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Cbt research exposed why people with me are right to be angry

G

Gerwyn

Guest
Patients were recruited from consecutive referrals to a hospital infectious diseases outpatient clinic. All patients aged 18-60 with a major complaint of fatigue were medically assessed by a consultant physician (DW or TP). Those whose symptoms were unexplained by organic disease were reinterviewed by one of us (MS) and a full history and psychiatric diagnostic interview17 completed to determine eligibility for inclusion.


The inclusion criteria specified that patients had to meet the "Oxford" criteria for the chronic fatigue syndrome.3

T




no clinically significant findings on physical examination or laboratory investigation (full blood count, C reactive protein concentration, biochemical measurements, and thyroxine and thyroid stimulating hormone concentrations).

That takes care of any ME patients that could have been present
Cognitive behaviour therapy for the chronic fatigue syndrome: a randomised controlled trial
Michael Sharpe, clinical tutor,a Keith Hawton, senior clinical lecturer,a Sue Simkin, research assistant,a Christina Surawy, research clinical psychologist,a Ann Hackmann, research clinical psychologist,a Ivana Klimes, consultant psychologist,a Tim Peto, consultant physician,b David Warrell, professor of tropical medicine and infectious diseases,b Valerie Seagroatt, statistician c

a University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, b Nuffield Department of Medicine, John Radcliffe Hospital, Oxford, c Unit of Health Care Epidemiology, University of Oxford
Introduction

The chronic fatigue syndrome is characterised by a principal complaint of severe fatigue of at least six months' duration associated with appreciable disability and unexplained by recognised organic disease.1
i THINK THAT ABOUT SAYS IT ALL

h
e required sample size of 60 patients was estimated with the assumption of (a) clinically significant improvement in 20% of the patients who received medical care13 and 60% who also received cognitive behaviour therapy,10 (b) a low drop out rate, and (c) a significance level of 5% and a power of 80%.
SIXTY PATIENTS WITH A POWER OF 80% TOTALLY MEANINGLESS BEFORE WE START


DESIGN
During treatment patients were encouraged to question a simple disease explanation of the illness and to consider the role of psychological and social factors. They were also invited to evaluate the effect of gradual and consistent increases in activity and to try strategies other than avoidance. Additional components of the treatment included strategies to reduce excessive perfectionism and self criticism and an active problem solving approach to interpersonal and occupational
SO IN ENGLISH:

The patients beliefs that their illness was physical was "questioned"b as being to simple(ie wrong)
and to to consider a more complex(correct) explanation
They were told to increase their level of excercise
They were given treatment for the assumed psychological factors involved


Patient functioning was assessed in several ways. The principal measure was based on interviewing the patient about his or her activities over the previous month (corroborated by a cohabitee when possible). A summary of the findings was subsequently rated on the Karnofsky scale
The patients gave subjective accounts of their activity levels over the last month.features of these accounts were given points and recorded on a scale.I,m sure there was no prompting involved here.

Subsidiary measures of fossunctioning included a patient rating of interference with daily activities,23 improvement in employment status, and number of days spent in bed each week. A timed walking test was also included. The patient was asked to walk as quickly as pible along a 20 metre corridor for six minutes and the distance covered recorded.2
So more patient ratings but now asked to walk down a 20 metre corridor!

Symptoms were assessed on patient rated scales. Fatigue was measured on a Likert-type scale scored from zero to 10 and depression and anxiety on the hospital anxiety and depression scale.25
MORE PATIENT RATED SCALES
llness beliefs and coping behaviours were also assessed as process measure
SO IF BELIEFS IN PSYCHOLOGICAL CAUSATION INCREASED THEN PATIENT WAS MAKING PROGRESS

Strength of beliefs about the illness was measured on patient rated seven point Likert-type scales ("totally agree" to "totally disagree") and frequency of coping behaviours (for example, avoiding exercise) on five point patient rated scales ("never" to "all the time"). Patients also indicated their view of the nature of the illness on a five point scale ("entirely physical" to "entirely psychological").2
6



At the final 12 month assessment the percentage of patients who had attained normal functioning (score 80 or more) on the Karnofsky scale was significantly greater in the group who had received cognitive behaviour therapy ( 2=11.3, df=1; P<0.001).
THEY PREDEFINED NORMAL FUNCTIONING AS HAVING A KARNOFSKY FUNCTIONING OF 80.

NORMAL FUNCTIONING DOES NOT MEAN FUNCTIONING NORMAL





ble 3--Principal outcome measures, expressed in percentages
attaining satisfactory outcome, or improvement
---------------------------------------------------------------------
Percentage (No) of
patients improved
----------------------------- Difference in
Cognitive percentage
Time from behavioural (95%
randomisation therapy Medical care confidence
(months) (n=30) (n=30) interval)
--
-------------------------------------------------------------------
Satisfactory outcome on Karnofsky scale+
5 27 (8) 20 (6) 7 (-15 to 28)
8 53 (16) 30 (9) 23 (0 to 48)
12 73 (22) 27 (8) 47 (24 to 69)
Improvement on Karnofsky scale++
5 23 (7) 7 (2) 17 (0 to 34)
8 60 (18) 20 (6) 40 (17 to 63)
12 73 (22) 23 (7) 50 (28 to 72)
---------------------------------------------------------------------
+Achieved final score of 80 or more.
++Improvement from baseline of 10 points or more.
NOW IN A GOOD STUDY THE CONFIDENCE INTERVALS WOULD BE NO MORE THAN 5% EITHER SIDE OF THE MEAN.lOOK HOW WIDE THEY ARE HERE
AT FIVE MONTHS STANDARD MEDICAL CARE MANAGED TO MAKE SOME PATIENTS WORST
AND ONLY GAVE MINIMAL IMPROVEMENT COMPARED TO BASELINE
AT 12 MONTHS ONLY 27% OF PATIENTS SHOWED ANY SUBJECTIVE BENEFIT TO MEDICAL TREATMENT

50% SHOWED SOME SUBJECTIVE BENEFIT

Distance walked in 6 minutes (m)+
Baseline 424 435
5 467 436 43 1 42 (8 to 76)
8 476 436 52 1 51 (14 to 88)
12 481 437 57 2 55 (17 to 94)

+Includes some estimated values. See text.

NOW HOW COULD THEY ACCURATELY MEASURE THE WALKING DISTANCES IN THE MEDICAL TREATMENT GROUP BUT HAD TO GUESS THE VALUES IN THE CBT GROUP.
WHY WERE THE BASELINE WALKING DISTANCES MORE IN THE CONTROL GROUP

CBT ENABLED SOME PATIENTS TO WALK AN ENTIRE 51 METRES FURTHER IN 6 MINUTES BUT WHAT HAPPENED IN THE SIX MINUTES AFTER THAT.THEY STILL WALK FOR ATOTAL TIME OF 6 MINUTES

NOTICE NO P VALUES HERE !


this trial cognitive behaviour therapy was both acceptable and more effective than medical care alone in improving patients' day to day functioning in the medium term (though not in the short term). It was also more effective in helping patients to feel better. Though the overall treatment effect was substantial, few patients reported complete resolution of symptoms and not all improved. Predictors of response to cognitive behaviour therapy will be the subject of a separate report.
The difference between the treatment groups at the final assessment was clinically important. Not only was the end point on the principal measure (Karnofsky score) predetermined for its clinical significance but similar clinically relevant changes were found on other objective and self rated measures. This difference can also confidently be attributed to the cognitive behaviour therapy, as randomisation achieved well balanced groups at baseline, all patients were included in the analysis, and there were no measurable differences between the groups in the other treatments received. Furthermore, the specificity of the treatment effect was supported by the observation that relevant illness beliefs and coping behaviour changed more in the patients given cognitive behaviour therapy.