Cognitive and behavioural

treatments for functional somatic

syndromes
Peter White & Kate Harri
London 2012
Agenda
Do these treatments work?
Do treatments help occupation?
An example of CBT for pain
Predictors
Mediators

Risk markers for prolonged CFS
Fatigue, symptoms, mood disorders,
physical illness beliefs, pervasive
inactivity, sleep problems

Risk markers for prolonged whiplash
- Unexpectedness
- low education, female
Pain, symptoms, ROM, passivity,
psychol. Distress

SJ Kamper et al, 2007
Risk markers for musculoskeletal
pain in primary care
- Pain, past history, multiple sites
- Passivity, psychol. distress
- ROM and disability
- Social adversity

CD Mallen et al, 2007
Initial
infection
Rest or
boom & bust
Bodily
adaptation
Sleep
problems
Fatigue
Beliefs
Biopsychosocial model of CFS
CBT for pain disorders
Effect sizes versus waiting list controls

Pain 0.40
Depression 0.36
Activity 0.46
Social function 0.60
RTW ????

S Morley et al, Pain, 1999
CBT & GET for CFS
Effect sizes for function

CBT 0.36
GET 0.39
RTW ????

BD Castell et al, 2011
CBT for fibromyalgia
Effect sizes

Pain 0.47
Function 0.42
RTW ????

JA Glombiewski et al, 2010
GET for fibromyalgia
Effect sizes

Pain 0.31
HRQOL 0.40
RTW ????

W Hauser et al, 2010
RTW after MDT for CWP: women
JS Skouen et al, 2006
Physical function
3
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Time
SMC GET
APT CBT
Main treatment phase Follow up phase
Remission in PACE
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APT CBT GET SMC
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Healthcare cost-effectiveness
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SMC
CBT
GET
APT
Informal Care and Lost Employment in PACE
APT CBT GET SMC
Informal care hours per week 11.0 8.0 7.7 11.4
Informal care cost (s) 6196 4008 4073 6507
Lost employment % 86 84 86 89
Lost employment cost (s) 14,865 13,958 14,638 14,157
P McCrone et al, 2012
Societal cost-effectiveness
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CBT
GET
SMC
APT
CBT & GET have moderate
efficacy but only modest effects
in helping RTW after FSS
What moderates response to
behavioural treatments?
Moderators of non-response to GET or
CBT for CFS
Membership of a self-help group
Severity of fatigue
Sickness benefit
High combined mood score
Involvement in legal proceedings to achieve
disability benefits
Not duration of illness!
R Bentall et al, 2002
J Prins et al, 2003

Moderators of non-response to CBT
for pain
More pain and pain sites
Depression
Rumination
Catastrophising
Life difficulties

JA Turner et al, 2007

Disability insurance claims:
return to work
Diagnosis %
CFS/ME 14
Depression 18
Low back pain 22
Swiss Re, 2001
FSS insurance claims
1. Interpersonal clash at work
Domestic responsibilities
2. Never referred for treatment
No CBT/GET available locally
Already received CBT and/or GET
3. Dr X mitochondrial disease
Prof Y Fibro is incurable and [X] will never
return to work
Social risks
If you have to prove you are ill, you cant get
well. (N Hadler, 1996)

ME is an incurable disease.


What mediates response to
behavioural treatments?
Mediators of response to GET or CBT
for CFS
Treatment dose (number of sessions)
Reduction in symptom focusing
Reduction in fear avoidance

Not increased activity
Not increased fitness
Not change in cognitions
Not change in mood

Mediators of response to CBT for pain
Treatment dose
Increased perceived pain control
Reduction in serious pain beliefs
Reduced catastrophising
Increased self-efficacy


Conclusion
Biopsychosocial model best fit for FSS
Rehabilitation based treatments are
moderately helpful, but are not aimed to
help RTW
Their effect on occupation is mild to
moderate
Targets for more effective rehab include
attitudes & beliefs of doctors, employers,
and patients, as much as developing more
vocationally targeted treatments.