Lecture 2 - Medically unexplained physical symptoms Flashcards
Predisposing factors:
- Personality factors (neuroticism)
- early experiences of adversity
- schemas
- lifestyle
Predisposing factors - personality
-Neuroticism/negative affectivity = stable lifelong tendency to experience negative affect rendering people more vulnerable to experiencing emotional / physical complaints –> predisposition to somatopsychic (physical and psychological) distress
Alexithymia:
1) not being able to distinguish between physical sensation and emotion
2) having difficulty to recognize and
3) label emotion
Example: sweaty palm, something in belly => ANGER
predisposing factors - Early experiences of adversity:
-childhood experiences of parental illness/ vicariously learned illness behavior > children copy the reaction of parents to symptoms and stress
-physical or sexual abuse in childhood (trauma) > fibromyalgia
predisposing factors -schemas:
Core beliefs/ schemas: ‘always perform perfectly’ > perfectionism, ‘never show weakness’
Precipitating (triggering) factors:
STRESS (Physical, events, chronic stress, etc.)
Physical:
o Infections
o Accidents
o Surgery
Life events:
o illness
o death of a partner/good friend
o moving houses
o violence
Chronic stress:
o home, work, study, relationship
what interaction leads to symptoms?
Interaction between predisposing and precipitating factors -> symptoms
- precipitating factors trigger the development of symptoms/complaints in people who are more predisposed (vulnerable) to developing such symptoms
- e.g. Person high on neuroticism that is confronted with a life-threatening disease of a good friend
- e.g. Person who as a child was confronted with a sick father and is involved in a car accident
what factors are the focus of psychotherapy?
Perpetuating factors
perpetuating factors
= factors that maintain or aggravate symptoms
* physiological factors
* cognitive factors (beliefs about the stability of symptoms, “I’m very sick”)
* emotional/affective factors (e.g., anxiety about not recovering, patients with low activity > mainly high levels of distress, patients with high frustration > mostly active)
* behavioral factors (e.g., overexertion)
* social factors (e.g., support)
perpetuating factors - cognitive processes (3)
- biased attention
- attribution
- beliefs/thoughts about symptoms (now/future)
- beliefs on relation about activity & symptoms (“it’s dangerous to exercise”)
perpetuating factors. Cognitive processes - attention
-Selective attention to bodily processes (attention intensifies physical symptoms; distraction ameliorates physical symptoms);
-Somatosensory amplification => tendency to focus on bodily sensations & experience these sensations as serious and threatening
perpetuation factors. cognitive processes -attribution
-somatic illness attributions (e.g. I must have a problem with my bloodflow, that’s why I have a headache; even if there is another explanation) predict increased symptom experience and illness behaviours (e.g. consulting MD);
-Psychological / mixed somatic and psychological attributions predict better symptom outcomes (e.g. ‘I’ve had a stressful week and didn’t sleep much, that’s why I have a headache)
» psychological / mixed attributions are better than just somatic illness attribution > no sign difference between the two
perpetuation factors. cognitive processes - beliefs/thoughts
-Catastrophizing (e.g., I have a tumor) > related to increased symptom experience
-Beliefs about the relationship between symptoms and activity (walking will increase the pain I feel -> make it worse because you avoid activities)
perpetuating factors - behaviors
- Avoidance of activity
- Overriding the signs of your body / overexertion => neglecting that your body says no
- Dysfunctional coping behaviors (medication use, alcohol abuse)
perpetuating factors - social support
- Not only how many people support you, but also the quality of support
- What is supported? The complaining about symptoms? The avoidance behavior? > not so good, can reinforce the symptoms
CBT for MUPS
- Treatment focuses on perpetuating factors , but some predisposing factors may also function as perpetuating factors (e.g. personality / core beliefs)
- Thoughts about bodily sensations influence mood, emotions, bodily processes (tension / arousal) and behaviour (avoidance of physical and social activities)➔reinforcement bodily sensations➔ vicious circle in which thoughts play a crucial role.
- Cogn. restructuring for beliefs and ATs, activity scheduling for behavioral avoidance/ overexertion
Effectiveness of CBT in MUPS
- CBT reduces somatic symptoms, but not so much the psychological distress
- Moderate beneficial effects of CBT for MUPS, not really helpful for CFS
Research: Interventions differ in terms of content (e.g. focus on cognitions or more on behavior), method of delivery, and patient group
Chronic fatigue syndrome (CFS) - general info
- Subjective feeling of aversion toward activity & a perceived inability to perform
- Tiredness/ weariness/ exhaustion
- Physical vs. mental fatigue > CFS patients often suffer also from mental fatigue
- Primary care: 5-10% have this as the main complaint
- Persistent over 6 months
- Substantial reduction of previous activity
- Diagnosis criteria depend on a diagnostic tool (oxford criteria vs. CDC criteria)
- Fatigue can be a symptom of physical disease
- Can be also a symptom of psychiatric disorders
- Medically unexplained fatigue = idiopathic fatigue > fatigue cannot be explained by a known medical or psychiatric condition
diagnosing chronic fatigue syndrome
Depending on which diagnostic criteria you use (Oxford or CDC), you will find different results for effectiveness, because CDC patient are more severely impaired
CFS - Risk factors for poor prognosis:
Older age
Longer illness duration
Fatigue severity
Comorbid psychiatric illness
Somatic illness attributions!!
Vicious circle of thoughts and behavior
- thoughts ( I should rest to get well) > behavior (avoid activity) > symptom reduction goes down, expectancies go up
- thoughts (I should try harder) > behavior (outburst of activity) > achievement goes up, but symptoms go up as well > start at the beginning again
Focus on illness perpetuating factors in CBT
cognitive restructuring
o thoughts about CFS > difficult to target
o thoughts about a relationship between activity and symptoms > it’s easier to target in therapy (e.g., I am making myself worse by exercising/going out with friends)
Behavior -> activity scheduling (not same as behavioral activation! from last lecture)
o We want to decrease avoidance of acitvity or outbursts of activity
Activity scheduling vs behavioral activation:
Activity scheduling:
o Focus on physical and social activities
o Increasing activity itself
Behavioral activation:
o Treatment for depression
o About having more positive reinforcement, experience more positive things
Activity scheduling: what do you do at baseline level of activity?
Self-monitoring:
-Patient notes everything he/she does the whole day
-Be specific
> What means resting? Sitting on the couch, Netflix, Book?? Is that really resting? > get an idea about the amount of energy to do this activity > helps judging if this is really resting for that person
-Keep track of fatigue level from 0 to 8 (worst possible fatigue)
activity scheduling - planning activity and rest
Setting goals:
-Long term (end of therapy) and short term (weekly) goals
-Must be realistic
-Goals must be defined operationally (getting better is not a good goal > what does better mean? > for example being able to resume part-time work
-Gradually increasing activity
-Gradually decreasing rest
- Balance between activity and rest > plan both activities!!
Relatively active vs. passive CFS patients
-Different treatment needed homework for first week > daily activity diary
-How to tell them apart: let them write a week-diary
-Relatively active: often regular outbursts of activity that lead to exhaustion > focus immediately on BALANCE
-Passive: stay in bed most of the time »_space;> patients focus mostly on thoughts that lead to avoidance behvaior»_space; INCREASE level of activity and decrease rest bit by bit
Effectiveness of CBT for CFS
- Not clear if cognitions act as a mechanism of change
- Graded exercise treatmemt (GET) »_space; patient continues to work on acitvitiy level (same as in CBT)
- Adaptive pacing is different»_space; encourage patients to be morw acitvie, but if patient is not feeling well > they are allowed to rest
- Most effective: CBT AND GET; CBT better for patient who have anxiety or depression comorbidity (to fatigue)
cognitions as a mechanism of change?
cognitions act as a mediator between behavior and fatigue
another word for the 3 P’s
classical CBT model of emotional distress proposed by Beck
idopathic fatigue
medically or psychiatric unexplained fatigue
model of perpetuating factors introduced by Vercoulen
- sense of control»_space; fatigue
-causal attribution»_space; physical activity > fatigue
-focusing on symptoms»_space; impairment & focusing
importance of the Complex CBT model for CFS
1) core beliefs (e.g. perfectionism)
2) model is based on two interacting cognitive- behavioural cycles:
- One cycle is based on a catastrophic (mis)interpretation of symptoms leading to distress and to avoidance of activity;
- The other cycle is based on ‘should’ statements that lead to frustration and to brief but unsustainable bursts of activity.
-> switch between these cycles leads to perpetuating fatigue
planning of activity for CFS patients
- Setting goals (St & LT)
-goals must be realistic - Goals must be defined operationally (e.g. getting better→being able to resume part-time work)
- Planning both activity and rest
Activity scheduling
❖ Baseline level of activity * → self-monitoring
❖ Planning activity and rest
* →gradually increasing activity
* →gradually decreasing rest ❖ Balance between activity & rest
