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Cognitive behavioral therapy (CBT) proposes that symptoms of anxiety and depression are mediated by erroneous thoughts (for example, "My heart is pounding—I must be having a heart attack") and maladaptive behaviors (such as avoiding situations that "make my heart pound" to prevent a heart attack). Changing these thoughts (as in, "When my heart pounds, it means that I'm anxious, not that I'm having a heart attack") and behaviors (for example, by using relaxation strategies and facing situations that create anxiety) can alleviate anxiety and depression. The initial focus of CBT is to increase awareness of thoughts and behaviors (see Figure 1).

As an example, consider Audrey, who is due for a screening colonoscopy. She has been avoiding making the appointment (behavior) because she fears the test may reveal that she has cancer (thought). Every time she sees a news program or reads a pamphlet about colon cancer, her heart starts racing, and she feels a knot in her stomach (physical symptoms). Then she has thoughts like, "My mother had cancer, so I probably will too" or "I've heard that the preparation for a colonoscopy is awful, and I don't want to learn that I'm going to die." These thoughts come to her in the middle of the night, which has led to sleep problems (behavior).

Although CBT cannot be fully conducted during the time allotted to primary care visits, PCPs can use elements of its approach. CBT techniques can help both patient and physician understand the patient's distress. These are some of the features of CBT:

  • The patient and therapist actively work together.
  • Treatment is directive, time limited, structured, and problem focused.
  • The focus is on the present.
  • Various techniques are used to help patients modify thoughts, behaviors, and physical responses.
  • Patients are taught skills that they can continue using after the treatment ends to achieve further gains and prevent relapse.

CBT is effective with older adults.11,12 The basic principles and techniques are no different from those used with younger patients, although adaptations are made to address specific needs of older persons that may be due to possible cognitive slowing or sensory deficits.13,14 For example, concepts can be repeated both verbally and visually, by using a dry-erase board and handouts; and wording of material can be modified to match a patient's educational level.14 Older patients may also need CBT to be presented more slowly and in smaller segments than would be the case with younger adults. With older patients, it is also important to consider common aging concerns, including health, finances, independence, diminishing social support, or loss of a loved one. Relationship conflicts, concerns about death, and coping with chronic or debilitating conditions are common antecedents of late-life depression and anxiety.15

CBT techniques

This section presents CBT background information, explains the techniques from the trained therapist's perspective, and includes examples of how the PCP can incorporate elements of CBT into patient visits.

Assessment The PCP initiates CBT by making a functional assessment of the patient's beliefs or thoughts, emotions, physical reactions, and behavior patterns. The information is obtained from the patient's responses to direct questions, the use of self-monitoring (described later), and standardized self-report scales. This process produces a more sophisticated understanding of the patient's distress than a simple checklist DSM-IV symptom endorsement.

Questions can be as simple as, "What was happening in your life when you first noticed sleeping problems/loss of appetite/etc?" To better understand the antecedents of symptoms, PCPs also can ask patients to keep a daily log of symptoms relating to mood and anxiety. The information gathered in these first meetings defines treatment goals and guides treatment planning, including decisions about medications and specialist referrals. For example, if a patient's sleeping problems and weight loss began a month earlier when a friend died, a discussion of a therapy referral might be appropriate.

Treatment CBT involves educating the patient about symptoms and teaching self-monitoring techniques. When therapy begins, patients are taught to identify the 3 components of mood (thoughts, behavior, physical response) and to recognize the ways in which they interact. This is also a time when the clinician and patient can collaborate on developing treatment goals. Next, treatment options are selected from a range of intervention techniques used in CBT. Not all approaches are appropriate for all patients or all problems.

Self-monitoring increases patients' awareness of their symptoms and allows them to keep track of their progress throughout treatment. First, the patient needs to be able to identify a troubling situation and recognize concurrent thoughts, physical feelings, and behaviors. The patient then records this information in a daily log. It is important that the record keeping conform to the patient's comfort level and ability: A simple form with check boxes may work well for some patients, but others may prefer another format (see "Self-monitoring form," page 24). At the beginning of treatment, self-monitoring provides information regarding the targeted symptom, such as rapid heartbeat or headaches. Between visits, it records the use and success of implemented interventions, such as medications, the exercise routine, and/or diet changes.

The next step requires the patient—and the physician—to review the patient's physical and emotional symptoms and to understand antecedents, consequences, and treatment implications. Appropriate treatment for a patient who has headaches only when he or she argues with a family member will differ from that for someone who has headaches continuously with a consistent constellation of symptoms.

Physical response The physical responses to anxiety or depression (including symptoms such as muscle tension, rapid heart rate, chills, perspiration, fatigue, and/or restlessness, or just the way the body "feels") are often the easiest symptoms for patients to identify. Breathing retraining and progressive muscle relaxation (systematic tensing and relaxing of muscles) can be helpful ways to cope with physiologic responses.

A PCP can teach breathing retraining within 2 to 3 minutes during an office appointment. If patients are anxious or stressed, their breathing can become rapid and shallow. When they pay attention to their breathing and slow it down, they become more relaxed. To teach this skill, instruct the patient to take slow, deep breaths from the diaphragm (not the chest) without pausing between inhaling and exhaling. Place the patient's hand on the abdomen about an inch above the navel. As the patient focuses on breathing, he or she should notice the hand moving. With practice, the patient should be able to implement this skill in stressful situations.

Thoughts CBT helps patients challenge their thinking by treating their thoughts as hypotheses. This promotes

  • Identification of erroneous thoughts
  • Examination of evidence for and against particular beliefs
  • Acquisition of specific skills for challenging maladaptive thoughts
  • Development of alternative beliefs.

This process does not simply involve replacing negative thoughts with positive ones. Rather, these skills help patients question how realistic their thoughts are and replace irrational with rational (realistic) thoughts. Examples of directed questions include, "Do I know for certain that I have cancer?" and "Does my mother's cancer have to mean that I have cancer?"

  • Identification of erroneous thoughts
  • Examination of evidence for and against particular beliefs
  • Acquisition of specific skills for challenging maladaptive thoughts
  • Development of alternative beliefs.


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