Cognitive-behavioral approach - PowerPoint Presentation

1. Cognitive-behavioral approach in medicineMgr. Barbora KóšaPodzim 2020ÚPP LF MU

2. What are common sources of problematic behavior?Go to:Menti.com code 26 76 91 5

3. Core intrapsychic processes

4. Learning: Classical conditioningStimulus  Reaction https://www.youtube.com/watch?v=V09FuazW8bc&ab_channel=Sprouts

5. Learning: Operant conditioningOperant conditioning, is a method of learning that employs rewards and punishments for behavior. Through operant conditioning, an association is made between a behavior and a consequence  P, of behavior to repeat depends on consequencesstimulus reaction consequence

6. Learned helplessnesshttps://www.youtube.com/watch?v=87Vuqvp2V7w

7. Learning: Operant conditioningPOSITIVE REINFORCEMENT4 year old Marie wants to get a cady in supermarket. She screams and lies on the floor to get it. Her mother is embarrased, therefore she buys the candy. Next time, Marie screams at the supermarket again.

8. External event after reactionProbability of behavior emerging againConsequence is presentConsequence is removedPositive reinforcement (REWARD)Negative reinforcement (RELIEF)Positive weakening (PUNISHMENT)Negative reinforcement (REWARD IS MISSING)Learning: Operant conditioning

9. Negative reinforcement:Standa is afraid of having COVID-19, because as he thinks, he would certainly die from it. To make sure he is healthy, he often controls his body temperature. He is always relieved from discovering, he has no symptoms of fever. After short whilis, his anxiety of COVID returns and he is now controlling his temperature more and more often. WHAT IS PROBLEMATIC BEHAVIOR? WHAT REINFORCED IT?Negative weakeningVendula is diabetic and she started her lifestyle change 1 year ago. Since then she attended every appointement with her pratictioner. Her practicioner was very supportive of her behavior, which supported Vendulas‘ commitmet to change. After some time, the practicioner was dedicating less and less time to Vendulas‘ behavior and she seemed to be bored with her. Vendula recently beginned to excercise less and skipping her appointements. WHAT WEAKENED HEALTHY BEHAVIOR?

10. Cofnitive factors in learning

11. Cofnitive factors in learningNot only does stimulus provoke certain behavior, but the meaning it has for a personBehavior can be predicted and understood based on cognitive processesstimulus organism reaction consequence

12. EXCERCISE: Create flexible thoughtsRIGID and EXTREME DEMANDThoughtMeaningFLEXIBLE, non-EXTREME PREFERENCEMeaning---„I want to be successful, therefore I must succeed.“PREFERENCE  DEMAND“I want to be successful but that does not mean I have to be” PREFERENCE  negation of demand

13. AWFULIZINGThoughtMeaningAnti-awfulizingMeaning“I must succeed and if I don't it will be awful” Nothing is worse than not succeeding. Nothing good comes from failure. ??? Worse things could happen. There is smth. good coming from failure.

14. Low frustration toleranceThoughtMeaningHigh frustration tolerance thoughtMeaning“I must succeed and it is unbearable to fail.” In the face of struggle, I will die if the discomfort continues, and I will lose the capacity to experience happiness if the discomfort continues.I will not die if the discomfort continues, and I will not lose the capacity to experience happiness if the discomfort continues.

15. Self-/other-downing ThoughtMeaningSelf-/other- acceptance thoughtMeaning“When I fail, it means that I am an idiot” “When they treat me poorly, it proves they are bad people” “When I fail, it is bad, but does not mean that I am an idiot” “When they treat me poorly it is bad, but does not prove they are bad people”

16. RIGID THOUGHTSCognitive distortions

17. RIGID THOUGHTSCognitive distortions

18. Excercise: can you identify distortions?“I‘ve blown my diet completely“„I have the worst luck in the entire world.“„I feel angry. This proves I‘m treated unfairly.“I just failed that math test. I’m just not good at school, and I might as well quit.““She’s late. It’s raining. She has hydroplaned and her car is upside down in a ditch.“

19. Cognitive restructuring – creating flexibile thoughtsSituation When? Where? Who? What? 2. Emotion Intesity 1-10 3. Automatic thought Persuasiveness 0 – 100%4. Evidence proving thought5. Evidence against thought6. Alternative thoughtPersuasiveness 0-100%7. Emotion nowIntensity 1-10 MENTI.com 26 76 91 5

20. Reasons for cognitive restructuringIncrease awareness of unhelpful thinking styles and contentDeceneter from unhelpful thinking ––>Decentering: thougths loose meaning See them as passing See them as separate from selfLet goFocus on goal-directed activity or thought

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22. Levels of cognitionsCORE BELIEFS global, rigid, overgeneralizeddeveloped in childhood„I am helpless“, „I am unlovable“INTERMEDIATE BELIEFSAttitudes: judgements, „being weak is bad“Rules: shoulds, „I should be able to handle everything“Assumptions: if/then, „If I succeed in school, people will respect me“ AUTOMATIC THOUGTHSSituation specificSurface “I can‘t handle this“, „I am going to fail“

23. Problem solving list of problems: relational, performance, experiential .... Subjective description of symptoms, their evolution, triggers, consequences, related problems ...defining problems with microanalysisgoal setting brainstorming planning realizationevaluation rewards

24. Goal setting to motivate the patientWhat do you want to happen at the end of your treatment?S: specificM: measurableA: attainableR: relevantT: timely

25. Microanalysis of problematic behaviorSituationCognitionEmotionBehaviorBodily signalsConsequenceModifying factors

26. ConsequencesRelationships, work, reputation, health....Short-term positive / negativeLong-term positive / negative

27. Example of problematic behaviorSYMPTOMSEg. Increased heart ratepalpitations(Mis)interpretation„It mus be a heart attack“EmotionIncreased anxiety  Increased symptoms

28. Cognitive behavioral interviewWhen too ambiguos or technical  “What exactly do you mean?“Reflective feedback: to make sure you understandDon‘t use suggestive questions („You were probably scared, right?“ better: „How did you feel in that situation?“)Open ended  more specific questions

29. Cognitive behavioral interviewAvoid starting with „Why...“ (asking for explanation), better: “Who?“, “Where?“, „How often?“ (asking for description)Assure the patient that his problems are commonStrong emotion – be patient, curious, compassionate (What does it mean for the patient? Why is he/she so upset?)

30. Trigger (situation)Thougts....BehaviorBodily signals...EmotionsConsequencesShort-term positive....Long-term positive....Long-term negative.....Short-term negative...

31. Dual processes theoryExperiential system (intuitive 1)Analytic system (2)HolisticEffortful Emotional: Pleasure – Pain Logical: resoning oriented (what is rational?)Associative connectionsLogical connectionsBehavior is influenced by previous emotionsBehavior is influenced by rational judgement of eventsReality is encoded in images, metaphores and narrativesReality is encoded in abstract symbols, words and numbersFast processing: focues on immediate actionSlow processing: focused on postponed actionValid for own person: „experiencing is believing“ Demands support wit logic and evidence

32. Cognitive functionsMental procesess to interpret the world around us, act and reactTo understand behavior of patients in health and ilnessTo understand physicians own thinking and prevent possible mistakesPerception, attention, memory, language, executive function, problem solvingALGORITHMIC / HEURISTIC problem solvingCognitive error – short cuts in problem solving and clinical decision making

33. Heuristicsproblem-solving method  shortcuts to produce good-enough solutionsderived from previous experiences with similar problemsusing readily accessible, though loosely applicable, information problem solving For example, pattern recognition: seeing a patient with grandiose delusions and pressured speech leading to a rapid differential with the most-likely diagnosis being bipolar disorder. + AdvantageReduce cognitive load: time and effort to make reasonably good judgments and decisions. - Disadvantage:Potential to lead to systematic cognitive errors called biases.Acad Med. 2011 Mar;86(3):307-13.

34. Dual Process TheoryRecognitionGestaltHeuristic BiasesNormative reasoningBayesianExhaustive strategyIntuitive/FASTthinkingAnalytical/SLOWthinkingDECISIONScience. 1974;185(4157):1124-1131.

35. THINKING, REASONING, DECIDINGFactors influencing which system is employedTask complexity Expertise

36. Affective heuristicOccurence: Open-ended questions, no intense attention is neededCurrent mood: highly affects reasoningAffective heuristic: relying on emotion concerning object in fast judgementH: People concentrate their attention less on losess than gains when they are in a good moodQuick emotional reactions (concern or safety?) can serve as relevant information (affect as information mechanism).

37. Heuristic or BiasMedical ExampleNon-medical exampleAnchoring is the tendency to lock onto salient features inthe patient’s initial presentation and failing to adjust this initial impression in the light of later information. A patient is admitted from the emergency department with a diagnosis of heart failure. The hospitalists who are taking care of the patient do not pay adequate attention to new findings that suggest another diagnosis. We buy a new car basedon excellent reviews and tend to ignore or downplay negative features that are noticed.

38. Heuristic or BiasMedical ExampleNon-medical exampleAvailability bias refers to our tendency to more easily recall things that we have seen recently or things that are common or that impressed us. A clinician who just recently read an article on the pain from aortic aneurysm dissection may tend toward diagnosing it in the next few patients he sees who present with nonspecific abdominal pain, even though aortic dissections are rare. Because of a recentnews story on a tourist kidnapping in Country “A,” we change the destination we have chosen for our vacation to Country “B.”

39. Heuristic or BiasMedical ExampleNon-medical exampleAnchoring is the tendency to lock onto salient features inthe patient’s initial presentation and failing to adjust this initial impression in the light of later information. A patient is admitted from the emergency department with a diagnosis of heart failure. The hospitalists who are taking care of the patient do not pay adequate attention to new findings that suggest another diagnosis. We buy a new car basedon excellent reviews and tend to ignore or downplay negative features that are noticed. Affective bias refers to the various ways that our emotions, feelings, and biases affect judgment. New complaints from patients known to be “frequent flyers” in the emergency department are not taken seriously. We may have the beliefthat people who are poorly dressed are not articulate or intelligent. Availability bias refers to our tendency to more easily recall things that we have seen recently or things that are common or that impressed us. A clinician who just recently read an article on the pain from aortic aneurysm dissection may tend toward diagnosing it in the next few patients he sees who present with nonspecific abdominal pain, even though aortic dissections are rare. Because of a recentnews story on a tourist kidnapping in Country “A,” we change the destination we have chosen for our vacation to Country “B.”

40. Heuristic or BiasMedical ExampleNon-medical exampleContext errors reflect instances where we misinterpret the situation, leading to an erroneous conclusion. We tend to interpret thata patient presenting with abdominal pain has a problem involving the gastrointestinal tract, when it may be something else entirely: for example, an endocrine, neurologic or vascular problem. We see a work colleague picking up two kids from an elementary schooland assume he or she has children, when they are instead picking up someone else’s children. Search satisficing, also known as premature closure, is the tendency to accept the first answer that comes along that explains the facts at hand, without considering whether there might be a different or better solution. The emergency department clinician seeing a patient with recent onset of low back pain immediately settles on a diagnosis of lumbar disc disease without considering other possibilities in the differential diagnosis. We want a plane ticket that costs no more than $1,000 and has no more than one connection. We perform an online search and purchase the first ticket that meets these criteria without looking to see if there is a cheaper flight or one with no connections.

41. Thank you for attentionSuggested study materials: Croskerry P. (2002). Achieving quality in clinical decision making: cognitive strategies and detection of bias. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 9(11), 1184–1204.Howard, J. (2018). Cognitive Errors and Diagnostic Mistakes. Springer Berlin Heidelberg.Mandatory study materials:Chapters from Psychology in medicine