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Cognitive Behavioural Therapy (CBT)

Definition:
Cognitive behavior therapy (CBT) is a type of psychotherapeutic treatment that helps patients understand the thoughts and feelings that influence behaviors. CBT is commonly used to treat a wide range of disorders including phobias, addictions, depression, and anxiety.

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Cognitive behavioral therapy (CBT) is a short-term psychotherapy originally designed to treat depression, but is now used for a number of mental illnesses. It works to solve current problems and change unhelpful thinking and behavior.  The name refers to behavior therapy, cognitive therapy, and therapy based upon a combination of basic behavioral and cognitive principles.  Most therapists working with patients dealing with anxiety and depression use a blend of cognitive and behavioral therapy. This technique acknowledges that there may be behaviors that cannot be controlled through rational thought, but rather emerge based on prior conditioning from the environment and other external and/or internal stimuli. CBT is “problem focused” (undertaken for specific problems) and “action oriented” (therapist tries to assist the client in selecting specific strategies to help address those problems),  or directive in its therapeutic approach.

CBT has been demonstrated to be 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.  However, other researchers have questioned the validity of such claims to superiority over other treatments.

Description:
Mainstream cognitive behavioral therapy assumes that changing maladaptive thinking leads to change in affect and behavior,[8] but recent variants emphasize changes in one’s relationship to maladaptive thinking rather than changes in thinking itself.  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.”  These errors in thinking are known as cognitive distortions. Cognitive distortions can be either a pseudo- discrimination belief or an over-generalization of something.  CBT techniques may also be used to help individuals take a more open, mindful, and aware posture toward them so as to diminish their impact. Mainstream CBT helps individuals replace “maladaptive… coping skills, cognitions, emotions and behaviors with more adaptive ones”,  by challenging an individual’s way of thinking and the way that they react to certain habits or behaviors,  but there is still controversy about the degree to which these traditional cognitive elements account for the effects seen with CBT over and above the earlier behavioral elements such as exposure and skills training.

Modern forms of CBT include a number of diverse but related techniques such as exposure therapy, stress inoculation training, cognitive processing therapy, cognitive therapy, relaxation training, dialectical behavior therapy, and acceptance and commitment therapy.  Some practitioners promote a form of mindful cognitive therapy which includes a greater emphasis on self-awareness as part of the therapeutic process.

CBT has six phases:
1.Assessment or psychological assessment;
2.Reconceptualization;
3.Skills acquisition;
4.Skills consolidation and application training;
5.Generalization and maintenance;
6.Post-treatment assessment follow-up.

The reconceptualization phase makes up much of the “cognitive” portion of CBT.   A summary of modern CBT approaches is given by Hofmann.

There are different protocols for delivering cognitive behavioral therapy, with important similarities among them.  Use of the term CBT may refer to different interventions, including “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”. Treatment is sometimes manualized, with brief, direct, and time-limited treatments for individual psychological disorders that are specific technique-driven. CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are cognitively oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (e.g. in vivo exposure therapy). Interventions such as imaginal exposure therapy combine both approaches.

Types of Cognitive Behavior Therapy:
There are a number of different approaches to CBT that are regularly used by mental health professionals. These types include:
•Rational Emotive Behavior Therapy (REBT)
•Cognitive Therapy
•Multimodal Therapy

Medical uses of CBT:
In adults, CBT has been shown to have effectiveness and a role in the treatment plans for anxiety disorders,  depressioneating disorders chronic low back painpersonality disorderspsychosis,  schizophrenia,  substance use disorders,  in the adjustment, depression, and anxiety associated with fibromyalgia,  and with post-spinal cord injuries.  Evidence has shown CBT is effective in helping treat schizophrenia, and it is now offered in most treatment guidelines.

In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders,  body dysmorphic disorder,  depression and suicidality,  eating disorders and obesity,  obsessive–compulsive disorder,  and posttraumatic stress disorder,  as well as tic disorders, trichotillomania, and other repetitive behavior disorders.

Cochrane reviews have found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition.   Other recent Cochrane Reviews found no convincing evidence that CBT training helps foster care providers manage difficult behaviors in the youth under their care,  nor was it helpful in treating men who abuse their intimate partners.

According to a 2004 review by INSERM of three methods, cognitive behavioral therapy was either “proven” or “presumed” to be an effective therapy on several specific mental disorders.  According to the study, CBT was effective at treating schizophrenia, depression, bipolar disorder, panic disorder, post-traumatic stress, anxiety disorders, bulimia, anorexia, personality disorders and alcohol dependency.

Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression.  However, psychodynamic therapy may provide better long-term outcomes.

Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating depression and anxiety disorders, including children,  as well as insomnia.  Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls.  CCBT was found to be equally effective as face-to-face CBT in adolescent anxiety  and insomnia.

Criticism of CBT sometimes focuses on implementations (such as the UK IAPT) which may result initially in low quality therapy being offered by poorly trained practitioners.  However evidence supports the effectiveness of CBT for anxiety and depression.

Mounting evidence suggests that the addition of hypnotherapy as an adjunct to CBT improves treatment efficacy for a variety of clinical issues.

CBT has been applied in both clinical and non-clinical environments to treat disorders such as personality conditions and behavioral problems.  A systematic review of CBT in depression and anxiety disorders concluded that “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.”

Emerging evidence suggests a possible role for CBT in the treatment of attention deficit hyperactivity disorder (ADHD);  hypochondriasis;  coping with the impact of multiple sclerosis;  sleep disturbances related to aging; dysmenorrhea;  and bipolar disorder,  but more study is needed and results should be interpreted with caution. CBT has been studied as an aid in the treatment of anxiety associated with stuttering. Initial studies have shown CBT to be effective in reducing social anxiety in adults who stutter,  but not in reducing stuttering frequency.

Martinez-Devesa et al. (2010) found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition. Turner et al. (2007) found no convincing evidence that CBT training helps foster care providers manage difficult behaviors in the youth under their care,[39] and Smedslund et al. (2007) found that it was not helpful in treating men who abuse their intimate partners.

In the case of metastatic breast cancer, Edwards et al. (2008) maintained that the current body of evidence is not sufficient to rule out the possibility that psychological interventions may cause harm to women with this advanced neoplasm.

In adults, CBT has been shown to have a role in the treatment plans for anxiety disorders; depression;  eating disorders;  chronic low back pain;  personality disorders;  psychosis; schizophrenia;  substance use disorders;  in the adjustment, depression, and anxiety associated with fibromyalgia;  and with post-spinal cord injuries.  There is some evidence that CBT is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia.  CBT has been shown to be moderately effective for treating chronic fatigue syndrome.

In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders;  body dysmorphic disorder;  depression and suicidality;  eating disorders and obesity;  obsessive–compulsive disorder;  and posttraumatic stress disorder;  as well as tic disorders, trichotillomania, and other repetitive behavior disorders. CBT-SP, an adaptation of CBT for suicide prevention (SP), was specifically designed for treating youth who are severely depressed and who have recently attempted suicide within the past 90 days, and was found to be effective, feasible, and acceptable. Sparx is a video game to help young persons, using the CBT method to teach them how to resolve their own issues. That’s a new way of therapy, which is quite effective for child and teenager. CBT has also been shown to be effective for posttraumatic stress disorder in very young children (3 to 6 years of age).  Cognitive Behavior Therapy has also been applied to a variety of childhood disorders,  including depressive disorders and various anxiety disorders.

In the United Kingdom, the National Institute for Health and Care 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

Use of CBT  in other different ways:
With older adults:
CBT is used to help people of all ages, but the therapy should be adjusted based on the age of the patient with whom the therapist is dealing. Older individuals in particular have certain characteristics that need to be acknowledged and the therapy altered to account for these differences thanks to age.   Some of the challenges to CBT because of age include the following:
The Cohort effect The times that each generation lives through partially shape its thought processes as well as values, so a 70-year-old may react to the therapy very differently from a 30-year-old, because of the different culture in which they were brought up. A tie-in to this effect is that each generation has to interact with one another, and the differing values clashing with one another may make the therapy more difficult.  Established role By the time one reaches old age, the person has a definitive idea of her or his role in life and is invested in that role. This social role can dominate who the person thinks he or she is and may make it difficult to adapt to the changes required in CBT. Mentality toward aging If the older individual sees aging itself as a negative this can exacerbate whatever malady the therapy is trying to help (depression and anxiety for example).  Negative stereotypes and prejudice against the elderly cause depression as the stereotypes become self-relevant.[88]Processing speed decreasesAs we age, we take longer to learn new information, and as a result may take more time to learn and retain the cognitive therapy. Therefore, therapists should slow down the pacing of the therapy and use any tools both written and verbal that will improve the retention of the cognitive behavioral therapy.

Prevention of mental illness:
For anxiety disorders, use of CBT with people at risk has significantly reduced the number of episodes of generalized anxiety disorder and other anxiety symptoms, and also given significant improvements in explanatory style, hopelessness, and dysfunctional attitudes.  In another study, 3% of the group receiving the CBT intervention developed generalized anxiety disorder by 12 months post intervention compared with 14% in the control group.  Subthreshold panic disorder sufferers were found to significantly benefit from use of CBT.  Use of CBT was found to significantly reduce social anxiety prevalence.

For depressive disorders, a stepped-care intervention (watchful waiting, CBT and medication if appropriate) achieved a 50% lower incidence rate in a patient group aged 75 or older.  Another depression study found a neutral effect compared to personal, social, and health education, and usual school provision, and included a comment on potential for increased depression scores from people who have received CBT due to greater self recognition and acknowledgement of existing symptoms of depression and negative thinking styles.[99] A further study also saw a neutral result. A meta-study of the Coping with Depression course, a cognitive behavioural intervention delivered by a psychoeducational method, saw a 38% reduction in risk of major depression.

For schizophrenia, one study of preventative CBT showed a positive effect   and another showed neutral effect.

Criticisms of Cognitive Behavior Therapy:
The research conducted for CBT has been a topic of sustained controversy. While some researchers write that CBT is more effective than other treatments,[148] many other researchers  and practitioners  have questioned the validity of such claims. For example, one study  determined CBT to be superior to other treatments in treating anxiety and depression. However, researchers responding directly to that study conducted a re-analysis and found no evidence of CBT being superior to other bona fide treatments, and conducted an analysis of thirteen other CBT clinical trials and determined that they failed to provide evidence of CBT superiority.

Furthermore, other researchers  write that CBT studies have high drop-out rates compared to other treatments. At times, the CBT drop-out rates can be more than five times higher than other treatments groups. For example, the researchers provided statistics of 28 participants in a group receiving CBT therapy dropping out, compared to 5 participants in a group receiving problem-solving therapy dropping out, or 11 participants in a group receiving psychodynamic therapy dropping out.

Other researchers  conducting an analysis of treatments for youth who self-injure found similar drop-out rates in CBT and DBT groups. In this study, the researchers analyzed several clinical trials that measured the efficacy of CBT administered to youth who self-injure. The researchers concluded that none of them were found to be efficacious. These conclusions  were made using the APA Division 12 Task Force on the Promotion and Dissemination of Psychological Procedures to determine intervention potency.

However, the research methods employed in CBT research have not been the only criticisms identified. Others have called CBT theory and therapy into question. For example, Fancher  writes the CBT has failed to provide a framework for clear and correct thinking. He states that it is strange for CBT theorists to develop a framework for determining distorted thinking without ever developing a framework for “cognitive clarity” or what would count as “healthy, normal thinking.” Additionally, he writes that irrational thinking cannot be a source of mental and emotional distress when there is no evidence of rational thinking causing psychological well-being. Or, that social psychology has proven the normal cognitive processes of the average person to be irrational, even those who are psychologically well. Fancher also says that the theory of CBT is inconsistent with basic principles and research of rationality, and even ignores many rules of logic. He argues that CBT makes something of thinking that is far less exciting and true than thinking probably is. Among his other arguments are the maintaining of the status quo promoted in CBT, the self-deception encouraged within clients and patients engaged in CBT, how poorly the research is conducted, and some of its basic tenets and norms: “The basic norm of cognitive therapy is this: except for how the patient thinks, everything is ok”.

Meanwhile, Slife and Williams  write that one of the hidden assumptions in CBT is that of determinism, or the absence of free will. They argue that CBT invokes a type of cause-and-effect relationship with cognition. They state that CBT holds that external stimuli from the environment enter the mind, causing different thoughts that cause emotional states. Nowhere in CBT theory is agency, or free will, accounted for. At its most basic foundational assumptions, CBT holds that human beings have no free will and are just determined by the cognitive processes invoked by external stimuli.

Another criticism of CBT theory, especially as applied to Major Depressive Disorder (MDD), is that it confounds the symptoms of the disorder with its causes.

A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in.

The importance of double-blinding was shown in a meta-analysis that examined the effectiveness of CBT when placebo control and blindedness were factored in.[156] Pooled data from published trials of CBT in schizophrenia, MDD, and bipolar disorder that used controls for non-specific effects of intervention were analyzed. This study concluded that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates, treatment effects are small in treatment studies of MDD, and it is not an effective treatment strategy for prevention of relapse in bipolar disorder. For MDD, the authors note that the pooled effect size was very low. Nevertheless, the methodological processes used to select the studies in the previously mentioned meta-analysis and the worth of its findings have been called into question.

Resources:
http://en.wikipedia.org/wiki/Cognitive_behavioral_therapy
http://psychology.about.com/od/psychotherapy/a/cbt.htm

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Memory Foggy? 5 Signs It’s Not Serious

It’s natural to feel nervous when you forget something, knowing that Alzheimer’s disease now affects 5.3 million Americans.  But a memory slip doesn’t always mean the worst. According to KPHO, the following five situations point toward normal, age-related memory loss.

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1.Lapses Don’t Interfere With Everyday Life
Slowed recall of information from time to time is normal — erverybody forgets stuff.  What’s not normal is when memory impairment interferes with your ability to get through the day.

2.You See an Improvement After ‘Brain Training’
Dementia is not a problem of retrieving old memories so much as it is is an inability to form new ones. If you can still learn new things, you’re still forming new memories.

3.You’ve Just Started A New Medication
Drug side effects are one of the more common causes of memory trouble.

4.Nobody Else Seems To Notice Anything’s Amiss
Usually, there’s a lot of family friction around the kind of memory loss that predates a diagnosis — arguments over who neglected to do something, missed appointments, or forgotten messages.

5.You’re Forgetful When Stressed, Sleep Deprived or Multitasking
A stressed brain is not the same thing as a demented brain.

Source: KPHO December 9, 2010

Posted By:  Dr. Mercola | December 30 2010

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Study Says Sleep More to Loose Weight

If you’re trying your best to eat right and exercise, it might be worth it to make sure you get the proper amount of sleep each night, according to a new study that suggests lack of sleep can throw off a diet.

According to CNN Health, research from the University of Chicago showed that dieters who slept for 8.5 hours lost 55 percent more body fat than dieters who slept 5.5 hours

“The dieters who slept less reported feeling hungrier throughout the course of the study,” CNN said, even though “they ate the same diet, consumed multivitamins and performed the same type of work or leisure activities.”

The study authors concluded that “Lack of sufficient sleep may compromise the efficacy of typical dietary interventions for weight loss and related metabolic risk reduction,” CNN said. The study was released October 4 in the Annals of Internal Medicine.

Source:CNN Health October 4, 2010

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Lost Sleep Can Never Be Made Up

Staying in bed on the weekends won’t make up for a weeks’ worth of sleep deprivation. A new study finds that going long periods without sleep can lead to a sort of “sleep debt” that cannot simply be undone with extra sleep later.

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Such chronic sleep loss may eventually interfere with a person’s performance on tasks that require focus, becoming particularly noticeable at nighttime. This could be due to the effects of your natural sleep-wake cycle, or circadian rhythm.

Your natural tendency to want to be awake during the day may mask signs of sleep debt when it’s light out. But this protective effect may go away as darkness arrives.

Further, just 10 percent of adolescents are getting the optimal hours of sleep each night.

Here’s how parents can help teens get the most possible sleep, despite the demands of school and work:

•Teenagers should stick to a consistent bedtime, preferably before 10 PM

•Keep sleep and wake times as consistent as possible from day to day; maintaining a more regular sleep schedule makes it easier to fall asleep

•Don’t sleep in — strive to wake up no more than two to three hours later on weekends to keep biological clocks on cycle

Resources:
Live Science January 13, 2010
U.S. News & World Report January 15, 2010

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It’s Dreams We Miss, Not Sleep

We need to dream regularly as a vital release for our emotions, a leading psychologist says. Like yoga for the soul.

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It has become one of the most cherished neuroses of Western culture that we exist in a state of acute sleep deprivation, a dearth to which legions of casual complaints and magazine headlines testify. Nevertheless, the psychologist and sleep guru Rubin Naiman is equally disturbed by another deficit: namely, that 21st-century society is undergoing an epidemic of dreamlessness.

In tones of soporific calm, Dr Naiman, Clinical Assistant Professor of Medicine at Dr Andrew Weil‘s University of Arizona Centre for Integrative Medicine, explains: “We are at least as dream deprived as we are sleep deprived.”

He says it is vital to dream. “An essential function of dreaming is psychological stretching, a kind of yoga for the soul: gently expanding, releasing, opening, and softening.” Like stretching a muscle, a dream can release emotional pain, tightness from earlier in the day – or even hurt from childhood. Dreaming provides “a poetic cushion” for our sharply literal lives, he says.

Modern lifestyles interfere with healthy dreaming. Overexposure to light at night suppresses melatonin and thus dreaming. Many commonly used medications, including sleeping pills, also restrict our ability to dream, or the REM [rapid eye movement] sleep that yields it. Sleep apnoea, usually associated with snoring, can significantly diminish dreaming too. “And, last, but certainly not least,” Dr Naiman says, “we live in a world where the dream has become devalued. ‘Forget it,’ we say to a loved one who has a nightmare, it’s just a dream’.”

The majority of dreams flit by in episodes of between five and 20 minutes, four or five times a night. Nevertheless, during an average life span, this nightly couple of hours will add up to a good six years enmeshed in fantasy. From the 1940s to 1985 the psychologist Calvin S. Hall collated more than 50,000 dream narratives at Case Western Reserve University, Ohio. He argued that sleepers the world over conjure the same sort of visions. Universal motifs include: education, being chased, an inability to move, tardiness, nudity and humiliation, flying, shedding of teeth, death, falling in love with or having intercourse with random individuals, car accidents and being accused of a crime.

Anxiety is the most common emotion experienced and negative sentiments tend to be more prevalent (or better recalled). America ranks the highest among industrialised nations for aggression in dreams, while sexual themes occur about a tenth of the time.

Theories about the function of dreams differ radically from the notion that they are Nature’s own form of psychotherapy to their being merely the brain’s mode of dejunking. Dr Naiman’s take is a fusion of the practical and the poetic. “Dreaming plays a critical role in learning and the formation of certain kinds of memory. It also helps us to heal from emotional losses.

“Much of the depression explosion we witness today is associated with an actual loss of dreams,” he says. If we cannot sleep on it, so the evidence suggests, the “it” in question may threaten to overwhelm us.

How might such a deficit be rectified? Better sleep as a whole will conjure better dreams. Thus, the dreamless are advised to avail themselves of the potions born of Dr Naiman’s collaboration with Origins, the natural skincare company: products designed to get us back to what he terms “deep-green sleep”, that is, chemical-free repose in a nurturing environment.

Beyond this, it may not be too complicated. “The simple act of directing our attention back towards our dreams will encourage them to come out of hiding,” he says. Once they begin to flow, make a note of them and share them. “The bottom line is about befriending our dreams and remaining open to all they bring.”

Another reason that we turn away from dreams is that so many of them are, in fact, “bad”. One study suggests that about two thirds of the emotional content of our dreams is negative. But they are bad only when viewed from a waking perspective. “We are a wake-centric culture,” he says. “We presume that waking consciousness is it: the gold standard for our experiences, happiness, sanity.”

He says that youngsters should be encouraged to talk about their dreams. “So many learn that dreams are of little consequence in the adult world … so, although they may experience them vividly, they tend to avoid discussing them and lose interest.” Parents, he says, should ask their children about their dreams, as well as share their own.

So what he advocates is an embrace of deep-green dreaming? “Why not? Healthy dreaming and healthy sleep are reciprocal. I dream best in deep-green forests.”

Sweet dreams :-

Limit your exposure to artificial light

This includes television screens, because the blue component restricts melatonin and thus dreaming. Invest in some blue light-eliminating bulbs and glasses (www.lowblue lights.com) or opt for candlelight.

Avoid excess alcohol and dream-suppressing medications
But you must treat conditions such as sleep apnoea that may interfere with dreaming. Melatonin, which requires a prescription in the UK, is a safe way to rekindle dreaming.

Look at dreaming as a form of psychological stretching
Keep a dream journal and discuss your dreams with your family and friends. Encourage children not to feel inhibited about sharing their nocturnal adventures.

Try to foster an awareness that you are dreaming when it’s happening
This is especially important when it comes to nightmares. Yield to the message of a nightmare rather than becoming embroiled in it

CLICK TO SEE:-
>Beating insomnia without popping sleeping pills
>Why can’t I get to sleep?

Sources:TIMES ON LINE  DATED:28TH.FEB ’09

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