Exaggeratedly Negative Beliefs Perpetuate LTCs and MUS?

This is answered resoundingly in the affirmative and prescriptively in a just published book ‘CBT for Long-Term Conditions and Medically Unexplained Symptoms’ by Philip Kinsella and Helen Moya (Routledge 2022). But the book represents a triumph of ideology over evidence. It carefully avoids any consideration of studies that challenge its modus operandi.  The take home message is

With evangelistic fervour these authors proclaim on P16 For the typical cognitive  behavioural therapists it’s not necessary to be fully understanding of the debates around medically unexplained symptoms it’s more helpful to be aware of what the contributing factors are how to recognise and consider them and how to consider whether they are relevant to current problems’.

The reader is not informed of the details of the debate or the range of opinion.

There is no mention of:

  1. The Editorial in the Journal of Health Psychology in 2021 hDttOpsI://1d0o.i1.o1r7g/71/01.13157971/103539210151302318103482042 The ‘medically unexplained symptoms’ syndrome concept and the cognitive-behavioural treatment model’  that I and others wrote. In this paper we explored the validity of the MUS construct and the proposed treatment model.
  2. A 2020 paper in BMC Psychology by Keith Geraghty and I [Geraghty, K., & Scott, M. J. (2020)] Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified]. BMC psychology, 8(1), 13. https://doi.org/10.1186/s40359-020-0380-2]  in which we identifiedan unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under- reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment.
  3. The study by [ Serfaty et al (2019)] of treating depressed cancer patients. In this study patients were given CBT by IAPT staff in addition to treatment as usual (TAU) and the results compared with TAU alone. Whether the outcome measure was the PHQ9 or Beck Depression inventory there was no difference in outcome. Serfaty et al add ‘our results suggest that resources for a relatively costly therapy such as IAPT-delivered CBT should not be considered as a first-line treatment for depression in advanced cancer. Indeed, these findings raise important questions about the need to further evaluate the use of IAPT for people with comorbid severe illness’.

Kinsella and Moya (2022) operate with a confirmatory bias, searching out studies that support their position and ignoring those that do not.

 

When research findings are presented they are not contextualised, for  the Liu et al (2019) meta analysis published in the Journal of Affective Disorders is cited by Kinsella and Moya (2022) and they report their broad conclusion that CBT is effective for somatoform disorders and medically unexplained symptoms. But fail to state that these authors concluded  that          

‘the overall quality of evidence is relatively low due to a high risk of bias with lack of blinding of the participants, therapists, and outcome assessors’. Further 12 of the 15 studies assessed patients using a ‘gold standard’ standardised diagnostic interview these are not used in IAPT making the generalisation from the studies problematic. None of the studies involved an active comparator in which a credible therapy rationale was given, thus there is no evidence that any effect of the CBT is specific to the CBT. Self-report outcome measure scores were used, these are likely to be subject to demand characteristics when people have invested time and energy undergoing treatment. There was no determination of whether the treatment made a real world difference to patients lives nor of how enduring such change was. 

No mention that the RCTs are of patients who find it acceptable to go for psychological treatment of their MUS, the likelihood is that many find it simply unacceptable to take this pathway. Thus the results of the RCTs may not generalise to all patients with MUS.

 A Gross Violation of Transparency

In our 2020 paper [Geraghty, K., & Scott, M. J. (2020). Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified. BMC psychology, 8(1), 13. https://doi.org/10.1186/s40359-020-0380-2] we wrotepatients should be fully informed of the rationale behind psychotherapy, before agreeing to take part’

Kinsella and Moya take no heed of this and write in Chapter 14 identifying and helping patients who are fearful of recovery

page 180-1 ‘This phenomena is delicate Which may be conscious or out of awareness If there is a lot of resistance and and hostility and the general sense that the patient will be unable to contemplate a formulation that includes fear of recovery then it would be better to hold back…. If the formulation is not shared it can still be used by the therapist to guide their interventions…. Sometimes however one gets a sense of the reinforces for being nil being so strong or the fear of recovery being so powerful that therapeutic progress can’t be made for example if there’s a very attentive spouse a generous pay benefits payment under strong fear of going back into the old situation that triggered the symptoms then there is little of the therapist can do to overcome this a possible step by step approach to this problem is as follows’

Whatever happened to transparency and openness as a pre-condition for CBT?

 

CBT Treatments Bereft of An Evidence Base 

Somatoform Disorders They fail to mention that the DSM-5 dropped the construct of MUS, absenting if from the definition of somatic symptom disorder. None of the CBT studies of somatoform disorders included in the Cochrane review of 2014 https://doi.org/10.1002%2F14651858.CD011142.pub2 involved independent blind assessors and in the only comparison with an active placebo (Progressive Muscle Relaxation) there was no difference  in outcome. Cochrane concluded that the quality of the evidence in the reviewed studies was weak. Whether or not IAPT therapists do not use a standardised diagnostic interview to determine the presence of a somatoform disorder, so there is no sound foundation for the proposed interventions.

Chronic Pain  In 2021 NICE published guidance on the management of chronic pain https://www.nice.org.uk/guidance/ng193 Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain www.nice.org.uk/guidance/ng193. They made a recommendations to consider CBT for chronic pain rather than make a stronger recommendation to offer CBT because the evidence was not of high quality. Most of the evidence showed that CBT for pain improved quality of life for people with chronic primary pain. A consistent benefit was not demonstrated in other outcomes

ME/CFS In 2021 NICE published guidance on the management of this condition https://www.nice.org.uk/guidance/ng206/resources/myalgic-encephalomyelitis-or-encephalopathychronic-fatigue-syndrome-diagnosis-and-management-pdf-66143718094021 ‘The committee wanted to highlight that cognitive behavioural therapy (CBT) has sometimes been assumed to be a cure for ME/CFS. However, it should only be offered to support people who live with ME/CFS to manage their symptoms, improve their functioning and reduce the distress associated with having a chronic illness’. So that clients should be informed at the outset that the scope of CBT is limited. Further NICE adopts a different theoretical base to that of CBT therapists working in this area, it does not assume people have ‘abnormal’ illness beliefs and behaviours as an underlying cause of their ME/CFS, but recognises that thoughts, feelings, behaviours and physiology interact with each other. No mention of this in the said volume. 

ME/CFS Clients May Have a ‘Fear of Recovery’ claim Kinsella and Moya (2021), I am lost for words

Dr Mike Scott