Cognitivebehavioural Therapy In Diabetes And Other Somatic Disorders

As CBT and RET have become well-established in the treatment of psychological disorders, their application has widened to the treatment of patients with various medical conditions. Information on the effect of psychosocial interventions in diabetes is meager, and often lacks systematic, quantitative evaluation51. Interventions that are described in the literature can be cate gorized either as psychotherapy, support groups or coping-oriented groups. To our knowledge there are no reports on cognitive-behavioural group interventions that are studied in a controlled randomized design.

Studies on the use of cognitive techniques in individual psychotherapy in diabetes include a study in which the effects of individual cognitive analytic therapy (CAT) are compared to diabetes education52. Glycaemic control improved in both conditions, but improvements were maintained in the longer term in the CAT group only. In addition, patients receiving CAT experienced fewer interpersonal difficulties in the longer term. To date, the only experience with CBT directed specifically at adults with diabetes is a randomized, controlled trial on the efficacy of CBT for type 2 patients suffering from depression53. In this study, the effects of CBT were compared to the effects of no specific antidepressant treatment in patients receiving diabetes education. Ten individual sessions of CBT proved to be an effective treatment for depression (85% of the treated patients achieved remission, compared with 27.3% of the controls). There were no direct effects on glycaemic control, but improvements were seen in the CBT group at 6 month follow-up. The prognosis for recovery was worse when complications of diabetes were present and when compliance with blood glucose monitoring was poorer54. The majority of patients with diabetes, however, do not suffer from depression, although affective disorders appear to be more prevalent than in the general population55.

Many patients do have difficulty coping with the diabetes regimen. Various group interventions have been described, aimed at helping patients to cope more effectively with their diabetes. These coping-oriented group interventions typically consist of problem-solving and/or social skills training. The short and structured nature of these interventions seems to have positive effects on attendance56 and assertiveness57. Uncontrolled studies with adolescents found increases in assertiveness58 and problem-focused coping59. In controlled studies, a trend was found towards reduced depression, increased self-esteem and a greater use of emotion-focused coping60, improved glycaemic control61, improved coping abilities62, and a reduction of diabetes-specific distress63. In two recent studies, a coping skills training (CST)64 and a behavioural programme to improve adherence and stress management65 were compared to standard medical care. Both interventions had positive effects on emotional well-being, which were maintained at follow-up. In participants of CST, glycaemic control also improved.

Beneficial effects of coping-oriented group interventions were demonstrated in adults, including improvements in self-reported compliance and self-confidence66. The number of participants in this study was, however, very small and there was no formal evaluation. A behavioural group programme developed by Zettler and colleagues67, teaching participants strategies to cope with complications, was aimed at reducing anxiety and avoidance behaviour, encouraging adherence, and preparing patients with type 1 diabetes for crises. Analysis of dysfunctional health beliefs was used as a cognitive strategy. The intervention resulted in a reduction of fear and an enhanced acceptance of the disease. Rubin and colleagues68 added two sessions of diabetes-specific coping skills training, focusing on attitudes and beliefs underlying self-care, to an outpatient education programme. This training, containing cognitive-behavioural elements, resulted in an improvement of emotional well-being and HbAlc, an increase in SMBG, and a decrease of bingeing 6 months after the intervention. Positive effects on self-esteem, anxiety, diabetes knowledge and self-efficacy were maintained at 12 months follow-up69. In a study by Anderson et al7°, the effects of a six-session patient empowerment programme were evaluated in a randomized, waiting list-controlled trial. The aim of the programme was to improve goal setting, problem-solving skills, emotional coping, stress management, obtaining social support and motivation. The intervention resulted in improvements in self-efficacy in these domains and reduced HbA1c.

In a review of cognitive approaches in various somatic disorders, Emmelkamp and Van Oppen71 found that though the relative contribution of cognitive therapy varies, positive effects are well established. In controlled studies, positive effects were found for patients with chronic pain, which were maintained at follow-up. Cognitive-based interventions also proved effective in the treatment of tension headaches. Reduction of emotional distress following cognitive programmes has been reported in HIV-seropositive men and patients with various forms of cancer. Applied to self-management training in patients with asthma, cognitive therapy resulted in improved coping behaviour, increased compliance to medication and less preoccupation with the disease in daily life. Patients with irritable bowel syndrome experienced a reduction of symptoms. The evidence for effects on risk factors for cardiovascular disorders (e.g. hypertension, components of type A behaviour, smoking) and on weight loss in obese patients remains inconclusive. In the treatment of bulimia, however, substantial changes in bingeing and vomiting and improvements in psychosocial problems are reported.

More recent randomized controlled trials of cognitive-behavioural-based group interventions continue to show encouraging results that vary for different somatic conditions and different groups of patients. For patients with chronic pain, beneficial effects are found72'73. Positive effects of a behavioural programme were magnified by adding a cognitive compo-nent74. For patients with fibromyalgia, this was not the case75, possibly due to poor compliance and difficulty of the programme76. In patients with cancer, a cognitive approach led to decreased pain77, reduced distress and improved psychosocial functioning78. In HIV-seropositive patients, improved cognitive coping and social support seemed related to enhanced psychological well-being and quality of life79. Two studies show a reduction of symptoms in patients with irritable bowel syndrome, and a reduction of signs of depression80'81. In patients with rheumatoid arthritis, a decrease in pain, emotional distress and disease activity eventually resulted in a reduction of clinic visits and hospitalization. Only minor changes in coping behaviour were found, possibly due to the progressive status of the illness82. In several studies, beneficial effects were maintained at long-term follow-up83"86.

We can conclude that the application of cognitive approaches in diabetes and other somatic disorders show promising results. Additional advantages of CBGT-based programmes are that these interventions can be delivered by professionals with varying backgrounds (including psychologists, diabetes educators/nurse specialists, doctors and social workers), are relatively short and can be transferred to other centres. In the next section, the content and effects will be discussed of a group intervention based on cognitive-behavioural therapy that was developed and evaluated at our centre.

Eliminating Stress and Anxiety From Your Life

Eliminating Stress and Anxiety From Your Life

It seems like you hear it all the time from nearly every one you know I'm SO stressed out!? Pressures abound in this world today. Those pressures cause stress and anxiety, and often we are ill-equipped to deal with those stressors that trigger anxiety and other feelings that can make us sick. Literally, sick.

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