Cognitive Behavioural Therapy For Chronic Health Conditions
Cognitive Behavioural Therapyfor chronic health conditionsWorking together with individuals, families and medical professionalsto offer support and information on syncope and reflex anoxic seizureswww.stars.org.ukRegistered Charity No. 1084898Registered Charity No. 1084898
Glossary of termsChronic illness A condition that is long lasting in itseffects or constantly recurringCounsellor A person trained to listen to people’sproblems and to help find ways of dealing with themDeconditioning The loss of muscle tone andfunction due to chronic diseaseNational Institute for Health and Care Excellence(NICE) Provides national guidance and advice toimprove health and social carePhysiology The way in which a part of the bodyfunctionsPostural Tachycardia Syndrome (PoTS) Defined asan increase in heart rate of over 30 beats per minutewhen standing upright but without a fall in bloodpressurePsychological A term used to describe a conditionrelating to or arising from the mind or emotions(brain)Reflex Syncope One of the most common formsof syncopeSyncope A medical term for a blackout that iscaused by a sudden lack of blood supply to the brain2ContentsWhat is CognitiveBehavioural Therapy(CBT)?Are you suggesting itis all in my head?What can I expectfrom CBT?Finding a therapistBut don’t I need areal doctor helpingme?!Evidence for thebenefits of CBTWhat about othertherapies?Will CBT work forme?
What is Cognitive Behavioural Therapy(CBT)?Cognitive behavioural therapy (CBT) is a structuredtalking therapy that can help us to accept and adjustas best as we can to our condition. It is not a curebut it can help improve recovery, ability to functionand quality of life.In essence CBT aims toteach us to be a betterfriend to ourselves interms of what we doand how we talk toourselves.Therapy can be particularly useful in helping us copebetter with some of the very real and frighteningsymptoms of reflex syncope, postural tachycardiasyndrome (PoTS) and related conditions (such asa racing heart, chest pain, and dizziness) in such away that prevents any anxious responses to thesesensations causing them to get worse. It can helpus cope better with the unpredictability of anillness. It can address stress that illness places onrelationships with others.CBT can help if our mood is or has become low. When our mood is low we oftenhave distorted negative thoughts about ourselves, the world and the future.With chronic illness, we are often facing a type of grief – a loss of a future thatwe had hoped for ourselves. We may have frustrations about the time beforediagnosis when we were not believed, or misdiagnosed with conditions such asanxiety or panic disorder.The CBT approach helps us understand that it is not the bare facts of a situationalone that causes how we end up feeling. Even when it comes to very genuinedifficult life-events, it is the way that we have learnt to think and respond to asituation that affects how we eventually feel. Our ways of thinking can becomesuch habits that they feel like ‘the truth’ but, with practise, we can choose tonotice these unhelpful patterns and to change them to help us feel better.3
Are you suggesting it is all in my head?Experience suggests that a referral to seek psychological support is often easierto accept when it comes from a trusted healthcare provider who is involved inour care. Unfortunately many individuals prior to correct diagnosis have hadsymptoms misdiagnosed, often as ‘all in their head’ (e.g. 50-80% of patients).As a consequence, any suggestion by a medical professional to seekpsychological support can be misinterpreted as a trivialisation andmisunderstanding of the physical nature of an illness, leaving some of usreluctant to access this important form of support.This is similar to patients with illnesses that are not caused by deconditioning,requiring input from physiotherapy services to prevent future deterioration andto adjust to the changes wrought by their illness. In the same way, patients withillnesses not begun by psychological processes can benefit enormously frompsychological support going forward.Some issues that could be addressed in CBT Adjusting to the unpredictability of the illness Coping with scary physiological sensations Strategies for switching off fight/flight mode Managing pre-existing or associated anxietyor mood/adjustment disorders Grief associated with loss of health and life/relationship changes Activity pacing Sleep difficulties Relationship difficulties Self-esteem and self-compassion Shaking off an illness-identity Acceptance, values-based living,and living optimally4
What can I expect from CBT?A good therapist should take time to help you understand how the treatmentwill work, address your questions and identify your goals. In terms ofbehavioural changes this might include working towards accepting yourlimitations, adjusting to the unpredictability of chronic illness, and helping youpace yourself to achieve the challenges of daily-living, whilst still maintainingactivities which most help you feel positive and fulfilled.A therapist should help you become aware how thoughts or cognitions abouthaving a long-term illness or disability can influence your mood and evenyour symptoms.Although there may not be many therapists who have experience working withPoTS and syncope, practitioners experienced in working with patients with otherlong-term health conditions should be able to adapt their approach usefullyto your particular situation. A good clinician will take time to read relevantinformation to understand the condition more fully if you can provide it.ThoughtWhat we think affectshow we act and feelCBTEmotionBehaviourWhat we feel affectswhat we think and doWhat we do affectshow we think and feel5
Finding a therapistYour GP should be able to advise you how toaccess a suitable NHS therapist in your area. TheBritish Association of Behavioural and CognitivePsychotherapies (BABCP) keeps a list of accreditedtherapists and has a search facility on their website.Psychologists should be registered with the HealthCare Professionals Council.Successful therapy is a lot about finding atherapist you feel comfortable with. Therefore,it is reasonable to take time and therapist-shop(a little!) to seek out someone with whom youhave confidence and with whom you feel you canestablish a good working relationship.6Although everyone’sneeds are different, agood CBT therapist cansupport you in findingoptimal ways to lookafter your mental andphysical needs, gettingyou in the best shape tomanage your conditionmost effectively.
But don’t I need a real doctor helping me?!Health providers are increasingly recognising that the separation that weattempt to make between mental and physical health is unhelpful. Recent NHSinitiatives No Health without Mental Health (2007) and Investing in emotional andpsychological well-being for patients with long-term conditions (2011) continueto prioritise and increase funding for psychological support for chronic andacute physical health conditions. Hopefully in the future physiological andpsychological support will be routinely provided together.We are yet to fully understand how trauma, inflammation, our genes,physiology, hormones, our gut microbiome, things that stress us, thoughts,expectations, social supports and other physiological and functional processeswork together to determine our health outcomes and recovery. It is likely thatthere is a unique ‘illness thumbprint’ for everyone.During the next decade ongoing research might hopefully bring us closer tosome understanding. In the meantime it seems sensible to positively influenceall the aspects of that complex process that are under our control.Therefore, it makes sense to enlist the support of an experienced therapist tooptimise our behaviours and thinking patterns, reduce our stress and prioritiserewarding relationships with those around us.So, yes, you do need a real doctor helping as part of a team you can trust,so that you can take the lead in co-ordinating and managing yourillness positively.7
Evidence for the benefits of CBTThere is very little published in medical journalsabout the effectiveness of CBT for PoTS, syncopeor reflex anoxic seizures (RAS). There are somecase-reports, unpublished studies, and patientsurvey data that are suggestive of benefits to qualityof life and functioning, and some good researchbeing undertaken currently.There is good and extensive evidence, however, onthe effectiveness of CBT for other physical healthconditions. The impact of chronic obstructivepulmonary disease (COPD) on quality of life has inresearch been equated with the impact of PoTS,and in both disorders patients have to manageunpleasant physical symptoms which can be easilyconfused with, and escalated by, anxiety. Thebenefit of CBT with this population has been wellevidenced. CBT has proved efficacious in terms ofquality of life, treatment adherence, mood and evendisease progression in physical health conditionsincluding cancers, multiple sclerosis and diabetes.As evidence accrues that changing our thoughtscan have a demonstrable influence on not justour brain-chemistry but also our physiology(and vice-versa), it seems increasingly sensiblethat improving our mental health can have animpact on our physical heath.8The 5 Elementsapproach tomanaging yourconditionwaterAchieving adequate hydration(water and salt) nutritionfirePassions and interests:relationships, inner-strengthsand value based livingearthPhysical: stretching andexercise, grounding exercisesand mindful living, corestrength, counter-manoueversairCalm: sleep/wake cycle,breathing, managingunhelpful thoughts, ways toswitch off, fight/flightchemistryPharmacological supportif needed
What about other therapies?Although CBT has been most extensively researchedand is recommended by NICE guidelines as the firstchoice psychological therapy for many physicalhealth conditions, other types of treatment can alsobe beneficial. To a certain extent therapy approachis a matter of individual preference.Many CBT practitioners also incorporate ‘thirdwave’ therapies such a mindfulness-based CBT,Acceptance and Commitment therapies andCompassion-focused approaches. As theyare new, evidence about their effectiveness islimited. However it is clear that meditation andmindfulness (being fully present, in the moment,with acceptance), can have a profound effect notjust on stress-management and energy-levels butalso on physiological processes including bloodpressure, heart-rate, blood sugar regulation andeven a measurable effect at the cellular level incancer patients.Cognitive behaviour therapy (CBT) is the psychological approach whoseeffectiveness has been most clearly established in research trials, and for thisreason it is recommended as the treatment of choice by NICE for a wide rangeof physical health conditions. Some more recent variants of CBT, especiallythose which incorporate ideas of mindfulness and acceptance are increasinglybeing advocated. More traditionally associated with eastern philosophies,these have been demonstrated to have direct impacts on our physiology,as well as patient-reported quality of life.Mindfulness based CBT (MBCBT) was originally developed to support anindividual’s long-term recovery from depression. Mindfulness is defined aspaying attention to what is happening in the present moment (in the mind,body and external environment) with an attitude of curiosity and kindness.9
Meditation is one technique to practise this type of attention, in order to use itin day-to-day life. For patients with PoTS and syncope it can be useful to helpnotice calmly, and respond helpfully, to symptoms. In emphasising that we canalways ‘deal’ with things as they come up in the present moment, MBCBT canalso help to resist getting drawn into unhelpful and distressing thoughts aboutthe future, or ‘if things get worse than they are now’.Acceptance and Commitment Therapy (ACT) places great emphasis on theneed to accept those difficulties and hardships which are out of our control,and which are an inevitable part of life. This does not mean giving up. Ratherthe approach feels that only when we accept, can we stop throwing energyuselessly at what we cannot change. Then instead we can consciously choose todirect our precious and limited time and energy to things which will improve ourquality of life, and give us purpose and meaning. It is easy to see how these skillscan be very useful in adjusting to long-term health issues.There are many other therapeutic approaches which may be of help to peopleexperiencing PoTS and syncope. You are probably now only too aware thatthere is rarely a ‘one size fits all’ with any aspect of varied conditions such asPoTS and syncope! We are all individuals and will vary in what language suits usand what we find helpful. Some people may prefer psychodynamic approacheswhich explore the effect of early childhood on the adult’s responses. Perhapsmost important is finding a therapist and approach which you can haveconfidence in. That is perhaps the essential factor to help to navigate as well aspossible the inevitable fears, difficulties and adjustments that PoTS and syncopesymptoms lead to at times.Introducing this support as early as possible following a diagnosis is likely to bea very important factor in preventing quality of life deterioration and associated‘secondary factors’ which can otherwise follow, such as reactive depression,anxiety, and avoidance-related physical deconditioning.10
Will CBT work for me?To reap the full benefit of therapy generally requiresa patient to be committed to engaging fully insessions and tasks between sessions, to have somehope or confidence in the approach and, guidedby their therapist, be able to gain good insightinto the consequences of their thinking styles andbehavioural patterns.It can be very hard-work making all the necessarylife-changes to live with a chronic illness. It can helpto know that after all their hard work, and adjustingto what they cannot do, while focusing on what theycan do, many patients will report enjoying happyand fulfilling lives.As with many long-term health conditions, althoughwe would never wish them upon ourselves or others,a positive outcome can be a new appreciationfor the things that really matter to us and anopportunity to re-establish priorities and live lifethereafter to our full potential.11
Working together withindividuals, families andmedical professionalsto offer support andinformation onsyncope and reflexanoxic seizuresPO Box 175Stratford upon AvonCV37 8YD 44(0)1789 867503@ info@stars.org.ukÀ www.stars.org.ukRegistered Charity No. 1084898 STARSPublished September 2016Please remember that this publication providesgeneral guidelines only. Individuals shouldalways discuss their condition with ahealthcare professional.STARS would like to thank all those whohelped in the development and review of thispublication. Principal author: Dr MorwennaOpie-Moran (Clinical Psychologist).PatronsProf. J B P Stephenson Consultant Paediatric NeurologistDr A P Fitzpatrick Consultant CardiologistProf. R A Kenny Professor of Cardiovascular ResearchProf. C J Mathias Professor of Neurovascular MedicineDr W Whitehouse Consultant Paediatric NeurologistDr W Wieling General Internist (Retired)Sir Elton JohnMrs Twiggy LawsonSelma BlairTrusteesMr Andrew FearMrs Cathrine ReidSir Roger Moore KBEMr John Burton RaceProf. Rose Anne KennyDr William WhitehouseFounder & Chief ExecutiveTrudie Lobban MBEendorsed bywww.heartrhythmalliance.orgIf you would like further information or would like to provide feedback please contact STARS.Affiliate
friend to ourselves in terms of what we do and how we talk to ourselves. Cognitive behavioural therapy (CBT) is a structured talking therapy that can help us to accept and adjust as best as we can to our condition. It is not a cure but it can help improve recovery, ability to function and quality of life.
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Cognitive-Behaviour Therapy 1 Cognitive-Behaviour Therapy and Problem Drinking: A Meta-analysis Introduction Cognitive-Behavioural Therapy (CBT) is a form of psychotherapy that combines cognitive-based and behaviour-based techniques in an effort to effect behaviour change (Beck, 1970; El
