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词条 Cognitive behavioral therapy
释义

  1. Description

     Cognitive distortions  Skills  Phases in therapy  Delivery protocols  Related techniques 

  2. Medical uses

      Anxiety disorders    Schizophrenia, psychosis and mood disorders    With older adults   Prevention of mental illness    Gambling addiction    Smoking cessation    Eating disorders    Internet addiction  

  3. History

      Philosophical roots    Behavior therapy roots    Cognitive therapy roots    Behavior and cognitive therapies merge - "third wave" CBT  

  4. Methods of access

      Therapist    {{anchor|Computerized}} Computerized or Internet-delivered    Smartphone app-delivered    Reading self-help materials    Group educational course  

  5. Types

      BCBT    Cognitive emotional behavioral therapy    Structured cognitive behavioral training    {{anchor|MRT}}Moral reconation therapy    Stress inoculation training    Mindfulness-based cognitive behavioral hypnotherapy    Unified Protocol  

  6. Criticisms

     Relative effectiveness  Declining effectiveness  High drop-out rates  Philosophical concerns with CBT methods  Side effects 

  7. Society and culture

  8. See also

  9. References

  10. Further reading

  11. External links

{{Redirect|Cognitive Behaviour Therapy |the peer-reviewed journal|Cognitive Behaviour Therapy (journal)}}{{Infobox medical intervention |name=Cognitive Behavioral Therapy|image=Depicting_basic_tenets_of_CBT.jpg|caption=The diagram depicts how emotions, thoughts, and behaviors all influence each other. The triangle in the middle represents CBT's tenet that all humans' core beliefs can be summed up in three categories: self, others, future.|ICD10=|ICD9=|MeshID=D015928|OPS301=|other_codes=|HCPCSlevel2=}}Cognitive behavioral therapy (CBT) is a psycho-social intervention[1][1] that aims to improve mental health.[2] CBT focuses on challenging and changing unhelpful cognitive distortions (e.g. thoughts, beliefs, and attitudes) and behaviors, improving emotional regulation,[1][3] and the development of personal coping strategies that target solving current problems. Originally, it was designed to treat depression, but its use has been expanded to include treatment of a number of mental health conditions, including anxiety.[4][5]

The CBT model is based on the combination of the basic principles from behavioral and cognitive psychology.[1] It is different from historical approaches to psychotherapy, such as the psychoanalytic approach where the therapist looks for the unconscious meaning behind the behaviors and then formulates a diagnosis. Instead, CBT is a "problem-focused" and "action-oriented" form of therapy, meaning it is used to treat specific problems related to a diagnosed mental disorder. The therapist's role is to assist the client in finding and practicing effective strategies to address the identified goals and decrease symptoms of the disorder.[6] CBT is based on the belief that thought distortions and maladaptive behaviors play a role in the development and maintenance of psychological disorders,[2] and that symptoms and associated distress can be reduced by teaching new information-processing skills and coping mechanisms.[1][6][7]

When compared to psychoactive medications, review studies have found CBT alone to be as effective for treating less severe forms of depression and anxiety, posttraumatic stress disorder (PTSD), tics, substance abuse, eating disorders and borderline personality disorder. It is often recommended in combination with medications for treating other conditions, such as severe obsessive compulsive disorder (OCD) and major depressive disorder, opioid use disorder, bipolar disorder and psychotic disorders.[1] In addition, CBT is recommended as the first line of treatment for majority of psychological disorders in children and adolescents, including aggression and conduct disorder.[1][3] Researchers have found that other bona fide therapeutic interventions were equally effective for treating certain conditions in adults.[8][9] Along with interpersonal psychotherapy (IPT), CBT is recommended in treatment guidelines as a psychosocial treatment of choice,[1][10] and CBT and IPT are the only psychosocial interventions that psychiatry residents are mandated to be trained in.[11]

Description

Mainstream cognitive behavioral therapy assumes that changing maladaptive thinking leads to change in behavior and affect,[12] but recent variants emphasize changes in one's relationship to maladaptive thinking rather than changes in thinking itself.[13] The goal of cognitive behavioral therapy is not to diagnose a person with a particular disease, but to look at the person as a whole and decide what can be altered.

Cognitive distortions

Therapists or computer-based programs use CBT techniques to help people challenge their patterns and beliefs and replace errors in thinking, known as cognitive distortions, such as "overgeneralizing, magnifying negatives, minimizing positives and catastrophizing" with "more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behavior".[12] Cognitive distortions can be either a pseudo-discrimination belief or an over-generalization of something.[14] CBT techniques may also be used to help individuals take a more open, mindful, and aware posture toward cognitive distortions so as to diminish their impact.[13]

Skills

Mainstream CBT helps individuals replace "maladaptive... coping skills, cognitions, emotions and behaviors with more adaptive ones",[15] by challenging an individual's way of thinking and the way that they react to certain habits or behaviors,[16] but there is still controversy about the degree to which these traditional cognitive elements account for the effects seen with CBT over and above the earlier behavioral elements such as exposure and skills training.[17]

Phases in therapy

CBT can be seen as having six phases:[15]

  1. Assessment or psychological assessment;
  2. Reconceptualization;
  3. Skills acquisition;
  4. Skills consolidation and application training;
  5. Generalization and maintenance;
  6. Post-treatment assessment follow-up.

These steps are based on a system created by Kanfer and Saslow.[18] After identifying the behaviors that need changing, whether they be in excess or deficit, and treatment has occurred, the psychologist must identify whether or not the intervention succeeded. For example, "If the goal was to decrease the behavior, then there should be a decrease relative to the baseline. If the critical behavior remains at or above the baseline, then the intervention has failed."[18]

The steps in the assessment phase include:

Step 1: Identify critical behaviors

Step 2: Determine whether critical behaviors are excesses or deficits

Step 3: Evaluate critical behaviors for frequency, duration, or intensity (obtain a baseline)

Step 4: If excess, attempt to decrease frequency, duration, or intensity of behaviors; if deficits, attempt to increase behaviors.[19]

The re-conceptualization phase makes up much of the "cognitive" portion of CBT.[15] A summary of modern CBT approaches is given by Hofmann.[20]

Delivery protocols

There are different protocols for delivering cognitive behavioral therapy, with important similarities among them.[21] Use of the term CBT may refer to different interventions, including "self-instructions (e.g. distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (e.g. minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting".[15] Treatment is sometimes manualized, with brief, direct, and time-limited treatments for individual psychological disorders that are specific technique-driven. CBT is used in both individual and group settings, and the techniques are often adapted for self-help applications. Some clinicians and researchers are cognitively oriented (e.g. cognitive restructuring), while others are more behaviorally oriented (e.g. in vivo exposure therapy). Interventions such as imaginal exposure therapy combine both approaches.[22][23]

Related techniques

CBT may be delivered in conjunction with a variety of diverse but related techniques such as exposure therapy, stress inoculation, cognitive processing therapy, cognitive therapy, relaxation training, dialectical behavior therapy, and acceptance and commitment therapy.[24][25] Some practitioners promote a form of mindful cognitive therapy which includes a greater emphasis on self-awareness as part of the therapeutic process.[26]

Medical uses

In adults, CBT has been shown to have effectiveness and a role in the treatment plans for anxiety disorders,[27][44] body dysmorphic disorder,[28] depression,[29][47] eating disorders,[30] chronic low back pain,[15] personality disorders,[31] psychosis,[32] schizophrenia,[33] substance use disorders,[34] in the adjustment, depression, and anxiety associated with fibromyalgia,[12] and with post-spinal cord injuries.[35]

In children or adolescents, CBT is an effective part of treatment plans for anxiety disorders,[36] body dysmorphic disorder,[37] depression and suicidality,[38] eating disorders and obesity,[39] obsessive–compulsive disorder (OCD),[40] and posttraumatic stress disorder,[41] as well as tic disorders, trichotillomania, and other repetitive behavior disorders.[42] CBT-SP, an adaptation of CBT for suicide prevention (SP), was specifically designed for treating youths who are severely depressed and who have recently attempted suicide within the past 90 days, and was found to be effective, feasible, and acceptable.[43] CBT has also been shown to be effective for posttraumatic stress disorder in very young children (3 to 6 years of age).[44] CBT has also been applied to a variety of childhood disorders,[45] including depressive disorders and various anxiety disorders.

CBT combined with hypnosis and distraction reduces self-reported pain in children.[46]

Cochrane reviews have found no evidence that CBT is effective for tinnitus, although there appears to be an effect on management of associated depression and quality of life in this condition.[47] Other recent Cochrane Reviews found no convincing evidence that CBT training helps foster care providers manage difficult behaviors in the youths under their care,[48] nor was it helpful in treating people who abuse their intimate partners.[49]

According to a 2004 review by INSERM of three methods, cognitive behavioral therapy was either "proven" or "presumed" to be an effective therapy on several specific mental disorders.[50] According to the study, CBT was effective at treating schizophrenia, depression, bipolar disorder, panic disorder, post-traumatic stress, anxiety disorders, bulimia, anorexia, personality disorders and alcohol dependency.[50]

Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression.[51][52]

Computerized CBT (CCBT) has been proven to be effective by randomized controlled and other trials in treating depression and anxiety disorders,[53][54][76][55][56][57][58] including children,[59] as well as insomnia.[60] Some research has found similar effectiveness to an intervention of informational websites and weekly telephone calls.[61][62] CCBT was found to be equally effective as face-to-face CBT in adolescent anxiety[63] and insomnia.[60] Sparx is a video game to help young persons, using the CBT method to teach them how to resolve their own issues.

Criticism of CBT sometimes focuses on implementations (such as the UK IAPT) which may result initially in low quality therapy being offered by poorly trained practitioners.[64][65] However, evidence supports the effectiveness of CBT for anxiety and depression.[56] Acceptance and commitment therapy (ACT) is a specialist branch of CBT (sometimes referred to as contextual CBT[66]). ACT uses mindfulness and acceptance interventions and has been found to have a greater longevity in therapeutic outcomes. In a study with anxiety, CBT and ACT improved similarly across all outcomes from pre-to post-treatment. However, during a 12-month follow-up, ACT proved to be more effective, showing that it is a highly viable lasting treatment model for anxiety disorders.[67]

Evidence suggests that the addition of hypnotherapy as an adjunct to CBT improves treatment efficacy for a variety of clinical issues.[68][69][70]

CBT has been applied in both clinical and non-clinical environments to treat disorders such as personality conditions and behavioral problems.[71] A systematic review of CBT in depression and anxiety disorders concluded that "CBT delivered in primary care, especially including computer- or Internet-based self-help programs, is potentially more effective than usual care and could be delivered effectively by primary care therapists."[72]

Emerging evidence suggests a possible role for CBT in the treatment of attention deficit hyperactivity disorder (ADHD);[73] hypochondriasis;[74] coping with the impact of multiple sclerosis;[75] sleep disturbances related to aging;[76] dysmenorrhea;[77] and bipolar disorder,[78] but more study is needed and results should be interpreted with caution. CBT can have a therapeutic effects on easing symptoms of anxiety and depression in people with Alzheimer's disease.[79] CBT has been studied as an aid in the treatment of anxiety associated with stuttering. Initial studies have shown CBT to be effective in reducing social anxiety in adults who stutter,[80] but not in reducing stuttering frequency.[81][82]

In the case of people with metastatic breast cancer, data is limited but CBT and other psychosocial interventions might help with psychological outcomes and pain management.[83]

There is some evidence that CBT is superior in the long-term to benzodiazepines and the nonbenzodiazepines in the treatment and management of insomnia.[84] CBT has been shown to be moderately effective for treating chronic fatigue syndrome.[85]

In the United Kingdom, the National Institute for Health and Care Excellence (NICE) recommends CBT in the treatment plans for a number of mental health difficulties, including posttraumatic stress disorder, obsessive–compulsive disorder (OCD), bulimia nervosa, and clinical depression.[86]

Anxiety disorders

CBT has been shown to be effective in the treatment of adults with anxiety disorders.[87]

A basic concept in some CBT treatments used in anxiety disorders is in vivo exposure. The term refers to the direct confrontation of feared objects, activities, or situations by a patient. For example, a woman with PTSD who fears the location where she was assaulted may be assisted by her therapist in going to that location and directly confronting those fears.[88] Likewise, a person with social anxiety disorder who fears public speaking may be instructed to directly confront those fears by giving a speech.[89] This "two-factor" model is often credited to O. Hobart Mowrer.[90] Through exposure to the stimulus, this harmful conditioning can be "unlearned" (referred to as extinction and habituation). Studies have provided evidence that when examining animals and humans that glucocorticoids may possibly lead to a more successful extinction learning during exposure therapy. For instance, glucocorticoids can prevent aversive learning episodes from being retrieved and heighten reinforcement of memory traces creating a non-fearful reaction in feared situations. A combination of glucocorticoids and exposure therapy may be a better improved treatment for treating patients with anxiety disorders.[91]

A 2015 Cochrane review also found that CBT might be helpful for patients with non-cardiac chest pain, and may reduce frequency of chest pain episodes.[92]

Schizophrenia, psychosis and mood disorders

{{See also|cognitive therapy|Beck's cognitive triad|cognitive distortions}}

Cognitive behavioral therapy has been shown as an effective treatment for clinical depression.[29] The American Psychiatric Association Practice Guidelines (April 2000) indicated that, among psychotherapeutic approaches, cognitive behavioral therapy and interpersonal psychotherapy had the best-documented efficacy for treatment of major depressive disorder.[93]{{page needed|date = April 2013}} One etiological theory of depression is Aaron T. Beck's cognitive theory of depression. His theory states that depressed people think the way they do because their thinking is biased towards negative interpretations. According to this theory, depressed people acquire a negative schema of the world in childhood and adolescence as an effect of stressful life events, and the negative schema is activated later in life when the person encounters similar situations.[94]

Beck also described a negative cognitive triad. The cognitive triad is made up of the depressed individual's negative evaluations of themselves, the world, and the future. Beck suggested that these negative evaluations derive from the negative schemata and cognitive biases of the person. According to this theory, depressed people have views such as "I never do a good job", "It is impossible to have a good day", and "things will never get better". A negative schema helps give rise to the cognitive bias, and the cognitive bias helps fuel the negative schema. Beck further proposed that depressed people often have the following cognitive biases: arbitrary inference, selective abstraction, over-generalization, magnification, and minimization. These cognitive biases are quick to make negative, generalized, and personal inferences of the self, thus fueling the negative schema.[94]

In long-term psychoses, CBT is used to complement medication and is adapted to meet individual needs. Interventions particularly related to these conditions include exploring reality testing, changing delusions and hallucinations, examining factors which precipitate relapse, and managing relapses.[32] Several meta-analyses suggested that CBT is effective in schizophrenia,[33][95] and the American Psychiatric Association includes CBT in its schizophrenia guideline as an evidence-based treatment. There is also limited evidence of effectiveness for CBT in bipolar disorder[78][96] and severe depression.[97]

A 2010 meta-analysis found that no trial employing both blinding and psychological placebos has shown CBT to be effective in either schizophrenia or bipolar disorder, and that the effect size of CBT was small in major depressive disorder. They also found a lack of evidence to conclude that CBT was effective in preventing relapses in bipolar disorder.[98] Evidence that severe depression is mitigated by CBT is also lacking, with anti-depressant medications still viewed as significantly more effective than CBT,[29] although success with CBT for depression was observed beginning in the 1990s.[99]

According to Cox, Lyn Yvonne Abramson, Patricia Devine, and Hollon (2012), cognitive behavioral therapy can also be used to reduce prejudice towards others. This other-directed prejudice can cause depression in the "others", or in the self when a person becomes part of a group he or she previously had prejudice towards (i.e. deprejudice).[100] "Devine and colleagues (2012) developed a successful Prejudice Perpetrator intervention with many conceptual parallels to CBT.[101] Like CBT, their intervention taught Sources to be aware of their automative thoughts and to intentionally deploy a variety of cognitive techniques against automatic stereotyping."[100] A 2012 systematic review investigated the effects of CBT compared with other psychosocial therapies for people with schizophrenia:

Cognitive behavioral therapy compared with other psycho-social therapies for schizophrenia[102]
Summary
For people with schizophrenia trial-based evidence suggests no clear and convincing advantage for cognitive behavioral therapy over other – and sometime much less sophisticated – therapies.[102]

　

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