Generalized Worry in Patients With Chronic Fatigue Syndrome Following Cognitive Behavioral Therapy: A Prospective Cohort Study in Secondary Care

Research has shown that generalized anxiety disorder is commonly associated with Chronic Fatigue Syndrome (CFS). This prospective cohort study aimed to investigate the prevalence of generalized worry in CFS patients and its relationship with fatigue, anxiety and social functioning, before and after Cognitive Behavioral Therapy (CBT). Our cohort consisted of 470 patients diagnosed with CFS who received CBT at a secondary care, specialist clinic. Patients completed self-report measures investigating levels of generalized worry, fatigue, work and social adjustment, anxiety and depression at baseline (pretreatment), discharge from treatment, 3-month and 6-month follow up (posttreatment). Analysis indicated a high prevalence of generalized worry (72.4%) at assessment. A significant reduction in worry following CBT (M = −3.42, p < .001, 95% CIs: 2.26, 4.57) was observed at discharge, which remained stable at follow-up. Severe baseline worriers had greater overall fatigue score (M = 3.74, p = .026, 95% CIs: .33, 7.15) and worse overall work and social adjustment than mild worriers across time-points (M = 5.42, p = .035 95% CIs: .27, 10.58). Avoidance behavior mediated the association between generalized worry and work and social adjustment (95% bootstrap CIs: 013, .080). The majority of patients with CFS had comorbid generalized worry and severe worriers reported greater fatigue, anxiety, and worse work and social adjustment. This suggests that CFS patients may benefit from targeting generalized worry during CBT.     

Therapist effects and the dissemination of cognitive behavior therapy for chronic fatigue syndrome in community-based mental health care

ObjectiveThe purpose of the present study was to explore the role of the therapist in the dissemination of manualized cognitive behavior therapy (CBT) for chronic fatigue syndrome (CFS) outside specialized treatment settings.MethodWe used the routinely collected outcome data of three community-based mental health care centers (MHCs) which implemented and sustained CBT for CFS during the course of the study. Ten therapists, who all received the same training in CBT for CFS, and 103 patients with CFS were included.ResultsRandom effects modeling revealed a significant difference in mean post-treatment fatigue between therapists. The effect of the therapist accounted for 21% of the total variance in post-treatment fatigue in our sample. This effect could be explained by the therapists’ attitude toward working with evidence-based treatment manuals as well as by the MHC where CBT for CFS was delivered.ConclusionThe context in which CBT for CFS is delivered may play an important role in the accomplishment of established therapy effects outside specialized treatment settings. Due to the small sample size of MHCs and the different implementation scenarios in which they were engaged, our findings should be interpreted as preliminary results which are in need for replication.     

Cognitive behavioural treatment for chronic fatigue syndrome in a rehabilitation setting: effectiveness and predictors of outcome

Cognitive behavioural therapy (CBT) was combined with graded exercise therapy (GET) for patients with chronic fatigue syndrome (CFS) in an uncontrolled implementation study of an inpatient multidisciplinary group therapy. During the intake procedure, 160 CFS patients completed a questionnaire on fatigue related measurements, physical impairment, depression, somatic and psychological attributions, somatic focus, and sense of control over symptoms. Pre-treatment physical activity level was measured with an actometer. At baseline, post-treatment and 6-month follow-up individual strength, subjective fatigue and physical impairment, were reassessed. Large effect sizes were found on subjective fatigue (1.2 post-treatment; 1.2 follow-up) and physical impairment (−.9 post-treatment; −.9 follow-up), Clinically significant improvement was found in 33.8% of the participants at post-treatment and 30.6% at follow-up. Individual strength at post-treatment was predicted by level of physical activity before treatment, and by sense of control over symptoms and physical activity at follow-up. Clinically significant improvement in subjective fatigue was predicted by not receiving a disablement insurance benefit, shorter duration of fatigue, higher sense of control over symptoms and, at follow-up by more pre-treatment physical activity. In conclusion, the intervention was effective for CFS patients. Cognitive behavioural factors that perpetuate fatigue symptoms are also predictors of treatment outcome.     

Family-focused cognitive behaviour therapy versus psycho-education for adolescents with chronic fatigue syndrome: Long-term follow-up of an RCT

The aim of this study was to investigate the long term efficacy of family-focused cognitive behaviour therapy (CBT) compared with psycho-education in improving school attendance and other secondary outcomes in adolescents with chronic fatigue syndrome (CFS). A 24 month follow-up of a randomised controlled trial was carried out. Participants received either 13 one-hour sessions of family-focused CBT or four one-hour sessions of psycho-education. Forty-four participants took part in the follow-up study. The proportion of participants reporting at least 70% school attendance (the primary outcome) at 24 months was 90% in CBT group and 84% in psycho-education group; the difference between the groups was not statistically significant (OR = 1.29, p = 0.80). The proportion of adolescents who had recovered in the family-focused CBT group was 79% compared with 64% in the psycho-education, according to a definition including fatigue and school attendance. This difference was not statistically significant (Fisher's exact test, p = 0.34). Family-focused CBT was associated with significantly better emotional and behavioural adjustment at 24 month follow-up compared to psycho-education, as reported by both adolescents (F = 6.49, p = 0.02) and parents (F = 4.52, P = 0.04). Impairment significantly decreased in both groups between six and 24 month follow-ups, with no significant group difference in improvement over this period. Gains previously observed for other secondary outcomes at six month follow-up were maintained at 24 month follow-up with no further significant improvement or group differences in improvement. In conclusion, gains achieved by adolescents with CFS who had undertaken family-focused CBT and psycho-education generally continued or were maintained at two-year follow-up. The exception was that family-focused CBT was associated with maintained improvements in emotional and behavioural difficulties whereas psycho-education was associated with deterioration in these outcomes between six and 24-month follow-up.     

A pilot randomised controlled trial of an Internet-based cognitive behavioural therapy self-management programme (MS Invigor8) for multiple sclerosis fatigue

The majority of people affected by Multiple Sclerosis (paMS) experience severe and disabling fatigue. A recent randomised controlled trial (RCT) showed that cognitive behaviour therapy with a clinical psychologist was an effective treatment for MS fatigue. An Internet-based version of this intervention, MS Invigor8, was developed for the current study using agile design and input from paMS. MS Invigor8 includes eight tailored, interactive sessions. The aim was to test the feasibility and potential efficacy and cost-effectiveness of the programme in a pilot RCT. 40 patients were randomised to MS Invigor8 (n=23) or standard care (n=17). The MS Invigor8 group accessed sessions over 8-10 weeks and received up to three 30-60min telephone support sessions. Participants completed online standardised questionnaires assessing fatigue, mood, quality of life and service use at baseline and 10 weeks follow-up. Large between group treatment effects were found for the primary outcomes of fatigue severity (d=1.19) and impact (d=1.02). The MS Invigor8 group also reported significantly greater improvements in anxiety, depression and quality-adjusted life years. These data suggest that Internet-based CBT may be a clinically and cost-effective treatment for MS fatigue. A larger RCT with longer term follow-up is warranted.     

Is cognitive behaviour therapy for chronic fatigue syndrome also effective for pain symptoms?

Patients with chronic fatigue syndrome (CFS) frequently report chronic pain symptoms. Cognitive behavioural therapy (CBT) for CFS results in a reduction of fatigue, but is not aimed at pain symptoms. In this study, we tested the hypothesis that a successful treatment of CFS can also lead to a reduction of pain. The second objective was to explore possible mechanisms of changes in pain. The third objective was to assess the predictive value of pain for treatment outcome. Data from two previous CBT studies were used, one of adult CFS patients (n=96) and one of adolescent CFS patients (n=32). Pain severity was assessed with a daily self-observation list at baseline and post-treatment. The location of pain in adults was assessed with the McGill Pain Questionnaire (MPQ). Patients were divided into recovered and non-recovered groups. Recovery was defined as reaching a post-treatment level of fatigue within normal range. Recovered adult and adolescent CFS patients reported a significant reduction of pain severity compared to non-recovered patients. Recovered adult patients also had fewer pain locations following treatment. The decrease in fatigue predicted the change in pain severity. In adult patients, a higher pain severity at baseline was associated with a negative treatment outcome.     

Cognitive Behavior Therapy for Relatively Active and for Passive Chronic Fatigue Syndrome Patients

In chronic fatigue syndrome (CFS), facilitating, initiating, and perpetuating factors are distinguished. Although somatic factors might have initiated symptoms in CFS, they do not explain the persistence of fatigue. Cognitive behavior therapy (CBT) for CFS focuses on factors that perpetuate and prolong symptoms. Recently it has been shown that, based on their level of activity, two groups of patients can be distinguished. For so-called “relatively active” CFS patients, the main perpetuating factors are nonaccepting and demanding cognitions leading to bursts of activity. For so-called “passive” CFS patients, their fear that activity might worsen their symptoms (which results in an avoidance of activity) is the most important perpetuating factor. These differences in perpetuating factors result in separate treatment manuals for relatively active and for passive CFS patients. Before describing the treatment manuals, we outline basic assumptions, considerations before starting CBT for CFS, and ways to determine the activity pattern.     

Causal Attributions,Perceived Control,and Psychological Adjustment: A Study of Chronic Fatigue Syndrome1

Causal attributions control, beliefs, and helpful and unhelpful support attempts were examined among people experiencing chronic fatigue syndrome (CFS) and their close others. Results revealed that 84% of respondents with CFS believed that their illness was due, at least in part, to physical or external causes, whereas 47% mentioned internal/psychological causes. Reports of internal causal attributions for CFS were positively correlated with indicators of poor psychological adjustment among those with CFS. Having an external locus of control (i.e., to powerful others) was also associated with poorer psychological adjustment among respondents with CFS. Close others' causal attributions to internal factors were related to frequency of self‐reported unhelpful support attempts and to reports of depression and anxiety those respondents with CFS.     

A pilot study of two-day cognitive-behavioral therapy for panic disorder

The present study investigated the short-term efficacy of brief, intensive cognitive-behavioral therapy (CBT) for panic disorder (PD). The treatment involved 9h of therapist contact over two consecutive days and was developed for the purpose of delivering CBT for PD to a largely rural patient population that must travel long distances to find a treatment provider. Ten patients who elected to participate in brief, intensive CBT instead of weekly CBT were recruited from routine clinical practice in a hospital-based anxiety disorders clinic. Patients were not excluded based on the presence of agoraphobia, diagnostic comorbidity, concurrent use of PRN benzodiazepine medications, or previous nonresponse to psychotherapy for PD. Assessments conducted at pre-treatment and 1-month follow-up revealed large, clinically significant reductions in PD symptoms, anxiety sensitivity, body vigilance, and anxiety and depressive symptoms. Most patients (60%) were panic-free after treatment and evidenced normative levels of symptomatology at follow-up. The present study suggests that brief, intensive treatment may be an effective means of delivering CBT for PD.     

More Power to the Executive? A Preliminary Test of CBT Plus Executive Skills Training for Treatment of Late-Life GAD

One hypothesized reason for the lower rates of cognitive behavior therapy (CBT) response among older as compared to younger anxiety patients is that they are more likely to show age-related deficits in executive skills, which are complex cognitive skills involved in the regulation of negative affect. Following an 8-week baseline period, this pilot study tested CBT augmented with an executive skills training program, Attention Process Training II (Sohlberg et al., 2001, Sohlberg and Mateer, 2001) against standard CBT in a small sample of 8 older adults with generalized anxiety disorder (comorbidity allowed) and low scores on executive skills tests. Those who received the augmented version (CBT/APT) evidenced more improvement on executive skills and a weekly process measure of worry than those who received CBT. All of the participants in CBT/APT, as compared to half the participants in CBT, met criteria for response, and more in CBT/APT met criteria for high endstate functioning at posttreatment and follow-up. It may be fruitful to test the intervention in a larger sample, and to continue to investigate the role of executive skills in CBT outcome and anxiety treatment.     

Hypnotherapy and cognitive behaviour therapy of acute stress disorder: a 3-year follow-up

The long-term benefits of cognitive behaviour therapy (CBT) for trauma survivors with acute stress disorder were investigated by assessing patients 3 years after treatment. Civilian trauma survivors (n=87) were randomly allocated to six sessions of CBT, CBT combined with hypnosis, or supportive counselling (SC), 69 completed treatment, and 53 were assessed 2 years post-treatment for post-traumatic stress disorder (PTSD) with the Clinician-Administered PTSD Scale. In terms of treatment completers, 2 CBT patients (10%), 4 CBT/hypnosis patients (22%), and 10 SC patients (63%) met PTSD criteria at 2-years follow-up. Intent-to-treat analyses indicated that 12 CBT patients (36%), 14 CBT/hypnosis patients (46%), and 16 SC patients (67%) met PTSD criteria at 2-year follow-up. Patients who received CBT and CBT/hypnosis reported less re-experiencing and less avoidance symptoms than patients who received SC. These findings point to the long-term benefits of early provision of CBT in the initial month after trauma.     

A controlled evaluation of cognitive behavioural therapy for posttraumatic stress in motor vehicle accident survivors

Seventy-eight motor vehicle accident survivors with chronic (greater than 6 months) PTSD, or severe sub-syndromal PTSD, completed a randomized controlled comparison of cognitive behavioral therapy (CBT), supportive psychotherapy (SUPPORT), or a Wait List control condition with two detailed assessments. Scores on the CAPS showed significantly greater improvement for those in CBT in comparison to the Wait List and to the SUPPORT conditions. The SUPPORT condition in turn was superior (p=0.012) to the Wait List. Categorical diagnostic data showed the same results. An analysis of CAPS scores including drop-outs (n=98) also showed CBT to be superior to Wait List and to SUPPORT with a trend for SUPPORT to be superior to Wait List. The CBT condition led to significantly greater reductions in co-morbid major depression and GAD than the other two conditions. Results held up well at a 3-month follow-up on the two active treatment conditions.     

Telephone-based guided self-help for adolescents with chronic fatigue syndrome: A non-randomised cohort study

The aim of this study was to gain preliminary evidence about the efficacy of a new telephone-based guided self-help intervention, based on cognitive-behavioural principles, which aimed to reduce fatigue and improve school attendance in adolescents with chronic fatigue syndrome (CFS). A non-randomised cohort design was used, with a two-month baseline period. Sixty-three 11–18 year-old participants recruited from a specialist CFS unit received the intervention. Participants received six half-hour fortnightly telephone sessions and two follow-up sessions. Fatigue and school attendance were the main outcomes and the main time point for assessing outcome was 6 months post-treatment. Using multi-level modelling, a significant decrease in fatigue was found between pre-treatment and 6 month follow-up, treatment effect estimate = – 5.68 (?7.63, ?3.72), a large effect size (Cohen's d = 0.79). The decrease in fatigue between pre and post-treatment was significantly larger than between baseline and pre-treatment. A significant increase in school attendance was found between pre-treatment and 6 month follow-up, effect estimate = 1.38 (0.76, 2.00), a medium effect size (d = ?0.48). Univariate logistic regression found baseline perfectionism to be associated with poorer school attendance at six-month follow-up. In conclusion, telephone-based guided self-help is an acceptable minimal intervention which is efficacious in reducing fatigue in adolescents with CFS.     

Naturalistic outcome of case formulation-driven cognitive-behavior therapy for anxious depressed outpatients

This article describes a case formulation-driven approach to the treatment of anxious depressed outpatients and presents naturalistic outcome data evaluating its effectiveness. Fifty-eight patients who received case formulation-driven cognitive-behavior therapy (CBT) in a private practice setting were studied. All received individual CBT guided by a case formulation and weekly outcome monitoring; in addition, 40 patients received adjunct therapies, including pharmacotherapy, which were added as indicated by the case formulation and the results of weekly outcome monitoring. Patients treated with case formulation-driven CBT showed statistically and clinically significant changes in anxiety and depression that were generally comparable to those reported in published randomized controlled trials of empirically supported therapies (ESTs) for single mood and anxiety disorders. Findings support the proposal that anxious depressed patients who have multiple comorbidities and require multiple therapies can benefit from empirically supported treatments guided by a case formulation and weekly outcome monitoring.     

Health-related quality of life in chronic fatigue syndrome: predictors of physical functioning and psychological distress

This study investigated health-related quality of life (HRQoL; physical functioning and psychological distress) in an Australian chronic fatigue syndrome (CFS) population. The aims of the study were to compare HRQoL in those with CFS to the normal population, and to investigate the extent to which sociodemographic (age, gender, partner status, education), illness-related (illness duration, symptom frequency), and fatigue severity (physical, mental) variables predicted HRQoL. A total of 139 people meeting CFS criteria completed questionnaires. HRQoL was assessed using standardised measures of distress and physical functioning. Compared with norms, those with CFS obtained significantly lower scores on all physical functioning areas, whereas 63% of participants reported clinically significant psychological distress. Hierarchical regression analyses indicated that physical fatigue severity and symptom frequency were the strongest predictors of deficits in physical domain HRQoL. Physical HRQoL outcomes were also predicted by mental fatigue severity, older age, and female gender. All predictors were unrelated to psychological distress apart from weak positive associations with physical fatigue and symptom frequency. Results identify a potent set of predictors of HRQoL and show that CFS has a pervasive negative impact on quality of life, particularly physical and psychological functioning.     

A Randomized Clinical Trial of Cognitive-Behavioral Therapy and Applied Relaxation for Adults With Generalized Anxiety Disorder

This randomized clinical trial compared cognitive-behavioral therapy (CBT), applied relaxation (AR), and wait-list control (WL) in a sample of 65 adults with a primary diagnosis of generalized anxiety disorder (GAD). The CBT condition was based on the intolerance of uncertainty model of GAD, whereas the AR condition was based on general theories of anxiety. Both manualized treatments were administered over 12 weekly 1-hour sessions. Standardized clinician ratings and self-report questionnaires were used to assess GAD and related symptoms at pretest, posttest, and at 6-, 12-, and 24-month follow-ups. At posttest, CBT was clearly superior to WL, AR was marginally superior to WL, and CBT was marginally superior to AR. Over follow-up, CBT and AR were equivalent, but only CBT led to continued improvement. Thus, direct comparisons of CBT and AR indicated that the treatments were comparable; however, comparisons of each treatment with another point of reference (either waiting list or no change over follow-up) provided greater support for the efficacy of CBT than AR.     

Patient utilization of cognitive-behavioral therapy for OCD

The current study examined utilization of cognitive-behavioral therapy (CBT) by individuals receiving treatment for obsessive-compulsive disorder (OCD). Participants were 202 adults with primary DSM-IV OCD who enrolled in a longitudinal, observational study of the course of OCD and completed 2 years of annual follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. One hundred twenty participants reported that a mental health professional recommended CBT for their OCD symptoms at some point during the 2-year follow-up period. One quarter (n = 31) of these participants did not initiate CBT despite receiving a treatment recommendation. Thirty-one percent of the 89 participants who entered CBT endorsed dropping out of CBT prematurely and less than one third received an adequate “dose” of CBT sessions. Self-reported CBT drop-out rates were significantly greater than attrition rates reported in clinical trials using intensive schedules of exposure and ritual prevention (EX/RP). Perceived environmental barriers and fears regarding treatment participation were the most frequently endorsed reasons for not participating or dropping out of CBT. Despite its efficacy for OCD, many individuals with clinically significant symptoms fail to initiate CBT when recommended by a mental health professional, receive treatments that are less intensive than those used in clinical trials, or drop out of treatment prematurely. Financial costs of CBT, difficulty attending sessions, and fears regarding treatment are significant barriers to initiating and completing therapy.     

Predictors of outcome in Internet-based cognitive behavior therapy for severe health anxiety

Internet-based cognitive behavior therapy (CBT) for severe health anxiety can be effective, but not all patients achieve full remission. Under these circumstances, knowledge about predictors is essential for the clinician in order to make reliable treatment recommendations. The primary aim of this study was to investigate clinical, demographic, and therapy process-related predictors of Internet-based CBT for severe health anxiety. We performed three types of analyses on data from a sample comprising participants (N = 81) who had received Internet-based CBT in a randomized controlled trial. Outcomes were a) end state health anxiety, b) improvement in health anxiety (continuous change scores), and c) clinically significant improvement. Outcomes were assessed at six-month follow-up. The results showed that the most stable predictors of both end state health anxiety and improvement were baseline health anxiety and depressive symptoms. Treatment adherence, i.e. the number of completed treatment modules, also significantly predicted outcome. Notably, health anxiety at baseline was positively associated with symptom improvement while depressive symptoms was negatively related to improvement. Demographic factors were largely without significant impact on end state symptoms or improvement. We conclude that baseline symptom burden and adherence to treatment have strong predictive effects in Internet-based CBT for severe health anxiety.     

Patients with chronic fatigue syndrome do not score higher on the autism‐spectrum quotient than healthy controls: Comparison with autism spectrum disorder

Clinically, there is an overlap of several symptoms of chronic fatigue syndrome (CFS ) and autism spectrum disorder (ASD ), including fatigue; brain “fog”; cognitive impairments; increased sensitivity to sound, light, and odour; increased pain and tenderness; and impaired emotional contact. Adults with CFS (n = 59) or ASD (n = 50) and healthy controls (HC ; n = 53) were assessed with the Autism‐Spectrum Quotient (AQ ) in a cross‐sectional study. Non‐parametric analysis was used to compare AQ scores among the groups. Univariate analysis of variance (ANCOVA ) was used to identify if age, sex, or diagnostic group influenced the differences in scores. Patients with ASD scored significantly higher on the AQ than the CFS group and the HC group. No differences in AQ scores were found between the CFS and HC groups. AQ results were influenced by the diagnostic group but not by age or sex, according to ANCOVA . Despite clinical observations of symptom overlap between ASD and CFS , adult patients with CFS report few autistic traits in the self‐report instrument, the AQ . The choice of instrument to assess autistic traits may influence the results.     

Cognitive behaviour therapy of acute stress disorder: a four-year follow-up

The aim of this study was to index the long-term benefits of early provision of cognitive behavior therapy to trauma survivors with acute stress disorder. Civilian trauma survivors (n = 80) with acute stress disorder were randomly allocated to either cognitive behavior therapy (CBT) or supportive counseling (SC) - 69 completed treatment, and 41 were assessed four years post-treatment for post-traumatic stress disorder (PTSD) with the Clinician Administered PTSD Scale. Two CBT patients (8%) and four SC patients (25%) met PTSD criteria at four-year follow-up. Patients who received CBT reported less intense PTSD symptoms, and particularly less frequent and less avoidance symptoms, than patients who received SC. These findings suggest that early provision of CBT in the initial month after trauma has long-term benefits for people who are at risk of developing PTSD.