Cognitive behavior therapy in patients with CFS: the role of illness acceptance and neuroticism

[Dolphin]

This was a group CBT study by the way.

Cognitive behavior therapy in patients with chronic fatigue syndrome: the role of illness acceptance and neuroticism

J Psychosom Res. 2013 May;74(5):367-72. doi: 10.1016/j.jpsychores.2013.02.011. Epub 2013 Mar 25.

Poppe C, Petrovic M, Vogelaers D, Crombez G.

Source
Department of General Internal Medicine, Ghent University Hospital, Belgium. Carine.Poppe@ugent.be

Abstract*

OBJECTIVE:

Increasing the quality of life (QoL) of patients with chronic fatigue is challenging because recovery is seldom achieved. Therefore, it is important to identify processes that improve QoL.

This study examined the extent of improvement related to cognitive behavior group therapy (CBT), and whether improvement is affected by initial levels of acceptance and neuroticism.

METHODS:

Eighty CFS patients followed CBT, and self-reported (pre-post design) on mental and physical QoL (MQoL and PQoL), fatigue, acceptance, and neuroticism.

The extent of improvement was analyzed using t-tests, effect sizes, and clinically significant change criteria.

Whether acceptance and neuroticism at baseline predicted changes was analyzed by means of correlation and regression analyses.

RESULTS:

Significant improvement was found for all variables.

The effect size for MQoL and PQoL was small; for acceptance and fatigue, effect size was moderate.

About 20% (MQoL) to 40% (fatigue) of the participants clinically improved.

Pre-treatment level of acceptance was negatively correlated with changes in MQoL, not with PQoL changes.

Neuroticism pre-treatment was positively related with MQoL changes.

Regression analysis showed an effect of acceptance on changes in MQoL beyond the effect of neuroticism.

CONCLUSIONS:


Although CBT is an evidence-based treatment, the sizes of the effects are often small regarding QoL.

Our study also revealed small effect sizes.

Our study showed that patient characteristics at baseline were significantly associated with MQoL outcome; indicating that CFS patients with high neuroticism or with a low acceptance show more improvement in MQoL.

We propose to specifically target acceptance and neuroticism before treatment in order to maximize clinical relevance.

*I gave each sentence its own paragraph

 

[SOC]

Let me see if I get this.... people with psychological issues (poor acceptance and neuroticism) benefit from psychological intervention (CBT), while people with the same illness, but not psychological issues don't benefit from CBT. Brilliant conclusion.

 

[Dolphin]

The authors said this about the form of CBT they used:

CBT aimed at increasing functioning, and its objective and content are comparable with manuals of other CBT trials [9,12].

[9] White P, Goldsmith K, Johnson A, Potts L, Walwyn R, DeCesare J, et al. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet 2011;377:823–36.

[12] Wiborg J, Knoop H, Prins J, Bleijenberg G. Does a decrease in avoidance behavior and focusing on fatigue mediate the effect of cognitive behavior therapy for chronic fatigue syndrome? J Psychosom Res 2011;70:306–10.

Reference 12 is a Nijmegen reference.
It says:

The intervention was based on the CBT for CFS manual described by Bleijenberg et al. [7]

[7] Bleijenberg G, Prins JB, Bazelmans E. Cognitive-behavioral therapies. In: Jason LA, Fennell PA, Taylor RR, editors. Handbook of chronic fatigue syndrome. New York: Wiley, 2003. p. 493–526.

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

Extract:

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.

[..]

GETTING RID OF THE "PATIENT LABEL"

Many patients find it hard to stop seeing themselves as patients. The term chronic fatigue syndrome seems to suggest a permanent condition. The fact that many CFS patients have been suffering from symptoms for some time before they are referred for CBT does not encourage them to have an optimistic outlook for a full recovery. In addition, patients who are referred to a psychotherapist for CFS generally assume that they will learn to cope with their complaints, not that they will learn to perceive themselves as healthy individuals again. This is why this goal should be one of the first points on the treatment agenda. In the final phase of the treatment, the therapist raises this point again by asking patients what they think still needs to happen before they can replace the marker reading "patient" with a label indicating "healthy." The response of healthy individuals who are suffering from all kinds of flu like symptoms will be quite different from the reactions of CFS patients, who usually interpret such incidental complaints by saying, "I told you, didn't I? I still have CFS."

This form of CBT is not something that encourages acceptance; it is pretty much the opposite.

Remember what they found was that people with lower levels of acceptance at the start did better. A lot of the discussion is about what is required is therapies that are good at encouraging acceptance.

From what I've picked up, the Belgians generally don't think now CBT leads to recovery so there is a chance what they used isn't like the Nijmegen CBT.

It would be interesting to explore all this in a letter. Unfortunately, I don't see myself doing this as I have quite a lot of work to get through.

 

[Dolphin]

The study contains some ordinary treatment data:

Table 1
t-Test of the differences between pre- and post CBT (paired)
Variables
1: Pre-treatment mean (SD);2. Post-treatment mean (SD);3. Treatment effect [95% CI];4. Effect size (Cohen's d)
[95% CI]

MQoL 50.98 (18.27) 57.20 (14.85) 6.22 [2.65 to 9.79]* .37 [.15 to .58]

PQoL 30.03 (11.40) 34.23 (12.97) 4.19 [1.75 to 6.63]* .34 [.14 to .54]

Acceptance 11.73 (3.35) 13.91 (3.71) 2.19 [1.43 to 2.95]** .61 [.38 to .85]

Fatigue severity 6.43 (.55) 6 (.89) −.42 [−.61 to −.24]** −.56 [−.82 to −.31]

* p < .001.
** p < .0001

Here is information on those two measures:

The 36-item Short Form Health Survey (SF-36)
The SF-36 is a 36-item questionnaire that consists of 8 subscales: 4 mental health subscales (vitality, social functioning, role—emotional, and mental health) and four physical health subscales (physical functioning, role—physical, bodily pain, and general health). There are two summary scores, the ‘mental and physical component summary scores’, which are used for our analyses. MQoL and PQoL refer to these summary scores. The items are scored on a 2- to 6-point Likert scale with the total scores transformed to scale values from 0 to 100. The higher the summary scores, the better is the quality of life. The SF-36 is a reliable and valid instrument with a Cronbach's alpha coefficient of 0.90 [42,43].

Checklist Interpersonal Attachment Strength (CIS)

We used the ‘fatigue severity’ subscale of the CIS as an indicator of fatigue. The CIS is a 20-item questionnaire with 4 subscales: ‘fatigue severity’ (8 items; e.g., ‘I feel tired’), ‘concentration’ (5 items), ‘motivation’ (4 items), and ‘physical activity level’ (3 items). The items are scored on a 7-point scale (from0 = ‘correct’ to 6 = ‘incorrect’). The total scores are transformed to scores from 0 to 7. The CIS has been shown to have good reliability and validity, and the subscale ‘fatigue severity’,whichwe used in our study, has a Cronbach's alpha coefficient of 0.88 [44].

The ‘mental and physical component summary scores’ are usually given as normalised scores in my experience (with population mean of 50). However these don't look normalised scores (the MQoL score is 57 after therapy, which is quite a lot better than the general population) so I'm not sure exactly what is being shown.

Very often in CFS papers, the CIS score is given out of 56 i.e. in this case the pre-score would have been 51.44 and after 48.
48 isn't really a great score. The main reason this has a moderate effect is because the SD is quite small (possibly due to lots of close at or near 56).

 

[Dolphin]

There were some deteriorations on individual measures, but they don't talk about them much.

Table 2
Clinically significant change

Measure n Recovered (%) Improved (%) Deteriorated (%)
MQoL 80 0 16 (20) 4 (5)
PQoL 80 6 (7.5) 21 (26.25) 7 (8.75)
Acceptance 80 4 (5) 19 (23.75) 2 (2.5)
Fatigue 80 13 (16.25) 32 (40) 8 (10)

Recovered = fulfilled both conditions: RCI > 1.96 (p < .05) and crossed over the
cut-off point.
Improved = fulfilled RCI > 1.96 (p < .05).
Deteriorated = fulfilled RCI > 1.96 (p < .05) in negative direction.
The ‘improved’ include the ‘recovered’.

They were defined as follows:

Finally we explored the clinical significance of the pre–post CBT change, and calculated how many patients improved. Two factors were taken into account: (1) how statistically reliable the change is by calculating a reliable change index, and (2) how the individual post-treatment score of our dysfunctional patient sample relates to a representative functional group by calculating a cut-off point [48,49]. Although there is no consensus about which method should be reported based on clinically significant change, we based our statistical analysis on the frequently used formulas of Jacobson [51,52]:

(1) We calculated a reliable change index (RCI) for each patient, based on the formula: RCI = (Xpost − Xpre) / Sdiff. Sdiff is calculated with the formula √2(SE)2, where SE = standard error of measure = SD√1 − rtest–retest reliability. When the RCI is >1.96 (p b .05), we may consider the post-treatment score as representing real, reliable change. For fatigue severity, there was a reliable change when RCI is b−1.96, because here lower scores mean more function whereas higher scores indicate less function (or more dysfunctionality).

(2) We calculated cut-off points for the variables of interest: acceptance, PQoL/MQoL, and fatigue. As we had no healthy reference groups with which to compare acceptance (ICQ), PQoL (SF-36),MQoL (SF-36), and fatigue (CIS), we used the formula: a = Mpre + (2SDpre). We inverted the direction (−2SDpre) for fatigue. This resulted in the following cut-off points: 18.43 (ICQ acceptance), 87.52 (MQoL), 52.83 (PQoL), and 5.33 (fatigue).

When the clinical change is statistically reliable (i.e., not occurring by measurement error) and the cut-off point at the post-treatment measurement is crossed, patients might be considered as ‘recovered’ on that variable. When clinical change is statistically reliable but the post-treatment score does not cross the cut-off point, patients are considered ‘improved’. Finally, when the clinical change is statistically reliable in the negative direction, patients are considered ‘deteriorated’.

 

[SilverbladeTE]

ah the Belgians again, trying to keep their fat useless asses out of law suits and jail, so they come up with this crap
Reminds me of the end of the Third Reich, with knobends in the Hitler bunker playing with toy tanks, showing how they KNEW how to win the war!
and the war's long lost and many folk have suffered for their hubris and inhumanity

*pulls down zip, takes a long leak on the psychobabblers*

 

[aimossy]

Far out if me/cfs could be cured or helped by this we would all be either doing it or all damn well cured by now.total crock!

 

[Snow Leopard]

Wouldn't a better conclusion be: CBT should only be provided to patients with high levels of 'neuroticism'?

 

[Dolphin]

Wouldn't a better conclusion be: CBT should only be provided to patients with high levels of 'neuroticism'?

Technically, I'm not sure one could say this with the evidence they present - it didn't explain enough of the variance:

Correlation and regression analyses

Acceptancepre was negatively correlated with MQoLchange (r = −0.32, p b .01) and acceptancechange (r = −0.40, p < 01), but not with PQoLchange (r = −0.03) or fatiguechange (r = 0.10). Neuroticismpre showed a significant positive relationship with MQoLchange (r = .27, p < .05), but not with PQoLchange (r = 0.09), fatiguechange (r = −0.16), or acceptancechange (r = 0.03). Fatiguepre showed no significant correlations with change variables. Based upon this pattern of correlation, we only performed a regression analysis with MQoLchange as outcome.

In the regression analysis with MQoLchange as the dependent variable, we found that neuroticismpre had a significant contribution for 7% of the patients (β = 0.27, Fchange (1,78) = 5.88, p < .05, R2 change = 0.07). However, neuroticismpre was no longer significant when acceptancepre was entered. Acceptancepre accounted for 5% additional variance in explaining MQoLchange (β = −0.26, p < .05, Fchange (1,77) = 4.59, p < .05, R2 change = 0.05). The finalmodel explained 10% of the variance of MQoLchange (adjusted R2 = 0.10, F (2,77) = 5.37, p < .01) and was significant (p < .05) (Table 3).

 

[SilverbladeTE]

Wouldn't a better conclusion be: CBT should only be provided to patients with high levels of 'neuroticism'?

What, you mean, psychiatrists?

 

[alex3619]

Hmmmm, neuroticism as defined by the DSM? By a bunch of psychs sitting around a beer asking themselves what sounds like a nifty diagnosis? Rigor needs to be returned to psychiatry before we can talk about them defining neuroticism ... not that psychiatric diagnoses have ever been robust.

Its a lot like what little I have read from religious witch-hunters. Some of the people they looked at were obviously sick, but they had no scientific/medical way to determine what was wrong. So they dreamt up various unlikely stories about demons and Satan, which gave the Church credibility and power. As a result they could torture, incarcerate and execute people with impugnity, based on nothing more than official fantasies.

 

[Roy S]

a) House of Cards
b) The Emperor's New Clothes
c) psychological sophistry
d) all of the above
e) none of the above
f) Beam me up, Scotty. This planet sucks.