Opinion Cognitive behavioural therapy for neurologists, 2023, Stanton, Chalder and Carvalho

[Andy]

Abstract

In neurological practice, we take pride in accurate diagnosis and using neuroscience to develop novel disease-modifying therapies, but we sometimes neglect symptom management and the treatment of distress. Most patients with neurological disorders report that their mental health needs are not being met. Of the many forms of psychological therapy, cognitive behavioural therapy (CBT) is the most likely to be available to our patients. This article sets out to answer the following questions: (1) What is CBT? (2) What will patients experience if they have CBT? (3) Is CBT effective for people with neurological disorders? (4) Who is most suitable for CBT? (5) How and where can a neurologist refer their patients for CBT? (6) Can we as neurologists use aspects of the CBT model in our own consultations?

Paywall, https://pn.bmj.com/content/early/2023/11/06/pn-2023-003857


[This was a hit for "chronic fatigue syndrome" in my daily searches, but obviously there is no sign of that in the abstract - it might be due to "Competing interests TC is the author of self-help books on chronic fatigue for which she has received royalties"]

 

[Hutan]

I'm disappointed. With the title of 'Cognitive behavioural therapy for neurologists', I thought it might be the neurologists who were the recipients of therapy aiming to change their behaviour. Certainly, the neurologist I saw would have benefitted from such a therapy.

 

[Hutan]

This article sets out to answer the following questions:... (6) Can we as neurologists use aspects of the CBT model in our own consultations?

The abstract suggests that the paper is written by neurologists

Biba Stanton 1
1. Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
https://www.kcl.ac.uk/people/biba-stanton
That description of Stanton's background indicates that she is hard core FND, but also does seem to be a neurologist

Dr Stanton is the clinical lead for neurology at King's College Hospital. She specialises in functional neurological disorder (FND), as well as behavioural symptoms in neurological disease. She runs a specialist clinic for FND at King’s College Hospital and contributes to the Maudsley neuropsychiatry service. She leads the FND workstream at King’s Health Partners Neurosciences. She has a particular interest in developing care pathways for FND and complex somatic symptoms.

Dr Stanton is the Honorary Secretary Elect of the Association of British Neurologists. She is a chair of the NICE Appeal Panel and sits on the NHS England National IFR Panel. She is a member of the FND Hope Medical Expert Committee, providing clinical support to this patient organisation.

Looks like Stanton is a large part of the FND problem in the UK. I feel very uneasy seeing that she is Chair of the NICE Appeal Panel.

Trudie Chalder 2 - last time I looked, Chalder was not a neurologist

Carolina Carvalho 2,3
2. Department of Psychological Medicine, King's College London, London, UK
3. School of Psychology, University of Surrey, Guildford, UK
I may be wrong, but the only person I can find with that name and those links is here on Linked In
That Linked In profile suggests that Carvalho is an undergraduate student at the University of Surrey, part of the way through a Bachelor of Science - Psychology (2020-2024). She is also an 'Honorary Research Assistant' at Kings College London. This is noted as an 'indirect contract'. This began in Sep 2022. It is hard to believe that the place traditionally occupied by a senior author in the author list of a paper is taken by someone who has not yet completed an undergraduate qualification, but I cannot find a more senior person with that name listed as an employee of either of the two institutions.
Fatigue outcomes following COVID-19: a systematic review and meta-analysis April 2023, has Chalder as senior author. It found that frequently reported associations with post-Covid-19 fatigue were female gender, age, physical functioning, breathlessness and psychological distress. And it concluded that 'Non-modifiable factors and psychological morbidity may contribute to ongoing fatigue and impede recovery.'

In the Acknowledgements of that paper, there is this:
"The authors thank Carolina Carvalho for her contribution to the quality assessment analysis."
So that does suggest that Carolina Carvalho is an undergraduate student who has been working as a research assistant in Kings College London. So, not a neurologist.

 

[cassava7]

The abstract suggests that the paper is written by neurologists

Biba Stanton 1
1. Department of Neurology, King's College Hospital NHS Foundation Trust, London, UK
https://www.kcl.ac.uk/people/biba-stanton
That description of Stanton's background indicates that she is hard core FND, but also does seem to be a neurologist



Looks like Stanton is a large part of the FND problem in the UK. I feel very uneasy seeing that she is Chair of the NICE Appeal Panel.

Trudie Chalder 2 - last time I looked, Chalder was not a neurologist

Carolina Carvalho 2,3
2. Department of Psychological Medicine, King's College London, London, UK
3. School of Psychology, University of Surrey, Guildford, UK
I may be wrong, but the only person I can find with that name and those links is here on Linked In
That Linked In profile suggests that Carvalho is an undergraduate student at the University of Surrey, part of the way through a Bachelor of Science - Psychology (2020-2024). She is also an 'Honorary Research Assistant' at Kings College London. This is noted as an 'indirect contract'. This began in Sep 2022. It is hard to believe that the place traditionally occupied by a senior author in the author list of a paper is taken by someone who has not yet completed an undergraduate qualification, but I cannot find a more senior person with that name listed as an employee of either of the two institutions.
Fatigue outcomes following COVID-19: a systematic review and meta-analysis April 2023, has Chalder as senior author. It found that frequently reported associations with post-Covid-19 fatigue were female gender, age, physical functioning, breathlessness and psychological distress. And it concluded that 'Non-modifiable factors and psychological morbidity may contribute to ongoing fatigue and impede recovery.'
In the Acknowledgements of that paper, there is this:
"The authors thank Carolina Carvalho for her contribution to the quality assessment analysis."
So that does suggest that Carolina Carvalho is an undergraduate student who has been working as a research assistant in Kings College London. So, not a neurologist.

Dr Stanton was among the co-authors / signatories of Prof Peter White’s position paper against the NICE ME/CFS guideline published in the JNNP (https://jnnp.bmj.com/content/early/2023/07/09/jnnp-2022-330463).

 

[Gradzy]

In neurological practice, we take pride in accurate diagnosis

hmmmm

 

[Sean]

Pride cometh before the fall.

Pity they are taking patients down with them.

Besides, seems to me they are more concerned with being precise (consistent) than accurate (correct), though obviously in an ideal world they would be both.

 

[ToneAl]

Pride cometh before the fall.

Pity they are taking patients down with them.

Besides, seems to me they are more concerned with being precise (consistent) than accurate (correct), though obviously in an ideal world they would be both.

They are showing their true colours they have a find mindset being biased towards the diagnosis. They will always diagnose fnd even if the evidence says otherwise. Recalling several papers come to mind prion disease diagnosed as fnd, ms diagnosed as fnd when MRI is clear, two papers come to mind 7t MRI showing damage done, when normal MRI is clear in another clear MRI is sign of progressive ms. PSP diagnosed as fnd, could go on forever.

 

[SNT Gatchaman]

Many of our patients with neurological disorders struggle with fatigue, pain and distress, which can be the main drivers of quality of life and social functioning. The prevalence of mental disorders in all neurological patients is 55.1%.

The 55.1% references Per Fink et al.: Mental illness in new neurological patients (2003, JNNP) —

Methods: 198 consecutive patients referred for the first time to a neurologist were studied using a two phase design. ICD-10 psychiatric diagnoses were established by means of the SCAN (Schedules for Clinical Assessment in Neuropsychiatry).

Results: The overall prevalence of current mental disorders was 55.1% (95% CI: 46.2 to 63.8), and 65.0% (95% CI: 56.1 to 73.0) had at least once in their life had a psychiatric disorder. The most frequent current diagnoses were somatoform disorders (33.8%, (95% CI: 25.9 to 42.7%)), followed by phobias (21.8%; 95% CI: 15.3 to 30.0), substance use disorders (13.3%; 95% CI: 8.3 to 20.6) and depression/dysthymia (14.4; 95% CI: 9.1 to 21.8). The psychiatric morbidity markedly declined with increasing age. Compared with 63.5% of the women, 46.4% of the men had a psychiatric disorder. Substance use disorders were more frequent in men than women (p=0.002). Patients with a psychiatric disorder were more frequently seen in the outpatients’ clinic than those without. The neurologists detected 14%–40% of the cases, 16.9% were in treatment, and only 4.6% were referred to mental health care.

As neurologists, we are most comfortable with a medical model. We are good at making a diagnosis and planning patients’ medical management.

No reference provided for either of those two statements.

 

[SNT Gatchaman]

CBT was first developed to treat fear. It is built on broad foundations, including many theories and therapies that evolved from experimental psychology and physiology. Mowrer used classical and operant conditioning theory to develop empirical hypotheses of patients’ problems. He proposed that people seek to avoid unpleasant physiological responses (eg, palpitations) by avoiding those situations (behavioural response) that provoke the symptom through fear of something awful happening (cognitive response). Behaviour therapy was used principally to change overt behaviour. Exposure therapy was used extensively for anxiety disorders and encouraged people to face their fears.

Ellis and Beck built on the work [...] Rather than focusing solely on behaviour change, the therapy focused on cognitive factors, such as identifying and challenging unhelpful thinking (eg, catastrophising). In a nutshell, ‘the three most important components of emotion are avoidance behaviour, physiological reactivity, and verbal/cognitive reports of subjective fear’. This can be referred to as a three systems model.

Empiricism is central to the cognitive–behavioural approach. An individualised formulation (a theoretical model of the patient’s problems) is developed, taking account of the patient’s experience as well as findings from empirical research.

Third wave therapies such as meta-cognitive therapy, mindfulness and acceptance and commitment therapy share many of the structural components of CBT. However, central to third wave therapies is the idea that it is one’s relationship with thoughts and feelings that is important, not the content of them. This differs to CBT, which explores the content of thoughts.

 

[SNT Gatchaman]

There's also —

Apathy: a practical guide for neurologists (2016, Practical Neurology)

Mindfulness for neurologists (2015, Practical Neurology)

 

[Ash]

Absolute appropriation.