"CBT and GET are effective"

[Denise]

The first author is at (Institute of Psychiatry) King's College London. (Article is behind a paywall, so I have not been able to read it.)



Behav Cogn Psychother. 2015 Apr 21:1-13. [Epub ahead of print]

Treatment Outcome and Metacognitive Change in CBT and GET for Chronic Fatigue Syndrome.
Fernie BA1, Murphy G2, 3, Nikčević AV4, Spada MM5.

Author information:

• 1King's College London,Institute of Psychiatry,Psychology and Neuroscience, and Cascaid,South London and Maudsley NHS Foundation Trust,UK.

• 2Royal Free Hampstead NHS Foundation Trust,London,UK.

• 3University of Manchester,UK.

• 4Kingston University,Kingston upon Thames,UK.

• 5London South Bank University,UK.

Abstract
BACKGROUND:
Studies have reported that Cognitive Behavioural Therapy (CBT) and Graded Exercise Therapy (GET) are effective treatments for Chronic Fatigue Syndrome (CFS).

METHOD:
One hundred and seventy-one patients undertook a course of either CBT (n = 116) or GET (n = 55) and were assessed on a variety of self-report measures at pre- and posttreatment and follow-up.

AIMS:
In this paper we present analyses on treatment outcomes for CBT and GET in routine clinical practice and evaluate whether changes on subscales of the Metacognitions Questionnaire-30 (MCQ-30) predict fatigue severity independently of changes in other covariates, and across the two treatment modalities.

RESULTS:
Both CBT and GET were equally effective at decreasing fatigue, anxiety, and depression, and at increasing physical functioning. Changes on the subscales of the MCQ-30 were also found to have a significant effect on fatigue severity independently of changes in other covariates and across treatment modalities.

CONCLUSION:
The findings from the current study suggest that CFS treatment protocols for CBT and GET, based on those from the PACE trial, achieve similar to poorer outcomes in routine clinical practice as in a RCT.

PMID: 25895437 [PubMed - as supplied by publisher]

 

[alex3619]

Still no objective measures? I wonder why?

 

[WillowJ]

funny, no measures of effect, significance, etc., are reported in the abstract.

 

[SilverbladeTE]

And what exactly do they think is a "good outcome"?

Emperor Wessely goes Water Skiing!

 

[lazzlazz]

In Lucinda Bateman's talk at the link below, at about the 51:00 minute mark, she talks about "subgroups" of "chronic fatigue" (not necessarily CFS) patients that she has observed in her clinic. Based on her experience (specifically, slide at about 51:25), she thinks exercise is "helpful" for gradual onset, but "impossible" for sudden onset, devastating CFS (she seems to think her "gradual onset" category (for which she says "often pain predominant") is really FM; it's not clear from this discussion why she thinks that; she also has another category called "definite but not sudden onset" which she thinks can be either CFS or FM). In this part of the talk, she's making some interesting comments about the similarities between CFS & FM; these reflect her opinions and aren't part of the IOM report.

Ultimately, the answer to whether exercise is helpful is probably quite complicated. It probably depends on many factors: severity of CFS, the person's ability to pace oneself, how many other demands are on the patient and the degree to which they "exert" the patient. In other words, each patient can handle X amount of exertion, and going beyond that leads to relapse/negative effects.
The real problem is when exercise is presented as a cure-all for everyone, and especially when physicians view patients as "not wanting to get better" because they don't comply with exercise regimes. There's plenty of evidence that exercise is not a cure-all for everyone, and as we all know, when you have CFS and over-exert yourself (via exercise or other activities that exert you), you can pay for it for many days (some weeks) as you relapse.

I have relatively mild CFS and I like to exercise, but I exercise at a fairly low intensity (especially compared to my pre-CFS days) - mostly walking or LifeCycle recumbent bike, watching a video (not at a high intensity - I'm not trying to get my heart rate up to max levels). I also have learned to not exercise when I have too many other demands, because too much total exertion has negative effects. Interestingly, I would have put myself in Bateman's "gradual onset" category (for me, pain is not prominent although it occurs very occasionally, 1-2 x month). (I'm fairly confident my CFS diagnosis is correct as I was diagnosed by a practitioner at a clinic that's recognized as having strong expertise in this area).

 

[IreneF]

Still need to know how the patients were diagnosed.

Anxiety and depression are not symptoms of CFS, so improvement doesn't tell you anything about the efficacy of CBT or GET in treating CFS. So according to the abstract, these modalities were effective to some extent in treating fatigue, depression, and anxiety.

 

[Snow Leopard]

It is slippery language. "equally effective" doesn't mean much when there is no placebo control. "Equally effective" could mean that neither work.

 

[Sean]

"Equally effective" could mean that neither work.

"Equally effective" could mean equally ineffective.

 

[DaiWelsh]

Makes me wonder - I do not recall the exact results of the pace trial but were they not similar for CBT and GET?

Is it reasonable to expect two completely different (on the surface) treatments to get the same moderate increases? Does it in fact provide more supporting evidence for the theory that this represents an increase in self-report results after any treatment from positive, encouraging practitioners?

In other words my guess would be that any treatment applied by enthusiastic practitioners would yield similar self-report changes. Crystals, meditation, reiki, homeopathy, lighting process, smile therapy - provided the practitioner convinced the patient it was a legitimate treatment that had a good chance of helping them and then asked them these questions themselves...? Of course I have no evidence to support this theory, how very unscientific of me, but I wanted to fit in

Just to be clear I am not talking about placebo effect, no actual improvement, merely an effect on self-report.

Of course it is possible both have the same effect by coincidence, but I would have more faith in their results if one came out clearly ahead (without them having "picked a horse" in order to achieve this end).

A cynic might say that if they did pick a horse they would lose half their invested believers.

 

[Bob]

CONCLUSION:
The findings from the current study suggest that CFS treatment protocols for CBT and GET, based on those from the PACE trial, achieve similar to poorer outcomes in routine clinical practice as in a RCT.

So, overall, worse outcomes were seen in this study compared to PACE. But it's not explained in the abstract which specific outcomes were 'poorer'. The National Outcomes Database (NOD) study, by Esther Crawley et al., found that CBT/GET in clinical settings had similar effects for fatigue as the PACE trial, but no useful effects for physical function.

 

[user9876]

They still have techniques that tell people to think about symptoms and then ask them 'are you thinking about your symptoms differently' and they get an answer of well maybe a little bit. They need to justify that this links to an actual improvement but I suspect they don't.

The Metacognitions Questionnaire-30 (MCQ-30) seems like a bit of a joke particularly to see it as a continuous linear scale which I suspect they do to calculate stats on it.

 

[user9876]

Perhaps all this type of paper proves is how poor peer review is.

 

[Sidereal]

They admit in the paper that all the measures were non-normally distributed but then go on to do parametric statistics for all the efficacy analyses.

 

[SOC]

They admit in the paper that all the measures were non-normally distributed but then go on to do parametric statistics for all the efficacy analyses.

Perhaps all this type of paper proves is how poor peer review is.

Yup. Even the most primitive intelligent review by someone with basic knowledge of statistics (which any decent scientific researcher has) should have caught that and booted the paper back to the authors for a rewrite. It doesn't even take any knowledge of the field to know that this paper fails.

My daughter came home from university today with an assignment to find a bad paper and review it, explaining what makes it unacceptable. It was not even required that the paper be in their own small field because any decent researcher can spot bad experimental design and statistical analysis. College students can do this but psychiatry researcher/reviewers can't?

Maybe I should drop the class a hint to take a look into psychiatry journals.

 

[user9876]

Yup. Even the most primitive intelligent review by someone with basic knowledge of statistics (which any decent scientific researcher has) should have caught that and booted the paper back to the authors for a rewrite. It doesn't even take any knowledge of the field to know that this paper fails.

My daughter came home from university today with an assignment to find a bad paper and review it, explaining what makes it unacceptable. It was not even required that the paper be in their own small field because any decent researcher can spot bad experimental design and statistical analysis. College students can do this but psychiatry researcher/reviewers can't?

Maybe I should drop the class a hint to take a look into psychiatry journals.

You could suggest the original PACE paper although I think the PACE recovery paper is a more extreme example especially if she could get the ONS data that they use to justify protocol changes

 

[msf]

Jesus, I think the UK will be the last redoubt of CBT/GET for ME. The only question is which will go first, CBT/GET, or the NHS?

 

[Dolphin]

Another psychological model to contend with.

The role of metacognitions in CFS

Research indicates that CBT and GET are beneficial; however, limited efforts have been focused on examining the effects of such treatment modalities on specific cognitive processes that are hypothesized to mediate change. Such studies are helpful to identify target treatments, consider suitability, and explore mechanisms of change.

The Self-Regulatory Executive Function (S-REF) model (Wells,2011) suggests that vulnerability to, and maintenance of, psychological problems is associated with a cognitive attentional syndrome (CAS), characterized by perseverative thinking (e.g. rumination and worry), threat monitoring, and self-regulation strategies that fail to modify maladaptive selfknowledge. The CAS is driven by metacognitions, which are beliefs that specify the execution of ruminative/worry processing, guide attention, and serve as a resource for interpreting and controlling cognitive events such as unwanted thoughts. A wide evidence base supports the relationship between metacognitions, aspects of the CAS, and a range of negative emotional outcomes and psychological problems (for a review see Wells,2011).

Recent studies have provided support for CAS configurations in CFS. For example, interpretative biases for processing somatic information (Moss-Morris and Petrie,2003), high levels of self-reported health-related worry, and preoccupation with health threats (Aggarwal, McBeth, Zakrzewska, Lunt and Macfarlane,2006), together with attentional biases for processing health-threat information (Hou, Moss-Morris, Bradley, Peveler and Mogg,2008), have been found to be present in CFS patients. For a review of these cognitive processes see Knoop, Prins, Moss-Morris and Bleijenberg (2010).

Other studies have posited a role for metacognitions in CFS. Specifically, metacognitions regarding lack of cognitive confidence and need to control thoughts have been found to predict CFS symptom severity when controlling for negative emotion (Maher-Edwards, Fernie, Murphy, Wells and Spada,2011). Metacognitions pertaining to the need to control thoughts may lead to the activation of effortful and maladaptive coping strategies (e.g. thought suppression, worry, and rumination) that may increase fatigue and negative appraisals of cognitive experiences. Metacognitions regarding a lack of cognitive confidence may limit choice and inhibit activation of adaptive coping strategies when feeling fatigued. Additionally, metacognitions pertaining to perserverative conceptual thinking about symptoms and bodyfocused attention were elicited from individuals with CFS (Maher-Edwards, Fernie, Murphy, Nikˇcevi´c and Spada,2012).

 

[Esther12]

There was some discussion of the Moss-Morriss attentional bias stuff here:

http://forums.phoenixrising.me/inde...onal-bias-for-health-related-threat-an.30044/

It all looked very weak.

My summary (may not work if the attachment doesn't copy over):

Their abstracts:

Compared to the control group, the CFS group showed greater attentional bias for health-threat words than pictures; ... attentional bias to threat was primarily evident in those with impaired executive attention control.

Results
When compared to the control group, the CFS group showed greater attentional bias towards threat-words, but not pictures, regardless of stimulus duration. This was not related to anxiety or depression. The CFS group was also significantly impaired on executive attention compared to the controls. Post-hoc analyses indicated that only CFS individuals with poor executive attention showed a threat-word bias when compared to controls and CFS individuals with good executive attention.

Conclusions
The findings from this study suggest that CFS individuals show enhanced attentional biases for health-threat stimuli, which may contribute to the perpetuation of the condition. Moreover, the attentional biases in CFS are dependent on an individual's capacity to voluntarily control their attention.

And their results:

View attachment 7221



As I said:

They don't seem that interested in the fact that CFS patients classed as having good executive function seem to have a significant bias against threat words. To me, those results look like a mess indicative of nothing. It looks like there would not be overall evidence of bias from pictures and words, as the 'bias' is going in opposite directions.​

Also, I thought I'd post the conclusion from the smaller Moss-Morris study which was positive, and this is a larger follow-up for:

Conclusion:
The finding of an AB towards
health-threat information in individuals with CFS is supportive of
models of CFS which underlie cognitive behavior therapy.

http://www.jpsychores.com/article/S0022-3999(08)00113-X/abstract

Shouldn't the conclusion for their larger study have been:

"The absence of evidence of an AB towards health-threat information in individuals with CFS challenges the models of CFS which underlie cognitive behavior therapy."

 

[Dolphin]

This is the comparison they make with PACE Trial:

The CGI data are comparable to that obtained by the PACE trial (White et al.,2011) but the clinical change data are worse (for CBT, comparing PACE to this evaluation, it was 59% versus 50% and for GET 61% to 34.3%).

"Clinical change data" refers to an improvement of 8 or more on SF-36 physical functioning and 2 or more on Chalder fatigue questionnaire.

The positive change % ("very much better" or "much better") in this were
(at follow-up):
CBT: 50.5%
GET: 51.2%

PACE Trial:
CBT: 41%
GET: 41%

 

[Dolphin]

Main results.
Note these results are less impressive when one realises that patients can improve over time when diagnosed and given basic care e.g. the SMC-only group in the PACE Trial (who didn't receive CBT, GET or APT) also improved a bit on such measures.