LECTURE 2: activity scheduling & cognitive restructuring in MUPS

Question 1

MUPS

Answer 1

Medically Unexplained Physical Symptoms

Question 2

Predisposing factors of MUPS

Answer 2

• Personality: neuroticism/ negative affectivity
• Alexithymia: not being able to distinguish between physical sensations and emotions, having difficulty labeling and translating emotions into words.
• Early life experiences of adversity: abuse in childhood, childhood experiences of parental illness
• Core beliefs: always perform perfectly, never show weakness.

Question 3

Precipitating (triggering) factors of MUPS

Answer 3

• Physical forms of stress: infections, surgery, accidents etc.
• Psychological stress: life events and chronic stress.

Question 4

Perpetuating (maintaining/aggravating) factors

Answer 4

1. Cognitions: attention, attributions, beliefs about symptoms (now/future), beliefs about relation between symptoms and activity.
2. Behaviours: avoidance, ignoring bodily signals to slow down.
3. Emotions: anxiety and depression
4. Social: social support, verbal an non-verbal responses of others, (lack of) explanations

Question 5

(1) (Perpetuating) COGNITIVE processes (that maintain/aggravate MUPS)

Answer 5

• Attention: selective attention to bodily processes, distraction leads to less symptoms. Somatosensory amplification is a tendency to focus on bodily sensations and experience them as serous/life-threatening.
• Attributions: somatic illness attributions and psychological attributions (or a mix) about the symptoms.
• Beliefs/thoughts: catastrophising belief about symptoms and relation between activity and symptoms.

Question 6

Somatic illness attributions vs. psychological attributions

(Cognitive perpetuating factor in MUPS)

Answer 6

• Somatic illness attributions (the cause of my symptoms is a tumor/illness). –> Leads to increased symptom experience and illness behaviour.
• Psychological attributions (the cause of my symptoms can also be the stress that I experienced) - or a combination of both –> predicts better symptom outcomes.

Question 7

(2) (Perpetuating) BEHAVIOURAL processes (that maintain/aggravate MUPS)

Answer 7

• Avoidance of activity (physical and social)
• Overextersion: being extremely active and overring signs of the body to stop.
• Dysfunctional coping behaviours (medication/alcohol abuse)

Question 8

(3) (Perpetuating) EMOTIONAL processen (that maintain/aggravate MUPS)

Answer 8

• Thinking that your symptoms are caused by something terrible (like a tumor) can cause a lot of ANXIETY .
• If you think your symptoms are linked to activity, then you start to do less, start isolating and this can lead to DEPRESSION.

Question 9

(4) (Perpetuating) SOCIAL factors (that maintain/aggravate MUPS)

Answer 9

• Social support: can be positive or negative, depending on if it focusses on anxiety or on social activities/distraction.
• Verbal and non-verbal responses: focus on pain or on progress.
• (Lack of) explanation: people receive for their symptoms. (No explanation –> more chronic symptoms).

Question 10

CBT for MUPS

Answer 10

• Treatment focusses on perpetuating (maintaining/aggravating) factors.
• Focus on thoughts about bodily sensations that influence their emotions (anxiety), bodily processes (tension), behaviour (avoidance) and vicious cycle.
• Some predisposing factors may also be seen as perpetuating factors (negative schema’s).

Question 11

Effectiveness of CBT for MUPS

Answer 11

• Moderate beneficial effects (but different interventions studied combined)
• CBT reduces somatic symptoms, depression and physical functioning
• Effects are durable
• Longer duration and higher frequency of contact increased effectiveness (but risk of drop-out!)

Question 12

Chronic Fatigue Syndrome (CFS)

Answer 12

Subjective feeling of aversion towards activity and a perceived inability to perform.

2 types:
- Physical fatigue
- Mental fatigue

Criteria:
A. >6 months duration
B. Definite onset in time
C. Substantial reduction of activity
D. No medical or psychiatric condition
(E. 4/8 symptoms)

Question 13

Ideopathic fatigue

Answer 13

Fatigue for which there is no medical or psychiatric explanation (only 10% of the physical symptoms are explained).

Question 14

4-P model for CFS

Answer 14

Predisposing factors –> precipitating factors (trigger) –> CFS

What influences this: perpetuating factors (maintain) and prognostic factors.

Question 15

Model of perpetuating factors of CFS

Answer 15

Focussen on cognitive factors which all influence the CFS and the physical activity.
- Sense of control
- Causal attributions
- Focussing on symptoms

Question 16

Vicious CFS cycle of thoughts and behaviours

Answer 16

Thoughts: “I should rest to get well” –>
Behaviour: avoid activity –>
Consequences: symptoms go down and expectancies go up –>

——->
Thoughts: “I should try harder” –>
Behaviour: outbursts of activity –>
Consequences: achievement goes up and symptoms go up

——-> back to starting point

Question 17

Treatment for CFS

Answer 17

• Focus on thoughts: about the symptoms and relation between symptoms and activity.
• Focus on behaviour: focus on activity scheduling (avoidance of activities and outbursts).

Question 18

Treatments for 2 different types of CFS

Answer 18

1. Relatively active CFS: first focus on the high demands/ overdoing it/ not respecting any limits (“I have to perform well”).
2. Relatively passive CFS: first focus on the catastrophising thoughts (“physical activity is bad for me”).

Question 19

Evidence for CBT for CFS

Answer 19

• Both CBT and graded exercise treatment work better than medical care.
• Adaptive pacing (following the pace of the client) was NOT better than medical care.
• CBT was more effective when patients had comorbid anxiety and depression.
• NICE-guidelines: CBT and/or GET should be offered, but only by healthcare practitioners who have experience with CFS.