CBT for the physical symptoms of menopause
By Dr Anita Goraya
In my first blog, I explained the principles and evidence base for how CBT works. In the second blog, I told the story of Ayesha, who is suffering with post-menopausal depression and anxiety, with tolerable menopausal physical symptoms. In this blog, I will tell the story of Suzy, who uses CBT skills to help manage her troublesome physical symptoms of tiredness, hot flushes, night sweats and sleep problems.
CBT is based on the observation that there are close connections between the way that we feel, the way that we think and the way that we behave. In addition, these components work together in a single system, with each component maintaining the others. It is clear that stress can be introduced to the system through any one of the boxes. This is how the distressing physical sensations (vasomotor symptoms) of menopause can end up creating such emotional distress and lead to behaviours that are ultimately unhelpful and self-defeating. Fortunately, CBT works like any system, the most important characteristic being that only one component has to be tweaked for impact to be felt across them all.
The CBT system
Consider Suzy, a healthy, attractive, 50 year old manager in a large company. She is generally self-confident socially and at work and leads a balanced lifestyle, including wine-filled nights out with friends, as well as regular exercise. Now as she enters the menopause, she is experiencing significant flushes during the day and enough night sweats to be disrupting her sleep, so she consistently awakens feeling groggy and unrefreshed. Her cycle of thoughts, feelings and behaviours is shown below.
Suzy’s vicious CBT cycle
It is apparent that Suzy’s distress is being maintained by the meanings and interpretations she makes of her physical symptoms. She thinks her flushes, sweats and fatigue mean that other people judge her negatively, and that she will quickly become unattractive. She perceives her symptoms as a threat to her very identity as an attractive, self-confident woman and a loss of what she once was. So it’s absolutely no wonder that she feels anxious and sad, her self-esteem plummets and she starts to avoid being in social situations where she thinks she might be judged. She tries to compensate for lost sleep by trying to nap, but then sleeps badly at night and has even less time for fun activities. She finds herself in a very vicious system or cycle.
Suzy uses some cognitive and behavioural techniques to develop a more balanced and accepting view of her situation.
She asks herself ‘What would I say to a friend in this situation?’ She comes up with the following: ‘‘Everyone is sweaty and hot in the gym and everyone’s too busy doing their own thing to pay much attention to you! Plus everyone at work looks exhausted sometimes and so what if you do? Your mates will just ask if you’re ok and who cares about the others anyway? And you’re never going to be frumpy – you’ve always had your own unique style! It might change a bit, sure, but you’ll still manage to look great!”
She asks herself: ‘Is it really a fact that “I’ll get frumpy and haggard soon?’” Or is this thought just an extreme worry/fear?’ She comes up with the following: ‘No, it’s not a fact as such, it’s just my worst worry. Thoughts are just thoughts, they’re not facts – I don’t have to get sucked in by my thoughts, I can just notice them and let them go.’
By generating these alternative perspectives to her original, distressing thoughts, Suzy is able to use the techniques of ‘walking away from worrying’ and a mindfulness exercise (see blog 2 in this series for further details).
Suzy then asks herself: ‘Are there other ways of behaving in this situation, instead of avoiding people and napping?’ She answers herself with: ‘Yes there are other ways of behaving in this situation. I can talk to my daughter Sam about how I’m feeling and ask her to come to the gym with me for moral support.’
She decides to test out these new thoughts about how else she could behave, by going to the gym with Sam. They both keep an eye out for how often people look at Suzy compared to Sam (who is not menopausal). They notice that no one looks much at either of them, even though Suzy does get very sweaty. In fact, a passing trainer tells Suzy ‘it’s great to see someone working out hard’. By the end of the session, Suzy feels a little more confident that no one is really judging her negatively and this makes her feel more confident about coming back to the gym again, albeit not yet alone. Suzy has carried out the behavioural experiment technique, in which she has tested out her anxious, worry-inducing predictions to see how they really match what happens in reality. Next, she plans to test another anxious prediction, which is that ‘I won’t enjoy going out with my friends if they’re drinking alcohol and I’m not. ’ She is keen to minimise drinking as worsens her flushes and poor sleep, but is anxious that this will impact her social life. Suzy is prepared to do a series of behavioural experiments, each building on previous learning or testing out different anxiety-inducing beliefs, to see how they match reality.
Like Ayesha, Suzy also schedules in a few pleasant or rewarding activities every day. She notes that this helps to lift her mood.
Suzy also learns and uses relaxation techniques during hot flushes. She uses the controlled breathing technique, in which she breathes slowly in to and out from her stomach, keeping her chest and shoulders relaxed and still. She accepts the hot flush rolling through and over her, without responding directly to it, acknowledging that it will pass.
Suzy also addresses the anxiety she experiences when night sweats disturb her sleep. She realises that much of this anxiety is caused by ‘worrying’ about disrupted sleep, so she practices ‘walking away from worrying’ about sleep (see Ayesha’s story in blog 2). She also does some behavioural experiments to test some of her anxious predictions about how dropping the afternoon nap after a disturbed night’s sleep really does impact on her work performance the next day. She finds that in fact, although she feels tired, she does not make more mistakes than usual and she gets almost all of her workload completed on time.
After some weeks of using these techniques, although Suzy still has frequent flushes and disturbed sleep, she is able to cope better and is less distressed by them. She notices that she is re-engaging with her usual pleasurable social activities and that her mood is lifting.
Dr Anita Goraya