Disorder specific models
•
•
•
•
•
•
•
Panic (Clark, 1986)
Social Phobia (Clark & Wells, 1995)
Health Anxiety (Salkovskis & Warwick, 1986)
OCD (Salkovskis, 1994)
GAD (Wells, 1997)
PTSD (Ehlers & Clark, 2000)
Depression (Beck, 1967)
See also Core CBT Competencies list for
recommended models:
http://www.ucl.ac.uk/clinicalpsychology/CORE/CBT_Competences/CBT_Competences_Map.pdf
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A vicious circle model of phobic anxiety
Situational Trigger
Physiological
Behavioural
Subjective
Heart thumping
Sweating
Trembling etc.
Running away
“freezing”
Shouting for help etc.
“I might fall”
“This is terrible”
Fear, embarrassment etc.
Symptoms
Reactions
Physiological
Behavioural
Subjective
Heart thumping
etc.
Fatigue
Avoidance, withdrawing
from demanding or
pleasurable activities
“I can’t cope”
“I must get out”
Lowered confidence worry,
frustration, fear
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A cognitive-behavioural model for the maintenance of specific phobias
Vomiting is unbearably awful and
terrible for me
Avoidance
Encountering the phobic object / situation
Catastrophic
beliefs
High
degree of
conviction
Autonomic
arousal
Escape or safety behaviour
The catastrophe does not occur and anxiety
reactions dissipate
Conclusion drawn: The escape / safety
behaviour prevent the catastrophe
The catastrophic belief is confirmed
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Pre-attentive
activation
The phobia remains unchanged
Prevents
disconfirmation
A model of the development and maintenance of specific phobias
Development
Biological preparedness, disposition, developmental stage, culture, experience (classical
conditioning, vicarious learning), memories/images, beliefs
Assumptions
With increased vulnerability to
Trigger
Frightening object or situation
Anxious Cognitions
(thoughts and images concerning stimulus)
OVERESTIMATING THREAT AND CONSEQUENCES/ UNDERESTIMATING COPING AND RESCUE
Anxious mood
Physiological symptoms
Increasingly anxious cognitions about
external triggers
Anxious cognitions about symptoms
(fear of fear)
Safety behaviours
(related to anxious thoughts about external trigger)
Safety behaviours
(related to fear of fear)
Secondary cognitions
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Depression, hopelessness, loss of confidence, low self-esteem
Hyper vigilance
about physical
symptoms
From Chapter 8 of Oxford Guide to
Behavioural Experiments in
Cognitive Behaviour Therapy (Kirk
& Rouf)
Cognitive model of social phobia
[Clarks and Wells (1995) and Wells and Clark (1997)]
Social Situation
Activates assumptions
a
Perceived social danger
(negative automatic thoughts)
Processing of Self as a Social
Object
Safety behaviours
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Somatic & cognitive
symptoms
Wells, A., 1997. Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide.
Chichester: John Wiley & Sons Ltd.
Cognitive cycle of fear for panic disorder
Biological
Vulnerability
Stressful
Events
Alarm reaction
Tachycardia, dyspnea,
chest pain,
depersonalisation etc.
Increase in anxiety
Increase in symptoms
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F
E
A
R
Hyper surveillance
Avoidance
Anticipatory Anxiety
Catastrophic thoughts
“Oh, oh, oh..”
“I’m gonna die, pass
out”
“Fall down, going crazy”
Conduct
Running away, escaping
A cognitive model of OCD
(Wells 1997, p.242)
Trigger
Activates
Meta-Beliefs
Appraisal of
Intrusion
Belief about
rituals
Behavioural
Response
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Emotion
Cognitive Model of OCD (Salkovskis)
Neutralising
actions (rituals,
reassurances etc.)
Intrusive thoughts, images, urges, doubts
Attention and
reasoning biases
(looking for
trouble)
Misinterpretation of
significance of intrusions –
responsibility for actions
Counterproductive “safety” strategies
(though suppression, impossible criteria,
avoidance etc.)
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Mood Changes
(distress, anxiety,
depression)
5 Part Cognitive Behavioural Therapy Model
Environment
Thoughts
Emotions
Behaviours
Physical
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Cognitive Conceptualisation Diagram
(Judith Beck, 1993)
Relevant Childhood Data
Core Belief(s)
Conditional Assumptions/Beliefs/Rules
Compensatory Strategies
Situation 1
Situation 2
Situation 3
Automatic Thought
Automatic Thought
Automatic Thought
Meaning of the A.T.
Meaning of the A.T.
Meaning of the A.T.
Emotion
Emotion
Emotion
Behaviour
Behaviour
Behaviour
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A Cognitive Model of Hypochondriasis
(Adapted from Salkovskis, 1989; Warwick and Salkovskis, 1990)
Previous Experience
Dysfunctional Schemas Formed
Critical Incident
Activates Schemas
Negative Automatic Thoughts
Cognitive
Selective Attention
Rumination
Self-Focus
Thinking Errors
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Anxiety
Depression
Anger
Physiological Changes
e.g Increased Arousal
Bodily Sensations
Sleep Disturbance
Behaviour
Reassurance Seeking
Avoidance
Bodily checking
safety / prevention
How did “the problem” develop?
What made me
vulnerable in the first
place?
Triggers for the most
recent episode
“The problem”
Things that keep “the problem” going
(These might include things that I do to
control the problem)
Positive things that
I’ve got going for me
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“The Vicious Flower” Cognitive Model of OCD
(Salkovskis, Forrester & Richards, 1998)
Early Experiences
Making you vulnerable to OCD
Critical Incidents
What started the OCD off
Activates
Assumptions, General Beliefs
E.G Not preventing disaster is as bad as making it happen
Better safe than sorry
Intrusive Thoughts, Images,
Urges, Doubts
Attention and
Reasoning Biases
Looking for
trouble
Neutralising Actions
Rituals, reassurance,
mental argument
Misinterpretations of
significance of intrusions
– responsibility for
action
Counterproductive
“Safety” Strategies
Thought suppression,
impossible criteria
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Mood Changes
Distress, anxiety,
depression
Depression Model
(Beck 1967, 1976)
Early Experiences
Core Beliefs and Assumptions
Critical Incident
Assumptions Activated
Negative Automatic Thoughts
Symptoms of Depression
Behavioural
Motivational
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Affective
Cognitive
Somatic
Depression
Increased
hopelessness
Loss of
pleasure &
achievement
(Westbrook, Kennerley & Kirk, 2007)
Depressed
Mood
More Negative
view of self
Reduced
Activity
Nothing
Changes
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Reduced
coping &
problemsolving
Negative thinking &
Physical symptoms
such as fatigue, poor
concentration etc.
Anxiety Maintenance
(Westbrook, Kennerley & Kirk, 2007)
Internal or
external event
1. Perceived threat:
Exaggerated and/or
inappropriate
4. Fear remains intact:
the alarming belief is
unchanged
2. Client’s best attempt
to protect him/herself
from threat
3. Strategy gives shortterm relief, but fails to
challenge the anxietyrelated belief
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Morrey, 2010
1. Automatic
Negative thinking
3. Motivation
and Physical
symptoms
Depression
Mode
Negative view
of self, world
and future
4. Unhelpful
behaviours
5. Mood /
emotion
6. Withdrawal
and avoidance
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2. Ruminations
and selfattacking
DEPRESSION
Cognitive-Behavioural Model of Body Dysmorphic Disorder (Veale, 2001)
Trigger
(e.g. reflection)
Mirror-checking and
selective attention
Mirror checking
Avoidance and
safety
behaviours to
change or
camouflage
appearance
Negative appraisal
of internal body
image
Processing of
self as an
aesthetic object
Mood
(depression &
disgust)
Rumination on
ugliness or
“defectiveness”
and comparison
to ideal
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What made me vulnerable in the first place
Core Beliefs – about myself, others and the world
Rules I live by…
Helpful
Unhelpful
Current Problem
What triggered the problem
What helps me cope
Helpful
Unhelpful
What maintains the problem now
Thoughts
Physical sensations
Emotions
Behaviours
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Cognitive Model of Postnatal Depression
[Milgrom A., Martin P.R., Negri L.M (1999) Treating Postnatal Depression: A psychological Approach for
Health Care Professionals. Wiley. Chichester. Adapted from Beck’s Cognitive Model of Depression (1979)]
Vulnerability Factors
Precipitating Factors,
including Biological Factors
Cultural
Factors
Post Natal Depression
Exacerbating & maintaining factors
Depression and other
emotions
Anxiety, Anger, Sadness
Mediational Cognitive
Factors
Negative Automatic Thoughts
Poor parenting self-efficacy
(mediational = appraisal process)
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Behaviour / Coping
Strategies
Lethargy, Indecision, Social
Withdrawal, Martial Conflict,
Difficulty dealing with infant
Diagnosis / symptoms
Formative influences
Situation / interpersonal
issues
Biological, genetic and
medical factors
Strengths / assets
Typical automatic thoughts,
emotions and behaviours
Underlying schemas
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Working
hypothesis
Treatment
Plan
“Vicious Flower” Generic conceptualisation
(Salkovskis, Warwick and Deal 2003)
Anxiety
Worry
Processes
Physical
Sensations
Images
Threat
Appraisal
Meaning
Selective
Attention
Safety
Behaviours
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Memories
Events,
Stimuli,
Situations
Clark’s cognitive model of panic with maintenance
cycles added (adapted from Clark, 1986)
INTERNAL / EXTERAL TRIGGER
PERCIEVED THREAT
ANXIETY
(Emotions)
MISINTERPREATION
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PHYSICAL / COGNITIVE
SYMPTOMS
AVOIDANCE AND SAFETY
BEHAVIOURS
(Including Selective Attention)
A cognitive Model of GAD (Wells, 1995)
Trigger
Positive meta-beliefs
activated (Strategy
Selection)
Type 1 Worry
Negative meta- beliefs
activated
Behaviour
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Type 2 Worry
(Meta-worry)
Thought control
Emotion
Cognitive-behavioural model of generalized anxiety disorder
[From Dugas, M.J., Gagnon, F., Ladoucer, R. & Freeston, M.H. (1998) Generalized Anxiety Disorder: A
preliminary test of a conceptual model. Behaviour Research and Therapy, 36, 215-226]
Situation
What if..?
Positive beliefs
about worry
Mood
State
Life
Events
Worry
Negative
problem
orientation
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Anxiety
Demoralization
Exhaustion
Cognitive
avoidance
The Bottom Line
Assessment of worth/ value as a person
Conclusions about the self, based on experience: this is the kind of person I am
Rules for living
Guidelines, policies or strategies for getting by, given the truth of the Bottom Line
Standards against which self-worth can be measured
Trigger Situations
Situations in which the Rules for Living are, or may be, broken
Activation of the Bottom Line
Depression
Negative Predictions
Anxiety
Self-critical thoughts
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Unhelpful behaviour
Confirmation of the Bottom Line
What keeps Low Selfesteem Going
(Early) Experience
Events, relationships, living conditions which have implications for ideas about the self
How Low Self-esteem Develops
Low Self-Esteem: A Map of the territory (Fennell, 1999)
Based on Wells 1997, adapted by Stopa
Social Situation
1.
What went through your mind at that time? What was the
worst you thought could happen? What did you think people
would notice / think about you? What would that mean/
what would be so bad about that?
Thoughts
3. As you became
anxious, and
thought that
(feared event)
might happen, did
you do anything to
try to prevent it
from happening?
Did you do
anything to try to
prevent people
from noticing?
Safety
Behaviours
4. When you are afraid (feared event) will happened
what happens to your attention? Do you become more
self-conscious? As you focus on yourself, what do you
notice? Do you have an image of how you feel you are
coming across? What does that look like?
Self-focus
5. As you did (safety
behaviours) did that
make you focus more or
less attention on
yourself?
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6. As you noticed
yourself becoming more
anxious, what effect did
that have on your
attention?
7. When you did (safety behaviours)
what effect did that have on your anxiety?
2. When you
thought (feared
event) might
happen, what did
you notice
happening in your
body? (Suggest
symptoms of
anxiety)
Anxiety
Symptoms
A. Ehlers., D.M Clarke. (2000) A Cognitive Model of posttraumatic stress disorder.
Behaviour Research and Therapy 38, p. 319-345
Characteristics of trauma / Sequelae
Prior Experiences/ Beliefs/ Coping
State of individual
Cognitive
Processing
during Trauma
Influences
Nature of Trauma Memory
Negative Appraisal of
Trauma and / or its Sequleae
P
E
R
S
I
S
T
E
N
T
Matching
Triggers
Current Threat
Intrusions
Arousal Symptoms
Strong Emotions
Strategies Intended to Control Threat / Symptoms
Arrows indicate the following relationships:
Influences =
Leads to =
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Prevents change in =
P
T
S
D
A cognitive-behavioural model for the maintenance of specific phobias
Various objects / situations are perceived as
potentially harmful
Avoidance
Encountering the phobic object / situation
Catastrophic
beliefs
High
degree of
conviction
Autonomic
arousal
Escape or safety behaviour
The catastrophe does not occur and anxiety
reactions dissipate
Conclusion drawn: The escape / safety
behaviour prevent the catastrophe
The catastrophic belief is confirmed
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Pre-attentive
activation
The phobia remains unchanged
Prevents
disconfirmation
Maintaining Cycles
• Safety Behaviours (e.g. OCD client)
Fear/threat
e.g. house burning down
Failure to disconfirm
threat
(attributed to safety behaviour)
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Safety Behaviour
e.g. repeated checking of
appliances
Maintaining Cycles
• Reduced activity (depressed client)
Depressed
mood
Negative Thoughts
(What’s the point?’, ‘I can’t be
bothered with anything’)
Loss of Positive Rewards
Reduced activity
(Loss of sense of pleasure/social
contacts)
General reduction in
achievement, activity levels,
social withdrawal
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Maintaining Cycles
• Perfectionism (e.g. depressed client)
Negative self
beliefs
(e.g. I am worthless)
Unable to achieve
standards/derive satisfaction
from achievement
(‘Nothing I do is good enough’)
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Has high standards
(‘If I don’t get 100%
success in everything I do
I’ve failed’)
Maintaining Cycles
• Catastrophic Misinterpretation (e.g. panic
client)
Symptoms
e.g. heart racing, chest
tight, breathless
Increased anxiety
Anxiety symptoms
increased
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Misinterpretation
‘I’m having a heart attack’
Maintaining Cycles
• Scanning/hypervigilence (e.g. health anxiety
client)
Worry about
illness
e.g. fear of cancer
Sensations noticed or
produced
Interpreted as confirmation of illness
‘I might have a brain tumour’
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Scanning/checking
e.g. headaches
Maintaining Cycles
• Escape/avoidance (e.g. social anxiety)
Feared situation
e.g. parties, social
gatherings
Escape/avoidance
Failure to change belief
(Client continues to believe boring)
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e.g. turn down invites, others see
them as dull, where possible, avoid
eye contact/talking to others if have
to go
Maintaining Cycles
• Fear of fear (e.g. GAD client)
Anxiety
(any cause)
Anticipatory fear of
becoming anxious
Aversive anxiety
symptoms
‘I can’t cope with anything’
Heart racing, tense, nausea
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Maintaining Cycles
• Performance Anxiety
Worry about
performance
e.g. public speaking
Apparent confirmation
‘I was right, I’m terrible at public
speaking’
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Anxiety symptoms
affect performance
e.g. hands shaking, speech
hesitant, dry throat
Maintaining Cycles
• Self-fulfilling prophecies
Negative beliefs
about others
Behaviour changes
towards others
(e.g. ‘Other people dislike
me’)
(e.g. appear tense/hostile,
withdrawn)
Apparent confirmation
of negative
beliefs/predictions
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Behaviour elicits negative
response from others
e.g. others appear uncomfortable, stop social
approaches
‘Vicious Flower’ model
(Salkovskis, Warwick & Deale, 2003)
Images
Emotion
Worry
Processes
Memories
Threat Appraisal/
Meaning
Physical
Sensations
Safety Seeking
Behaviours
Events, stimuli, situations
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Selective
Attention
‘Vicious Flower’ model
(Salkovskis, Warwick & Deale)
Anxiety;
panic
Rumination; thinking
over past events
(what went wrong)
and rehearsing
future ones (what to
say, etc)
Standing in the corner at party,
looking odd, wild staring eyes,
drenched in sweat. People
laughing and pointing
People think I am
weird; I will end up
rejected and alone
Sweating,
restlessness,
shaky hands
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Parties, social occasions,
memories of social events
School – called
‘weirdo’. Ignored. Told I
had staring eyes.
Mocked
Focus on self & how
I appear. Ignore any
friendly remarks from
others (‘just being kind’)
Hold arms down to hide
sweat; avoid eye contact.
Avoid parties or stay in
kitchen out of the way &
leave early. Cross road to
avoid people. Look at road.
Keep eyes semi-closed
6 Cycles Maintenance Model – A ‘Vicious
Flower’ for Depression (Moorey, 2010)
1. Automatic
negative thinking
6. Motivation
and physical
symptoms
2. Ruminations &
self attacking
Depression
Mode
5. Unhelpful
behaviours
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Negative view
of self, world
& future
4. Withdrawal
and avoidance
3. Mood/emotion
Longitudinal Formulation
Depression:
Early experience
Core beliefs/assumptions
Critical Incident(s)
Activation of beliefs/ assumptions
Negative Automatic Thoughts (NATs)
Feelings
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Physical
Behaviour
Longitudinal Formulation
Depression:
Deprived of affection; Lack of attention vs. siblings
There’s something wrong with me; I’m unlovable
Break up of relationship
Activation of beliefs/ assumptions
I’m unlovable, If I get into relationship it goes wrong
Upset
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Lethargic, heavy
Withdraw
Longitudinal Formulation
Anxiety:
Learning Experience
Danger Schemas Formed
Critical Incident
Schema Activated
Negative Automatic Thoughts
Anxiety Symptoms
Behavioural Responses
Cognitive Biases
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Generic cognitive theory
of anxiety disorder
Ref: Wells, A. (2007)
Cognitive Therapy of
Anxiety Disorders.
Chichester: John Wiley &
Sons
Longitudinal Formulation
Anxiety:
Learning Experience
Generic cognitive theory of anxiety
disorder, Wells, A. (2007) Cognitive
Therapy of Anxiety Disorders.
Chichester: John Wiley & Sons
Danger Schemas Formed
The world is dangerous; people will
harm me; I am vulnerable; worrying
keeps me safe
Critical Incident
Neighbour’s house burgled
Schema Activated
I will be next; I need to get more locks;
I need to have the police’s number
handy; what if it happens when I’m
alone at night?
Heart pounding; rapid breathing;
sweating; restless; racing thoughts;
rumination
Behavioural Responses
Cognitive Biases
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The world is dangerous
(& I am vulnerable)
Negative Automatic Thoughts
Anxiety Symptoms
Plan escape routes & location of
weapons; check locks frequently; have
mobile by bed; buy alarm system
Highly anxious mother: not allowed
out alone until age 16; fear of
abduction, etc)
Selective abstraction (neighbour’s
house less secure)
Catastrophising