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Cognitive Therapy: Current Status and Future Directions

 

Aaron T. Beck 1 and David J.A. Dozois 2

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1 Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania; email: abeck@mail.med.upenn.edu

 

Annu. Rev. Med. 2011. 62:397–409

2 Department of Psychology, University of Western Ontario, London, Ontario, Canada; email: ddozois@uwo.ca

Keywords

Annu. by

First published online as a Review in Advance on August 3, 2010

cognitive vulnerability, psychotherapy, treatment outcome, cognitive behavior therapy

The Annual Review of Medicine is online at med.annualreviews.org

This article’s doi:

10.1146/annurev-med-052209-100032

Copyright c 2011 by Annual Reviews. All rights reserved

0066-4219/11/0218-0397$20.00

Abstract

Cognitive therapy is a system of psychotherapy with a powerful theoret- ical infrastructure, which has received extensive empirical support, and a large body of research attesting to its efficacy for a wide range of psy- chiatric and medical problems. This article provides a brief overview of the conceptual and practical components of cognitive therapy and highlights some of the empirical evidence regarding its efficacy. Cog- nitive therapy (often labeled generically as cognitive behavior therapy) is efficacious either alone or as an adjunct to medication and provides a prophylaxis against relapse and recurrence.

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Cognitive schema:

a well-organized cognitive structure of stored information and memories that forms the basis of core beliefs about self and others

OVERVIEW

From its inception more than 45 years ago (1–3), cognitive therapy has been theory driven. Specifically, Beck’s objectives for deriving and evaluating this system of psychotherapy in- volved an overall plan to construct a compre- hensive theory of psychopathology that maps clearly onto the treatment approach, to inves-

tigate scientific support for the theory, and to test the efficacy of therapeutic interven- tions (3, 4). Cognitive theory and therapy were first developed for depression (1, 2) and later systematically applied to suicide prevention (5), anxiety disorders (6), personality disorders (7), substance abuse (8), and, most recently, schizophrenia (9, 10). Cognitive therapy (CT), often discussed un- der the generic label cognitive behavior therapy (CBT), is now widely represented in training programs in psychology, psychiatry, medicine, social work, nursing, and other allied health professions that value evidence-based practice (11). CT and CBT have been described as “the fastest growing and most heavily researched systems of psychotherapy on the contemporary scene” (12, p. 332). This article provides a brief overview of the conceptual, practical, and em- pirical aspects of CT. After highlighting some of its basic concepts and the research pertain- ing to Beck’s cognitive theory, we discuss the general approach to treatment and review the literature on its efficacy. We conclude by out- lining some directions for future research.

COGNITIVE THEORY

Cognitive theory is based on the presumption that information processing is crucial for human adaptation and survival. Without the ability to process information from the envi- ronment, synthesize it, and formulate a plan for dealing with it, we would not survive. The cognitive (or information processing) system is intricately tied to other affective, motivational, and behavioral repertoires. Each of these repertoires, or systems, serves an individual function and also operates in synchrony toward

398 Beck · Dozois

coordinated, goal-oriented strategies (e.g., approaching pleasure, avoiding pain) (13, 14). The fight-flight response, for instance, arises from four systems (13): cognitive (perception of threat), affective (feelings of anxiety or anger), motivational (the impulse to confront or flee the threatening stimulus), and behavioral (the implementation of action). In this construct, onset of a particular condition (e.g., panic disorder) is believed to occur when these different systems shift from a fairly quiescent state to a highly activated state. In the example of panic disorder, this might occur when the fight-flight response is activated by “false alarms” (e.g., misperceiving bodily sensations as harmful to the organism). Cognitive theory suggests that psychopathology is characterized by the activation of a conglomerate of related or contiguous dysfunctional beliefs, meanings, and memories that operate in coordination with affect, motivation, behavior, and physio- logical responses. Different psychopathological conditions are associated with specific biases that influence how an individual incorporates and responds to new information. According to Beck’s model (1–3, 6, 15, 16), the cognitive appraisal of internal or external stimuli influences and is, in turn, impacted by these other systems. Thus, although cognition plays a key role in this model (i.e., the as- signment of meaning is crucial to understand- ing maladaptive behavior), it is recognized that mental health problems involve a complex in- terplay among diverse and interrelated systems

(17).

Within the cognitive system are different levels of cognition, ranging from surface-level thoughts to “deeper” cognitive schemas (18, 19). Cognitive schemas are organized structures of stored information that contain individuals’ perceptions of self and others, goals, expecta- tions, and memories. These elements are well- organized within the cognitive structure (20) and influence the screening, coding, categoriza- tion, and interpretation of incoming stimuli and the retrieval of stored information. Schemas are adaptive insofar as they afford efficient pro- cessing of information; however, when they

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become negatively biased, maladaptive, rigid, and self-perpetuating, they can contribute to psychopathology. Maladaptive cognitive schemas are believed to develop during early periods of the life span and become increasingly consolidated and

proximal to a given situation than are other lev- els of cognition, they are functionally related to one’s deeper beliefs and schemas and seem to arise associatively as different aspects of one’s core belief system are activated. When negative cognitive schemas are acti-

organized as new experiences are assimilated into the existing belief structure (3, 15). Poor early attachment experiences and other adverse events (e.g., childhood maltreatment), for ex- ample, may contribute to the development of

vated, as in depression, they are not only identi- fiable but can be shown to have an influence on information processing, as manifested by cog- nitive biases, and have an impact on symptom development. When a depressive episode has

a

maladaptive belief system. Cognitive theory

remitted, the negative schemas are deactivated

is

essentially a diathesis-stress model. In other

(or vice versa).

words, it is possible to have a maladaptive belief

Another aspect of Beck’s model is content

system and not exhibit symptoms so long as the cognitive schema (and related systems) is not activated. Once triggered by external events, drugs, or endocrine factors, however, the cog- nitive schema triggers a cascade of information- processing biases (1, 4, 15, 16, 18). These may be attention, memory, or interpretational bi- ases. For instance, individuals with anxiety dis- orders perceive themselves as vulnerable and the world as dangerous. Such individuals at- tend selectively to threat-pertinent information at the expense of information that is inconsis- tent with threat or information that suggests one has sufficient resources for dealing with it. An individual who is vulnerable to depression, to consider another example, may have an un- derlying belief that he or she is unlovable. This belief may become especially salient when ad-

specificity (16, 17). That is, different emotional experiences and forms of psychopathology are related to a unique cognitive profile or set of beliefs (see Table 1 for some examples of sys- tematic biases associated with different disor- ders). To illustrate, depression is related to thoughts and beliefs concerning personal loss, deprivation, and failure (15). Persons with clini- cally significant anxiety tend to overestimate the probability of risk while simultaneously under- estimating their resources for coping with po- tential threats. Their thoughts focus on themes of the self as vulnerable, the world as danger- ous, and the future as potentially catastrophic (6). A person with dependent personality disor- der has a view of the self as weak, helpless, and incompetent (7). The empirical literature has provided con-

verse circumstances activate an underlying neg- ative schema. Such an individual may then at- tend selectively to and recall information that is consistent with this negative view of self (e.g., paying attention to cues that are suggestive of being unloved and minimizing information that

siderable support for various aspects of Beck’s cognitive theory. Hundreds of studies have demonstrated that individuals filter informa- tion and respond to stimuli in a way that is consistent with their preexisting beliefs and assumptions. Some research has also demon-

is

inconsistent with that belief).

strated that negative cognitive biases precede

The activation of a maladaptive cognitive schema, along with the ensuing information- processing biases, is also apparent in more surface-level cognitions or what are referred to as automatic thoughts. This term refers to the stream of positive and negative thoughts that runs through an individual’s mind unaccom- panied by direct, conscious deliberation. Al- though such thoughts are more superficial and

the development of anxious (e.g., 21) and de- pressive (e.g., 22) symptoms. Supportive ev- idence has been obtained for the ideas that there are distinct levels of cognition that work in synchrony to impact emotional and behav- ioral responses and that an emotional experi- ence or clinical disorder can be characterized by a unique set of beliefs and automatic thoughts (i.e., content specificity; see 16, 18). Schema

www.annualreviews.org Cognitive Therapy

Diathesis-stress

model:

a psychological theory

that predicts that psychiatric disorders result from the interaction of a predisposition (e.g., genetic, cognitive

diatheses) and negative life events. When an

underlying

vulnerability is strong,

less stress is necessary to trigger the behavior or disorder; when the predisposition is weak,

a greater amount of

stress is typically

needed before an individual develops the

disorder

Automatic thoughts:

the flow of cognitions (considered the cognitive byproducts of activated schemas) that arise in our day-to-day lives and are not accompanied by direct deliberation or volition

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Table 1 The cognitive profile of psychological disorders (14; reprinted with permission)

Disorder

Systematic bias in processing information

Depression

Negative view of self, experience, and future

Hypomania

Inflated view of self and future

Anxiety disorder

Sense of physical or psychological danger

Panic disorder

Catastrophic interpretation of bodily/mental experiences

Phobia

Sense of danger in specific, avoidable situations

Paranoid state

Attribution of bias to others

Hysteria

Concept of motor or sensory abnormality

Obsession

Repeated warning or doubts about safety

Compulsion

Rituals to ward off perceived threat

Suicidal behavior

Hopelessness and deficiencies in problem solving

Anorexia nervosa

Fear of being fat

Hypochondriasis

Attribution of serious medical disorder

organization (see 18), activation (e.g., 23), and the contribution of cognitive vulnerability to the incidence of psychiatric disorders (e.g., 24) have also been supported by empirical research.

COGNITIVE THERAPY

CT rests on three main propositions (25, 26):

The access hypothesis: With appropriate training, motivation, and attention, indi- viduals can become aware of the content and process of their thinking. The mediation hypothesis: The manner in which individuals think about, inter- pret, and construe events influences their emotional and behavioral responses. The change hypothesis: Individuals can become more functional and adaptive by intentionally modifying their cognitive and behavioral responses to the circum- stances they face.

Cognitive therapy is a structured, collaborative process that helps individuals to consider both the accuracy and usefulness of their thoughts through processes of exploration (determin- ing one’s idiosyncratic meaning system and maladaptive beliefs), examination (reviewing the evidence for and against a particular be- lief and considering alternative interpretations or explanations), and experimentation (testing

400 Beck · Dozois

the validity of one’s belief system) (27). This general approach is used early in therapy to target more proximal and surface-level cogni- tions (e.g., automatic thoughts, dysfunctional attitudes) and in later sessions to modify deeper cognitive structures and core beliefs. CT is not the replacement of negative thoughts with positive ones; rather, it aims to help individuals shift their cognitive appraisals from ones that are unhealthy and maladaptive to ones that are evidence-based and adaptive. Essentially, patients learn how to become sci- entific investigators of their own thinking—to treat thoughts as hypotheses rather than as facts and to put these thoughts to the test. Framing a belief as a hypothesis provides an opportunity to test its validity, affords patients the ability to consider alternative explanations, and permits them to gain distance from a thought to allow more objective scrutiny (11). Patients learn to modify their thoughts so that they are congruent with existing evidence. When thoughts are aligned with evidence, and negative feelings exist, the cognitive therapist helps patients to deal with emotional sequelae by introducing coping strategies, fostering skill development and/or problem solving. Cognitive therapists help patients to move through the process of exploration, exami- nation, and experimentation using collabora- tive empiricism, guided discovery, and Socratic

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dialogue. Collaborative empiricism means that the patient and the therapist become coinvesti- gators both in ascertaining the goals for treat- ment and investigating the patient’s thoughts. Methods of guided discovery are used to help patients to test their own thinking through per- sonal observations and experiments rather than via cajoling or persuasion. Through this pro- cess, patients are able to shift from “a convic- tion mode to a questioning mode” (28, p. 216). In addition, by collaboratively designing new experiences to try out (called behavioral exper- iments), patients are able to acquire a different perspective on themselves and their situations (14). Socratic dialogue is a method of guided discovery in which the therapist asks a series of carefully sequenced questions to help define problems, assist in the identification of thoughts and beliefs, examine the meaning of events, or assess the ramifications of particular thoughts or behaviors. CT is time limited. The average length of CT in outcome studies is between 12 and 24 weekly sessions, although there is more variability in clinical practice (25). The initial sessions are often focused on enhancing the therapeutic alliance, identifying the specific problem(s) that brought the patient into treat- ment, socializing the patient to the cognitive understanding of psychopathology, and symp- tom relief via behavioral strategies. At this time, the therapist plays a more active role than the patient. As therapy progresses, the emphasis shifts from symptom amelioration to the exam- ination and modification of the patient’s pat- terns of thinking, and the patient assumes a more active role in identifying problems and so- lutions and developing homework assignments. Toward the end of therapy, sessions are usually spread apart so that the patient can consolidate gains and increase his or her confidence in the application of newly learned skills. “Booster” sessions are frequently scheduled one or two months after the end of therapy. Homework assignments (also called action plans) are an important component of CT. Homework provides opportunities to enhance the mastery and generalization of skills learned

in the weekly therapy session by applying them in the “real world,” and improves treatment outcome (29). The specific techniques utilized in CT tend to vary depending on the disorder being treated and the case formulation. They typically in- clude ( a) establishing the therapy relationship, ( b) behavioral change strategies, ( c ) cognitive restructuring strategies, ( d ) modification of core beliefs and schemas, and ( e ) prevention of relapse/recurrence. Given that it is not possible to describe the science and art of CT in this brief article (interested readers are referred to more detailed discussions in 11, 14, 25, 30), we instead provide a capsule summary of these five components. The therapeutic relationship is a key in- gredient of all psychotherapies, including CT. There appears to be a bidirectional relationship between the patient’s perception of the thera- peutic alliance and outcome: The connection between patient and therapist may facilitate change, and symptom change, in turn, en- hances the bond between patient and therapist (11). Many of the basic interpersonal vari- ables common to other psychotherapies (e.g., warmth, accurate empathy, unconditional pos- itive regard) serve as an important foundation for cognitive and symptomatic change. As Beck et al. (15) noted, however, these characteristics “in themselves are necessary but not sufficient to produce an optimum therapeutic effect” (p. 45). Behavioral strategies are used to test and al- ter automatic thoughts and assumptions and to facilitate new learning. In a behavioral experi- ment, for instance, a patient may predict an out- come based on his or her automatic thoughts and beliefs, conduct an agreed-upon behavior, and evaluate the evidence in the context of the results of this new experiment. A related ap- proach is hypothesis testing, which has both cognitive and behavioral components. A resi- dent who insists, “I am not a good doctor,” for example, can be asked to generate a list of char- acteristics or criteria that would constitute be- ing a good physician (e.g., ability to establish rapport; knowledge base; capacity for making

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decisions under pressure). The “experiment” would then involve collecting data by monitor- ing his or her behavior and seeking input from colleagues and supervisors which may help to modify this conviction (e.g., “I am a good doctor for my level of experience and training”) (14). Other behavioral techniques are used to alter the patient’s reinforcement schedule (thereby increasing pleasure or mastery), habituate to feared stimuli (exposure therapy), relax (pro- gressive muscle relaxation), or prepare for up- coming situations (behavioral rehearsal). Given that these strategies are used to foster cognitive change, the therapist routinely assesses the pa- tient’s perceptions, thoughts, and conclusions after each experiment (14). Cognitive restructuring strategies are also used to help patients identify and test the va- lidity of their cognitions. One important tech- nique for eliciting and evaluating negative auto- matic thoughts is the Daily Record of Thoughts (DRT). A DRT entry consists of three columns representing the situation encountered, the emotion or symptoms experienced, and associ- ated thoughts. Once patients are reliably able to identify the automatic thoughts that carry the greatest emotional charge, the process of an- swering back to these thoughts (or putting them on trial) can begin. This process often involves writing down the evidence that pertains to a particular belief and developing an alternative thought that incorporates the facts that bear on the belief. By writing down an activating event, the mediating thoughts, and the ensuing emotional response, the patient maintaining a DRT achieves more objectivity about and dis- tance from his or her thoughts. The evidence pertaining to a particular belief is then exam- ined using guided discovery and collaborative empiricism. Specifically, patients are asked a number of questions, including: “What is the evidence for or against this belief?” “What are the alter- native ways to think about this situation?” “If my best friend or loved one knew that I had this thought, what would he or she say to me?” “What would it mean about me even if this par- ticular thought was true?” (25, 30–32). From

402 Beck · Dozois

this analysis of the evidence, patients are then taught to generate alternative thoughts that in- corporate the evidence and lead to a shift in their emotional experience. If a given thought is inconsistent with the weight of factual evi- dence on the subject (e.g., “I am unlovable”), the therapist helps the patient to alter and re- align the thought so that it is evidence-based and, consequently, more adaptive and helpful. Sometimes collecting more information or con- ducting a behavioral experiment is also used to test a certain belief. After a number of sessions using the DRT, the therapist and patient may notice a consistent pattern in the types of automatic thoughts that are elicited. This is because automatic thoughts and cognitive distortions (e.g., “If I fail at X, then I am not worthwhile”) are functionally re- lated to deeper core beliefs and schemas. The modification of these core beliefs and schemas is believed to result in the most generaliz- able change and the greatest prevention of re- lapse (33, 34). These “deeper” beliefs are tested and reconfigured using Socratic dialogue and guided discovery, role plays, behavioral exper- iments, and other change strategies (11, 15, 25, 30). The final sessions of treatment are focused on consolidating the skills learned and on the prevention of relapse/recurrence. This in- cludes, among other things, a gradual titra- tion of sessions and spreading apart of their timing, reviewing the treatment strategies that were utilized and were most helpful, creating a plan for the future, discussing feelings about the termination of therapy, preparing for set- backs, identifying possible triggers of relapse, and ensuring that the patient makes internal at- tributions for change.

EMPIRICAL EVIDENCE FOR COGNITIVE THERAPY

CT/CBT is one of the most actively researched psychotherapies (35) and has received consis- tent empirical support for a host of mental health problems and conditions (36, 37). We focus first on the efficacy of CT for depression,

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as this has been most extensively studied, and also highlight findings for other psychiatric dis- orders and medical illnesses.

CT for Unipolar Depression

More than 75 clinical trials and numerous meta- analyses have been published on CT for unipo- lar depression (35). For an acute episode of depression, the response achieved with CT is similar to that achieved with behavior therapy (38), other bona fide psychological treatments (39), and antidepressant medication, and all of these produce results superior to placebo (see 27, 40). Early findings (41) suggesting that CT was not effective for severe depression (42) have generated considerable controversy among re- searchers, and the perception that CT is not effective for severe depression has persisted despite compelling data to suggest otherwise (see 11 for review). DeRubeis et al. (43), for example, conducted a mega-analysis in which they pooled the data from four related tri- als and found that CT was as effective as an- tidepressants (imipramine and nortripyline) for the treatment of severely depressed individu- als. More recent studies have also demonstrated that CT and pharmacotherapy (paroxetine) are equally effective for severe depression (44, 45). The weight of evidence suggests that CT/CBT is efficacious for depression, though it remains possible that the effect may be somewhat over- estimated as a result of publication bias (e.g., the file-drawer effect; see 46). In addition to its efficacy for the acute phase of major depressive disorder, CT also carries an advantage, relative to antidepressant medi- cation, for the prevention of relapse. Gloaguen et al. (47), for instance, reported that the av- erage risk of relapse (based on follow-up pe- riods of one to two years) was 25% following CT compared to 60% following antidepres- sant medication. Some studies also indicate that patients who receive CT alone are no more likely to relapse after treatment than are those who continue to receive medication (45, 48). Hollon et al. (45) found equal outcomes be- tween medication and CT in the acute phase of

treatment, but a lower relapse rate for CT com- pared to continuance medication. Consistent with these findings are studies that have examined potential mechanisms for the prophylactic benefits of CT. It appears that CT and antidepressant medication may both change certain aspects of negative thinking (such as information processing, automatic thoughts, and dysfunctional attitudes; e.g., 22, 33) but that CT may further modify some of the “deeper” cognitive structures (e.g., reduced activation of negative thinking following a negative mood manipulation 1 in CT relative to pharmacotherapy) that give rise to relapse and recurrence (23, 33, 34, 49). Several studies have also assessed neuroimaging changes in cognitive therapy (50). Goldapple et al. (51), for example, examined neurobiological responses to CT (in unmedicated depressed outpatients) and compared these findings to an independent sample of individuals treated with selective serotonin reuptake inhibitors (SSRIs). Dif- ferential pre- versus post-treatment changes in brain metabolic activity (measured by positron emission tomography) were obtained in individuals treated with CT compared to those treated with antidepressant medication. These researchers proposed that a top-down (cortical-limbic) therapeutic mechanism may have been active in CT, whereas a bottom-up (limbic-cortical) mechanism may have been active in antidepressant treatment.

CT for Other Psychiatric Disorders

Butler et al. (35) reviewed meta-analyses of treatment outcome for CT/CBT for a num- ber of psychological disorders. A total of 16 methodologically rigorous meta-analyses were identified from 1967 to 2004, which incorpo- rated 9,995 research participants in 332 stud- ies. The review focused on effect sizes found by studies that compared outcomes of CT/CBT

1 A negative mood state is induced by prompting research participants to think of a sad time in their lives, by listening to sad music, etc.

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with outcomes for control groups, providing an overview of the efficacy of CT/CBT. Large ef- fect sizes were obtained for patients with unipo- lar depression, generalized anxiety disorder, panic disorder, social anxiety, and childhood internalizing problems (the latter included de- pressive, anxious, and somatic disorders). Mod- erate effect sizes were found for patients treated for couple distress, anger, childhood somato- form disorders, and chronic pain. Small effect sizes were obtained for recidivism in sexual of- fenders. CBT also showed promising results as an adjunct to medication for schizophrenia (10). Epp & Dobson (40) recently reviewed the treatment-outcome literature for CT/CBT and summarized the meta-analytic data according to absolute efficacy (the extent to which CBT demonstrates superior outcome to no treat- ment, waitlist controls, or treatment as usual), efficacy relative to pharmacotherapy, and effi- cacy compared to other forms of psychotherapy (see Table 2). Considerable empirical support has accumulated for the efficacy of CT/CBT. For some disorders (e.g., some anxiety disor- ders, bulimia nervosa), the evidence is com- pelling enough to suggest that CT/CBT should be considered the treatment of choice. The literature also suggests that CT/CBT is at least as effective as medication for a range of problems, although direct comparisons are not found for some disorders (e.g., bipolar disorder, psychosis) for which CT/CBT is used adjunc- tively (25). A recent meta-analysis of CT/CBT in the treatment of schizophrenia, severe de- pression, and bipolar disorder was less positive (52), suggesting that CT/CBT is no more ef- fective than nonspecific interventions for the treatment of schizophrenia, although method- ological flaws in the meta-analysis tend to vitiate the findings (53).

CT for Medical Illnesses

CT/CBT is also effective for the treatment of anxiety and depression that are comorbid with medical problems (54). In addition, a number of randomized controlled trials have reported benefits of CT/CBT for a wide range of

404 Beck · Dozois

physical illnesses including chronic pain, back pain, sleep disorders, fatigue and functional impairments related to cancer, health-related anxiety, rheumatoid arthritis, chronic fatigue syndrome, fibromyalgia, irritable bowel syn- drome, hypertension, tinnitus, headaches, sexual dysfunctions, and various neurological conditions (54, 55). CT/CBT has demon- strated efficacy for a number of psychological outcome variables (e.g., distress, attitudes, adherence to treatment regime, improved coping with pain) as well as physiological in- dices that are impacted by stress (e.g., lowered blood pressure, improved immune response; see Reference 54 for review). For some ill- nesses, there have been a sufficient number of studies to warrant systematic reviews and meta-analyses. This literature demonstrates various biopsychosocial benefits of CT/CBT for back pain (56, 57), hypochrondriasis (58), irritable bowel syndrome (59), chronic fatigue (58, 60), fibromyalgia (61), headache (62), insomnia (63, 64), adjustment to cancer (65, 66), and the management of diabetes (67).

SUMMARY AND FUTURE DIRECTIONS

Considerable empirical evidence has accumu- lated that supports the theory and practice of CT, and this model has been expanded over time to incorporate evidence from experimen- tal cognitive science and the neurosciences (13, 16, 68). Moreover, several official reports in the United Kingdom and the United States have recommended the use of CT/CBT for a number of common psychiatric conditions (4). Notwithstanding these treatment recommen- dations and the wealth of research underlying CT, it is not a panacea for all mental health problems (e.g., 69). For example, more purely behavioral interventions sometimes perform as well as CT/CBT for depression and anxiety in psychotherapy outcome trials. It is important to point out, however, that the use of behav- ioral interventions has always been part and parcel of CT proper (15). In addition, the the- ory states that whatever treatment is used so

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Table 2 Summary of efficacy findings by disorder or problem (40; reprinted with permission)

       

Efficacy relative

Absolute

Efficacy relative

to other

Disorder

Treatment

efficacy

to medications

psychotherapies

Unipolar depression

CBT

+

+

Bipolar disorder

CBT

+

 

=

Specific phobia

Exposure and cognitive restructuring

++

+

+

Social phobia

Exposure and cognitive restructuring

++

Obsessive-compulsive disorder

Exposure and response prevention and cognitive restructuring

+

 

+

Panic disorder

Exposure and cognitive restructuring

++

+

Chronic post-traumatic stress disorder

Exposure and cognitive techniques

+

 

=

Generalized anxiety disorder

CBT

+

+

+

Bulimia nervosa

CBT

+

+

+

Binge eating disorder

CBT

+

 

=

Anorexia nervosa

CBT

+

+

=

Schizophrenia

CBT

+

 

+

Marital distress

CBT

+

 

Anger & violent offending

CBT

+

   

Sexual offending

CBT

+

∗∗

+

Chronic pain

CBT

+

 

Borderline personality disorder

CBT

+

 

Substance-use disorders

CBT

+

 

=

Somatoform disorders

CBT

+

+

+

Sleep difficulties

CBT

+

+

+

Symbols: A blank space indicates insufficient or no evidence; –, negative evidence; +, positive evidence; = , approximate equivalence; ++, treatment of choice; equivocal evidence; CBT, efficacy of specific components unknown; , CBT is typically used as an adjunct to medication in these disorders; , efficacy relative to physical treatments (i.e., surgical castration and hormonal treatments).

that the patient improves (or if improvement occurs via spontaneous remission), the negative beliefs must also normalize. Indeed, Harmer et al. (22) recently found that the administra- tion of antidepressant medication modulated emotional processing in depressed individuals prior to shifts in their mood state or symptoms. Such findings support the primacy of cognition in therapeutic change and are consistent with the idea that there are myriad ways in which to modify cognition. In addition to altering infor- mation processing, however, we contend that

CT also produces shifts in “deeper” levels of cognition (23, 33) and that targeting this depth of change may account for reduced relapse rates in CT relative to medication. There are a number of important future di- rections for the field. During the past couple of decades, we have witnessed a tremendous in- crease in multiwave 2 longitudinal studies that

2 Multiple points of assessment, not just pre- and post- intervention.

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have supported the diathesis-stress model of cognitive vulnerability (18). Researchers are also better understanding gene-environment interactions in the context of psychopathology. For example, a replicable relationship has been found between negative cognitive processing and the short version of the serotonin trans- porter gene (68). Additional empirical work is necessary to further elucidate how genetic, neu- rophysiological, environmental, and cognitive factors contribute to psychopathology and to understand the intricate relationships among cognitive, affective, motivational, and behav- ioral systems. Future research will no doubt also

clarify the important mechanisms of change in CT. Some studies have, indeed, suggested that cognitive change is an important mediator of symptom change (11, 19, 33), but additional re- search is needed to ensure that these findings are robust and, if they are, to determine which strategies (and psychotherapeutic doses) pro- duce the most stable cognitive change. Enor- mous strides have been made in understanding, evaluating, and refining CT over the past four and a half decades. We believe that similar fu- ture progress will be made in improving our knowledge base of cognitive vulnerability and optimizing the delivery of CT.

SUMMARY POINTS

1. CT/CBT is the fastest growing and most researched contemporary system of psychotherapy.

2. The empirical literature has provided considerable support for Beck’s cognitive theory and therapy.

3. Three main propositions in CT are the access hypothesis (it is possible for individuals to become aware of the content and processing of their thinking), the mediation hypothesis (the way in which individuals think about themselves and their circumstances impacts subsequent emotional and behavioral responses), and the change hypothesis (by modi- fying cognitive and behavioral responses, an individual can become more functional and adaptive).

4. The main techniques used in CT focus on establishment of the therapeutic relationship, behavioral change strategies, cognitive restructuring, the modification of core beliefs and schemas, and the prevention of relapse and recurrence.

5. A key advantage of CT is that it effectively treats the acute episode of psychiatric disorders (with or without medication) and provides a prophylaxis against relapse.

DISCLOSURE STATEMENT

Aaron T. Beck is President Emeritus of the Beck Institute for Cognitive Therapy, a nonprofit organization. He has no financial interest in this organization.

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Contents

Role of Postmarketing Surveillance in Contemporary Medicine Janet Woodcock, Rachel E. Behrman, and Gerald J. Dal Pan ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 1

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Kawasaki Disease: Novel Insights into Etiology and Genetic Susceptibility

H. Rowley ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 69

State of the Art in Therapeutic Hypothermia Joshua W. Lampe and Lance B. Becker ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 79

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Therapeutics Development for Cystic Fibrosis: A Successful Model for a Multisystem Genetic Disease Melissa A. Ashlock and Eric R. Olson ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 107

Early Events in Sexual Transmission of HIV and SIV and Opportunities for Interventions Ashley T. Haase ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 127

HIV Infection, Inflammation, Immunosenescence, and Aging Steven G. Deeks ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 141

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Interactions Between Gut Microbiota and Host Metabolism Predisposing to Obesity and Diabetes Giovanni Musso, Roberto Gambino, and Maurizio Cassader ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 361

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Cognitive Therapy: Current Status and Future Directions Aaron T. Beck and David J.A. Dozois ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 397

Toward Fulfilling the Promise of Molecular Medicine in Fragile X Syndrome Dilja D. Krueger and Mark F. Bear ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 411

Stress- and Allostasis-Induced Brain Plasticity Bruce S. McEwen and Peter J. Gianaros ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 431

Update on Sleep and Its Disorders Allan I. Pack and Grace W. Pien ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 447

A Brain-Based Endophenotype for Major Depressive Disorder Bradley S. Peterson and Myrna M. Weissman ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 461

Indexes

Cumulative Index of Contributing Authors, Volumes 58–62 ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 475

Cumulative Index of Chapter Titles, Volumes 58–62 ♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣♣ 479

Errata

An online log of corrections to Annual Review of Medicine articles may be found at http://med.annualreviews.org/errata.shtml