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Changes in illness perceptions mediated the effect of CBT in severe functional somatic syndromes

Dolphin

Senior Member
Messages
17,567
J Psychosom Res. 2015 Apr;78(4):363-70. doi: 10.1016/j.jpsychores.2014.12.005. Epub 2014 Dec 13.
Changes in illness perceptions mediated the effect of cognitive behavioural therapy in severe functional somatic syndromes.
Christensen SS1, Frostholm L1, Ørnbøl E1, Schröder A2.
Author information

Abstract
OBJECTIVE:
Although there is substantial evidence that cognitive behavioural therapy alleviates symptoms in functional somatic syndromes, the mechanisms of change are less investigated. This study examined whether changes in illness perceptions mediated the effect of cognitive behavioural therapy.

METHODS:
We analysed additional data from a randomised controlled trial comparing completers of cognitive behavioural group therapy (46 patients) to an enhanced usual care group (66 patients). Proposed mediators (illness perceptions) and primary (physical health) and secondary (somatic symptoms and illness worry) outcomes were assessed by means of questionnaires at referral, baseline, end of treatment, and 10 and 16 months after randomisation. Multiple mediation analysis determined whether (1) changes in specific illness perceptions during treatment mediated the effect of cognitive behavioural therapy (primary analysis), and (2) whether changes in illness perceptions during the whole trial period were associated with improved outcome (secondary analysis).

RESULTS:
Improvements in illness perceptions during treatment partially mediated the effect of cognitive behavioural therapy on physical health one year after treatment (sum of indirect effects 1.556, BCa 95% CI (0.006; 3.620)). Improving perceived control was particularly important. Changes in illness perceptions from baseline to 16 months after randomisation were associated with clinically meaningful improvements in physical health, somatic symptoms and illness worry during the same period.

CONCLUSION:
Our results suggest that changing patients' illness perceptions is an important process in cognitive behavioural therapy for functional somatic syndromes. Challenging patients' own understanding of their illness may hence be a key element of successful treatment.

Copyright © 2014 Elsevier Inc. All rights reserved.

KEYWORDS:
Chronic fatigue syndrome; Cognitive-behavioural therapy; Fibromyalgia; Functional somatic syndromes; Illness perceptions; Mediation

PMID:
25541119
DOI:
10.1016/j.jpsychores.2014.12.005
[PubMed - indexed for MEDLINE]
 

Dolphin

Senior Member
Messages
17,567
Instruments

Illness perceptions

Illness perceptions were assessed by means of a revised, Danish version of the IPQ-R [26]. The Danish version of the IPQ-R was initially made for primary care use, and a strong correlation between emotional representations and negative consequences (Pearson correlation coefficient= 0.67) was reported in this [26] and other previous studies [24,29,34]. In order to reduce the risk of multicollinearity, we performed a Pearson correlation analysis of baseline data, examining the correlation between the components. We found low intercorrelations (ranging from ±0.10 to 0.25) with exception of a strong correlation between emotional representations and consequences (Pearson correlation coefficient = 0.58, p b 0.0001). We therefore combined these two components into an index with unweighted means. The following components were addressed during the group CBT programme and hypothesized key agents of change; lack of control (e.g. I think I have the power to influence my symptoms (reversed)), IPQ index of negative consequences (e.g. I think that my health problem could have major consequences for my life) and emotional representations (e.g. my health problem worries me), and a recently introduced component regarding uncertainty (e.g. it is hard to figure out,what iswrongwithme) [26]. All illness perception scores were converted to a 0-100 scale; higher scores representing more negative illness perceptions. An optional “I don't know” category was recorded as missing.


This is a version of the questionnaire they used to look for mediating factors:

ILLNESS PERCEPTION QUESTIONNAIRE (IPQ-R)

We are interested in your own personal views of how you now see your current illness.
Please indicate how much you agree or disagree with the following statements about your illness by
ticking the appropriate box.

VIEWS ABOUT YOUR ILLNESS STRONGLY
DISAGREE
DISAGREE NEITHER
AGREE NOR
DISAGREE
AGREE STRONGLY
AGREE

IP1 My illness will last a short time
IP2 My illness is likely to be permanent rather than temporary
IP3 My illness will last for a long time
IP4 This illness will pass quickly
IP5 I expect to have this illness for the rest of my life
IP6 My illness is a serious condition
IP7 My illness has major consequences on my life
IP8 My illness does not have much effect on my life
IP9 My illness strongly affects the way others see me
IP10 My illness has serious financial consequences
IP11 My illness causes difficulties for those who are close to me
IP12 There is a lot which I can do to control my symptoms
IP13 What I do can determine whether my illness gets better or worse
IP14 The course of my illness depends on me
IP15 Nothing I do will affect my illness
IP16 I have the power to influence my illness
IP17 My actions will have no affect on the outcome of my illness
IP18 My illness will improve in time
IP19 There is very little that can be done to improve my illness
IP20 My treatment will be effective in curing my illness
IP21 The negative effects of my illness can be
prevented (avoided) by my treatment
IP22 My treatment can control my illness
IP23 There is nothing which can help my condition
IP24 The symptoms of my condition are puzzling to me
IP25 My illness is a mystery to me
IP26 I don’t understand my illness
IP27 My illness doesn’t make any sense to me
IP28 I have a clear picture or understanding of my condition
IP29 The symptoms of my illness change a great deal from day to day
IP30 My symptoms come and go in cycles
IP31 My illness is very unpredictable
IP32 I go through cycles in which my illness gets better and worse.
IP33 I get depressed when I think about my illness
IP34 When I think about my illness I get upset
IP35 My illness makes me feel angry
IP36 My illness does not worry me
IP37 Having this illness makes me feel anxious
IP38 My illness makes me feel afraid

SCORING THE IPQ-R

Please note:


High scores on the identity, timeline, consequences, and cyclical dimensions represent strongly held beliefs about the number of symptoms attributed to the illness, the chronicity of the condition, the negative consequences of the illness, and the cyclical nature of the condition.


High scores on the personal control, treatment control and coherence dimensions, represent positive beliefs about the controllability of the illness and a personal understanding of the condition.



Coding: for identity scale yes = 1; no = 0


strongly disagree =1, disagree =2, neither agree or disagree = 3, agree = 4, strongly agree = 5


Reverse score: IP1, IP4, IP8, IP15, IP17, IP18, IP19, IP23, IP24, IP25, IP26, IP27, IP36



1. Identity: sum yes-rated symptoms in column 2 (this symptom is related to my illness) on p. 1


2. Timeline (acute/chronic): sum items IP1 - IP5 + IP18


3. Consequences: sum items IP6 - IP11


4. Personal control: sum items IP12 - 1P17


5. Treatment control items: sum items IP19 – IP23


6. Illness coherence items: sum items IP24 – IP28


7. Timeline cyclical: sum items IP29 – IP32


8. Emotional representations: sum items IP33 – IP38
 

A.B.

Senior Member
Messages
3,780
If the illness serverity is measured in a way that is highly dependent on perception, and a therapy whose goal is to change perception is applied, is it surprising that the illness seems to improve?

I would not be surprised if there is some intervention that can change the perception of car engine problems in car owners. Only an idiot would conclude that altered perception is the same as altered physical reality. Yet here they are, doing exactly that.
 
Last edited:

Dolphin

Senior Member
Messages
17,567
Outcomes

A validation study of pre-baseline data from the original trial questioned the validity of the widely used Short Form Health survey (SF-36) Physical Component Summary in this particular patient group. Instead the primary outcome was a mean change in aggregate score on the SF-36 subscales ‘physical functioning’, ‘bodily pain’, and ‘vitality’ from baseline to 16 months after randomisation [31,35,36]. Consequently,we used the same primary outcome in the present study. The aggregate score ranges from 15 to 65; higher scores representing better physical health. The secondary outcome measures were reductions in the 90-item symptom checklist-revised, SCL-90-R, somatisation subscale [37] and Whiteley-7 [38], addressing somatic symptoms and illness worry, respectively. Both measures were recorded on a 0-4 scale, with higher scores representing more symptoms and more worrying.
 

Dolphin

Senior Member
Messages
17,567
If the illness serverity is measured in a way that is highly dependent on perception, and a therapy whose goal is to change perception is applied, is it surprising that the illness seems to improve?
Agree. But if somebody could highlight specific connections between the questions used regarding mediating factors and the questions used for the outcome measures, that would be great. Though just for general interest: I'm not sure I will do anything specifically on this at this stage.
 

Snow Leopard

Hibernating
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5,902
Location
South Australia
If the illness serverity is measured in a way that is highly dependent on perception, and a therapy whose goal is to change perception is applied, is it surprising that the illness seems to improve?

I was about to say the same thing.

In the absence of objective measures of functioning, all they have is tautological evidence - the therapy aims to modify illness perceptions, therefore patients report differently on questionnaires. There are of course.many possible biases involved, that could explain such an effect without any change in underlying health or functioning.
 

user9876

Senior Member
Messages
4,556
I've not read it but I suspect there are assumptions of independence in the mediation and final variables yet they are all derived from questionnaire whose answers will have some common underlying semantics.

Shouldn't get through a peer review without properly dealing with these issues (i.e. using more objective measures of outcomes).
 

Hutan

Senior Member
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1,099
Location
New Zealand
We analysed additional data from a randomised controlled trial comparing completers of cognitive behavioural group therapy (46 patients) to an enhanced usual care group (66 patients).

So, presumably the treatment arms had around the same number of people, in which case some 20-odd people did not complete the trial. (I can only see the abstract, so I don't know how many didn't finish the course, but the fact that 'completers' was mentioned suggests that at least some did not complete the course ).

And is it likely that the non-completers were just like the completers? No, of course not. The non-completers are much more likely to have had worse functionality at the beginning and/or to have deteriorated during the course. That is, they were physically less able to make it to the sessions and were a lot more likely to get mightily pissed off at being told that they are failing to think better and that's why they aren't improving.

And those recalcitrant sick people have just been swept under the carpet.

Improving perceived control was particularly important. Changes in illness perceptions from baseline to 16 months after randomisation were associated with clinically meaningful improvements in physical health, somatic symptoms and illness worry during the same period.

So, we have a set of completers with a higher percentage of people whose illness has improved than the set of controls. And these improved completers have been told that their successful thinking has made them better.

And of course, if you are physically better, then you feel better. And you also feel that you have more control over your life and you are worrying much less about your illness. Being physically better causes the improved outlook, not the other way around.

And then of course you have the participants reporting what the researchers want to hear etc etc

The stupidity apparent in these kinds of papers never fails to amaze me.
 

Dolphin

Senior Member
Messages
17,567
A reminder that physical health was measured by a questionnaire:
Instead the primary outcome was a mean change in aggregate score on the SF-36 subscales ‘physical functioning’, ‘bodily pain’, and ‘vitality’ from baseline to 16 months after randomisation [31,35,36].
 

PennyIA

Senior Member
Messages
728
Location
Iowa
What really bugs me (above and beyond what everyone else is reporting)... is that there are people that sometimes have an improvement of symptoms that are spontaneous. We don't KNOW WHY, we DON'T KNOW HOW LONG, but geez... if it happens to occur while you're being given CBT, you can bet they are going to claim it was their treatment.

UGH
 

Dolphin

Senior Member
Messages
17,567
What really bugs me (above and beyond what everyone else is reporting)... is that there are people that sometimes have an improvement of symptoms that are spontaneous. We don't KNOW WHY, we DON'T KNOW HOW LONG, but geez... if it happens to occur while you're being given CBT, you can bet they are going to claim it was their treatment.

UGH
And indeed some patients will come to the same conclusion i.e. having more people do CBT can create fans for CBT even when the improvement isn't really down to the CBT.
 

daisybell

Senior Member
Messages
1,613
Location
New Zealand
Is it just me - when I see that there's a new paper in the journal of psychosomatic research, my inner voice just goes
'Blah, blah, blah, blah, blah.......bleurgh."

I can't even summon up any energy to feel annoyed. It's just too stupid for wasting more words on.