Tag: CBT

Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial

Abstract:

BACKGROUND: Cognitive behaviour therapy (CBT) seems a promising treatment for chronic fatigue syndrome (CFS), but the applicability of this treatment outside specialised settings has been questioned. We compared CBT with guided support groups and the natural course in a randomised trial at three centres.

METHODS: Of 476 patients diagnosed with CFS, 278 were eligible and willing to take part. 93 were randomly assigned CBT (administered by 13 therapists recently trained in this technique for CFS), 94 were assigned the support-group approach, and 91 the control natural course. Multidimensional assessments were done at baseline, 8 months, and 14 months. The primary outcome variables were fatigue severity (on the checklist individual strength) and functional impairment (on the sickness impact profile) at 8 and 14 months. Data were analysed by intention to treat.

FINDINGS: 241 patients had complete data (83 CBT, 80 support groups, 78 natural course) at 8 months. At 14 months CBT was significantly more effective than both control conditions for fatigue severity (CBT vs support groups 5.8 [2.2-9.4]; CBT vs natural course 5.6 [2.1-9.0]) and for functional impairment (CBT vs support groups 263 [38-488]; CBT vs natural course 222 [3-441]). Support groups were not more effective for CFS patients than the natural course. Among the CBT group, clinically significant improvement was seen in fatigue severity for 20 of 58 (35%), in Karnofsky performance status for 28 of 57 (49%), and self-rated improvement for 29 of 58 (50%). Prognostic factors for outcome after CBT were a higher sense of control predicting more improvement, and a passive activity pattern and focusing on bodily symptoms predicting less improvement.

INTERPRETATION: CBT was more effective than guided support groups and the natural course in a multicentre trial with many therapists. Our study showed a lower proportion of patients with improvement than CBT trials with a few highly skilled therapists.

Comment in:

Cognitive behaviour therapy for chronic fatigue syndrome. [Lancet. 2001]

Cognitive behaviour therapy for chronic fatigue syndrome. [Lancet. 2001]

Cognitive behaviour therapy for chronic fatigue syndrome. [Lancet. 2001]

Cognitive behaviour therapy for chronic fatigue syndrome. [Lancet. 2001]

ACP J Club. 2001 Sep-Oct;135(2):47.

Cognitive behaviour therapy for chronic fatigue syndrome. [Lancet. 2001]

Cognitive behaviour therapy for chronic fatigue syndrome. [Lancet. 2001]

 

Source: Prins JB, Bleijenberg G, Bazelmans E, Elving LD, de Boo TM, Severens JL, van der Wilt GJ, Spinhoven P, van der Meer JW. Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial. Lancet. 2001 Mar 17;357(9259):841-7. http://www.ncbi.nlm.nih.gov/pubmed/11265953

 

Causal attributions for somatic sensations in patients with chronic fatigue syndrome and their partners

Abstract:

BACKGROUND: Patients with chronic fatigue syndrome (CFS) often make somatic attributions for their illness which has been associated with poor outcome. A tendency to make somatic attributions in general may be a vulnerability factor for the development of CFS.

METHODS: This cross-sectional study based on self-report questionnaire data aimed to investigate the type of attributions for symptoms made by patients with CFS and to compare this to attributions made by their partners. It was hypothesized that patients with CFS would make more somatic attributions for their own symptoms than control subjects and that partners of patients with CFS would make more somatic attributions for their ill relative’s symptoms but would be similar to controls regarding their own symptoms. Fifty patients with CFS were compared to 50 controls from a fracture clinic in the same hospital and 46 relatives living with the patients with CFS. A modified Symptom Interpretation Questionnaire was used to assess causal attributions.

RESULTS: CFS patients were more likely to make somatic attributions for their symptoms. The relatives of patients with CFS made significantly more somatic attributions for symptoms in their ill relative. However, they were like the fracture clinic controls in terms of making predominantly normalizing attributions for their own symptoms.

CONCLUSIONS: The data support modification of existing cognitive behavioural treatments for CFS to investigate whether addressing partners’ attributions for patients’ symptoms improves recovery in the patient. Furthermore, a tendency to make somatic attributions for symptoms may be a vulnerability factor for the development of CFS.

 

Source: Butler JA, Chalder T, Wessely S. Causal attributions for somatic sensations in patients with chronic fatigue syndrome and their partners. Psychol Med. 2001 Jan;31(1):97-105. http://www.ncbi.nlm.nih.gov/pubmed/11200964

 

Cognitive behaviour therapy for adults with chronic fatigue syndrome

Update in: Cognitive behaviour therapy for chronic fatigue syndrome in adults. [Cochrane Database Syst Rev. 2008]

 

Abstract:

OBJECTIVES: 1. To systematically review all randomised controlled trials of cognitive-behaviour therapy (CBT) for adults with chronic fatigue syndrome (CFS); 2. To test the hypothesis that CBT is more effective than orthodox medical management or other interventions in adults with CFS.

SEARCH STRATEGY: 1. Electronic searching of bibliographic databases, including Medline, PsycLIT, Biological Abstracts, Embase, SIGLE, Index to Theses, Index to Scientific and Technical Proceedings, and Science Citation Index, using multiple search terms in order to perform a highly sensitive search. 2. Electronic searching of the Trials Register of the Depression, Anxiety and Neurosis group. 3. Citation lists of relevant studies and reviews were perused for other relevant trials. 4. Contact with the principal authors of relevant studies, and with researchers in the field.

SELECTION CRITERIA: All randomised controlled trials were included in which – adult patients with CFS; – received CBT or a control intervention, being either orthodox medical management or another intervention; – and whose outcomes were assessed in an appropriate way. CBT could be either type ‘A’ (encouraging return to ‘normal’ levels of rest and activity) or type ‘B’ (encouraging rest and activity which were within levels imposed by the disorder).’

DATA COLLECTION AND ANALYSIS: The two reviewers worked independently throughout the selection of trials and data extraction, comparing findings only when there was disagreement. Relevant trials were allocated to one of three quality categories. Full data extraction, using a standardised data extraction sheet, was performed on studies which were of high or moderate quality. Trials of low quality were excluded from the review. The comparisons made to test the review hypothesis were of type ‘A’ CBT versus other intervention(s), and of type ‘B’ CBT versus other intervention(s). Functional outcome was used as the main outcome for comparison, but other appropriate outcomes were compared where possible. Results were synthesised using the Review Manager software. For dichotomous data, the odds ratio was calculated for each study. For continuous data, effect sizes were obtained and the standardised mean difference, with 95% confidence intervals, was calculated.

MAIN RESULTS: Only three relevant trials of adequate quality were found. These trials demonstrated that CBT significantly benefits physical functioning in adult out-patients with CFS when compared to orthodox medical management or relaxation. It is necessary to treat about two patients to prevent one additional unsatisfactory physical outcome about six months after treatment end. CBT appeared highly acceptable to the patients in these trials. There is no satisfactory evidence for the effectiveness of CBT in patients with the milder forms of CFS found in primary care or in patients who are so disabled that they are unable to attend out-patients. Additionally, there is no satisfactory evidence for the effectiveness of group CBT.

REVIEWER’S CONCLUSIONS: Cognitive behaviour therapy appears to be an effective and acceptable treatment for adult out-patients with chronic fatigue syndrome. CFS is a common and disabling disorder. Its sufferers deserve the medical profession to be more aware of the potential of this therapy to bring lasting functional benefit, and health service managers to increase its availability. Further research is needed in this important area. Trials should conform to accepted standards of reporting and methodology. The effectiveness of CBT in more and less severely disabled patients than those usually seen in out-patient clinics needs to be assessed. Trials of group CBT and in-patient CBT compared to orthodox medical management, and of CBT compared to graded activity alone, also need to be conducted.

 

Source: Price JR, Couper J. Cognitive behaviour therapy for adults with chronic fatigue syndrome. Cochrane Database Syst Rev. 2000;(2):CD001027. http://www.ncbi.nlm.nih.gov/pubmed/10796733

Cognitive behavior therapy for chronic fatigue syndrome: a case study

Abstract:

The case of a 26-year old woman with Chronic Fatigue Syndrome (CFS) is presented. Multidimensional assessment showing severe debilitating fatigue and considerable psychological, social and occupational impairment confirmed the diagnosis. Cognitive behavior therapy (CBT) was based on a tested causal model of CFS and individual behavioral analyses. Key elements in CBT were process variables from the CFS model, like sense of control, causal attributions, physical activity and focusing on bodily functions. Goals were recovery from fatigue, returning to work and relapse prevention. The course of therapy is described in detail to illustrate difficulties in treating CFS. Assessments were made five times, at baseline and at 8, 14, 21 and 33 months. Comparison of the pretest, post-test and follow-up scores of the outcome variables, fatigue and functional impairment and of the process variables showed clinically significant improvement from the range of CFS patients to the range of healthy controls.

 

Source: Prins JB, Bleijenberg G. Cognitive behavior therapy for chronic fatigue syndrome: a case study. J Behav Ther Exp Psychiatry. 1999 Dec;30(4):325-39. http://www.ncbi.nlm.nih.gov/pubmed/10759328

 

An evaluation of multidisciplinary intervention for chronic fatigue syndrome with long-term follow-up, and a comparison with untreated controls

Abstract:

Individuals meeting the Fukuda et al definition for chronic fatigue syndrome completed a multidisciplinary assessment that included medical, psychiatric, behavioral, and psychological evaluations. Patients were then offered a comprehensive multidisciplinary intervention that included (1) bringing the patient under optimal medical management; (2) treating any ongoing affective or anxiety disorder pharmacologically; and (3) implementing a comprehensive cognitive-behavioral treatment program. Fifty-one patients proceeded to treatment.

The cognitive-behavioral component was carried out through the use of a therapist working with the patients in their own environments. The program was individually tailored to patients, but included (1) structured physical exercise and activation; (2) sleep management strategies; (3) careful activity management; (4) regulation of stimulant intake and reductions in use of symptomatic medications; (5) cognitive intervention designed to deal with patients’ beliefs concerning the nature of their disorder; (6) participation of patients’ family; and (7) efforts to establish specific vocational and avocational goals. Third parties were encouraged to collaborate cooperatively.

Employers were urged to provide employment opportunities and facilitate a graduated but time-targeted return to work. Disability carriers were encouraged to provide interim financial support in the form of disability benefits, support therapeutic intervention, but also to establish a clear time-frame to access to benefits.

Of 51 treated patients, 31 returned to gainful employment, 14 were functioning at a level equivalent to employment, and 6 remained significantly disabled. Twenty of the original 71 patients were contacted an average of 33 months later. Patients who had been treated showed good maintenance of gains. Untreated patients showed improvement in only a minority of cases.

 

Source: Marlin RG, Anchel H, Gibson JC, Goldberg WM, Swinton M. An evaluation of multidisciplinary intervention for chronic fatigue syndrome with long-term follow-up, and a comparison with untreated controls. Am J Med. 1998 Sep 28;105(3A):110S-114S. http://www.ncbi.nlm.nih.gov/pubmed/9790492

 

Cognitive behavior therapy for chronic fatigue syndrome: efficacy and implications

Abstract:

Cognitive behavior therapy (CBT) is a form of non-pharmacologic treatment. It is based on a model of chronic fatigue syndrome (CFS) that hypothesizes that certain cognitions and behavior may perpetuate symptoms and disability–that is, act as obstacles to recovery. Treatment emphasizes self-help and aims to help the patient to recover by changing these unhelpful cognitions and behavior.

There is now good evidence from 2 independent randomized clinical trials to support the efficacy of CBT in patients with CFS. The treatment effect is substantial, although few patients are cured. The urgent clinical need is to make this form of treatment available to patients with CFS. One approach is to incorporate the principles of CBT into routine clinical practice. The preliminary evaluation of these simpler forms of CBT are promising, although the results of controlled trials are awaited. At present, intensive individual CBT administered by a skilled therapist remains the treatment of choice for patients with CFS.

 

Source: Sharpe M. Cognitive behavior therapy for chronic fatigue syndrome: efficacy and implications. Am J Med. 1998 Sep 28;105(3A):104S-109S. http://www.ncbi.nlm.nih.gov/pubmed/9790491

 

Illness beliefs and treatment outcome in chronic fatigue syndrome

Abstract:

Longitudinal studies have shown that physical illness attributions are associated with poor prognosis in chronic fatigue syndrome (CFS). Speculation exists over whether such attributions influence treatment outcome. This study reports the effect of illness beliefs on outcome in a randomized controlled trial of cognitive-behavior therapy versus relaxation.

Causal attributions and beliefs about exercise, activity, and rest were recorded before and after treatment in 60 CFS patients recruited to the trial. Physical illness attributions were widespread, did not change with treatment, and were not associated with poor outcome in either the cognitive-behavior therapy group or the control group.

Beliefs about avoidance of exercise and activity changed in the cognitive behavior therapy group, but not in the control group. This change was associated with improved outcome. These findings suggest that physical illness attributions are less important in determining outcome (at least in treatment studies) than has been previously thought. In this study, good outcome is associated with change in avoidance behavior, and related beliefs, rather than causal attributions.

 

Source: Deale A, Chalder T, Wessely S. Illness beliefs and treatment outcome in chronic fatigue syndrome. J Psychosom Res. 1998 Jul;45(1):77-83. http://www.ncbi.nlm.nih.gov/pubmed/9720857

 

Cognitive behavior therapy for functional somatic complaints. The example of chronic fatigue syndrome

Abstract:

Somatic complaints such as pain and fatigue that are unexplained by conventional disease are common in medical practice and are referred to as functional, somatoform, or somatization symptoms. Despite frequent chronicity, disability, and high associated medical costs, patients with these complaints are rarely offered either constructive explanations or effective treatment. In this perspective, a cognitive-behavioral approach to the problem is described, using chronic fatigue syndrome as an example. It is concluded that the utility of the cognitive-behavioral theory and the proven effectiveness cognitive behavior therapy provide the basis for a new evidence-based approach to psychosomatics.

 

Source: Sharpe M. Cognitive behavior therapy for functional somatic complaints. The example of chronic fatigue syndrome. Psychosomatics. 1997 Jul-Aug;38(4):356-62. http://www.ncbi.nlm.nih.gov/pubmed/9217406

 

Chronic fatigue syndrome and occupational health

Abstract:

Chronic fatigue syndrome (CFS) is a controversial condition that many occupational physicians find difficult to advise on. In this article we review the nature and definition of CFS, the principal aetiologic hypotheses and the evidence concerning prognosis. We also outline a practical approach to patient assessment, diagnosis and management. The conclusions of this review are then applied to the disability discrimination field. The implications of the new UK occupational health legislation are also examined. Despite continuing controversy about the status, aetiology and optimum management of CFS, we argue that much can be done to improve the outcome for patients with this condition. The most urgent needs are for improved education and rehabilitation, especially in regard to employment. Occupational physicians are well placed to play an important and unique role in meeting these needs.

 

Source: Mounstephen A, Sharpe M. Chronic fatigue syndrome and occupational health. Occup Med (Lond). 1997 May;47(4):217-27. http://occmed.oxfordjournals.org/content/47/4/217.long (Full article)

 

Chronic fatigue syndrome. A practical guide to assessment and management

Abstract:

Chronic fatigue and chronic fatigue syndrome (CFS) have become increasingly recognized as a common clinical problem, yet one that physicians often find difficult to manage. In this review we suggest a practical, pragmatic, evidence-based approach to the assessment and initial management of the patient whose presentation suggests this diagnosis. The basic principles are simple and for each aspect of management we point out both potential pitfalls and strategies to overcome them.

The first, and most important task is to develop mutual trust and collaboration. The second is to complete an adequate assessment, the aim of which is either to make a diagnosis of CFS or to identify an alternative cause for the patient’s symptoms. The history is most important and should include a detailed account of the symptoms, the associated disability, the choice of coping strategies, and importantly, the patient’s own understanding of his/her illness. The assessment of possible comorbid psychiatric disorders such as depression or anxiety is mandatory.

When the physician is satisfied that no alternative physical or psychiatric disorder can be found to explain symptoms, we suggest that a firm and positive diagnosis of CFS be made.

The treatment of CFS requires that the patient is given a positive explanation of the cause of his symptoms, emphasizing the distinction among factors that may have predisposed them to develop the illness (lifestyle, work stress, personality), triggered the illness (viral infection, life events) and perpetuated the illness (cerebral dysfunction, sleep disorder, depression, inconsistent activity, and misunderstanding of the illness and fear of making it worse).

Interventions are then aimed to overcoming these illness-perpetuating factors. The role of antidepressants remains uncertain but may be tried on a pragmatic basis. Other medications should be avoided. The only treatment strategies of proven efficacy are cognitive behavioral ones. The most important starting point is to promote a consistent pattern of activity, rest, and sleep, followed by a gradual return to normal activity; ongoing review of any ‘catastrophic’ misinterpretation of symptoms and the problem solving of current life difficulties.

We regard chronic fatigue syndrome as important not only because it represents potentially treatable disability and suffering but also because it provides an example for the positive management of medically unexplained illness in general.

 

Source: Sharpe M, Chalder T, Palmer I, Wessely S. Chronic fatigue syndrome. A practical guide to assessment and management. Gen Hosp Psychiatry. 1997 May;19(3):185-99. http://www.ncbi.nlm.nih.gov/pubmed/9218987