Cognitive Behavioural Therapy in Chronic Fatigue SyndromeME

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Cognitive Behavioural Therapy in Chronic Fatigue
Syndrome/ME

• Alice E. Green
• Highly Specialist Counselling Psychologist
• Oldchurch Hospital CFS Team

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Overview

• What is CFS/ME?
• CBT Overview
• Psychological Models of CFS/ME
• Psychological Factors in CFS/ME
• Evidence-based Practice
• Using CBT in Treatment of CFS/ME
• Conclusions

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Diagnosis of CFS/ME

• Ongoing disabling fatigue 6m
• Defined onset of symptoms
• Impairment of short-term memory concentration
• Sore throat/Tender cervical or axillary lymph
  nodes
• Muscle pain/ Multijoint pain/Headaches
• Unrefreshing sleep
• Post-exertion malaise lasting more than 24 hours

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Exclusion Criteria

• Any active medical condition that could explain
  the chronic fatigue
• Past / current major depressive disorder with
  psychotic or melancholic features bipolar
  affective disorders, schizophrenia delusional
  disorders, dementias, anorexia nervosa, bulimia
  nervosa
• Alcohol or other substance abuse within 2 years
  prior to the onset

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CBT Models of CFS/ME
Illness beliefs and coping strategies are key
factors in the onset perpetuation of CFS/ME
Cognitions, Behaviours, Emotional reactions and
Physiological factors interact to maintain CFS/ME
symptoms
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Cognitive Behavioural Therapy
Emotions
Cognitions
Schemas
Physiology
Behaviour
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Process of CBT Therapy

• Therapeutic Alliance Trust
• Awareness of Domains of experience
• Underlying Core Beliefs (Schemas)
• Understanding Links between Domains
• Instilling the Possibility of Change
• Challenging Beliefs Experimentation
• Reviewing Changes made in therapy

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Wessely, Butler, Chalder David (1991)
Organic Insult e.g. virus
Physical Symptoms
Rest to relieve symptoms
Physical Deconditioning
Increased Pain / Fatigue
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Cycle of Avoidance
Pain symptoms are misinterpreted by patient as
due to a physical disease / illness. Rest is
used to cope and perpetuates the CFS/ME
Cycle of Symptoms, Avoidance and Deconditioning
Demoralisation Depression Anxiety etc
Exacerbates CFS/ME symptoms
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Additional Factors

• Precipitants Virus / Excessive stress
• Predisposition Personality traits / Biology
• Perpetuators Boom Bust, personality
  traits, beliefs

• CFS/ME patients tend to be high-achievers, basing
  their self-esteem on high standards and
  expectations of others
• (Suraway, Hackmann, Hawton Sharpe, 1995)

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Interpretation of SymptomsAttributional Styles

• Somatic attributions e.g. virus
• Psychological attribution e.g. stress
• Normalising attribution e.g. Symptoms due to
  change in lifestyle, behaviour, environment etc.

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Somatic Attributions and CFS/ME

• CFS/ME patients tend to attribute symptoms using
  a somatic attributional style. Butler, Chalder
  Wessely (2001)

- People are of greater risk of developing CFS/ME
post-virally if they use a somatic attributional
style (Cope et al., 1994)

• Patients who somatise will be less active in the
  face of pain and fatigue symptoms, maintaining
  the illness, leading to CFS/ME (Vercoulen et al.,
  1998)

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How are Symptoms Experienced?
CFS/ME patients are more Hypervigilant to
symptoms (Vercoulen et al., 1998)
CFS/ME patients subjectively experience more
sleep disturbance than non-CFS/ME controls, even
when there is no objective difference in the
sleep recordings (Twin study Watson et al,
2003).
CFS/ME patients underestimate their activity
levels and overestimate their symptoms (Fry
Martin, 1996)
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Possible Underlying Reasons.
Could be due to patients very high expectations
of themselves?
CFS/ME patients set themselves very high
standards to uphold, therefore, may underestimate
own activity and overestimate symptom levels
Attribution of CFS/ME to external factors may
help protect patients from feelings of depression
and sense of failure?
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Illness Beliefs in CFS/ME

• Studies using the Illness Perception
  Questionnaire (Weinmann, Petrie, Moss-Morris
  Horne, 1996)
• patients attribute symptom control to biological
  factors and not so much to their own behaviour
  (compared to other long-term conditions e.g.
  R.A., chronic back pain)
• Symptoms will have a profound impact upon their
  life, will last a long time and will be
  wide-ranging in nature

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Illness Beliefs cont.

• Spence Moss-Morris (in press) Prospective
  study
• Patients with glandular fever who have
• Lack of understanding of their illness
• Highly distressed due to illness
• Low perceived control over their illness
• are more likely to go on to develop CFS/ME

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Cognition leads to Coping styles
Sense of Internal Control vs External
Control of symptoms
Cope more positively Will seek out social support
Maladaptive coping Disengagement Avoidance Vent
emotions
Moss-Morris et al (1996)
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Coping styles

• Reduction in Activity
• Fear that activity will make their condition
  worse (Ray et al., 1995)

• Catastrophising thinking styles
• - these increase CFS/ME symptoms (Petrie et al,
  1995)

• Negative beliefs lead to withdrawal, giving up,
  helplessness
• (Less) negative beliefs lead to boom and bust
  such action is determined by subjective symptom
  experience

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Cognitive Behavioural Therapy Strategies
Increasing Patients Awareness Interplay
between persons beliefs about their illness,
their feelings, their bodys expression of
symptoms and their own behaviour upon these
domains

• Cognitive Restructuring exercises
• These can be used to reduce patients fear of
  activity
• Can reduce symptoms of CFS/ME compared to control
  group (Deale, Chalder Wessely, 1998)

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CBT interventions cont/

• Thought diaries awareness of thinking
• Increase awareness of belief systems
• Re-labelling and Reinterpreting symptoms
• Reducing symptom-focusing behaviours
• Normalising rather than Catastrophising
• Experiments e.g. Graded activity and effect upon
  attributional style

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Cont.

• Eradicate boom and bust mode
• Challenging Perfectionist beliefs
• Anxiety management skills
• Increasing Internal Locus of Control
• Re-education re CFS precipitators and
  perpetuators and treatment programme

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However
CBT does not address some other important issues

• Interpersonal Relationships Systemic issues
• Adjustment difficulties Impact upon life
• Identity issues
• Personality Disorders / Other co-morbidities
• Coping with Losses due to CFS
• (e.g. job / education / friendships)

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Conclusions
In order to help patients work towards recovery
in CFS/ME there needs to be a shared
understanding between client and practitioner of
the underlying psychological factors maintaining
CFS/ME
Alongside other therapies, CBT can be used to
increase awareness of patients CFS/ME and to
help them make the necessary changes to reduce
some of their symptoms.
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Any Questions?.

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Thank You!

• Alice E. Green, Highly Specialist Counselling
  Psychologist
• Chronic Fatigue Syndrome Team,
• Essex Centre for Neurosciences, Oldchurch
  Hospital, Waterloo Road, Romford, Essex RM7 0BE
• Alice.Green_at_bhrhospitals.nhs.uk
• 01708 708 052