Cognitive Behaviour Therapy For Chronic Fatigue Syndrome Research Articles

The role of partners' fatigue and the patient-partner relationship in the outcome of cognitive behavioural therapy for chronic fatigue syndrome

BackgroundIn chronic fatigue syndrome (CFS) little is known about how partner-related factors influence patients' fatigue symptoms and treatment outcome. We examined partners' fatigue severity, and determined the role of partner-related factors for patients' symptoms and the outcome of cognitive behavioural therapy (CBT). Methods1356 CFS patients and their partners completed baseline measures of fatigue severity (Checklist Individual Strength), causal attributions of symptoms, partner responses to patient symptoms, and relationship satisfaction. Fatigue in partners of patients with CFS was compared with fatigue in age- and gender-matched controls from the Dutch population. Associations between partners' fatigue severity and other partner-related factors were determined. In a subgroup of 760 CFS patients who completed CBT, logistic regression analyses were used to identify partner-related baseline predictors for treatment outcome (fatigue severity, functional impairment). ResultsPartners' fatigue (M = 21.66, SD 11.60) was significantly lower than in controls (M = 24.58, SD = 11.02) (p < .001) and not related to patients' fatigue (r = −0.02, p = .58). Partners' fatigue was correlated with patients' functional impairment (p = .001), partners' and patients' relationship dissatisfaction, negative partner responses, and partners' and patients' psychological attributions of patient symptoms at baseline (all p < .001). After controlling for patients' baseline fatigue severity and functional impairment, only relationship dissatisfaction as reported by (female) patients significantly predicted worse treatment outcome. For male patients with female partners, higher partners' fatigue severity predicted higher fatigue severity after CBT. ConclusionsFemale partners' fatigue and relationship dissatisfaction as reported by the female patient should be addressed in CBT for CFS, as these factors affect treatment outcome.

Testing the efficacy of web-based cognitive behavioural therapy for adult patients with chronic fatigue syndrome (CBIT): study protocol for a randomized controlled trial.

BackgroundCognitive behavioural therapy (CBT) is an effective treatment for fatigue and disabilities in patients with chronic fatigue syndrome (CFS). However, treatment capacity is limited. Providing web-based CBT and tailoring the amount of contact with the therapist to the individual needs of the patient may increase the efficiency of the intervention. Web-based CBT for adolescents with CFS has proven to be effective in reducing fatigue and increasing school attendance. In the proposed study the efficacy of a web-based CBT intervention for adult patients with CFS will be explored. Two different formats of web-based CBT will be tested. In the first format named protocol driven feedback, patients report on their progress and receive feedback from a therapist according to a preset schedule. In the second format named support on demand, feedback and support of the therapist is only given when patients ask for it. The primary objective of the study is to determine the efficacy of a web-based CBT intervention on fatigue severity.Method/DesignA randomized clinical trial will be conducted. Two-hundred-forty adults who have been diagnosed with CFS according to the US Centers for Disease Control and Prevention (CDC) consensus criteria will be recruited and randomized to one of three conditions: web-based CBT with protocol driven feedback, web-based CBT with support on demand, or wait list. Feedback will be delivered by therapists specialized in CBT for CFS. Each of the web-based CBT interventions will be compared to a wait list condition with respect to its effect on the primary outcome measure; fatigue severity. Secondary outcome measures are level of disability, physical functioning, psychological distress, and the proportion of patients with clinical significant improvement in fatigue severity. Outcomes will be assessed at baseline and six months post randomization. The web-based CBT formats will be compared with respect to the time therapists need to deliver the intervention.DiscussionAs far as we know this is the first randomized controlled trial (RCT) that evaluates the efficacy of a web-based CBT intervention for adult patients with CFS.Trial registrationNTR4013

The role of the therapeutic relationship in cognitive behaviour therapy for chronic fatigue syndrome

Cognitive behaviour therapy (CBT) for chronic fatigue syndrome (CFS) can reduce fatigue and impairment. Recently, it was found that changes in fatigue-perpetuating factors, i.e. focusing on symptoms, control over fatigue, perceived activity and physical functioning, are associated with and explain up to half of the variance in fatigue during CBT for CFS. The therapy relationship, e.g. outcome expectations and working alliance, may also contribute to treatment outcome. We aimed to examine the role of the therapy relationship in CBT and determine whether it exerts its effect independently of changes in fatigue-perpetuating factors. We used a cohort of 217 CFS patients in which the pattern of change in fatigue-perpetuating factors was examined previously. Fatigue, therapy relationship and fatigue-perpetuating factors were measured at the start of therapy, three times during CBT and at the end of therapy. Baseline outcome expectations and agreement about the content of therapy predicted post therapy fatigue. A large part of the variance in post-treatment fatigue (25%) was jointly explained by outcome expectations, working alliance and changes in fatigue-perpetuating factors. From this, we conclude that positive outcome expectations and task agreement seem to facilitate changes in fatigue-perpetuating factors during CBT for CFS. It is therefore important to establish a positive therapy relationship early in therapy.

Therapist effects and the dissemination of cognitive behavior therapy for chronic fatigue syndrome in community-based mental health care

ObjectiveThe purpose of the present study was to explore the role of the therapist in the dissemination of manualized cognitive behavior therapy (CBT) for chronic fatigue syndrome (CFS) outside specialized treatment settings. MethodWe used the routinely collected outcome data of three community-based mental health care centers (MHCs) which implemented and sustained CBT for CFS during the course of the study. Ten therapists, who all received the same training in CBT for CFS, and 103 patients with CFS were included. ResultsRandom effects modeling revealed a significant difference in mean post-treatment fatigue between therapists. The effect of the therapist accounted for 21% of the total variance in post-treatment fatigue in our sample. This effect could be explained by the therapists’ attitude toward working with evidence-based treatment manuals as well as by the MHC where CBT for CFS was delivered. ConclusionThe context in which CBT for CFS is delivered may play an important role in the accomplishment of established therapy effects outside specialized treatment settings. Due to the small sample size of MHCs and the different implementation scenarios in which they were engaged, our findings should be interpreted as preliminary results which are in need for replication.

Cognitive behavior therapy for chronic fatigue syndrome: Where to go from here?

[Clin Psychol Sci Prac 18: 325–330, 2011] The meta-analytic review of Castell, Kazantzis, and Moss-Morris (2011) is a valuable contribution to the debate about the efficacy of behavioral interventions for chronic fatigue syndrome (CFS). Again it is found that cognitive behavior therapy (CBT) has a positive effect on the outcomes of patients with CFS. However, a substantial number of patients do not profit (enough) from this intervention. Increasing our knowledge about the mechanisms of change and other relevant aspects related to the treatment response could help to improve further the efficacy and applicability of CBT for CFS. This commentary discusses some of these aspects and, where possible, research strategies are proposed.

Mindfulness‐Based Cognitive Therapy for People with Chronic Fatigue Syndrome Still Experiencing Excessive Fatigue after Cognitive Behaviour Therapy: A Pilot Randomized Study

Cognitive behaviour therapy (CBT) is an effective treatment for chronic fatigue syndrome (CFS; sometimes known as myalgic encephalomyelitis). However, only a minority of patients fully recover after CBT; thus, methods for improving treatment outcomes are required. This pilot study concerned a mindfulness-based cognitive therapy (MBCT) intervention adapted for people with CFS who were still experiencing excessive fatigue after CBT. The study aimed to investigate the acceptability of this new intervention and the feasibility of conducting a larger-scale randomized trial in the future. Preliminary efficacy analyses were also undertaken. Participants were randomly allocated to MBCT or waiting list. Sixteen MBCT participants and 19 waiting-list participants completed the study, with the intervention being delivered in two separate groups. Acceptability, engagement and participant-rated helpfulness of the intervention were high. Analysis of covariance controlling for pre-treatment scores indicated that, at post-treatment, MBCT participants reported lower levels of fatigue (the primary clinical outcome) than the waiting-list group. Similarly, there were significant group differences in fatigue at 2-month follow-up, and when the MBCT group was followed up to 6 months post-treatment, these improvements were maintained. The MBCT group also had superior outcomes on measures of impairment, depressed mood, catastrophic thinking about fatigue, all-or-nothing behavioural responses, unhelpful beliefs about emotions, mindfulness and self-compassion. In conclusion, MBCT is a promising and acceptable additional intervention for people still experiencing excessive fatigue after CBT for CFS, which should be investigated in a larger randomized controlled trial. Only about 30% of people with chronic fatigue syndrome (CFS) recover after cognitive behaviour therapy (CBT); thus, methods for improving treatment outcomes are needed. This is the first pilot randomized study to demonstrate that a mindfulness-based intervention was associated with reduced fatigue and other benefits for people with CFS who were still experiencing excessive fatigue after a course of CBT. Levels of acceptability, engagement in the intervention and rated helpfulness were high. A larger-scale randomized controlled trial is required.

Childhood maltreatment and the response to cognitive behavior therapy for chronic fatigue syndrome

Objective To examine the relationship between a history of childhood maltreatment and the treatment response to cognitive behavior therapy for chronic fatigue syndrome (CFS). Methods A cohort study in a tertiary care clinic with a referred sample of 216 adult patients meeting the Centers for Disease Control and Prevention criteria for CFS, and starting cognitive behavior therapy. Main outcome measures changes between pre- and post therapy in fatigue (Checklist Individual Strength fatigue subscale), disabilities (Sickness Impact Profile total score), physical functioning (short form 36 health survey subscale) and psychological distress (Symptom checklist 90 total score). Results At baseline, patients with a history of childhood maltreatment had significantly more limitations and a higher level of psychological distress, but were not more severely fatigued. Change scores on the outcome measures after cognitive behavior therapy did not differ significantly between patients with or without a history of childhood maltreatment, or between the different types of childhood maltreatment. However, patients with a history of childhood maltreatment still experienced more limitations and a higher level of psychological distress after CBT. Conclusions A history of childhood maltreatment was not related to the treatment response of cognitive behavior therapy for CFS. In patients with a history of childhood maltreatment CFS symptoms can be treated with CBT just as well as those without.

Possible Detrimental Effects of Cognitive Behaviour Therapy for Chronic Fatigue Syndrome

Background: Cognitive behaviour therapy (CBT) for chronic fatigue syndrome (CFS) can decrease the level of fatigue and disabilities, but it has been suggested that during therapy some patients experience a deterioration of their symptoms rather than an improvement. The aim of this study is to examine the frequency and severity of symptom deterioration during CBT for CFS. Methods: Data from 3 randomised controlled trials on CBT for CFS were pooled and reanalysed. Symptom deterioration during the trial was rated by patients and measured as deterioration in fatigue, pain, functional impairment and psychological distress. Both the frequency and severity of deterioration in these domains were compared between the patients receiving CBT and those in the control group. Predictors of symptom deterioration were identified by comparing their means in patients with and without an increase in fatigue. Statistically significant predictors were then combined in a logistic regression model. Results: The frequency of symptom deterioration varied from 2 to 12% in patients receiving CBT and from 7 to 17% in the control group. None of the measures showed a significantly higher frequency of symptom deterioration in the CBT group. The severity of deterioration was also comparable in the CBT and in the control group. No predictors of symptom deterioration specific to CBT were found. Conclusion: Patients receiving CBT do not experience more frequent or more severe symptom deterioration than untreated patients. The reported deterioration during CBT seems to reflect the natural variation in symptoms. Thus, CBT is not only a helpful, but also a safe treatment for CFS.

The ratio of cortisol/DHEA in chronic fatigue syndrome

Introduction: Hypoactivity of the hypothalamic-pituitary-adrenal axis (HPA axis) has been one of the most consistent biological findings in chronic fatigue syndrome (CFS). However, it has been hypothesised that the adrenal steroid dehydroepiandrosterone (DHEA) may counteract the effects of cortisol in the brain (Kroboth et al., 2003) and that consequently a true measure of the “net” effect of cortisol on the brain is better obtained by calculating the ratio of cortisol to DHEA. Studies have not attempted to measure this pre and post Cognitive Behavioural Therapy (CBT), an effective treatment for CFS (Whiting et al., 2000) also recommended byNational UK guidelines. Methods: Basal (0900 h) plasma levels of cortisol, DHEA and their ratio were measured in 41 patients with CFS without depression and in 28 matched controls. In 33 of the above patients this ratio was repeated following a 6 month course of CBT. Furthermore diurnal salivary cortisol profiles were measured at 0800, 1200, 1600 and 2000 h pre- and post-CBT in all 41 patients. Results: The plasma ratio of cortisol/DHEA (mean±SD) did not differ between patients and controls (5.91±0.46 vs 5.86±0.46, p=0.97). Although there was no difference comparing the 0900 h plasma cortisol/DHEA ratio before and after CBT, 0900 h plasma DHEA was significantly lower after CBT (34.7±18.4 vs. 31.2± 21.0 nmol/l, p=0.001). While total daily salivary cortisol output from 0800–2000 h (measured as the area under the curve) increased significantly from 68.2±19.6 to 79.4±21.8 nmol/l h (t=2.62, p<0.05) after CBT. Conclusions: The combined novel findings of increased total daily salivary cortisol output and reduced plasma DHEA suggest that ‘functional’ cortisol is increased following CBT for CFS. We suggest that there disavantages in using single plasma levels and that further clarity will be obtained in future research by measuring both cortisol and DHEA concurrently in saliva throughout the day.

The Beliefs about Emotions Scale: Validity, reliability and sensitivity to change

Objective Beliefs about the unacceptability of experiencing or expressing negative emotions have been noted in individuals with a range of problems, including chronic fatigue syndrome (CFS), irritable bowel syndrome, somatization disorder, depression, eating disorders, social phobia, posttraumatic stress disorder, and borderline personality disorder. These beliefs are likely to have implications for emotion regulation and processing, and are addressed explicitly or implicitly within many therapies including cognitive behavior therapy (CBT), mindfulness-based cognitive therapy (MBCT), and Acceptance and Commitment Therapy (ACT). This article describes the development, validation, and internal reliability of the Beliefs about Emotions Scale (BES), a self-report questionnaire to assess such beliefs. Methods The new scale was completed by people with CFS ( n=121) and healthy controls ( n=73). Twenty-two individuals with CFS completed the scale before and after CBT. Results People with CFS had significantly higher scores on this new questionnaire than healthy controls. Principal components analysis identified one factor, and the scale had high internal consistency (0.91). Scores on the BES were most highly correlated with a measure of negative perfectionism ( r=0.59) and also showed significant correlations with measures of dysfunctional attitudes, self-sacrifice, depression, anxiety, and fatigue. When completed before and after CBT for CFS, the questionnaire was sufficiently sensitive to detect a significant reduction in endorsement of unhelpful beliefs about emotions. Conclusion The new Beliefs about Emotions Scale showed good internal reliability, validity and sensitivity to change.

Salivary cortisol output before and after cognitive behavioural therapy for chronic fatigue syndrome

BackgroundThere is evidence that patients with chronic fatigue syndrome (CFS) have mild hypocortisolism. One theory about the aetiology of this hypocortisolism is that it occurs late in the course of CFS via factors such as inactivity, sleep disturbance, chronic stress and deconditioning. We aimed to determine whether therapy aimed at reversing these factors – cognitive behavioural therapy for CFS – could increase cortisol output in CFS. MethodsWe measured diurnal salivary cortisol output between 0800 and 2000h before and after 15 sessions (or 6 months) of CBT in 41 patients with CDC-defined CFS attending a specialist, tertiary outpatient clinic. ResultsThere was a significant clinical response to CBT, and a significant rise in salivary cortisol output after CBT. LimitationsWe were unable to control for the passage of time using a non-treated CFS group. ConclusionsHypocortisolism in CFS is potentially reversible by CBT. Given previous suggestions that lowered cortisol may be a maintaining factor in CFS, CBT offers a potential way to address this.

Cognitive-behaviour therapy for chronic fatigue syndrome: Comparison of outcomes within and outside the confines of a randomised controlled trial

Outcomes for cognitive-behaviour therapy (CBT) in randomised controlled trials (RCTs) have rarely been compared to those in routine clinical practice. Taking the case of CBT for chronic fatigue syndrome (CFS), we evaluated the results of a successful RCT against those of the same treatment given in the same setting as part of routine practice. Fatigue and social adjustment scores were compared for patients who received CBT for CFS as part of a RCT ( N = 30 ) and patients who received CBT as part of everyday clinical practice ( N = 384 ). The results in the RCT were superior to those in routine clinical practice. Between pre-treatment and 6-month follow-up, the RCT showed a larger reduction in fatigue and greater improvement in social adjustment than those in routine treatment. The changes in fatigue scores were similar for both groups during treatment but were greater in the RCT between post-treatment and follow-up. Potential reasons for the superior results of the RCT include patient selection, therapist factors and the use of a manualised treatment protocol. Practitioners need to pay particular attention to relapse prevention and ensuring adequate follow-up in addition to encouraging patients to continue with cognitive-behavioural strategies once treatment has ended.

Cognitive behaviour therapy for chronic fatigue syndrome: predictors of treatment outcome

Although cognitive behaviour therapy (CBT) for chronic fatigue syndrome (CFS) is effective in several RCTs, little is known about predictors of treatment outcome. With the data of our RCT, where CBT for CFS was significantly more effective in improving fatigue severity and functional impairment than guided support groups and natural course, the predictive value of activity pattern, disability claims and psychiatric comorbidity was tested for outcome of CBT. Patients with a passive activity pattern and patients who were engaged in a legal procedure concerning financial benefits had a worse outcome. Psychiatric comorbidity was not a predictor. For patients with a passive activity pattern, another type of CBT has to be offered. CBT should not be offered to patients during their engagement in legal procedures of disability claims.