CognitiveBehaviouralTherapyinChronicFatigueSyndrome：认知行为疗法对慢性疲劳综合征.ppt

Cognitive Behavioural Therapy in Chronic Fatigue Syndrome/ME Alice E. Green Highly Specialist Counselling Psychologist Oldchurch Hospital CFS Team 1 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences Overview nWhat is CFS/ME? nCBT Overview nPsychological Models of CFS/ME nPsychological Factors in CFS/ME nEvidence-based Practice nUsing CBT in Treatment of CFS/ME nConclusions 2 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences Diagnosis of CFS/ME nOngoing disabling fatigue 6m nDefined onset of symptoms nImpairment of short-term memory concentration nSore throat/Tender cervical or axillary lymph nodes nMuscle pain/ Multijoint pain/Headaches nUnrefreshing sleep nPost-exertion malaise lasting more than 24 hours 3 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences Exclusion Criteria nAny active medical condition that could explain the chronic fatigue nPast / current major depressive disorder with psychotic or melancholic features; bipolar affective disorders, schizophrenia; delusional disorders, dementias, anorexia nervosa, bulimia nervosa nAlcohol or other substance abuse within 2 years prior to the onset 4 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences CBT Models of CFS/ME Illness beliefs and coping strategies are key factors in the onset Depression; Anxiety etc Exacerbates CFS/ME symptoms 9 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences Additional Factors nPrecipitants: Virus / Excessive stress nPredisposition: Personality traits / Biology nPerpetuators:“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) 10 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences Interpretation of Symptoms: Attributional Styles nSomatic attributionse.g. virus nPsychological attributione.g. stress nNormalising attributione.g. Symptoms due to change in lifestyle, behaviour, environment etc. 11 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences Somatic Attributions and CFS/ME -CFS/ME patients tend to attribute symptoms using a somatic attributional style. Butler, Chalder & Wessely (2001) -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) - People are of greater risk of developing CFS/ME post-virally if they use a somatic attributional style (Cope et al., 1994) 12 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences 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) 13 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences 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? 14 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences 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 15 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences Illness Beliefs cont. Spence & Moss-Morris (in press) Prospective study Patients with glandular fever who have: 1. Lack of understanding of their illness 2. Highly distressed due to illness 3. Low perceived control over their illness are more likely to go on to develop CFS/ME 16 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences Cognition leads to Coping styles Sense of Internal Controlvs External Control of symptoms Cope more positively Will seek out social support Maladaptive coping Disengagement Avoidance Vent emotions Moss-Morris et al (1996) 17 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences 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 18 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences Cognitive Behavioural Therapy Strategies 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) Increasing Patients Awareness: *Interplay between persons beliefs about their illness, their feelings, their bodys expression of symptoms and their own behaviour upon these domains* 19 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences CBT interventions cont/ nThought diaries awareness of thinking nIncrease awareness of belief systems nRe-labelling and Reinterpreting symptoms nReducing symptom-focusing behaviours nNormalising rather than Catastrophising nExperiments e.g. Graded activity and effect upon attributional style 20 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences Cont. nEradicate “boom and bust” mode nChallenging Perfectionist beliefs nAnxiety management skills nIncreasing Internal Locus of Control nRe-education re CFS precipitators and perpetuators and treatment programme 21 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences However nInterpersonal Relationships Systemic issues nAdjustment difficulties Impact upon life nIdentity issues nPersonality Disorders / Other co-morbidities nCoping with Losses due to CFS (e.g. job / education / friendships) CBT does not address some other important issues 22 Alice Green, Oldchurch Hosiptal, Essex Centre for Neurosciences Conclusions In order to help patients work towards recovery in CFS/ME there needs to be a