Cognitive behavioural therapy

Posted on October 22, 2024October 22, 2024 Multiple Sclerosis

Multiple sclerosis: medication with cognitive behavioral therapy lower fatigue

Combining treatments was not more effective than either intervention delivered individually.

A University of Michigan-led study of commonly used treatments for people with multiple sclerosis finds that medical and behavioural interventions, and a combination of the two, result in meaningful improvements in fatigue.

The randomized clinical trial compared the effectiveness of modafinil, a wake-promoting medication used to treat sleepiness in people with sleep disorders, and cognitive behavioural therapy, or CBT, in reducing fatigue for over 300 adults with multiple sclerosis whose symptoms interfered with their daily activities.

Overall, investigators found that treatment with either modafinil or CBT alone, delivered over the phone, significantly reduced fatigue over 12 weeks.

A combination of both treatments, as did each therapy, also worked, but it did not result in better fatigue scores than the independent interventions.

“Fatigue is one of the most common and debilitating symptoms of multiple sclerosis, yet there is still uncertainty about how available treatments should be used or how medication-based treatments compare to behavioural treatments in the real world,” said first author Tiffany J. Braley, M.D., M.S., director of the Multiple Sclerosis/Neuroimmunology Division and co-founder of the Multidisciplinary MS Fatigue and Sleep Clinic at University of Michigan Health.

“This research offers new evidence to show that both CBT and modafinil are comparably effective for MS fatigue, which could shape treatment approaches to one of the most challenging symptoms experienced by people with multiple sclerosis.”

Of nearly 3 million people with multiple sclerosis worldwide, up to 90% experience fatigue. Nearly half describe it as their most disabling and impactful symptom.

The research used a real-world approach that more closely resembled clinical practice than traditional clinical trials. It included stakeholders with MS who helped design the study.

More than 60% of participants in each study group reported clinically meaningful improvement in fatigue, which was measured using the Modified Fatigue Impact Scale.

“These treatments, individually and as a combination, should be considered as potential options for people with multiple sclerosis with chronic, problematic fatigue,” said senior author Anna L. Kratz, PhD, professor of physical medicine and rehabilitation at U-M Medical School.

Collaborators at a secondary study site, the University of Washington, contributed to this pragmatic trial.

“This study focused intently on patient-centred outcomes, and our findings highlight the importance of shared decision-making about treatment selection, considering patient characteristics and broader treatment goals,” Braley said.

Trial participants who received only CBT maintained lower fatigue scores at an additional follow-up appointment 12 weeks after the study treatments ended.

CBT has shown robust and durable effects on fatigue in previous research.

“While many people with multiple sclerosis have limited access to behavioural health care like CBT, offering the treatment through telehealth can help reach more patients,” Kratz said.

“Our study shows that CBT is a feasible treatment that teaches fatigue management skills that can be employed indefinitely, with enduring benefits that last well beyond the treatment period.”

Although the three treatment assignments worked similarly well overall, participants’ sleep habits, or “sleep hygiene”, affected how well the treatment worked for fatigue.

Those with poor sleep hygiene tended to have better fatigue outcomes with CBT, and participants with excellent sleep hygiene showed better fatigue outcomes with modafinil.

“Using wake-promoting medications such as modafinil could worsen sleep quality in patients whose sleep problems are behavioral,” Braley said.

“As sleep disturbances also contribute to fatigue in people with MS, it is important to avoid selecting fatigue treatments that could worsen sleep. Behavioural treatments such as CBT that include sleep education may be preferable for people with MS who have poor sleep habits.”

Leave a comment Posted on June 8, 2017June 8, 2017 Mental health

Cognitive behavioural therapy (CBT) – how does it work?

Cognitive behavioural therapy (CBT)

[Original article on NHS Choices website]

Cognitive behavioural therapy (CBT) can help you make sense of overwhelming problems by breaking them down into smaller parts.

In CBT, problems are broken down into five main areas:

situations

thoughts

emotions

physical feelings

actions

CBT is based on the concept of these five areas being interconnected and affecting each other. For example, your thoughts about a certain situation can often affect how you feel both physically and emotionally, as well as how you act in response.

How CBT is different

CBT differs from many other psychotherapies because it’s:

pragmatic – it helps identify specific problems and tries to solve them

highly structured – rather than talking freely about your life, you and your therapist discuss specific problems and set goals for you to achieve

focused on current problems – it’s mainly concerned with how you think and act now rather than attempting to resolve past issues

collaborative – your therapist won’t tell you what to do; they’ll work with you to find solutions to your current difficulties

Stopping negative thought cycles

There are helpful and unhelpful ways of reacting to a situation, often determined by how you think about them.

For example, if your marriage has ended in divorce, you might think you’ve failed and that you’re not capable of having another meaningful relationship.

This could lead to you feeling hopeless, lonely, depressed and tired, so you stop going out and meeting new people. You become trapped in a negative cycle, sitting at home alone and feeling bad about yourself.

But rather than accepting this way of thinking you could accept that many marriages end, learn from your mistakes and move on, and feel optimistic about the future.

This optimism could result in you becoming more socially active and you may start evening classes and develop a new circle of friends.

This is a simplified example, but it illustrates how certain thoughts, feelings, physical sensations and actions can trap you in a negative cycle and even create new situations that make you feel worse about yourself.

CBT aims to stop negative cycles such as these by breaking down things that make you feel bad, anxious or scared. By making your problems more manageable, CBT can help you change your negative thought patterns and improve the way you feel.

CBT can help you get to a point where you can achieve this on your own and tackle problems without the help of a therapist.

Exposure therapy

Exposure therapy is a form of CBT particularly useful for people with phobias or obsessive compulsive disorder (OCD).

In such cases, talking about the situation isn’t as helpful and you may need to learn to face your fears in a methodical and structured way through exposure therapy.

Exposure therapy involves starting with items and situations that cause anxiety, but anxiety that you feel able to tolerate. You need to stay in this situation for one to two hours or until the anxiety reduces for a prolonged period by a half.

Your therapist will ask you to repeat this exposure exercise three times a day. After the first few times, you’ll find your anxiety doesn’t climb as high and doesn’t last as long.

You’ll then be ready to move to a more difficult situation. This process should be continued until you have tackled all the items and situations you want to conquer.

Exposure therapy may involve spending six to 15 hours with the therapist, or can be carried out using self-help books or computer programs. You’ll need to regularly practice the exercises as prescribed to overcome your problems.

CBT sessions

CBT can be carried out with a therapist in one-to-one sessions or in groups with other people in a similar situation to you.

If you have CBT on an individual basis, you’ll usually meet with a CBT therapist for between five and 20 weekly or fortnightly sessions, with each session lasting 30-60 minutes.

Exposure therapy sessions usually last longer to ensure your anxiety reduces during the session. The therapy may take place:

in a clinic

outside – if you have specific fears there

in your own home – particularly if you have agoraphobia or OCD involving a specific fear of items at home

Your CBT therapist can be any healthcare professional who has been specially trained in CBT, such as a psychiatrist, psychologist, mental health nurse or GP.

First sessions

The first few sessions will be spent making sure CBT is the right therapy for you, and that you’re comfortable with the process. The therapist will ask questions about your life and background.

If you’re anxious or depressed, the therapist will ask whether it interferes with your family, work and social life. They’ll also ask about events that may be related to your problems, treatments you’ve had, and what you would like to achieve through therapy.

If CBT seems appropriate, the therapist will let you know what to expect from a course of treatment. If it’s not appropriate, or you don’t feel comfortable with it, they can recommend alternative treatments.

Further sessions

After the initial assessment period, you’ll start working with your therapist to break down problems into their separate parts. To help with this, your therapist may ask you to keep a diary or write down your thought and behaviour patterns.

You and your therapist will analyse your thoughts, feelings and behaviours to work out if they’re unrealistic or unhelpful and to determine the effect they have on each other and on you. Your therapist will be able to help you work out how to change unhelpful thoughts and behaviours.

After working out what you can change, your therapist will ask you to practise these changes in your daily life. This may involve:

questioning upsetting thoughts and replacing them with more helpful ones

recognising when you’re going to do something that will make you feel worse and instead doing something more helpful

You may be asked to do some “homework” between sessions to help with this process.

At each session, you’ll discuss with your therapist how you’ve got on with putting the changes into practice and what it felt like. Your therapist will be able to make other suggestions to help you.

Confronting fears and anxieties can be very difficult. Your therapist won’t ask you to do things you don’t want to do and will only work at a pace you’re comfortable with. During your sessions, your therapist will check you’re comfortable with the progress you’re making.

One of the biggest benefits of CBT is that after your course has finished, you can continue to apply the principles learned to your daily life. This should make it less likely that your symptoms will return.

Computerised CBT

A number of interactive software programs are now available that allow you to benefit from CBT with minimal or no contact with a therapist.

The main program currently approved for use by the NHS is Beating the Blues, which is approved for treating mild to moderate depression.

However, there are many similar computerised CBT (CCBT) packages that may also be effective.

Some people prefer using a computer rather than talking to a therapist about their private feelings. However, you may still benefit from occasional meetings or phone calls with a therapist to guide you and monitor your progress.

Multiple Sclerosis – ‘Cognitive behavioural therapy worked for me’

Multiple Sclerosis Awareness Month

Leonie Martin has relapsing remitting multiple sclerosis (MS). She resigned from her job in management seven years ago after a series of relapses and cognitive problems left her unable to carry out her role. She explains how she learnt to manage her symptoms.

“When I was diagnosed with MS I tried to ignore it. I had a busy, hectic lifestyle and a well-paid job in office management at a local school.

“I thought I’d be able to manage my MS and that my lifestyle wouldn’t have any effect on my symptoms, but problems soon started to occur. I would be in the middle of an important presentation when my mind would suddenly go blank. I found concentrating extremely difficult; if I was interrupted while in the middle of something, I would need to start from the beginning again.

“I lost the ability to delegate work to my staff, mainly because I couldn’t keep track of what I’d asked, and I began taking unfinished work home so I could concentrate on it in the evening. I could no longer multi-task and gradually lost all sense of perspective – I would regularly break down in floods of tears at my desk, which was unsettling for my colleagues.

“I knew the problems were connected to my MS, as I’d been doing the job very capably for years – and I think it was because of this that my employer and colleagues struggled to understand. I became anxious, paranoid and depressed, and two years after my diagnosis, decided to leave work. At the time, I was having three relapses a year and my neurologist prescribed me weekly beta interferon injections.

“Following a full neuropsychological assessment by a specialist, I became involved in a cognitive behavioural therapy (CBT) pilot study. The course helped me understand more about managing my symptoms and showed me how to focus more on what I could do rather than what I couldn’t. I learnt to pace myself more and be kinder to myself – refraining from getting angry when I forgot to do something.

“I found that by splitting my day into three sections – morning, afternoon and evening – I could manage my fatigue, and therefore my cognitive problems and mood swings. Now I know that I can’t do something in all three sections, so if I’m out to dinner with friends on an evening, I’ll sleep in the afternoon. I also try to exercise more, but have to ensure I build in a rest period afterwards.

“I’ve learnt more about the types of fatigue and now understand that applying a lot of concentration to something for a period of time can be as exhausting as standing all afternoon. I need to get the right balance and think about my daily choices.

“I’m now self employed as a freelance writer – it’s flexible and has reduced my stress levels and relapses. I haven’t had a major flare-up in three years, but understandably it’s had a major impact on the family in terms of finances.

“Cognitive behavioural therapy worked for me – but it’s not a magic wand. You need to be open-minded and want to learn how to get the best out of your own circumstances. You also have to be prepared to commit time and energy, both during the sessions and at home in between.

“I wish I had known about CBT earlier – I learnt to deal with my symptoms the hard way, but I’m happy that I’ve now found the right balance.”