Thesis Psychological Treatment of Stress-Induced Disorder: Towards a Contextual Behavioral Approach, van de Leur, 2024

Kalliope

Kalliope

Senior Member (Voting Rights)
Abstract [en]

Long-term sick leave due to stress-related disorders has been steadily increasing in Western society. A portion of these sick leave rates is attributed to severe symptoms of exhaustion, assumed to be the result of persistent work stress. In Sweden, this symptomatology is currently classified using the diagnosis of stress-induced exhaustion disorder (ED). There are, however, no evidence-based treatments for ED, nor are there any established theoretical models to guide clinical interventions. Most current treatments revolve around promoting recovery behaviors, as ED is assumed to result from depleted psychophysiological resources. This thesis discusses the merits of this assumption and whether it is compatible with contemporary theories of stress and a contextual behavioral treatment approach. Additionally, a contextual behavioral model of ED is introduced with an accompanying biopsychosocial treatment, aiming to bridge the gap between theories of stress, basic learning principles, and clinically useful methods. The model suggests that ED can be conceptualized as a crisis of engagement rather than a result of depleted psychophysiological resources.

Complementing this theoretical work are empirical studies of different aspects of multimodal interventions (MMI) for ED with the overarching aim of fostering a more theoretically coherent ED treatment that can be made accessible to more patients. Study I was an open clinical trial tracking ED patients (N = 390) participating in a 24-week MMI based on cognitive behavior therapy (CBT). Study II explored sub-groups and predictors of improvements in a large cohort (N = 915) of ED patients participating in the same MMI as Study I. Study III explored mediators commonly suggested to be relevant within ED treatment in the same cohort as Study II: sleep concerns, pathological worry, perfectionistic concerns, and psychological flexibility. Study IV was an uncontrolled pilot trial (N = 26) of the biopsychosocial treatment for ED presented in this thesis, delivered within a 12-week online MMI.

In summary, the results of this thesis indicate that ED patients participating in CBT-based MMI benefit from treatment and report few adverse effects. Moreover, high degrees of perfectionism and high treatment credibility were identified as predictors of improvement, indicating the importance of addressing perfectionistic behaviors and treatment credibility in ED treatment. With positive results similar to those of Study I, Study IV provides preliminary support that ED can be treated more effectively with fewer clinical resources than more extensive MMIs when a more focused and theoretically stringent approach is utilized.


Opponent
Chalder, Trudie, Professor


https://uu.diva-portal.org/smash/record.jsf?pid=diva2:1851259&dswid=-8252
 
The research news site forskning.se wrote an article about the thesis a few days ago. In Sweden burn out syndrome is called fatigue syndrome, but I think the BPS crowd is mixing it all together with ME and making this much more confusing than necessary:


Vila inte alltid bäst vid utmattningsyndrom

google translation: Rest is not always the best with fatigue syndrome

quote:
- There is a lack of established evidence-based models for the psychological treatment of exhaustion syndrome. The concepts of recovery and stress are so accepted in our time that it is difficult to critically examine them, says Jakob Clason van de Leur, who recently received his doctorate in psychology at Uppsala University.

"It is easy to think that fatigue patients should prioritize resting and taking it easy, but a too one-sided focus on recovery can lead to a passive existence that is easy to get stuck in and instead become harmful over time," he continues.
 
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Reminds of those "forever soups". It's the same soup, they keep adding the same stuff. It's technically not the same soup as last year, but it's the same soup as last year, and the year before that, and the one before that, and so on.
 
The Norwegian research news site forskning.no has an article today about the study. They interview researcher van de Leur who criticises rest as treatment. It seems that he's confusing pacing in ME with rest as treatment for burnout syndrome.

His preferred treatment is based on Acceptance Commitment Therapy where burnout syndrome is seen as an existential crisis due to lack of meaning in life. Professor Silje Reme says this is important knowledge in order to understand or treat conditions with long term fatigue. She says it's natural to believe that you need rest and to adapt to symptoms, but that this belief has never been investigated in research.

There is also additional information mentioning The Oslo Chronic Fatigue Consortium and that they are critical of the current use of various diagnoses as ME, chronic covid, fatigue and burnout as the symptoms overlap.

Personer med utbrenthet behandles feil, mener forsker

google translation: people with burnout syndrome are treated incorrectly, according to researcher
 
Reme said:
She says it's natural to believe that you need rest and to adapt to symptoms, but that this belief has never been investigated in research.
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Somehow this makes perfect sense to them, regardless of what data show. They know it's the problem, they just don't have any evidence. About something that can't even be researched properly, and so can indefinitely remain as a "we know, we just need to research it properly". And without any evidence, they've decided that this is burnout. Zero concern with making sense, in general, or of the actual data. It's feels, beliefs and opinions all the way.
 
A portion of these sick leave rates is attributed to severe symptoms of exhaustion, assumed to be the result of persistent work stress.
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And what if it's nothing of the sort?

Trish said:
Are they saying high degrees of perfectionism predicts improvement?
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They're saying perfectionism, if present, is amenable to treatment which causes improvement. However, it might just mean that perfectionism remains present despite attempts to "treat" it and that is much more likely to lead to favourable responses in the subjective patient questionnaires at follow-up. This would be a missing option #3 as an explanation below. (Similarly treatment credibility.)

While several predictors of change were identified in Study II, perfectionism and treatment credibility stood out as potentially clinically relevant. On a group level, patients scoring high on perfectionism before treatment reported higher degrees of exhaustion symptoms and improved more during treatment. Two possible interpretations of this trend are that 1) perfectionism may be a risk factor in developing ED, and 2) ED patients with a high degree of perfectionism benefit more from treatment. Previous research has highlighted that ED patients often struggle with high self-imposed demands (Gulin et al., 2021), and perfectionism seems to be associated with the development of burnout (Hill & Curran, 2016b). In relation to the contextual behavioral model presented within this thesis, perfectionism can be seen as an indicator of tendencies of rule-governed avoidance and control in relation to value- incongruent demands.
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Results show that ED patients participating in MMI report large symptom improvements and return-to-work rates. Moreover, the negative effects reported were negligible and comparable to other forms of psychological treatment. High degrees of perfectionism and treatment credibility were identified as predictors of improvement, indicating the importance of addressing perfectionistic behaviors and treatment credibility during ED treatment. While the mediators concerns about sleep, psychological flexibility, clinical perfectionism, and pathological worry were explored, mediation could not be established.
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Although reported return-to-work rates could very well be objective and valid.
 
Sean said:
Exactly.

Stop with the assumptions, and get to robustly testing them, or discarding them.
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There's a saying in the legal profession: never ask a witness a question you don't already know the answer to, certainly not in a deposition, and even less so in front of a jury. It may throw off an entire defense/prosecution if one of your key assumptions, one of the pillars of your argument, gets dismantled, because of the "beyond all reasonable doubt" requirement. A requirement that is light-years above what's needed in clinical research, where mere innuendo from biased badgering somehow counts.

That's why they almost never do that. The few times they did in the past, it made zero difference anyway, they believe in it and trying to falsify what they believe to be true is never in their interest. So they don't. That's why their questions nowadays are always weird and even when they do "free style" analysis of patient input, it's always framed in their own words and themes. They're following the old dictator mantra where it doesn't matter who votes, what matters is who counts the votes. And they're the ones selecting the voters and counting the votes.

They don't even need to do that anyway. It isn't just the medical profession that believes it, most people are willing to, having been primed to see disabled people as fully expandable since forever. They have zero incentives to provide real evidence when all their models require no evidence and have been believed for decades. It'd be like someone who scammed everyone about having magical powers decide to do a demonstration. The wizard of Oz has no reason to step on the stage.

And even if there were money available, if somehow an influx of funding made it worthwhile for actual independent good faith validation, it wouldn't make any difference, the mass of biased opinions is too big. The very word 'stress' has become meaningless, it means anything and everything as needed in the circumstances it's used. Same with anxiety and depression. Hell most symptoms are used as metaphors in the biopsychosocial model, and making those words lose their meaning is necessary for that.
 
rvallee said:
Reminds of those "forever soups". It's the same soup, they keep adding the same stuff. It's technically not the same soup as last year, but it's the same soup as last year, and the year before that, and the one before that, and so on.
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My father and his family called this "resurrection broth" when he was young.
 
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