discussion #6 disease

Cognitive behavioral principles in managing
chronic disease
Craig A White, Department of Psychological Medicine, University of Glasgow, Academic Centre, Gartnavel Royal Hospital, 1055 Great Western Rd, Glasgow, Scotland, UK,
[email protected]

Competing interests: None declared

West J Med 2001;175:338-342

Medical problems that previously carried
considerable mortality risk can now be man-
aged more effectively. As a result, chronic
medical illnesses have become more prevalent
in recent years. With the increase in life ex-
pectancy comes a set of psychological chal-
lenges that face the chronically ill.

Chronic disease is associated with high

levels of uncertainty. Patients need to change
their behavior as part of a new lifestyle of
self-care. They also have to endure debilitat-
ing and demanding treatments. These are
some of the factors that make adjustment
to chronic medical illness psychologically
demanding.

It is generally accepted that around a quar-

ter of patients with chronic medical problems
have clinically significant psychological symp-
toms. In some cases, these psychological
symptoms themselves are associated with
physical morbidity. For example, when medi-
cal factors are controlled for, the risk of myo-
cardial infarction increases 4- to 5-fold as a
result of the presence of depressive symp-

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338 wjm Volume 175 November 2001 www.ewjm.com

toms.1 Even in the absence of overt psycho-
logical or psychiatric disorder, patients have
to regulate often-complex and ever-changing
thoughts, feelings, and behaviors.

In this article, I outline how primary care
physicians can incorporate some principles
from cognitive therapy into their manage-
ment of patients with chronic disease. Cog-
nitive therapy is effective in managing
chronic mental health problems2 and many
of the long-term symptoms of chronic physi-
cal illnesses, including chronic pain.3,4

WHAT IS COGNITIVE THERAPY?
Two patients may have the same physical
health problems, yet have markedly different
psychological responses. For example, a man
with multiple sclerosis who believes that his
ability to make a useful contribution to life is

finished is likely to experience depressed
mood and avoidance of previously enjoyed
activities. But a different man with the same
condition who acknowledges that his life will
have to change, but who believes that he will
be able to discover new ways to make a con-
tribution, is likely to make a better psycho-
logical adjustment to his illness.

These differences in patient psychological
responses can be understood by examining
patients’ thoughts about their illness. This is a
fundamental principle behind cognitive
therapy—a focused, structured, collaborative,
and usually short-term psychological therapy
that aims to facilitate problem solving and to
modify dysfunctional thinking and behavior
(figure).

Several factors make a cognitive therapy
framework particularly suited to address the
problems associated with chronic disease:

• Chronic medical problems are often as-
sociated with the types of psychological
problems for which cognitive therapy has
proven efficacy, such as mood disorder
and fatigue

• The importance of adopting an active
self-management approach and the need
for patients to establish collaborative re-
lationships with health care staff both
lend themselves to the philosophy and
central tenets of cognitive therapy

• The emphasis on building a repertoire
of skills for the management of psycho-
logical problems within cognitive ther-
apy can be applied to promoting the

acquisition of skills in chronic disease self-
management

The generic cognitive model outlines how
the thoughts, behaviors, moods, and physical
reactions that patients have each tend to con-
tribute to the other components in the
model. In other words, thinking “There is no
point—nothing I do makes any difference”
will not only contribute to sadness but also is
likely to increase the avoidance of activities.
This in turn will lower energy levels, which
further depresses mood (and so on). There is
a growing number of psychological disorders
for which cognitive behavioral models and
therapy protocols have been developed, many
of which have been shown in research trials to
be effective.

Cognitive therapy sessions are usually
structured by a collaboratively agreed-on
agenda. Active participation is encouraged by
giving patients homework assignments to do
between therapy sessions. Treatment involves
the application of a range of cognitive and
behavioral strategies designed to alter the fac-
tors that trigger, maintain, or exacerbate
symptoms. The strategies are effective in
helping patients to gain control over both
psychological and physical symptoms.

A number of simple cognitive therapy
techniques can be used by primary care phy-

Generic cognitive behavioral model illustrating the links between mood, behavior, thoughts, and physical reactions
(based on Greenberger D, Padeksy C.5 Reproduced with permission.)

Summary points

• Adjustment to chronic medical illness
can be psychologically demanding

• Different patients adjust in different
ways through their own thoughts and
interpretations about themselves, the
world, and their illness

• Primary care physicians can use
cognitive therapy techniques to manage
patients with chronic disease in a more
structured, problem-focused, and
psychologically sensitive way

• Some patients with chronic disease will
develop psychological disorders that
require referral to a specialist for
cognitive therapy

Stoic philosopher Epictetus (ca 55-ca 135 CE),
considered the father of cognitive behavior, wrote:
“men are disturbed not by things but by the views
they take of them.”

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Volume 175 November 2001 wjm 339www.ewjm.com

sicians to care for their patients with chronic
diseases—agenda setting, self-monitoring, ex-
perimentation, and changing distressing
thoughts.

Agenda setting
Patients with chronic medical problems have
many physical, social, and psychological
problems. Physicians do not always have time
to address all of these within a single consul-
tation. This fact, combined with the fact that
some presenting problems have no apparent
solution, can be overwhelming for physicians,
who may not know where to start. Setting an
agenda is one method for maximizing the
chance that a consultation will make some
progress toward solving a patient’s problems.
For example:

We have about 15 minutes today, and I
want to make sure that we use the time we
have to the best effect. The best way I have
found to do this is to set an agenda that
highlights the main things we want to talk
about. Is there something that you particu-
larly wanted to cover today?

Agenda setting reflects the collaborative
stance of cognitive therapy in that both phy-
sician and patient can assign agenda items.
This minimizes the risk that patients will dis-
close their main concern just as they are leav-
ing the consulting room. When a series of
appointments is being arranged, there may be
a standing item that always appears on the
agenda, such as symptom severity or the pres-
ence of side effects.

Self-monitoring
Cognitive therapy usually involves a series of
tasks (“homework”) that are completed out-
side sessions and at various phases of therapy.
During assessment, this often involves self-

monitoring in the form of diary keeping (see
sample above). Examples of this might be re-
cording mood fluctuations, discrete episodes
of problem behavior, or the thoughts and im-
ages associated with a negative mood state. In
a patient with a chronic illness, this approach
need not be restricted to psychological symp-
toms; it could equally be focused on collect-
ing data to inform medical management,
such as keeping a diary of physical symptom
severity. For example:

There are 168 hours in the week, and I am
in contact with you for only part of 1 of
them. It will be useful for you to keep a
record of some aspects of your rheumatoid
arthritis. Today we talked about how you
find that your energy is particularly low at
the moment. I think it might help me to
help you if you could start maintaining a
diary of how much energy you have at par-
ticular times during the day.

There are no limits to the range of moni-
toring assignments that might result from a
session. For example, you might ask your pa-
tients to write about their thoughts and feel-
ings about their illness, its effects, and its
treatment; to compile a list of unanswered
questions; to write down thoughts related to
worries for the future; to rate the extent to
which pain interferes with certain activities;
or to count the number of times that a rela-
tive provides reassurance.

Patients who have medical problems with
an uncertain cause may develop unhelpful
and inaccurate beliefs that in turn influence
their psychological adjustment (for example,
the beliefs provoke anxiety states) and behav-
ioral responses (they seek unconventional
cures). Inviting them to write a brief account
of their understanding of a particular condi-
tion may reveal inaccurate beliefs that require

correction or thoughts that mediate psycho-
social difficulties (or both). Inviting them to
write an account might simply involve ask-
ing, “What do you think are the causes of
your condition?” and “What factors make it
better or worse, and how do you explain
this?” An example of a belief that could easily
be corrected is, “If I take too much medica-
tion, I will become immune to its effects.”
Homework that includes writing in this way
may prompt a discussion about improving
the self-management of a patient’s disease, or
it might identify the need for information
and support.

Experimentation
Patients often report psychological benefits
from assignments that have a purely moni-
toring role. Indeed, some homework tasks
can be assigned primarily as a therapeutic
intervention.

If you suspect that a patient’s symptoms
are being triggered by a certain event, you
could ask that patient to keep a symptom
diary to note any triggers. For example, you
might suspect that the patient’s mood and
adherence to medication vary according to
the presence of family disagreements. You say
to the patient that the monitoring is “an ex-
periment.” This can be of particular benefit
when you have differing views from your pa-
tient as to the precise trigger behind certain
symptoms. In a spirit of collaboration, you
first acknowledge that your views differ from
the patient’s before suggesting that the experi-
ment can test out these differing views. For
example:

I have been wondering if there is a link
between the times that you take your
medication and when you are feeling anx-
ious. I know you don’t think that there is a
strong link (patient agrees). I may be
wrong. It could be that there is no link at
all. Or perhaps there is a link only some of
the time. Will you consider keeping a diary
to look at this in more detail? Can you note
down the times that you take your medi-
cation and at the same time keep a rating of
your anxiety? This way, we can check out
which of our views is more accurate.

Changing distressing thoughts
Cognitive therapy usually involves the modi-
fication of thoughts and behaviors that seem

Example of self-monitoring in a patient with chronic pain

Time Activity Depression, 0-10 Pain, 0-10

M = medication
R = relaxation
C = challenge thoughts

9 AM Getting dressed 8 7 M, C
10 AM Eating breakfast 7 5
11 AM Walking dog 4 5 C
12 noon Phoning Michael 3 4
1 PM Tidying basement 8 8 M, C

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340 wjm Volume 175 November 2001 www.ewjm.com

to be contributing to a patient’s symptoms.
Clearly, the application of a simple strategy
cannot change a major psychological disor-
der. However, the application of simple tech-
niques based on cognitive therapy may alle-
viate some distress. An example of one such
simple technique is when you verbally chal-
lenge a patient’s distress-producing thoughts.
For example:

When you are feeling distressed, it can help
to stop and think about what thoughts are
passing through your mind. This way, you
get to see what thoughts are feeding your
distress. You can write these down and
then start to challenge them as a way of
gaining some control. Challenges are easier
to come up with if you think of your own
responses to questions like, “If someone I
loved thought this, what would I advise
them?” or “When I am less distressed, how
would I tend to think about this?” Some-
times it helps to simply write down a less-
distressing alternative.

Most cognitive therapy self-help manuals
provide further information on this strategy
of verbally challenging thoughts (and on a
range of other treatment strategies) (see next
box). In some clinical situations, it may be
appropriate to complement medical manage-
ment with the use of a structured patient
manual that patients can use to work through
problems between consultations.5,6

REFERRING A PATIENT FOR
COGNITIVE THERAPY
Patients with psychological problems related
to their chronic medical illness may benefit
from referral for cognitive therapy. Patients
most likely to benefit from cognitive therapy
are those who are able to identify and differ-
entiate emotions and behaviors, accept that
they have some responsibility toward address-
ing their problems, and accept the application
of a cognitive theory approach to their prob-
lems and situation.

When physicians decide that a patient is
presenting with problems for which cognitive
therapy is indicated, it is important that they
refer the patient to a suitably qualified and
skilled clinician. The Academy of Cognitive
Therapy is responsible for the certification of
clinicians skilled in cognitive therapy. Certi-

fication is awarded to those individuals who,
based on an objective evaluation, have dem-
onstrated an advanced level of expertise in
cognitive therapy. The academy includes
physicians, psychologists, social workers, and
other mental health professionals from
around the world. Details on certified cogni-
tive therapists can be found at the academy’s
web site (www.academyofct.org).

CONCLUSIONS
Management of the psychological aspects of
living with a chronic medical illness can chal-
lenge physicians and patients. Cognitive
therapy has proven efficacy in the manage-
ment of common emotional and psychologi-
cal disorders, and cognitive therapy tech-
niques can be used to manage chronic disease
in a problem-focused and psychologically
sensitive manner.

Author: Craig White is cancer research campaign fellow
in Psychosocial Oncology at the Department of Psycho-
logical Medicine, University of Glasgow, Glasgow, Scot-
land. He is author of Cognitive Behaviour Therapy for
Chronic Medical Problems and a founding fellow of the
Academy of Cognitive Therapy.

Questions that can help patients
discover less-distressing
alternative thoughts

• What experiences have you had that
show you that this thought is not
completely true all of the time?

• If you were trying to help someone you
loved who had a similar thought in the
same situation, what would you tell him?

• What would they tell you if they knew
that you were thinking about things in
this way?

• Do you think about things this way when
you are feeling less distressed? How do
you think about things at these times?

• What is the worst thing that could
happen? What is the best outcome?
What is the most realistic outcome?

• Might you be underestimating the
chances of your being able to do
something to lessen your distress?

• What is the evidence to support your
distressing thought? Is this the only way
of looking at things? Are you basing your
thought on how you feel as opposed to
how it actually is?

Resources

Published sources
• BeckJS.CognitiveTherapy:Basicsand
Beyond.NewYork,NY:GuilfordPress;1995.

• Enright SJ. Cognitive behavior
therapy—clinical applications. BMJ
1997;314:1811-1816.

• Leahy R. Cognitive Therapy: Basic
Principles and Applications. Northvale,
NJ: Jason Aronson; 1996.

• Moorey S. When bad things happen to
rational people: cognitive therapy in
adverse circumstances. In: Salkovskis P,
ed. Frontiers of Cognitive Therapy. New
York, NY: Guilford Press; 1996:450-469.

• White CA. Cognitive Behaviour Therapy
for Chronic Medical Problems: A Guide to
Assessment and Treatment in Practice.
Chichester, UK: John Wiley & Sons; 2001.

Online resources
• Beck Institute for Cognitive Therapy and
Research, Philadelphia. This is the site
for the Institute founded by the “father
of cognitive therapy,” Dr Aaron T Beck
and his daughter, Dr Judith Beck. The
Bookstore and Newsletter sections are
essential ways to keep up to date with
latest developments. Available at
www.beckinstitute.org

• American Institute for Cognitive Therapy,
New York. This site has links to helpful
fact sheets and a section on commonly
asked questions. Available at
www.cognitivetherapynyc.com

• Center for Cognitive Therapy, Huntington
Beach, CA. Dr Padesky, one of the
authors of a best-selling cognitive
therapy treatment manual (see list of
references) is based at this center. This
site has a useful section on ordering
top-quality audiovisual materials for
cognitive therapy training. Available at
www.padesky.com

• British Association for Behavioural and
Cognitive Psychotherapies. This site
includes a searchable database of
UK-accredited cognitive behavioral
therapists, conference information, and
leaflets on a range of topics (including
“Chronic Pain” and “General Health
Problems”).Availableatwww.babcp.org.uk

• New York Institute for Cognitive and
Behavioral Therapies. This site includes
a section that provides a full explanation
of the background and principles behind
cognitive therapy. Available at
www.cognitivetherapy.com

• Division of Health Psychology, American
Psychological Association. A useful
source of information for upcoming
events and publications relating to
psychological aspects of physical health.
Available at www.health-psych.org

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References

1 Hippisley-Cox J, Fielding K, Pringle M. Depression as
a risk factor for ischaemic heart disease in men:
population based case-control study. BMJ
1998;316:1714-1719 [erratum published in BMJ
1998;317:185].

2 DeRubeis RJ, Crits-Christoph P. Empirically supported
individual and group psychological treatments for adult
mental disorders. J Consult Clin Psychol 1998;66:37-52.

3 Greer S, Moorey S, Baruch JDR, et al. Adjuvant
psychological therapy for patients with cancer: a
prospective randomised trial. BMJ 1992;304:675-680.

4 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
1999;80:1-13.

5 Greenberger D, Padeksy C. Mind Over Mood:
Changing How You Feel by Changing the Way You
Think. New York, NY: Guilford Press; 1996.

6 Williams CJ. Overcoming Depression. London: Arnold;
2001.

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