Category: Psychiatry/Psychology

Cognitive behaviour therapy for the chronic fatigue syndrome. Essential elements of the treatment must be identified

Comment on: Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial. [BMJ. 1996]

 

EDITOR,-We have several practical and theoretical concerns about Michael Sharpe and colleagues’ study of cognitive behaviour therapy in the chronic fatigue syndrome.’ The authors managed to obtain almost 100% uptake of treatment and compliance among patients who were attending an infectious diseases clinic and were strongly convinced that their chronic fatigue had a physical cause. We would struggle to engage our patients similarly, even with two hours for an initial appointment, and we could not offer them anything approaching an hour of treatment a week for four months. The difference between what was provided in the study and what clinicians can routinely offer their patients makes it important to identify the essential elements of the treatment.

The package given included cognitive techniques such as “question[ing] a simple disease explanation,” “strategies to reduce excessive perfectionism and self criticism,” and a problem solving approach of “gradual and consistent increases in activity.” The continuing improvement after the end oftreatment is unusual for the cognitive psychotherapies and suggests that the behavioural component was most effective. We find it puzzling, therefore, that the authors attribute the beneficial effects of treatment to “a specific effect on illness perpetuating beliefs and coping behaviour,” particularly as these attitudes did not change substantially. The patients would inevitably report less avoidance of exercise if they were complying with the study. After treatment at least half of the patients still believed that the illness was physical (from tables 2 and 5), and the vast majority still applied the damaging label of “myalgic encephalomyelitis”2 to their condition.

You can read the full comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350875/pdf/bmj00539-0053b.pdf

 

Source: Lawrie SM. Cognitive behaviour therapy for the chronic fatigue syndrome. Cognitive behavior therapy. Essential elements of the treatment must be identified. BMJ. 1996 Apr 27;312(7038):1097; author reply 1098. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350875/

 

Cognitive behaviour therapy for the chronic fatigue syndrome. Cognitive behavior therapy should be compared with placebo treatments

Comment on: Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial. [BMJ. 1996]

 

EDITOR,-Lest Michael Sharpe and colleagues’ paper lends respectability to the notion that the chronic fatigue syndrome is a diagnostic entity or suggests that cognitive behaviour therapy has any value specific to the condition,1 I wish to make three points.

Firstly, the disorder that the authors treated is heterogeneous, the only defining criteria used being fatigue, impaired daily activities, and the absence of signs of physical disease or “severe depression.” Claims for a specific effect in any diffuse symptom complex are dangerous. Quinine is effective in many cases of cramp, but neither the symptom nor the benefit is specific.

Secondly, cognitive behaviour therapy and any comparable substitute were denied the control patients, who were therefore matched only on pretreatment criteria regarding their clinical state and not controlled in respect of a comparable treatment. Despite the authors’ claim for a “specificity of treatment effect” the benefits shown are consistent with the provision of much attention, encouragement, and a positive attitude to the nature of the illness and the strategies to counter it.’

You can read the full comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350872/pdf/bmj00539-0053c.pdf

 

Source: Pearce J. Cognitive behaviour therapy for the chronic fatigue syndrome. Cognitive behavior therapy should be compared with placebo treatments. BMJ. 1996 Apr 27; 312(7038): 1097–1098. http://www.ncbi.nlm.nih.gov/pubmed/8616428

 

Cognitive behaviour therapy for the chronic fatigue syndrome. Use an interdisciplinary approach

Comment on: Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial. [BMJ. 1996]

 

EDITOR,-From their randomised trial in the chronic fatigue syndrome Michael Sharpe and colleagues conclude that cognitive behaviour therapy is more effective than “medical care” in improving day to day function.1 It is not clear that the data presented justify this conclusion. Firstly, the authors do not compare like with like: the group given cognitive behaviour therapy received 16 hours of therapy while the “medical” group received no intervention. Secondly, the “medical” group of patients were “advised to increase their level of activity by as much as they felt able,” which may have had adverse effects if the activity was unsupervised and inappropriate.2 This could have affected the results by making the group given cognitive behaviour therapy seem to improve by more than they did. Thirdly, all patients, and particularly those with the chronic fatigue syndrome, need detailed discussion of their problems. Many doctors will not have been aware that in providing such discussion-surely the duty of all doctors-they were in part providing cognitive behaviour therapy.

You can read the full comment here:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350862/pdf/bmj00539-0053a.pdf

 

Source: Eaton KK. Cognitive behaviour therapy for the chronic fatigue syndrome. Use an interdisciplinary approach. BMJ. 1996 Apr 27;312(7038):1096; author reply 1098. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350862/

 

Cognitive behaviour therapy for the chronic fatigue syndrome. Patients were not representative of all patients with the syndrome.

Comment on: Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial. [BMJ. 1996]

 

EDITOR,-Michael Sharpe and colleagues conclude that cognitive behaviour therapy leads to a sustained reduction in functional impairment for patients with the chronic fatigue syndrome.1 The levels of disability of the 60 patients who took part in the study suggest, however, that these patients do not represent a comprehensive cross section of patients with the syndrome. The 60 patients scored 60-78 on the Karnofsky scale assessing disability and so represent a different population from the 143 patients reported on by Case History Research on ME (myalgic encephalomyelitis), who would have scored 30-60 (R Gibbons et al, first world congress on chronic fatigue syndrome and related disorders, Brussels, Nov 1995). Fifty nine of these 143 patients reported functional deterioration after sustained, incrementally increased physical exertion.

The authors did not assess other symptoms common in the chronic fatigue syndrome, such as pain, nausea, muscle weakness, or balance problems-a measure of the reduction of which was taken as a standard for “success” in an earlier trial.2 The lack of evidence of significant changes in other measures besides “the principal complaint of severe fatigue” in the authors’ study tends to diminish the validity of their conclusions.

You can read the full comment here:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350876/pdf/bmj00539-0052c.pdf

 

Source: Gibbons R, Macintyre A, Richards C. Cognitive behaviour therapy for the chronic fatigue syndrome. Patients were not representative of all patients with the syndrome. BMJ. 1996 Apr 27;312(7038):1096; author reply 1098. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350876/

Cognitive behaviour therapy for the chronic fatigue syndrome. Good general care may offer as much benefit as cognitive behaviour therapy

Comment on: Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial. [BMJ. 1996]

 

EDITOR,-Successful outcomes have been reported from controlled clinical trials of an eclectic range of treatments-from immunotherapy to magnesium supplementation-for the chronic fatigue syndrome.’ Unpublished data suggest that equal success can be achieved with some forms of alternative therapy (for example, homoeopathy) when patients believe strongly in the approach. Most physicians, however, continue to view all such results with healthy scepticism. An equally cautious view needs to be taken when assessing Michael Sharpe and colleagues’ study of cognitive behaviour therapy.2 In a disorder that is almost certainly heterogeneous in nature, two important questions need to be answered before we can conclude that cognitive behaviour therapy is of value.

You can read the full comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350899/pdf/bmj00539-0052b.pdf

 

Source: Shepherd C. Cognitive behaviour therapy for the chronic fatigue syndrome. Good general care may offer as much benefit as cognitive behaviour therapy. BMJ. 1996 Apr 27;312(7038):1096; author reply 1098. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2350899/

 

Chronic fatigue syndrome–psychiatric aspects

Abstract:

Diagnosis of the chronic fatigue syndrome depends on various somatic and psychopathological symptoms. Somatic symptoms of the syndrome have been subject of an extensive body of literature. In comparison, psychiatric aspects have caught relatively less attention.

Psychiatric aspects of etiological, diagnostic, and therapeutic concepts are essential for evaluation of the syndrome. Application of CDC-criteria to a well known disease does not solve the nosological problem, but may define the syndrome more accurately. In this respect, issues including psychiatric comorbidity and specificity of neuropathological symptoms are discussed.

Psychological variables seem to have a high predictor value for time course and outcome of the symptoms. Etiological concepts emphasize on biological or psychosocial factors. Alterations of biological parameters including immune functions, sleep regulation, and hypothalamic-pituary-adrenocortical function have been reported. The role of cultural factors has been discussed extensively. Somatic and psychological stress may result in the same clinical syndrome via psychoimmunological mechanisms. An integrated, interdisciplinary approach to further refine diagnostic criteria, understanding of etiology and development of adequate therapeutic measures seems necessary.

 

Source: Lemke MR. Chronic fatigue syndrome–psychiatric aspects. Fortschr Neurol Psychiatr. 1996 Apr;64(4):132-41. [Article in German] http://www.ncbi.nlm.nih.gov/pubmed/8655125

 

Neurocognitive functioning in chronic fatigue syndrome

Abstract:

Although substantial research has been conducted on chronic fatigue syndrome (CFS) over the past decade, the syndrome remains poorly understood. The most recent case definition describes CFS as being characterized both by disabling fatigue and by subjective reports of difficulty with concentration and “short-term” memory. However, research into the neurocognitive and psychological functioning of individuals with CFS has provided mixed objective results. The current paper reviews studies that have examined the neurocognitive and/or psychological functioning of individuals with CFS. Changes in research design and instruments employed to study individuals with CFS are suggested.

 

Source: DiPino RK, Kane RL. Neurocognitive functioning in chronic fatigue syndrome. Neuropsychol Rev. 1996 Mar;6(1):47-60. http://www.ncbi.nlm.nih.gov/pubmed/9144668

 

Screening for psychiatric morbidity in subjects presenting with chronic fatigue syndrome

Abstract:

BACKGROUND: There is a need for a valid self-rating questionnaire to screen for psychiatric morbidity in patients with chronic fatigue syndrome (CFS). This study had the aim of assessing the utility and validity of two commonly used measures.

METHOD: Scores obtained on the General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) were compared with various diagnostic and severity ratings obtained via a validating clinical interview, the Schedules for the Clinical Assessment of Neuropsychiatry (SCAN) in 95 consecutively referred subjects at a medical out-patient clinic who fulfilled standard criteria for CFS, and 48 healthy controls. Outcome measures were validating coefficients and receiver operating characteristics (ROC) for different thresholds and scoring on GHQ and BDI and index of definition (ID) as measured by SCAN; and Pearson and point by serial correlation coefficients for different diagnostic groups derived via SCAN and defined according to ICD-10 and DSM-III-R.

RESULTS: GHQ and BDI perform poorly as screeners of psychiatric morbidity in CFS subjects when compared with various SCAN derived ratings although results for controls are comparable with other studies.

CONCLUSIONS: Neither the GHQ nor BDI alone can be recommended as screeners for psychiatric morbidity in CFS subjects.

 

Source: Farmer A, Chubb H, Jones I, Hillier J, Smith A, Borysiewicz L. Screening for psychiatric morbidity in subjects presenting with chronic fatigue syndrome. Br J Psychiatry. 1996 Mar;168(3):354-8. http://www.ncbi.nlm.nih.gov/pubmed/8833692

 

Hypochondriasis influences quality-of-life outcomes in patients with chronic fatigue

Abstract:

BACKGROUND: To determine how hypochondriacal symptoms influence the quality-of-life outcomes of patients with a chief complaint of chronic fatigue.

METHODS: Cross-sectional cohort study of a consecutive sample of 71 patients (mean duration of fatigue of 4.1 years). Forty-eight (68%) patients met criteria for current major depression and 32 (45%) met criteria for chronic fatigue syndrome (CFS). All patients received a comprehensive medical and psychiatric evaluation. Quality-of-life and physical, depressive and hypochondriacal symptom scores were assessed through reliable self-report questionnaires and a structured interview. A path model expressing the relation between predictor variables (hypochondriasis and depression), intervening variables (physical symptoms) and quality of life was postulated and evaluated using structural equation methods.

RESULTS: The paths linking hypochondriasis with physical symptoms and mental health and the path connecting physical symptoms and quality of life were each statistically significant. The model applied especially well to patients who fulfilled CFS criteria.

CONCLUSIONS: The quality of life of chronic fatigue patients correlates with the severity of their physical symptoms and their hypochondriacal disposition toward illness.

 

Source: Manu P, Affleck G, Tennen H, Morse PA, Escobar JI. Hypochondriasis influences quality-of-life outcomes in patients with chronic fatigue. Psychother Psychosom. 1996 Mar-Apr;65(2):76-81. http://www.ncbi.nlm.nih.gov/pubmed/8711085

 

An assessment of cognitive function and mood in chronic fatigue syndrome

Abstract:

Data were gathered regarding the associates of chronic fatigue syndrome (CFS) with: (1) speed of cognitive processing, (2) motor speed, (3) ability to sustain attention, and (4) mood. Patients were given a brief neuropsychological test battery before and after double-blind treatment with terfenadine or placebo and completed a daily mood rating scale (Positive and Negative Affect Schedule) during the study.

CFS patients exhibited slower cognitive processing and motor speed and lower positive affect, as compared to data reported from previous studies of healthy subjects and other patient groups; however, CFS patients did not exhibit deficits in sustained attention in comparison to other groups.

The CFS patients’ ability to attend to verbal versus figural stimuli and mood ratings were different from those reported in studies of patients with depression. Because of methodological limitations, these findings are preliminary, but they encourage further assessment of cognitive dysfunction and mood in CFS.

 

Source: Marshall PS, Watson D, Steinberg P, Cornblatt B, Peterson PK, Callies A, Schenck CH. An assessment of cognitive function and mood in chronic fatigue syndrome. Biol Psychiatry. 1996 Feb 1;39(3):199-206. http://www.ncbi.nlm.nih.gov/pubmed/8837981