Menopause: The Journal of The North American Menopause Society Vol. 21, No. 6, pp. 553/555 DOI: 10.1097/gme.0000000000000255 * 2014 by The North American Menopause Society
EDITORIAL Beliefs about hot flashes drive treatment benefit BBelief creates actual fact.[VWilliam James
here is growing interest in nonhormonal treatments of hot flashes, but several promising treatments, such as yoga and exercise, have proved disappointing in randomized clinical trials.1,2 One nonhormonal approach that has been shown to be effective in double-blind, randomized controlled clinical trials is cognitive-behavioral therapy (CBT). In two noteworthy studies, CBT has been demonstrated to be effective in reducing the problem ratings of hot flashes and night sweats (HFNS) in women who had undergone breast cancer treatment (MENOS 1)3 and in perimenopausal and postmenopausal women without a history of breast cancer (MENOS 2).4 In MENOS 2, 140 women who experienced 10 or more HFNS per week for at least 1 month were randomized to 4 weeks of group CBT, self-help CBT, or care as usual. The primary outcome was the problem rating subscale of the Hot Flash Rating Scale,5 which examines the extent to which HFNS are perceived as a problem, how much distress they cause, and the extent to which they interfere with daily routines. Secondary outcomes included subjective (frequency subscale of the Hot Flash Rating Scale) and physiologic (sternal skin conductance) measures of hot flash frequency. Group CBT consisted of four weekly sessions that focused on psychoeducation, stress management, relaxation/paced breathing, individual goal setting, and homework. Self-help CBT consisted of a self-help book that covered content identical to that of group CBT and weekly homework tasks. Participants in both arms were given a CD for daily relaxation/paced breathing practice. Results indicated that both group CBT and self-help CBT were effective at reducing HFNS problem ratings, with 65% of group CBT participants and 73% of self-help participants reporting a clinically significant improvement in HFNS problem ratings, compared with 21% of control group participants. Group CBT and self-help CBT were also effective at reducing subjectively reported night sweat frequency, but not hot flash frequency. There were no group differences in physiologically measured HFNS. In a subsequent study, objective HFNS were reanalyzed using pattern recognition software, and both CBT groups demonstrated a significant reduction in physiologic hot flashes in perimenopausal and postmenopausal women, but not in women who had undergone breast cancer treatment, compared with usual-care controls.6 Together, those studies suggest that both self-CBT and group CBT are effective nonhormonal treatments of HFNS. In this issue of Menopause, Norton et al7 extended their work by asking two key questions about the effects of self-help
CBT and group CBT on HFNS problem ratings: (1) For whom does CBT work (ie, are there subgroups of women for whom this intervention will or will not be effective)? (2) How does this intervention work? The study revealed that demographic (age, body mass index, and education), clinical (menopause status, hormone therapy use, physical illness, and duration of HFNS), health behavior (smoking, alcohol, and exercise) and psychological (depression, anxiety, stress, sleep, and others) variables did not modify treatment effects. Importantly, there was a dose-response effect such that women who read the entire manual (self-help arm) and women who completed homework on most weeks (group CBT arm) showed greater improvements in hot flash problem ratings than those who did not, but frequency of participation in assigned exercises (relaxation/paced breathing) did not impact the treatment effect. Most notably, when mediators of CBT were examined, the group found that beliefs about coping and control over hot flashes and beliefs about sleep and night sweats mediated the effects of CBT on HFNS problem ratings. Although CBT was effective at reducing stress, anxiety, and depression, changes in these surprisingly did not mediate treatment outcome. Essentially, the treatment was effective for all women as long as they completed the program, and the treatment worked by changing beliefs. Beliefs (or cognitions) and their resulting behaviors are the key elements in cognitive-behavioral theories of psychopathology and are therefore the focus of CBT treatment. In the case of panic disorder, a trigger (public speaking) initiates a physiologic response (increased heart rate, sweating, and difficulty breathing), which is interpreted negatively (I am having a myocardial infarction, I am going to die), which then increases the focus on the symptoms, escalates the physiologic response, and leads to avoidance of possible triggers. Therapy is focused on changing the cognitive appraisal given to the physiologic response, pairing the trigger with an alternative sensation (guided relaxation/paced breathing), and changing the behavioral response (exposure to the feared stimulus). Hunter and Mann8 used the same conceptualization in their cognitive model of HFNS. There are four essential components: information input, detection and attribution, cognitive appraisal, and behavior. Information input is physiologic: estrogen withdrawal leads to changes in central thermoregulation. The remaining components involve psychological processes. Detection and attribution focus on how physiologic events are perceived as HFNS. This perception is affected Menopause, Vol. 21, No. 6, 2014
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by the environment and by the individual’s propensity toward somatization and negative affect. For instance, environmental stimuli may divert attention away from bodily sensations. In contrast, a tendency to somaticize (focus on bodily sensations and attribute a physical cause to the sensation) and/or the experience of negative affect may lower the threshold for detecting physical sensations. Cognitive appraisal involves the interpretation of physical sensations and the meaning that an individual ascribes to them. An individual may evaluate the sensation as normal, problematic, or bothersome. The final component, behavior, refers to the actions an individual may take in response to the sensation and appraisal; these actions may ameliorate or exacerbate HFNS. For instance, the individual may avoid social situations, cover her face, or use breathing techniques and remind herself that there is nothing to be embarrassed about, or she may ignore the sensation and carry on. Importantly, this model accounts for the significant discrepancy between physiologic and self-reported measures of HFNS described in numerous studies.9