Dr Taft Discusses the Role of CBT for Patients With Autoimmune Diseases

Cognitive behavioral therapy (CBT), which is based on the concept that how we think affects our behavior and emotions, can be used to help patients with autoimmune diseases cope and better manage their disease, said Tiffany N. Taft, PsyD, research assistant professor and clinical psychologist at Northwestern University Feinberg School of Medicine in Chicago, Illinois. Dr Taft presented on the use of CBT for patients with autoimmune diseases at IAS 2020.

Research has shown CBT is effective for many conditions in adults and children, specifically for improving quality of life measures. In addition, online CBT sessions were found to have similar efficacy as in-person CBT sessions, Dr Taft added.

“It is a very interactive therapy where I am leading patients on a discovery process,” she said. Typically, patients undergo 8 to 10 sessions of CBT. “We give homework or tasks for them to work on between sessions and they report back to us,” said Dr Taft. The homework can include keeping thought records, which are used to document mainly disease-specific situations and thoughts patients experience during the week. “Because they have a chronic condition, patients sometimes decide to stay for ongoing supportive therapy,” she added.

The emphasis of CBT is to help patients articulate their automatic thoughts and figure out ways to uncover and reshape their beliefs through questions. Automatic thoughts consist of a cycle where a situation triggers emotional and physical reactions. These thoughts are based on a person’s core beliefs, attitudes, rules, and assumptions. “This cycle happens quickly, and CBT is putting the brakes on a very rapid process,” explained Dr Taft.

In patients with autoimmune diseases, the common cognitive-affective processes include illness anxiety, symptom-specific anxiety, hypervigilance, attentional bias, and catastrophizing. For example, a patient with inflammatory bowel disease will wake up and assess and think about their body in a way they did not prior to their disease; they may be worried about experiencing a flare or not having access to a bathroom, which could lead to avoiding certain social functions. They may think this experience will never end because they are caught in this stress-cycle. 

Dr Taft reviewed the rates of mental health conditions in several autoimmune diseases she sees in her practice. She noted that post-traumatic stress disorder (PTSD) is becoming more common. In one study, researchers found 32% of patients with inflammatory bowel disease had symptoms of PTSD, although this still needs to be verified, she noted. “We need to recognize that patients with chronic conditions undergo multiple procedures, hospitalizations, and surgeries, each of which has the potential to be traumatic,” she said. She added that about 20% to 25% of patients, overall, will have symptoms of depression or anxiety, but that does not mean they meet the diagnostic criteria for a clinical diagnosis.

In addition to thought records, other strategies for addressing the cognitive-affective processes and helping patients get out of the stress cycle include psychoeducation, relaxation techniques such as diaphragmatic breathing, problem solving, and exposure plus response therapy.

Exposure plus response therapy is helpful for patients with anxiety and avoidance, said Dr Taft—for example, patients who restrict their social interactions or ones who have a fear of food. The patient creates a hierarchy based on their fear and starts with a situation that they would consider to be a 10 out 100 on the fear scale and move up that scale over time to the most feared, explained Dr Taft.

She empathized the importance of making sure clinicians think of and talk to patients about referring to a psychologist or social worker as an integrated process. “I want to drive home that the psychologist or social worker should be discussed as part of the treatment team early and not later because the patient might feel like they are being abandoned,” she said. There is still a lot of stigma around mental health and this feeling is amplified among patients with chronic conditions.

According to Dr Taft, the best mental health professionals for referral are ones with chronic illness experience, ideally ones with disease-specific experience. She also noted that clinicians should generally avoid anyone who lists every problem “under the sun” on their profile. These providers are not necessarily bad, but patients might not feel like they are receiving the best care because they are not as well-versed in this area, she added.

One of the problems clinicians might have when referring patients is finding a mental health provider who is accessible. She recommended using Rome Psychogastroenterology, Psychology Today Therapist Finder, American Psychology Association, National Register of Health Service Psychologists, and Association of Behavioral and Cognitive Therapy to locate a mental health specialist.

CBT for autoimmune diseases is covered by Medicare and most private insurances, she said. Therapists do accept insurance, with some geographic variation, offer sliding-scale fees, and some practices have trainees that offer reduced fees for patients who may be concerned about cost.

“Patients do want integrated mental health, but they feel more stigmatized,” she said. It is important that clinicians keep psychologists in mind early and to navigate these discussions careful to reduce patients’ feelings of stigma, she concluded.

For more coverage of IAS 2020 virtual, visit the newsroom.

–Melissa Weiss

Reference

Taft T. The role of cognitive behavioral therapy in the treatment of IMIDs. Presented virtually at: Interdisciplinary Autoimmune Summit 2020; July 12, 2020.