"Chronic Fatigue Syndrome" by Chalder in The Wiley Handbook of Cognitive Behavioral Therapy

[Dolphin]

Chronic Fatigue Syndrome
Part Two. Specific Disorders

1. Trudie Chalder

Published Online: 29 NOV 2013

DOI: 10.1002/9781118528563.wbcbt23

Book Title


The Wiley Handbook of Cognitive Behavioral Therapy
Abstract

Chronic fatigue syndrome is characterized by severe fatigue and is associated with profound disability.

Cognitive behavioral therapy and graded exercise therapy are the treatments for which there is most evidence.
Results from a large randomized controlled trial found that both cognitive behavioral therapy and graded exercise therapy were superior to adaptive pacing therapy.

About 20% of people recover and it is important clinically to share this optimistic message with patients.

Evidence suggests that people's perceptions are important in mediating change in fatigue and physical functioning for both cognitive behavioral therapy and graded exercise therapy.

Keywords:

• chronic fatigue syndrome;
• cognitive behavioral therapy

Useful article if anyone needs reminding that the CBT model for CFS is annoying.

 

[Dolphin]

I have heard that the article is available on http://www.sci-hub.cc/

 

[Dolphin]

Diagnosis

There are no unequivocal diagnostic signs or symptoms of CFS. The clinical evaluation of chronically fatigued patients is aimed at excluding underlying medical or psychiatric causes of fatigue. In individuals with fatigue of more than 6 months’ duration, a thorough history, physical examination, routine laboratory tests (full blood count, erythrocyte sedimentation rate, renal, liver, and thyroid function, and urinary protein and glucose), and mental state examination are sufficient to reach a diagnosis of CFS in most cases. Where abnormalities are revealed on physical or laboratory investigation, further investigations can be helpful (serological tests for Epstein–Barr virus, cytomegalovirus, Q fever, toxoplasmosis, and HIV; chest X-ray, rheumatoid factor, and antinuclear factor) but should otherwise be limited to avoid the risk of iatrogenic harm. Specialist referral should be limited to situations where there is an increased probability of an alternative diagnosis.

 

[Dolphin]

A wide range of factors may act to perpetuate chronic fatigue. Coping responses to acute fatigue are important determinants of prolonged fatigue: Extreme physical activity after an acute illnessmay allow insufficient time for recovery whereas prolonged bed rest may cause physical deconditioning and further exacerbate symptoms. Illness beliefs and the attribution of symptoms to a physical cause, with minimization of psychological or personal contributions, are also important and have been related to increased symptoms and worse outcomes in CFS (see Chalder & Hill, 2012, for a review). Similarly, catastrophic beliefs that exercise will be damaging or worsen symptoms lead to the avoidance of physical and mental activities and greater disability (Petrie, Moss-Morris, & Weinman, 1995). Disrupted sleep patterns resulting from excessive daytime rest may contribute to fatigue, muscle pain, and poor concentration.

The response and attitudes of others are also important in determining the course of fatigue. Overly concerned carers may reinforce patients’ maladaptive beliefs and coping strategies by inadvertently encouraging disability. Skeptical or stigmatizing reactions from relatives, health professionals, or work colleagues can cause frustration and leave the patient feeling isolated and unsupported (Deale & Wessely, 2001; Van Houdenhove et al., 2002).

 

[Dolphin]

Surawy, Hackmann, Hawton, and Sharpe (1995) described a cognitive model of understanding CFS. They suggested that a patient’s interpretation of somatic symptoms such as fatigue as being physical as opposed to psychological was vital for the development and continuation of the disorder. The model advocated that these physical illness attributions may have evolved as a consequence of childhood experiences in which the expression of negative emotion would have been met with unsympathetic or hostile responses. The model proposed that a somatic attribution (attributing symptoms to a physical cause) makes the patient’s symptoms and illness easier to understand. The diagnosis of CFS, in a sense, can be seen as a protective mechanism that the individual has employed in order to preserve identity and selfesteem. Over time the individual’s focus on the symptom of fatigue leads him or her to try and control it. The downside to this is that the individual then purportedly gets into a vicious circle in which the desire to control symptoms leads to avoidance in general. Although avoidant coping strategies may help in the short term, the longterm consequences are potentially extremely unhelpful. The side effects of behavioral avoidance or inactivity are well understood, whether related to disease processes or not.

 

[Dolphin]

Previous trauma in childhood is associated with CFS in adulthood, and making links between trauma and fatigue may be helpful during the process of therapy.

 

[Dolphin]

The engagement section appears to suggest that the therapist disguises or hides from the patient what the therapist thinks.

 

[Dolphin]

Initially, keeping a diary of activity and sleep patterns will highlight areas of inconsistency. These are used to set goals with a view to establishing a consistent level of activity every day regardless of symptoms.

A recipe for problems with this illness I think.

 

[Dolphin]

Modifying Negative and Unhelpful Thinking

The initial aim of this component is to prevent unhelpful thoughts from blocking progressive increases in activity.

 

[Dolphin]

Others may be on state benefits, which makes recovery more difficult.

 

[duncan]

In what world is a 20% recovery rate an "optimistic message"?

 

[Dolphin]

In the first instance, the therapist should support the patient’s point of view, thus accepting and working with his or her attributions of cause and control. Therapeutic change can then occur slowly without arousing too much dissonance
(Kirmayer, 1990).

How they sneakily try to change people.

 

[Dolphin]

The PACE Trial is mentioned including the very dubious recovery figures:

The recently published PACE trial found that CBT and GET were more effective in reducing both fatigue and physical disability than adaptive pacing therapy, when each was added to specialist medical care, and more effective than specialist medical care alone (White et al., 2011). Recovery was defined operationally using multiple criteria, and compared the proportions of participants meeting each individual criterion as well as two composite criteria, defined as (a) recovery in the context of the trial, and (b) clinical recovery from the current episode of the illness, however defined, both at 52 weeks after randomization. The percentages (number/total) meeting trial criteria for recovery were 22% after CBT and after GET, 8% after adaptive pacing therapy, and 7% after specialist medical care. Similar proportions met criteria for clinical recovery. The odds ratio (OR, 95% CI) for trial recovery after CBT was 3.36 (1.64, 6.88) and for GET 3.38 (1.65, 6.93), when compared to adaptive pacing therapy. This confirmed that recovery from CFS is possible, and that CBT and GET are the therapies most likely to lead to recovery (White, Goldsmith, Johnson, Chalder, & Sharpe, 2013).

More recent evidence suggests that recovery from CFS is possible and that CBT and GET are the therapies most likely to lead to recovery (White et al., 2013).

 

[alex3619]

The engagement section appears to suggest that the therapist disguises or hides from the patient what the therapist thinks.

I think this is called the Benevolent Lie.

 

[alex3619]

So, speculation and theory equal fact?

 

[JaimeS]

"Coping responses to acute fatigue are important determinants of prolonged fatigue: Extreme physical activity after an acute illnessmay allow insufficient time for recovery whereas prolonged bed rest may cause physical deconditioning and further exacerbate symptoms."

Wonder what they'd make of me: I've neither pushed nor retreated to my bed. I go for short walks every day so my muscles don't atropy (I'm aware this isn't in everyone's capacity: I've graduated to 'very minor' ME). Fascinating, the way I'm still sick, though, eh? Despite following this advice to the letter!

"Illness beliefs and the attribution of symptoms to a physical cause, with minimization of psychological or personal contributions, are also important and have been related to increased symptoms and worse outcomes in CFS (see Chalder & Hill, 2012, for a review). Similarly, catastrophic beliefs that exercise will be damaging or worsen symptoms lead to the avoidance of physical and mental activities and greater disability (Petrie, Moss-Morris, & Weinman, 1995). Disrupted sleep patterns resulting from excessive daytime rest may contribute to fatigue, muscle pain, and poor concentration"

I don't sleep during the day, either, or even lie down, on 9 days of 10. Fascinating, the way I'm still sick, eh? Despite following this advice to the letter!

In other news, I love how they can only cite themselves and research that's 20+ years old... before all that pesky biomedical stuff came out.

"The response and attitudes of others are also important in determining the course of fatigue. Overly concerned carers may reinforce patients’ maladaptive beliefs and coping strategies by inadvertently encouraging disability. Skeptical or stigmatizing reactions from relatives, health professionals, or work colleagues can cause frustration and leave the patient feeling isolated and unsupported (Deale & Wessely, 2001; Van Houdenhove et al., 2002)."

Everyone knows that sympathy is the worst for chronic illness. Ensure that they KNOW that if they continue to be ill -- a drain on society -- even their friends and family will abandon them. It's this kind of 'tough love' that sends UK patients off to be sectioned, which is clearly just best for everyone.

"The model advocated that these physical illness attributions may have evolved as a consequence of childhood experiences in which the expression of negative emotion would have been met with unsympathetic or hostile responses."

...my family encouraged the expression of emotion. No one in my family is emotionally stunted / limited: we're very open, emotionally. Fascinating, the way I'm still sick, eh? Despite not having my emotional responses met with hostility as a child!

"The model proposed that a somatic attribution (attributing symptoms to a physical cause) makes the patient’s symptoms and illness easier to understand."

We're apparently morons as well, and can't 'grasp' the delicate and complex nature of the way that our beliefs can cause dramatic shifts in our blood tests and such. Well, all right; that's accurate. I have trouble grasping how anybody could believe in that if I close my eyes and think happy thoughts -- with the help of Chalder's magic pixie dust... I'll be able to fly!

I also WISH the biomedical aspects were 'easy to understand.' Also, if they are, why doesn't Chalder understand them as we all do?

"Previous trauma in childhood is associated with CFS in adulthood, and making links between trauma and fatigue may be helpful during the process of therapy."

My favorite is that I know patients who insisted they had no childhood trauma during therapy sessions. The therapists' response?

"You must've suppressed it." = (If my conception does not match my pre-approved reality, reality is incorrect. Is this a healthy stance, psychologically?)

"Others may be on state benefits, which makes recovery more difficult."

Wowww. (I'm amazed it took me that long to get to that particular emoji.)

"In the first instance, the therapist should support the patient’s point of view, thus accepting and working with his or her attributions of cause and control. Therapeutic change can then occur slowly without arousing too much dissonance (Kirmayer, 1990)."

Again, citations from ages ago, as well as being creepily insistent on techniques that read as brainwashing: "agree with the patient. Make them your friend. Slowly shift their perception of reality until it matches yours..."

Preceded by "this works in 1 of 5 patients"!

I guess those are the percentage naturally susceptible to suggestion.

D'you know who I always think of when I see or hear about this lady?

Chalder seems like just the sort of creature who'd really (pretend to) believe it was in your best interest to carve I must not tell lies into your hand to remind you that her reality supercedes yours every time you glance down. Chalder's motivation appears to be to punish patients for not conforming to the societally-acceptable mold of which she believes she is the only right and proper example. If electroshock were still common, she would relish dishing it out while claiming it was best for patients.

I found Umbridge's character far creepier than Voldemort, personally, because people like her are recognizable IRL: they often end up high in government or politics because they know how to present a facade of respectability in front of 'the right people.'

You guys know me, I am seldom this condemnatory, but I can't possibly come up with a fairer reply after reading what appears to be a direct, hateful, intentional assault on patients under the guise of a sweet let me HELP you. She must deeply despise her patients and test subjects.

And if she isn't aware of that, she must be suppressing it.

-J

 

[Esther12]

Thanks for the notes on this. It was one of those things I'd been meaning to find a copy of for ages. Sounds like it is worth a read.

 

[JaimeS]

So, speculation and theory equal fact?

The important part is, @alex3619 , that Umbridge's mythos is better than your hypotheses, because she herself is better than all patients put together.

Sorry, I'm calling her that from now on...

 

[GreyOwl]

So, speculation and theory equal fact?

Only if the person speculating and theorising is a proponent of BPS theory.

 

[taniaaust1]

I think this is called the Benevolent Lie.

Maybe they should be writing a section in their books on how this kind of lying causes distrust between them and their patients once they are found out. Also leads to ME patients then not trusting other doctors either.