COGNITIVE DISTORTIONS

COGNITIVE THERAPY
Dr. SURESH
PG
PSYCHIATRY,
KIMS
Narketpally
TELANGANA
OUT LINE

INTRODUCTION

CAUSES OF COGNITIVE DISTORTIONS

IMPACT OF COGNITIVE DISTORTIONS

TYPES OF COGNITIVE DISTORTIONS

IDENTIFICATION

MEASURING SCALES

COGNITIVE THERAPY
 INTRODUCTION

Cognitive distortions are errors in thinking that

impinge upon the person’s view of themselves,
of other people and of their own future.

In general, cognitive distortions represent the different

means by which individuals modify their experiences,
thereby creating dysfunctional subjective constructs.

These are the main concepts of CT/CBT refers to

inflated inaccurate thoughts.
 CAUSES OF THINKING ERRORS
Information-processing shortcuts
Using outdated , dichotomous schemas
Mental noise
 The brain's limited information processing capacity
Age
Crisis
Emotional causes
I feel bad , therefore it must be bad
Moral causes
It was the right thing to do
Social causes
Everyone is doing it
The following type of CD's have been adapted from
Dr.David Burns (1990) and from Ellis & Grieger (1986)

1. All-or-nothing thinking
2. Disqualifying positive
3. Emotional Reasoning
4. Approval-seeking
5. Comparison
6. Fallacy Of Fairness Mind Reading
7. Jumping To Conclusions
8. Labeling Mislabeling The Fortune-teller Error
9. Magnification (Catastrophising) Minimization
10.Mental Filtering/ Selective Perception
11. Overgeneralization
12.Perfectionism
13. Personalization
14. Reductionism
15.Self-rightous cognitions
16. Should Statements
17. ‘Woe Is Me’
18.Tunnel vision
 1. All-or-nothing thinking
Things are seen in black and white, if performance
falls short of perfect, the person regards them self as
a total failure.

Example: If a person fails to be promoted to the post

he desperately wanted, He believes they will never
be promoted and that his career is in ruins.
2.Disqualifying positive:
You reject positive experiences by insisting they ‘don’t
count’ for some reason or other. In this way you can
maintain a negative belief that is contradicted by your
everyday experiences.

Example:

A pleasant employee pays you a compliment and you

say it is in order to get a good reference. This takes the
joy out of living and leaves you feeling unrewarded.
3. Emotional Reasoning:

You assume that your negative emotions necessarily

reflect the way things really are:
‘I feel it, therefore it must be true’.

Example:
You look at the large volume of work and feel
overwhelmed, you conclude there is no point in even
trying.
4. Approval-seeking:

You must be approved of all the time and if not then

life is terrible. This results in compromising
your needs so as to gain the approval others.

You cannot take any decisive action without their

approval.

5. Comparison:

You constantly compare yourself to others with little

information or on the basis of an isolated event ,so you
feel either superior or inferior.
6.Fallacy Of Fairness:

You judge a negative event as unfair when it isn’t

an issue of justice.

Example:
You cling to the idea that life is always supposed to be fair
, and when it is not , it causes you to feel negatively
towards your situations and others who are benefiting.
Mind reading
7. Jumping To Conclusions:
The fortune teller error
You make a negative interpretation even though
there are no definite facts that convincingly support
your conclusion.
• Mind Reading:
You automatically draw a negative conclusion without
facts to support it.

Example:
A Person's daughter won’t tidy her room and he believes
it is because she is deliberately trying to wind him up.
The Fortune-teller Error:
You can predict that things will turn out badly, and
you feel convinced that your prediction is a fait
accompli.

Example:
You decide not to ask someone for a dinner
because you know they’ll refuse anyway.
8.Labelling Mislabeling:

This is an extreme form of overgeneralization, and

instead of describing your error, you attach a negative
label to yourself.

Example:
You break your diet and say ‘I’m a weak-willed slob’. When
somebody else’s behavior annoys you, you attach a
negative label to them – ‘they’re a selfish pig’.

Mislabeling involves describing an event with

language that is highly coloured and emotionally loaded.
9. Magnification (Catastrophising) Minimisation:

You focus on the worst possible outcome and overestimate

the probability that it will happen (magnification) or you
inappropriately shrink the importance of an attribute or event
(minimisation). This is also called the ‘binocular trick’.

Example:
You have a pain in your head and you think it is
cancer(magnification)
(Or)
You are playing tennis and lose the first set but your
game picks up and you win. When others compliment
you, you say it was just chance that you won as you
played badly (minimisation).
10.Mental Filtering/ Selective Perception:
You pick out a single negative detail and dwell on it
exclusively, while ignoring all the rest, so that your vision
of all reality becomes darkened.

Example:
A driver waves you into a traffic lane, but later when
another car cuts-in in front of you, you believe that
all drivers are rude and thoughtless.
11. Overgeneralisation :

One takes a single negative event and makes a general

rule out of it without ever testing this rule.
Words such as ‘always’, ‘never’, ‘everybody’
permeate the thinking like– ‘I’m always messing
things up, ‘I never get anything right, Everybody is
sick of me’, or the shy person who, when ignored
by one person, sees no point in trying to meet
other people because ‘everybody is out for
themselves’.
12.Perfectionism:

Perfectionism is the situation in which someone

constantly strives to live up to some internal or external
standard of perfection without scrutinizing the
reasonableness of such standards.

You and others must be perfect and when this does not
happen you become upset even if the matter is
unimportant.
13. Personalization:
You see yourself as the cause of some negative
external event, which in fact you were not primarily
responsible For.

Example:
Blaming yourself when your child is misbehaving at
school. The emotional consequence is guilt.
14. Reductionism:

You fail to see the complex causes or the potential

benefits of a situation. Instead you reduce it to a
simple cause and a simple consequence.

Example:
Your son has not got the points for university and you
think he will never be a success in life or that the
experience may lead to him working harder for the next
exam.
15.Self-rightous cognitions:

People should always do what you think is right

and if they don’t they are wrong and should be
punished. These people are critical of others and
see them as ‘stupid’, ‘bad’, etc.
16. Should Statements:

You try to motivate yourself with should and shouldn’t,

must and ought, as if you had to be punished before
you could be expected to do anything; the emotional
consequences are guilt. When you direct should
statements towards others, you feel anger, frustration,
and resentment.
 Example:
You are kept waiting in your psychiatrist’s waiting
room and you think to yourself, ‘he should be more
considerate. I’ve had to rush to get here’. In fact, he’s
dealing with an emergency.

This has also been termed ‘musterbation’( Making

'MUST' statements)
by Albert Ellis.
17. ‘Woe Is Me’:

You see yourself as a victim even when the situation

is ordinary.

Example:
You have to go to the shop because you have run out of
milk. You see this as a huge challenge and fail to take
responsibility because you couldn’t be bothered getting
it when you were shopping earlier in the day.
18.Tunnel vision
•The tendency to only see or focus on limited
perspective or priority while neglecting other
important priorities that part of bigger picture.

•Common cognitive distortion occurs when we are

only able to see the negative aspects of a situation.

•Failure to take in all known information and failure to

explore realistic outcomes based on evidence.
 Measuring instruments
•Inventory of Cognitive Distortions (ICD) - Yurica
,DiTomasso 2002-2011 .

•Dysfunctional Attitudes Scale (DAS) - Weissman and

Beck 1978.

•Perceived Stress Scale (PSS).

•Cognitive Errors Questionnaire(CEQ) , Lefebvre 1981.

•Cognitive distortion scale (CDS) Briere 2000.

 COGNITIVE THERAPY (CT)
This therapy is a system of psychotherapy based on the
theories of pathological information processing in mental
disorders directed to modify distorted cognitions and
related behavioral dysfunction.

Developed by Aaron T. Beck, investigated "anger turned

inward" a psychoanalytic concept in 1960s and found
evidence for negative cognitions.

Ellis 1962 (rational emotive therapy) , Beutler 1987 CT for

geriatric patients , Freeman 1990 CT for personality
disorder , Agras 1992 CT for eating disorders , Wright
2004 CT and pharmacotherapy combination, Selmi 1990 ;
Wright 2005 developed computer assisted CT.
 CT vs CBT
Cognitive therapy
It is a discrete form of therapy
Based on the cognitive model
Developed by Aaron T. Beck, MD an
American psychiatrist
Cognitive behavioral therapy
It is an umbrella term for a group of
therapies like stress inoculation ,
Dialectical behavioral therapy , response
prevention, problem solving therapies.
Based on either a behavioral or cognitive
framework
Developed from behaviorists like
Goldfried, Meichenbaum and Mahoney
COGNITIVE DISTORTIONS - II
(cognitive therapy)
 OUT LINE

• Basic concepts

• Therapeutic principles

• Cognitive techniques

• Computer assisted CT

• Selecting patients for CT

• CT applications

• Effectiveness of CT
 BASIC CONCEPTS
•The cognitive model
•Levels of dysfunctional cognitions
•Cognitive pathology in depression
This model is used as a guide for the actions of the
cognitive therapist in clinical practice but it does not
presume that cognitive pathology is the cause of
specific syndromes.

It explains close relationship between cognition and

emotion.

Heightened emotion can stimulate and intensify

cognitive distortion.

Therapeutic procedures in CT involve interventions at

all points , mostly directed at stimulating either
cognitive or behavioral change.
 Levels of dysfunctional cognitions
Automatic thoughts (cognitive errors)
• 2 levels
Basic beliefs incorporated in schemas

• Cognitions that occur rapidly while a person is in a

situation (or recalling an event).

• These are not subjected to rational analysis , are based

on erroneous logic only.

• In CT these are accessible through questioning

techniques.
• Schemas are deeper cognitive structures that contain
the basic rules for screening ,filtering , and coding
information from the environment.

• Adaptive schemas play main role in assimilation of

data and appropriate decision making.
Ex: I can manage somehow, If I work at something I
can master it, I am a survivor.

• Maladaptive schemas have influence in development

of psychiatric disorders.
Ex: I must be perfect to be accepted, if I choose to do
something I must succeed, I am a fake.
Cognitive pathology in depression

•Depressed patients are more likely to remember negative than

positive self-referent information.

•Hopelessness is highly associated with suicide risk, CT is effective

treatment approach to reduce both of these.

•Schemas become dormant during remissions.

• Attributions to life events are negatively distorted in depression.

# Beck's cognitive triad of depression #
 Therapeutic principles
• General procedures
• The therapeutic relationship
• Assessment and case conceptualization
• Structuring therapy
• Psycho education

General procedures:
• usually short term treatment, lasting from 5 to 20 sessions.

• After completion of the initial course of treatment ,

intermittent booster sessions may be useful to decrease the
chances of relapse.
• History taking can be augmented in CT by asking the
patient to write a brief "autobiography" as the early
homework assignments.

• The problem-oriented approach is emphasized for 3

reasons
1) Directing the patient's attention to current problems
2) Data on cognitive responses to recent life events are
more accessible and verifiable than for events
happened in the past.
3) Practical work on present problems helps to prevent
the development of dependency in the therapeutic
relationship.
 The therapeutic relationship
• Also known as "collaborative empiricism"

• It is characterized by a high degree of collaboration

between patient and therapist and an empirical tone
to the work of therapy.

Methods of enhancing collaborative empiricism

• Work together as an investigating team.

• Adjust therapist activity level to match the severity of

illness and phase of treatment.

• Encourage self-monitoring and self help.

• Obtain accurate assessment of validity of cognitions
and efficacy of behavior.

• Develop coping strategies for real losses and actual

deficits.

• Promote essential "nonspecific" therapist variables

(ex: kindness , empathy , positive general attitude).

• Provide and request feedback on regular basis.

• Recognize and manage transference.

• Customize therapy interventions.

• Use gentle humor.

 Assessment and case conceptualization
• Assessment begins with completion of a standard
history and mental status examination.
• The academy of cognitive therapy designed some
flow charts and worksheets
 EXERCISE
Therapist: "How did you react to your wife's
criticism?"
Mr.B :(Suddenly appears sad , anxious) "It was
just too much to take"
Therapist: "I can see this really upsets you.
Can you think back to what went through
your mind right after I asked you the last
question? Try to tell me all the thoughts.
Mr.B : (pause) " I am always making mistakes.
I can not do anything right. There is no way to
please her. I might as well give up.
Therapist: ' I can see why you felt so
sad.When these kind of thoughts just
automatically pop into your mind , you don’t
stop to think if they are accurate or not.
That's why we call them automatic thoughts.
Mr.B : I guess you are right. I hardly realized I
was having those thoughts until you asked
me to say them out loud.
Therapist: Recognition of automatic thoughts
is one of the first steps in therapy. Now let us
see what we can do to help you with your
thinking and with the situation with your
wife.
 Structuring therapy

structuring procedures

• Set agenda for therapy sessions.

• Give constructive feedback to direct the course of
therapy.
• Employ common cognitive therapy techniques on a
regular basis.
• Assign homework to link sessions together.
• Prepare the agenda with 2 to 4 items as a short list of
topics.
• Agenda can be managed within the time frame of an
individual session.
• Follows up on material from earlier session.
• Reviews any homework from the previous session.
• Contains specific items that are highly relevant to the
patient but not too global.
• Agenda setting helps to counteract hopelessness and
helplessness. And initiates the process of change.
 Psycho education

• It is a routine component of cognitive therapy.

• Its major goal is to teach patients a new way of

thinking and behaving.

• Its effort usually begins with the process of

socializing the patient to therapy.

• It can be facilitated with reading assignments and

computer programs.
 Cognitive techniques

• Identifying and Modifying automatic thoughts

• Identifying and modifying schemas

• Behavioral procedures
 Identifying automatic thoughts
Methods for identifying and modifying automatic
thoughts

• Socrastic questioning
• Use of mood shifts to demonstrate automatic
thoughts in vivo
• Imagery exercises
• Role - play
• Thought recording
• Generative alternatives
• Cognitive rehearsal
 Socratic questions:
• 1) questions for clarification
Why do you say that?
How does this related to our discussion?

• 2) questions targeting assumptions

What could we assume instead?
How can you verify that assumption?

• 3) questions targeting reasons and evidence

What would be an example?
What do you think causes to happen? Why?
• 4) Questions about view points and perspectives
What would be an alternative?

• 5) Questions targeting consequences

How does A… affect B… ?

• 6) questions about the question

Why do you think I asked this question?
 Behavioral procedures
In CT behavioral interventions are used for :
• 1)change dysfunctional patterns of behavior ex: helplessness ,
phobic avoidance
• 2)reduce troubling symptoms ex: tension, somatic and psychic
anxiety
• 3)assist in identifying and modifying maladaptive cognitions.

Methods are :
• Self-monitoring
• Graded task assignments
• Exposure and response prevention
• Coping cards
• Distraction
• Relaxation exercises
• Social skill training
• Respiratory control
 Identifying and modifying schemas

• Psychoeducation
• Listing schemas in therapy notebook
• Listing advantages and disadvantages
• Thought recording
• Imagery and role-play
• Examining the evidence
• Generating alternatives
 Selecting patients for CT

• CT should be considered an adjunctive therapy to the

pharmacotherapy.

• There are no contraindications to using this treatment

approach.

• It is usually not attempted with the patients who have

marked brain disease.

• Chronicity and symptom severity have been associated

with proper response to cognitive therapy.
 CT Applications

• Depression
• Anxiety
• Eating disorders
• Personality disorders
• Psychosis
• Bipolar disorders
Efficacy & Effectiveness of CT
Thank you