NEWS - Trial of cognitive behavioral therapy in CFS sparks criticism

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Trial of cognitive behavioral therapy in CFS sparks criticism

Rheumawire

Jan 20, 2005

Zosia Chustecka

Nijmegen, the Netherlands - A clinical trial in adolescents with chronic

fatigue syndrome (CFS) that concludes cognitive behavioral therapy (CBT) is

an " effective treatment " has been harshly criticized. Several researchers

are questioning what " effective " means, considering many of the participants

continue to have symptoms and are unable to attend school. The trial has

also sparked a debate about the ideology behind the CBT approach to this

condition, which is based on the underlying belief that CFS is a

psychosomatic illness, say critics.

The trial was carried out by Dr Maja Stulemeijer (Expert Centre for Chronic

Fatigue, Nijmegen University, the Netherlands) and colleagues, reported

online December 7, 2004 in BMJ and published in the January 1, 2005 issue

[1]. The criticisms appear as email rapid responses.

Stulemeijer et al explain that CBT has already been shown to be effective in

adults with chronic fatigue syndrome in several randomized controlled

trials, but this is the first controlled study to be carried out in

adolescents. The participants in the trial were aged between 10 and 17.2

years (to allow completion of the study before they reached 18).

" Development of potentially effective interventions is especially important

in young people to avoid prolonged absence from school and restricted social

activities, which threaten healthy development, " the researchers comment.

Sixty-nine adolescents were randomized either to receive CBT (carried out in

10 individual sessions over 5 months) or to a waiting list. In addition, the

adolescents were divided into 2 groups depending on their level of activity.

The majority were considered to be " active patients " (70% of those assigned

to CBT and 79% of those on the waiting list). They were relatively active

and alternated between periods of activity and periods of rest, and they

were taught to recognize and accept their current state of fatigue and

impairment, the researchers explain. " Subsequently, they reduced their

levels of activity and learned to respect the limitations. After achieving

this balance, the patient started to build up activity levels. "

The other group of " passive patients " (30% of CBT and 21% on a waiting list)

spent most of their time lying down and went out infrequently. Most did not

attend school. " We started a systematic program of building activity as soon

as possible, " the researchers comment, after " challenging their beliefs that

activity would aggravate symptoms. "

Stulemeijer and colleagues report that CBT was more effective than remaining

on a waiting list in reducing the severity of fatigue, improving physical

functioning, and increasing school attendance. Almost 60% of those in the

CBT group returned to full time education, an important indication of

recovery, they comment. Treatment resulted in a greater proportion of

patients with clinically significant change in these variables, more

self-reported improvement, and a significant reduction in several additional

symptoms. However, many of the young people continued to report additional

symptoms, but the researchers comment that " a complete resolution of

additional symptoms is not a requirement of recovery, as has been suggested

before. " Passive and active patients showed equal improvement on all primary

outcome variables.

Stulemeijer et al conclude that CBT is an effective treatment for chronic

fatigue syndrome in adolescents and add that these results endorse the

findings of previous studies on the efficacy of CBT for adults with this

condition.

But several correspondents take issue with this conclusion. " In my day,

'effective' meant more than 'useful to a degree,' " writes Ellen Goudsmit, a

psychologist trained in behavioral therapy based in Teddington, UK. She

points out that at the end of the trial, over 42% of adolescents were still

unable to go to school full-time and the mean physical functioning score

remained below normal. In addition, about 30% of the participants did not

rate themselves as improved. And only some symptoms were alleviatedfatigue,

sleep, and muscle pain improved, but there was little change in others such

as impaired concentration and memory, tiredness after exercise, headache,

sore throat, and sensitive lymph nodes.

Abhijit Chaudhuri, senior lecturer in clinical neurosciences at the

University of Glasgow, Scotland, criticizes several aspects of the study.

There was a high dropout rate (nearly 20% in the intervention arm), and the

control group on the waiting list could have been offered contact with

health professionals but not CBT, as it may have been this regular contact

itself that was beneficial. " This study does not have the strength to

conclude that CBT is an effective treatment for chronic fatigue in

adolescents, " Chaudhuri says, and he expects an amendment regarding this

conclusion from the authors and/or editors. " Failure to do so would

perpetuate the view that the BMJ has a selective bias toward research that

supports a psychological view of chronic fatigue syndrome irrespective of

the quality of the presented material. "

The researchers " construct a meaning of 'recovery' as still having

symptoms, " and this is " ludicrous, " says Kennedy, a lecturer in

social science (Essex, UK). Assigning the discursive categories of " active "

and " passive " suggests that functional impairment is somehow " optional, "

which is " a clear betrayal of the researchers' ideological assumptions, " she

says. The authors quite obviouslyfrom their narrative subscribe to the

belief that CFS is a psychosomatic illness and assume that young people with

CFS have perpetuating health beliefs about their illness that need to be

challenged, she adds. And the list of references contains an abundance of

papers produced by proponents of the psychiatric paradigm of CFS.

Kennedy says the authors " therefore hold a specific ideological standpoint

which is contested, but which means they also hold certain assumptions that

bias their research approach. They believe that their patients have a

psychosomatic illness that can be 'cured' or that 'recovery' from such

illness can be effected by challenging their patients' 'illness beliefs.'

This approach cannot be proven as a definitive success and has been shown to

be potentially harmful. "

Goudsmit comments that " yet another " study on CBT isn't needed, especially

if there are no immunological and neurological measures. " We already have a

considerable amount of information on the effectiveness of CBT and what we

need now is more biomedical research, " she says. " We need to focus our

attention on developing a diagnostic test and evaluating new antiviral

drugs. "

Stulemeijer and the lead author, Gils Bleijenberge (professor of psychology,

Expert Centre for Chronic Fatigue, Nijmegen University), when approached by

rheumawire about these criticisms, commented: " Studies on CBT for CFS have

always led to a lively debate, and our study indeed is no exception. "

They responded to the criticisms as follows: " First of all, we believe that

our study clearly shows that many of the participants benefited from CBT.

Many of the participants of our study were able to function as normal

adolescents at the end of treatment, whereas many youngsters on the waiting

list still experienced substantial limitations in daily functioning. To name

a few results, after 10 sessions of CBT, 71% of the youngsters reported to

be completely recovered or to feel much better, and 60% attend school full

time. Furthermore, unpublished follow-up shows that the results are

maintained at least 3 months after the end of therapy even in the absence of

contacts with the therapist. Because CBT has led to large improvements in a

substantial portion of all patients in our study, we conclude that CBT can

be effectively applied to treat adolescents with CFS. We agree that CBT is

not a cure for all CFS patients. As in other chronic conditions, no 1

therapy leads to recovery in all patients or establishes the same effect for

all patients. "

" Second, we would like to stress that the assumption of several respondents

that we consider CFS to be a psychological condition because we treat

patients with a primarily psychological approach is incorrect. The views

expressed enforce the old paradigm in which diseases or complaints were

considered as somatic or psychogenic in origin. We do not deny that physical

factors, such as a virus, may have caused the CFS symptomatology, but we do

believe that once the illness has started, its expression is affected by

beliefs, coping styles, and behaviors; also, physiological and other

psychological processes may act in some way or the other to maintain and/or

modify the disease process. This view is based on extensive empirical

evidence yielded by our own research group as well as by others. Our

research group has always applied such a biopsychosocial approach to study

CFS and applies many different techniques to explore mechanisms in CFS

symptoms. Therefore we are also busy trying to detect the neurobiological

mechanisms in CFSfor example, by investigations with functional and

structural magnetic resonance imaging, with clinical neurophysiological

investigations, and with research into the serotonergic system. "

However, they emphasize that " CBT is aimed at influencing factors that are

repeatedly found to be involved in the perpetuation of symptoms in CFS " and

point out that " at present, there are no evidence-based treatments available

for adolescents with CFS, and our study is the first systematic and

controlled evaluation of CBT for CFS in adolescents. "

Stulemeijer and Blenijenberg tell rheumawire, " We hope that scientists from

different fields and with different methods continue to put effort in

finding ways to help youngsters with CFS overcome this debilitating

condition and enable them to live their lives like healthy teens. Because in

the end, isn't that what it's all about? "

Source

Stulemeijer M, de Jong LWAM, Fiselier TJW, et al.

Cognitive behavioural therapy for adolescents with chronic fatigue syndrome:

randomised controlled trial. BMJ 2005; 330:14.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org