CognitiveBehaviouralTherapyinChronicFatigueSyndrome：認知行為療法對慢性疲勞綜合征

CognitiveBehaviouralTherapyinChronicFatigueSyndrome/MEAliceE.GreenHighlySpecialistCounsellingPsychologistOldchurchHospitalCFSTeam1AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesOverviewWhatisCFS/ME?CBTOverviewPsychologicalModelsofCFS/MEPsychologicalFactorsinCFS/MEEvidence-basedPracticeUsingCBTinTreatmentofCFS/MEConclusions2AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesDiagnosisofCFS/MEOngoingdisablingfatigue>6mDefinedonsetofsymptomsImpairmentofshort-termmemoryconcentrationSorethroat/TendercervicaloraxillarylymphnodesMusclepain/Multijointpain/HeadachesUnrefreshingsleepPost-exertionmalaiselastingmorethan24hours3AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesExclusionCriteriaAnyactivemedicalconditionthatcouldexplainthechronicfatiguePast/currentmajordepressivedisorderwithpsychoticormelancholicfeatures;bipolaraffectivedisorders,schizophrenia;delusionaldisorders,dementias,anorexianervosa,bulimianervosaAlcoholorothersubstanceabusewithin2yearspriortotheonset4AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesCBTModelsofCFS/MEIllnessbeliefsandcopingstrategiesarekeyfactorsintheonset&perpetuationofCFS/MECognitions,Behaviours,EmotionalreactionsandPhysiologicalfactorsinteracttomaintainCFS/MEsymptoms5AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesCognitiveBehaviouralTherapyCognitionsEmotionsPhysiologyBehaviour&Schemas6AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesProcessofCBTTherapyTherapeuticAlliance&TrustAwarenessofDomainsofexperienceUnderlyingCoreBeliefs(Schemas)UnderstandingLinksbetweenDomainsInstillingthePossibilityofChangeChallengingBeliefs&ExperimentationReviewingChangesmadeintherapy7AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesWessely,Butler,Chalder&David(1991)OrganicInsulte.g.virusPhysicalSymptomsResttorelievesymptomsPhysicalDeconditioningIncreasedPain/Fatigue8AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesCycleofAvoidancePainsymptomsaremisinterpretedbypatientasduetoaphysicaldisease/illness.RestisusedtocopeandperpetuatestheCFS/ME CycleofSymptoms,AvoidanceandDeconditioningDemoralisation;Depression;AnxietyetcExacerbatesCFS/MEsymptoms9AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesAdditionalFactorsPrecipitants: Virus/ExcessivestressPredisposition: Personalitytraits/BiologyPerpetuators: “Boom&Bust”, personalitytraits,beliefsCFS/MEpatientstendtobehigh-achievers,basingtheirself-esteemonhighstandardsandexpectationsofothers

(Suraway,Hackmann,Hawton&Sharpe,1995)10AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesInterpretationofSymptoms:

AttributionalStylesSomaticattributions e.g.virusPsychologicalattribution e.g.stressNormalisingattribution e.g.Symptomsduetochangeinlifestyle,behaviour,environmentetc.11AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesSomaticAttributionsandCFS/MECFS/MEpatientstendtoattributesymptomsusingasomaticattributionalstyle.Butler,Chalder&Wessely(2001)Patientswhosomatisewillbelessactiveinthefaceofpainandfatiguesymptoms,maintainingtheillness,leadingtoCFS/ME

(Vercoulenetal.,1998)-PeopleareofgreaterriskofdevelopingCFS/MEpost-virallyiftheyuseasomaticattributionalstyle

(Copeetal.,1994)12AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesHowareSymptomsExperienced?CFS/MEpatientsaremoreHypervigilanttosymptoms

(Vercoulenetal.,1998)CFS/MEpatientssubjectivelyexperiencemoresleepdisturbancethannon-CFS/MEcontrols,evenwhenthereisnoobjectivedifferenceinthesleeprecordings

(Twinstudy–Watsonetal,2003).

CFS/MEpatientsunderestimatetheiractivitylevels

andoverestimatetheirsymptoms

(Fry&Martin,1996)13AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesPossibleUnderlyingReasons….Couldbeduetopatients’veryhighexpectationsofthemselves?

CFS/MEpatientssetthemselvesveryhighstandardstouphold,therefore,mayunderestimateownactivityandoverestimatesymptomlevelsAttributionofCFS/MEtoexternalfactorsmayhelpprotectpatientsfromfeelingsofdepressionandsenseoffailure?14AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesIllnessBeliefsinCFS/MEStudiesusingtheIllnessPerceptionQuestionnaire

(Weinmann,Petrie,Moss-Morris&Horne,1996)patientsattributesymptomcontroltobiologicalfactorsandnotsomuchtotheirownbehaviour(comparedtootherlong-termconditionse.g.R.A.,chronicbackpain)

Symptomswillhaveaprofoundimpactupontheirlife,willlastalongtimeandwillbewide-ranginginnature15AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesIllnessBeliefscont….Spence&Moss-Morris(inpress)–ProspectivestudyPatientswithglandularfeverwhohave:LackofunderstandingoftheirillnessHighlydistressedduetoillnessLowperceivedcontrolovertheirillness

aremorelikelytogoontodevelopCFS/ME16AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesCognitionleadstoCopingstylesSenseofInternalControl

vsExternalControlofsymptomsCopemorepositivelyWillseekoutsocialsupportMaladaptivecopingDisengagementAvoidanceVentemotions

Moss-Morrisetal(1996)17AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesCopingstyles…ReductioninActivity

Fearthatactivitywillmaketheirconditionworse

(Rayetal.,1995)Catastrophisingthinkingstyles-theseincreaseCFS/MEsymptoms(Petrieetal,1995)++Negativebeliefsleadtowithdrawal,givingup,helplessness(Less)negativebeliefsleadto“boomandbust”–suchactionisdeterminedbysubjectivesymptomexperience

18AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesCognitiveBehaviouralTherapyStrategiesCognitiveRestructuringexercisesThesecanbeusedtoreducepatients’fearofactivityCanreducesymptomsofCFS/MEcomparedtocontrolgroup

(Deale,Chalder&Wessely,1998)IncreasingPatients’Awareness:*Interplaybetweenperson’sbeliefsabouttheirillness,theirfeelings,theirbody’sexpressionofsymptomsandtheirownbehaviouruponthesedomains*19AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesCBTinterventionscont/…ThoughtdiariesawarenessofthinkingIncreaseawarenessofbeliefsystemsRe-labellingandReinterpretingsymptomsReducingsymptom-focusingbehavioursNormalisingratherthanCatastrophisingExperimentse.g.Gradedactivityandeffectuponattributionalstyle20AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesCont….Eradicate“boomandbust”modeChallengingPerfectionistbeliefsAnxietymanagementskillsIncreasingInternalLocusofControlRe-educationreCFSprecipitatorsandperpetuatorsandtreatmentprogramme21AliceGreen,OldchurchHosiptal,EssexCentreforNeurosciencesHowever…InterpersonalRelationships–SystemicissuesAdjustmentdifficulties–ImpactuponlifeIdentityissuesPersonalityDisorders/Otherco-morbiditiesCopingwithLossesduetoCFS (e.g.job/education/friendships)CBTdoesnotaddresssomeotherimportantissues…22AliceGreen,OldchurchHosiptal,EssexCentreforN