Problems Addressed with CBT and DBT Treatment

Adults with attention-deficit hyperactivity disorder (ADHD) often have difficulty beginning or completing tasks that are routine and uninteresting. They may also have difficulty following instructions, being on time, and making deadlines. They may be disorganized and prone to losing things: offices may be cluttered with unfiled papers and homes with clothes and unpacked boxes. Those with ADHD also have a harder time tolerating the delay between thought and action as well as refraining from acting on impulses. Difficulty controlling impulses may be apparent in problems involving greater amounts of risk-taking behavior as well as excess consumption of food, or sex. Individuals with ADHD may talk excessively, blurt out answers to questions, or interrupt others. Hyperactivity may also be seen in physical restlessness, fidgeting, and difficulty staying seated. In terms of thinking, impulsivity may lead the individual to jump to conclusions and make decisions without adequate consideration of the consequences.

According to Diagnostic and Statistical Manual of Mental Disorders, individuals must meet 5 of 9 criteria from 2 clusters of symptoms: inattention and hyperactivity. Several of these symptoms must have been present prior to age 12 and present in two or more settings. There is evidence that the symptoms interfere with social, academic, and occupational functioning.

The appropriate diagnosis of ADHD is made after a thorough evaluation to determine 1) that symptoms are of the scope, severity and frequency that satisfy the DSM-5 diagnostic criteria; 2) whether symptoms were present in childhood; and 3) what other conditions may be present that could account for inattention and hyperactivity. Such conditions include depression, anxiety, learning disabilities, and bipolar disorder. In addition to a thorough clinical interview, the assessment of ADHD may also involve the use of structured assessments such as the Conner’s Adult ADHD Diagnostic Interview. Often, a neuropsychological evaluation is needed to definitively diagnose ADHD and rule out other conditions that cause problems of attention and hyperactivity.

CBT [in individual or group formats, with or without medication] has been demonstrated to decrease inattention as well as improve time management, organization, and planning (Safran, Sprich, Mimiaga, Surman, Knouse, et al., 2010; Solanto, Marks, Wasserstein, Mitchell, Abikoff, Alvir, et al., 2010). Treatment for ADHD also targets failure to complete tasks, forgetfulness, indecisiveness, and procrastination. Treatment for ADHD is multifaceted and involves skills training, the development of compensatory strategies, and the use of reinforcement to strengthen new behaviors. The length of treatment is generally 8 to 12 sessions.

Anger is one of the most basic human emotions and is not inherently problematic. However, if anger is experienced in great intensity, for long periods of time, or is difficult to control, an individual may experience negative consequences – this is when anger becomes a problem. If a person identifies anger as a personal issue and is ready to address it, change-oriented therapy can be effective (Deffenbacher, 2011). Anger problems are part of many disorders including depression, anxiety, and trauma disorders like PTSD (Novaco, 2011).

Anger is defined as an internal experience with emotional, physiological, and cognitive components. The CBT model of anger emphasizes the role of triggering events. In this model, anger arises due to the interaction of triggering events, an individual’s pre-anger state, appraisals of the event, and coping skills (Deffenbacher, 2011). Triggering events are divided into different classes: specific external events (e.g. being stuck in traffic), a combination of external events and anger-related memories (often found in PTSD sufferers), or internal experiences like thoughts and emotions. The pre-anger state includes negative mood states (e.g. feeling tired or sick), as well as enduring characteristics of the individual. The enduring traits are comprised of cultural/familial norms regarding anger and an individual’s way of thinking about the world. Appraisals are the individual’s judgments about the triggering event, or a self-judgment about one’s ability to cope (e.g. feeling that you are overwhelmed) (Deffenbacher, 2011).

In CBT, the therapist helps the client to identify and understand the anger triggers, appraisals, behavioral responses, and outcome. Using an analysis of thoughts, emotions, and behaviors leading up to an anger episode, the client gains insight into the anger response and develops individualized anger-reduction strategies (Deffenbacher, 2011). They will learn to self-monitor: detecting thoughts and arousal that predict anger and recognizing situational cues that can elicit anger (Novaco, 2011). The goals of CBT interventions are to enhance self-awareness and acceptance, reduce avoidance, and identify and challenge maladaptive assumptions and beliefs. Cognitive restructuring and problem-solving interventions are used with relaxation techniques for coping with elevated emotional and physiological arousal. Behavioral interventions identify dysfunctional angry behaviors and train the patient in conflict-management skills, leading to increases in self-efficacy (Deffenbacher, 2011). Meta-analyses have shown that CBT treatment is efficacious in treating anger (Beck and Fernandez, 1998) and has the largest effect of any psychotherapy (Novaco, 2011).

Anxiety is characterized by excessive worry that is difficult to control. It is accompanied by symptoms such as fatigue, restlessness, irritability, muscle tension, and possible insomnia. Examples of situational anxiety include:

Health anxiety/hypochondriasis is the worry of having a serious but undiagnosed medical condition. CBT/DBT Associates offers short-term interventions focused on teaching and strengthening skills for coping with stress, anxiety, or pain associated with medical conditions and procedures as well as identifying and overcoming barriers to adherence with health care regimens. Presenting concerns frequently include: medication adherence, pill-swallowing, receiving injections and blood draws, bowel and bladder management, restricted diet, pain management, and adherence with exercise programs.

Performance anxiety or “stage fright” is the anxiety, fear, or persistent phobia which may be brought about in a child by the requirement to perform in front of an audience. Such anxiety may precede or accompany participation in any activity involving public performance. In some people, the anxiety may be more pervasive and occur in many social environments. If this is the case, the anxiety may be better diagnosed as social anxiety disorder, or social phobia.

Social anxiety involves fear induced by social interactions and oftentimes involves the worry of being negatively judged. This extends beyond shyness or simple discomfort as those with social phobias tend to excessively worry about embarrassment and potentially offending others. Self-consciousness also plays a significant role in those who suffer from social anxiety.

Sports performance and competition anxiety often go hand-in-hand. The ability to cope with pressure and anxiety is an integral part of sports, whether among children, collegians, amateur adults, or elite athletes. A certain level of physical arousal is helpful in preparing us to perform. But being unable to regulate your anxiety prior to or during an athletic event can negatively impact your performance as well as your quality of life. Similarly, a certain amount of worry about how you will perform can be helpful in competition, but severe cognitive symptoms of anxiety such as negative thought patterns and expectations of failure can bring about a self-fulfilling prophecy: they can adversely effect your performance, causing you to perform worse in the end.

Test anxiety involves a combination of physiological hyperarousal, worry or dread about test-taking, and an avoidance of effective preparation which often interferes with normal learning and lowers test performance. It can result in extreme stress, anxiety, and discomfort during and/or before taking a test. CBT/DBT Associates offers an individualized program for students on how to conquer test anxiety and perform to the best of your abilities. (NOTE: This is not a test prep course. We do not teach you how to pick the best answer on a multiple choice test, or what kind of material you should study. Instead, this program focuses on conquering the emotional component of test-taking anxiety which often interferes with effective performance.)

The primary goal of Cognitive Behavioral Therapy (CBT) for anxiety is to decrease excessive worry. In treatment, clients will learn to identify and modify beliefs about worry using cognitive restructuring strategies like questioning evidence and validity of worry, challenging appraisals about the uncontrollability of worry, and normalizing. Furthermore, clients will work to change their tendency to overestimate threat and learn coping skills (Wells, 1997). Because worry thoughts are future focused, people with chronic worry experience decreased contact with the present moment. For this reason, mindfulness, the skill of bringing one’s awareness to the present moment, is an important part of GAD treatment (Borkovec & Sharpless, 2004).

CBT has repeatedly been shown to have a lasting effect in the treatment of depression. Meta-analyses of 48 randomized controlled trials have shown that Cognitive Therapy (CT) is effective in treating mild to moderate depression (Gloaguen, Cottraux, Cucherat, & Blackburn, 1997). Research has demonstrated that CBT is superior to anti-depressant treatment and can be used as an alternative or adjunctive to pharmacological therapy. Combination therapy (medication plus CBT) is beneficial for cases of chronic and severe depression (Parker, Roy, and Eyers, 2003). For those who cannot tolerate medicine, have medication-resistant depressive disorders, or children and adolescents for whom early prescribing poses concerns, CBT is shown to be a particularly effective and preventative treatment (Parker et al., 2003).

In addition, CBT has been shown to significantly reduce the recurrence of depression over the following 1-2 years (Gloaguen et al., 1997). In a six year study of patients suffering from recurrent depression, those who received CBT after initial pharmacotherapy exhibited a significantly lower relapse rate at a six year follow-up compared to those who did not receive CBT (Fava, Ruini, Rafanelli, Fionis, Conti, & Grandi, 2004).

Feeding and eating disorders are characterized by rigid and extreme eating behaviors that significantly impair physical or psychosocial functioning. Some eating disorders also involve a preoccupation with body shape and weight. These disorders include the following:

Pica is defined as persistent eating of nonfood and non-nutritive products (e.g., paper, soap, cloth, wool, chalk) that is not consistent with the developmental level of the individual. Childhood onset is most common, however, children, adolescents, and adults can exhibit symptoms.

Rumination disorder is characterized by repeated regurgitation of food over at least a one month period. The regurgitation is not related to a fear of gaining weight or concerns about body image. Regurgitation is also not better explained by a medical condition or another feeding or eating disorder. Rumination disorder can be diagnosed in children, adolescents, and adults.

Avoidant/restrictive food intake disorder is characterized by failure to meet appropriate nutritional or energy needs due to lack of interest in eating or food, avoidance of certain characteristics of food, and/or concern about consequences of eating (e.g., fear of choking). This disorder is more common in children than in adults, and may include significant weight loss, dependence on oral nutritional supplements, and/or significant nutritional deficiency.

Anorexia Nervosa is defined as an intense fear of gaining weight and refusal to maintain a minimally normal body weight. A distorted body image, or a significant misperception of body shape and size, is also a feature of this disorder. Anorexia Nervosa is characterized by restriction of food intake and/or fasting, low weight, and potentially other methods of weight loss, such as self-induced vomiting, the misuse of laxatives, or excessive exercise.

Bulimia Nervosa is characterized by preoccupation with shape and weight and repeated episodes of binge-eating followed by compensatory behavior. Compensatory behaviors may include self-induced vomiting, misuse of laxatives or diuretics, fasting, and/or excessive exercise. Binge-eating is defined as consuming a quantity of food that is larger than most individuals would eat in a discrete period of time, as well as a sense of lack of control during the binge episode.

Binge-eating disorder is defined as recurrent episodes of binge eating that leads to marked distress. Binge-eating episodes may be associated with eating much faster than normal, eating until uncomfortably full, eating large amounts of food when not physically hungry, eating alone due to embarrassment about the quantity of food intake, and/or feeling disgusted, depressed, or guilty after the binge eating episode. Binge-eating is defined as consuming a quantity of food that is larger than most individuals would eat in a discrete period of time, as well as a sense of lack of control during the binge episode.

CBT/DBT Associates offers individual CBT and comprehensive DBT for adults and adolescents with eating disorders. We also offer a CBT group for adults with disordered eating behaviors. The determination of the appropriateness of CBT vs. DBT is based on the nature of other difficulties that the individual is struggling with.

We are not born knowing how to regulate our emotions. Ideally, we are taught how to do this as children by observing our parents effectively handle their emotions, having our parents acknowledge and assist us with our emotions, and receiving the message that our emotions make sense given the context. Individuals with difficulties regulating their emotions are often sensitive to emotional triggers in their environment, react intensely to those triggers, and then have trouble getting back to their baseline emotional state. To further complicate matters, these individuals may also have difficulty accurately identifying their emotions, completing tasks when upset, and tolerating distressful emotions in an effective manner. These difficulties in emotion regulation are sometimes referred to as emotion dysregulation. Persistent emotion dysregulation may create problems in relationships, work, and other areas of life. In efforts to escape or decrease intense negative emotions like sadness, anger, and anxiety, individuals may develop other problems such as anger management difficulties, anxiety disorders, eating disorders, overspending, or self-injurious behaviors.

Since emotion regulation is conceptualized as a set of skills that can be learned, treatment focuses on teaching these skills in either individual or group therapy. The skills taught include the accurate identification of emotions as they are happening, learning how to tolerate emotions, learning how to change emotions, and developing the ability to be less vulnerable to emotional cues in the environment.

Generalized Anxiety Disorder is characterized by excessive worry and anxiety that is difficult to control. It is accompanied by symptoms like fatigue, restlessness, irritability, muscle tension and possible insomnia. Unlike situational anxiety, individuals with GAD often worry about a variety of things rather than one specific issue (American Psychiatric Association, 2000). GAD is a basic anxiety disorder (Brown, Barlow, & Leibowtiz, 1994) from which other anxiety and mood disorders develop. Many patients with GAD also present with co-morbid disorders like social phobia, panic disorder, and major depression (Heimberg, Turk, & Mennin, 2004). Successful treatment of GAD often results in improvement of these co-morbid disorders (Borkovic, Abel, & Newman, 1995).

The Cognitive Behavioral model of GAD emphasizes how the negative biases in an individual’s thinking contribute to anxiety. In GAD, the predominant bias is the tendency to anticipate the worst and assume that the worst is most likely to happen. The CBT model also emphasizes the tendency of individuals with GAD to underestimate their ability to cope with anticipated problems, which heightens anxiety (Beck, Emery & Greenberg, 1985). Individuals with GAD may use worry as an ineffective form of coping or problem-solving. When we worry, it can create the illusion that we are “on a problem” or addressing it, when in actuality, all we are doing is thinking (and thinking catastrophically). CBT helps to short circuit this cognitive churn and move us more quickly into problem-solving.  Worry may also be a way to avoid unwanted emotions or thoughts (Wells, 1997). Unfortunately, avoiding thoughts and feelings only increases fear of them. For this reason, CBT helps clients bring these thoughts and feelings into awareness.

The primary goal of CBT for GAD is to decrease excessive worry.  In treatment, clients will learn to identify and modify beliefs about worry using cognitive restructuring strategies like questioning evidence and validity of worry, challenging appraisals about the uncontrollability of worry, and normalizing. Furthermore, clients will work to change their tendency to overestimate threat and learn coping skills (Wells, 1997). Because worry thoughts are future focused, people with chronic worry experience decreased contact with the present moment. For this reason, mindfulness, the skill of bringing one’s awareness to the present moment, is an important part of GAD treatment  (Borkovec & Sharpless, 2004).

See “Anxiety”.

Insomnia is the most prevalent sleep disorder, affecting as much as one-third of adults. CBT is the only non-medication insomnia treatment that has been supported by clinical research studies. For more information about CBT for insomnia, click here.

CBT/DBT Associates offers social skills training for individuals struggling with low self-esteem, peer problems, and broader problems navigating their social environment successfully. Those with low self-esteem can learn new social skills, coping skills, and ways of thinking in a supportive peer environment through CBT.

Obsessive Compulsive Disorder (OCD) is characterized, just as the name suggests, by two parts: obsessions and compulsions.

Obsessions are thoughts, images, or impulses to do something that repeat over and over again. They are generally unwanted, distressing, or disturbing, and get in the way of doing important things, such as job responsibilities, schoolwork, parenting, and participating in relationships. Obsessions are often accompanied by intensely uncomfortable feelings, such as fear, anxiety, doubt, disgust, and persistent worry.

Compulsions are the behaviors that one may do in order to neutralize, satisfy, or otherwise reduce their obsessions and the uncomfortable feelings that come along with them. Compulsions include doing things over and over and/or in a certain ways, thinking certain thoughts to counteract the obsessions, asking repetitive questions to other people in order to obtain reassurance, and avoiding things or situations likely to trigger obsessions.

Like obsessions, compulsions typically take up a significant amount of time, can get in the way of doing important things, and can also be embarrassing. Many people with OCD will find that doing their compulsions does help at least to some degree in the short-run, keeping their obsessions at bay or reducing them. But the obsessions typically come back as strong as ever, reinforcing an escalating cycle of obsession, compulsion, obsession, compulsion, and so on.

When many of us think about OCD, we think of the most well-known symptoms, such as excessive hand-washing or keeping things in order. However, there are many ways in which OCD manifests and can be addressed in treatment. Common reasons why people with OCD seek treatment include, but are not limited to:

• Persistent anxiety that something bad will happen to loved ones, particularly if a certain ritual is not performed
• Fear of getting sick or contaminated, either in general, or with respect to specific diseases
• Repeated washing, showering, decontaminating, or research into diseases and how they are contracted
• Feeling dirty, contaminated, or unclean, without fear of actual illness. The contamination may be by something physically dirty, or by objects or people thought to have something wrong or undesirable about them.
• Fear of losing control and hurting one’s self or others (e.g., hurting loved ones with a knife, pushing someone into the street)
• Fear of being responsible for harm to others due to negligence (e.g., one’s carelessness may start a fire or cause someone to slip and fall)
• Worries about having hit someone while driving and checking repeatedly
• Need for things to feel “just right,” leading to repetitive cleaning, ordering, arranging, light switching, door or window-locking, walking up and down stairs or through doors
• Fears about having inappropriate sexual thoughts; These may be violent images, or related to people that it feels perverse to have thoughts about, such as family members, children, or a gender that one does not want to be attracted to
• Fears about offending God or imperfect adherence to one’s religious requirements. (Religious rituals themselves are not compulsions, but fear of not following the rules properly to a degree that is significantly beyond what others in one’s community experience may be symptomatic)
• Fear of forgetting things, not understanding things sufficiently, not making one’s self perfectly understood, or “needing to know” something; repeated questions to neutralize these obsessions
• Compulsions around counting or doing things in multiples of certain “good” numbers or on “good” dates and/or avoidance of “bad numbers”
• Fear that one may do or say something inappropriate in social or work situations, such as blurting out obscenities
• Inordinate perfectionism

The most effective form of psychotherapeutic treatment for OCD is a type of CBT called Exposure and Response Prevention (ERP). In the exposure aspect of ERP, the individual works together with the therapist to confront the thoughts, people, things, and situations that are the focus of their obsessions and trigger their discomfort. The key element of this treatment is the response prevention aspect, in which the individual makes the choice – in the service of improving their lives in the long run – to refrain from doing the compulsions that they typically rely on, whether it be washing, performing a ritual, asking questions, repeating things, or trying to push thoughts away or otherwise deny them.

By breaking this cycle of obsessions and compulsions, most individuals will find that their anxiety and discomfort will eventually decrease without having to do the compulsion. At the outset, this may take longer. But by repeating these exercises over time, individuals build up a level of comfort with the situations that were previously thought to be unbearable. As this happens, individuals may begin to think differently about their obsessions, finding that these warnings of inescapable danger that the OCD insists upon are exaggerated, and that the situations are in fact survivable and less threatening than initially feared. As this comfort level grows, individuals with OCD can begin to reclaim the hours of their lives occupied by the condition.

To some, this approach may sound counterintuitive at first. Many seek treatment to make these thoughts and feelings just go away rather than to confront them. However, it is often because of desperately wanting to feel better and think differently that many get stuck in that escalating cycle of obsessions, compulsions, and worse obsessions. ERP is a choice to take a different approach from the one many are stuck in, one that may be quite challenging at first, but life-altering and positive in the long-run. An essential ingredient of the process is an experienced and compassionate therapist who will work with the individual to move along at the right pace, provide support, and troubleshoot potential obstacles.

A panic attack is a sudden episode of intense fear that develops for no apparent reason and that triggers severe physical reactions. Panic attacks can be very frightening. When panic attacks occur, you might think you’re losing control, having a heart attack, or even dying. Other symptoms include racing or pounding heartbeat, chest pains, dizziness/lightheadedness, nausea, difficulty breathing, tingling or numbness in your hands, trembling or shaking, and terror (or a sense that something unimaginably horrible is about to occur).

You may have only one or two panic attacks in your lifetime. But if you have had several panic attacks and experience persistent fear of another attack, you may have a chronic condition called panic disorder.  You may be suffering from panic disorder if you experience frequent, unexpected panic attacks that aren’t tied to a specific situation, worry a lot about having another panic attack, and are behaving differently because of the panic attacks, such as avoiding places where you’ve previously panicked.

Post-Traumatic Stress Disorder (PTSD) is a Trauma and Stress-Related Disorder that can develop following exposure to a traumatic or very stressful event, such as physical or sexual abuse, assault, military combat, natural disaster, prolonged illness, or an abusive relationship. PTSD can develop through direct exposure or by witnessing the trauma of another individual. For example, PTSD may develop indirectly after learning about the trauma of a friend or loved one. Not all individuals who experience or witness trauma will develop PTSD. Individuals who do develop symptoms typically re-experience traumatic events in the following ways: repeated thoughts or memories of the event; nightmares; flashbacks; intense emotional distress at reminders of what happened; and physiological changes such as insomnia, increased startle-response,  edginess, or hyper-vigilance. Individuals suffering from PTSD often avoid environmental triggers that may remind them of their trauma. Avoidance behaviors, increased anxiety, depression, and feelings of anger, shame, and/or isolation make almost all areas of life extremely difficult for those with PTSD. Many people experience changes in their sense of who they are or how they see the world around them. Some individuals with PTSD may react with impulsive or self-destructive behaviors or develop difficulties with trust and intimacy. For more information about therapy for trauma, click here.

Did you know that social anxiety disorder is the second most commonly diagnosed anxiety disorder in the United States? It affects approximately 15 million adults and is characterized by intense fear, anxiety, and worry about being judged negatively and/or rejected by others. There are various situations that might elicit social anxiety, including interacting with strangers, talking to an authority figure, public speaking, talking to someone who you are attracted to, and interacting with a small group of people.