ThinkCBT Conditions Specific Formulations

Disorder specific models
Panic (Clark, 1986)

Social Phobia (Clark & Wells, 1995)
Health Anxiety (Salkovskis & Warwick,
1986)
OCD (Salkovskis, 1994)
GAD (Wells, 1997)
PTSD (Ehlers & Clark, 2000)
Depression (Beck, 1967)
See also Core CBT Competencies list for
recommended models:
http://www.ucl.ac.uk/clinical-psychology/CORE/CBT_Competences/CBT_Comp
etences_Map.pdf
Think CBT Ltd. info@thinkcbt.com
01732 808 626 www.thinkcbt.com
A vicious circle model of

phobic
anxiety
Situational
Trigger
Physiologica
l
Heart thumping
Sweating
Trembling etc.
Behavioural
Subjective
Running away
freezing
Shouting for help etc.
I might fall
This is terrible
Fear, embarrassment
etc.
Sympto
ms
Reaction
s
Physiologica
l
Heart thumping
etc.
Fatigue
Behavioural
Avoidance,
withdrawing from
demanding or
pleasurable activities
Subjective
I cant cope
I must get out
Lowered confidence
worry, frustration, fear
A cognitive-behavioural model for the maintenance of

specific phobias
Avoidan
ce
High
degree
of
convictio
n
Vomiting is unbearably awful

and
terrible for me
Encountering the phobic object /

situation
Catastro
phic
beliefs
Autonom
ic
arousal
Escape or safety behaviour

The catastrophe does not occur
and anxiety reactions dissipate
Conclusion drawn: The escape /
safety behaviour prevent the
catastrophe
The catastrophic belief is
confirmed

Preattentive
activatio
n
The phobia remains
Prevents
disconfirmatio
n
A model of the development and maintenance of

specific phobias
Development
Biological preparedness, disposition, developmental stage, culture,
experience (classical conditioning, vicarious learning),
memories/images, beliefs
Assumptions
With increased vulnerability to
Trigger
Frightening object or situation
Anxious Cognitions
(thoughts and images concerning stimulus)
OVERESTIMATING THREAT AND CONSEQUENCES/
UNDERESTIMATING COPING AND RESCUE
Hyper
vigilance
about
physical
symptoms
Physiological
symptoms
Anxious
mood
Increasingly anxious
cognitions about external
triggers
Anxious cognitions about

symptoms
(fear of fear)
Safety behaviours
(related to anxious thoughts about
external trigger)
Safety behaviours
(related to fear of fear)
Secondary
cognitions
Depression, hopelessness, loss of confidence, low

self-esteem
From Chapter 8 of Oxford

Guide to Behavioural
Experiments in Cognitive
Behaviour Therapy (Kirk &
Rouf)
Cognitive model of social phobia

[Clarks and Wells (1995) and Wells and Clark (1997)]
Social Situation
Activates
assumptions
a
Perceived social
danger
(negative automatic thoughts)
Processing of Self as
a Social Object
Safety
behaviours
Somatic &
cognitive
symptoms
Wells, A., 1997. Cognitive Therapy of Anxiety Disorders: A Practice Manual and Co
Chichester: John Wiley & Sons Ltd.
Cognitive cycle of fear for panic

disorder
Biological
Stressful
Vulnerabilit
y
Increase in anxiety
Increase in
symptoms

Events
Alarm reaction
Tachycardia,
dyspnea, chest
pain,
depersonalisation
etc.
F
E
A
R
Hyper surveillance
Avoidance
Anticipatory
Anxiety
Catastrophic
thoughts
Oh, oh, oh..
Im gonna die,
pass out
Fall down, going
crazy
Conduct
Running away,
escaping
A cognitive model of OCD

(Wells 1997, p.242)
Trigge
r
Activates
MetaBeliefs
Appraisa
l of
Intrusion
Behavioural
Response
Belief
about
rituals
Emotion
Cognitive Model of OCD

(Salkovskis)
Neutralising
actions
(rituals,
reassurances
etc.)
Intrusive thoughts, images,

urges, doubts
Attention and
reasoning
biases (looking
for trouble)
Misinterpretation of
significance of
intrusions
responsibility for
actions
Counterproductive safety
strategies (though suppression,
impossible criteria, avoidance etc.)
Mood Changes
(distress,
anxiety,
depression)
5 Part Cognitive Behavioural Therapy

Model
Environment
Thoughts
Emotions
Behaviours
Physical
Cognitive Conceptualisation Diagram

(Judith Beck, 1993)
Relevant Childhood Data

Core Belief(s)
Conditional
Assumptions/Beliefs/Rules
Compensatory Strategies
Situation 1
Situation 2
Situation 3
Automatic Thought
Automatic Thought
Automatic Thought
Meaning of the
A.T.
Emotion
Meaning of the
A.T.
Emotion
Meaning of the
A.T.
Emotion
Behaviour
Behaviour
Behaviour

A Cognitive Model of Hypochondriasis

(Adapted from Salkovskis, 1989; Warwick and Salkovskis, 1990)
Previous Experience
Dysfunctional Schemas
Formed
Critical Incident
Activates Schemas
Negative Automatic
Thoughts
Cognitive
Selective Attention
Rumination
Self-Focus
Thinking Errors

Anxiety
Depression
Anger
Physiological
Changes
e.g Increased
Arousal
Behaviour
Reassurance
Seeking
Avoidance
Bodily checking
safety / prevention
How did the problem

develop?
What made me
vulnerable in
the first place?
Triggers for the

most recent
episode
The problem
Positive things
that Ive got
going for me
Things that keep the

problem going
(These might include things
that I do to control the
problem)
The Vicious Flower Cognitive Model of OCD
(Salkovskis, Forrester &
Richards, 1998)
Early Experiences
Making you vulnerable to
OCD
Critical Incidents
What started the OCD of
Activate
s
Assumptions, General Beliefs

E.G Not preventing disaster is as bad as making
it happen
Better safe than sorry
Neutralising
Actions
Rituals,
reassurance,
mental
argument
Counterproduct
ive Safety
Strategies
Thought
suppression,
impossible
criteria
Intrusive Thoughts,
Images, Urges, Doubts
Misinterpretation
s of significance
of intrusions
responsibility for
action
Attention
and
Reasoning
Biases
Looking for
trouble
Mood
Changes
Distress,
anxiety,
depression
Depression Model
(Beck 1967, 1976)
Early Experiences
Core Beliefs and Assumptions
Critical Incident
Assumptions Activated
Negative Automatic Thoughts
Symptoms of Depression
Behaviour
Motivatio
Think CBT
al Ltd. info@thinkcbt.com nal
Affective
Cognitive
Somatic
Depression
Increased
hopelessne
ss
Loss of
pleasure &
achieveme
nt
(Westbrook, Kennerley & Kirk, 2007)
Depressed
Mood
More
Negative
view of self
Reduced
Activity
Nothing
Changes

Reduced
coping &
problemsolving
Negative
thinking &
Physical
symptoms such
as fatigue, poor
concentration
etc.
Anxiety Maintenance
(Westbrook, Kennerley & Kirk, 2007)
Internal or
external
event
1. Perceived
threat:
Exaggerated
and/or
inappropriate
4. Fear remains
intact: the
alarming belief
is unchanged

2. Clients best
attempt to
protect
him/herself from
threat
3. Strategy
gives short-term
relief, but fails
to challenge the
anxiety-related
belief
Morrey, 2010
1. Automatic
Negative
thinking
3. Motivation
and Physical
symptoms
4. Unhelpful
behaviours
Depression
Mode
Negative
view of self,
world and
future
6. Withdrawal
and
avoidance

DEPRESSI
ON
2.
Ruminations
and selfattacking
5. Mood /
emotion
Cognitive-Behavioural Model of Body Dysmorphic

Disorder (Veale, 2001)
Trigger
(e.g.
reflection)
Mirror-checking and
selective attention
Mirror
checking
Avoidance
and safety
behaviours
to change or
camouflage
appearance
Negative
appraisal of
internal body
image
Mood
(depression
& disgust)
Processing
of self as
an
aesthetic
object
Rumination
on ugliness
or
defectiven
ess and
comparison
What made me vulnerable in the first place

Core Beliefs about myself, others and the world
Rules I live by
Helpful
Unhelpful
Current Problem
What triggered the problem
What helps me cope
Helpful
Unhelpful
What maintains the problem now

Thoughts
Physical sensations
Emotions
Behaviours
Cognitive Model of Postnatal

Depression
[Milgrom A., Martin P.R., Negri L.M (1999) Treating Postnatal Depression: A psychological
Vulnerability Factors
Approach for
Health Care Professionals. Wiley. Chichester. Adapted from Becks Cognitive
CulturModel of
Depression (1979)]
Precipitating
Factors, including
Biological Factors
al
Factor
s
Post Natal
Depression
Exacerbating & maintaining fact
Depression and
other emotions
Anxiety, Anger,
Sadness
Mediational
Cognitive Factors
Negative Automatic
Thoughts
Poor parenting self-

Behaviour / Coping
Strategies
Lethargy, Indecision,
Social Withdrawal,
Martial Conflict,
Diagnosis / symptoms
Formative influences
Situation / interpersonal
issues
Biological, genetic and
medical factors
Strengths / assets
Typical automatic
thoughts, emotions and
behaviours
Underlying schemas
Working
hypothe
sis
Treatme
nt Plan
Vicious Flower Generic

conceptualisation (Salkovskis, Warwick and Deal 2003)
Anxiety
Worry
Processes
Physical
Sensations
Images
Threat
Appraisal
Meaning
Selective
Attention
Safety
Behaviours

Memories
Events,
Stimuli,
Situation
s
Clarks cognitive model of panic with

maintenance cycles added (adapted from Clark, 1986)
INTERNAL / EXTERAL
TRIGGER
PERCIEVED THREAT
ANXIETY
(Emotions)
MISINTERPREATION

PHYSICAL / COGNITIVE
SYMPTOMS
AVOIDANCE AND SAFETY

BEHAVIOURS
(Including Selective
Attention)
A cognitive Model of GAD

(Wells, 1995)
Trigger
Positive meta-beliefs
activated (Strategy
Selection)
Type 1
Worry
Negative metabeliefs activated
Behaviour

Type 2
Worry
(Metaworry)
Thought control
Emotion
Cognitive-behavioural model of generalized

anxiety disorder
[From Dugas, M.J., Gagnon, F., Ladoucer, R. & Freeston, M.H. (1998) Generalized Anxiety
Disorder: A preliminary test of a conceptual model. Behaviour Research and Therapy,
36, 215-226]
Situation
What if..?
Positive
beliefs about
worry
Worry
Mood
State
Negative
problem
orientati
on

Anxiety
Demoralizati
on
Exhaustion
Life
Events
Cogniti
ve
avoida
nce
(Fennell, 1999)
(Early) Experience
Events, relationships, living conditions which have implications for ideas
about the self
The Bottom Line
Assessment of worth/ value as a person
Conclusions about the self, based on experience: this is the kind of
person I am
Rules for living
Guidelines, policies or strategies for getting by, given the truth of the
Bottom Line Standards against which self-worth can be measured
How Low Self-esteem

Develops
Low Self-Esteem: A Map of the territory
Depressio
n
Self-critical
thoughts
Activation of the
Bottom Line
Anxie
ty
Confirmation of the
Bottom Line
Negative
Predictions
Unhelpful
behaviour
What keeps Low

Self-esteem
Going
Trigger Situations
Situations in which the Rules for Living are, or may be, broken
Based on Wells 1997, adapted by Stopa
Social Situation
1.
What went through your mind at that time?

What was the worst you thought could happen?
What did you think people would notice / think
about you? What would that mean/ what would
be so bad about that?
Thoughts
3. As you
became
anxious, and
thought that
(feared event)
might happen,
did you do
anything to try
to prevent it
from
happening? Did
you do
anything to try
to prevent
people from
Safety
noticing?
Behavio
urs
4. When you are afraid (feared event) will

happened what happens to your attention?
Do you become more self-conscious? As you
focus on yourself, what do you notice? Do
you have an image of how you feel you are
coming across? What does that look like?
Self-focus
5. As you did
(safety behaviours)
did that make you
focus more or less
attention on
yourself?

6. As you noticed
yourself becoming
more anxious, what
efect did that have
on your attention?
7. When you did (safety behaviours)

what efect did that have on your anxiety?
2. When you
thought (feared
event) might
happen, what
did you notice
happening in
your body?
(Suggest
symptoms of
anxiety)
Anxiety
Sympto
ms
A. Ehlers., D.M Clarke. (2000) A Cognitive Model of posttraumatic stress disorder.

Behaviour Research and Therapy 38, p. 319-345
Characteristics of trauma /
Sequelae Prior Experiences/
Beliefs/ Coping State of
individual
Nature of Trauma
Memory
Matchin
g
Triggers
Cognitive
Influen
Processing
ces
during
Trauma
Negative Appraisal of
Trauma and / or its
P
Sequleae
E
Current Threat
Intrusions
Arousal Symptoms
Strong Emotions
Strategies Intended to Control

Threat / Symptoms
Arrows indicate the following relationships:
Influences =
Leads to =
Prevents change in =
R
S
I
S
T
E
N
T
P
T
S
D
A cognitive-behavioural model for the maintenance of

specific phobias
Various objects / situations are
perceived as potentially harmful
Avoidan
ce
High
degree
of
convicti
on
Encountering the phobic object /

situation
Catastro
phic
beliefs
Autonom
ic
arousal
Escape or safety behaviour

The catastrophe does not occur
and anxiety reactions dissipate
Conclusion drawn: The escape /
safety behaviour prevent the
catastrophe
The catastrophic belief is
confirmed

Preattentive
activatio
n
The phobia remains
Prevents
disconfirmati
on
Maintaining Cycles
Safety Behaviours (e.g. OCD
client)

Maintaining Cycles
Reduced activity (depressed client)

Maintaining Cycles
Perfectionism

(e.g. depressed client)
Maintaining Cycles
Catastrophic Misinterpretation
(e.g. panic client)

Maintaining Cycles
Scanning/hypervigilence (e.g.
health anxiety client)

Maintaining Cycles
Escape/avoidance (e.g. social
anxiety)

Maintaining Cycles
Fear of fear

(e.g. GAD client)
Maintaining Cycles
Performance Anxiety

Maintaining Cycles
Self-fulfilling prophecies

Vicious Flower model

(Salkovskis, Warwick & Deale, 2003)
Images
Emotion
Worry
Processes
Memories
Threat
Appraisal/
Meaning
Physical
Sensations

Selectiv
e
Attentio
n
Safety Seeking
Behaviours
Events, stimuli,
situations
Vicious Flower model

(Salkovskis, Warwick & Deale)
Anxiety;
panic
Rumination;
thinking over
past events
(what went
wrong) and
rehearsing future
ones (what to
say, etc)
Standing in the corner at

party, looking odd, wild
staring eyes, drenched in
sweat. People laughing
and pointing
People think I
am weird; I will
end up
rejected and
alone
Sweating,
restlessness,
shaky hands

Parties, social occasions,

memories of social
events
School called
weirdo. Ignored.
Told I had staring
eyes. Mocked
Focus on self & how

I appear. Ignore any
friendly remarks
from
others (just being
kind)
Hold arms down to
hide sweat; avoid eye
contact. Avoid parties
or stay in kitchen out
of the way & leave
early. Cross road to
avoid people. Look at
road. Keep eyes semi-
6 Cycles Maintenance Model A

Vicious Flower for Depression (Moorey, 2010)
6.
Motivation
and
physical
symptoms
5. Unhelpful
behaviours

1. Automatic
negative
thinking
Depression
Mode
Negative
view of self,
world &
future
4.
Withdrawal
and
2.
Ruminations
& self
attacking
3.
Mood/emotion
Longitudinal Formulation
Depression:
Early experience
Core beliefs/assumptions
Critical Incident(s)
Activation of beliefs/ assumptions
Negative Automatic Thoughts (NATs)
Feelings
Behaviour
Physical
Depression:
Deprived of afection; Lack of attention vs.
siblings
Theres something wrong with me; Im unlovable
Break up of relationship
Activation of beliefs/ assumptions
Im unlovable, If I get into relationship it goes wrong
Upset
Lethargic, heavy
Withdraw
Anxiety:
Learning
Experience
Danger Schemas
Formed
Critical Incident
Schema Activated
Negative Automatic
Thoughts
Anxiety Symptoms
Behavioural Responses
Cognitive Biases

Generic cognitive
theory of anxiety
disorder
Ref: Wells, A. (2007)

Cognitive Therapy of
Anxiety Disorders.
Chichester: John
Wiley & Sons
Anxiety:
Generic cognitive theory

of anxiety disorder, Wells,
A. (2007) Cognitive Therapy of
Anxiety Disorders. Chichester:
John Wiley & Sons
Learning Experience
Danger Schemas
Formed
The world is dangerous;

people will harm me; I am
vulnerable; worrying keeps
me safe
Critical Incident
Neighbours house burgled
Schema Activated
I will be next; I need to get
more locks; I need to have
the polices number handy;
what if it happens when Im
alone at night?
Plan escape routes &
location of weapons; check
locks frequently; have
mobile by bed; buy alarm
system
Highly anxious mother: not

allowed out alone until age
16; fear of abduction, etc)
The world is dangerous

(& I am vulnerable)
Negative Automatic
Thoughts
Anxiety Symptoms
Behavioural Responses
Cognitive Biases
Heart pounding; rapid

breathing; sweating;
restless; racing thoughts;
rumination
Selective abstraction
(neighbours house less
secure)
Catastrophising

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Disorder specific models

Panic (Clark, 1986)

A vicious circle model of

A cognitive-behavioural model for the maintenance of

Vomiting is unbearably awful

Encountering the phobic object /

Escape or safety behaviour

Think CBT Ltd. info@thinkcbt.com

The phobia remains

A model of the development and maintenance of

Anxious cognitions about

Depression, hopelessness, loss of confidence, low

From Chapter 8 of Oxford

Cognitive model of social phobia

Cognitive cycle of fear for panic

Think CBT Ltd. info@thinkcbt.com

A cognitive model of OCD

Cognitive Model of OCD

Intrusive thoughts, images,

5 Part Cognitive Behavioural Therapy

Cognitive Conceptualisation Diagram

Relevant Childhood Data

Think CBT Ltd. info@thinkcbt.com

A Cognitive Model of Hypochondriasis

Think CBT Ltd. info@thinkcbt.com

How did the problem

Triggers for the

Things that keep the

The Vicious Flower Cognitive Model of OCD

(Salkovskis, Forrester &

Assumptions, General Beliefs

(Westbrook, Kennerley & Kirk, 2007)

Think CBT Ltd. info@thinkcbt.com

Think CBT Ltd. info@thinkcbt.com

Think CBT Ltd. info@thinkcbt.com

Cognitive-Behavioural Model of Body Dysmorphic

What made me vulnerable in the first place

What maintains the problem now

Cognitive Model of Postnatal

Exacerbating & maintaining fact

Think CBT Ltd. info@thinkcbt.com

Vicious Flower Generic

Think CBT Ltd. info@thinkcbt.com

Clarks cognitive model of panic with

Think CBT Ltd. info@thinkcbt.com

AVOIDANCE AND SAFETY

A cognitive Model of GAD

Think CBT Ltd. info@thinkcbt.com

Cognitive-behavioural model of generalized

Think CBT Ltd. info@thinkcbt.com

How Low Self-esteem

Low Self-Esteem: A Map of the territory

What keeps Low

Based on Wells 1997, adapted by Stopa

What went through your mind at that time?

4. When you are afraid (feared event) will

Think CBT Ltd. info@thinkcbt.com

7. When you did (safety behaviours)

A. Ehlers., D.M Clarke. (2000) A Cognitive Model of posttraumatic stress disorder.

Strategies Intended to Control

A cognitive-behavioural model for the maintenance of

Encountering the phobic object /

Escape or safety behaviour

Think CBT Ltd. info@thinkcbt.com