Cognitive Behaviour Therapy for People with Multiple Sclerosis

Stirling MooreyConsultant Psychiatrist in CBT

South London and Maudsley NHS Trust and Visiting Senior Lecturer

Institute of Psychiatry, Psychology and Neuroscience

Depression in MS

• Lifetime prevalence 25-50% • Higher than other chronic medical conditions• Psychosocial factors

– Poor social support– Avoidance v active coping

• Organic factors– Brain lesions > spinal cord lesions– ? IFN treatment

Anxiety in MS

• Lifetime prevalence 36%• Panic Disorder, Obsessive Compulsive

Disorder, Generalised Anxiety Disorder most common

• Higher at time of diagnosis• Not associated with MRI changes• Self-injection anxiety may affect 50% patients

Characteristics of CBTCBT is brief (10-20 sessions), focused and problem-oriented. structured grounded in a cognitive behavioural rationale:

the generic cognitive model, disorder specific model and individual case formulation.

based on a normalising philosophy of psychological disorder. based on a partnership between therapist and client

collaborative empiricism and guided discovery. active

using cognitive and behavioural techniques in sessions and as homework.

Cognitive Behaviour Therapy for MS

1. saMS study• 8 sessions nurse administered CBT v

supportive listening• CBT > supportive listening for distress (GHQ)

2. Comparison of CBT, Supportive Expressive Group Therapy and Sertraline in depression• 16 sessions CBT or SEG • (CBT = Sertraline) > SEG

The Cognitive ModelMaintenance model

ENVIRONMENT

COGNITION

AFFECT PHYSIOLOGY

BEHAVIOUR

The Cognitive ModelDepression

Situation – Feeling tired, faced with invitation to meet some friends

“I’m not the person I used to be. They won’t want to know me.”

“What’s the point. It’s all too hard”

“If I can’t do the things I used to do, it’s not worth doing anything”

Shame, anxiety, depression

Fatigue

Decreased mobility

Withdraw socially

Reduce activity

Maintenance conceptualisation in physical illness

• 5 areas model or “hot cross bun” can be used to map the appraisal and coping in relation to:– symptoms e.g. fatigue– illness related events e.g. clinic appointments– the illness as a whole

• It allows physical symptoms to be included in the conceptualisation and so avoids problems of patients feeling they are being told “it’s all in the mind.”

• It is simple and readily understood by patients who may be weak and tired with reduced attention span.

• It provides a framework for patient and clinician to make sense of confused and overwhelming experiences.

• It often lets the patient find ways out of the vicious circles of anxiety or depression.

Cognitive modelPanic

Visiting Cinema – stuck at Pic-n-Mix stall

I’m stuck here. If I move I’ll fall overEveryone will look at me and think I’m weirdMy boyfriend should be helping me

AnxiousAngry

Physical tension and rigidity

Cognitive modelPanic cycle

Visiting Cinema – stuck at Pic-n-Mix stall

I’m trapped. I can’t escape I’ll make a fool of myself and lose control

PANICPhysical tension and rigidity

Lock legsHold on to the counter

CATASTROPHIC THOUGHTS

SAFETY BEHAVIOURS

Proof of concept and competence

Defining the need

Establishing effectiveness

Cascading skills

Training palliative care professionals in “First Aid CBT”

Mannix et al (2006) Effectiveness of brief training in Cognitive Behaviour Therapy

techniques for palliative care practitioners. Palliative Medicine 20: 579-584.

Proof of concept and competence”

Training palliative care professionals in “CBT First Aid”

• 3 months taught component (9 days teaching)

• 3 months’ skills-building supervision• then randomised to 6 months’ further

supervision, or supervision discontinued.

Moorey, S, Cort, E, Monroe, B, Hansford, P, Mannix, K, Fisher, L& Hotopf, M (2009)

A Cluster Randomised Controlled Trial Of Cognitive Behaviour Therapy For Common Mental Disorders In Patients With Advanced

Cancer. Psychological Medicine, 39(5):713-23.

Demonstrating effectiveness

Study design

• 14 Clinical Nurse Specialists randomised to– CBT training (6 days training + weekly

supervision) or– continue usual practice

• Training : Knowledge and competence assessed

• Treatment: Anxiety and depression scores of patients by both groups of nurses assessed at 6,10,and 16 weeks.

CBT Training

• Cognitive model as applied to cancer• Problem definition• Structuring sessions• Collaborative empiricism and guided

discovery• Homework in palliative care setting• Application of CBT to commonly occurring

problems

Ratings of knowledge and use of CBT techniques

Knowledge of cognitive model before and after training

0

0.5

1

1.5

2

2.5

Pre-training Post-training

CBT group

Control group

Knowledge of panic cycle before and after training

0

0.5

1

1.5

2

2.5

Pre-training Post-training

CBT group

Control group

Treatment plan for working with hopelessness before and after training

0

0.5

1

1.5

2

2.5

3

Pre-training Post-training

CBT group

Control group

Use of CBT techniques

0

0.5

1

1.5

2

2.5

Pre-training Post-training

CBT group

Control group

CFARS scores for CBT and control nurses at the end of the study

0

5

10

15

20

25

30

35

40

CBT ControlCTFARS: Mannix et al (2006) Effectiveness of brief training in Cognitive Behaviour Therapy techniques for palliative care practitioners. Palliative Medicine 20: 579-584.

Clinical Nurse Specialists’ perception of the skills acquired during CBT training from Cort et al (2009)

• Improved communication skills: increased ability to listen and respond.

• Improved assessment. Confidence to “stay with” difficult issues and feelings. Less tempted to provide reassurance, less tempted to refer on.

• Ability to clarify, break down the patient’s concerns and areas of anxiety into more detail.

• Improved ability to summarise and feed back.• Confidence in identifying analysing and

challenging negative thoughts.

CBT Treatment

• Minimum of 4 sessions• CBT techniques delivered in patients own

homes• Integrated with usual physical palliative

care support from home care nurses

Mean HAD Anxiety Scores 4

68

1012

mea

n H

AD

S a

nxie

ty s

core

0 5 10 15weeks

TAU CBT95% CI 95% CI

Kathryn Mannix, Nigel Sage, Christine Baker, Stirling Moorey,

Kelly Barnes, Jackie Booth, Elaine Glenister, David Oliviere, Declan Ryan

Cascading CBT Skills

CBT Skills Cascade Model for Palliative Care (Mannix 2012)

Mental health staff and CBT Therapists from physical health IOG levels 3 & 4

CBT “First Aiders IOG level 2

IOG levels 1 & 2 Multidisciplinary staff with excellent communication skills IOG levels 3 & 4

Training and supervisionReferrals

CBT Diploma

Intermediate CBT Skills

Course

Creating a cognitive-behavioural skills cascade for palliative care practitioners

Department of Health Innovations grant 2009-2012

Aims to improve access for palliative care patients to CBT based interventions by

1. increasing the pool of CBT “First aiders” by 120 over 3 years

and 2. training a cohort of 12 trainers to deliver

the programme in the future.

Palliative care professionals’ CFARS scores following CBT training

N=104

Palliative care professionals’ CFARS scores following CBT training

Comments from course participants

• “In a single consultation, the skills help to get a clearer history and the bigger picture, which then helps to address patient’s physical and emotional symptoms.”

• “I see things differently. I feel I can challenge patients if needed – a new skill.”

• “This course has completely turned my practice round in only positive directions.”

The Cognitive ModelMaintenance model

ENVIRONMENT

COGNITION

AFFECT PHYSIOLOGY

BEHAVIOUR