Cognitive behavioral therapy adapted for patients with acromegaly

In acromegaly, excess secretion of growth hormone and insulin-like growth factor 1 may result in coarse features and enlargement of the extremities. Its negative repercussion on self-esteem can impair quality of life. Ten patients with acromegaly participated in this study. The treatment covered nine weekly group sessions. Unhealthy behaviors, thoughts, and emotions were identified, and healthy behaviors and thoughts were constructed, along with positive reflections on their associated emotions. In Session 7, the “Think healthy and feel the difference” technique was adapted to help patients better deal with their physical appearance and improve their quality of life. Qualitative data was obtained from an analysis of the content of a collaborative exercise developed in Session 7. Factors, especially thoughts, emotions, and advantages and disadvantages associated with both healthy and unhealthy behaviors, were identified. The technique improved quality of life for patients with acromegaly in relation to their acceptance of their physical appearance. UTN U 1111–1220-9846 (September 24th, 2018).


Introduction
Acromegaly is a rare and insidious disease, usually caused by a pituitary adenoma that produces an excess of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) (Abreu et al., 2016;Fujio et al., 2017;Pantanetti et al., 2002). Orofacial changes are among the comorbidities characteristic of the disease, which result in soft tissue changes (an increase in the volume of the tongue, uvula, lips, and nose), facial asymmetry, and increased space between the teeth. In addition to coarse features, patients with acromegaly may have difficulty articulating words and malocclusion (Abreu et al., 2016). The increased size of feet and hands requires them to wear bigger shoes and larger rings and gloves (Pantanetti et al., 2002).
Prolonged exposure to GH and IGF-1 is related to worsening comorbidities and impaired quality of life (Abreu et al., 2016;Fujio et al., 2017;Pantanetti et al., 2002), in terms of both physical condition and self-perception (Fujio et al., 2017). Therefore, there is impairment in functional and social quality of life (Abreu et al., 2016).
The SF-36 is the most commonly used instrument to evaluate quality of life. It allows the comparison of results of patients with acromegaly with those of the general population (Szcześniak et al., 2015). The most frequently used instruments to evaluate quality of life among patients with acromegaly are AcroQol and the SF-36 (Geraedts et al., 2017). AcroQol is a questionnaire specifically designed for patients with acromegaly (Fujio et al., 2017). It was developed by Webb and Badia in 1999(Szcześniak et al., 2015, with the objective of analyzing the impact of the disease and/ or its treatment (Badia et al., 2004).
Patients with acromegaly present distorted thoughts about the disease and/or its treatment, impairing their quality of life (Szcześniak et al., 2015;Tiemensma et al., 2011), similarly to cancer patients undergoing chemotherapy (Bonapart et al., 2005). Depression, distortion of body image, and social isolation impair interpersonal relationships (Abreu et al., 2016;Pantanetti et al., 2002). Psychiatric disorders featuring intense negative emotions such as anger, anxiety, and depression are more frequent in patients with acromegaly 1 3 compared to other clinical diseases (Szcześniak et al., 2015). Despite being a chronic and debilitating disease, few studies have addressed mental and emotional dysfunction in patients with acromegaly (Pantanetti et al., 2002).
Currently, there are three treatment options with good results in controlling the activity of acromegaly: surgery, radiotherapy, and pharmacotherapy (Geraedts et al., 2017). However, impairment in quality of life is observed even when the disease is considered biochemically cured, (Geraedts et al., 2017), with low scores in the emotional dimensions (Fujio et al., 2017). Therefore, to improve psychological well-being, the treatment plan should also aim to reduce the symptoms of depression, anxiety, irritability, and fear of social situations (Pantanetti et al., 2002).
In this context, psychotherapeutic strategies, such as those offered by cognitive behavioral therapy (CBT), may have a synergistic effect towards the three treatment options described for acromegalic patients, as pointed out in psychiatric treatment (Stahl, 2012). CBT was developed by Aaron Beck in the 1960s (Ferreira de Lima & Kunzler, 2017;Knapp & Beck, 2008). This therapy is brief and collaborative. It evaluates thinking patterns, identifies and restructures distorted thoughts, and creates coping mechanisms (Ferreira de Lima & Kunzler, 2017;Knapp & Beck, 2008). Learning outcomes are recorded using a therapy notepad, which can be reviewed in future situations (Kunzler, 2015). Psychoeducation generates hope and improves therapy effectiveness (Knapp & Beck, 2008). One of the objectives is for patients to become their own therapists (Ferreira de Lima & Kunzler, 2017;Knapp & Beck, 2008).
In addition to Aaron Beck, Albert Ellis plays a key role in CBT. Ellis introduced his ABC theory of emotional dysfunction, the rational emotive behavior therapy (REBT). Beliefs are important in CBT, both for Aaron Beck and Albert Ellis. A major difference between the two is that Aaron Beck's psychotherapy is empirically based, whereas Albert Elli's REBT is a philosophical psychotherapy (McEachrane, 2009). The philosophical influence on CBT is quite broad and includes Hieraclitus, Stoicism, Epicureanism, Hedonism, Buddhism, Taoism, Existentialism, Yoga, Baruch Spinoza, and Immanuel Kant (Díaz & Murguia, 2015).
CBT is considered by the American National Institute of Health and the American Psychological Association as a first-line treatment for various diseases (David et al., 2018). A literature review of CBT found 16 meta-analyses with rigorous methodologies, covering more than 9000 subjects in 330 studies. When a CBT group was compared with a control group, the effect size was moderate (Knapp & Beck, 2008). In the 1960s, several types of cognitive distortion were compared among 50 depressed patients and 31 nondepressed control group participants (Beck, 1963). The themes identified were self-criticism, deprivation, loneliness, overestimation of problems and difficulties, and the desire to escape or die (A.T. Beck, 1963). When depressed, the patient overvalues their faults and defects and dismisses any favorable characteristics (Beck, 1963), an attitude that generally maintains or aggravates the problem, which can be observed in acromegaly.
One of the goals of CBT is emotional regulation, and it is essential that acromegalic patients maintain their decision to engage in physical activity, take care of their health, and deal with situations of emotional imbalance also in situations of social exposure. Negative views about the self, the personal world, and the future affect patients' responses to life situations (Knapp & Beck, 2008). Behavioral change can be mediated through monitoring and evaluation of cognitions (Knapp & Beck, 2008). A decision creates uncertainty as the result is often unpredictable and there is no easy and guaranteed answer (Bechara, 2004). CBT teaches the patient that there is more than one way of viewing a situation; therefore, their point of view is a matter of choice (Butler & Hope, 2007).
Decision making is an executive function and a complex, multidimensional cognitive process that results in a choice between two or more options. It also involves the analysis and prediction of the consequences that the choice will entail, reflected in behavior (Bechara, 2004;Fellows, 2004;Rutz & Hamdan, 2013). In the 1940s, decision making was studied by economists and later implemented in the business world using cognitive psychology techniques (Fellows, 2004). The current discussions on decision making in health began in the 1980s (Rutz & Hamdan, 2013). Impairment is seen in the ability to perform tasks that require mental flexibility, executive functions, and working memory (Shan et al., 2017). The authors applied five tests to investigate possible causes of executive dysfunction in acromegalic patients. The results indicated severe impairment in semantic inhibition, executive processing, working memory, and executive inhibition. In addition to executive function assessment tests, these patients underwent cranial MRI and IGF-1 hormone levels. High IGF-1 levels and the duration of the disease may have contributed to the impairment of specific aspects of the executive function.
As with decision making (Bechara, 2004), quality of life is also influenced by emotions: it is an important part of motivational systems that give more or less flexible responses to life events based on personal values and objectives, and contexts of change (Renna et al., 2017). The results of studies of patients with acromegaly, concerning quality of life, show the need for further medical investigation and psychosocial counseling, even after normalization of IGF-1 concentrations (Siegel et al., 2013;Szcześniak et al., 2015). Therefore, an interdisciplinary approach becomes fundamental (Siegel et al., 2013;Szcześniak et al., 2015).
Based on concepts from CBT, decision making, and Quality of life, the "Think healthy" technique was systematized.
The technique uses an analogy to cross-sections of gray and green avocados to illustrate the difficulties (gray avocado on the left) and possible alternatives (green avocado on the right), associated with written text under each image. One of the goals of systematizing the technique is to help the patient maintain healthy and desired decisions.
Taking decision making into account to improve quality of life, CBT can be adapted for several diseases, including acromegaly. In a previous study of healthy participants, CBT with the Think Healthy technique led to improvements in four domains of the quality of life assessment questionnaire: general health, mental health, physical aspects, and emotional aspects (Kunzler & Araujo, 2013). The results of psychotherapeutic treatment for patients with acromegaly had never been published, in spite of this treatment being well established for other chronic diseases (Geraedts et al., 2017). In a recent publication, we showed that CBT with the Think Healthy technique improved the quality of life of patients with acromegaly in two domains of the SF-36: general health and mental health (Kunzler et al., 2018). Improvement in the mental health dimension, comparing the intervention group to the control group, was maintained at the 9-month followup (Kunzler et al., 2019).
Social situations are particularly difficult for acromegalic patients to deal with, especially because of their physical appearance. This research proposes the adaptation of a specific CBT technique, "Think healthy and feel the difference," to promote improved quality of life for patients with acromegaly in terms of acceptance of their physical appearance. This article will present the theoretical foundation for the six steps of the technique, where the content was jointly developed by the research participants and the investigator, in session number 7.

Methods
This was a non-randomized clinical trial. We established the following inclusion criteria: patients with acromegaly, attending the neuroendocrinology outpatient clinic of the University Hospital of Brasília, both genders, aged between 18 and 75, who agreed to participate in the study. The exclusion criterion was risk of suicide, evaluated according to the response to item nine of the Beck Depression Inventory.
The study was conducted with 10 acromegaly patients (1 man and 9 women) who showed interest in participating in the research. Their ages ranged from 42 to 69. The time between diagnosis and participation in the research ranged from 2 to 216 months. Tumor size ranged between 8 and 34 mm. Their BMIs ranged from 21.5 to 39.2 Kg/m2. Two participants were considered obese, 7 were overweight, and 1 had a normal BMI. As for disease activity, 2 participants were classified as cured, 5 had disease control, and 3 had active disease. During the study, there was no change in their medication regimen. Participants received nine 90-min "Think Healthy" group therapy sessions weekly, which happened from September to November 2015. The group sessions were conducted in a well-lit, cooled, and private room. Participants sat in a circle, which facilitated interaction among participants and the practice of cognitive behavioral strategies during the session. Chairs had armrests, making it easier to use the material, complete the exercises, and take notes.
All participants expressed their agreement by signing a free and informed consent form. The sessions were recorded for later transcription. The study was conducted by a researcher trained in CBT by the Beck Institute for Cognitive Behavior Therapy, who works professionally in a private practice and a public institution.

Quality of Life Questionnaire (AcroQol)
AcroQol is the first acromegaly-specific quality of life questionnaire. It is used in clinical trials and for routine monitoring of patients with acromegaly. It facilitates the perception of the impact of the disease on well-being and functioning. The questionnaire has 22 items divided in two scales: one that evaluates physical aspects (eight items) and another that evaluates psychological aspects (14 items). Psychological items are related to physical appearance or personal relations (Badia et al., 2004).
For acromegaly, AcroQol is the instrument used in 80% of studies to evaluate quality of life (Geraedts, Andela, Stalla, Pereira, van Furth, Sievers, et al., 2017). Regarding the level of cognition, some questions touch on conditional beliefs with emotional dysregulation of moderate intensity, such as item 13 "The illness affects my performance at work or in my usual tasks" and item 17 "It is hard for me to articulate words due to the size of my tongue." Some of them touch on core beliefs with greater emotional dysregulation, such as item 2 "I feel ugly" and item 10 "People stare at me because of my appearance" (Badia et al., 2004). Participants were asked about the effect of these thoughts on their emotions and behavior. AcroQol was used for them to be able to identify the unhealthy thoughts and complete Step 1. They chose the unhealthy thoughts, the starting point. Because of the risk of intense emotional imbalance, AcroQol was not used as an instrument to collect data for quantitative analysis. AcroQol questions were used only in the seventh session, with the investigator. The items were presented for participants to identify their cognitive distortions, restructure them, and build healthier behaviors.

Treatment Protocol
The "Think healthy and feel the difference" protocol, adapted for patients with acromegaly, was applied in nine weekly group sessions. Therapy sessions were designed according to the basic principles of CBT: brief approach, structured sessions, active participation in treatment, psychoeducation, education on difficulties, written records, decision making for healthy behaviors, emotional regulation, psychotherapeutic process, and application in a group setting (A.T. Beck, 1963;Knapp & Beck, 2008;Ferreira de Lima & Kunzler, 2017;Kunzler, 2015;Padesky, 1994).
The content of the sessions was presented as follows: 1) basic concepts of CBT and practical examples of the relationship between unhealthy and healthy levels of cognition with the associated emotions and behaviors; 2) emotional regulation; 3) increase in self-esteem and selfconfidence using a brain-shaped piggy bank (identification and valuation of personal qualities and achievements); 4) "Think healthy and feel the difference" technique-guidelines for completing the six adapted steps for engaging in physical activity; 5) the six adapted steps for approaching anger, assertiveness training, and the coping card; 6) the six adapted steps for approaching fear; 7) the six steps for shame about physical appearance adapted for patients with acromegaly; 8) clarifications on acromegaly; and 9) a summary of the topics covered in the sessions. On the 8th session, professors Luciana Naves and Luiz Augusto Casulari, specialists in the area of endocrinology, clarified misconceptions about acromegaly with the objective of promoting healthy attitudes (Tiemensma et al., 2011).
In the therapy sessions, verbal interaction was spontaneous, with no obligation to speak. According to the guidelines for completing the six steps of the Think Healthy technique (Fig. 1), exercises were constructed in collaboration with the participants in order to regulate emotional imbalances and maintain healthy behaviors. At the session following their construction, the printed-out exercises were handed out to all participants.

The Six Stages of the "Think Healthy and Feel the Difference" Technique and the Adaptation of its Content for Patients with Acromegaly
Some emotional experiences are a reaction to events that happen on a daily basis. Emotional reactions depend on the interpretation of the event, not on the event itself (A.T. Beck, 1963Beck, , 1964. To facilitate the maintenance of healthy behaviors, the technique presents not only cognitive restructuring, but also acceptance, regulation of emotional imbalances, understanding of the negative effects of difficult situations faced in the past, decision making, valuing of personal qualities and achievements, and application of summaries in the form of coping cards. In relation to coping cards and cognitive restructuring, CBT includes three levels of thought: automatic thought, conditional belief, and core belief. Greenberger and Padesky use the example of a garden to display the three levels of cognition and their distortions, with flowers (healthy cognitions) and weeds (unhealthy cognitions) on the surface and conditional and core beliefs under the ground. Therefore, core beliefs are represented by deeper roots. However, the deeper the root, the more fragile it is, which complicates the analogy that a core belief is rigid and absolute (Greenberger & Padesky, 2015).
Another cognitive behavioral therapist, Judith Beck, uses the example of an onion. The more layers are removed, the closer we get to the core belief. However, the example of an onion does not favor the differentiation between the three levels of thought, since the layer structures are similar (J.S. Beck, 2011).
Given the importance of making clear the difference between the three levels of cognition, our initial objective was to find an image that facilitated the understanding of the three levels of thought and the intensity of associated emotions: the deeper the thought, the greater the triggering of emotions. The cognitive formulation reveals the relationship between the three levels of thought: 1) automatic thought = avocado skin, which occurs in several daily situations, arises spontaneously and is not related to reflection or deliberation; 2) conditional belief = avocado flesh, the level of cognition activated when the person makes predictions about the consequences of their behavior or behaves according to the rules; and 3) core belief = avocado stone, in which absolute or rigid thoughts are present (J. S. Beck, 2011).
In the current version of the technique, the upper portion is composed of illustrative representations of gray and green avocados. The lower portion, consisting of text, is didactically constructed in six steps: two on the gray unhealthy side -Steps 1 and 3 -and four on the green healthy side -Steps 2, 4, 5 and 6 (Fig. 1). The image facilitates reflection on illness and health, based on the theoretical concepts of CBT, decision making, and quality of life. It is up to the health professional to help the patient to make the best decisions in order to improve their quality of life. After the identification of a problem or unbalanced emotion, an exercise is constructed following the guidelines for completing the six steps of the Think Healthy technique (Figs. 1 and 2).

Type of Study
This is a methodological study with qualitative features to describe the application of the "Think healthy and feel the difference" technique to acromegalic patients. The descriptive study of its six steps is related to the theoretical framework and broad philosophical foundations of CBT (Díaz & Murguia, 2015).
In the group therapy sessions, the content of the Think Healthy technique was constructed collaboratively by the investigator and the participants. Issues such as sedentary lifestyle, fear, depression, and shame about their physical appearance were selected by the participants. The content of the exercise developed in Session 7, in collaboration with the participants, was used for the presentation of this study. In Session 7, because of the damage that My appearance is an embarrassment! + When I arrive somewhere, everyone looks at me and thinks I'm ugly and weird. = To feel less ashamed, it is best to leave the house as little as possible.
My appearance leaves a lot to be desired + If beauty were everything, there would be no beautiful unhappy people, and there would be no ugly happy people.

Results and Discussion
Based on the principles of CBT, research has been conducted and the positive effect on patients' well-being has been demonstrated (Díaz & Murguia, 2015). The effects of the treatment on patients' quality of life and on the indications of depression in patients with acromegaly are presented in Kunzler et al., 2018, and maintenance of effects at 9 months of follow-up is described in Kunzler et al., 2019. Two self-report evaluation instruments were used: Quality of Life Questionnaire (SF-36), and Beck Depression Inventory (BDI). Participants filled out these two instruments at the three stages of the study: pre-intervention, post-intervention, and follow-up. A qualitative data analysis was performed to assess the effect of the treatment. The adapted and collaboratively constructed content illustrates the theoretical and philosophical foundations of each of the six steps. The content of each step depends on the difficulty faced, and in this article it is adapted to acromegaly. Because of that, results and discussion are presented in the same section. It is important that both the health care provider and the patient understand the basics and complete the exercise, which facilitates practice of the new cognitive behavioral skills outside of therapy sessions. We will now present the technique as adapted for patients with acromegaly, focusing on physical appearance shame, and comments on the basis of each of the steps (Fig. 2).
Step 1: Difficulties and complaints-the starting point.
In general, patients reported that the negative thoughts were independent of their will, and that they occurred even when they decided not to think them or tried to avoid them. They complained that they passed through their minds without any reflection or reason (A.T. Beck, 1963). Since most people are unaware that negative thoughts precede unpleasant emotions and behavioral inhibitions (A.T. Beck, 1963;Knapp & Beck, 2008), the emotion attached to the distorted thinking must be identified and the distorted cognition must be restructured (A.T. Beck, 1963). As Stoic Epictetus said, "Men are disturbed not by the things which happen, but by their opinion about the things (Díaz & Murguia, 2015)." Therefore, drawing on Stoicism, the way patients with acromegaly view their appearance determines their emotional reaction to it.
Adolescents dissatisfied with their body image are 3.7 times more likely to present depressive symptoms, which may be related to intimidation and chronic stress (Flores-Cornejo et al., 2017). Due to their emotional imbalance, patients believe that their problem is the biggest problem in the world, or they believe that there is no way to deal with the adversity (A.T. Beck, 1963). When psychoeducation is delivered, patients realize that when they believe they are inadequate, abandoned, or guilty, they will feel sadness, loneliness, and guilt, and will choose to avoid certain situations (Beck, 1963).
This situation may be reported by patients with acromegaly due to their physical appearance. The research participants reported that even before they received the diagnosis of acromegaly they had already been nicknamed "Shrek," because of their appearance. It has been said that the famous and beloved film character, the ogre Shrek, was inspired by Maurice Tillet, who was born in Russia in 1903 to French parents. At age 17, he was diagnosed with acromegaly. He was a wrestling star of the 1930s and 1940s, known at the time as "The French Angel." Even when the disease activity is under control, patients with acromegaly perceive themselves and their lives as different, which compromises their quality of life (Szcześniak et al., 2015). Differentiating the levels of thinking was important for the participants to understand that the greater the emotional imbalance, the truer the cognitions appear to be, and the greater the difficulty of maintaining healthy behaviors (Beck, 1963;J. S. Beck, 2011). Automatic thoughts (e.g., "Acromegaly is a disease that causes changes in my appearance") trigger negative emotions at a mild level. Conditional beliefs (e.g., "If I leave the house, people will look at me and notice my appearance") trigger emotions of moderate intensity. Core beliefs (e.g., "I am horrible") trigger emotions of high intensity.
Addressing the questionnaire items with participants emphasizes the importance of knowing the impact of the disease on their perception of well-being and functioning (Badia et al., 2004). Cognitive restructuring promotes healthier behaviors and emotional balance. Beginning the exercise by Step 1, shame about appearance was the starting point.
Step 1 is placed on the gray (distorted) left side of the technique. In order to make the relationship between the factors clear, Step 1 is represented by a mathematical addition operation: unhealthy emotions plus unhealthy thoughts equals unhealthy behaviors.
My appearance is an embarrassment! (Emotion) + When I arrive somewhere, everyone looks at me and thinks I'm ugly and weird. (Thought) = To feel less ashamed, it is best to leave the house as little as possible. (Behavior) Therefore, Step 1 allowed the participants to be aware of the factors that maintain the unwanted or unhealthy behavior. Reflections similar to those presented in Step 1 favored the construction of Step 2, aiming at promoting emotional regulation and maintaining the decision to interact socially despite their physical appearance.
Step 2: A healthy alternative for learning to deal with appearance.
After the construction of Step 1, on the gray and unhealthy side, we addressed Step 2, on the green and healthy side. Steps 1 and 2 are organized as an addition operation to highlight the relationship between unhealthy and healthy emotions, thoughts, and behaviors (A.T. Beck, 1963).
During times of adversity, accepting the situation and emotional imbalance, instead of suppressing them, strengthens the ability to regulate emotions (Renna et al., 2017). Because it is not possible to avoid cognitive distortions related to physical appearance, acceptance aims to decrease their impact on behavior and to seek healthy choices (Hulbert-Williams et al., 2015). Thus, acceptance favors psychological flexibility, which functions as a buffer in situations of psychological stress (Hulbert-Williams et al., 2015). It is emphasized that acceptance does not mean agreeing with or appreciating what is happening.
Accepting that thoughts about inferiority and abandonment are related to the emotions of loneliness, humiliation, and guilt (Beck, 1963), which are factors in Step 1, favors building and maintaining the healthy side of the technique. Acceptance of the situation facilitates cognitive restructuring and rerouting of the mind. In Step 2, related to cognitive restructuring, thinking "I am beautiful" would not be true and effective as it would be unrealistic. The challenge is to learn to deal with emotional imbalance despite the coarse features, growth of the extremities, intimidation, and rejection. A reduction in emotional intensity is observed when patients learn to question the validity of their thoughts (A.T. Beck, 1963).
Cognitive restructuring refers to the ability to change the evaluation of an event with a consequent change in the emotional load (Renna et al., 2017). Patients are taught to reassess the situation, validate the emotional imbalance, and experience compassion for such life situation (Renna et al., 2017). Regulation of emotions allows individuals to re-evaluate their life situation as it really is and not how the emotional imbalance caused them to evaluate it.
For the Stoics, reason is crucial to well-being. Human nature is characterized by the ability to reason. Thus, building healthy thoughts moderates the emotions (Díaz & Murguia, 2015). For Existentialism, it is important to change the irrational thoughts causing pain. You should first decide on your values so that your attitudes can be in agreement with them. (Díaz & Murguia, 2015). The participants with acromegaly learned to change the way they think about their appearance.
Healthy behavior then results from the acceptance of emotional imbalance and the disease, and the restructuring of thought. For Stoicism, questioning a situation and what can and cannot be done strengthens reason (Díaz & Murguia, 2015). People with acromegaly cannot do anything about their physical appearance, but they can learn to place less emphasis on it. Just as in Step 1, these factors, comprising Step 2, were also presented as an addition operation: emotion and situation acceptance plus thought equals behavior.
My appearance leaves a lot to be desired! (Acceptance) + If beauty were everything, there would be no beautiful unhappy people, and there would be no ugly happy people. (Thought) = I can choose to be happy despite being ugly. I can value my qualities. (Behavior) After starting from Step 1 and completing the reasoning with Step 2, esteem and trust must be prioritized. To this end, the Think Healthy technique is associated with making lists of personal qualities and achievements. The two lists should always be remembered and improved on. With acromegaly, especially because of the appearance and physical limitations generated by the disease, this becomes an even more important activity. Despite being ugly and deformed, valuing personal qualities leads to improved self-esteem, and valuing achievements improves self-confidence. In this context, replacing self-criticism with compassion alleviates the intensity of unbalanced emotions (Renna et al., 2017).
The study participants made a list of personal qualities: "I am a charismatic, affectionate, responsible, dedicated, confident, worthy… person" (improvement in esteem = green avocado stone). In addition to investing in self-esteem, a list of achievements and healthy behaviors was developed to improve self-confidence: "I go to the gym and the beauty salon, I work on my treatment, I come to my consultations, I take my medications, I'm taking part in the therapy sessions..." (improvement in confidence = green avocado flesh).
During difficult moments and times of adversity experienced on a daily basis, the construction of Steps 1 and 2 and the use of lists of qualities and achievements are enough to restore a healthy pattern. However, in some cases, unbalanced emotions and negative memories constantly trigger unhealthy thoughts and unwanted behaviors. Distorted thoughts are considered automatic, plausible, and involuntary (Beck, 1964) and may prevent the patient from drawing a line under the healthy reasoning of Step 2, leaving their options open. When this occurs, the gray side is triggered again, which is represented by Step 3.
Step 3: Factors that maintain complaints and difficulties.
By leaving things open after Step 2, Step 3 is activated; the participant turns to the gray side where more thoughts and behaviors are unbalanced by negative emotions ("but people criticize me," "I feel very ashamed of my appearance," "whenever I arrive somewhere people reject me..."). As a result, patients cannot avoid negative thoughts or focus on other things (A.T. Beck, 1964). Rather than understanding that their thoughts are interpretations of reality, they evaluate them as being reality, allowing their thoughts to influence their emotional responses (Beck, 1964).
The symptoms related to processes that include rumination, fear, and self-criticism reflect greater sensitivity in response to the systems of danger/security and reward/loss (Renna et al., 2017). Emotional dysregulation is most intense when core beliefs, such as "I look awful in photographs," are triggered, which aggravates cognitive distortions (A.T. Beck, 1964).
In addition to dysregulation of emotions by unhealthy thoughts and behaviors, Step 3 can be triggered when the current problem is related to difficult situations from the past (A.T. Beck, 1964;Wild et al., 2007). The research participants reported a previous history of feeling ashamed of their appearance in family, school, academic, and/or work contexts. A situation is remembered and relived, which keeps the patient in the past, not the present. The events typically involve intimidation, criticism, and humiliation. These cause aversive reactions and lead to avoidance (Wild et al., 2007).
In a collaborative way, Step 3 was then summarized by the research participants: "But what really appears is my ugliness. Nobody wants to know my qualities. I am ridiculed. A beautiful person gets more things in life. I'll never be seen in a good light." When the present visits difficult situations from the past, the unhealthy side of the technique-represented by steps 1 and 3-becomes more prevalent. Consequently, strengthening the healthy side of the technique-represented initially by stage 2-is challenging. Moving between the gray and green sides is characteristic of mental health. Staying longer on the gray side is associated with greater psychological suffering, while strengthening the green side is associated with emotional balance. Seeking the prevalence of the healthy side of the technique, decision making becomes crucial.
Steps 4 and 5: Less emotional and more rational decision making.
Since Existentialism focuses on choice and responsibility (Díaz & Murguia, 2015), decision making is reinforced in steps 4 and 5. Choices are affected by the environment, but there is freedom of choice (Díaz & Murguia, 2015). Regarding decision making, the participants concluded that they can choose to be happy despite being ugly and they realized that valuing qualities and healthy behaviors improves quality of life. Accepting one's physical appearance and interacting naturally with people may sound simple and easy. However, putting the obvious and simple into practice is not always easy, especially in times of emotional dysregulation. Steps 4 and 5 aim to make it clear that emotion imbalance causes body shame to prevail, increasing the risk of acromegalic patients giving up on social interaction again. It is a seesaw battle between reason and emotion, influencing the maintenance of a choice among options. Despite the importance of evaluating the consequences of a given option, some decisions are made based only on emotions (Bechara, 2004). This is often the case of social and interpersonal situations, where it is not possible to know exactly what will happen in the future, and negative emotions can lead one to anticipate difficulties and generate physical symptoms of anxiety (Bechara, 2004). Thus, evaluations are often based on assumptions. Avoiding leaving the house is an unhealthy behavior, but it is maintained by the advantages of staying home ("to avoid feeling ashamed about appearance") and the disadvantages of trying to interact with other people ("wherever I go, people find me very ugly"). Based on these arguments, staying at home seems to be the best option, especially at that moment. This characterizes decision making based on emotion and maintains the difficulties.
As an example, say a patient makes the decision to interact with other people and again refuses an invitation to a family Sunday lunch. The patient must then remember their objective of dealing with shame, how difficult it is to deal with unbalanced emotions, the disadvantages of staying at home (Step 4), and the advantages of accepting the invitation (Step 5). It is important for the patient to know that applying the technique is difficult; however, it is doable.
The decision in favor of accepting appearance and investing in social interaction is facilitated by Steps 4 and 5. After analyzing the disadvantages of focusing on physical appearance -Step 4 -, which leads to greater emotional dysregulation and compromised quality of life, and the advantages of investing in healthier thoughts and behaviors, strengthening healthy decision making and its maintenance, Step 5 is constructed.
Step 4: Disadvantages of remaining on the unhealthy "gray avocado" side. Therefore, if the objective is to learn to deal with the shame about one's appearance, making a decision that is less emotional and more rational makes the difference. The disadvantages of spending more time in the house should be maximized. Step 5: Advantages of investing in the healthy "green avocado" side.

Disadvantages of Staying in the "Gray Avocado" Side
In addition to Step 4, the advantages of leaving the house and interacting with people should be valued ("learn how to deal with appearance, value my qualities and achievements, and feel good"). Therefore, decision making based on accepting physical appearance can contribute to the balance of emotions.

Advantages of Investing in the "Green Avocado" Side
Advantages of accepting my appearance: "having friends, accepting invitations, feeling good, studying, working, and having a normal life. I can do something to face the problems that I can really change and overcome." Steps 4 and 5 favor the reflections necessary to maintain the decision to value quality and achievements, despite physical appearance. It should be emphasized that improvements in a patient's quality of life depend on choices that are less emotional and more rational.
Step 6: Summary and reminders to re-balance emotions.
After studying and completing Steps 1 to 5, the purpose of Step 6 is to summarize the content that was covered in the exercise. The rationale learned in the first five steps is simple and logical, but maintaining balance when negative emotions become intense is a challenge. The contents of Steps 2, 4, 5, and 6--on the green and healthy side of the technique-are written on coping cards, which can be used in situations that generate self-criticism (Renna et al., 2017).
Regarding the importance of summaries and coping cards, Judith Beck, author of The Beck diet solution: train your brain to think like a thin person, offers 24 examples of coping cards in her proposed 6-week cognitive restructuring for weight loss and maintenance of the desired body weight. The program can be applied to any diet, as it does not teach what to eat, but rather how to think thin (J. S. Beck, 2007).
These healthy reflections are recorded in the form of coping cards, in small blocks or on electronic devices.
The cards work as reminders to practice the new cognitive and behavioral skills (Renna et al., 2017). The participants were instructed to remember these reflections in moments of emotional imbalance so as to deal with adverse situations in a healthy way. For example, "If I learn to deal with shame, I will have friends and feel better" and "If my goal is to live with people in a natural way, it is best to remove the focus from my appearance and remember my qualities and progress." Though executive function is impaired in acromegalic patients, the research participants were able to identify unhealthy thoughts, emotions and behaviors, restructure their thoughts, and develop alternative ways to deal with difficulties, leading to emotional regulation and improved quality of life. Improvement in their quality of life may have been facilitated by CBT features, such as visual resources, printed material, reflection and exercise completion, structured sessions, use of a notepad, and creation of coping cards (Kunzler et al., 2018).

Final Considerations
As no research has so far shown that acromegalic patients were able to achieve improved quality of life when submitted to the available treatment options (Geraedts et al., 2017), this research sought such an outcome by associating a CBT technique. During the weeks of group therapy sessions, there was no change in the medication regimen of participants.
The Think Healthy technique, based on the principles of CBT, decision making, and quality of life, can be used in diverse contexts to address different issues. It facilitates decision making through healthy thoughts and behavioral patterns and prioritizes autonomy in patients so that they can become their own therapist. This article presents an adaptation for acromegaly, and the technique can be used along with surgical, radiotherapeutic, and medicinal treatment. It can be applied in groups when a great number of patients are seen by the same health professional, which contributes to the optimization of results in health services with high demand (Flores-Cornejo et al., 2017).
In summary, the technique was adapted to facilitate the acceptance of changes in body image and the difficulties resulting from excess GH and IGF-1. Improvement in quality of life is supported by the reflections resulting from the following question: "Although I have acromegaly, when I perceive an emotional imbalance, what can I think and what can I do that is healthier?" In addition to adapting the technique to address concerns regarding the physical appearance of patients with acromegaly, the technique has also been improved and adapted for use with different disorders and situations: oral presentation and oral/written tests (Kunzler, 2015), and management of