CBT in Multiple Sclerosis review
Dennison L, Moss-Morris R.(2010) Cognitive Behavioural Therapy: what benefits
can it offer people with Multiple Sclerosis? Expert Review of Neurotherapeutic,
s10(9), 1383-1390.
Cognitive Behavioral Therapy: what benefits can it offer
people with Multiple Sclerosis?
Laura Dennison and Rona Moss-Morris
Centre for the Applications of Health Psychology, School of Psychology, University
of Southampton, Highfield Campus, Southampton, United Kingdom, SO17 1BJ
Corresponding Author: Rona Moss-Morris
School of Psychology
University of Southampton
Highfield Campus
Southampton
UK
SO17 1BJ
Tel: (+44) 02380 597549
Fax: (+44) 02380 592606
Email: remm@soton.ac.uk
Keywords: Cognitive Behavioral Therapy; Multiple Sclerosis; depression, anxiety,
fatigue, psychological adjustment
Summary
Cognitive Behavior Therapy (CBT) originated as a treatment for emotional disorders.
However, it is increasingly used to help people with chronic illnesses manage
symptoms and improve psychosocial outcomes such as depression and quality of life.
In this review we focus on uses of CBT in patients with Multiple Sclerosis (MS), an
incurable neurological disease which causes potentially debilitating symptoms and
poses numerous challenges to psychological well-being. We examine the rationale
for using cognitive-behavioral therapy to deal with distress, symptoms, impairment
and disease exacerbation and progression and discuss examples of existing research
on the efficacy and acceptability of these interventions. Finally we consider areas
where CBT could potentially benefit people with MS in the future. Ongoing
challenges in this field are discussed.
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CBT in Multiple Sclerosis review
Introduction
Multiple Sclerosis (MS) is currently thought to affect more than 2.5 million people
worldwide including around 400,000 in the United States (101) . Symptoms vary but
can include abnormal gait, spasticity, disturbances in sensation and vision, bowel and
bladder disturbances, sexual dysfunction, cognitive impairment, pain and fatigue.
Around 85% of patients are initially diagnosed with a relapsing-remitting form of MS
however for the majority, the disease becomes progressive over time and impairment
increases (1). There is no cure for MS, although disease-modifying drugs are
somewhat successful in reducing the severity and frequency of relapses (2,3).
As well as the physical manifestations, living with this chronic illness poses numerous
and profound psychosocial challenges. Onset is usually in young or mid adulthood, a
time when people are typically establishing careers, relationships and families. People
with MS frequently experience losses or changes in employment, income, and
relationships and disruptions to self-care, home management, and social and leisure
activities. Uncertainty about the future means that longer-term goals and plans are
threatened.
Cognitive Behavioral Therapy (CBT) originated as a treatment for emotional
disorders, in particular depression and anxiety (4). In recent years it has been
increasingly used within chronic illness populations to manage symptoms such as
pain (5) and fatigue (6) and improve psychosocial outcomes (7). CBT is based on the
principle that physiological, behavioral, cognitive (thinking) and emotional responses
interact and influence one another within the context of a social environment. Change
in any one of the response systems may instigate changes in other response systems (8).
CBT is a pragmatic and collaborative form of therapy whereby the therapist guides
clients in gaining insight into how their own responses can contribute to or perpetuate
their difficulties, and assists them to change responses in one or more systems (e.g.
cognitions or behaviors) in order to produce change in other systems (e.g. emotions).
Clients practice new skills and behaviors, often in the form of homework between
sessions. Individual patients will differ in their unhelpful responses. Contrary to
common belief, cognitive techniques in CBT are not simply focused on discovering
irrational and negative thinking and imposing positive thinking about matters (e.g.
MS) which have few if any positive aspects. Instead they specifically aim to discern
and modify thoughts which are inaccurate and unhelpful in terms of psychological
adjustment.
Figure 1 depicts a formulation of a potentially problematic cycle of symptoms,
thoughts, feeling and behaviors for one individual. In this example, MS symptoms
(physiology) lead to unhelpful thoughts about the reactions of other people
(cognitions). These thoughts could lead to the person reducing social activities in
order to avoid perceived negative judgement from others (behaviors). This avoidant
behavior could then influence mood, exacerbating feelings of depression and
loneliness (emotions). A lonely and depressed individual may then focus more on
somatic symptoms, and their subjective experience of them may be heightened
(physiology). The figure also indicates some typical CBT techniques which might be
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CBT in Multiple Sclerosis review
used to break the cycle and bring about relief from negative emotions. The figure
shows how therapy could intervene at the point of cognitions by using a range of
methods to become aware of, and alter unhelpful thinking. Alternatively (or
additionally), therapy could employ various approaches to address behaviors or
emotions.
[Insert figure about here]
This review examines research on applications of CBT in populations with MS. It
examines the rationale for using CBT to address both psychosocial outcomes and
physical symptoms, discusses research on its efficacy and acceptability and considers
areas where CBT could potentially benefit people with MS in the future.
Exhaustive and systematic reviews of psychological interventions for MS have been
published in recent years (9,10). The current review article, however, is intended as a
succinct and accessible overview, commentary and update. Therefore, key published
papers of high quality, relevance and recency have been selected following searches
of Medline PsychInfo, Embase, Web of Knowledge and UK and US trial registries.
We concentrate specifically on CBT, rather than combined psychosocial management
approaches, or approaches which include, amongst others, CBT techniques.
Reducing clinical depression and anxiety
People with MS have high rates of depression and anxiety (11,12). Depression is
particularly common; the lifetime prevalence of major depression may be as high as
around 50% and the annual prevalence is in the region of 20% (12). Evidence has
accumulated for the effectiveness of CBT as a treatment for depression and anxiety
within mental health. Furthermore, a substantial literature demonstrates that various
unhelpful cognitions and behaviors are linked to depression and anxiety in people
with MS suggesting that CBT may be a useful treatment approach (13).
Reducing depression
A recent Cochrane review of research into psychological interventions concluded that
CBT may be helpful for treating depression in MS (10). Many of the larger and good
quality studies of CBT to tackle depression in MS have been conducted by Mohr and
colleagues (14,15,16). Their therapy included behavioral activation (planning, goal
setting and monitoring adaptive behaviors) and cognitive restructuring (identifying
and altering unhelpful thoughts) components typical to CBT. However, the focus was
on MS-specific problems such as fatigue, pain, and social and relationship difficulties
resulting from the disease. This programme has been compared to treatment as usual
(15)
, the anti-depressant sertraline, a supportive-expressive psychotherapy group
treatment (14) and individual supportive-expressive psychotherapy (16). In all studies
CBT was an effective treatment for reducing symptoms of depression compared to the
controls or comparisons. Each study has limitations (e.g. small samples, high attrition)
which future studies should address. Nonetheless, the research provides encouraging
evidence that CBT can successfully treat depression in MS. Because CBT teaches
patients to identify and modify factors involved in their depression, it may mean they
are able to prevent or self-manage episodes of depression in the future without
requiring medication which they may be reluctant to take, or which may cause
unpleasant or intolerable side effects.
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CBT in Multiple Sclerosis review
An interesting consideration is whether CBT for depression needs to be specifically
tailored in the context of chronic illness; Mohr et al’s CBT programme was adapted
specifically for people with MS. A recent qualitative investigation of people with
MS experiences of widely available web-based CBT depression programmes
(‘Beating the Blues’ and ‘MoodGym’) suggested that many participants found these
generic interventions less relevant to their needs (17) .Participants felt that the
interventions lacked attention to natural grief over MS-related losses and that the
examples given were often inappropriate or irrelevant to them.
Dealing with anxiety
People with MS demonstrate high rates of anxiety (18) which is unsurprising given the
unpredictability of MS and often sudden and alarming nature of MS symptoms.
Interestingly, CBT for generalised anxiety is relatively neglected in the MS literature.
However, a series of studies focused on self-injection anxiety. Many MS diseasemodifying therapies (DMTs) such as IFNB-1a (Rebif or Avonex), are self-injected.
Patients’ expectations of their ability to self-inject successfully and anxiety about selfinjection are important predictors of treatment adherence (19). Certain dysfunctional
thoughts seem to be associated with self-injection anxiety. Some are related to the
injection process itself (e.g. “there will be loads of blood”), whilst some relate to
acceptance of MS (e.g. “doing this shot means I’m allowing MS into my life”) (20).
Two small studies demonstrated that CBT leads to substantial increases in the ability
to self-inject. The intervention included systematic desensitization (graded exposure
to feared stimulus – in this instance the injection), cognitive restructuring (identifying
and modifying unhelpful thoughts), psycho-education (providing information and a
model of difficulties experienced) and relaxation skills1. In a pilot study seven out of
eight participants became capable of self-injecting after six 50 minute sessions. The
final participant self-injected after one further session. Seven participants were selfinjecting at three month follow-up (22). A follow-up study compared the same
intervention to telephone support (23). CBT participants were more likely to be able to
self-inject post-therapy but a high drop out rate, meant the analysis showed a trend
towards the superiority of CBT rather than a statistically significant difference. Whilst
encouraging, we need larger, more rigorous trials examining maintenance of gains.
Improving adjustment and coping
In addition to patients who develop clinically significant levels of depression and
anxiety, many more people with MS show evidence of more broadly defined
adjustment difficulties such as heightened distress and reduced quality of life (24,11,25).
Again, cognitions and behaviors explain variance in these outcomes suggesting that
CBT addressing these factors may be useful (13). Qualitative research also shows
patients’ dissatisfaction with support in the post-diagnosis period, and desire for
assistance with emotional distress and coping with the disease (26).
A Cochrane review which included the rather limited trial evidence in this area
concluded that cognitive-behavioral approaches may be beneficial in helping people
adjust to, and cope with, MS (10). Another review suggested that interventions with
1
The treatment manual has been made available by the authors online
(21)
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CBT in Multiple Sclerosis review
CBT elements (e.g. goal setting, homework) tend to be most beneficial in terms of
improving quality of life (9). Unfortunately, existing studies have been
methodologically flawed in various ways which makes drawing firm conclusions at
this stage problematic (10).
Our research team is currently conducting a RCT aimed at reducing distress and the
impact of illness on domains such as work, relationships and leisure activities (27).
The intervention is for patients in the early stage of MS but is intended not just for
those with clinically significant distress. The CBT is manualized and modules
include symptom management, social support, problem-solving, setting goals, sleep
management, and tackling unhelpful thoughts. Sessions are tailored to the individual
patient’s problem formulation. The focus is on developing an individualised toolbox
of skills to manage aspects of the MS experience which will be beneficial now, and if
disease progresses or relapses in the future. Data from this trial should be published
in late 2010. The trial also includes an economic analysis to assess the costeffectiveness of the therapy.
Reducing MS symptoms and impairment
Reducing fatigue
Fatigue is one of the most common and debilitating MS symptoms, affecting around
80% of patients (28). The pathophysiological processes of MS fatigue are poorly
understood. However, psychological factors explain significant variance in fatigue [32,
33] and a cognitive-behavioral model has been proposed whereby primary MS disease
factors trigger fatigue, which is then perpetuated or worsened by people’s cognitive,
emotional and behavioral responses to the symptom (28). Thus, breaking the vicious
cycle of fatigue by modifying unhelpful cognitions (e.g. “this fatigue must mean I am
having a relapse”) and behaviors (e.g. excessive rest and avoidance of activity) should
help reduce fatigue. Cognitive-behavioral therapy has been affective in treating
fatigue in other chronic conditions, including chronic fatigue syndrome (e.g. 6).
The first trial to specifically apply CBT to fatigue in MS compared CBT to relaxation
training (29). An experienced clinical psychologist delivered a combination of face-toface and telephone sessions. An individualized CBT model for understanding the
patient’s fatigue was developed collaboratively. Sessions involved activity scheduling,
reducing symptom focusing and the tendency to attribute all symptoms to MS and/or
signs of relapse, addressing unhelpful thoughts about fatigue and high personal
expectations, stress-management and goal-setting. CBT treatment produced superior
improvements, although participants in both treatment groups improved significantly
following treatment and there were no difference between the groups at 6 months post
therapy. The post-therapy effect size for CBT was substantial (3.03). Post-treatment
levels of fatigue were even lower than those of healthy controls and gains were
largely maintained at 6 months post therapy. No participants withdrew from treatment
and most found the approach more helpful than other treatments they had received for
their fatigue
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CBT in Multiple Sclerosis review
Although these results were encouraging few patients with MS fatigue currently have
access to an experienced CBT therapist. To counter this problem, we have recently
designed MSInvigor8, a web-based interactive computerised version of the therapist
CBT package. The programme was modified and developed with extensive input and
testing from seven patients with MS fatigue. A small pilot RCT of 40 patients
showed that those randomised to work through the website over 8 weeks with three
telephone support sessions from an assistant psychologist, reported substantial
reductions in both fatigue severity and impact at the end of treatment (30). If these
results hold up in a larger trial with a longer follow-up period, MSInvigor8 may be a
viable option for many MS patients. Another recent pilot study of 16 MS patients
looked at the possible efficacy of a group-based intervention for the management of
MS fatigue which incorporated some elements of CBT (31). This intervention
appeared to improve patients’ sense of self-efficacy for managing fatigue but did not
reduce fatigue severity itself. Patients found the approach acceptable and a larger trial
may show more promising data.
Behavioral manifestations of cognitive impairment
Cognitive impairment is common in MS and often causes distress to the patient and
family. It can also be associated with personality and behavior changes such as
inappropriate social behavior, angry outbursts, inappropriate language, risk-taking
behavior and excessive speech. In a small (n=15) trial a neuropsychological
counselling (NC) treatment was compared to non-specific psychotherapy (32). The NC
used, amongst other approaches, CBT strategies to enhance patients’ self control and
help them regulate behavior. This included monitoring of abnormal social behavior,
early identification of negative behaviors, refocusing of attention, relaxation, and
selection of other behavior. Socially inappropriate and aggressive behavior reduced
more in the NC group., with a significant effect on excessive speech. Although these
are only modest findings they suggest that CBT could be useful for managing
behavioral manifestations of cognitive impairment.
Influencing disease severity and progression
To date, research has focused on using CBT for improving mental health, wellbeing,
symptom severity and impact. Existing research is yet to demonstrate effects of CBT
on “hard” neurological endpoints. However, actually altering disease outcomes
through CBT may also be plausible, at least in theory. Firstly, CBT may influence
disease processes via improved adherence to medical advice and treatments.
Depression is associated with poor adherence to DMTs (33) and CBT for depression
has been shown to improve adherence (15). By treating depression, adherence could be
improved with possible positive impact on disease processes. Similarly, CBT for selfinjection anxiety could potentially reduce exacerbations and influence longer term MS
progression via increased adherence to DMTs. CBT may also have the potential to
influence disease outcomes given that psychological states impact on immune
functioning (34). Psychological distress and depression appear to be implicated in the
immune system’s attack on the central nervous system (35) and a meta-analysis
suggests psychological stress can trigger MS disease exacerbation (36). An innovative
trial is currently underway testing the efficacy of stress management CBT for
reducing markers of MS inflammation and deterioration (37) The primary outcome in
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CBT in Multiple Sclerosis review
this trial is gadolinium enhancing (Gd+) MRI, a measure of MS inflammation and
blood-brain barrier breakdown. The research also examines the effects of CBT on T2weighted MRI (disease burden) and brain parenchymal fraction (brain atrophy).
Positive results from this research domain might eventually lead to a novel way of
influencing MS exacerbation and progression.
Therapy Delivery
Delivering CBT to people with MS may raise important practical considerations.
Patients may require short sessions due to fatigability and concentration difficulties.
Furthermore, cognitive impairment may limit the amount and intensity of content
covered. Flexibility may be required for session scheduling in order to deal with
unpredictable symptoms and disease exacerbations. Furthermore, travel to sessions
may be difficult for those with mobility difficulties or other symptoms, especially if
services are not local.
Telephone therapy is one means by which some of these practical considerations have
been addressed. Efficacious CBT for people with MS can be delivered wholly (15,16) or
partly (29) by telephone. However, no trials have directly compared telephone and
face-to-face CBT. Drawbacks may arise from telephone delivery, including difficulty
building a supportive, empathic relationship without face-to-face contact. Furthermore,
uncomfortable silences, lack of non-verbal communication and difficulties using
visual aids and reviewing homework tasks (e.g. activity records) may pose problems.
A combination of face-to-face and telephone sessions may provide a good
compromise.
Another way of addressing disease-related obstacles to access, as well as barriers
arising from cost and therapist availability, is through CBT provision through
interactive websites. As discussed in the section on fatigue, computerised CBT
(CCBT) may offer a potentially cost-effective and convenient service to patients (30).
However, lessons from CCBT trials on other patient groups suggests it unlikely that
these websites will be effective without at least some minimal therapist contact, either
by telephone or email (38). Similarly, preliminary work on CCBT programmes for
depression, showed that some patients with MS were unable to grasp and apply basic
premises of CBT (e.g. links between cognitions and emotions) or define problems and
set goals without therapist input. Patients also felt the programme lacked important
supportive and social contact(17).
It is, as yet also unclear whether highly trained clinical psychologists or CBT
therapists are required to deliver CBT, or whether other health professionals, already
traditionally employed by MS services such as nurses can be taught to deliver
effective (and more cost-effective) interventions. Again, existing trials have not made
direct comparisons. However, some findings suggest that non-expert therapists may
not be optimally effective. For example, in the CBT for self-injection anxiety research
the initial trial used psychologists as therapists and obtained a strong treatment effect
(22)
. The same programme delivered by nurses had a high drop out rate and only a
trend towards significant results (23). However, it is possible that factors such as
differences in personality or communication style between therapists may explain
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CBT in Multiple Sclerosis review
these results rather than training and skill level. Clearly, further research is needed to
compare different delivery forms and different therapists before clear conclusions can
be reached.
It is also worth noting that people with MS vary in their need for CBT interventions.
Face-to-face CBT with an experienced therapist is unlikely to be needed across the
board. However, it is possible that a number of patients may benefit from
interventions which aim to improve broader outcomes such as adjustment and coping
skills for living with chronic illness and managing symptoms (e.g. 27)). Further work is
needed to understand whether psychological variables such as distress or MS disease
variables such as relapse or progression should be used as a basis for offering CBT
services to patients and whether a stepped approach may be helpful. For example,
web-based interventions or group approaches incorporating some CBT techniques (39)
may suffice for people with lower levels of distress and difficulties managing
symptoms, while face-to-face therapy may be beneficial for more complex cases.
Expert commentary
The literature reviewed suggests that CBT has the potential to improve many aspects
of living with MS. However, important questions remain. We need more research to
establish efficacy through larger, more robust RCTs, particularly beyond the realm of
CBT for depression in MS. We also need to improve our understanding of the active
ingredients within CBT in each application: through what mechanisms are
interventions operating? Understanding whether benefits are achieved principally
through behavior change, thought modification, or more non-specific therapeutic
factors such as empathy can build theoretical understanding of the role of
psychological factors in MS-related problems and direct the improvement of
interventions.
Further exploration is needed regarding optimum delivery methods. How ‘diluted’
CBT can become whilst still maintaining its efficacy? Can CBT be delivered by
novices? Can results be achieved with little or no therapist contact? We also need
better understanding of long-term effectiveness. Existing trials have rarely looked
beyond a short term (3-6 month) post treatment follow-up but longer term
maintenance of gains is of particular interest, given the progressive/relapsing disease
course and the ongoing challenges for the patient.
Little is known about how CBT for MS would work beyond the research environment.
Most research has excluded patients with high levels of disability (e.g. EDSS >7, nonambulatory), severe cognitive dysfunction, and medical co-morbidities. Therefore, it
is hard to predict effectiveness within a wider, more morbid patient population.
Finally, and of considerable importance if CBT is to become widely available, we can
identify no published cost-effectiveness research on CBT in MS.
Five year view
Within the coming years we expect that research will gradually address the above
problems. In addition, we anticipate that the focus of efficacy trials will continue to
evolve from reducing depression to improving broader psychosocial outcomes such as
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CBT in Multiple Sclerosis review
quality of life and illness impact as well as reducing anxiety. We also anticipate an
increasing emphasis on using CBT for symptom management extending the work on
MS fatigue. At least two trials of CBT which include patients with MS pain are
currently in progress (40,41). We also foresee the application of CBT in managing
sexual dysfunction and cognitive impairment; areas where thoughts and behaviors
would be expected to influence the symptoms experienced and the resulting distress.
Before such interventions are pursued, empirical evidence and theoretical models of
psychological contributions to these problems should be established. Research may
also turn its focus to whether distress or stress reduction translates into benefits for
disease course, with more research investigating if and how CBT influences
physiological processes such as immune function.
Another area which may develop is family-focused CBT. Partners and children of the
patient with MS can experience considerable psychosocial difficulties themselves
(42,43,11)
and also contribute to the adjustment of the patient (44). Conceivably, inclusion
of significant others in CBT could benefit all family members, including the patient
with MS. In addition, CBT for family members who are distressed and not coping
well with their ill relative could also be of benefit.
Finally, the coming years may witness exploration of newer CBT approaches which
emphasize mindfulness and acceptance (e.g. 45). These approaches differ from
traditional CBT by emphasising tolerance of negative thoughts and emotions, rather
than identification and modification of them. Acceptance approaches are designed to
increase patients’ willingness to face and live with uncomfortable thoughts and
feelings. Mindfulness approaches teach individuals to increase awareness of thoughts
and feelings and to develop a detached perspective where thoughts are viewed as
passing events in the mind, rather than reflections of reality. These contemporary
approaches could be highly relevant to people with MS. Worrying thoughts and
preoccupation with uncertainty are typical difficulties experienced by people with MS.
Furthermore, the nature of MS means patients may have little to gain by constant
active attempts to alter symptoms and disease course. These approaches have
demonstrated initial success in populations with other health problems such as chronic
pain (46). A cognitive-behavioral mindfulness study in MS patients is currently in
progress (47).
Conclusion
CBT is an effective treatment for managing psychological distress as well as certain
somatic symptoms associated with MS. It could potentially alleviate a wide range of
MS-related symptoms and psychosocial problems where thoughts and behaviors
contribute to difficulties. In particular we need to investigate if and how CBT can be
made available in cost-effective, acceptable and accessible ways.
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CBT in Multiple Sclerosis review
Key issues
1. MS produces unpredictable and potentially disabling symptoms and poses
multiple challenges for psychosocial adjustment.
2. CBT is a pragmatic, collaborative psychological intervention. The client gains
insight into how their thought processes, behaviors and emotions can contribute to,
or perpetuate their difficulties and learns skills to change aspects of their behavior
and thinking style in order to bring about physiological and emotional changes.
3. CBT specifically tailored to address MS-related difficulties can reduce
depression in those with diagnosed major depressive disorder or high levels of
depressive symptoms.
4. Encouraging but small trials demonstrate that CBT for self-injection anxiety is
effective; this has implications for adherence to disease modifying medications.
5. CBT may promote psychosocial adjustment more broadly (e.g. reducing
illness impact and increasing wellbeing and quality of life). Research so far is
limited, but more work is in progress.
6. One RCT has shown that CBT for addressing MS fatigue has a beneficial
effect on fatigue levels.
7. It is yet to be seen whether CBT has beneficial effects on disease severity and
progression. This is theoretically plausible either via reductions in stress/distress and
their effects on the immune system or via promoting better adherence and selfmanagement.
8. Telephone and web-based CBT delivery may reduce difficulties associated with
lack of availability and attending therapy sessions in this population. Health
professionals traditionally employed by MS hospital services such as nurses can be
trained to deliver CBT. It remains unclear whether these interventions are as
successful as those delivered face-to-face by specialist CBT therapists.
9. Further applications of CBT may include reducing anxiety, and symptom
management (e.g. pain, sexual dysfunction and cognitive impairment)
10. Evidence so far comes from tightly controlled efficacy trials with short followup periods. It is unclear how findings would translate to long term effects in real
world settings. Pragmatic trials and cost-effectiveness studies of CBT interventions
in MS are lacking.
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Acknowledgements/financial disclosure
Rona Moss-Morris holds grants from the UK MS Society for a trial of CBT for
adjustment to MS and a pilot trial of web-based CBT for MS fatigue. Laura Dennison
works on the adjustment to MS trial.
Reference List
1. Goodkin D. Interferon beta therapy for multiple sclerosis. The Lancet 352,
1486-1487 (1998).
2. Goodin DS. Disease-modifying therapy in multiple sclerosis: Update and
clinical implications. Neurology 71(24_suppl_3), 8-13 (2008).
3. Rudick RA. Disease-modifying drugs for relapsing-remitting multiple
sclerosis and future directions for multiple sclerosis therapeutics.
Arch Neurol 56(9), 1079-1084 (1999).
4. Beck AT. Cognitive therapy and the emotional disorders. In: Penguin
Books, 1976)
5. Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of
randomized controlled trials of cognitive behaviour therapy and
behaviour therapy for chronic pain in adults, excluding headache.
Pain 80(1-2), 1-13 (1999).
6. Malouff JM, Thorsteinsson EB, Rooke SE, Bhullar N, Schutte NS. Efficacy
of cognitive behavioral therapy for chronic fatigue syndrome: A
meta-analysis. Clinical Psychology Review 28(5), 736-745 (2008).
7. Moorey S, Cort E, Kapari M et al. A cluster randomized controlled trial of
cognitive behaviour therapy for common mental disorders in
patients with advanced cancer. Psychological Medicine 39(05), 713723 (2008).
8. Beck.A. Cognitive therapy: a 30-year retrospective. American Psychologist
46, 368-375 (1991).
9. Malcomson KS, Dunwoody L, Lowe-Strong AS. Psychosocial interventions
in people with multiple sclerosis: a review. Journal of Neurology 254,
1-13 (2007).
**10.
Thomas PW, Thomas S, Hiller C, Galvin K, Baker R. Psychological
interventions for multiple sclerosis. Cochrane Database of Systematic
Reviews 1(CD004431) (2006).
This Cochrane systematic review includes an examination of the use of CBT in
people with MS. Despite methodological limitations to existing studies it concludes
that CBT appears efficacious for treating depression in MS, and may be beneficial for
promoting coping and psychological adjustment.
11
CBT in Multiple Sclerosis review
11. Janssens A, van Dorn P, de Boer J, van der Meche F, Passchier J, Hintzen
R. Impact of recently diagnosed multiple sclerosis on quality of life,
anxiety, depression and distress of patients and partners. Acta
Neurologica Scandinavica 108(6), 389-395 (2003).
12. Siegert RJ , Abernethy DA. Depression in multiple sclerosis: a review.
Journal of Neurology, Neurosurgery and Psychiatry 76(4), 469-475
(2005).
**13.
Dennison L, Moss-Morris R, Chalder T. A review of psychological
correlates of adjustment in patients with multiple sclerosis. Clinical
Psychology Review 29, 141-153 (2009).
This review paper examines cognitions and behaviors which are associated with
adjustment to MS and presents a cognitive behavioral model of adjustment. Ways of
addressing relevant cognitions and behaviours using CBT techniques are discussed.
*14. Mohr D, Boudewyn A, Goodkin D, Bostrom A, Epstein L. Comparative
outcomes for individual cognitive-behavior therapy, supportiveexpressive group psychotherapy, and Sertraline for the treatment of
depression in multiple sclerosis. Journal of Consulting and Clinical
Psychology 69(6), 942-949 (2001).
One of a series of trials by Mohr and colleagues which test their CBT package for
people with MS and depression.
15. Mohr DC, Likosky W, Bertagnolli A et al. Telephone-administered
cognitive-behavioral therapy for the treatment of depressive
symptoms in multiple sclerosis. Journal of Consulting and Clinical
Psychology 68(2), 356-361 (2000).
16. Mohr DC, Hart SL, Julian L et al. Telephone-administered psychotherapy
for depression. Archives of General Psychiatry 62(9), 1007-1014
(2005).
17. Hind D, O'Cathain A, Cooper C et al. The acceptability of computerised
cognitive behavioural therpay for the treatment of depression in
people with choric physical disease: a qualitative study of people
with multiple sclerosis. Psychology and Health 24(1), 1-14 (2009).
18. Mohr DC , Cox D. Multiple Sclerosis: Empirical Literature for the Clinical
Health Psychologist. Journal of Clinical Psychology 57(4), 479-499
(2001).
19. Mohr DC, Boudewyn AC, Likosky W, Levine E, Goodkin DE. Injectable
medication for the treatment of multiple sclerosis: The influence of
self-efficacy expectations and infection anxiety on adherence and
12
CBT in Multiple Sclerosis review
ability to self-inject. Annals of Behavioral Medicine 23(2), 125-132
(2001).
20. Cox D, Mohr DC, Epstein L. Treating self-injection phobia in patients
prescribed injectable medications: A case example illustrating a sixsession treatment model. Cognitive and Behavioral Practice 11(3),
278-283 (2004).
21. Mohr D, Cox D, and Boudewyn A. Self-injection anxiety counseling (SIAC)
manual for counselors.
http://www.preventivemedicine.northwestern.edu/Divisions/behavioral
medicine/Mohr%20Lab/mohrlab.htm (2003)
22. Mohr D, Cox D, Epstein L, Boudewyn A. Teaching patients to self-inject:
pilot study of a treatment for injection anxiety and phobia in
multiple sclerosis patients prescribed injectable medications.
Journal of Behavior Therapy and Experimental Psychiatry 33, 39-47
(2002).
23. Mohr D, Cox D, Merluzzi N. Self-Injection Anxiety Training: a treatment
for patients unable to self-inject injectable medications. Multiple
Sclerosis 11, 182-185 (2005).
24. Hakim EA, Bakheit AMO, Bryant TN et al. The social impact of multiple
sclerosis-a study of 305 patients and their relatives. Disability and
Rehabilitation 22(6), 288-293 (2000).
25. Mohr DC, Dick PP, Russo D et al. The Psychosocial Impact of Multiple
Scleoris: Exploring the Patient's Perspective. Health Psychology
18(4), 376-382 (1999).
26. Dennison L, Yardley L, Devereux A, Moss-Morris R. Experiences of
adjusting to early stage MS; the patient's perspective. British
Journal of Health Psychology, In press (2010).
27. Moss-Morris R, Dennison L, Yardley L et al. Protocol for the saMS trial
(supportive adjustment for multiple sclerosis): A randomized
controlled trial comparing cognitive behavioural therapy to
supportive listening for adjustment to multiple sclerosis. BMC
Neurology (2009).
*28. van Kessel K , Moss-Morris R. Understanding multiple sclerosis fatigue: A
synthesis of biological and psychological factors. Journal of
Psychosomatic Research 61(5), 583-585 (2006).
This paper explains how a range of factors appear to contribute to the experience of
MS fatigue and presents a cognitive-behavioral model which can inform interventions
to manage fatigue.
**29.
van Kessel K, Moss-Morris R, Willoughby E, Chalder T, Johnson M,
Robinson E. A randomized controlled trial of cognitive behavior
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CBT in Multiple Sclerosis review
therapy for multiple sclerosis fatigue. Psychosomatic Medicine 70,
205-213 (2008).
The first CBT trial aimed at reducing fatigue in people with MS. Post-therapy fatigue
levels were below those observed in a healthy population.
30. Moss-Morris R, Bell L, Wills G, Yardley L, McCrone P. Piloting the
feasibility, efficacy and economics of MS Invigor8- a web based
cognitive behavioural therapy programme for multiple sclerosis
fatigue. In preparation (2010).
31. Thomas S, Thomas P, Nock A et al. Development and preliminary
evaluation of a cognitive behavioural approach to fatigue
management in people with multiple sclerosis. Patient Education and
Counseling 78, 240-249 (2010).
32. Benedict R, Shapiro A, Priore R et al. Neuropsychological counseling
improves social behavior in cognitively-impaired multiple sclerosis
patients. Multiple Sclerosis 6, 391-396 (2000).
33. Mohr D, Goodkin D, Likosky W et al. Therapeutic expectations of patients
with multiple sclerosis upon initiating interferon beta-1b:
Relationship to adherence to treatment. Multiple Sclerosis 2, 222-226
(1996).
34. Kern S , Ziemssen T. Review: Brain immune communication
psychoneuroimmunology of multiple sclerosis. Multiple Sclerosis
14(1), 6-21 (2008).
35. Foley FW, Traugott U, LaRocca NG. A prospective study of depression and
immune dysregulation in multiple sclerosis. Arch Neurol 49(3), 238244 (1992).
36. Mohr D, Hart S, Julian L, Cox D, Pelletier D. Association between stressful
life events and exacerbation in multiple sclerosis: a meta-analysis.
BMJ 328(7442), 731- (2004).
37. Mohr D, Daikh D, and et al. Stress management for patients with multiple
sclerosis. NCT00147446 (2010)
38. Cuijpers P, van Straten A, Andersson G. Internet-administered cognitive
behavior therapy for health problems: A systematic review. Journal
of Behavioral Medicine 31(2), 169-177 (2008).
39. Forman AC , Lincoln NB. Evaluation of an adjustment group for people
with multiple sclerosis: a pilot randomized controlled trial. Clinical
Rehabilitation 24(3), 211-221 (2010).
40. Ehde DM and et al. Telephone Intervention for Pain Study (TIPS).
NCT00323271
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CBT in Multiple Sclerosis review
41. Kerns R and et al. Cognitive-behavior Therapy for MS-Related Chronic
Pain. NCT00663663
42. Bogosian A, Moss-Morris R, Yardley L, Dennison L. Experiences of
partners of people in the early stages of multiple sclerosis. Multiple
Sclerosis 15(7), 876-884 (2009).
43. Bogosian A, Moss-Morris R, Bishop F, Hadwin J. Psychosocial adjustment
in children and adolescents with a parent with Multiple Sclerosis: A
Systematic Review. Clinical Rehabilitation In press (2010).
44. Schwartz L , Kraft GH. The role of spouse responses to disability and
family environment in multiple sclerosis. American Journal of
Physical Medicine & Rehabilitation 78(6), 525-532 (1999).
45. Hayes SC, Follette VM, Lineham M. Mindfulness and acceptance:
expanding the cognitive behavioural tradition. In: The Guilford
Press, 2004)
46. McCracken LM, Vowles KE, Eccleston C. Acceptance-based treatment for
persons with complex, long standing chronic pain: a preliminary
analysis of treatment outcome in comparison to a waiting phase.
Behaviour Research and Therapy 43(10), 1335-1346 (2005).
47. Grossman P. Effects of a cognitive-behavioural mindfulness intervention
upon quality of life, depression and fatigue among multiple sclerosis
(MS) patients. ISRCTN21643919
Web references
101. National MS Society. Who gets MS?
http://www.nationalmssociety.org/about-multiple-sclerosis/who-gets-ms/index.aspx
(2009)
Further reading
**Mohr D. The stress and mood management programme for individuals with
multiple sclerosis: Therapist guide. In: Oxford Press, 2010)
This workbook is based on the CBT programme which Mohr’s series of studies have
shown to be efficacious. This therapist guide provides instruction for delivering
treatment to individuals with MS who are experiencing stress and depressed mood.
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CBT in Multiple Sclerosis review
Figure 1: Examples of CBT techniques to address possible unhelpful thoughts and
behaviours in response to experiencing MS-related speech and gait problems
16