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The present study sought to clarify the role of cognitive change in Cognitive Behavioural Therapy (CBT) by examining the relationship between depression outcome and changes to automatic thoughts and dysfunctional attitudes at different points of therapy. Thirty patients suffering from Major Depression (MDD) or Dysthymia attended the 12 sessions of a group CBT program. Multiple regressions found total scores on the Automatic Thoughts Questionnaire (ATQ) and cumulative change scores on the Dysfunctional Attitudes Scale (DAS) to predict scores on the Beck Depression Inventory (BDI) at later stages of therapy, though neither form of cognition was predictive from earlier stages of therapy. Only scores on the ATQ were significantly related to both cognitive and somatic subscales of the BDI, indicating that automatic thoughts are more directly related to cognitive change than dysfunctional attitudes. Overall findings suggest that significant reductions in both automatic thoughts and dysfunctional attitudes are related to non-clinical levels of depressive symptoms at the end of the treatment.
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Behavioural and Cognitive Psychotherapy, 2002, 30, 351–360
Printed in the United Kingdom DOI: 10.1017/S1352465802003107
CHANGES TO AUTOMATIC THOUGHTS AND
DYSFUNCTIONAL ATTITUDES IN GROUP CBT FOR
DEPRESSION
Michele Furlong and Tian P. S. Oei
University of Queensland, Brisbane, Australia
Abstract. The present study sought to clarify the role of cognitive change in Cognitive Behavi-
oural Therapy (CBT) by examining the relationship between depression outcome and changes
to automatic thoughts and dysfunctional attitudes at different points of therapy. Thirty patients
suffering from Major Depression (MDD) or Dysthymia attended the 12 sessions of a group
CBT program. Multiple regressions found total scores on the Automatic Thoughts Question-
naire (ATQ) and cumulative change scores on the Dysfunctional Attitudes Scale (DAS) to pre-
dict scores on the Beck Depression Inventory (BDI) at later stages of therapy, though neither
form of cognition was predictive from earlier stages of therapy. Only scores on the ATQ were
significantly related to both cognitive and somatic subscales of the BDI, indicating that auto-
matic thoughts are more directly related to cognitive change than dysfunctional attitudes. Over-
all findings suggest that significant reductions in both automatic thoughts and dysfunctional
attitudes are related to non-clinical levels of depressive symptoms at the end of the treatment.
Keywords: Depression, psychotherapy, cognitive behaviour therapy, cognition, treatment
outcome.
Introduction
The need for further investigation into the active mechanisms of change in CBT is partly
due to equivalent treatment outcomes when comparing different therapies (Free & Oei,
1989; Oei & Free, 1995; Jacobson et al., 1996) and to the finding that cognitive change is
not exclusive to cognitive therapies, but is evident in the treatment outcomes of other therap-
ies such as pharmacotherapy and behavioural therapy (Oei & Free, 1995; Oei, Llamas, &
Devilly, 1999). In addition, previous studies have used ANOVA to analyse the roles of
cognitions during therapy and thus only infer their specific relationship during recovery
(Keller, 1983; DeRubeis et al., 1990; Oei & Sullivan, 1999), while other studies did not
separately examine the difference between cognitive and somatic outcome measures of
depression (Kwon & Oei, in press). Thus, while previous studies have added to the know-
ledge of cognitive change during recovery from depression, further investigation is required.
The current study firstly aimed to further clarify the role of cognitive change in the
recovery from depression by examining the relationship between BDI outcome scores and
Reprint requests and requests for extended report to Tian Oei, School of Psychology, University of Queensland
and Cognitive Behaviour Therapy Unit, Toowong Private Hospital, 496 Milton Road, Toowong, QLD 4066, Aus-
tralia. E-mail: oei@psy.uq.edu.au
2002 British Association for Behavioural and Cognitive Psychotherapies
M. Furlong and T. P. S. Oei352
changes to automatic thoughts and dysfunctional attitudes scores at different points in ther-
apy for depression. It was expected that outcome measures of depression would be predicted
at an earlier stage (Weeks 1 to 6) of assessment by automatic thoughts and at a later stage
(Weeks 7 to 12) by dysfunctional attitudes. This expectation was derived from the following
factors encompassed in cognitive theory of depression: changes in automatic thoughts are
proposed to have a direct effect on changes in depressive symptoms while changes in dys-
functional attitudes are said to have an indirect effect on changes in depressive symptoms,
mediated by automatic thoughts (Kwon & Oei, 1994, in press); automatic thoughts are
described as surface level and are therefore more accessible to change than the deeper
dysfunctional attitudes; automatic thoughts are the primary target of cognitive therapy in
the early stages of treatment while attention to dysfunctional attitudes is given later in
treatment (Jacobson et al., 1996).
The second aim of the current study was to analyse the relationship of two cognitive
measures with the Cognitive and Somatic subscales of the Beck Depression Inventory (BDI:
Beck & Steer, 1993). The expectation was that scores on the ATQ and DAS would predict
changes in outcome on the BDI Total and Cognitive scores, but that the scores on the
Somatic subscale would be better predicted by the ATQ than the DAS due to the direct
effect that automatic thoughts are said to have on changes to depressive symptoms (Kwon &
Oei, 1994). Although there have been a number of comprehensive reviews about the applica-
tion and psychometric properties of the BDI (Beck, Steer, & Garbin, 1988; Robinson &
Kelley, 1996), less attention has been given to the BDI subscales, which have been shown to
differentiate among psychiatric, medical and normal samples. In particular, previous studies
investigating the role of cognition in recovery from depression have used the BDI Total
score rather than subscales.
Method
Participants
The participants were 30 patients (21 males and 9 females) who had been diagnosed with
MDD or Dysthymia and who had completed all sessions of a 12-week, group CBT program.
The mean age of participants was 41.8 years (SD = 12.5) and ranged from 18 to 69 years.
Reports of marital status revealed 30.6% of subjects were single, 52.8% were married and
16.7% were divorced or separated. Although some patients were taking anti-depressant med-
ication during the course of therapy, recent studies have shown that, overall, pre-existing
medication regimes did not significantly affect the long-term outcome of a CBT program
(Oei, Llamas, & Evans, 1997; Oei & Yeoh, 1999).
Recruitment of participation
Participants were recruited from the Brisbane community through a local media release
seeking persons suffering from depression (Free, Oei, & Sanders, 1991). Participants were
screened through a series of interviews before being selected into the group CBT program.
Patients meeting DSM-IIIR criteria for current MDD (either single episode or recurrent) or
Dysthymia were selected for participation. Diagnosis was established through a 1.5 hour
interview that included the Structured Clinical Interview for Depression (SCID). Exclusion
Automatic thoughts and dysfunctional attitudes 353
from the study was based on participants meeting the criteria for the following DSM-IIIR
diagnoses: bipolar mood disorder or other major psychiatric disorder (e.g. schizophrenia,
personality disorder); organic brain disorder; abuse of drugs and/or alcohol. Exclusion from
the study was also based on the presence of a major physical illness or problems in reading
English. For more information on recruitment and exclusion criteria see Free et al. (1991)
and Oei and Shuttlewood (1997).
Procedure
A series of group CBT programs were run by the University of Queensland between 1992–
1994. CBT was delivered in a series of identical programs. Each program consisted of 12
two-hour group format sessions, held weekly. An outline of the program has been published
previously (Oei & Shuttlewood, 1997) and will therefore not be detailed here. Measures for
the study were taken pre-treatment (Week 1), post-treatment (Week 13) and approximately
fortnightly (Weeks 3, 5, 7,9, and 11) throughout the CBT program.
Assessment measures
Beck Depression Inventory. The 21 items of the Beck Depression Inventory (BDI; Beck &
Steer, 1993) are designed to assess the severity of the affective, cognitive, motivational, psy-
chomotor and vegetative components of depression (Beck, Ward, Mendelson, Mock, &
Erbaugh, 1961; Beck et al., 1988). Alpha reliability coefficients of the BDI have been found to
exceed .90 in a range of populations (Beck et al., 1988). The 21 items of the BDI can also be
separated into two subscales: a cognitive-affective subscale (the sum of the first 13 items) and
a somatic-performance subscale (the sum of the last eight items) (Beck & Steer, 1993). These
subscales, as well as the Total score of the BDI, were used in the analyses of the current study.
Finally, in accordance with guidelines stipulated by Beck and Steer (1993), the cut-offs for
assessing different levels of depression were as follows: 0–9 = minimal depression, 10–16 =
mild depression, 17–29 = moderate depression; and 30–36 = severe depression.
Automatic Thoughts Questionnaire. The Automatic Thoughts Questionnaire (ATQ;
Hollon & Kendall, 1980) is a 30-item inventory in which clients are asked to indicate, on a
scale of 1 (not at all) to 5 (all the time), how frequently negative automatic thoughts such
as ‘‘I’m worthless’’ have occurred in the past week. Scores on the ATQ can range from 30
to 150: scores for depressed persons usually range from 90–130 and between 40–60 for
non-depressed persons (DeRubeis et al., 1990). The ATQ is a widely accepted scale and
has been found to have good reliability and validity (Hill, Oei, & Hill, 1989).
Dysfunctional Attitudes Scale. The Dysfunctional Attitudes Scale (DAS; Weissman & Beck,
1978; Weissman, 1979; Beck, Brown, Steer, & Weissman, 1991) uses a 7-point rating scale
ranging from ‘‘totally agree’’ to ‘‘totally disagree’’ to measure those stable cognitive schemas
associated with depression (Beck et al., 1991). For example, ‘‘I should be happy all the time’’
and ‘‘My life is wasted unless I am a success’’. The 66-item version of the DAS was used in
the current study with scores ranging from 66 to 462. Lower scores indicate less dysfunction
in attitudes, with 236 being the lowest clinical level (Oei & Sullivan, 1999). Finally, the DAS
has been used widely and has good reliability and validity (Hill et al., 1989).
M. Furlong and T. P. S. Oei354
Statistical analyses
Transformations to the univariate and multivariate outliers that were present had little or no
effect on the interpretation of the results. Thus an untransformed, mean substituted data set
was chosen for analysis. Missing values were minimal (about 5%) and thus mean substitu-
tions were used. A series of repeated measures ANOVA with polynomial contrasts was
performed to analyse the significance between pre-treatment scores and changes in scores
that occurred at each fortnightly assessment time. ANOVA were performed for scores on
the ATQ, DAS, BDI Total, Cognitive, and Somatic measures.
A series of Linear Multiple Regressions were also performed using actual scores and
cumulative change scores as predictors of outcome. Actual scores were the raw scores taken
from the ATQ and DAS at each measurement time. Cumulative change scores were calcu-
lated by subtracting the pre-treatment raw scores from subsequent weeks of measurement
(i.e., from Week 3, Week 5, Week 9, etc.). Multiple regressions were run for each week of
assessment using the post-treatment Total, Cognitive and Somatic measures from the BDI
as the dependent variables each time.
Results
Table 1 displays the means and standard deviations of scores for the measures taken fort-
nightly across therapy. At Weeks 9 and 11 of therapy the DAS and ATQ, respectively,
showed that on average the scores were within non-depressed ranges (i.e. DAS < 236; ATQ
< 60) (Oei & Sullivan, 1999; De Rubeis et al., 1990). Although it appears that the mean
scores on the DAS reached a non-depressed range sooner than those of the ATQ, the latter
group mean was on the border of the non-depressed range at Week 9. In addition, the mean
scores on the ATQ up until Week 11 were within a range of scores that were below the range
for depressed persons, but above the range for non-depressed persons, possibly indicating a
lower level of depression. Repeated measures ANOVAs with polynomial contrasts revealed
that from Week 9 onwards subjects’ ATQ scores showed a significant change from pre-
treatment baseline scores, Fs (1,26) > 24.04, ps<.01; while for DAS scores a significant
change from baseline scores was not found until Week 11, Fs (1,25) > 7.19, ps<.01.
Table 1. Means and standard deviations of the scores on the ATQ, DAS, and BDI Total, Cognitive
and Somatic scales at the seven times of assessment
Pre Week 3 Week 5 Week 7 Week 9 Week 11 Post
ATQ Mean 81.77 77.87 76.73 71.11 61.5 58.70 50.03
SD 27.62 28.88 29.70 30.41 26.77 26.05 25.68
DAS Mean 242.80 260.08 251.58 247.27 229.6 220.27 193.07
SD 58.85 47.13 56.44 58.50 65.2 67.37 72.76
BDI Tot Mean 20.33 15.91 15.65 13.76 11.98 10.72 7.16
SD 7.62 7.61 8.37 8.13 8.64 9.46 7.23
BDI Cog Mean 12.98 10.04 9.95 8.62 7.43 7.02 4
SD 4.98 5.30 6.35 5.78 6.99 6.94 4.35
BDI Som Mean 7.19 5.87 5.75 5.22 5.54 4 3.16
SD 3.13 4.00 3.32 3.43 3.70 3.25 3.74
Automatic thoughts and dysfunctional attitudes 355
For the BDI Total, baseline scores ranged from 12–37 and on average were within the mod-
erately depressed range (17–29). BDI Total scores were not within the recovered/minimally-
depressed range (0–9) until the completion of therapy and, at this time, 22 of the 30 participants
had BDI Total scores within the range of 0–9. Repeated measures ANOVAs with polynomial
contrasts revealed that the mean BDI Total scores were significantly different from pre-
treatment scores at all of the measurement times across therapy, Fs (1,15) > 9.40, ps<.01.
Excluding Week 5, changes in mean BDI Cognitive scores were significant throughout assess-
ment, Fs (1,25) > 14.40, ps<.001; and for the BDI Somatic measure, Fs (1.25) > 8.34, ps<.01
for Weeks 5, 9, 11 and 13. These findings indicate that at these times of assessment, levels of
depression were significantly less than pre-treatment levels of depression. Lastly, although on
average the scores on the ATQ and the Total and subscales of the BDI all showed a steady
decrease over the course of therapy, scores on the DAS worsened for the first three weeks of
therapy and remained above pre-treatment levels until Week 9 of assessment.
The multiple regression analyses using raw scores from the ATQ and DAS as predictors
and the BDT Total, Cognitive and Somatic scores as outcome variables showed significant
results only for Week 9, Fs (2,27) > 5.42, p<.01; for Week 11, Fs (2,27) > 5.69, p<.01; and
for Week 13, Fs (2,27) > 7.04, p<.01. Weeks 1–7 were not significant (p>.05). Table 2
summarizes the findings for the significant regression analyses at Weeks 9, 11, and 13. At
Week 9, 41% of the variance in BDI Total scores was accounted for by the ATQ and DAS
Table 2. Multiple regression analyses predicting BDI Total, BDI Cognitive and BDI Somatic scores
from ATQ and DAS scores at Weeks 9, 11, and 13 of assessment
Criterion Predictor β 95% CI for β sr
2
pr R
2
Adj R
2
Week 9 Lower Upper
BDI Tot ATQ .62** .24 1.01 .24 .54 .41*** .37
DAS .03 .35 .41 .0005 .03
BDI Cog ATQ .54** .15 .93 .18 .48 .39*** .35
DAS .12 .26 .51 .0009 .13
BDI Som ATQ .59** .17 1.01 .22 .48 .29** .23
DAS .09 .51 .33 .0005 .09
Week 11 Lower Upper
BDI Tot ATQ .57** .18 .95 .19 .50 .44*** .40
DAS .14 .24 .52 .01 .14
BDI Cog ATQ .48** .09 .88 .14 .14 .42*** .38
DAS .22 .16 .61 .03 .03
BDI Som ATQ .54** .11 .97 .17 .44 .30** .24
DAS .01 .42 .44 .00005 .01
Week 13 Lower Upper
BDI Tot ATQ .70** .38 1.01 .32 .65 .56*** .53
DAS .08 .24 .40 .004 .10
BDI Cog ATQ .62** .31 .93 .25 .62 .59*** .56
DAS .23 .08 .53 .03 .28
BDI Som ATQ .64** .25 1.03 .27 .54
DAS .11 .28 .50 .008 .11 .34** .29
* p<.05 ** p<.01 *** p<.001.
M. Furlong and T. P. S. Oei356
Table 3. Correlations between the predictors (ATQ and DAS); and between the predictors and the
criterions (BDI Total, Cognitive and Somatic) for Weeks 9, 11, and 13
Predictors DAS BDI Total BDI Cognitive BDI Somatic
Week 9 ATQ .61*** .64*** .62*** .53***
DAS .41** .46** .27
Week 11 ATQ .64*** .66*** .63*** .54***
DAS .60** .53** .36
Week 13 ATQ .58*** .74*** .75*** .58***
DAS .48*** .58*** .26
* p<.05 ** p<.01 *** p<.001.
scores with up to 56% of the variance by Week 13. Similarly, the ATQ and DAS scores
from Weeks 9–13 accounted for 39–59% of the variance in BDI Cognitive scores and 29–
34% in BDI Somatic scores. As a predictor, the ATQ accounted for a greater proportion of
the total variance in each of the BDI criterion scores from Weeks 9, 11, and 13. The DAS
was not a significant predictor despite its significant correlations (p<.01 level) with the BDI
Total and BDI Cognitive scores from Week 9 onwards. Table 3 shows the correlations
between the predictors (ATQ and DAS); and between the predictors and the criterions (BDI
Total, Cognitive and Somatic) for Weeks 9, 11, and 13. The correlations amongst the pre-
dictors (p<.001 level) may account for the lack of prediction by the DAS. A non-significant
correlation was found between the DAS and the BDI Somatic measure at these times.
Similarly, analyses of cumulative change scores showed that only two regression analyses
were significant while the other multiple regressions were not significant at a p<.01 level.
The two significant regressions occurred when Week 9 ATQ and DAS scores minus pre-
treatment ATQ and DAS scores, respectively, were used as cumulative change scores with
the BDI Total as the criterion, F(2,27) = 5.35, p<.01; and similarly when Week 13 ATQ and
DAS scores minus pre-treatment ATQ and DAS scores, respectively, were used as cumulat-
ive change scores with the BDI Cognitive scores as the criterion, F(2,27) = 5.35, p<.01.
Table 4 summarizes the findings from these two significant regression analyses using cumu-
lative change ATQ and DAS scores as predictors. As indicated 28% of BDI Total and 28%
Table 4. Multiple regression analyses predicting BDI Total scores and BDI Cognitive scores from
cumulative ATQ and DAS scores
Criterion Predictor change scores β 95% CI for β sr
2
pr R
2
Adj R
2
Lower Upper
BDI Tot Week 9 ATQ minus .01** .39 .41 .0006 .02 .28** .23
pre-treatment ATQ
Week 9 DAS minus .53 .12 .93 .19 .14
pre-treatment DAS
BDI Cog Week 13 ATQ minus .15* .39 .54 .02 .15 .28** .23
pre-treatment ATQ
Week 13 DAS minus .44 .05 .82 .14 .40
pre-treatment DAS
* p<.05 ** p<.01 *** p<.001.
Automatic thoughts and dysfunctional attitudes 357
Table 5. Correlations between the predictors (Cumulative ATQ and DAS scores); and between the
predictors and the criterions (BDI Total, Cognitive and Somatic scores) for Week 9 minus
pre-treatment and Week 13 minus pre-treatment
Change Scores DAS BDI Total BDI Cognitive BDI Somatic
Week 9 ATQ minus .58*** .31* .29 .24
pre-treatment ATQ
Week 9 DAS minus .53*** .24 .21
pre-treatment DAS
Week 13 ATQ minus .52*** .29 .38 .26
pre-treatment ATQ
Week 13 DAS minus .23 .52** .21
pre-treatment DAS
* p<.05 ** p<.01 *** p<.001.
of BDI Cognitive outcome scores could be predicted by scores measuring the amount of
improvement in patients’ automatic thoughts and dysfunctional attitudes between pre-
treatment and Week 9 of therapy and between pre-treatment and Week 13 (post-treatment).
The cumulative-change DAS scores showed to be better predictors and accounted for a
greater proportion of total variance in the BDI Total measure, (when using Week 9 minus
pre-treatment scores as predictors) and in the BDI Cognitive measure, (when using Week
13 minus pre-treatment scores as predictors) than did the cumulative-change ATQ scores at
these times of assessment. The lack of significance of the cumulative change ATQ scores
as a predictor in these regression analyses may be due to the correlations of .58 (p<.001)
and .52 (p<.01), respectively, between the predictors (see Table 5 for correlations between
the cumulative-change predictors; and between the cumulative-change predictors and the
criterion for Week 9 minus pre-treatment and Week 13 minus pre-treatment).
Discussion
Examination of the mean scores on the ATQ and DAS indicates that changes in automatic
thoughts occur early in treatment while improvements in dysfunctional attitudes occur later
after an initial worsening. The early change to scores on the ATQ supports previous findings
that automatic thoughts change relatively quickly during therapy (Oei & Shuttlewood, 1997;
Oei & Sullivan, 1999); however, in the current study such changes were not significantly
different from baseline scores until Week 9. At this time, ATQ scores were also significantly
related to outcomes in both cognitive and somatic depression as measured by BDI Total,
Cognitive and Somatic scales. The significant relationship between later ATQ scores and
depression outcome may reflect the greater changes in automatic thoughts that have occurred
by the end of therapy (Oei & Sullivan, 1999); alternatively the relationship may be due to
the correlation of two similar depression measures (the ATQ and BDI) when completed
closer in time to each other. Thus there appears to be some support for the association of
depression outcome with significant changes to be automatic thoughts over therapy, but
some caution must be taken when making conclusions about these findings.
As predicted, cumulative change scores on the DAS taken later in assessment were signi-
ficantly related to depression outcome. A similar finding was not found for the actual DAS
M. Furlong and T. P. S. Oei358
scores. Possibly, cumulative change scores reduce much of the initial differences between
individuals and are in fact measuring a rate of change throughout recovery. It is suggested
that cumulative change scores are a more conservative measure of cognitive change and are
less affected by depression severity compared to actual scores. Furthermore, the ability of
cumulative change DAS scores to predict BDI total and Cognitive scores rather than Somatic
scores supports the proposal that dysfunctional attitudes have an indirect effect on somatic
symptoms of depression while their predictive ability towards the end of therapy rather than
early in therapy supports the proposal that dysfunctional attitudes are of a deeper more rigid
structure compared to automatic thoughts (Rude & Rehm, 1991; Kwon & Oei, 1994).
While early changes in ATQ scores lend support for their surface structure, it is possible
that these changes are too small to predict depression outcome scores taken at the completion
of therapy. Although scores on the DAS were not significantly different from baseline scores
until Week 11, the finding that at Week 9 both ATQ and DAS mean scores reached non-
clinical levels and were able to predict depression outcome scores may suggest that signific-
ant reductions in both automatic thoughts and dysfunctional attitudes may be required before
a predictive relationship between cognitions and depression symptoms can be found. In fact,
regression statistics may require critical changes in measurement scores before detection of
change is statistically and clinically possible.
Alternatively, limitations in sample size may have prevented a true detection of cognitive
change in the process of recovery from depression. Any results (significant or
non-significant) may be confounded with the lack of variability that a small sample size
offers. Clients who begin therapy with moderate levels of depression may not show signi-
ficant changes to cognitions or somatic symptoms until later in therapy.
Finally, the initial worsening of dysfunctional attitudes over the first 7 weeks of therapy
may be due to an increased awareness of cognitions brought about by therapeutic techniques
(Oei & Shuttlewood, 1997). Dysfunctional attitudes may remain rigid and resistant to change
until this type of cognition is addressed later in therapy. Automatic thoughts, having a
surface level, situation-specific nature are addressed early in therapy and may be more
accessible to change though increased awareness (Rude & Rehm, 1991; Kwon & Oei, 1994).
Findings in the current study must be taken with caution due to the small sample (N = 30)
that affected the power of analyses.
In summary, support is found for the proposal that automatic thoughts are more strongly
related to changes to depressive symptoms and would be more closely related to both cognit-
ive and somatic change in depression compared to dysfunctional attitudes (Kwon & Oei,
1994). That is, despite the correlation between actual DAS scores and the BDI Total and
BDI Cognitive measures from Week 9 onwards, the ATQ was still the better predictor. This
may be due to the correlation amongst the predictors, but also to the effect that automatic
thoughts mediate between dysfunctional attitudes and depressive symptoms (Kwon & Oei,
1994, 2002). Finally, the current study supports previous findings that cognitive change
coincides with the recovery from depression (De Rubeis et al., 1990, Oei & Shuttlewood,
1997; Oei & Sullivan, 1999) as decreases in both cognitive and somatic symptoms of depres-
sion to a ‘‘recovered’’ or ‘‘non-depressed’’ level were found.
Acknowledgements
This project was supported by a grant from the Australian Research Council. We would like
to thank the patients and Ms Anna Lamberton and Dr Michael Free for their help.
Automatic thoughts and dysfunctional attitudes 359
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... Powers and colleagues (2017) reviewed the core mechanisms of CBT for anxiety and depression and reported that cognitive change largely mediates CBT for depression. Specifically, the change in automatic thoughts is related to the change in depressive symptoms at the end of the CBT treatment (Furlong & Oei, 2002). Changes in dysfunctional attitudes were found to mediate the effect of CBT on depression, anxiety, and stress (Xie & Wong, 2020). ...
... Changes in dysfunctional attitudes were found to mediate the effect of CBT on depression, anxiety, and stress (Xie & Wong, 2020). However, the change in automatic thoughts is more related to the change in depressive symptoms than dysfunctional attitudes (Furlong & Oei, 2002). It confirms the theoretical assumption that automatic thoughts are at the surface level which is more accessible to change (Jacobson et al., 1996), while dysfunctional attitudes are in a deeper level which may take more time to bring about changes in mental health outcomes (Xie & Wong, 2020). ...
... Participants' changes in positive and negative thoughts in group CBT confirms the previous findings (Pan et al., 2017). Changes in automatic thoughts and dysfunctional attitudes are associated with changes in depressive/anxiety symptoms and stress at the end of the CBT treatment (Furlong & Oei, 2002;Xie & Wong, 2020). In addition to the CBT skills that we found useful to mainland university students, we observed some possible therapeutic factors that may contribute to the positive intervention effects in a group setting. ...
Article
Purpose This study developed a culturally appropriate cognitive behavioral group prevention program for Mainland Chinese university students in Hong Kong and tested its effectiveness. Method A total of 74 Chinese students were recruited and randomly assigned to an 8-week cognitive behavior prevention program (experimental group) or a waiting list control (WLC) group. Results Compared with the WLC group, participants in the experimental group significantly reduced psychological distress, acculturative stress, negative emotions, and negative thoughts and increased positive emotions, positive thoughts, and postmigration growth, with medium to large effect sizes. Upon immediate completion of the program, about 46% and 30% of the participants in the experimental group and WLC group, respectively, were classified as non-at-risk cases for developing mental health problems. Discussion The positive intervention effects and clinical implication of cultural adaptation of cognitive behavioral group therapy to Chinese students are discussed.
... The goal of the process is to encourage patients to think more accurately and adaptively, which makes possible effective problem solving and a more satisfying life (Wenzel, 2017). It has been suggested in various studies that CBT reduces negative thoughts (Furlong & Oei, 2002;Pan et al., 2017;Rana et al., 2017). ...
... The evaluation measurements were con- showing that CBT-based group counseling decreased depressive symptoms in nursing students (Hamdan-Mansour et al., 2009;Koutra et al., 2010). It has been found in a group-CBT study conducted among adult patients suffering from depression that the decrease in automatic thoughts was associated with nonclinical levels of depressive symptoms (Furlong & Oei, 2002). In the present study, both the depressive symptoms and the automatic thoughts of the students decreased after the CBT-based group counseling. ...
Article
Purpose: This study aimed to evaluate the effectiveness of cognitive behavioral therapy (CBT)-based group counseling focused on depressive symptoms, anxiety levels, automatic thoughts, and coping ways among undergraduate nursing students with mild to moderate depressive symptoms. Design and methods: A randomized, nonblinded, controlled trial was conducted. The study was completed with a total of 63 participants (n = 31, intervention group; n = 32, control group). The effect of the intervention was evaluated with Beck depression inventory, Beck anxiety inventory, automatic thoughts questionnaire, and ways of coping questionnaire. The measurements were taken three times: pretest, posttest, and 2-months posttest. Findings: CBT-based group counseling was found to reduce depressive symptoms, automatic thoughts, and ineffective coping with stress and to increase effective coping with stress. In both groups, 2-months posttest mean anxiety score was lower than the pre-test mean score. Practice implications: CBT-based group counseling reduced depressive symptoms, automatic thoughts, and emotion-focused/ineffective ways for coping with stress.
... Importantly, CBT is a treatment that targets emotion regulation directly. Research shows CBT treatment can lead to decrease of dysfunctional attitudes and change in spontaneous thoughts [27]. CBT can alleviate the symptoms of depression by targeting the ability to regulate maladaptive emotions [27]. ...
... Research shows CBT treatment can lead to decrease of dysfunctional attitudes and change in spontaneous thoughts [27]. CBT can alleviate the symptoms of depression by targeting the ability to regulate maladaptive emotions [27]. CBT treatment can also facilitate the emotional regulation process while reducing psychiatric symptoms via modifying maladaptive cognitions [28]. ...
... The occurrence of 'negative automatic thoughts' (NAT) in depressive patients has been repeatedly confirmed [Crandell and Chambless, 1986;Dobson and Shaw, 1986;Dozois et al., 2009;Hjemdal et al., 2013;Oei and Sullivan, 1999]. It has been shown that improvement in depressive symptoms through psychotherapy is associated with a reduction in NAT [Furlong and Oei, 2002] and an increase in 'positive automatic thoughts' (PAT) [Dozois, 2007;Dozois et al., 2009;Shiraishi, 2005]. Therefore, an inverse relationship is assumed between PAT and depressive symptoms [Ingram et al., 1995;Missel and Sommer, 1983]. ...
... 16 months after the end of intervention, those who had no relapse showed stronger access to PAT and a lower level of NAT compared to those with relapses. Thus, our findings confirm the results of previous studies [Dozois, 2007;Dozois et al., 2009;Furlong and Oei, 2002;Shiraishi, 2005]. Those without relapses also had much higher PF. ...
... Today it is well established that (meta)cognitive biases including dysfunctional thought patterns characterize the psychopathology of depression. Classic CBT accounts (Beck et al., 1979) attribute a central role to depressive thought patterns in the development and maintenance of the disorder (Carver, 1998;Wisco, 2009) and their modification has become an integral part of established CBT protocols (Furlong & Oei, 2002). Besides dysfunctional cognitions, it has been shown that metacognitive beliefs can significantly predict change in depression over time (Faissner et al., 2018). ...
Article
Background: Metacognitive Training for Depression (D-MCT) is a novel low-intensity group training for economic treatment of depression. Previous studies demonstrate its efficacy in moderately depressed outpatients. The present study evaluated efficacy and patient's perspective of the D-MCT in severely depressed psychiatric inpatients. Methods: In a randomized-controlled trial, 75 individuals with a major depressive disorder (MDD) were allocated to D-MCT versus Euthymic therapy as add-on (twice a week) to cognitive-behavioural-based (CBT) inpatient-care. Depressive symptoms (HDRS, BDI), dysfunctional (meta)cognition (DAS, MCQ-30), and subjective appraisal were assessed at baseline, 4 weeks (post) and 3 months (follow-up). Results: Participants in both conditions showed a large decline in depression at post and follow-up-assessment. No superior add-effect of D-MCT versus active control emerged for depression severity on top of the inpatient care. However, among patients with a diagnosis of MDD with no (vs. at least one) comorbidity, D-MCT participants showed a larger decline in depressive (meta-)cognition at follow-up with medium-to-large effect sizes. D-MCT was evaluated as superior in overall appraisal, treatment preference, motivation, and satisfaction. Limitations: The follow-up time interval of 3 months may have been too short to detect long-term effects. There is emerging evidence that modification of (meta)cognition unfolds its full effects only with time. Effects of CBT inpatient-care on outcome parameters cannot be differentiated. Conclusions: Although D-MCT as an add-on was not superior in complete case analyses, results suggest greater benefit for patients with MDD and no comorbidity. D-MCT proved feasible in acute-psychiatric inpatient-care and was highly accepted by patients. Future studies should investigate the role of modified (meta)cognition on long-term treatment outcome, including dropout and relapse rates.
... However, other studies found no evidence that DA and related NAT mediate the negative effects of stressful events on depression (Lethbridge & Allen, 2008;Marchetti et al., 2021;Wojnarowski et al., 2019). It was also established that improving depression through psychotherapy accompanies reduction of NAT (Furlong & Oei, 2002;Riley et al., 2017;Tang et al., 2020). ...
Article
Full-text available
Background Stressful event exposure, dysfunctional attitudes (DA), negative automatic thoughts (NAT), and declining positive automatic thoughts (PAT) have been associated with depressive relapse/recurrence. Few studies have investigated the course of these variables and their relevance for relapse/recurrence in remitted depression. Methods Following successful inpatient treatment, in 39 remitted depressive patients, stressful events, DA, NAT, PAT, and depressive relapse/recurrence were assessed five times during a 16-month follow-up. Data were analyzed with mixed effect models, and mediation effects were tested. Results Stressful events after discharge correlated with depressive relapse/recurrence. This association was mainly mediated by a stress-related decline of PAT within four months post discharge. Patients’ DA were relatively stable during the observation period and did not depend on stressful events, indicating DA as a risk trait for depressive relapse/recurrence. Mediation analyses revealed that independent of stress, DA were linked to depressive relapse/recurrence through more NAT. Conclusion Our findings suggest stressful events evoke relapse/recurrence in remitted depression through rapid deterioration of PAT after discharge from inpatient therapy. DA are expressed through NAT which additionally contribute to higher risk of depressive relapse/recurrence. Consequently, maintenance therapy requires techniques to promote the maintenance of PAT, and to effectively restructure DA and NAT.
... Past research has demonstrated that Malays have distinct culture, as they are reserved in expressing psychological problems and display characteristics of loyalty and obedience (13,31,32). The Malays are shown to have a specific set of psychopathologies, culture, values and belief system with a strong religious background (13,29). ...
Article
Full-text available
Background: Over the years, cognitive-behavioural therapy (CBT) has gained momentum because of its robust evidence in the treatment of several disorders. However, there is an issue of religious and cultural appropriateness as CBT principles are based on Western conceptualization. This single‐case study (N = 1) implements a culturally and religiously adapted CBT on a 34‐year‐old male with panic disorder with agoraphobia in Malaysia. The client had symptoms comprising various episodes of sudden onset of breathlessness, accelerated heart rate, and fear of dying for the last 14 years. The CBT was culturally and religiously adapted based on (1) A CBT manual in Bahasa Malaysia that was previously modified and adjusted according to the norms of the Malaysian society and (2) General guidelines in “Religious–Cultural Psychotherapy in the Management of Anxiety Patients” by Razali et al in 2002. The present modified CBT had 3 assessments formulation sessions and 12 intervention sessions. Methods: The first 6 sessions were based on the behaviour component of CBT (ie, a relaxation technique using Islamic prayer, reciting verses from the Holy Quran, slow breathing exercise, body scan, and progressive muscular relaxation). However, sessions 7 to 12 were focused on cognitive restructuring and exercises, such as identification of negative automatic thoughts, cognitive distortions, dysfunctional thought records, vertical arrow technique, and the coping statement was practised through collaborative empiricism, while implementing Islamic and cultural elements. The focus of termination sessions was on interoceptive exposure, cognitive rehearsal, and in vivo situational exposure. Results: Beck Anxiety Inventory (BAI) was administered at regular intervals. BAI scores revealed the effectiveness of adapting the intervention.
... In a cognitive behavioral group therapy study of 30 patients with major depression or dysthymia, automatic thoughts were found to be more directly related to cognitive change compared with dysfunctional attitudes, and that the significant decrease in both automatic thoughts and dysfunctional attitudes were found to be related to levels of nonclinical depressive symptoms (Furlong and Oei 2002). According to the results of our study, the main determinant of the severity of symptoms was the severity of automatic thoughts and these automatic thoughts were affected by the cognitive structures at a schematic level. ...
Article
Full-text available
According to the cognitive model, the cognitive structure has three layers. It consists of core beliefs, intermediate beliefs and automatic thoughts. In this study, it was aimed to investigate the relationship between depression clinical severity, automatic thoughts, intermediate beliefs and core beliefs. Core beliefs and intermediate beliefs are defined as schemas according to Beck and form a source for automatic thoughts. We aimed to discuss our findings in terms of schema activation model. A total of 101 outpatients and 82 healthy controls were evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), sociodemographic data form, Automatic Thoughts Questionnaire (ATQ), Dysfunctional Attitudes Scale-short form (DAS-SF), and Social Comparison Scale (SCI). For the clinical sample, higher depression scores were associated with more automatic thoughts (r = .75) and intermediate beliefs (r = .55). When the structural equation model was examined, it was found that automatic thoughts significantly predicted the severity of depressive symptoms in both the clinical group (β = .64) and the non-clinical group (β = .57). For the clinical sample, automatic thoughts directly predict the severity of depression. Intermediate beliefs predict the severity of depression indirectly through automatic thoughts; core beliefs predict both directly and indirectly through automatic thoughts as weaker than automatic thoughts. For the non-clinical sample, the relationship between automatic thoughts and severity of depressive symptoms are significant, but other ways are not. This may indicate that the disease does not occur clinically without scheme activation.
Article
Background : Despite the importance of Beck's theoretical cognitive model of psychopathology, the neural mechanisms underlying future thinking in cognitive behavioral therapy (CBT) remain elusive. Recent neuroimaging studies have shown that the function of the frontopolar cortex (Brodmann area 10 [BA10]) is associated with future thinking. We hypothesized that, compared with unstructured psychotherapy (talking control: TC), CBT may involve different neural responses in BA10 associated with future thinking. Methods : This randomized clinical trial included 38 adult patients with moderate-to-severe major depressive disorder who underwent up to 16 weeks of CBT or TC with a 6-month follow-up period. We evaluated changes in BA10 activation during distant future thinking using functional magnetic resonance imaging during a future-thinking task. We assessed frontal neurocognitive function and clinical symptoms at baseline and post-treatment. Depression severity and automatic thoughts were assessed at the 6-month follow-up. Results : We found decreased activation in the frontopolar cortex during distant future thinking after CBT (t=3.00, df=15, p=0.009) and no changes after TC. Further, the reduction in BA10 activity significantly correlated with changes in frontal cognitive function after the treatment (r=0.48, p=0.007), and in positive automatic thought after 6 months of treatments (r=0.39; p=0.03). Limitations : Relatively small sample size and homogenous clinical profile could limit the generalizability. Patients received pharmacotherapy including antidepressant. Conclusions : CBT appears to improve frontopolar cortex function during future thinking in a manner distinct from TC. Larger clinical trials are necessary to provide firm evidence whether BA10 activity may serve as a neuro-marker for monitoring successful depression treatment with CBT.
Article
Background and objectives Determinants of psychosocial adjustment in newly diagnosed Multiple Sclerosis (MS) patients include not only disease-related factors but also cognitive-behavioral factors. This study aimed to investigate the level of depression and anxiety symptoms and to examine the role of cognitive distortions in the development of depression and anxiety in newly diagnosed MS patients. Methods 63 MS patients and 58 healthy controls 18–65 years of age were included. Hamilton Depression Scale (HAM-D), Hamilton Anxiety Scale (HAM-A), Dysfunctional Attitudes Scale (DAS), Automatic Thoughts Questionnaire (ATQ) were administered to the sample. Results MS patients had significantly higher HAM-D and HAM-A scores (p < 0.05). HAM-D and HAM-A scale scores were correlated with each other in the MS patients group (p < 0.05). ATQ scores were significantly higher in the MS group than healthy controls (p < 0.01). HAM-D and HAM-A scores were also both correlated with ATQ and DAS scores in MS patients group (p < 0.05). There is a statistically significant difference for marital status and ATQ scores between the MS patients group with significant depressive symptoms (according to HAM-D cut off point above 17) and those without significant depressive symptoms (p < 0.05). ATQ is the only independent variable that predicts the depression levels (OR = 1.12 CI = 1.068–1.176; p < 0.001) in stepwise regression analysis. The overall disclosure percentage of the model to 52%. Conclusions Automatic thoughts are a vulnerability factor for the development of depressive symptoms in newly diagnosed MS patients. Psychological stress affects not only MS patients with advanced-stage but also newly diagnosed MS patients.
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Although the Dysfunctional Attitude Scale has been used extensively in clinical research, its psychometric properties in a clinical population have not been reported. In this study, the responses of a large clinical sample (N = 2,023) on the original 100-item DAS were factor analyzed. On the basis of exploratory and confirmatory factor analyses, the scale was reduced to 80 variables, 66 of which loaded on 9 first-order factors. The factor solution was found to be stable on cross-validation and invariant with respect to gender. The implications of the resulting factors for future research on cognitive vulnerability are discussed.
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The efficacy of Cognitive Behaviour Therapy (CBT) in the treatment of depression is now established. However, explanations for the efficacy of CBT are mixed. The evidence needed to support the explanation advanced by cognitive theory is lacking. This paper critically reviews the available empirical evidence. Forty-four outcome or process studies of therapy with depression are reviewed and 21 of these are subjected to a meta-analysis to investigate the relationship between change in cognitions and change in level of depression during different kinds of therapy. Our analysis shows that: (1) change in cognitive style occurs in all four categories of treatment: CBT, Drug Therapy, Other-Psychological Therapy, and Waiting List; (2) there was a significant difference between Waiting List and all the active treatments in change in cognitions, but not between active treatments; (3) the degree of change in cognitive style is significantly related to change in depression as measured by the Beck Depression Inventory (BDI), but not the Hamilton Rating Scale for Depression (HRS-D); and (4) the relationship between cognitive change and depression is not unique to CBT. Our findings show that CBT does provide some support for the cognitive models of depression but the relationship between cognitive change and recovery from depression is not unique to CBT.
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We attempt to clarify the roles of maladaptive cognitions in depression by making distinctions between two different types of cognition and among three dijferent phases of depression. A stable and deep level of cognition and an unstable and surface level of cognition are distinguished. These two types of cognitions are assumed to play different roles in the development, maintenance, and recovering or treatment phases of depression. Based on these distinctions, Beck's cognitive theory of depression is clarified and elaborated. In addition, on the basis of the existing theoretical and empirical literature, alternative or competing models are outlined and evaluated. Finally, some methodological considerations are suggested for future investigations.
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A 30-item questionnaire was devised to measure the frequency of occurrence of automatic negative thoughts (negative self-statements)associated with depression. Male and female undergraduates were asked to recall dysphoric experiences and to report associated cognitions. One hundred representative cognitions were selected and administered to a second sample, along with the MMPI D scale and the Beck Depression Inventory. Thirty items discriminating between criterion groups of psychometrically depressed and nondepressed subjects were identified. The resultant 30-item automatic thoughts questionnaire (ATQ-30)was cross-validated and found to significantly discriminate psychometrically depressed from nondepressed criterion groups. No differences were found between males and females on the measure. Factor analysis indicated a four-factor solution, with a large first factor reflecting Personal Maladjustment, a second factor indicative of Negative Self-Concept and Negative Expectations, and two lesser factors. The ATQ-30 may provide a means of testing basic theory relating cognitive content to behavioral and affective processes and assessing change in cognitions associated with experimental manipulation or psychotherapeutic intervention.
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Cognitive assessment of depression is not well advanced and the evidence for the validity and reliability of measures is incomplete. This study examined two cognitive assessments of depression-the Automatic Thoughts Questionnaire (ATQ) and the Dysfunctional Attitudes Scale (DAS). There were two major objectives of this study. The first objective was to examine the ability of these two measures of cognitions to discriminate depressive symptomatology within a variety of sample populations-university undergraduate students, medical and psychiatric outpatients, and acute psychiatric inpatients. The second objective was to examine the ability of the ATQ and DAS succesfully to classify depressed and nondepressed patients. The results of this study suggest that the ATQ is a sensitive and specific measure of depression. Nonspecificity to the ATQ, however, was demonstrated in the substance abuse disorder group and the personality disorder group. In contrast, the DAS, although correlated with depressive symptomatology, was not found to be specific to depression.
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Nineteen depressed community volunteers received a replication of the cognitive therapy group treatment used by Shaw (1977). Two groups were created based upon a median split of pretreatment scores on the Dysfunctional Attitude Scale (Weissman & Beck, Note 1). The Beck Depression Inventory, Hamilton Rating Scale for Depression, Hopelessness Scale, and Social Adjustment Scale were administered prior to and following a 4-week treatment and following a 4-week follow-up. Subjects with higher initial levels of dysfunctional attitudes evidenced a poorer response to the treatment than their attitudinally more functional counterparts. This result was robust and held over a residual gain scoring procedure. Results lend support to the hypothesis that dysfunctional attitude level acts as a general psychopathological indicator.
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While the efficacy of biological and psychological treatments of depression is now well established, the relationship between biological and psychological processes in the maintenance and treatment of depression is still unclear. This paper critically examines the evidence for and against the pharmacological and cognitive models of depression. Evidence is reviewed from statistical studies, studies attempting to find biological markers for depression, studies comparing various sets of criteria for endogenous depression, and treatment studies comparing the effectiveness of psychological and biological treatments of depression. It is concluded that the evidence for two discontinuous groupings (biological/endogenous, and psychological/reactive) is scanty. Psychological or biological models cannot by themselves account for recent findings, and therefore an interactional approach to depression is advocated. Three models, a separate processes model, a linear processes model, and a circular process model, are put forward as possible explanations for the interaction of psychological and biological processes in depression, and evidence for each is considered. It is concluded that although there is now sufficient evidence to support an interactive model of some kind in depression, there is still insufficient evidence to support the circular over the linear process model. Suggestions are made for future research.
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Cognitive and behavioral treatments of depression target specific deficits for remediation. Depressives who show the targeted deficits are typically expected to benefit most from therapy. This article reviews therapy outcome studies in which measures of cognitive or behavioral deficits were employed as predictors of response to related therapy. Contrary to expectation, there was no relationship between deficit score and outcome in many studies and, in several, a finding opposite to prediction obtained: Ss with more functional scores on the cognitive or behavioral measures did better in therapy than those with less functional scores. It is unclear whether the advantage seen in these studies is a response to a particular type of treatment or whether it represents general prognosis. Methodological and conceptual implications of these results are discussed.
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Research studies focusing on the psychometric properties of the Beck Depression Inventory (BDI) with psychiatric and nonpsychiatric samples were reviewed for the years 1961 through June, 1986. A meta-analysis of the BDI's internal consistency estimates yielded a mean coefficient alpha of 0.86 for psychiatric patients and 0.81 for nonpsychiatric subjects. The concurrent validitus of the BDI with respect to clinical ratings and the Hamilton Psychiatric Rating Scale for Depression (HRSD) were also high. The mean correlations of the BDI samples with clinical ratings and the HRSD were 0. 72 and 0.73, respectively, for psychiatric patients. With nonpsychiatric subjects, the mean correlations of the BDI with clinical ratings and the HRSD were 0.60 and 0.74, respectively. Recent evidence indicates that the BDI discriminates subtypes of depression and differentiates depression from anxiety.