Letter to the Editor: What is the aim of cognitive behaviour therapy in patients with chronic fatigue syndrome? Psychother Psychosom. 2006;75(6):396-7. Van Houdenhove B. Department of Liaison Psychiatry, University Hospital Gasthuisberg BE3000Leuven, Belgium. E-Mail: NLM Citation: PMID: 17053343 We read with great interest the article by Bazelmans et al. [1], [see http://listserv.nodak.edu/cgi-bin/wa.exe?A2=ind0506B&L=CO-CURE&P=R3050 ] in which the authors reported their unexpected ‘negative’ results of group cognitive behaviour therapy (CBT) in patients with chronic fatigue syndrome (CFS). In short, although patients mentioned less fatigue after the therapeutic programme, this symptomatic improvement was not refl ected by a higher level of functioning. The authors speculated about four possible reasons for their fi ndings: the therapists might have laid too much emphasis on rest and waited too long before encouraging patients to resume activity; the therapists might have been too inexperienced in treating CFS patients; the group therapy format might have been less effective compared to individual CBT, or the patient group might have been too unselected. In our opinion, however, another possibility could be considered. The patients’ symptomatic amelioration might have been due to the fact that they had learned to better manage their energy, not exceed their limits and avoid peaks of activity which might eventually have resulted in a decrease of their global activity level. Thus, according to this interpretation, the reported results of the group CBT programme were not that negative! The above shows that the aim of CBT (and graded exercise therapy, which is often associated with CBT) in CFS patients is far from clear-cut. Indeed, in CBT-oriented literature concerned with CFS, different treatment goals can be discerned. Some authors suggest that the therapist should mainly incite patients to diminish their somatic focus and correct inappropriate physical attributions [2, 3] . However, the usefulness of this goal is doubtful since the majority of patients with CFS and the largely overlapping fi bromyalgia syndrome (FM) seems to accept a combined psychological/somatic causation of their illness [4] . According to other authors, the therapist should in the fi rst place tackle the patients’ activity avoidance or irregular activity patterns (outburst of activity followed by prolonged periods of rest), and stimulate them to engage in a graded exercise program in order to fi ght physical deconditioning [5] . However, most CFS patients do not show kinesiophobia [6, 7] and loss of exercise capacity does not seem to play a major role in the pathophysiology of CFS [8, 9] . Moreover, recent physical therapists do not recommend ‘pure’ graded exercise therapy in CFS patients (i.e. progressively increasing physical effort irrespective of possible symptom worsening), but modulate exercises by an individualized pacing scheme [10] . Finally, some CBT therapists are convinced that patients should, at the end of the therapy, stop considering themselves as CFS sufferers, even claim their therapy being curative [11] , while others point to the patients’ lasting vulnerability necessitating long-term adaptation to prevent relapse [9, 12] . In our own daily practice with patients suffering from CFS/FM, we base our group CBT programme on the following pathophysiological working hypothesis: both CFS and FM result from a ‘loss of resilience’ of the stress system, after a prolonged period of physical or mental overburdening in which the system functions ‘in overdrive’ [12, 13] . Given the fact that direct treatment of this neurobiological dysregulation is at present not available, we explain to the patients that the recovery of their stress system might be indirectly facilitated under the following conditions: First, they should accept their ailment and functional limitations and work through the painful grieving process resulting from the fact that CFS means giving up many important things in life. Second, they should realistically adapt to their effort intolerance by learning to carefully pace activities in order to avoid post-exertional malaise refl ecting abnormal immune activation [12] . In many patients, this implies abandoning their previous ‘overactive’ lifestyles, which may be rooted in narcissistic, perfectionistic or counter-dependent tendencies [14] . Third, they should try to gradually increase their physical and mental activity level, again without provoking post-exertional malaise. And fourth, they should realize that long-term readjustment of lifestyle, life-goals and priorities is a conditio sine qua non to maintain symptomatic amelioration and regain stress system resilience. In sum, if our hypothesis is correct (namely that the aetiopathogenesis of CFS/FM is based on long-lasting physical and/or mental overburdening, leading to severe and persistent disturbances of the stress system in vulnerable individuals), the aim of CBT should be to help patients find a ‘new equilibrium’, taking fully account of their personal illness and life history [13, 15] . In terms of McEwen’s [16] neurobiological stress paradigm, this aim could also be formulated as ‘restoring allostasis’. References 1 Bazelmans E, Prins JB, Lulofs R, van der Meer JW, Bleijenberg G: Cognitive behaviour group therapy for chronic fatigue syndrome: a non-randomized waiting list controlled study. Psychother Psychosom 2005; 74: 218 224. 2 Chalder T, Power MJ, Wessely S: Chronic fatigue in the community: ‘a question of attribution’. Psychol Med 1996; 26: 791800. 3 Moss-Morris R, Charon C, Tobin R, Baldi JC: A randomized controlled graded exercise trial for chronic fatigue syndrome: outcomes and mechanisms of change. J Health Psychol 2005; 10: 245259. 4 Neerinckx E, Van Houdenhove B, Lysens R, Vertommen H, Onghena P: Attributions in chronic fatigue syndrome and fi bromyalgia syndrome in tertiary care. J Rheumatol 2000; 27: 10511055. 5 Fulcher KY, White PD: Strength and physiological response to exercise in patients with chronic fatigue syndrome. J Neurol Neurosurg Psychiatry 2000; 69: 302307. 6 Nijs J, Vanherberghen K, Duquet W, De Meirleir K: Chronic fatigue syndrome: lack of association between pain-related fear of movement and exercise capacity and disability. Phys Ther 2004; 84: 696705. 7 Gallagher AM, Coldrick AR, Hedge B, Weir WR, White PD: Is the chronic fatigue syndrome an exercise phobia? A case control study. J Psychosom Res 2005; 58: 367373. 8 Bazelmans E, Bleijenberg G, van de Meer JW, Folgering H: Is physical deconditioning a perpetuating factor in chronic fatigue syndrome? A controlled study on maximal exercise performance and relations with fatigue, impairment and physical activity. Psychol Med 2001; 31: 107114. 9 Pardaens K, Haagdorens L, Van Wambeke P, Van den Broeck A, Van Houdenhove B: How relevant are exercise capacity measures for evaluating treatment effects in chronic fatigue syndrome? Results of a prospective, multidisciplinary outcome study. Clin Rehabil, 2006;20:5666. 10 Wallman KE, Morton AR, Goodman C, Grove R: Exercise prescription for individuals with chronic fatigue syndrome. Med J Aust 2005; 183: 142 143. 11 Prins J, Bleijenberg G, van der Meer JM: Chronic fatigue syndrome and myalgic encephalomyelitis. Lancet 2002; 359: 1699. 12 Van Houdenhove B, Egle UT: Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together. Psychother Psychosom 2004; 73: 267 275. 13 Van Houdenhove B, Neerinckx E, Onghena P, Vingerhoets A, Lysens R, Vertommen H: Daily hassles reported by chronic fatigue syndrome and fi bromyalgia patients in tertiary care: a controlled quantitative and qualitative study. Psychother Psychosom 2002; 71: 207213. 14 Van Houdenhove B, Neerinckx E, Onghena P, Lysens R, Vertommen H: Premorbid ‘overactive’ lifestyle in chronic fatigue syndrome and fi bromyalgia. An etiological factor or proof of good citizenship? J Psychosom Res 2001; 51: 571576. 15 Van Houdenhove B: Listening to CFS. Why we should pay more attention to the story of the patient. J Psychosom Res 2002; 52: 495499. 16 McEwen BS: Stressed or stressed out: what is the difference? J Psychiatry Neurosci 2005; 30: 315318. Boudewijn Van Houdenhove, MD, PhD Department of Liaison Psychiatry, University Hospital Gasthuisberg BE3000 Leuven (Belgium) Tel. +32 16 348701, Fax +32 16 348700