Cognitive behaviour therapy for chronic fatigue syndrome: Differences in treatment outcome between a

[Dolphin]

Dubious claim:

A subgroup of patients fully recovers [15–18].

[15] A. Deale, K. Husain, T. Chalder, S. Wessely, Long-term outcome of cognitive behaviour therapy versus relaxation therapy for chronic fatigue syndrome: a 5-year follow-up study, Am. J. Psychiatry 158 (2001) 2038–2042.
[16] H. Knoop, G. Bleijenberg, M. Gielissen, J. Van der Meer, P. White, Is a full recovery possible after cognitive behavioral therapy for chronic fatigue syndrome? Psychother. Psychosom. 76 (2007) 171–176.
[17] P.White, K. Goldsmith, A. Johnson, T. Chalder, M. Sharpe, Recovery from chronic fatigue syndrome after treatments given in the PACE trial, Psychol. Med. 43 (2013) 2227–2235.
[18] J.Wiborg, J. Van Bussel, A. Van Dijk, G. Bleijenberg, H. Knoop, Randomised controlled trial of cognitive behaviour therapy delivered in groups of patients with chronic fatigue syndrome, Psychother. Psychosom. 84 (2015) 368–376.

 

[Dolphin]

Lots of physical functioning. I would like it said each time it is mentioned that this self- reported physical functioning.

 

[Dolphin]

Both protocols include an initial adoption of a consistent approach to activity, a gradual increase in activity, sleep management, and cognitive restructuring.

 

[Dolphin]

First, in the Dutch protocol treatment recovery is set as a therapy goal more explicitly. Although recovery rates are similar [16,17,29], stating recovery as the treatment goal may boost treatment effect, as outcome expectation of patients, especially the idea that recovery is possible, is known to contribute to treatment outcome [13].

[13] M. Heins, H. Knoop, W. Burk, G. Bleijenberg, The process of cognitive behaviour therapy for chronic fatigue syndrome; which changes in perpetuating cognitions and behaviour are related to a reduction in fatigue? J. Psychosom. Res. 75 (2013)
235–241.

I can't remember what is in reference 13 but I doubt it proves what this sentence claims it does.

 

[Dolphin]

Protocol of Knoop & Bleijenberg [27]

Activity program
- Activity is increased by one minute per day, irrespective of symptom level. Therefore fully time contingent.

The Dutch protocol includes a specific physical activity program, in which the patient learns to increase physical activity regardless of symptoms and to modify cognitions that reflect low self-efficacy with respect to being active. These same principles are applied during the gradual increase of social and mental activity. This graded activity program is prescriptive. Patients increase walking or cycling by a minute per day, from an achievable level. The increase is time contingent, irrespective of the symptom level.

I think this is a reckless approach to recommend.
It is pretty much a surefire way to cause a relapse.

I imagine the reason there may not be more relapses because people don't stick to the program.

The actometer results from their CBT studies, which measure total activity levels, have not been impressive.

 

[Dolphin]

In both protocols, unhelpful cognitions are identified and modified. Different cognitions are aimed at. In the Dutch protocol the physical activity program is aimed at increasing self-efficacy regarding fatigue and activity. Furthermore, specific interventions are applied to teach patients to redirect attention from symptoms towards other stimuli. First, the effect of attention on the perception of bodily symptoms is illustrated during therapy and its role in the perpetuation of fatigue is discussed. Then patients are invited to no longer talk about fatigue and to ask significant others not to inquire about fatigue. Finally, patients practice with redirecting the focus of their attention away from the fatigue to an activity or their environment, e.g. during social interactions or the graded activity program. In the UK protocol, patients learn that they can manage an increase in activities, knowing that symptoms may get worse before they get better. The UK protocol advocates a shift in the focus of attention from fatigue, but no specific intervention targets this.

It seems quite plausible that such therapy could alter how people respond to questions about fatigue and other symptoms and impairments.

patients learn that they can manage an increase in activities

I think this may be partly achieved by tricking patients by starting them at a lower level than they might otherwise have been doing. Then it looks like the patient can do more.

Also some studies have shown that people are not necessarily doing more total activity; they can be giving up doing some activities to enable them to walk as part of the therapy. Patients are not given actometers which could show this to them i.e. that they can't necessarily increase their activity levels.

Cognitions

Protocol of Knoop & Bleijenberg [27]
“I can increase my activity level, following specific principles and irrespective of symptoms.”

Protocol of Burgess & Chalder [22,23]
“I can increase my activity level and will be able to cope with an increase in symptoms.” This
focuses on reducing fear avoidance of symptoms.

 

[Dolphin]

Treatment duration, number of sessions and drop-out rates for the Dutch and UK centre were compared, as well as baseline characteristics. This was done for all patients who started treatment and also for the groups that completed post-assessment, since they were the patients included in the effect size calculation.

This could lead to a biased population. They say this themselves:

Furthermore, since only the patients who completed post-treatment assessment were included in the effect size calculations, a selection bias may have occurred.

In the Netherlands 23 patients dropped out (8%) and in the UK 11 patients dropped out (7%; χ(1):0.17, p:0.68). The number of treatment sessions was significantly higher in the Netherlands (13.5, sd: 4.1) compared to the UK (12.5, sd:2.8; t(400): 2.63, p < 0.05).

There were 34 patients in the UK who did not complete post-treatment CFQ (21%), and 68 in the Netherlands (23%; χ(1):0.33, p:0.56).

 

[Dolphin]

There are no control groups but even still the Dutch results appear on the surface impressive.

However these are all self-report measures which could be biased.

As I said, a trial of a similar form of CBT on people with multiple sclerosis with fatigue found that after treatment and at follow-up patients with multiple sclerosis fatigue reported lower fatigue scores than healthy people (Chalder Fatigue (likert scoring): 7.90 at post-treatment, 8.99 at 3 months follow-up)!

Psychosom Med. 2008 Feb;70(2):205-13. doi: 10.1097/PSY.0b013e3181643065. Epub 2008 Feb 6.
A randomized controlled trial of cognitive behavior therapy for multiple sclerosis fatigue.
van Kessel K1, Moss-Morris R, Willoughby E, Chalder T, Johnson MH, Robinson E.

 

[Dolphin]

The analyses do not allow for the identification of predictors of treatment effect, as treatment variables were not controlled for and the magnitude and direction of the predictors of treatment effect may differ in both countries.

They could have examined this issue if they had wanted to.

 

[Snow Leopard]

I think this is a reckless approach to recommend.
It is pretty much a surefire way to cause a relapse.

I imagine the reason there may not be more relapses because people don't stick to the program.

Exactly. It's likely to be wilfully ignored. Very sloppy to state this and expect high compliance without any evidence!

 

[JaimeS]

It seems quite plausible that such therapy could alter how people respond to questions about fatigue and other symptoms and impairments.

I recently had a conversation with a good friend about people who 'live on the surface' vs 'people who live at depth'. People who live on the surface are primarily interested in how things appear. If things appear good, they consider that they are doing a good job. This seems like what's going on here. There is no attempt to delve behind the reasons why; it's more, "what can we do to promote our therapy as useful and effective?" and "what can we ensure would not give us poor results?" In contrast, people who live at depth are attempting to make what they see as significant and lasting change in the world.

While we would all immediately protest that the latter is far more important (oh, gosh, I sure HOPE so) I've encountered consuming interest in how things seem on the surface lo, even here on these very boards. I'd also add that if you only live 'at depth' no one ever knows you're doing any good, and therefore you don't stay in a position to do good for very long.

-J

 

[daisybell]

I can increase my activity levels and cope with an increase in symptoms right up to the point that I crash and have to spend at least a day in bed..... Then I can start from scratch and repeat the process. Obviously this is what the protocol meant to say.

Or perhaps I can pace myself instead.... But that wouldn't be sensible.

 

[slysaint]

I just came accross this quote and once again didn't know where to post it so picked this thread (apologies if it's off topic):
"A basic question never addressed by those who favour the psychosocial model of “CFS/ME” is: if patients are not cured by psychotherapy (which its proponents concede), then what is it that they are not cured from?"

 

[JaimeS]

Their false illness beliefs... due, undoubtedly, to the stubbornness or unwillingness of the patient.

J

 

[Glycon]

I just came accross this quote and once again didn't know where to post it so picked this thread (apologies if it's off topic):
"A basic question never addressed by those who favour the psychosocial model of “CFS/ME” is: if patients are not cured by psychotherapy (which its proponents concede), then what is it that they are not cured from?"

Their false illness beliefs... due, undoubtedly, to the stubbornness or unwillingness of the patient.

J

I think we can all agree that at the very least psychotherapy is a promising tool for identifying the falsely diagnosed (as well as, hopefully, helping them with whatever issues they really have).

 

[worldbackwards]

I think we can all agree that at the very least psychotherapy is a promising tool for identifying the falsely diagnosed (as well as, hopefully, helping them with whatever issues they really have).

Given that it's psychotherapy that falsely diagnoses them, not really.

 

[Chrisb]

Given that it's psychotherapy that falsely diagnoses them, not really.

I have to disagree.

Its the psychiatrist who diagnoses them and who prescribes the psychotherapy.

The deficiency in the treatment possibly indicates the error in the diagnosis.

 

[trishrhymes]

Its the psychiatrist who diagnoses them and who prescribes the psychotherapy.

The deficiency in the treatment possibly indicates the error in the diagnosis.

If I understand correctly what you are saying, I agree.

For example it's just been shown again what we already knew, that the PACE and FINE trials were both null trials, ie they showed conclusively that CBT and GET don't work for Chronic fatigue syndrome as defined for the trials.

That means that these trials proved conclusively that the condition the psychiatrists call 'Chronic fatigue syndrome' diagnosed by the Oxford criteria which they say is caused by false illness beliefs and de-conditioning is WRONG.

The patients do not have this illness defined by the psychiatrists. Their diagnosis it wrong. They do not have false illness beliefs or deconditioning. If they did the treatments would have worked. They didn't. End of story.

Now how can we persuade people like Chalder that PACE proves that she is the one with false illness beliefs? Maybe a course of CBT for Chalder et al by nice people in blue cardigans will help her overcome these false beliefs. She can then write it up for publication on some nice pink paper (for Harry Potter fans, think Dolores Umbridge).

 

[Gijs]

If I understand correctly what you are saying, I agree.

For example it's just been shown again what we already knew, that the PACE and FINE trials were both null trials, ie they showed conclusively that CBT and GET don't work for Chronic fatigue syndrome as defined for the trials.

That means that these trials proved conclusively that the condition the psychiatrists call 'Chronic fatigue syndrome' diagnosed by the Oxford criteria which they say is caused by false illness beliefs and de-conditioning is WRONG.

The patients do not have this illness defined by the psychiatrists. Their diagnosis it wrong. They do not have false illness beliefs or deconditioning. If they did the treatments would have worked. They didn't. End of story.

Now how can we persuade people like Chalder that PACE proves that she is the one with false illness beliefs? Maybe a course of CBT for Chalder et al by nice people in blue cardigans will help her overcome these false beliefs. She can then write it up for publication on some nice pink paper (for Harry Potter fans, think Dolores Umbridge).

" The patiënts do not have this illness defined by psychiatrists''. Oxford criteria. Well Said! This is the main problem.

 

[SilverbladeTE]

Again, it reminds me of the Soviet's system:
after they got rid of Stalin's butchery but still needed to squash dissidents, they used psychiatry:
if you don't support the Soviet system, you must be insane, comrade!
Can't you see it's the best system? that it works!
Anyone who says otherwise is cuckoo!
That's why we are locking you away and giving you drugs,
it's for your own good!

seriously, that's what went on
so folk instead of being "sent to count trees" in a Gulag, or neck shot, they got locked up in the huge State mental asylums

Extremes become evil, and are much alike in the end.