cognitive behaviour therapy for people with multiple sclerosis - stirling moorey
TRANSCRIPT
![Page 1: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/1.jpg)
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
![Page 2: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/2.jpg)
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
![Page 3: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/3.jpg)
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
![Page 4: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/4.jpg)
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.
![Page 5: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/5.jpg)
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
![Page 6: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/6.jpg)
The Cognitive ModelMaintenance model
ENVIRONMENT
COGNITION
AFFECT PHYSIOLOGY
BEHAVIOUR
![Page 7: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/7.jpg)
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
![Page 8: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/8.jpg)
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.
![Page 9: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/9.jpg)
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
![Page 10: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/10.jpg)
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
![Page 11: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/11.jpg)
Proof of concept and competence
Defining the need
Establishing effectiveness
Cascading skills
Training palliative care professionals in “First Aid CBT”
![Page 12: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/12.jpg)
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”
![Page 13: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/13.jpg)
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.
![Page 14: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/14.jpg)
![Page 15: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/15.jpg)
![Page 16: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/16.jpg)
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
![Page 17: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/17.jpg)
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.
![Page 18: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/18.jpg)
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
![Page 19: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/19.jpg)
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
![Page 20: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/20.jpg)
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.
![Page 21: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/21.jpg)
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.
![Page 22: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/22.jpg)
CBT Treatment
• Minimum of 4 sessions• CBT techniques delivered in patients own
homes• Integrated with usual physical palliative
care support from home care nurses
![Page 23: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/23.jpg)
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
![Page 24: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/24.jpg)
Kathryn Mannix, Nigel Sage, Christine Baker, Stirling Moorey,
Kelly Barnes, Jackie Booth, Elaine Glenister, David Oliviere, Declan Ryan
Cascading CBT Skills
![Page 25: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/25.jpg)
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
![Page 26: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/26.jpg)
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.
![Page 27: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/27.jpg)
Palliative care professionals’ CFARS scores following CBT training
N=104
![Page 28: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/28.jpg)
Palliative care professionals’ CFARS scores following CBT training
![Page 29: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/29.jpg)
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.”
![Page 30: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/30.jpg)
The Cognitive ModelMaintenance model
ENVIRONMENT
COGNITION
AFFECT PHYSIOLOGY
BEHAVIOUR
![Page 31: Cognitive Behaviour Therapy for People with Multiple Sclerosis - Stirling Moorey](https://reader035.vdocument.in/reader035/viewer/2022070516/58738a581a28ab272d8b67d1/html5/thumbnails/31.jpg)