COMMENTARY
Cognitive Behavior Therapy for Chronic Fatigue Syndrome: Where to Go From Here?
Hans Knoop
Article first published online: 19 DEC 2011
DOI: 10.1111/j.1468-2850.2011.01263.x
Clinical Psychology: Science and Practice
Volume 18, Issue 4, pages 325330, December 2011
The meta-analytic review of Castell, Kazantzis, and Moss-Morris (2011) is a valuable contribution to the debate about the efficacy of behavioral interventions for chronic fatigue syndrome (CFS).
Again it is found that cognitive behavior therapy (CBT) has a positive effect on the outcomes of patients with CFS.
However, a substantial number of patients do not profit (enough) from this intervention.
Increasing our knowledge about the mechanisms of change and other relevant aspects related to the treatment response could help to improve further the efficacy and applicability of CBT for CFS.
This commentary discusses some of these aspects and, where possible, research strategies are proposed.
I just read this is paper from Hans Knoop, who appears (from a distance) to be Gijs Bleijenberg's heir apparent at Nijmegen. He has been involved in all sorts of frustrating papers incl. PACE Trial commentary (they talked about the strict criteria for recovery used!), CBT is safe for CFS (post-hoc study with dodgy definitions of/reporting of harms), CBT leads to full recovery in CFS (v. dodgy definition of full recovery), etc.
In this paper, one gets a one-sided view of the evidence, with virtually no mention of any other opinions - the only one that comes to mind is:
By the end of the paragraph, after quoting Heins study and PACE Trial, he says:Some patient advocacy groups have also published reports on the negative effects of behavioral interventions on CFS symptoms.
On the basis of existing evidence, it seems reasonable to conclude that CBT for CFS is a safe intervention.
As well as the one-sided review of the current evidence, one is also given an insight into other research that could be done.
Not very exciting at all.
Biology is only mentioned that I can recall in this one-sided paragraph:
LINKING THERAPY OUTCOMES WITH SOMATIC VARIABLES
There is no known somatic cause of CFS, but there is
evidence that patients show neurobiological abnormalities
such as reduced gray matter volume and changes in
HPA-axis functioning. It is unclear to what extent the
abnormalities are the consequences of having CFS or
are causally linked to symptoms. Data of two uncontrolled
treatment studies suggest that some of these
abnormalities, that is, a reduced gray matter volume
and hypocortisolism, may be (partly) reversible with
CBT (de Lange et al., 2008; Roberts, Papadopoulos,
Wessely, Chalder, & Cleare, 2009). Assessment of
relevant neurobiological parameters before and after
treatment in future RCTs could help to better understand
the biological correlates of CFS and mechanisms
of change in CBT.
No mention of the fact:
- de Lange had no control group.
- This study:
Psychol Med. 2010 Mar;40(3):515-22. Epub 2009 Jul 17.
Does hypocortisolism predict a poor response to cognitive behavioural therapy in chronic fatigue syndrome?
Roberts AD, Charler ML, Papadopoulos A, Wessely S, Chalder T, Cleare AJ.
Low cortisol is of clinical relevance in CFS, as it is associated with a poorer response to CBT.
- Jason studies which found presence of biological abnormalities tended to predict a poor response from non-pharm interventions incl. CBT.
Even though their review found that CBT patients weren't do more than the controls after CBT, he suggests this might not have been true during therapy:
All studies mentioned here
did not assess the role of changes in the level of physical
activity during the intervention for the reduction in
fatigue. It could be that a temporary increase in physical
activity during the intervention helps patients to
change cognitions with respect to fatigue. Perhaps they
learn that they can be active despite being fatigued,
which may increase self-efficacy and reduce the focus
on fatigue (Knoop, Prins, Moss-Morris, & Bleijenberg,
2010). To determine the function of physical activity,
future treatment studies should assess changes in physical
activity during the intervention to determine its
relationship with changes in cognitions and symptoms.
There is no talk that if people aren't do any more than controls at the end of treatment, that this is important. And generally no talk of possible problems with outcome measures used.
All in all, frustrating.