Cognitive behavioural and neuropsychiatric treatment of post‐traumatic conversion disorder: a case study

Conversion disorder consists of involuntary sensory or motor symptoms and deficits that cannot be explained by a general medical condition. There are several treatment options, although none has emerged as the treatment of choice. The present case study examined the effects of adding cognitive behaviour therapy to neuropsychiatric management of conversion disorder (motor subtype). The patient, a retired emergency services worker, presented with a history of intermittent episodes of speech disruption (inability to speak or difficulty speaking properly). Although episodes of speech disturbance sometimes occurred unexpectedly, they were more likely to occur under conditions of stress and fatigue, and were triggered by reminders of work‐related traumatic events. The patient was treated with pharmacotherapy and psychoeducation from a neuropsychiatrist. With the aim of improving treatment outcome, cognitive behaviour therapy was added, involving imaginal exposure to trauma memories, along with cognitive restructuring. The frequency of between‐ and within‐session speech disturbance episodes declined over the course of cognitive behaviour therapy to the point that the patient was essentially symptom‐free. Within‐session distress ratings also decreased, which suggested habituation to trauma‐related memories. This case study demonstrates how particular cognitive behaviour therapy interventions can be usefully applied to one form of conversion disorder.     

Treatment of Assaultiveness

Summary

Assaultiveness and abusiveness have a psychology that must be addressed in therapy; they are not merely the product of “bad attitudes” or social roles, nor can they be narrowly defined as the robotic imitation of action. Perceptions and feelings about the world of intimate relationships both sustain and are sustained by abusive actions. These provide points of intervention for cognitive behavioral therapy (CBT). Given the tendency to shame easily, abusive men must not be confronted too quickly or too strongly. On the other hand, given their well-established denial system and tendency to minimize the consequences of their abusiveness, some confrontation must occur. Hence a “Zen” line of least resistance must be found between the opposites of acceptance and confrontation. Treatment outcome studies indicate moderate success for cognitive behavioral treatment (CBT) for batterers. Treatment is less successful with men who have personality disorders, especially psychopathy.     

Practising family therapy in India: how many people are there in a marital subsystem?

Systemic therapy would appear to be a viable form of treatment for people who exist in cultures that contain complex, extended family systems, such as those found in India. The practice of family therapy in India has evolved from Western concepts. These concepts appear to offer Indian therapists relevant and practical ways of working with families. However, some of these concepts need modifying before they can be used in an Indian context. Indian families may have very different worldviews and ideas of 'self' compared to families in the West, leading to different family organization. The situation can be further complicated by the cultural norms of therapists themselves. Therapists in India are often highly educated, come from upper-middle-class families and have been exposed to different cultures. They increasingly share many of the values of their counterparts in the West. At the same time, they retain aspects of their own cultural heritage, which is also the dominant culture for a large number of the families with whom they work. Thus, not only must Indian family therapists seek to work in culturally appropriate ways; they must also tolerate their own internalized conflicts regarding differing cultural norms. With the use of clinical data, this paper describes some of the personal and professional problems experienced by an Indian family therapist working with Western constructs of family organization.     

The treatment of borderline personalities with rational emotive behavior therapy

The rational emotive behavior therapy (REBT) theory holds that individuals with severe personality disorders in general, and borderline personalities in particular usually are biologically different from “normal” neurotics and are born with a predisposition to be highly vulnerable to stressful environmental conditions. They tend to have cognitive, emotional, and behavioral deficits or disabilities that handicap them socially, vocationally, and in other important aspects of their lives. But they also have distinct, and sometimes exceptionally strong, neurotic tendencies to demand that they absolutely must perform well, that other people have to treat them kindly and fairly, and that frustrating conditions ought not exist. Their neurosis exacerbates their cognitive-emotive-behavioral handicaps, produces even greater life difficulties, and often interferes with their working hard at therapy. A summary is presented of how borderline personalities can be treated with rational emotive behavior therapy (REBT).     

The dual pathway to creativity model: Creative ideation as a function of flexibility and persistence

The dual pathway to creativity model argues that creativity—the generation of original and appropriate ideas—is a function of cognitive flexibility and cognitive persistence, and that dispositional or situational variables may influence creativity either through their effects on flexibility, on persistence, or both. This model is tested in a number of studies in which participants performed creative ideation tasks. We review work showing that cognitive flexibility, operationalised as the number of content categories surveyed, directly relates to idea originality, but that originality can also be achieved by exploring a few content categories in great depth (i.e., persistence). We also show that a global processing mode is associated with cognitive flexibility, but only leads to high originality in tasks that capitalise on cognitive flexibility. We finally show that activating positive mood states enhance creativity because they stimulate flexibility, while activating negative mood states can enhance creativity because they stimulate persistence. Implications for theory and practice are discussed.     

Self-knowledge: An expanded view

This paper argues for a more extensive study of self-knowledge. From the cognitive perspective, self-knowedge is a critical component of personality. Until quite recently, however, the study of self-knowledge has been narrowly conceived, focusing primarily on how individuals describe their roles and characteristic behaviors. Yet individuals also have knowledge about their preferences and values, their goals and motives, and their rules and strategies for regulating behavior. These dynamic aspects of self-knowledge are significant because they can be importantly revealing of future behavior. The content and organization of self-knowledge is important first because it indicates which domains of behavior are regarded as the most self-relevant. It is in these domains that the strongest links between personality and behavior will be observed. Second, self-knowledge cognitively represents desired and undesired states for the self, as well as specific ideas about how to realize or avoid these states. It thus indicates the likely course of behavior in self-relevant domains. A number of recent research efforts can be intepreted as explorations of self-knowledge. These are briefly reviewed and integrated to provide a general outline for an expanded view of self-knowledge.     

Introduction: Using Techniques via the Therapeutic Relationship

In this work, we have the opportunity to hear people’s most private concerns, worries, distress, and share in their hopes, aspirations, and dreams for the future. The work involved in the practice of cognitive behavior therapy; our knowledge, theories, techniques, and strategies are practically useless if we are unable to relate to our clients. Relational attributes were incorporated as part of the defining features essential to therapeutic change in the seminal guide for cognitive therapy (A. T. Beck, Rush, Shaw, & Emery, 1979). Conceptualizations of “collaboration” and “empiricism” have since been misconstrued with the construct of the working alliance in the past, although both have unique distinctions and implications for practice. This article presents an introduction to a special series in Cognitive and Behavioral Practice, which illustrates the vital role of collaborative empiricism within culturally responsive CBT, through the structure of the therapy session, cognitive case conceptualization, self-monitoring, interventions focused on cognitive change, and exposure to emotions and situations. We invite you to join with us in considering the extent to which the ideas shared herein are relevant for your work with clients. It is also our hope that you will consider evaluating and incorporating the utility of these ideas in your therapy.     

Mediators in psychological treatment of social anxiety disorder: Individual cognitive therapy compared to cognitive behavioral group therapy

According to cognitive-behavioral models of social anxiety disorder (SAD), four of the important maintaining mechanisms are avoidance, self-focused attention, anticipatory processing and post-event cognitive processing. Individual cognitive therapy (ICT) and cognitive behavioral group therapy (CBGT) both have substantial empirical support. However, it is unclear whether they achieve their effects by similar or different mechanisms. The aim of this study was to investigate whether changes in the four maintenance processes mediate clinical improvement in ICT and CBGT for SAD. We analyzed data from participants (N = 94) who received either ICT or CBGT in two separate RCTs. The results showed that ICT had larger effects than CBGT on social anxiety and each of the four potential mediators. More pertinently, moderated mediation analyses revealed significant between-treatment differences. Whereas improvement in ICT was mainly mediated by reductions in avoidance and self-focused attention, improvement in CBGT was mediated by changes in self-focused attention and in anticipatory and post-event processing. These results support the importance of the putative mediators, but suggest that their relative weights are moderated by treatment type.     

Assessing Individual Family Members' Constructions of Family Problems

Much contemporary family therapy theory and practice takes into account clients' cognitive constructions of their family problems. Recent calls for therapists to elicit and work with clients' causal explanations and narratives parallel accumulating evidence in the social-clinical literature about the predictive importance of attributions in family relationships. In this article, we introduce the Constructions of Problems Scale (CPS), provide preliminary evidence of its reliability and validity, and suggest ways in which it can be used clinically to reveal new areas for questioning and to generate new ideas. The CPS is a brief questionnaire that can be used to create a profile of each individual family member's private constructions. To complete the CPS, each family member writes a free-form narrative of the presenting problem and then rates his or her perceptions of the contributing causes. The CPS profiles can be used to compare the perspectives of different family members and to assess cognitive constructions at different points in treatment. We discuss its potential for these and other clinical uses.     

Belief disconfirmation versus habituation approaches to situational exposure in panic disorder with agoraphobia: a pilot study

Exposure therapy and cognitive behaviour therapy (CBT) are both effective in the treatment of panic disorder with agoraphobia. Cognitive theories suggest that the way in which exposure to avoided situations is implemented in either treatment may be crucial. In particular, it is suggested that clinical improvement will be greatest if opportunities for disconfirmation of feared catastrophes are maximized. In a small pilot study, 16 patients with panic disorder and (moderate or severe) agoraphobia were randomly allocated to either habituation based exposure therapy (HBET) or exposure planned as a belief disconfirmation strategy and accompanied by dropping of safety-seeking behaviours. Both treatments were brief (total of 3.25 h of exposure) and were similar in terms of expectancy of change. Patients in the CBT condition showed significantly greater improvements in self-report measures of anxiety, panic and situational avoidance. They also completed significantly more steps in a standardized behavioural walk, during which they experienced significantly less anxiety. The controlled effect sizes for CBT were substantial (range 1.7-2.7), which suggests it may be a particularly efficient way of managing therapeutic exposure to feared situations in panic disorder with agoraphobia. Further research is needed to clarify the mechanism of change involved.     

Commentary on “Trauma to the Psyche and Soma”

This case report addresses assessment and treatment considerations for a patient suffering from posttraumatic stress disorder (PTSD) in the context of mild traumatic brain injury and ongoing pain. Management of this case is based on the application of evidence-based therapy, and of cognitive behaviour therapy, for PTSD reduction. Assessment and treatment approaches recognize that delivery of treatment requires modification to allow exposure therapy for individuals who are partially amnesic of their traumatic experience. Further, administering exposure and cognitive therapy for patients with cognitive impairment requires specific means of treatment delivery to allow adequate compliance with therapy tasks. This case highlights that evidence-based approaches can be usefully applied to complex presentations but they may require modifications that recognize obstacles associated with comorbid conditions.     

REBT in Italy: Dissemination and Integration with Constructivism and Metacognition

This paper describes and critically discusses how rational emotive behavior therapy (REBT) spread among Italian cognitive psychotherapists. In the 1980s Cesare De Silvestri, with the help of Carola Schimmelpfennig, Franco Baldini, and Mario Di Pietro, brought REBT to Italy and eagerly disseminated it. In addition, De Silvestri cooperated with the two leading figures in the Italian clinical cognitive movement, Vittorio Guidano and Gianni Liotti. Guidano and Liotti applied the ABC framework to their constructivist version of cognitive therapy. Given that the large majority of Italian cognitive therapists adopted Guidano and Liotti’s approach, they all started applying the ABC framework and are still applying it today. However, Italian therapists adapted the ABC framework to their constructivist training. For example, Guidano and Liotti interpreted the ABC framework as aimed at promoting cognitive and emotional awareness in clients, while they considered the ‘disputing’ phase to be not compatible with the constructivist principles they held. They also encouraged the application of John Bowlby’s ideas to REBT and the use of life experience report techniques in the ABC. Sandra Sassaroli and Roberto Lorenzini applied George Kelly’s “laddering” technique to the ABC framework, a technique more focused on dilemmatic structures than on REBTian dysfunctional thought. Caselli investigated REBT’s influence on Adrian Wells’ metacognitive version of the ABC. Finally, Ruggiero and Ammendola have made a strong call for “back to Ellis”. This implies that any innovation should involve a more stringent and faithful application of REBT principles.     

Repeated checking causes distrust in memory but not in attention and perception

Repeated checking to reduce memory distrust seems to be counterproductive: it increases memory distrust. Obsessive-compulsive (OC) patients tend to be uncertain about other cognitive domains as well, like attention and perception. In an experiment with 70 healthy participants, we tested whether perseverative checking induces distrust not only in memory, but also in attention and perception. Participants were administered a computer task in which they had to activate, deactivate, and check threat-irrelevant stimuli, and rate their confidence in memory, attention, and perception in a pre-test and post-test. In between these tests, the relevant checking group performed 20 checks of the same stimuli used in the pre- and post-test. The irrelevant checking group performed 20 checks of different stimuli. Although memory accuracy improved in both groups, repeated checking reduced confidence in memory, vividness, and detail in the relevant checking group, but not in the irrelevant checking group. A trend was found towards a decline in attentional confidence in the relevant checking group only. Perception was not affected by repetitive checking. A replication study revealed similar results of relevant checking on meta-memory, however, the trend for attentional distrust was not confirmed. The results suggest that perseveration may be domain specific, i.e., only the cognitive processes that are subject to perseveration are affected.     

Attitudes and cognitive distances: On the non-unitary and flexible nature of cognitive maps

Spatial relations of our environment are represented in cognitive maps. These cognitive maps are prone to various distortions (e.g., alignment and hierarchical effects) caused by basic cognitive factors (such as perceptual and conceptual reorganization) but also by affectively loaded and attitudinal influences. Here we show that even differences in attitude towards a single person representing a foreign country (here Barack Obama and the USA) can be related to drastic differences in the cognitive representation of distances concerning that country. Europeans who had a positive attitude towards Obama’s first presidential program estimated distances between US and European cities as being much smaller than did people who were skeptical or negative towards Obama’s ideas. On the basis of this result and existing literature, arguments on the non-unitary and flexible nature of cognitive maps are discussed.     

自闭谱系障碍:一种主动性的社会认知控制缺陷

认知控制是一项高级的认知能力,是个体执行功能的一部分。包括认知控制在内的执行功能缺陷被认为是自闭谱系障碍的主要原因之一。本研究基于双重认知控制模型,通过非社会性和社会性两个领域的任务比较了自闭谱系障碍儿童（ASD）与正常发展儿童（TD）的认知控制能力的差异。结果发现：（1）ASD儿童在非社会性领域的认知控制上不存在缺陷,ASD儿童在社会性领域的认知控制上仅表现出了主动性认知控制缺陷,不存在反应性认知控制缺陷;(２)ASD儿童的主动性控制并不像TD儿童一样出现两个领域的加工分化,他们没有像TD儿童一样,表现出社会性领域的主动性控制的优势;（３）社会性领域的主动性控制和反应性控制可以显著从负正两个方向上预测自闭症状的严重程度。本研究认为,可以把ASD看成是一种主动性的社会认知控制缺陷。社会性领域的认知控制指标可为ASD的诊断与训练提供重要参考。     

On Rationales for Cognitive Values in the Assessment of Scientific Representations

Cognitive values like simplicity, broad scope, and easy handling are properties of a scientific representation that result from the idealization which is involved in the construction of a representation. These properties may facilitate the application of epistemic values to credibility assessments, which provides a rationale for assigning an auxiliary function to cognitive values. In this paper, I defend a further rationale for cognitive values which consists in the assessment of the usefulness of a representation. Usefulness includes the relevance of a representation regarding the investigation of a given problem and its practicability for the users. This rationale builds on the claim that any evaluation of scientific representations should pursue two aims: providing information about their credibility and providing information about their usefulness. Cognitive values relating to the usefulness of a representation and epistemic values relating to its credibility both perform a first-order function. Cognitive values are abstract, and several values with first-order functions may conflict in their application. Thus, in order for cognitive values to account for the sort of problem that is to be investigated by means of a representation, they need to be appropriately specified and weighed. Comprehensiveness, complexity, high resolution, and easy handling, for instance, may be required in a first-order function for model-based prediction of regional climate impacts but not for explaining how the global climate system works. Specifying and weighing cognitive and epistemic values relative to a given problem is a legitimate second-order function of social values.     

Hoarding Disorder and a Systematic Review of Treatment with Cognitive Behavioral Therapy

Until recently, compulsive hoarding has been treated as a type of obsessive-compulsive disorder with mixed results. Little research exists on the efficacy of behavioral interventions specifically designed to treat hoarding disorder, and most existing research is limited with regard to the numbers of participants, their ethnic and cultural diversity, and study replication; therefore, the generalizability of findings is limited. This article reviews the prevalence of hoarding disorder, cognitive behavioral therapy treatment approaches, and measurement of symptoms. A systematic review compares the efficacy of various CBT methods, with particular attention to comparing therapy that is traditionally used to treat OCD with those designed specifically to treat hoarding disorder. Only clinical studies using CBT interventions designed to treat hoarding associated with OCD or hoarding disorder were included. Studies included participants of all ages, and articles were published in peer-reviewed journals. Case studies were excluded. After a comprehensive search and removing duplicates from databases and references, 65 articles were reviewed, of which 12 met criteria for review. Preliminary results demonstrate improvement in hoarding symptoms with CBT interventions that are both for OCD and those designed to specifically treat hoarding disorder; however, when compared to each other, the efficacy of these treatments is inconclusive, thus more research is needed.     

Cognitive-behavioral therapy and decision science

In recent decades cognitive-behavioral therapy (CBT) and decision science (DS) have emerged within the field of psychological science. Though these are two vastly different areas of study, they are similar in that they address human information processing, cognition, behavior, and the link between them. In this article, we provide brief summaries of CBT and decision science, discuss their similarities and differences, and discuss how future research can identify ways in which these fields can inform each other. Several CBT techniques that might be of use to the efforts of the decision science field to prevent cognitive biases are suggested. Research that integrates these two fields may lead to the improvement of both.