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

Cognitive Behavioural Therapy in Chronic Fatigue Syndrome/MEAlice E.GreenHighly Specialist Counselling Psychologist Oldchurch Hospital CFS Team OverviewnWhat is CFS/ME?nCBT OverviewnPsychological Models of CFS/MEnPsychological Factors in CFS/MEnEvidence-based PracticenUsing CBT in Treatment of CFS/MEnConclusions2Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesDiagnosis of CFS/MEnOngoing disabling fatigue 6mnDefined onset of symptomsnImpairment of short-term memory concentration nSore throat/Tender cervical or axillary lymph nodesnMuscle pain/Multijoint pain/HeadachesnUnrefreshing sleepnPost-exertion malaise lasting more than 24 hours3Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesExclusion CriterianAny 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 4Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesCBT Models of CFS/MEIllness beliefs and coping strategies are key factors in the onset&perpetuation of CFS/MECognitions,Behaviours,Emotional reactions and Physiological factors interact to maintain CFS/ME symptoms5Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesCognitive Behavioural Therapy6Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesProcess of CBT TherapynTherapeutic Alliance&TrustnAwareness of Domains of experiencenUnderlying Core Beliefs(Schemas)nUnderstanding Links between DomainsnInstilling the Possibility of Change nChallenging Beliefs&ExperimentationnReviewing Changes made in therapy7Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesWessely,Butler,Chalder&David(1991)Organic Insult e.g.virusPhysical SymptomsRest to relieve symptomsPhysical DeconditioningIncreased Pain/Fatigue8Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesCycle of AvoidancePain symptoms are misinterpreted by patient as due to a physical disease/illness.Rest is used to cope and perpetuates the CFS/MECycle of Symptoms,Avoidance and DeconditioningDemoralisation;Depression;Anxiety etcExacerbates CFS/ME symptoms9Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesAdditional FactorsnPrecipitants:Virus/Excessive stressnPredisposition:Personality traits/BiologynPerpetuators:“Boom&Bust”,personality traits,beliefsCFS/ME patients tend to be high-achievers,basing their self-esteem on high standards and expectations of others(Suraway,Hackmann,Hawton&Sharpe,1995)10Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesInterpretation of Symptoms:Attributional StylesnSomatic attributionse.g.virusnPsychological attributione.g.stressnNormalising attributione.g.Symptoms due to change in lifestyle,behaviour,environment etc.11Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesSomatic 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)12Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesHow 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)13Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesPossible 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 levelsAttribution of CFS/ME to external factors may help protect patients from feelings of depression and sense of failure?14Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesIllness Beliefs in CFS/MEStudies 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 nature15Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesIllness Beliefs cont.Spence&Moss-Morris(in press)Prospective study Patients with glandular fever who have:1.Lack of understanding of their illness2.Highly distressed due to illness3.Low perceived control over their illness 4.are more likely to go on to develop CFS/ME16Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesCognition leads to Coping stylesSense of Internal Controlvs External Control of symptomsCope more positivelyWill seek out social supportMaladaptive coping Disengagement AvoidanceVent emotions Moss-Morris et al(1996)17Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesCoping stylesReduction 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 18Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesCognitive Behavioural Therapy StrategiesCognitive 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*19Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesCBT interventions cont/nThought diaries awareness of thinkingnIncrease awareness of belief systemsnRe-labelling and Reinterpreting symptomsnReducing symptom-focusing behavioursnNormalising rather than Catastrophising nExperiments e.g.Graded activity and effect upon attributional style20Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesCont.nEradicate“boom and bust”modenChallenging Perfectionist beliefsnAnxiety management skillsnIncreasing Internal Locus of ControlnRe-education re CFS precipitators and perpetuators and treatment programme21Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesHowevernInterpersonal Relationships Systemic issuesnAdjustment difficulties Impact upon lifenIdentity issuesnPersonality Disorders/Other co-morbiditiesnCoping with Losses due to CFS(e.g.job/education/friendships)CBT does not address some other important issues22Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesConclusionsIn 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/MEAlongside 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.23Alice Green,Oldchurch Hosiptal,Essex Centre for NeurosciencesAny Questions?.Thank You!Alice E.Green,Highly Specialist Counselling PsychologistChronic Fatigue Syndrome Team,Essex Centre for Neurosciences,Oldchurch Hospital,Waterloo Road,Romford,Essex RM7 0BEAlice.Greenbhrhospitals.nhs.uk01708 708 052