Cognitive

Behaviour
Therapy
BASICS
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LET US LEARN CBT
THROUGH A CASE
STUDY
• NAME : RAJU
• AGE : 35 YEARS WITH NO MEDICAL PROBLEMS
• PROBLEM : PANIC DISORDER WITH AGORAPHOBIA.
• WORKS AT A COMPANY IN A SEMI URBAN AREA
• HE WORKS IN A CUBICLE WITHOUT ANY
HUMAN CONTACT FOR HOURS.
• FATHER NO MORE AND MOTHER 70 YEARS OLD
• GOT TRANSFER TO CITY 5 YEARS BEFORE, BUT DID
NOT JOIN
• ELDER BROTHER MET WITH ACCIDENT
• He had been symptomatic for at least 5 years
• His condition had deteriorated to the point where he was largely
housebound,
• When Mr. Raju considered driving to the city to see an old friend or
to a mall near his home, he gets thoughts such as
• “I can’t do it . . .
• I’ll faint or
• I’ll have a heart attack . . .
• I’ll panic and lose control . . . I’ll have a wreck and kill everyone in
my path, Police will arrest me, Police will hit me ,
• I am worthless”
 As might be expected, he had intense anxiety and
autonomic arousal associated with these thoughts. His
behavioral response was to avoid driving anywhere other
than work and to avoid going anywhere there might be
crowds. Each time he avoided these activities, his basic fears
were reinforced, and eventually his symptoms became
deeply ingrained.
Agoraphobia is diagnosed based on
symptoms and signs.
DSM-5 Criteria-Panic Attack1
An abrupt surge of intense fear or intense
discomfort that reaches a peak within
minutes and during which time four or more
of the following symptoms occur.
• Palpitations, pounding heart, or
accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath
or smothering
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady,
lightheaded, or faint
• Derealization (feelings of
unreality) or depersonalization
(being detached from oneself)
• Fear of losing control or “going
crazy”
• Fear of dying
• Paresthesias (numbness or tingling
sensation)
• Chills or hot flushes.
Agoraphobia AS PER DSM-V
 • A marked fear or anxiety about two (or more) of the following
five situations:
• Using public transportation
• Being in open spaces
• Being in enclosed spaces (e.g., shops, theaters, cinemas)
• Standing in line or being in a crowd
• Being outside the home alone.

The situations are avoided (e.g., travel is restricted) or else are endured with marked
distress or with anxiety about having a panic attack or panic-like symptoms, or require the
presence of a companion.
The agoraphobic situations almost always
provoke fear or anxiety.
The fear or anxiety is out of proportion to
the actual danger posed by the agoraphobic
situations and to the sociocultural context.
The fear, anxiety, or avoidance is persistent,
typically lasting 6 months or more.
The fear, anxiety, or avoidance causes
clinically significant distress or impairment
in important areas of functioning
The anxiety or phobic avoidance is not
better accounted for by another mental
disorder.
The individual fears or avoids these
situations because of thoughts that escape
might be difficult or help might not be
available in the event of developing panic-
like symptoms or other incapacitating or
embarrassing symptoms.
If an associated general medical condition
is present, the fear described in Criterion A
is clearly in excess of that usually
associated with the condition.
 PEOPLE WITH AGORAPHOBIA ARE TYPICALLY:

• afraid of leaving their home for extended periods of time

• afraid of being alone in the social situation
• afraid of losing control in a public place
• afraid of being in places where it would be difficult to
escape, such as a car or elevator
• detached or estranged from others
• anxious or agitated
 PANIC DISORDER AND AGORAPHOBIA
Some people have panic disorder in addition to agoraphobia. Panic
disorder is a type of anxiety disorder that includes panic attacks. A
panic attack is a sudden feeling of extreme fear that reaches a peak
within a few minutes and triggers a variety of intense physical
symptoms. You might think that you're totally losing control, having a
heart attack or even dying.
 SYMPTOMS OF A PANIC ATTACK
PHYSICAL SYMPTOMS
chest pain CAN INCLUDE:
a racing heart
shortness of breath Rapid heart rate.
dizziness Trouble breathing or a feeling of choking.
trembling Chest pain or pressure.
choking Lightheadedness or dizziness.
sweating Feeling shaky, numb or tingling.
hot flashes Sweating too much.
chills Sudden flushing or chills.
nausea
Upset stomach or diarrhea.
diarrhea
Feeling a loss of control.
numbness
Fear of dying.
tingling sensations
 BEHAVIOURA MOTIVATION AFFECTIV
L E

SYMPTOMS

COGNITIVE SOMATIC PHYSICAL

THE PHYSICAL SYMPTOMS
• rapid heartbeat
• rapid breathing (hyperventilating)
• feeling hot and sweaty
• feeling sick
• chest pain
• difficulty swallowing (dysphagia)
• diarrhoea
• trembling
• dizziness
• ringing in the ears (tinnitus)
• feeling faint
 COGNITIVE SYMPTOMS MAY INCLUDE FEAR THAT:

• a panic attack will make you look stupid or feel embarrassed in front of other people
• a panic attack will be life threatening – for example, you may be worried your heart will
stop or you'll be unable to breathe
• you would be unable to escape from a place or situation if you were to have a panic attack
• you're losing your sanity
• you may lose control in public
• you may tremble and blush in front of people
• people may stare at you
PSYCHOLOGICAL SYMPTOMS THAT AREN'T RELATED TO
PANIC ATTACKS, SUCH AS:

• feeling you would be unable to function or survive without the help

of others
• a fear of being left alone in your house (monophobia)
• a general feeling of anxiety or dread
 BEHAVIOURAL SYMPTOMS
• avoiding situations that could lead to panic attacks, such as crowded
places, public transport and queues
• being housebound – not being able to leave the house for long periods
of time
• needing to be with someone you trust when going anywhere
• avoiding being far away from home
CBT USES ` CBT MODEL'
INDEPENDANT THERAPY
 The assessment centers primarily on
cognitive and behavioral observations, but
biological, interpersonal, social, spiritual,
and other factors are also considered.
CBT is based on an ever-evolving formulation
of patients’ problems and an individual
conceptualization of each patient in cognitive
terms
 Cognitive-behavioral therapy doesn’t use a “one size fits
all” approach. Every patient is different, which is why
their needs vary. The most significant principle of CBT is
the strong focus on the conceptualization of a patient. In
other words, therapist strives to formulate and
understand patients’ problems first before they
recommend more specific techniques.
CBT NEEDS A STRONG THERAPEUTIC
ALLIANCE
CBT EMPHASIZES COLLABORATION
AND ACTIVE PARTICIPATION
CBT IS GOAL-ORIENTED AND PROBLEM-
FOCUSED
CBT PRIORITIZES THE PRESENT AT FIRST
CBT EMPHASIZES RELAPSE PREVENTION, AIMS
TO EDUCATE THE PATIENT TO BE THEIR OWN
THERAPIST, AND IS EDUCATIONAL

PSYCHO-EDUCATION
 CBT TEACHES PATIENTS HOW TO
RECOGNIZE, ASSESS, AND DEAL WITH
DYSFUNCTIONAL BELIEFS AND
THOUGHTS
CBT AIMS TO BE TIME-LIMITED
CBT SESSIONS ARE STRUCTURED
• Introduction: doing a mood check, a brief review of the
week, collaboratively setting an agenda for the session

• Middle: reviewing homework, discussing problems on

the agenda, setting new homework, and summarizing

• Final: eliciting feedback

 CBT USES A VARIETY OF TECHNIQUES TO
CHANGE THINKING, MOOD, AND BEHAVIOR