CFS, FM, and related illnesses: a clinical model of assessment and intervention.

[leelaplay]

J Clin Psychol. 2010 Feb 22. [Epub ahead of print]

Chronic fatigue syndrome, fibromyalgia, and related illnesses: a clinical model of assessment and intervention.

(if: It would be interesting to see the full article. For those who don't know, I think Dr F Friedberg is still the president of the IACFSME. My spacing and bolds.)

Friedberg F.

Stony Brook University.

A clinically informative behavioral literature on chronic fatigue syndrome (CFS) and fibromyalgia (FM) has emerged over the past decade. The purpose of this article is to

(a) define these conditions and their less severe counterparts, i.e., unexplained chronic fatigue (UCF) and chronic widespread pain;

(b) briefly review the behavioral theory and intervention literature on CFS and FM; and

(c) describe a user-friendly clinical model of assessment and intervention for these illnesses. The assessments described will facilitate understanding of the somewhat unusual and puzzling somatic presentations that characterize these patients.

Using an individualized cognitive-behavioral approach the mental health clinician can offer significant help to these often stigmatized and medically underserved patients.

(c) 2010 Wiley Periodicals, Inc. J Clin Psychol 66:1-25, 2010.

PMID: 20186721 [PubMed - as supplied by publisher]

 

[Dolphin]

J Clin Psychol. 2010 Feb 22. [Epub ahead of print]

Chronic fatigue syndrome, fibromyalgia, and related illnesses: a clinical model of assessment and intervention.

(if: It would be interesting to see the full article. For those who don't know, I think Dr F Friedberg is still the president of the IACFSME. My spacing and bolds.)

Friedberg F.

Stony Brook University.

A clinically informative behavioral literature on chronic fatigue syndrome (CFS) and fibromyalgia (FM) has emerged over the past decade. The purpose of this article is to

(a) define these conditions and their less severe counterparts, i.e., unexplained chronic fatigue (UCF) and chronic widespread pain;

(b) briefly review the behavioral theory and intervention literature on CFS and FM; and

(c) describe a user-friendly clinical model of assessment and intervention for these illnesses. The assessments described will facilitate understanding of the somewhat unusual and puzzling somatic presentations that characterize these patients.

Using an individualized cognitive-behavioral approach the mental health clinician can offer significant help to these often stigmatized and medically underserved patients.

(c) 2010 Wiley Periodicals, Inc. J Clin Psychol 66:1-25, 2010.

PMID: 20186721 [PubMed - as supplied by publisher]

I like some of his analyses and criticisms e.g. not everyone is underactive.

But at the same time, there is no mention of viruses or infections in the whole piece including here (not even in the triggering factors!):

It has been argued that the above principles of behavioral intervention may not fully
address the psychosocial dimensions and mind–body complexities of these illnesses
(Friedberg, 2008). Relevant to this point, a recent biopsychosocial model of CFS and
FM (Van Houdenhove & Egle, 2004; Van Houdenhove, Neerinckx, Onghena, Lysens,
& Vertommen, 2001) offers a more comprehensive view of these illnesses based on a
number of interactive etiological factors:

(a) genetic/environmental interactions, as
supported by recent studies in CFS reporting defects in genes associated with
adaptation to stress (e.g., Smith, White, Aslakson, Vollmer-Conna, & Rajeevan, 2006)
and studies in FM reporting early adversities such as sexual abuse (e.g., Van
Houdenhove et al., 2001);

(b) stress-producing personality styles characterized by an
overactive, hyperachievement orientation, and lack of emotional openness (Anderberg,
Marteinsdottir, Theorell, & Von Knorring, 2000; Egle et al., 1989; Johnson, Panaanen,
Rahinatti, & Hannonen, 1997; Van Houdenhove et al., 2001; Ware, 1993);
and
(c) proximal triggering factors including physical or emotional trauma, lack of support,
and daily hassles (Van Houdenhove & Egle, 2004).

He believes if you are in the 1/4 who are less active, you should simply do more. I don't think it is a simple as that at all. He has pushed this line before.

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Therapeutic Goals

The overarching goal of the cognitive-behavioral intervention outlined here is to help
the patient achieve a healthy balance between activity, rest, and leisure (Bleijenberg
et al., 2003; Friedberg, 2006; Friedberg & Sohl, 2009a; Jason et al., 2007). The
therapeutic techniques that will bring about a desirable balance between activity and
rest are informed by the patterns of activity and affect identified in the clinical
assessment.

Based on the three most commonly encountered types of activity patterns (above),
these types of changes would be recommended:

1. The up-and-down pattern may require moderating activity during periods of high
energy, whereas down times are focused on gradually increasing activity levels.
Thus, daily activity and energy levels are stabilized between these maladaptive
extremes. As stabilization occurs, consistent daily activity (including more loweffort
pleasant activities) can be incrementally increased to the highest sustainable
level that does not trigger symptom or stress flare-ups.

2. A sustained high-activity pattern may require a reduction of stress and/or a
moderation of activity levels in combination with increased low-effort pleasant
activities.

3. A low-level activity pattern may be modified with gradual increments in regular
daily activity and increased exposure to pleasant events.

For patterns 1 and 2, behavioral prescriptions typically involve substitution of
voluntary, stress-reducing activities (e.g., low-effort activities such as short-duration
daily walking plus other low-effort pleasant activities) for more obligatory stressexacerbating
activities (e.g., additional work hours, housework; cf. Friedberg, 2002).

For the low-activity pattern, gradually increased activity levels would replace general
inactivity.

Here are two examples of the sort of analysis/review of the literature in it that I find interesting:

Evidence for Fear-Based Activity Avoidance

People with CFS in comparison to sedentary controls do not have exercise phobia
(greater anticipatory anxiety, heart rate, GSR) when tested on an incremental
treadmill test (Gallagher, Coldrick, Hedge, Weir, & White, 2005) nor are they more
physically deconditioned in comparison to healthy controls (Bazelmans et al., 2001).
However, in a subsequent CFS study (Silver et al., 2002), a kinesiophobia (fear of
movement) self-report measure (TSK-F) did correlate significantly with distance
traveled on an exercise bicycle. The TSK-F explained 12% of the variance in exercise
performance, i.e., the avoidance of exercise. On the other hand, in a later study in
CFS patients (Nijs, Vanherberghen, Duquet, & De Meirleir, 2004), no significant
associations were found between pain-related fear of movement and exercise
capacity and disability in patients with high fears of activity.

Clinical Significance of CBT
Clinical significance of CBT outcomes would be confirmed by improvement to
normative functioning in daily life or by large pre–post changes, say >.5 standard
deviation, in the primary outcome measure (Ogles, Lunnen, & Bonesteel, 2001).
Often, in CBT studies for patients with CFS and FM, the standard of improvement
has been the finding of statistical significance of outcomes for fatigue, pain, or
functioning. Yet more recently, attempts to develop and test standards of clinical
significance in CFS (Friedberg & Sohl, 2009a) and FM (Asenlof, Denison, &
Lindberg, 2006) have been published. The clinical importance standard is a much
more impressive (and much less debatable) indication of substantive improvement.

In addition, the absence of in vivo measures in CBT trials leaves open to question
what types of changes occurred in the patient’s home environment. For instance, did
patients’ actual activity levels increase, as assumed in graded activity oriented
interventions, or was activity change simply inferred from self-report measures? Of
equal importance, did patients’ role status change with respect to employment,
relationships, etc.? A not unreasonable conclusion from the CFS literature is that
patients learned to cope better with symptoms (e.g., less catastrophizing) and
lowered their performance expectations, rather than exhibiting empirically verifiable
functional improvements (Whiting et al., 2001).

[..]

In sum, findings of statistical improvement on standard self-report measures in
behavioral interventions need to be considered in light of the important, but often
neglected issues of clinical significance and the assessment of in vivo outcomes. Thus,
conclusions about treatment efficacy should be tempered by some reasonable
concern about these potentially important factors.