Cognitive Behavioural Therapy in Chronic Fatigue Syndrome/ME

1
Cognitive Behavioural Therapy in Chronic Fatigue
Syndrome/ME

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

2
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

3
Diagnosis of CFS/ME

• Ongoing disabling fatigue gt 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

4
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

5
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
6
Cognitive Behavioural Therapy
Emotions
Cognitions
Schemas
Physiology
Behaviour
7
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

8
Wessely, Butler, Chalder David (1991)
Organic Insult e.g. virus
Physical Symptoms
Rest to relieve symptoms
Physical Deconditioning
Increased Pain / Fatigue
9
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
10
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)

11
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.

12
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)

13
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)
14
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?
15
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

16
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

17
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)
18
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

19
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)

20
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

21
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

22
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)

23
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.
24
Any Questions?.

25
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