364830163

As the safety behaviours are involved in the maintenance of the disorder, one of the main aims of cognitive therapy for social anxiety is to remove them. Wells et al (1995) asked patients with social anxiety to carry out two exposure sessions (social interactions): one with and one without safety behaviours. They found that decreasing safety behaviours reduced anxiety and the belief that their most feared outcome would take place. A ‘cognitive shift’ must also occur for the therapy to be successful – the sufferer must learn to direct their attention outwards and look for evidence that contradicts their belief that they are bad or boring to talk to.

Another aspect of cognitive therapy is for pictures or videos to be taken of the individual during a social interaction, which are then shown to them during a therapy session. The aim of this is to provide more contradictory evidence to their beliefs, for example by showing them that they do not go bright red when they blush, or look really nervous when talking to others.

Thank you for reading, I hope you found this interesting – check back soon for more posts!