289 What is cognitive behavioural therapy and does it work? Commentary Steven d Hollon Addresses Department 37240, of Psychology, USA; Current Vanderbilt University, Nashville, Tennessee e-mail: [email protected] Opinion in Neurobiology 1998, 8:289-292 http:/lbiomednet.com/elecref/O959438800800289 0 Current Biology Ltd ISSN and observing the consequences, neither die nor go crazy. In both Cognitive behavioural therapy is an approach to treatment based on the notion that the way an individual thinks about an event determines in part how he or she responds to that event, both in terms of affect and behaviour [l]. According to cognitive theory, dysfunctional beliefs and maladaptive information processing lie at the core of many psychiatric disorders. In cognitive behavioural therapy, the therapist helps the patient learn to identify and correct erroneous beliefs and systematic distortions in information processing in the service of reducing distress and enhancing efforts to cope. Although there are several different variations of the approach, they all share the same basic characteristic [Z]. In essence, patients are encouraged to treat their beliefs as hypotheses to be tested and are guided to do so in ways that protect against the biases and distortions that preserve the idiosyncratic misconceptions inherent in each disorder. The approach is closely tied to experimental cognitive science, which suggests that information processes tend to be dominated by strategies and heuristics that are unduly conservative in nature and structured to maintain existing beliefs, even in the absence of motivation . What this means is that patients often suffer as a consequence of their misperceptions without having any underlying motivation for doing so or for maintaining those beliefs, than that they dire possibility leads to a state of panic, which patients then take as confirmation of their initial belief. Rather than avoiding situations in which this process patients are encouraged to test these catastrophic by engaging in activities that exacerbate their 0959-4388 Introduction other Similarly, patients with panic disorder tend to misinterpret normal arousal as an indication that they are about to have a heart attack or go crazy. Entertaining such a fear they might be true. overwhelmed by their magnitude) and to test their negative beliefs by engaging in the requisite behaviours, carefully monitoring the outcome of each step and its impact on their mood. which is that they instances, the role of the therapist is to encourage patients to identify and test their own beliefs, subjecting them to a process of empirical scrutiny, much the same way that scientists test hypotheses. Just as science has had to rely on empirical observation and controlled experimentation to overcome existing prejudices and preconceived notions, so too can patients make observations in a structured fashion and engage in behaviours that are inconsistent with existing notions to overcome the conservatism inherent in any existing belief In general, system. cognitive behavioural therapy has typically been found to be at least as effective as more traditional psychotherapies or drugs for most nonpsychotic disorders and quite often longer lasting. For many of these disorders, it has emerged as the treatment of choice, and there are clear indications that its effects transcend the nonspecific benefits provided by more traditional interventions. Medications remain the treatment of choice for psychotic disorders, but there are growing indications that cognitive behavioural interventions may have an important role to play. Specific disorders Unipolar depression Few disorders have searchers For example, depressed patients tend to magnify the magnitude of the difficulties they face and typically believe that they are not competent to accomplish cherished goals or enjoy the fruits of their labours if they do. As a consequence, they fail to initiate goal-directed behaviours (not because they do not want to succeed but because they believe they will not) and then interpret their subsequent lack of success as evidence of their own incompetence. In essence, they fall prey to self-fulfilling prophecies. Such patients are encouraged to break larger tasks into their specific components (to forestall being occurs, beliefs arousal interested received in cognitive more attention from rebehavioural therapy than depression, with Beck’s cognitive therapy [l] the modality most often studied. Beck has long argued that depression can be viewed as a consequence of negative beliefs about the self, the personal world, and the future (the negative cognitive triad). The sadness and behavioural passivity that are the hallmarks of the disorder are seen as the direct consequences of the expectation that one will not get what one wants out of life, which itself is seen as the logical consequence of the tendency to see oneself as unlovable or incompetent. Thinking is viewed as being schematic in nature; that is, beliefs are organized into meaning systems that govern information processing under conditions of uncertainty. These meaning systems range in depth from specific beliefs in specific situations (automatic thoughts) through more general probabilistic statements 290 Commentary of relationship (dysfunctional attitudes and conditional assumptions) to rigid and absolutistic trait theories about the self and others (core beliefs). These schemas operate as latent diatheses that are only activated under conditions of stress in more episodic disorders, but can also represent hypervalent constructs that are always in operation in more chronic disorders. Cognitive therapy has been found to be at least as effective as drugs in the treatment of unipolar depression and is possibly longer lasting . Beginning with the classic study of Rush etal: [S], cognitive therapy has either matched or bettered drugs with respect to the relief of acute distress in a series of direct comparisons in a number of different studies . Moreover, in most of these studies, patients treated to remission with cognitive therapy were about half as likely to relapse following treatment termination as patients treated to remission pharmacologically [9-121. However, few of these studies were placebo-controlled and the adequacy of the medication treatment provided has been called into question. The recent National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDCRP) did provide such a pill-placebo control and cognitive therapy was less effective found than evidence that drugs for more severely depressed outpatients [13,14]. Nonetheless, this finding was not robust across the multiple sites in the TDCRP [l&16]. Several studies are currently under way to compare the efficacy of drugs and cognitive therapy in more severely depressed groups of patients. Panic disorder Recent studies also suggest that cognitive behavioural therapy may be particularly effective and have an enduring effect in the treatment of panic disorder. As previously described, cognitive theory suggests that it is the catastrophic misinterpretation of relatively benign bodily sensations that triggers the firing of the locus coeruleus in the brain stem and gives rise to the experience of panic [17,18]. That is, panic attacks occur when the individual misconstrues some transient physiological sensation as a sign of an impending heart attack (or stroke) or psychotic decompensation. Clark and colleagues (see [l&19]) at Oxford have done some of the seminal work in this area. In a carefully controlled trial, cognitive therapy was found to be superior to either applied relaxation or drugs in the treatment of panic disorder, which were, in turn, superior to a minimum-treatment control . Moreover, as has been the case for depression, patients treated with cognitive therapy were far less likely to relapse following treatment termination than those patients treated with drugs alone. Similarly, Beck et al. [ZO] found cognitive therapy superior to a nonspecific control, and Barlow and colleagues [Zl-231 have impressive results with a closely related cognitive behavioural intervention called panic control therapy. Generalized anxiety disorder Generalized anxiety disorder is yet another disorder in which cognitive therapy appears to be particularly effective. In generalized anxiety disorder, patients experience high levels of persistent and pervasive distress across a variety of situations. This disorder has always presented something of a problem to more conventional behavioural therapy (based on exposure or counter conditioning) because there is often no clear external precipitant to which anxiety can be extinguished. Butler et al.  at Oxford found an approach modelled after Beck’s cognitive therapy both superior to and more enduring than either behaviour therapy or a wait-list control. Similarly, Power et a/. [25,26] intervention have both found a related cognitive superior to and longer behavioural lasting than minor tranquilizers. These studies suggest that cognitive behavioural therapy is both more effective and longer lasting than either behaviour therapy or drugs in the treatment of generalized anxiety disorder. Social phobia The picture is not so clear with respect to social phobia, but still quite promising. Social phobia involves persistent fears of being embarrassed in front of others and leads patients to avoid normal social interactions such as speaking or eating in public. Some of the best work in this regard has been done by Heimberg and colleagues (see [27-29]), who have adapted a cognitive behavioural intervention to deal with unrealistic concerns about being negatively evaluated by others in a group context . In a series of studies, cognitive behavioural therapy was found to be more effective than supportive therapy [Z&29] and as effective as, and quite possibly longer lasting than, phenelzine in the treatment of social phobia (RG Heimberg, personal communication). Recently, Clark (DM Clark, personal communication) and colleagues have begun to turn their attention to adapting Beck’s cognitive therapy to the treatment of social phobia. Just how fruitful these efforts will prove remains to be seen, success with panic disorder is any indication, prove quite interesting. but if their they should Bulimia nervosa and the eating disorders Bulimia nervosa is yet another area in which cognitive behavioural therapy has emerged as the treatment of choice . In this disorder, patients engage in periodic binge eating, often followed by purge by vomiting or laxative abuse. There is a growing consensus that overvalued beliefs about weight and shape lead to restrictive dieting, which, in turn, leads to loss-of-control binge eating when those overly strict rules are violated. Fairburn etal. [31,32] at Oxford found cognitive behavioural therapy somewhat more effective and at least as long-lasting as interpersonal psychotherapy and no less effective and longer lasting than behaviour therapy in the treatment of bulimia. Similarly, Agras and colleagues [30,33] at Stanford have found cognitive behavioural therapy at least as effective and longer lasting than drugs in a series of studies. These findings suggest that no other intervention is as effective as What is cognitive behavioural therapy and does it work? Hollon cognitive behavioural and freedom Personality Patients therapy from relapse and impulse with borderline when are taken control both initial response disorders personality disorder are noto- riously difficult to treat. They frequently engage in parasuicidal behaviours and self-mutilation and tend to have stormy relationships with others, including their therapists. Linehan  has developed an approach to treatment called dialectic behaviour therapy that is based on the premise that an inability to tolerate strong states of negative affect is central to the disorder. In dialectic behaviour therapy, the patient is taught to use behavioural and cognitive skills to deal with this distress without engaging in self-destructive behaviours. In the only controlled trial to date in this population, Linehan et (I/.  found that patients treated with dialectic behaviour therapy engaged in fewer suicidal or self-destructive behaviours and required fewer days of hospitalization than patients who received treatment-as-usual in the community. Given how difficult these patients are to treat, this study has generated tremendous interest in the larger treatment community, even prior to replication. Virtually nothing is known about the ocher personality disorders. However, Beck and Freeman  have recently extended cognitive therapy for just this purpose, noting that those pervasive pathological behaviours that typically define the respective disorders can be viewed as compensatory strategies designed to protect the individual from the interpersonal consequences of his or her erroneous beliefs. While it is still too early to know whether these theoretical extensions will be of use clinically, they do appear to make better sense out of a particularly vexing and refractory set of disorders. Similar work under way with other impulse control disorders, such as substance abuse, also appears promising. Schizophrenia and the psychotic Conclusions There is considerable therapy is effective disorders. The body into account. disorders lore holds that the delusions found among schizophrenic and other psychotic patients are largely impervious to empirical disconfirmation. However, recent studies have suggested that cognitive interventions aimed at reducing the conviction with which these beliefs are respect viewed effect patient [37,38]. directly Care with the treatment of choice for a number of nonpsychotic disorders, often proving more effective than alternative interventions and typically longer lasting. That a relatively brief intervention can produce lasting change in such long-standing and severe emotional disorders is truly remarkable and suggest-s that it may directly address underlying etiological processes. Indications are not so clear with the personality disorders and problems with impulse control such as substance abuse, but initial findings are promising. Finally, there are indications that it may be of use in the treatment of schizophrenia and the other psychotic disorders, albeit largely as an adjunct to medications. Cognitive theorists have long looked to the emerging principles of cognitive neurobiology to understand the etiologies of the disorders they treat and to shape the clinical strategies they try to apply. It appears that these interventions represent a valuable addition to the clinical armamentarium. Acknowledgements ‘I‘he author expresses his appreciation to David M Clark for his helpful comments on an earlier draft of this manuscript. Preparation of this article was supported by a National Institute of Mental Health grant (MH-55875) tO the author. References 1. Beck AT: Cognitive therapy: a 30-year Psycho/ 1991, 46:368-375. 2. Hollon SD, Beck AT: Cognitive and cognitive-behaviour therapies. In Handbook of Psychotherapy and Behavior Change: An Empirical Analysis, edn 4. Edited by Bergin AE, Garfield SL. New York: Wiley; 1994:428-466. 3. Hollon SD, Garber J: Cognitive therapy of depression: a socialcognitive perspective. Pers Sot Psycho/ Bull 1990, 16:58-73. 4. Hollon SD, Shelton RC, Loosen PT: Cognitive therapy and pharmacotherapy for depression. J Consult C/in Psycho/ 1991, 59:88-99. 5. Rush AJ, Beck AT, Kovacs M, Hollon SD: Comparative efficacy of cognitive therapy and pharmacotherapy in the treatment of depressed outpatients. Cogn Ther Res 1977, 1 :17-38. 6. Blackburn IM, Bishop S, Glen AIM, Whalley LJ, Christie JE: The efficacy of cognitive therapy in depression: a treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. Br I Psychiatry 1981, 139:181-l 89. 7. Murphy GE, Simons AD, Wetzel RD, Lustman PJ: Cognitive therapy and pharmacotherapy, singly and together, in the treatment of depression. Arch Gen Psychiatry 1984, 41:33-41. 0. Hollon SD, DeRubeis RJ, Evans MD, Wiemer MJ, Garvey MJ, Grove WM, Tuason VB: Cognitive therapy and pharmacotherapy for depression: singly and in combination. Arch Gen Psychiatry 1992, 49:774-781, 9. Kovacs M, Rush AJ, Beck AT, Hollon SD: Depressed treated with cognitive therapy or pharmacotherapy: follow-up. Arch Gen Psychiatry 1981, 38:33-39. 10. Blackburn IM, Eunson KM, Bishop S: A two-year naturalistic follow-up of depressed patients treated with cognitive therapy, pharmacotherapy and a combination of both. J Affect Disord 1986, 10:67-75. to the delusional belief. Rather, the delusion is as an effort to make sense out of problematic or puzzling life-experiences. The patient is encouraged to treat his or her delusion as one possible explanation for those experiences, but to consider others as well, and to contrast the accuracy and plausibility of each. Using this approach, a number of investigators have separately reported a diminution in the conviction with which the delusion was held [39-44]. 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