Cognogens—Disease-Causing Beliefs Can Be Addressed Using Cognitive Behavioural Therapy

| 3 October 2017

Definition*: Cognogen—Cog-no-gen: A belief that contributes to psychological or physical pathology*The term cognogen is a neologism. We are all familiar with the idea of diseases being caused by bacteria and viruses. We know that infectious disease can be transmitted person to person and across the population. However, misguided beliefs can be as dangerous and transmissible as a bacteria and virus! Dr Johanna Murphy presented a fascinating Morbidity and Mortality round at Queen’s University on this topic last week. She noted that, “Cognition or a thought can cause illness, poor health, disease and even death. The belief that you don’t need a vaccine or that you do need more antibiotics can lead to disease. Likewise, the belief that the “smokes and beers” aren’t doing any harm can lead to self-harm while a loss of hope or self-hatred can lead to suicide. Isn’t Takutsubo disease (the broken heart syndrome) an example of how a negative thought can kill you?” She referred to these maladaptive ideas as cognogens, a neologism that conjures similarities to conventional pathogens, as we refer to bacteria and viruses. The idea of a cognogen resonated with me and inspired this blog.

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Dr. Johanna Murphy, Assistant Professor General Internal Medicine, Department of Medicine

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A distillation of Dr. Murphy’s thesis, “beliefs and thoughts as pathogens”

Dr. Murphy made a compelling case that patients can fall in to a number of cognogenic traps, that complicate their medical care and may lead to harm. These include: emotional reasoning (I had to wait in the Emergency Department overnight and thus this hospital is poorly run and unsafe), mind-reading (The doctor seemed distracted, I know that he doesn’t respect my concerns), fortune telling (I know I will get a side effect from this medication), over-generalizing (I took one blood pressure medicine and felt dizzy and I know that the next type of blood pressure medicine will cause the same problem), personalizing, (the doctor was late coming into the exam room, she doesn’t respect me), polarizing (These palpitation I’m having are a symptom of a life threatening heart rhythm problem and I’ve got to eliminate them), shoulding (I should be able to walk 10,000 steps/day like my cardiologist advises, but I can’t and I’m a failure). Knowing that these ideas commonly exist and may drive refusal to accept treatment or contribute to a lack of treatment adherence allows a physician, to pre-emptively address these thoughts and achieve a better outcome for the patient. The approach Dr. Murphy suggests for achieving this improved interaction with the patient involves conversation to better understanding their views and the application of a rudimentary form of Cognitive Behavioural Therapy (CBT). CBT techniques have long been used by psychiatrists in the management of common psychiatric disorders-but they are just as relevant to the cognogens that accompany physical ailments. Dr. Greg Dubord is the director of CBT Canada and teaches health professionals how to incorporate CBT tools into everyday practice. Dr. Murphy applied the concepts taught by Dr. Dubord to common internal medicine cases in order to persuade us that we can enhance our practice through CBT tools. The diagram below illustrates the basis for Cognitive Behavioural Therapy (CBT)

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The diagram depicts how emotions, thoughts, and behaviours all influence each other. The triangle in the middle represents CBT's tenet that all humans' core beliefs can be summed up in three categories: self, others, future. My friend and colleague Dr. Flynn, a psychiatrist, reminds me that this is Beck’s cognitive triad. It was originally established as Self, World, and Future. Nonetheless, it shows how, in any patient encounter, the patient’s thoughts shape their feelings and drive their behavior. The physician needs to treat the patient that has the disease, not just the disease. This requires a practical approach to CBT. A practical approach to this aspect of the patient care is to use CBT (in a brief and formal manner) to deal with cognogens uncovered and exposed during the history. CBT can be augmented by the art of persuasion, which requires empathy and information. CBT ensures the physician address the cognogen (patient viewpoint/beliefs) that drives what may appear to be an illogical and/or harmful decision. The cognogen then becomes a target for CBT and if addressed may cause the patient to reconsider their decision. For example, Dr. Murphy learns what the patient thinks and, if it is a cognogen, asks, “What would it take to change your mind?” Should a patient refuse the influenza vaccine she might ask, Why do you not want the vaccine? Let’s say the answer is, “it doesn’t work for me”. She then asks, “What do you mean when you say it doesn’t work? What is your evidence for this?” This involves double-checking statements that may on the surface mean one thing but in fact reflect incorrect interpretation of a life event or piece of evidence. Perhaps the failure was a weak vaccine but equally or more likely it was a noninfluenza infection that the patient mistook for “the flu”. Getting the patient to provide the evidence that supports their belief offers the opportunity to respectfully offer facts and persuade the patient of the value of your plan. If they do not initially change their mind she may point out inconsistencies in their logic (if they exist). Assuming there remains an impasse, she takes another tack, engaging the patient in an assessment of the risk of their decision by saying, "Does this thought/belief serve you well?" What is the cost of your belief? For example, if you’re right the vaccine doesn’t work and you take it there is little lost; however, if you’re wrong and you don’t get vaccinated you have a high risk of contracting influenza with its risk of suffering and mortality. At this point she tries suggesting another viewpoint, perhaps relying on someone the patient trusts…I see your wife got the flu shot? Or I know your family doctor recommends these as well… Dr. Murphy knows that patients come with a variable mix of the following concerns/beliefs:

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Dr. Murphy notes, “People are riddled with cognitive distortions, some of which cause morbidity (and mortality)” and the goal of a physician is to offer an appropriate dose of empathy, have a conversation that reveals the patient’s thoughts and finally, whether or not the physician’s view point prevails, educate the patient so they accept a treatment or better tolerate the symptoms. For example, in a patient with an anxiety disorder who declines medical therapy the MD might explain, this is what a panic attack feels like, this is what you’re experiencing, it’s not going to kill you (though it may feel that way), this is how to attenuate the episodes (meditation, control of respiration, avoidance of precipitants etc.). CBT simply is a way of actioning the Oslerian adage, “The good physician treats the disease, the great physician treats the patient who has the disease”. Dr. Paterson, an experience gastroenterologist, dealt with cognogens from a different perspective, reminding us that patients are bombarded with conflicting information from the Medical media and have to deal with Fake News. It’s not hard to understand why a parent worries about the MMR measles vaccine for their child when celebrities, and even the current US president, suggest the potential for irreparable harm. Healthy young child goes to doctor, gets pumped with massive shot of many vaccines, doesn't feel good and changes - AUTISM. Many such cases! — Donald J. Trump (@realDonaldTrump) March 28, 2014

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Dr. Bill Paterson, Gastroenterology, Dept. Medicine

Dr. Paterson used as an example of harm from the false knowledge cognogen created by fears raised regarding proton pump inhibitors (PPI), a ubiquitous class of drugs used to treat and prevent acid reflux disease and peptic ulcers. PPIs have been (likely falsely) purported to cause dementia and lead to premature death. PPIs have been transformational and we rarely see perforated peptic ulcers anymore (indeed ulcer diets and ulcer surgery have largely disappeared). However, because PPIs are so ubiquitous that they are often associated with adverse events (even though in randomized clinical trial data (RCT) shows they are safe). Dr. Paterson points out that there have been 1500 papers on adverse effects of PPIs in the past 5-years and most purport complications not found in the RCTs, many of which lack biological plausibility or, if plausible, have a small effect size (i.e. even if true, the number of patients one would need to treat to cause harm is very large). Decorative Image

Alleged adverse effects of PPI-reports that confuse the patient will require CBM approach to the therapeutic discussion with many patients A recent study in BMJ Open (Xie et al 2017) suggested there was 25% increase in all-cause mortality for those who took a PPI (1 extra death for every 500 patients using the drug for a year). As a result, many patients are stopping the PPI because they are worried about death or dementia even though the increase in risk of either is low (or as Dr. Paterson argues not increased by the PPI at all). However, in many cases the patient avoids the “fake risk” and falls victim to their real risk (gastrointestinal ulcers and bleeding). As an example, he reviewed the case of an octogenarian who was supposed to remain on life-long PPI for stage C reflux. His PPI was stopped because of concerns by his family about cognitive decline. In fairness, this idea of a PPI-dementia association is in the medical literature…so not the fault of the family physician or the patient.

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A few months later the patient presents with heartburn and difficulty swallowing. Endoscopy reveals a stricture (see below), a known complication of uncontrolled, severe acid reflux. This patient was harmed by “fake news” which incubated a cognogen! Decorative Image

Esophagram shows patient who should have been taking a PPI and developed a stricture when the medicine was discontinued because of fears of PPI-induced dementia. The stricture was successfully dilated and PPIs resumed. An example of how overstatement of risks in methodologically flawed studies causes patients to make choices that avoid a red herring and suffer shark bites! Let’s look at the study suggesting PPIs increase the risk of death. The methodology of this study, a retrospective inquiry into large data base, is not robust. Dr. Paterson introduced the concept of a “zone of potential bias”, described by Grimes et al-see below), reminding us that when trolling for associations, the standards must be high or false discoveries of benefit or harm may occur! The effect size in a data base interrogation has to be large to be believable in such outcomes studies. In retrospective data base analysis, a credible protective effect should be a relative risk of <0.33 whilst a credible relative risk (RR) should be >3 (i.e. the drug increases risk of an adverse event 3-fold or more). These RR thresholds are after adjustment for confounders. In addition, the finding should be biologically plausible. Apparent association with a RR between 0.33 and 3.0 the findings are often not real or reproducible and are driven by unidentified confounders. They really risk generating more material for creation of cognogens! The uses of data bases to identify adverse effects of drugs or procedures are often fraught with these confounding biases (i.e. spurious associations). In the case of the PPI study, the magnitude of the imputed risk was small and the biological plausibility low. Likely the apparent increase in mortality risk reflects the fact that sicker patients get PPIs and they are more likely to die. Even the authors best attempts at adjusting risk for confounders was likely ineffective. Likewise, on the scale below, the possible adverse effects of PPI (ie the RR of causing dementia) is an association that falls well within the “Zone of Potential Bias”. Decorative Image

Grimes DA & Schulz KF. False Alarms and Pseudo-Epidemics: The Limitations of Observational Epidemiology. Obstet Gynecol 2012

Dr Paterson provided evidence that the PPI dementia association was false. Better designed trials, such as the Nurses Health Study II Cohort trial and a large Finnish trial of 70,000 PPI users vs 28,000 controls, found no association between PPI and dementia…but sadly this does not make news! Hard to blame the patient for confusion and the related cognogens. The only solution in cases like this is to apply some of Dr. Murphy’s CBT approaches to the patient who approaches his doctor with the dementia concern. It is likely too much to remind patients to ignore them unless they have biological plausibility, appear in peer reviewed journals and have an effect size greater than a 3-fold increase in risk. However, you as the physician can use just such information to address their concerns and use examples like the one Dr. Paterson offered to illustrate the “cost” of the mistaken belief that PPIs cause dementia. Ready for a test? Can you identify the one idea that is not a cognogen?

Vaccines cause autism
Vitamins can prevent disease and extend life
Testosterone therapy will make me stronger and more athletic
My blood pressure is 150/96 mmHg and that’s fine for me (besides, I get dizzy if its lower)
I’m 39 years old and have smoked for 25 years. It’s too late to stop now.
I am old and overweight, there is no point in starting to exercise!
I’m not taking the PPI my doctor prescribed-I hear it kills people!
Canada’s Universal Health Care system is the best (or at least better than the American system) so let’s not tinker with it!
I am a healthy first-time mother and I think it is safe to have my baby delivered by a midwife.

Answer at end of blog Cognogen Cleanser: So, if dangerous ideas are the disease what is the cure? I submit it is some combination of education and persuasion. The more formal tool we can use as physicians and scientists is CBT, which address these ideas from the perspective that thought distortions and the related maladaptive or self-harming behaviours can be treated by helping the person with the cognogen learn new and more beneficial means of processing information and coping with their beliefs. For the physician knowing information about pivotal publications and sharing them with the patients helps inform a CBT conversation and may aid in dispelling their cognogen. Here are some facts related to the test above. This information is the type one might share with a patient in dealing with a cognogen.

The shot heard round the world: A friend of mine, Dr. Kristin Nichol performed a definitive study of the impact of influenza vaccine in 20,000 senior citizens. She observed that vaccination over the 6 seasons study reduced hospitalizations for pneumonia by 39% and also decreased heart failure admission by 27%. This simple vaccine even reduced all-cause mortality for 50%. All these benefits and it saved $73 per individual vaccinated. So, what will it take to persuade a person to be vaccinated?

So, in the brief time available during your visit with the patient what can be done? Here we return to Dr. Murphy’s art of persuasion. Find out what their concern is? (egg allergy? autism? Mercury poisoning?). Be respectful and patient (man is a giddy thing-i.e. we are prone to illogic). Address the patient’s concerns with calm presentation of the facts. For example, tell them about the discredited paper of the vaccine autism story. British physician Andrew Wakefield, alleged a connection between the measles, mumps, and rubella (MMR) vaccine and autism in a Lancet paper. The data were fabricated and he no longer practices Medicine, having been shown to be a fraud. Role model a positive approach to the behaviours, “I myself am vaccinated”, “I vaccinate my kids”. Finally, remind them that when vaccination rates have fallen diseases that were once suppressed begin to rear their ugly heads again-exposing the patient and their loved ones to the ravages of some pretty scary infectious diseases. For example Romania’s vaccination rate is only 86 per cent, (below the 95 per cent recommended for “herd immunity” against infectious disease) and this has resulted in an outbreak with over 2000 cases in children in 2016-167 (including 17 deaths). “So, that’s why I think the risk/benefit ratio favours you try the vaccine!” Decorative Image

Vitamins-Biologically plausible but empirically not helpful: This is an example of an idea that has biological plausibility. Small amounts of a vitamin are required for health. However, for most people able to consume food and eat even a relatively normal diet there is little likelihood of vitamin deficiency. Moreover, that idea that if a little is good a lot is better doesn’t stand up.

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In 2007, Copenhagen University reported on a study that reviewed 815 clinical trials into the benefits of vitamins A, E, and C, beta-carotene and selenium and found no evidence of improved health or increased lifespan in vitamin users. Indeed, in some studies vitamin supplement use was associated with an increased risk of death. “So, that’s why I advise against spending your money on vitamins”

Testosterone: While testosterone levels do fall with age (andropause), the limited studies examining their health benefits and risks find no convincing evidence of improved stamina or strength. In this study of 790 men 65 years of age or older with a serum testosterone concentration of less than 275 ng per deciliter, Snyder et al note “Symptomatic men 65 years of age or older, raising testosterone concentrations for 1 year from moderately low to the mid-normal range for men 19 to 40 years of age had a moderate benefit with respect to sexual function and some benefit with respect to mood and depressive symptoms but no benefit with respect to vitality or walking distance. The number of participants was too few to draw conclusions about the risks of testosterone treatment.” “So, that’s why I won’t prescribe testosterone for you”
Optimal blood pressure: The SPRINT trial in the NEJM showed that 9361 people with systolic blood pressures of >130 mm Hg and an increased cardiovascular risk managed to a target BP of 120/80 mmHg achieved greater survival than those managed to the prior target pressure, 140/90 mmHg. Those treated to the lower target had lower rates of fatal and nonfatal major cardiovascular events and death from any cause, although significantly higher rates of some adverse events were observed in the intensive-treatment group. “So, it’s worth the trouble to find a BP regimen that works for you!”
No Buts-Butt Out: Smokers lose at least one decade of life expectancy, as compared with those who have never smoked. Jha et al obtained smoking and smoking-cessation histories from 113,752 women and 88,496 men 25 years of age or older who were interviewed between 1997 and 2004 in the U.S. National Health Interview Survey and related these data to the causes of deaths that occurred by December 31, 2006 (8236 deaths in women and 7479 in men). Cessation before the age of 40 years reduces the risk of death associated with continued smoking by about 90%. As a CBT equipped MD you can use studies like this to persuade you patient that it’s never too late to stop! “So, that’s why I am encouraging you to pick a date and stop smoking”.
Exercise in the elderly obese patient: It’s never too late to start! Exercise improves cardiovascular health and reduces weight You can use short videos like this one to encourage and educate your patient. “I believe this video may help you believe what I have been telling you…people your age benefit a lot from exercise, even when they are overweight.
PPIs are relatively safe medications and if indicated the benefits outweigh the risks (as discussed previously).
Oh Canada: Patients are not the only ones at risk of cognogens. Physicians and policy makers can be infected. In fact, our system has many virtues but we are not the best. In a ranking of heath care in 11 wealthy countries we did beat the USA, which was dead last, but we ranked a lowly 9 out of 11. The fact is our system is slow, our hospitals are overcrowded and we struggle to balance a primary care mandate with the need for state of the art quaternary care. Moreover, the gray tsunami is hitting us hard and older people who have inadequate family support have no clear home in the system. As a country, we need senior care every bit as much as we need day care for children. The problem with this nationalistic cognogen is that feeling morally superior to the American system stifles reflection on our weaknesses and dampens the enthusiasm for the hard changes required to keep the system financially viable and deal with rising demands. “So, it’s worth discussing changes in the Canada Health act without considering the conversation seditious!”

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9. Home birth versus hospital birth? This statement is correct (evidence based) and is not a cognogen. It is safe to have a low risk pregnancy managed by a midwife. Number 9 is not a cognogen. A 2015 3-year study from McMaster University of almost 23,000 pregnancies showed that indeed, it is safe to have a low risk pregnancy managed by a midwife at home. There was no difference in fetal or maternal mortality between home vs in hospital delivery. However, the study acknowledged that 25% of women who intended to deliver at home did ultimately give birth in a hospital.

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What’s the best way to deal with Cognogens? Be aware they exist and employ a CBT approach that works for you and your patients. For society, an ounce of prevention is worth a pound of cure. To reduce the prevalence of cognogens in Canada we need:

A robust, science-based, public education system that creates an educated and critical public. To quote our new Governor General, Julie Payette, “Canada, we really have a lot of work to do. I think the path for us to take is to trust science, to believe that innovation and discovery are good for us and to make decisions based on data and evidence.”
A reliable mainstream media with health reporters that can critically appraise conflicting data sets and help present a balanced perspective on news stories.
A medical profession that understands humanity’s susceptibility to cognogens and is willing and able to take the time to deal with them.
Doctors that are familiar with a CBT approach to patient interactions. In dealing with a patient’s cognogen be armed with facts and empathy but rely on persuasion!

Caveat Emptor: We live in an era of Fake News, Predatory Journals that publish rubbish and new types of media (blogs, Twitter, Facebook), which allows even the most ill-informed voice to be heard. I look forward to hearing your thoughts on this topic.