Cognitive Therapy: Current Status and Future Directions

ME62CH28-Beck ARI 4 December 2010 14:36

Aaron T. Beck1 and David J.A. Dozois2

1Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania; email: [email protected] 2Department of Psychology, University of Western Ontario, London, Ontario, Canada; email: [email protected]

Annu. Rev. Med. 2011. 62:397–409 Keywords First published online as a Review in Advance on cognitive vulnerability, psychotherapy, treatment outcome, cognitive

Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org August 3, 2010 behavior therapy The Annual Review of Medicine is online at med.annualreviews.org

Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. Abstract This article’s doi: Cognitive therapy is a system of psychotherapy with a powerful theoret- 10.1146/annurev-med-052209-100032 ical infrastructure, which has received extensive empirical support, and Copyright c 2011 by Annual Reviews. a large body of research attesting to its efficacy for a wide range of psy- All rights reserved chiatric and medical problems. This article provides a brief overview 0066-4219/11/0218-0397$20.00 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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OVERVIEW coordinated, goal-oriented strategies (e.g., From its inception more than 45 years ago approaching pleasure, avoiding pain) (13, 14). The fight-flight response, for instance, arises Cognitive schema: (1–3), cognitive therapy has been theory driven. a well-organized Specifically, Beck’s objectives for deriving and from four systems (13): cognitive (perception of cognitive structure of evaluating this system of psychotherapy in- threat), affective (feelings of anxiety or anger), stored information and volved an overall plan to construct a compre- motivational (the impulse to confront or flee memories that forms hensive theory of psychopathology that maps the threatening stimulus), and behavioral (the the basis of core beliefs implementation of action). In this construct, about self and others clearly onto the treatment approach, to inves- tigate scientific support for the theory, and onset of a particular condition (e.g., panic to test the efficacy of therapeutic interven- disorder) is believed to occur when these tions (3, 4). Cognitive theory and therapy were different systems shift from a fairly quiescent first developed for depression (1, 2) and later state to a highly activated state. In the example systematically applied to suicide prevention of panic disorder, this might occur when the (5), anxiety disorders (6), personality disorders fight-flight response is activated by “false (7), substance abuse (8), and, most recently, alarms” (e.g., misperceiving bodily sensations schizophrenia (9, 10). as harmful to the organism). Cognitive theory Cognitive therapy (CT), often discussed un- suggests that psychopathology is characterized der the generic label cognitive behavior therapy by the activation of a conglomerate of related (CBT), is now widely represented in training or contiguous dysfunctional beliefs, meanings, programs in psychology, psychiatry, medicine, and memories that operate in coordination social work, nursing, and other allied health with affect, motivation, behavior, and physio- professions that value evidence-based practice logical responses. Different psychopathological (11). CT and CBT have been described as “the conditions are associated with specific biases fastest growing and most heavily researched that influence how an individual incorporates systems of psychotherapy on the contemporary and responds to new information. scene” (12, p. 332). This article provides a brief According to Beck’s model (1–3, 6, 15, 16), overview of the conceptual, practical, and em- the cognitive appraisal of internal or external pirical aspects of CT. After highlighting some stimuli influences and is, in turn, impacted by of its basic concepts and the research pertain- these other systems. Thus, although cognition ing to Beck’s cognitive theory, we discuss the plays a key role in this model (i.e., the as- general approach to treatment and review the signment of meaning is crucial to understand- literature on its efficacy. We conclude by out- ing maladaptive behavior), it is recognized that lining some directions for future research. mental health problems involve a complex in- terplay among diverse and interrelated systems (17). Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org Within the cognitive system are different COGNITIVE THEORY levels of cognition, ranging from surface-level

Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. Cognitive theory is based on the presumption thoughts to “deeper” cognitive schemas (18, that information processing is crucial for 19). Cognitive schemas are organized structures human adaptation and survival. Without the of stored information that contain individuals’ ability to process information from the envi- perceptions of self and others, goals, expecta- ronment, synthesize it, and formulate a plan tions, and memories. These elements are well- for dealing with it, we would not survive. The organized within the cognitive structure (20) cognitive (or information processing) system is and inﬂuence the screening, coding, categoriza- intricately tied to other affective, motivational, tion, and interpretation of incoming stimuli and and behavioral repertoires. Each of these the retrieval of stored information. Schemas repertoires, or systems, serves an individual are adaptive insofar as they afford efﬁcient pro- function and also operates in synchrony toward cessing of information; however, when they

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become negatively biased, maladaptive, rigid, proximal to a given situation than are other lev- and self-perpetuating, they can contribute to els of cognition, they are functionally related to psychopathology. one’s deeper beliefs and schemas and seem to Diathesis-stress Maladaptive cognitive schemas are believed arise associatively as different aspects of one’s model: to develop during early periods of the life core belief system are activated. a psychological theory span and become increasingly consolidated and When negative cognitive schemas are acti- that predicts that organized as new experiences are assimilated vated, as in depression, they are not only identi- psychiatric disorders into the existing belief structure (3, 15). Poor fiable but can be shown to have an influence on result from the interaction of a early attachment experiences and other adverse information processing, as manifested by cog- predisposition (e.g., events (e.g., childhood maltreatment), for ex- nitive biases, and have an impact on symptom genetic, cognitive ample, may contribute to the development of development. When a depressive episode has diatheses) and negative a maladaptive belief system. Cognitive theory remitted, the negative schemas are deactivated life events. When an is essentially a diathesis-stress model. In other (or vice versa). underlying vulnerability is strong, words, it is possible to have a maladaptive belief Another aspect of Beck’s model is content less stress is necessary system and not exhibit symptoms so long as the specificity (16, 17). That is, different emotional to trigger the behavior cognitive schema (and related systems) is not experiences and forms of psychopathology are or disorder; when the activated. Once triggered by external events, related to a unique cognitive profile or set of predisposition is weak, drugs, or endocrine factors, however, the cog- beliefs (see Table 1 for some examples of sys- a greater amount of stress is typically nitive schema triggers a cascade of information- tematic biases associated with different disor- needed before an processing biases (1, 4, 15, 16, 18). These may ders). To illustrate, depression is related to individual develops the be attention, memory, or interpretational bi- thoughts and beliefs concerning personal loss, disorder ases. For instance, individuals with anxiety dis- deprivation, and failure (15). Persons with clini- Automatic thoughts: orders perceive themselves as vulnerable and cally significant anxiety tend to overestimate the the flow of cognitions the world as dangerous. Such individuals at- probability of risk while simultaneously under- (considered the tend selectively to threat-pertinent information estimating their resources for coping with po- cognitive byproducts of activated schemas) at the expense of information that is inconsis- tential threats. Their thoughts focus on themes that arise in our tent with threat or information that suggests of the self as vulnerable, the world as danger- day-to-day lives and one has sufficient resources for dealing with it. ous, and the future as potentially catastrophic are not accompanied An individual who is vulnerable to depression, (6). A person with dependent personality disor- by direct deliberation to consider another example, may have an under has a view of the self as weak, helpless, and or volition derlying belief that he or she is unlovable. This incompetent (7). belief may become especially salient when ad- The empirical literature has provided con- verse circumstances activate an underlying neg- siderable support for various aspects of Beck’s ative schema. Such an individual may then at- cognitive theory. Hundreds of studies have tend selectively to and recall information that is demonstrated that individuals filter informa- Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org consistent with this negative view of self (e.g., tion and respond to stimuli in a way that is paying attention to cues that are suggestive of consistent with their preexisting beliefs and

Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. being unloved and minimizing information that assumptions. Some research has also demon- is inconsistent with that belief). strated that negative cognitive biases precede The activation of a maladaptive cognitive the development of anxious (e.g., 21) and de- schema, along with the ensuing information- pressive (e.g., 22) symptoms. Supportive ev- processing biases, is also apparent in more idence has been obtained for the ideas that surface-level cognitions or what are referred to there are distinct levels of cognition that work as automatic thoughts. This term refers to the in synchrony to impact emotional and behav- stream of positive and negative thoughts that ioral responses and that an emotional experi- runs through an individual’s mind unaccom- ence or clinical disorder can be characterized by panied by direct, conscious deliberation. Al- a unique set of beliefs and automatic thoughts though such thoughts are more superﬁcial and (i.e., content speciﬁcity; see 16, 18). Schema

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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 validity of one’s belief system) (27). This the contribution of cognitive vulnerability to general approach is used early in therapy to the incidence of psychiatric disorders (e.g., 24) target more proximal and surface-level cogni- have also been supported by empirical research. tions (e.g., automatic thoughts, dysfunctional attitudes) and in later sessions to modify deeper cognitive structures and core beliefs. COGNITIVE THERAPY CT is not the replacement of negative CT rests on three main propositions (25, 26): thoughts with positive ones; rather, it aims to help individuals shift their cognitive appraisals The access hypothesis: With appropriate from ones that are unhealthy and maladaptive training, motivation, and attention, indi- to ones that are evidence-based and adaptive. viduals can become aware of the content Essentially, patients learn how to become sci- and process of their thinking. entiﬁc investigators of their own thinking—to The mediation hypothesis: The manner treat thoughts as hypotheses rather than as in which individuals think about, inter- facts and to put these thoughts to the test. pret, and construe events inﬂuences their Framing a belief as a hypothesis provides an emotional and behavioral responses. opportunity to test its validity, affords patients The change hypothesis: Individuals can the ability to consider alternative explanations, Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org become more functional and adaptive by and permits them to gain distance from a intentionally modifying their cognitive thought to allow more objective scrutiny (11).

Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. and behavioral responses to the circum- Patients learn to modify their thoughts so that stances they face. they are congruent with existing evidence. Cognitive therapy is a structured, collaborative When thoughts are aligned with evidence, and process that helps individuals to consider both negative feelings exist, the cognitive therapist the accuracy and usefulness of their thoughts helps patients to deal with emotional sequelae through processes of exploration (determin- by introducing coping strategies, fostering skill ing one’s idiosyncratic meaning system and development and/or problem solving. maladaptive beliefs), examination (reviewing Cognitive therapists help patients to move the evidence for and against a particular be- through the process of exploration, exami- lief and considering alternative interpretations nation, and experimentation using collabora- or explanations), and experimentation (testing tive empiricism, guided discovery, and Socratic

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dialogue. Collaborative empiricism means that in the weekly therapy session by applying them the patient and the therapist become coinvesti- in the “real world,” and improves treatment gators both in ascertaining the goals for treat- outcome (29). ment and investigating the patient’s thoughts. The specific techniques utilized in CT tend Methods of guided discovery are used to help to vary depending on the disorder being treated patients to test their own thinking through per- and the case formulation. They typically in- sonal observations and experiments rather than clude (a) establishing the therapy relationship, via cajoling or persuasion. Through this pro- (b) behavioral change strategies, (c) cognitive cess, patients are able to shift from “a convic- restructuring strategies, (d ) modification of tion mode to a questioning mode” (28, p. 216). core beliefs and schemas, and (e) prevention of In addition, by collaboratively designing new relapse/recurrence. Given that it is not possible experiences to try out (called behavioral exper- to describe the science and art of CT in this iments), patients are able to acquire a different brief article (interested readers are referred to perspective on themselves and their situations more detailed discussions in 11, 14, 25, 30), we (14). Socratic dialogue is a method of guided instead provide a capsule summary of these five discovery in which the therapist asks a series components. of carefully sequenced questions to help define The therapeutic relationship is a key in- problems, assist in the identification of thoughts gredient of all psychotherapies, including CT. and beliefs, examine the meaning of events, or There appears to be a bidirectional relationship assess the ramifications of particular thoughts between the patient’s perception of the thera- or behaviors. peutic alliance and outcome: The connection CT is time limited. The average length between patient and therapist may facilitate of CT in outcome studies is between 12 and change, and symptom change, in turn, en- 24 weekly sessions, although there is more hances the bond between patient and therapist variability in clinical practice (25). The initial (11). Many of the basic interpersonal vari- sessions are often focused on enhancing the ables common to other psychotherapies (e.g., therapeutic alliance, identifying the specific warmth, accurate empathy, unconditional pos- problem(s) that brought the patient into treat- itive regard) serve as an important foundation ment, socializing the patient to the cognitive for cognitive and symptomatic change. As Beck understanding of psychopathology, and symp- et al. (15) noted, however, these characteristics tom relief via behavioral strategies. At this time, “in themselves are necessary but not sufficient the therapist plays a more active role than the to produce an optimum therapeutic effect” patient. As therapy progresses, the emphasis (p. 45). shifts from symptom amelioration to the exam- Behavioral strategies are used to test and al- ination and modification of the patient’s pat- ter automatic thoughts and assumptions and to Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org terns of thinking, and the patient assumes a facilitate new learning. In a behavioral experi- more active role in identifying problems and so- ment, for instance, a patient may predict an out-

Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. lutions and developing homework assignments. come based on his or her automatic thoughts Toward the end of therapy, sessions are usually and beliefs, conduct an agreed-upon behavior, spread apart so that the patient can consolidate and evaluate the evidence in the context of the gains and increase his or her conﬁdence in the results of this new experiment. A related ap- application of newly learned skills. “Booster” proach is hypothesis testing, which has both sessions are frequently scheduled one or two cognitive and behavioral components. A resi- months after the end of therapy. dent who insists, “I am not a good doctor,” for Homework assignments (also called action example, can be asked to generate a list of char- plans) are an important component of CT. acteristics or criteria that would constitute be- Homework provides opportunities to enhance ing a good physician (e.g., ability to establish the mastery and generalization of skills learned rapport; knowledge base; capacity for making

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decisions under pressure). The “experiment” this analysis of the evidence, patients are then would then involve collecting data by monitor- taught to generate alternative thoughts that in- ing his or her behavior and seeking input from corporate the evidence and lead to a shift in colleagues and supervisors which may help to their emotional experience. If a given thought modify this conviction (e.g., “I am a good doctor is inconsistent with the weight of factual evi- for my level of experience and training”) (14). dence on the subject (e.g., “I am unlovable”), Other behavioral techniques are used to alter the therapist helps the patient to alter and re- the patient’s reinforcement schedule (thereby align the thought so that it is evidence-based increasing pleasure or mastery), habituate to and, consequently, more adaptive and helpful. feared stimuli (exposure therapy), relax (pro- Sometimes collecting more information or con- gressive muscle relaxation), or prepare for up- ducting a behavioral experiment is also used to coming situations (behavioral rehearsal). Given test a certain belief. that these strategies are used to foster cognitive After a number of sessions using the DRT, change, the therapist routinely assesses the pa- the therapist and patient may notice a consistent tient’s perceptions, thoughts, and conclusions pattern in the types of automatic thoughts that after each experiment (14). are elicited. This is because automatic thoughts Cognitive restructuring strategies are also and cognitive distortions (e.g., “If I fail at X, used to help patients identify and test the va- then I am not worthwhile”) are functionally re- lidity of their cognitions. One important tech- lated to deeper core beliefs and schemas. The nique for eliciting and evaluating negative auto- modification of these core beliefs and schemas matic thoughts is the Daily Record of Thoughts is believed to result in the most generaliz- (DRT). A DRT entry consists of three columns able change and the greatest prevention of re- representing the situation encountered, the lapse (33, 34). These “deeper” beliefs are tested emotion or symptoms experienced, and associ- and reconfigured using Socratic dialogue and ated thoughts. Once patients are reliably able to guided discovery, role plays, behavioral exper- identify the automatic thoughts that carry the iments, and other change strategies (11, 15, greatest emotional charge, the process of an- 25, 30). swering back to these thoughts (or putting them The final sessions of treatment are focused on trial) can begin. This process often involves on consolidating the skills learned and on writing down the evidence that pertains to a the prevention of relapse/recurrence. This in- particular belief and developing an alternative cludes, among other things, a gradual titra- thought that incorporates the facts that bear tion of sessions and spreading apart of their on the belief. By writing down an activating timing, reviewing the treatment strategies that event, the mediating thoughts, and the ensuing were utilized and were most helpful, creating emotional response, the patient maintaining a a plan for the future, discussing feelings about Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org DRT achieves more objectivity about and dis- the termination of therapy, preparing for set- tance from his or her thoughts. The evidence backs, identifying possible triggers of relapse,

Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. pertaining to a particular belief is then exam- and ensuring that the patient makes internal at- ined using guided discovery and collaborative tributions for change. empiricism. Specifically, patients are asked a number of questions, including: “What is the evidence for EMPIRICAL EVIDENCE FOR or against this belief?” “What are the alter- COGNITIVE THERAPY native ways to think about this situation?” “If CT/CBT is one of the most actively researched my best friend or loved one knew that I had psychotherapies (35) and has received consis- this thought, what would he or she say to me?” tent empirical support for a host of mental “What would it mean about me even if this par- health problems and conditions (36, 37). We ticular thought was true?” (25, 30–32). From focus first on the efficacy of CT for depression,

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as this has been most extensively studied, and treatment, but a lower relapse rate for CT com- also highlight findings for other psychiatric dis- pared to continuance medication. orders and medical illnesses. Consistent with these findings are studies that have examined potential mechanisms for the prophylactic benefits of CT. It appears that CT for Unipolar Depression CT and antidepressant medication may both More than 75 clinical trials and numerous meta- change certain aspects of negative thinking analyses have been published on CT for unipo- (such as information processing, automatic lar depression (35). For an acute episode of thoughts, and dysfunctional attitudes; e.g., 22, depression, the response achieved with CT is 33) but that CT may further modify some of similar to that achieved with behavior therapy the “deeper” cognitive structures (e.g., reduced (38), other bona fide psychological treatments activation of negative thinking following a (39), and antidepressant medication, and all of negative mood manipulation1 in CT relative these produce results superior to placebo (see to pharmacotherapy) that give rise to relapse 27, 40). Early findings (41) suggesting that CT and recurrence (23, 33, 34, 49). Several studies was not effective for severe depression (42) have have also assessed neuroimaging changes in generated considerable controversy among re- cognitive therapy (50). Goldapple et al. (51), for searchers, and the perception that CT is not example, examined neurobiological responses effective for severe depression has persisted to CT (in unmedicated depressed outpatients) despite compelling data to suggest otherwise and compared these findings to an independent (see 11 for review). DeRubeis et al. (43), for sample of individuals treated with selective example, conducted a mega-analysis in which serotonin reuptake inhibitors (SSRIs). Dif- they pooled the data from four related tri- ferential pre- versus post-treatment changes als and found that CT was as effective as an- in brain metabolic activity (measured by tidepressants (imipramine and nortripyline) for positron emission tomography) were obtained the treatment of severely depressed individu- in individuals treated with CT compared to als. More recent studies have also demonstrated those treated with antidepressant medication. that CT and pharmacotherapy (paroxetine) are These researchers proposed that a top-down equally effective for severe depression (44, 45). (cortical-limbic) therapeutic mechanism may The weight of evidence suggests that CT/CBT have been active in CT, whereas a bottom-up is efficacious for depression, though it remains (limbic-cortical) mechanism may have been possible that the effect may be somewhat over- active in antidepressant treatment. estimated as a result of publication bias (e.g., the file-drawer effect; see 46). In addition to its efficacy for the acute phase CT for Other Psychiatric Disorders Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org of major depressive disorder, CT also carries Butler et al. (35) reviewed meta-analyses of an advantage, relative to antidepressant medi- treatment outcome for CT/CBT for a num- Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. cation, for the prevention of relapse. Gloaguen ber of psychological disorders. A total of 16 et al. (47), for instance, reported that the av- methodologically rigorous meta-analyses were erage risk of relapse (based on follow-up pe- identified from 1967 to 2004, which incorpo- riods of one to two years) was 25% following rated 9,995 research participants in 332 stud- CT compared to 60% following antidepres- ies. The review focused on effect sizes found by sant medication. Some studies also indicate that studies that compared outcomes of CT/CBT patients who receive CT alone are no more likely to relapse after treatment than are those who continue to receive medication (45, 48). 1A negative mood state is induced by prompting research Hollon et al. (45) found equal outcomes be- participants to think of a sad time in their lives, by listening tween medication and CT in the acute phase of to sad music, etc.

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with outcomes for control groups, providing an physical illnesses including chronic pain, back overview of the efficacy of CT/CBT. Large ef- pain, sleep disorders, fatigue and functional fect sizes were obtained for patients with unipo- impairments related to cancer, health-related lar depression, generalized anxiety disorder, anxiety, rheumatoid arthritis, chronic fatigue panic disorder, social anxiety, and childhood syndrome, fibromyalgia, irritable bowel syn- internalizing problems (the latter included de- drome, hypertension, tinnitus, headaches, pressive, anxious, and somatic disorders). Mod- sexual dysfunctions, and various neurological erate effect sizes were found for patients treated conditions (54, 55). CT/CBT has demon- for couple distress, anger, childhood somato- strated efficacy for a number of psychological form disorders, and chronic pain. Small effect outcome variables (e.g., distress, attitudes, sizes were obtained for recidivism in sexual of- adherence to treatment regime, improved fenders. CBT also showed promising results as coping with pain) as well as physiological in- an adjunct to medication for schizophrenia (10). dices that are impacted by stress (e.g., lowered Epp & Dobson (40) recently reviewed the blood pressure, improved immune response; treatment-outcome literature for CT/CBT and see Reference 54 for review). For some ill- summarized the meta-analytic data according nesses, there have been a sufficient number to absolute efficacy (the extent to which CBT of studies to warrant systematic reviews and demonstrates superior outcome to no treat- meta-analyses. This literature demonstrates ment, waitlist controls, or treatment as usual), various biopsychosocial benefits of CT/CBT efficacy relative to pharmacotherapy, and effi- for back pain (56, 57), hypochrondriasis (58), cacy compared to other forms of psychotherapy irritable bowel syndrome (59), chronic fatigue (see Table 2). Considerable empirical support (58, 60), fibromyalgia (61), headache (62), has accumulated for the efficacy of CT/CBT. insomnia (63, 64), adjustment to cancer (65, For some disorders (e.g., some anxiety disor- 66), and the management of diabetes (67). ders, bulimia nervosa), the evidence is compelling enough to suggest that CT/CBT should be considered the treatment of choice. The SUMMARY AND literature also suggests that CT/CBT is at FUTURE DIRECTIONS least as effective as medication for a range of Considerable empirical evidence has accumu- problems, although direct comparisons are not lated that supports the theory and practice of found for some disorders (e.g., bipolar disorder, CT, and this model has been expanded over psychosis) for which CT/CBT is used adjunc- time to incorporate evidence from experimen- tively (25). A recent meta-analysis of CT/CBT tal cognitive science and the neurosciences (13, in the treatment of schizophrenia, severe de- 16, 68). Moreover, several official reports in pression, and bipolar disorder was less positive the United Kingdom and the United States Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org (52), suggesting that CT/CBT is no more ef- have recommended the use of CT/CBT for a fective than nonspecific interventions for the number of common psychiatric conditions (4).

Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. treatment of schizophrenia, although method- Notwithstanding these treatment recommen- ological flaws in the meta-analysis tend to vitiate dations and the wealth of research underlying the findings (53). CT, it is not a panacea for all mental health problems (e.g., 69). For example, more purely behavioral interventions sometimes perform as CT for Medical Illnesses well as CT/CBT for depression and anxiety in CT/CBT is also effective for the treatment of psychotherapy outcome trials. It is important anxiety and depression that are comorbid with to point out, however, that the use of behav- medical problems (54). In addition, a number ioral interventions has always been part and of randomized controlled trials have reported parcel of CT proper (15). In addition, the the- benefits of CT/CBT for a wide range of 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 Exposure and cognitive + = disorder 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). Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org

that the patient improves (or if improvement CT also produces shifts in “deeper” levels of

Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. occurs via spontaneous remission), the negative cognition (23, 33) and that targeting this depth beliefs must also normalize. Indeed, Harmer of change may account for reduced relapse rates et al. (22) recently found that the administra- in CT relative to medication. tion of antidepressant medication modulated There are a number of important future di- emotional processing in depressed individuals rections for the ﬁeld. During the past couple prior to shifts in their mood state or symptoms. of decades, we have witnessed a tremendous in- Such ﬁndings support the primacy of cognition crease in multiwave2 longitudinal studies that in therapeutic change and are consistent with the idea that there are myriad ways in which to

modify cognition. In addition to altering infor- 2Multiple points of assessment, not just pre- and post- mation processing, however, we contend that intervention.

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have supported the diathesis-stress model of clarify the important mechanisms of change in cognitive vulnerability (18). Researchers are CT. Some studies have, indeed, suggested that also better understanding gene-environment cognitive change is an important mediator of interactions in the context of psychopathology. symptom change (11, 19, 33), but additional re- For example, a replicable relationship has been search is needed to ensure that these ﬁndings found between negative cognitive processing are robust and, if they are, to determine which and the short version of the serotonin trans- strategies (and psychotherapeutic doses) pro- porter gene (68). Additional empirical work is duce the most stable cognitive change. Enor- necessary to further elucidate how genetic, neu- mous strides have been made in understanding, rophysiological, environmental, and cognitive evaluating, and reﬁning CT over the past four factors contribute to psychopathology and to and a half decades. We believe that similar fu- understand the intricate relationships among ture progress will be made in improving our cognitive, affective, motivational, and behav- knowledge base of cognitive vulnerability and ioral systems. Future research will no doubt also 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 modifying 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. Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org

DISCLOSURE STATEMENT Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. Aaron T. Beck is President Emeritus of the Beck Institute for Cognitive Therapy, a nonproﬁt organization. He has no ﬁnancial interest in this organization.

LITERATURE CITED 1. Beck AT. 1963. Thinking and depression 0.1. Idiosyncratic content and cognitive distortions. Arch. Gen. Psychiatry 9:324–33 2. Beck AT. 1964. Thinking and depression. 2. Theory and therapy. Arch. Gen. Psychiatry 10:561–71 3. Beck AT. 1976. Cognitive Therapy and the Emotional Disorders. New York: Int. Univ. Press. 346 pp. 4. Beck AT. 2005. The current state of cognitive therapy: a 40-year retrospective. Arch. Gen. Psychiatry 62:953–59

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58. Looper KJ, Kirmayer LJ. 2002. Behavioral medicine approaches to somatoform disorders. J. Consult. Clin. Psychol. 70:810–27 59. Blanchard EB, Scharff L. 2002. Psychosocial aspects of assessment and treatment of irritable bowel syndrome in adults and recurrent abdominal pain in children. J. Consult. Clin. Psychol. 70:725–38 60. Malouff JA, Thorsteinsson EB, Rooke SE, et al. 2008. Efficacy of cognitive behavioral therapy for chronic fatigue syndrome: a meta-analysis. Clin. Psychol. Rev. 28:736–45 61. Hauser¨ W, Thieme K, Turk DC. 2010. Guidelines on the management of fibromyalgia syndrome—a systematic review. Eur. J. Pain 14:5–10 62. Holroyd KA. 2002. Assessment and psychological management of recurrent headache disorders. J. Consult. Clin. Psych. 70:656–77 63. Wang MY, Wang SY, Tsai PS. 2005. Cognitive behavioural therapy for primary insomnia: a systematic review. J. Adv. Nurs. 50:553–64 64. de Niet GJ, Tiemens BG, Kloos MW, et al. 2009. Review of systematic reviews about the efficacy of nonpharmacological interventions to improve sleep quality in insomnia. Int. J. Evidence-Based Health 7:233–42 65. Osborn RL, Demoncada AC, Feuerstein M. 2006. Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: meta-analyses. Int. J. Psychiatry Med. 36:13–34 66. Hersch J, Juraskova I, Price M, et al. 2009. Psychosocial interventions and quality of life in gynaecological cancer patients: a systematic review. Psychooncology 18:795–810 67. Fisher EB, Thorpe CT, Devellis BM, et al. 2007. Healthy coping, negative emotions, and diabetes management: a systematic review and appraisal. Diabetes Educ. 33:1080–103; discussion 104–6 68. Beck AT. 2008. The evolution of the cognitive model of depression and its neurobiological correlates. Am. J. Psychiatry 165:969–77 69. Longmore RJ, Worrell M. 2007. Do we need to challenge thoughts in cognitive behavior therapy? Clin. Psychol. Rev. 27:173–87 Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only.

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Annual Review of Medicine Contents Volume 62, 2011

Role of Postmarketing Surveillance in Contemporary Medicine Janet Woodcock, Rachel E. Behrman, and Gerald J. Dal Pan pppppppppppppppppppppppppppppp1 Genome-Wide Association Studies: Results from the First Few Years and Potential Implications for Clinical Medicine Joel N. Hirschhorn and Zoﬁa K.Z. Gajdos pppppppppppppppppppppppppppppppppppppppppppppppppp11 Imaging of Atherosclerosis D.R.J. Owen, A.C. Lindsay, R.P. Choudhury, and Z.A. Fayad ppppppppppppppppppppppppppp25 Novel Oral Factor Xa and Thrombin Inhibitors in the Management of Thromboembolism Bengt I. Eriksson, Daniel J. Quinlan, and John W. Eikelboom ppppppppppppppppppppppppppp41 The Fabry Cardiomyopathy: Models for the Cardiologist Frank Weidemann, Markus Niemann, David G. Warnock, Georg Ertl, and Christoph Wanner ppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp59 Kawasaki Disease: Novel Insights into Etiology and Genetic Susceptibility Anne H. Rowley ppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp69 State of the Art in Therapeutic Hypothermia Joshua W. Lampe and Lance B. Becker ppppppppppppppppppppppppppppppppppppppppppppppppppppp79 Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org Therapeutic Potential of Lung Epithelial Progenitor Cells Derived from Embryonic and Induced Pluripotent Stem Cells Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. Rick A. Wetsel, Dachun Wang, and Daniel G. Calame ppppppppppppppppppppppppppppppppppp95 Therapeutics Development for Cystic Fibrosis: A Successful Model for a Multisystem Genetic Disease Melissa A. Ashlock and Eric R. Olson ppppppppppppppppppppppppppppppppppppppppppppppppppppp107 Early Events in Sexual Transmission of HIV and SIV and Opportunities for Interventions Ashley T. Haase ppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp127 HIV Infection, Inﬂammation, Immunosenescence, and Aging Steven G. Deeks pppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp141

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The Increasing Burden of HIV-Associated Malignancies in Resource-Limited Regions Corey Casper pppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp157 Biliary Atresia: Will Blocking Inﬂammation Tame the Disease? Kazuhiko Bessho and Jorge A. Bezerra pppppppppppppppppppppppppppppppppppppppppppppppppppp171 Advances in Palliative Medicine and End-of-Life Care Janet L. Abrahm ppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp187 Clostridium difﬁcile and Methicillin-Resistant Staphylococcus aureus: Emerging Concepts in Vaccine Development David C. Kaslow and John W. Shiver pppppppppppppppppppppppppppppppppppppppppppppppppppp201 Antiestrogens and Their Therapeutic Applications in Breast Cancer and Other Diseases Simak Ali, Laki Buluwela, and R. Charles Coombes ppppppppppppppppppppppppppppppppppppp217 Mechanisms of Endocrine Resistance in Breast Cancer C. Kent Osborne and Rachel Schiff pppppppppppppppppppppppppppppppppppppppppppppppppppppppp233 Multiple Myeloma Jacob Laubach, Paul Richardson, and Kenneth Anderson pppppppppppppppppppppppppppppppp249 Muscle Wasting in Cancer Cachexia: Clinical Implications, Diagnosis, and Emerging Treatment Strategies Shontelle Dodson, Vickie E. Baracos, Aminah Jatoi, William J. Evans, David Cella, James T. Dalton, and Mitchell S. Steiner ppppppppppppppppppppppppppppppp265 Pharmacogenetics of Endocrine Therapy for Breast Cancer Michaela J. Higgins and Vered Stearns ppppppppppppppppppppppppppppppppppppppppppppppppppp281 Therapeutic Approaches for Women Predisposed to Breast Cancer Katherine L. Nathanson and Susan M. Domchek pppppppppppppppppppppppppppppppppppppppp295 New Approaches to the Treatment of Osteoporosis ppppppppppppppppppppppppppppppppppppppppppppppppp Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org Barbara C. Silva and John P. Bilezikian 307 Regulation of Bone Mass by Serotonin: Molecular Biology

Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only. and Therapeutic Implications Gerard Karsenty and Vijay K. Yadav ppppppppppppppppppppppppppppppppppppppppppppppppppppp323 Alpha-1-Antitrypsin Deﬁciency: Importance of Proteasomal and Autophagic Degradative Pathways in Disposal of Liver Disease–Associated Protein Aggregates David H. Perlmutter ppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppppp333 Hepcidin and Disorders of Iron Metabolism Tomas Ganz and Elizabeta Nemeth ppppppppppppppppppppppppppppppppppppppppppppppppppppppp347

vi Contents ME62-Frontmatter ARI 15 December 2010 15:56

Interactions Between Gut Microbiota and Host Metabolism Predisposing to Obesity and Diabetes Giovanni Musso, Roberto Gambino, and Maurizio Cassader pppppppppppppppppppppppppppp361 The Brain-Gut Axis in Abdominal Pain Syndromes Emeran A. Mayer and Kirsten Tillisch pppppppppppppppppppppppppppppppppppppppppppppppppppp381 Cognitive Therapy: Current Status and Future Directions Aaron T. Beck and David J.A. Dozois pppppppppppppppppppppppppppppppppppppppppppppppppppp397 Toward Fulﬁlling the Promise of Molecular Medicine in Fragile X Syndrome Dilja D. Krueger and Mark F. Bear pppppppppppppppppppppppppppppppppppppppppppppppppppppp411 Stress- and Allostasis-Induced Brain Plasticity Bruce S. McEwen and Peter J. Gianaros pppppppppppppppppppppppppppppppppppppppppppppppppp431 Update on Sleep and Its Disorders Allan I. Pack and Grace W. Pien pppppppppppppppppppppppppppppppppppppppppppppppppppppppppp447 A Brain-Based Endophenotype for Major Depressive Disorder Bradley S. Peterson and Myrna M. Weissman ppppppppppppppppppppppppppppppppppppppppppp461

Indexes

Cumulative Index of Contributing Authors, Volumes 58–62 ppppppppppppppppppppppppppp475 Cumulative Index of Chapter Titles, Volumes 58–62 ppppppppppppppppppppppppppppppppppp479

Errata

An online log of corrections to Annual Review of Medicine articles may be found at http://med.annualreviews.org/errata.shtml Annu. Rev. Med. 2011.62:397-409. Downloaded from www.annualreviews.org Access provided by University of Puerto Rico - Rio Piedras on 10/29/20. For personal use only.

Contents vii