cbt lewis.pptx
TRANSCRIPT
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COGNITIVE ANDBEHAVIORAL
THERAPIESAnne Cristine D. Guevarra, MD
Child Psychiatry Rotator
Lewis’s Child and Adolescent Psychiatry:
A Comprehensive Textbook 4th edition
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Objectives
• To introduce cognitive-behavioraltherapy as a modality for treatment ofpsychiatric disorders especially inchildren and adolescents
• To review basic concepts that formthe basis for CBT
• To discuss specic disorders whereinCBT may be eective
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Cognitive Therapy
Foundations• it is not events, but people's interpretations of events, thatcause psychological disturbance
• focuses on identifying and changing people's cognitions asa way of changing their feelings and reducing psychological
distress
• behavioral changes are thought to inuence thoughts and
feelings• etting concrete goals and measuring specic behaviors
• !"#CT$%#& ()*()CT$+) !unctional &ssessment )valuation
&ntecedents B).&+$%* Conse/uences
Behavior Therapy Foundations
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Classical Conditioning
Establishes the connection of
an existing response to a new stimulus
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Classical Conditioning &
Phobias
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Classical Conditioning & CBT
The subsequent avoidance behavior does not allowextinction to occur, such that the phobia is maintained
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Classical Conditioning & CBT
• )motional responses, addictions, andpsychosomatic disorders
• Therapy techni/ues0• Counterconditioning
• ystematic desensiti1ation
• Covert sensiti1ation
• )2posure and response prevention
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Classical Conditioning
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Operant Conditioning
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Operant Conditioning:Schedules of Reinforceent
• Continuous schedule 3 initially teaching a newbehavior
• Thinning 3 to decrease the ratio of reinforcers to
responses• $ntermittent
45 2ed interval
65 variable interval
75 2ed ratio85 variable ratioThe variable ratio schedule is the
most effective schedule when trying
to maintain a behavior because it
creates relatively high steady rates of
responding.
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Initial Behavir Res!nse "re#uen$%
Rein&r$e'ent
Re've(
E)tin$tin
Burst
S!ntaneus
Re$ver%
O$$urs
E)tin$tin
!"tinction #raph
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Operant Conditioning & CBT
• &pplied behavior analysis 9&B&5
• (arent management training 9(:T5
• (roblem solving s;ills training 9(T5
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Coon Therapy Techni$ues %ssociatedith
Principles Of Operant ConditioningRein&r$e'ent t In$rease Behavir
T%!e an( Te$hni#ue Des$ri!tin
T*ene$n'%
Reinorcin! tar!et behavior with tokens "stickers# points# poker chips$ that can then be traded in or reinorcers once m%ltiple tokenshave been earned
DRO+Di&&erential
Rein&r$e'ent& Other Behavir
Reinorcin! speciic appropriate behaviors while i!norin! inappropriate behaviors that serve
the same %nction
Sha!in- Reinorcin! !rad%al approximations o a behavior
Punish'ent t De$rease Behavirs
Over$rre$tin Applied conse&%ence that involves en!a!in! in a series o retrib%tionsteps that are related to the inappropriate behavior "washin! soiled clothes ater toiletin! accident$
Res!nse $st Removal o previo%sly earned reinorcers as conse&%ence o ne!ative behavior' (sed especially incon)%nction with token economy when tokens are removed
Ti'e ut Removin! all so%rces o reinorcement or allotted period o time' Typically involves placin! the individ%alin a location where access to reinorcin! activities# incl%din! social attention# is not available
E)tin$tin t De$rease Behavirs
Removin! previo%sly available reinorcement rom an inappropriate behavior to decrease theprobability that the behavior will occ%r in the %t%re
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Cognitive'Behavior TherapyFoundations
*ehavior
Tho%!hts
+eelin!s
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Cognitive'Behavioral (odel
• Escape or Avoidance Conditioning• why negative thoughts and beliefs persist
• why behavioral cycles do not get bro;en over time
• avoidance, escape and safety-see;ing behaviors
• individuals erroneously believe they prevented the feared situation
from occurring by engaging in certain behaviors
• Attention-related Factors• electively attend to cues that conrm or e2acerbate their condition
• Cognitive images• $mages are interpreted as signs of danger li;elihood that
distressing events will occur
• Memor !rocesses• *ecall of instances that conrm an2iety
• *umination 3 thin;ing of the li;elihood of the event occurring• :a;es the event more abstract and threatening vs< constructive processing
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Clinical Considerations )n *se of CBT+ith Children and %dolescents
• Collaborative empiricism• (atient-therapist relationship= team
• .igh degree of collaboration and scientic attitude towardtesting the validity and accuracy of the patient>s cognitionsand behaviors
• developing hypotheses about thoughts and behaviors,collecting data on those thoughts and behaviors,
e2amining patterns, and generating alternative, moreadaptive, ways of thin;ing and behaving
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,evelopental Perspective
• The child's level of autonomy and independencemust be ta;en into consideration
• Consider what other individuals or systems andhow they are involved in the child's life and whattheir role should be in therapy
• (arent, teacher, and other adult-focused training isoften necessary in addition to individual therapysessions
• &dapting treatment concepts to children'sdevelopmental level
• Cognitive-behavioral play therapy 9CB(T5 in veryyoung children
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Faily'Related Factors
• The Role of Families and OtherSystems in Cognitions and Behaviors• %ther people in the child's life are ma;ing
accommodations that support and maintain,rather than discourage, the maladaptivebehaviors
• Parent/Family Involvement in Therapy
• family conte2t, and parental cognitions,emotions, and behaviors
• family routines, dynamics, and disciplinepractices
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#enerali-ation and
(aintenance• &cross settings
• &cross functional domains 9behavior, cognitions5
• %ver time 9maintenance5
"r su$$ess&ul $han-e, the !atient 'ust use the te$hni#ues learne( insessin a$rss settin-s, learn t a!!l% the' t a variet% & ('ains, an(
$ntinue t use the' ver ti'e &r as ln- as ne$essar%.
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Strategies for prooting generali-ationand aintenance of iproveents in
functioning ./endall and 0ochan 1• *ewarding behavior change using attainable goalsthat are applied across an increasing number ofsettings over time
• Treatment length is an important consideration inprogramming for maintenance of changes made 9?months or longer5= intensity may be an importantfactor as well
• "se of behavioral rehearsal 9role-playing5
• (roblem solving processes that apply to multiplebehaviors and situations
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Course of Therapy
General Characteristics of CBT TreatmentPlans
45 The patient will be an active participant in trying newstrategies
65 the patient will be e2pected to complete homewor;75 therapy outcomes will be measured via data collection,and techni/ues will be modied if they are unsuccessful
85 therapy will focus on symptoms and daily functioning
@5 therapy will be time limited
?5 maintenance of treatment gains and relapse preventionwill depend on generali1ation of techni/ues into everydaylife
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Three Phases of Treatent
,nitial Active +inal
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Fre$uency and ,uration ofTreatent• 7- to ?-month period
• once or twice per wee; in an outpatient setting
• Booster session
• Tapering the therapy
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(.&) %! T*)&T:)#T
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Phases of Treatent
• %ssessent for Treatent Planning
• Psychoeducation
• (iddle Phase of Treatent
•Terination and Relapse Prevention
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%ssessent for TreatentPlanning• To develop a cognitive behavioral model of the presentingproblem that can be used to guide treatment
• Aescriptions of when the symptoms occur
• Cognitions that accompany each symptom
• Behaviors that accompany each symptom
• )motions that occur with each symptom• $f cognitions and behaviors relieve symptoms, detailed description of
how this occurs
• $nformation about factors that help or e2acerbate the symptoms
• :aintaining variables0 avoidance, escape, safety behaviors,
attentionfocus, dysfunctionalfaulty beliefs, automatic thoughts
• %verall beliefs 9cognitive schemas5 that lead to cognitions, behavior,and feelings
• (revious treatment and treatment outcome
• %nset0 including any possible causal factors that are not maintainingfactors 9e<g<, traumatic event in (TA, negative situation paired with
stimuli in specic phobias5
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ays of !liciting
• &s; patient to describe a recent event in detail,while as;ing pointed and specic /uestions, suchas0• hat were you thin;ing when that happenedDE or
• .ow did your body feel at that momentDE
• .omewor;• )2plicit information from children
• elf-monitoring
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Psychoeducation
• Techni/ues utili1ed in CBT are driven by theoreticalor empirical underpinnings that, when understood,allow the patient to better grasp wh suchtechni/ues are being used and how change will
occur, thus increasing motivation and followthrough
• )2plained or demonstrated• (hysiological
• Cognition• Connection between thoughts and events
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(iddle Phase of Treatent
• %ngoing active participation in therapy
• .omewor;
"oals and content of therap sessions during this phase will var widel depending on the chiefcomplaint#
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Terination and RelapsePrevention• (rogramming for generali1ation and maintenance
• Thinning of schedule of therapy sessions
• *elapse prevention• Cognitive framewor; for thin;ing about brief relapses
• $dentifying antecedents to relapse behaviors
• Booster sessions
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CBT T!C23)4*!S
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CBT Techni$ues
• Cognitive Restructuring• $dentifying &utomatic Thoughts
• imagerey F role-playing, thought recording
• ocratic Guestioning)2amining the )vidence• eliciting automatic thoughts and calling their validity into
/uestion
• Thoughts are considered hypotheses determine andevaluate evidences for and against them
• Can be combined with self monitoring
• Correct :isinterpretations
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Cognitive !rrorsCOGNITIVE ERROR DESCRIPTION EAMPLE
Catastr!hi/in- Placin! %nrealistic importance on tho%!hts andeventsand ass%min! terrible ne!ative o%tcomes willocc%r as a res%lt
, !ot a C on my report card# so , will never !etinto colle!e and , will ail in lie'
Ma-ni&%in-0Mini'i/in- Placin! an inacc%rate amo%nt o importance ontho%!hts# eelin!s# -vents "either too m%ch or toolittle$
*elievin! !ettin! ca%!ht doin! dr%!s is notimportant beca%se the ,mplications o havin!a dr%! problem are too anxiety provokin!
"minimi.in!$
A1slutis' All events and experiences are tho%!ht o inextremecate!ories# rather than moderately
, will never lose any wei!ht beca%se , )%st atea cookie'
Persnali/atin Attrib%tin! responsibility or external events to thesel with no basis or the attrib%tion
,t is my a%lt that my parents are !ettin!divorced'
Sele$tive A1stra$tin Takin! inormation o%t o context and i!norin!relevant details
/y soccer coach hates me when s0he did notplay yo% in spite o the act that yo% havestarted the last three !ames
Ar1itrar% in&eren$e /akin! arbitrary concl%sions contrary to orwitho%t evidence
*elievin! homework is too hard when in actthe child completed the same work that dayin class
I-nrin- evi(en$e Leavin! o%t important inormation when ormin!tho%!hts abo%t events
*elievin! that werewolves are a dan!er atni!ht in spite o the act that m%ltiple ad%ltshave told the child they do not exist# and allthe doors in the ho%se are locked'
Atten(in- t ne-ative
&eatures & events
Placin! !reater co!nitive importance on ne!ativeeat%res o events and i!norin! positive eat%res
+oc%sin! on one poor !rade when all otherswere !ood
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CBT Techni$ues
• Behavioral)2periments
• :odication of$magery
• <ering Core Beliefs
• (hysiological Techni/ues
• *egulated Breathing
• *ela2ation Training
• )2posure Techni/ues
• &ctivity cheduling
• &pplied Behavior&nalysis 9&B&5 Behavioral:odication
• Counterconditioning
• ystematicAesensiti1ation
• &versive
Counterconditioning• Covert ensiti1ation
• .abit *eversal
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CBT Techni$ues
• Behavioral !"perients• Auring psychoeducation= e2ercises that patient can complete in
a session= demonstrates error in thin;ing in a concrete manner
• Thought suppression increased fre/uency of a thought 9e<g<pin; elephants5
• $nstead of supressing thoughts observe thoughts as theycome F go
reduction of intrusive thoughts
• (odi5cation of )agery•
$dentify e2aggerated aspects of the imagery associated withtraumatic event
• %ften stops at the height of crisis help patient continueimage to a positive resolution
• (assing out !alling to the ground getting embarrassed standing up
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CBT Techni$ues
• %ltering Core Beliefs• "nderlying belief cognitive schemas automatic thought
• 9tupid ;ids are unlovable5 9$ am stupid5 $f $ don>t write that sentenceeveryone will ;now $ am stupid Therefore, no one loves me
• :aladaptive &daptive
• Physiological Techni$ues• &n2iety= catastrophi1ing physical symptoms
• Regulated Breathing• Counteracts hyperventilation, reduces physical tension, decreases
physical sensations associated with an2iety
• "ncovering the patient>s understanding of the physiology decreases fears
• Rela"ation Training• (rogressive tensing and rela2ation of muscles= target large muscle groups
• )ective for sleep-onset insomnia, anger management, impulsive children
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CBT Techni$ues
• !"posure Techni$ues• Based on &voidance afety Behaviors
• Hraded series of e2posures
• .abituation 9Classical Conditioning5 3 an2iety e2tinguish over time
• &n2iety, phobia
• %CA 3 compulsive behavior 9safety behavior5
• !looding 3 not graded= begins by eliciting a full-blown fear response=needs good self-control to prevent avoidanceescape
• Challenge core beliefs Cognitive *esponse (revention• Behaving inconsistently with pathological belief
• Ao homewor; with some imperfections 9a couple of mista;es do not ma;eme stupid5
• %ctivity Scheduling• Bec;>s cognitive triad negative 9thin;ing, evaluations of self, world,
future5
• *einforcing daily activities
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CBT Techni$ues
• Self'(onitoring 6 Self'(anageent• &utomatic thoughts, habits, evaluation plan
• %pplied Behavior %nalysis .%B%1 6 Behavioral(odi5cation• $ncrease desirable decrease undesirable• Contingent reinforcers reinforcement is applied to a
positive behavior increases the fre/uency of that
behavior occurring
• Counterconditioning• olpe 3 $f a response antagonistic to an2iety can be made
to occur in the presence of an2iety-provo;ing stimuli so that
it is accompanied by a complete or partial suppression ofthe an2iety responses, the bond between these stimuli andthe an2iety response will be wea;ened<E
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CBT Techni$ues
• Systeatic ,esensiti-ation• :ost commonly used counterconditioning techni/ue= subclinical fears
• *ela2ation training
• Constructing an2iety heirarchy
• Aesensiti1ation in imagination
• $n vivo Aesensiti1ation• $maginal or in vivo e2posure heirarchy paired with progressive
muscle rela2ation to reduce fearan2iety
• +isuali1ation in vivo training
• %versive Counterconditioning• &ddictions, se2ual fetishes
• Target behavior or conditioned stimulus paired with unconditionedstimulus that naturally elicits an unpleasant response maladaptivebehavior is avoided
• Aisulram I alcohol consumption physical ilness reducedrin;ing behavior
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CBT Techni$ues
• Covert Sensiti-ation• $magining an aversive condition while imagining engaging
in maladaptive behavior
• 2abit Reversal
• Trichotillomania, Tourette>s syndrome, Tic disorders• &wareness training
• Training in an incompatible competing response
• ocial support
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C%H#$T$+) B).&+$%*&
:%A) &#A T*)&T:)#T!%* )&C. A$%*A)*
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Cognitive Behavioral (odel Treatent• overestimation of the dangerassociated with certainsituations, bodily sensations,or even thoughts
45 the li;elihood of an event
65 the severity of an event
75 one's coping s;ills and theavailability of help, support, or escape
• interpret events from anegative and therefore
inaccurate perspective• two-factor learning theory
• (hysiological symptoms,especially ongoing somaticcomplaints, are often the mostcommon an2iety symptoms inchildren
• (hysiologicaltreatment strategies
• Behavioral Treatmentstrategies
• Cognitive strategies
• Combined trategies
ANIET2
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Cognitive Behavioral (odel Treatent
• $ntrusive anddistressing thoughts,impulses, or images
about possible harmcoming to oneself orothers
• counterthoughts or
behaviors to preventharm or negativeconse/uences fromoccurring
• )2posure andresponse prevention9)*(5 has substantial
• based on models ofclassical e2tinction
• CBT alone was founde/ually eJcacious as
CBT I *$ - (ediatric%CA Treatment tudy9(%T5
OCD
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Cognitive Behavioral (odel Treatent
• two-factor learningtheory
• brea;ing the operantconditioning cycle andteaching the individualthat the fearedsituation is unli;ely to
occur again even whenit is not avoided
• Hraded e2posure
• ystematicdesensiti1ation
• *ela2ation training
PHOBIAS
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Cognitive Behavioral (odel Treatent
• fear of impendingdisaster, which isconrmed by
physiological andcognitive symptoms misinterpret theirsymptoms asconrmation that their
an2iety represents realdanger :%*) &#K$)TL
• precipitating factor in theattac; is a fear of havingone, rather than a fear ofa specic stimulus
• cognitive andphysiologicalstrategies
• e2posure therapy
PANIC DISORDER
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Cognitive Behavioral (odel Treatent
• $nability to cope withintrusive, unwanteddistressing thoughts
and memories after atraumatic event
• )2posure
• Cognitiverestructuring
• *ela2ation
• &n2iety managementtraining
PTSD
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%lternative set of diagnostic criteria forpreschool'agedtraua victis .Scheeringa145 the individual does not have to be able to report the an2ietyreaction, as many young children are incapable of doing so
65 recurrent recollection of the event may manifest in repetitivetrauma-related play themes
75 recurrent distressing dreams do not have to include trauma-related
content, but must be distressing85 ashbac;s may be behavioral in nature, with no accompanyingverbal description
@5 diminished interest in signicant activities may present asconstriction of play
?5 a feeling of detachment or estrangement may manifest aswithdrawal
M5 loss of developmental s;ills may occur
N5 increased arousal may manifest as tantrums and fussiness<
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%dditional Cluster OfSyptos• 45 new separation an2iety
• 65 new onset of aggression
• 75 new fears 9e<g<, fear of the dar;5 withoutobvious lin;s to the trauma
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,S('7 Criteria for PTS, inChildren
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,S('7 Criteria for PTS, inChildren
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Cognitive Behavioral (odel Treatent• intrusive negative thoughts
9e<g<, selective ruminationsabout past unpleasant
events, hopelessness aboutthe future, andhelplessness aboutimproving their situation5
• overgenerali1ation,
catastrophi1ing, ta;ingresponsibility for negativeoutcomes, and attending tonegative features of events
• restricted behavioralrepertoires
• Cognitiverestructuring
• elf control strategies
• ;ills training
• &dolescent Copingwith AepressionCourse 9CA-&5
DEPRESSION
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Cognitive Behavioral (odel Treatent• lac; of motivation and
learned helplessness• &pplied Behavior&nalysis 9&B&5
• discrete trial training
• pivotal response training• incidental teaching
• Techni/ues
• (rompting
• !ading
• haping• Tas; &nalysis
• Bac;wards Chaining
• Behavior plans
• %vercorrection
A3TISM 4 PERVASIVE DEV5T DISORDERS
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Cognitive Behavioral (odel Treatent• Coercive interactions
• $nformation (rocessing:odel
• !our types oftherapeutic change
• )cological
• %perant methods• :edication
• Behavioral parenttraining
• (erspective ta;ing and
social problem solving• (arent managementtraining 9(:T5
• (roblem solving s;ills
training 9(T5
EMOTIONAL 4 BEHAVIORAL DIST3RBANCE
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Cognitive Behavioral (odel Treatent• $nattention, hyperactive,
impulsive symptoms
• poor self-monitoring and
self-evaluation s;ills, mayhave diJculty withreceptive and e2pressivelanguage, and suer fromassociated e2ecutivefunctioning decits
• (harmacological andbehavioral treatments
• (rogramming at home
• chool intervention• ong-term goal in &A.A
treatment is gradually tofade the adult control tochild-driven self-
management
ADHD
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Cognitive Behavioral (odel Treatent• Cognitive distortions
• mista;en view thatcompensatory behaviors
9vomiting, la2ative use,diuretics, overe2ercising5are eective means ofweight control
• binge-purge cycle is also
associated with theantecedent of negativeaect
• tages 9!airborn5• Teaching the patient self-
monitoring of eating andrelated behaviors
• )ducating the patient abouteating and weight 9physicaleects of binge eating,information about weightuctuation, ineectivenessof compensatory strategies,
eects of dieting5• (rescribing a regularpattern of eating 9regular,planned meals and snac;s5
• Aeveloping a plan toaddress post-meal vomitingwhen this behavior is partof the illness<
B3LIMIA
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Cognitive Behavioral (odel Treatent• Cognitive distortions
• do not believe they have aproblem
• they believe that they arefat and truly need to loseweight
• !irst goal 3 weight gain
• &ddress the lac; ofmotivation of the
patient• tages 9Harner, +itouse;, and (i;e5
• tabili1ation of thepatient's physical healthand building a therapeutic
alliance
• Continued emphasis on
weight gain and normaleating
• (rogress is summari1ed
and emphasi1ed
ANOREIA
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Cognitive Behavioral (odel Treatent• role of negative
reinforcement 9dissipationof the urge upon
performance of the tic5 as acontributing factor in theshaping and maintenanceof tic e2pression
• .abit reversalprocedures
• &ssessment phase
• &wareness training
• Competing responsetraining
• ocial support
TO3RETTE S2NDROME
7/23/2019 CBT Lewis.pptx
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Cognitive Behavioral (odel Treatent• hair pulling behaviors are
maintained by a negativereinforcement paradigm
similar to %CA and ticdisorders, as tension isreduced when thehairpulling behavior occurs
• .abit reversalprocedures
• &ssessment phase
• &wareness training
• Competing responsetraining
• ocial support
TRICHOTILLOMANIA
7/23/2019 CBT Lewis.pptx
http://slidepdf.com/reader/full/cbt-lewispptx 61/61
Other Probles
• )nuresis 3 night alarm
• )ncopresis - la2ative prescription, dietary changes,and behavioral methods
• elective mutism - behavioral methods0 shaping,
fading 9situational F individual5• tuttering 3 rela2ation training