CRITICAL REVIEWS AND COMMENTS ON CURRENT RESEARCH

Cognitive Behavioural Therapy as Cure-All for CFS

Journal of Chronic Fatigue Syndrome, Vol. 11(4) 2003, pp. 43-47

Elke Van Hoof

Elke Van Hoof is affiliated with the Chronic Fatigue Clinic,
Klinisch Psychologe, Vrije Universiteit Brussel, Belgium.


The doctoral thesis by Judith Prins, a psychologist of the research team of
Nijmegen, has created a controversy in Belgium and the Netherlands. Many
patients have suggested that if the concepts within the doctoral thesis
become mainstream, this will create a situation where the newly emerging
medically orientated treatments could be sidelined at the cost of both
research and the patients' well-being. Thus a critical assessment of the
published work of the Nijmegen group is required to air the controversy and
encourage open discussion of the concepts it contains.

According to Prins, CFS is characterised by debilitating fatigue that lasts
at least six months, where no physical explanation can be found, which
leads to serious restraints in daily life activities (1). The Nijmegen
groups model for CFS implies that the sufferer attributes their severe
fatigue syndrome to a physical cause which in turn contributes to the
persistance of their CFS (2-4). Thus their concept suggests that
psychological processes are a major contributor to the problem. To treat
such a process they use Cognitive Behavioural Therapy (CBT), which is a
form of psychotherapy that aims to change the patients' cognition and
behaviour which in turn will alter their physical complaints.

Studies by the Nijmegen group, conducted in three different centers with a
total of 278 patients, assessed the effect of CBT on subjects who only had
contact with fellow-sufferers. Thirteen therapists with no experience with
CFS received training for treating patients with CFS by CBT. The CBT
consisted of 16 one-hour sessions over eight months. The CBT consisted of
an explanation of the model of sustaining factors, motivation for CBT,
restructuring of fatigue related behaviour, establishing a base level of
daily activities, a gradual build up of physical activity and the
achievement of employment or personal goals (5). CBT was claimed to be an
efficient treatment based on the primary scales, fatigue and restraints.

Depending on the criteria used, more than a third or half of the patients
had clinically significant recovery or had improved according to the
independent administrator and the patients (1). A positive self-efficacy,
the belief that one can do something about the complaints, appeared to
predict more improvement after CBT, while a passive pattern of activity and
a strong focus on the physical symptoms predict less recovery after CBT.

Interestingly it was reported that psychiatric comorbidity (present in 32%
of the cases) didn't influence the result of treatment with CBT. Patients
who achieved their employment goal during the treatment had a significantly
worse result after treatment compared with patients who hadn't achieved
this CBT goal (6). A quarter of the patients with CFS in the analysis had a
passive pattern of activity and did not show evidence of improvement
following CBT. Also of interest, the negative interactions of CFS patients
decreased significantly after treatment with CBT only in those groups that
did not have contact with fellow-sufferers. They concluded that social
support had to be added to the CBT model (7). Finally, they claimed that
CBT resulted in a better effect and a lower use of medical facilities than
both other conditions, although statistical uncertainty of the findings is
extensive (8). In the Netherlands, the utility was tested in view of
implementation of this as a strategy to treat CFS.  Importantly, they
concluded that CBT was not cost-effective yet should be implemented as
there were no other alternatives (9).

Examination of Prins' doctoral thesis revealed: good design of inclusive
and exclusion criteria; the randomisation protocol was clearly described;
use of reliable and valid assessment tools; reasons for drop-out reported;
clearly described statistical methods and therapeutic intervention. In
spite of these well designed aspects of the thesis, others parts of the
thesis have problems. The patients were not randomly assigned to groups,
which may indicate potential bias in patient selection. Patients were not
excluded who had psychiatric comorbidity (1/3rd of the subjects) and
patients had to be able to make a trip of at least 1 1/2 hours which would
exclude the more severe CFS patients from becoming members of the study.
The thesis evaluated the use of CBT for fatigue and failed to separate
idiopathic fatigue (either lasting less than 6 months, or more than 6
months, but without the minor criteria of the definition of CFS) from CFS
(10). Most subjects in the Prins thesis were composed of patients with
idiopathic fatigue and not CFS (4), which questions the validity of any
conclusions directed at CFS patients.

Apart from the problems with the CFS definition (major criteria without the
minor criteria (1)), it was noted that 28% (28-41%) did not complete the
Cognitive Behavioural Therapy study. Importantly the drop outs were mostly
from the group that received CBT. Scientific convention suggests that these
people should be regarded as negative outcomes and importantly this
percentage drop out coincided very closely with the 33% of subjects who
reported a positive result (33%). Most treatment studies that achieve a
1/3rd improved, a 1/3rd no change and a 1/3rd worsened result are observing
an ineffective therapy as the changes appear to be a result of the normal
course of the disease process. This is consistent with the report by one of
the coresearchers that the effects of CBT were no longer present after 3
years (Bleijenberg G, communication, Fifth International Research, Clinical
and Patient Conference). Also, no evaluation of the minor criteria (lymph
nodes, etc.) were evaluated, therefore introducing a potential bias in the
reporting of symptom improvement. We therefore would suggest that the
conclusions may lack validity. Another problem with treatment trials, such
as the use of CBT in the Prins case, is that the therapy gains a
significant improvement in certain measures that are then claimed as proof
of the effectiveness of a therapy. Nowhere in the thesis is any evidence
presented that the patients have fully recovered. Similarly, those patients
with psychiatric comorbidity were not assessed to see if this had an effect
upon CBT or the patients' outcome.

The purpose of CBT is to improve the quality of life of patients by
allowing them to Iive within the constraints of their illness and should
not be presented as a therapy that will lead to recovery from a disease.
CBT should not, therefore, be presented as an all-emcompassing therapy that
can distract from the research into the biological basis of CFS (11-15).

Graded exercise programs may have dangers for some CFS patients (12,13) and
if they are part of a CBT program need to be tailored for the individual
patient. We must not forget the lessons of the past where mistakenly
psychological or psychiatric attributes have been suggested to be causitive
for certain diseases and refuted after important biological causes are
found for the disease (16,17).


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RECEIVED: 07/22/03
REVIEWED: 09/01/03
ACCEPTED: 09/30/03