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Process of CBT for CFS: Which perpetuating cognitions & behaviour changes related to fatigue reductn

Dolphin

Senior Member
Messages
17,567
Possibly a minority interest.

The process of cognitive behaviour therapy for chronic fatigue syndrome: Which changes in perpetuating cognitions and behaviour are related to a reduction in fatigue?
Journal of Psychosomatic Research

Available online 19 July 2013

Marianne J. Heins,
Hans Knoop,
William J. Burk,
Gijs Bleijenberg

Expert Centre for Chronic Fatigue, Radboud University Nijmegen Medical Centre, The Netherlands
http://dx.doi.org/10.1016/j.jpsychores.2013.06.034, How to Cite or Link Using DOI

--------------------------------------------------------------------------------


Abstract*

Objective

Cognitive behaviour therapy (CBT) can significantly reduce fatigue in chronic fatigue syndrome (CFS), but little is known about the process of change taking place during CBT.

Based on a recent treatment model (Wiborg et al. J Psych Res 2012), we examined how (changes in) cognitions and behaviour are related to the decrease in fatigue.

Methods

We included 183 patients meeting the US Centers for Disease Control criteria for CFS, aged 18 to 65 years, starting CBT.

We measured fatigue and possible process variables before treatment; after 6, 12 and 18 weeks; and after treatment.

Possible process variables were sense of control over fatigue, focusing on symptoms, self-reported physical functioning, perceived physical activity and objective (actigraphic) physical activity.

We built multiple regression models, explaining levels of fatigue during therapy by (changes in) proposed process variables.

Results

We observed large individual variation in the patterns of change in fatigue and process variables during CBT for CFS.

Increases in the sense of control over fatigue, perceived activity and self-reported physical functioning, and decreases in focusing on symptoms explained 20 to 46% of the variance in fatigue.

An increase in objective activity was not a process variable.

Conclusion

A change in cognitive factors seems to be related to the decrease in fatigue during CBT for CFS.

The pattern of change varies considerably between patients, but changes in process variables and fatigue occur mostly in the same period.


Keywords
Chronic fatigue syndrome;
Cognitive behaviour therapy;
Process;
Change;
Sense of control;
Focusing
* I gave each sentence its own paragraph
 

Dolphin

Senior Member
Messages
17,567
An increase in objective activity was not a process variable
So improvements/reductions in fatigue aren't related to doing more. Given fatigue isn't an objective measure, this means all the fatigue reduction they have talked about over the years may not be that interesting - it may simply due to patients answering questionnaires differently.
 

Firestormm

Senior Member
Messages
5,055
Location
Cornwall England
So improvements/reductions in fatigue aren't related to doing more. Given fatigue isn't an objective measure, this means all the fatigue reduction they have talked about over the years may not be that interesting - it may simply due to patients answering questionnaires differently.

Taken at face value and without reading the full crap paper:

Possible process variables were sense of control over fatigue, focusing on symptoms, self-reported physical functioning, perceived physical activity and objective (actigraphic) physical activity.

I actually think this is good. Good because - if considered applicable to all CBT - it does reveal it's true nature. CBT does not 'treat' any disease. It enables some to better live with their condition.

You are not asking a patient: are you recovered? In the sense that any normal person would understand the word 'recover'. You are asking a patient: do you think less about your condition now? Do you stress less about your symptoms etc.

In other words CBT attempt to help patients reach an accommodation with their condition. If and when actual treatments come on line i.e. drugs; the reliance on CBT and any form of graded activity will diminish.

The whole problem with these therapies is the lack of bloody honesty. I am fed up thinking about the damn things.
 

Dolphin

Senior Member
Messages
17,567
Taken at face value and without reading the full crap paper:



I actually think this is good. Good because - if considered applicable to all CBT - it does reveal it's true nature. CBT does not 'treat' any disease. It enables some to better live with their condition.

You are not asking a patient: are you recovered? In the sense that any normal person would understand the word 'recover'. You are asking a patient: do you think less about your condition now? Do you stress less about your symptoms etc.

In other words CBT attempt to help patients reach an accommodation with their condition. If and when actual treatments come on line i.e. drugs; the reliance on CBT and any form of graded activity will diminish.

The whole problem with these therapies is the lack of bloody honesty. I am fed up thinking about the damn things.

Unfortunately, I'm not sure how praiseworthy this group are. They believe the aim of CBT should be recovery.

The manual is available here: https://listserv.nodak.edu/cgi-bin/...CO-CURE&P=R1774&I=-3&d=No+Match;Match;Matches

Here's an extract:


GOAL SETTING AND EXPLANATION OF THE TREATMENT

Objective: Recovery The aim of the treatment is to modulate the fatigue, thereby reducing the symptoms and enabling patients to return to work or resume other normal, daily activities. Recovery is the therapist's goal (Prins, Bleijenberg, & van der Meer, 2002). Recovery, or cure, should be interpreted as meaning that the patient's self-view is no longer that of a patient suffering from CFS but is that of a healthy individual. After all, healthy people at times also feel tired or experience pain. Recovery, however, does not imply a return to one's old self. Before the onset of CFS, the extremely active lives that some patients led may even have contributed to the development of their symptoms. Helping patients to look on and treat their body in a different way automatically entails that they will never feel the way they did before the illness. Recovery in this context means adopting a new lifestyle, in which patients are aware of their body's normal limitations.

The therapist describes the intended recovery in such a way that it becomes a real and feasible target for the patient. Together, they inventory the activities that the patient needs to be able to do again in order to feel like a healthy person. Try to prevent the patient from becoming discouraged or debilitated by anxiety or the notion that the set targets are no longer obtainable or that recovery is still a long way off. Recovery may be formulated in terms of the number of hours spent working at one's job, doing the shopping, preparing meals, taking the kids to school, playing sports, reading, visiting friends,and so on. This way, recovery no longer is a general and abstract goal that the therapist has established but becomes a realistic target that the patient, with the help of the therapist, can work toward achieving. These goals as well as the steps (subtargets) to achieve these objectives are formulated during the initial CBT sessions. Here, relatively active CFS patients tend to set themselves targets that are too high, whereas low-active patients aim too low.

Objective: Return to Work Before a return to work is possible, the therapist and the patient need to fully clarify and discuss the (former) work situation and financial status in relation to medical evaluations and benefit claims. Recovery from CFS may have considerable impact on any future work and/or benefits. It is important for patients to be aware that they will eventually lose (the right to) any disability payments in case of recovery. Furthermore, if they do not succeed in finding a new job, their financial situation may become even worse. This is why it is necessary to discuss patients' work expectations at an early stage. When finding a job is likely to pose serious problems and a patient has become dependent on benefits, the chances of recovery or improvement are slim. It is therefore important to ask patients whether they anticipate that recovery will have negative financial consequences. Financial consequences or the wish not to go back to work or to cut down on hours to have more time for housework or leisure activities almost certainly will stand in the way of recovery. It is necessary to formulate alternative personal objectives for the final goals if return to work is not an option, or if the patient only wants to work part-time on recovery despite the possible financial consequences. These may involve being able to fulfill domestic or caregiver duties, attending training courses, finding work as a volunteer, or performing other daily tasks. The goals are formulated in such a way that patients who have actually achieved them can perceive themselves as healthy individuals.
 

peggy-sue

Senior Member
Messages
2,623
Location
Scotland
I see it comes from an "expert" centre. I've already used this definition today, but will go public with it now.:p
ex = a has been
spurt = what comes from a pipe with a big leak
 

Sean

Senior Member
Messages
7,378
Here, relatively active CFS patients tend to set themselves targets that are too high, whereas low-active patients aim too low.

Translation: You are psychopathological if you do, and also if you don't. Only the therapist knows which is which, and they are always right, even when they are wrong.

All this bullshit about 'negotiating goals', what a bunch of dishonest obscurantist crap, designed to give the appearance of patients being 'equal' partners in the process, while really just allowing the psychs to run the show and still pin blame for failure on the patient.
 

Dolphin

Senior Member
Messages
17,567
Here, relatively active CFS patients tend to set themselves targets that are too high, whereas low-active patients aim too low.

Translation: You are psychopathological if you do, and also if you don't. Only the therapist knows which is which, and they are always right, even when they are wrong.

All this bullshit about 'negotiating goals', what a bunch of dishonest obscurantist crap, designed to give the appearance of patients being 'equal' partners in the process, while really just allowing the psychs to run the show and still pin blame for failure on the patient.
Also, with regard to dividing patients up into active and patients patients and over them different therapy, another group found this isn't so easy:



Differences in physical functioning between relatively active and passive patients with Chronic Fatigue Syndrome

Journal of Psychosomatic Research

Desirée C.W.M. Vos-Vromansemail address, Ivan P.J. Huijnenemail address, Albère J.A. Kökeemail address, Henk A.M. Seelenemail address, J. André Knottnerusemail address, Rob J.E.M. Smeetsemail address

Received 16 January 2013; received in revised form 8 April 2013; accepted 8 May 2013. published online 03 June 2013.

Abstract

Objective

According to the Cognitive behavioral therapy (CBT) protocol for patients with Chronic Fatigue Syndrome (CFS), therapists are advised to categorize patients in relatively active and passive patients. However, evidence to support the differences in physical functioning between these subgroups is limited. Using the baseline data from a multicentre randomized controlled trial (FatiGo), the differences in actual and perceived physical functioning between active and passive patients with CFS were evaluated.

Methods

Sixty patients, who received CBT during the FatiGo trial were included. Based on the expert opinion and using the definitions of subgroups defined in the CBT protocols, the therapist categorized the patient. Data from an activity monitor was used to calculate actual physical functioning, physical activity, daily uptime, activity fluctuations and duration of rest during daily life. Perceived physical functioning was assessed by measuring physical activity, physical functioning and functional impairment with the Checklist Individual Strength, Short Form-36 and Sickness-Impact Profile 8.

Results

Relatively active patients have a significantly higher daily uptime and show significantly less fluctuations in activities between days. Passive patients experience a significantly lower level of physical functioning and feel more functionally impaired in their mobility. However, no significant differences were found in the other actual or perceived physical functioning indices.

Conclusions

A clear difference in actual and perceived physical functioning between relatively active and passive patients with CFS as judged by their therapists could not be found. Future research is needed to form a consensus on how to categorize subgroups of patients with CFS.
 

Firestormm

Senior Member
Messages
5,055
Location
Cornwall England
Unfortunately, I'm not sure how praiseworthy this group are. They believe the aim of CBT should be recovery.

The manual is available here: https://listserv.nodak.edu/cgi-bin/wa.exe?A2=ind1009C&L=CO-CURE&P=R1774&I=-3&d=No Match;Match;Matches

Here's an extract:

Thanks Dolphin. I read that interpretation of 'recovery' as being rather different to White and PACE. But it has been so long now since I read their manuals - but it does seem that even White has now acknowledged a difficulty exists in this area - though I still can't help but feel he and they expected much more from PACE than they got. You know I was surprised and oddly reassured with that explanation for the 6 minute walking test thing he provided in his letter. I always had the impression that PACE forced people to do things - but in this regard at least apparently not. And if people were left to walk for example at their own pace and the results were not worthy of inclusion - because they were less than satisfactory for recovery purposes - doesn't it add to the indictment that PACE was a disappointment? That they hadn't managed to convince PATIENTS of their recovery or if they had that this didn't translate into objective data.
 

Bob

Senior Member
Messages
16,455
Location
England (south coast)
The therapist describes the intended recovery in such a way that it becomes a real and feasible target for the patient. Together, they inventory the activities that the patient needs to be able to do again in order to feel like a healthy person. Try to prevent the patient from becoming discouraged or debilitated by anxiety or the notion that the set targets are no longer obtainable or that recovery is still a long way off.
...
These goals as well as the steps (subtargets) to achieve these objectives are formulated during the initial CBT sessions. Here, relatively active CFS patients tend to set themselves targets that are too high...

How does this last sentence fit into the 'fear' and 'avoidance' of activity theories?

Talk about Contradiction City!

First they talk about patients being debilitated by anxiety, and then they say that relatively active patients tend to set themselves targets that are too high. Why would they do that if they were debilitated by anxiety?

When they say that they set targets that are too high, what do they mean? Too high for what? Too high so that their ambitious targets cause their symptoms to flare up due to post-exertional malaise? Or are they trying to say that if you have 'deconditioning' then being ambitious about activity is counter-productive? What a load of bloody nonsense. (How long is deconditioning supposed to last if you set yourself ambitious targets every day?)

There's clearly no anxiety or avoidance behaviour problems with those patients.
The problem is that they suffer from persistent pain, malaise and exhaustion and their symptoms flare up in reaction to exertion.

You would have thought that if someone was consistently over-ambitious, then deconditioning would not be a problem.
But these ideologues can't accept that actually it's not deconditioning that's the problem with these patients, but it's a biomedical disease which has post-exertional malaise as a symptom, that is the problem.

Rant over. Grrrrr.
 
Messages
15,786
First they talk about patients being debilitated by anxiety, and then they say that relatively active patients tend to set themselves targets that are too high. Why would they do that if they were debilitated by anxiety?

When they say that they set targets that are too high, what do they mean? Too high for what? Too high so that their ambitious targets cause their symptoms to flare up due to post-exertional malaise? Or are they trying to say that if you have 'deconditioning' then being ambitious about activity is counter-productive? What a load of bloody nonsense. (How long is deconditioning supposed to last if you set yourself ambitious targets every day?)
I think the explanation stems from some Nijmegen BS. To answer these questions, they have decreed that there must be two dysfunctional types of responses to psychosomatic deconditioning or whatever the hell they're assuming we have.

One group is (too) passive, and one is (over-)active. The passive ones supposedly do too little due to fear, etc, and the active ones consistently do too much due to being obsessive perfectionist over-achievers :rolleyes:

This is all pure speculation on their part, and conveniently ignores evidence of biological dysfunction, including actometer results in their own studies. They also don't seem to realize that by separating ME patients into two separate groups based on their type of "dysfunctional" reactions, they are essentially saying that there are two completely different (psychological) illnesses somehow arising in response to the same trigger.

Basically they have had to back-peddle and re-invent their theories when various parts are proven wrong, resulting in ever stranger and less credible explanations. The active/passive dichotomy is just one more step along that dead-end path.
 

Bob

Senior Member
Messages
16,455
Location
England (south coast)
Thanks for the explanation, Valentijn.

One group is (too) passive, and one is (over-)active. The passive ones supposedly do too little due to fear, etc, and the active ones consistently do too much due to being obsessive perfectionist over-achievers :rolleyes:

So we have pathological fear and deconditioning whether we do too much or too little?!?
How ridiculously convenient for them! :rolleyes:

Like Sean said, we just can't get it right! They're going to pathologize our behaviour, whatever course of action we take.
It seems like a very creepy approach to medicine.

We can't possibly have a biomedical illness, with symptoms of exhaustion, pain, and post-exertional malaise, where some patients respond by pushing at their pain boundaries etc, and others respond by limiting their activities in order to reduce and modulate their symptoms. No, it absolutely has to be a behavioural disorder. A biomedical illness is not a possibility, despite the evidence. Ideology, ideology, ideology.

(Sorry, I seem to be ranting a lot today!)

Basically they have had to back-peddle and re-invent their theories when various parts are proven wrong, resulting in ever stranger and less credible explanations. The active/passive dichotomy is just one more step along that dead-end path.

Maybe there's some hope that their theories are slowly imploding!
 

Dolphin

Senior Member
Messages
17,567
How does this last sentence fit into the 'fear' and 'avoidance' of activity theories?

Talk about Contradiction City!

First they talk about patients being debilitated by anxiety, and then they say that relatively active patients tend to set themselves targets that are too high. Why would they do that if they were debilitated by anxiety?

When they say that they set targets that are too high, what do they mean? Too high for what? Too high so that their ambitious targets cause their symptoms to flare up due to post-exertional malaise? Or are they trying to say that if you have 'deconditioning' then being ambitious about activity is counter-productive? What a load of bloody nonsense. (How long is deconditioning supposed to last if you set yourself ambitious targets every day?)

There's clearly no anxiety or avoidance behaviour problems with those patients.
The problem is that they suffer from pain and exhaustion and their symptoms flare up in reaction to exertion.

You would have thought that if someone was consistently over-ambitious, then deconditioning would not be a problem.
But these ideologues can't accept that actually it's not deconditioning that's the problem with these patients, but it's post-exertional malaise that is that problem.

Rant over. Grrrrr.

This is something Fred Friedberg is good on and has written about which can be useful to quote: the deconditioning/fear avoidance model doesn't fit more mobile patients (he seems to be inclined to think it does fit, to some extent anyway, the more severely affected).
 

alex3619

Senior Member
Messages
13,810
Location
Logan, Queensland, Australia
Maybe there's some hope that their theories are slowly imploding!

Historically that is about what happens, again and again and again, and yet psychogenic medicine goes on, ignoring the lessons, the evidence and reason. Neurasthenia died about a century ago, yet was still lingering in London up to the end of WW2. Its still used in China, and Simon resurrected it to apply to ME. Hysteria has been discredited repeatedly, but refuses to go away, no matter how little evidence there is for it, nor how irrational their thinking has to be to diagnose it.

Look at all the diseases that we now know are biomedical, not psychiatric, from gastrointestinal ulcers to diabetes and MS. Once they were "obviously" psychosomatic. Then the science advanced. Now only the most bold psychogenic theorists would want to claim diabetes, or lupus, or rheumatoid arthritis are psychiatric disorders. Gastric ulcers still have a few psychogenic hold-outs, but in time they will go the way of the dodo and nobody will remember them.

The same will happen with ME. The question is: how soon, and how can we make it happen sooner?
 

SOC

Senior Member
Messages
7,849
Has this group just published what we all know and have been saying for years about this illness -- there's no F-ing way to win with activity/exercise in ME/CFS?
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
I think the explanation stems from some Nijmegen BS. To answer these questions, they have decreed that there must be two dysfunctional types of responses to psychosomatic deconditioning or whatever the hell they're assuming we have.

One group is (too) passive, and one is (over-)active. The passive ones supposedly do too little due to fear, etc, and the active ones consistently do too much due to being obsessive perfectionist over-achievers :rolleyes:

This is all pure speculation on their part, and conveniently ignores evidence of biological dysfunction, including actometer results in their own studies. They also don't seem to realize that by separating ME patients into two separate groups based on their type of "dysfunctional" reactions, they are essentially saying that there are two completely different (psychological) illnesses somehow arising in response to the same trigger.

Basically they have had to back-peddle and re-invent their theories when various parts are proven wrong, resulting in ever stranger and less credible explanations. The active/passive dichotomy is just one more step along that dead-end path.

Dear Psychoquacks (if I may be so familiar),

Are you aware of different personality types? Are you aware that people with different personality-types can nevertheless get the same illnesses?

Sincerely, but definitely not yours,

MeSci
 

Snow Leopard

Hibernating
Messages
5,902
Location
South Australia
So improvements/reductions in fatigue aren't related to doing more. Given fatigue isn't an objective measure, this means all the fatigue reduction they have talked about over the years may not be that interesting - it may simply due to patients answering questionnaires differently.

Got it in one. There is a commentary soon to be published in Clinical Psychology: Science and Practice on this topic too...
 

biophile

Places I'd rather be.
Messages
8,977
If a picture is worth 1000 words, this is what I want to say on the subject:

a_house_of_cards_falling_down_M15816RG.jpg