CHAPTER 15 CBT in Medical Patients LEARNING MAP Rationale for using CBT in medical illnesses £ | g High-yield CBT interventions for patients with ‘medical problems AA grea: deal of research and clinical work hae been focused on the de velopment of cognitive-behavior therapy (CBT) methods thet can help patients with medical illnesses (Safran etal. 2008; Sensky 2004; Wright et al, 2008), Our goal inthis chapter isto explain how some of the most practical and efficient CBT methods for patients with physical disorders can be implemented in bref sessions. Because CBT applicetions for med: ica illnesses may be unfamiliar to some readers, we outline a feww of the important reasons for doing this type of work and provide a short tour through some of the empirical backing for this approach, Rationale for Using CBT in Medical Illnesses CBT, of course, is not used for treatment of the primary disease state patients with medical disorders but is an adjunctive therapy thet ist 279aS 260 High-Yield Cognitive-Behavior Therapy for Brief Sessions geted toward reducing symptom burden snd helping people better ac- cept and manage physical illnesses. Although many effective treatments are available for medical problems, a great number of patients have chronic diseases with residual problems such as pain, reduced mobility, ‘weakness, or impaited daly functioning, Others are experiencing the on. set ofa severe illness and are struggling to come to grips with the diagno- sisand engoge in an effective treatment plan, Still others are grieving over loss of function or have problems adhering to needed treatments. CBT can be used to asist patents in coping with all of these situations ‘An additional reason for using CBT is that patients with physical prob- lems often have anxiety or depression thats sufficient to wacrantreferal to 2 mental health specialist for treatment. A varity of studies have found high rates of depression and anxiety in medical disorders such as heart disease Ganuzzi et al. 2000; Lichtman et al. 2008), diabetes (Anderson et al. 2001), cancer {Spiegal and Giese-Davis 2003), and stroke (Morris etal. 1993). Depression is three times more common in patients following myocardial infarction than in the normal population (Lichtman etal. 2008) and is frequently observed in patients with posi- ‘ive burnan immunodeficiency virus (HIV) status (Dew et al, 1997), Many patients who have mental ilinesses such as bipolar disorder or schizophrenia and who are being followed with brief medication man- agement develop physical illnesses over their lifetimes. Having a severe psychiatric disorder substantially increases morbidity and mortality from rnedical problems, Depression raises the risk of death in patients with cardiovascular disease (Focht et sl. 2004; Lichtman etal, 2008; van Melle ‘tal, 2004) and diabetes (Katon and Ciechanowski 2002) and decreases Jmmmune function in patients with positive HIV [Antoni etal. 2005). An- ‘ther ominous finding is that patients with bipolar disorder and schizo- hrenia have shortened life spans because of increased rates of medical cisorders, particularly cardiovascular ditease (Newcomer and Hennekins 2007), Thus, clinicians who ere providing combined CBT and pharma cotherapy for patients with psychiatric conditions also need to be on the lookout for medical problems in these patients, be advocates for their re- ceiving high-level medical care, help them learn how to lead healthier lifestyles, and teach them coping skills for physical symptoms. Empirical Evidence for Efficacy of CBT in Medical Illnesses ‘Numerous mets-analyses and reviews have found thet CBT has benefite for patients with physical illnesses (Safran et al. 2008; Sensky 2004; CBT in Medical Pastents 281 Wright etal 2008). Positive results from adjunctive CBT inchide de- creased distress and pain in patients with breast cancer (Fetrow and Montgomery 2006), beiter glycemic contel in patients with diabetes Lostman etal 1998; Snock eta. 2008), and decreased symptoms in vaciety of patients with chronic pain (Linton and Nordin 2006; Linton and Ryberg 2001; Moore et al. 2000; Morley etal 1999; Turner and Jensen 1993). Other studies have shown that treatment with CBT? can help patients with multiple sclerosis ta have improved paychologial and physical functioning (Rodgers tal. 1986), enable people with hyperten- sion to have decreased medication requirements (Shapiro etal. 1997), and benefit patents with fibromyalgia and chronic fatigue syndromes (Bennett and Nelion 2006; Deale etal. 2001; Stulemeijr e al. 2005) The list of additional CBT applications ia medical disorders is quite laege and includes conditions such as asthma (Maes and Schloss 1988), inflammatory and imtable bowel syndeomes (Kennedy eta. 2006; Payne and Blanchard 1995), and termparamandibula joint syndrome (Mishra et al, 2000; Turner et sl 2006). Taken together these studies suggest that CBT can be combined with indicated physical teatments to enhance quale Sty oflife and dally functioning a many patients with medical meses jh-Yield CBT Interventions for Patients With Medical Problems ‘The CBT approach to treating people with medical disarders in brief ses- sons uss all ofthe general procedures outlined in Chapters 1, "Introduc- ‘ion’; 2, “Indications and Formats for Brief CBT Sessions"; 3, “Enhancing ‘the Impact of Brief Sessions", and 4, “Case Formulation and Treatment Planning." Special ettention should be peid to understanding the mean- Ings that patients atzch to having medical diagnosis and requiring tent ment, screening for depression and anxiety thet may have been triggeved by the medica illness, and developing effective coping strategies for physical symptoms. Also, cliniciens need to coordinate thelr work with the plans of other physicians who are treating the patients, Table 15-1 lists some of the high-yield CBT methods that we recommend for sesst- ing people who have medical problems. These methods are discussed in the fallowing subsections Identify Patient’s Explanatory Model for the Illness Psychological problems produced by medical illnesses are highly influ enced by the personal meaning that « patient imparts to having the dis-| | eset aoe seem 262 High-Yield Cognitive-Behavior Therapy for Brief Sessions CBT ix Medical Patients 283 ‘Table 15-1. Ten high-yield cognitive-behavior therapy interventions for patients with medical problems dently patient's explanatory rode for the iliness. Provide psychoeducation. Employ motivational interviewing. Use cognitive-behavior therapy tools to promote adherence. “Teach patients skills to facilitace communication with care providers. Implement activity scheduling to enhance personal contra Problem-solve when necessary. ‘Take steps to reduce arouse Corvact misconceptions and distortions. Facilitate grieving end acceptarce of losses. cease (Sensky 2004), Categories of dysfunctional thinking about illness include maladaptive thoughts an¢ beliefs about the experience of being il about the consequences of «particular illness; about the type of illness itself or about physicians, medications, or hospitals. Some ofthese ideas ‘an be widely held in a patients culture or subculture and may need ‘houghtfal exploration to effect change, A few examples of mesnings that might be attached to having en illness are noted in Table 15-2. CBT methods can be directed at modifying potentially deleterious meanings end developing and strengthening postive meenings, ‘Anillustation of the way personel meaning canbe addressed effectively ina brief session can be found in Dr Sudak's treatment of Allan, a 53-year cold man who has been strugaing since having a eat attack 6 month «go He isahigh choo! teacher who previously was an avid exercise: He believed that his vigorous exercise program, which included running marathons, ‘would “immunize” him against having an early hart attack. He had an uncle who died suddenly of heart attack at age 54; however, Allan’ father, who ‘was very active man, lived into his mid-80s until his death 2 years ago. ‘Now Allan seams adsift. He feels very vulnerable to sudden death and is voiding any exercise, despite his doctor's epor that his heart is much beter ‘and chat moderate exercise i highly recommended. Allan aso is avoiding having sex with his wife due to an intense fear that the exertions of sex will ‘be too much for his heart. Before the heart attack, they had a “great” sex life ‘The meanings that Allan has attached to having an unexpected heart attack appear to include a 180-degree switch from feeling fully protected by exercise to his current view of being totally vulnerable. Understanding ‘Table 15-2. Personal meanings that may be attached to having @ medical illness Meanings that could negatively impact adjustment Having this condition meuas that Iam weak, ‘This just proves that life is futile, Why try so hard? It is shameful to have this problem. Natural remedies are always better than chemicals that dctors push. cen do this better on my own, Everything | did to live a healkby life was « waste You have tobe careful about trusting doctors. They are in the pockets of the drug companies. can’t do everything | wed to do, it is’t worth tying 1 deserved to get this dlness, Meanings that could positively impact adjustment Iki tough fuck, but anybody can get this type of disease ‘This disease will test me, but Ican approach it ike ny other problems. Get as much information as possble—then figure out the best, solution, 1've coped with lots of other problems; I can face this illness, I've seen other people ight this disesse; I can too. ‘This i @ wake-up call olive a healthier lf need to live my lif in @ meaningful way with bis les, Tam not my disease; Iam stil myself ‘My doctor, my family, and Ican be an effective team to fight this problem. Ineed to make sure that we ace on the stme page with our plans. this switch helped Dr. Sudak formulate plan for helping Allan develop amore realistic view of his personal health, including risks involved in ex- cercise and sex, 2 Video illustration 18. Helping a Pationt With 2 Medical Disorder rr. Sudak and Allan Jn Video llustration 18, Dr, Sudak uses Socratic questions to help Al- lan evaluate his predictions about physical activity end to uncover his ex- planatory model for his current physical states feeling of intense exhaustion, Allan reports that he beliaves heart disease isthe cause of his severe tiredness (“haven't recovered completely from the heart attack")