رفتار درمانی شناختی برای برای بیماران مبتلا به سندرم خستگی مزمن نسبتا فعال و منفعل

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.

Chronic fatigue syndrome (CFS) is characterized by a clinically evaluated, unexplained persistent or relapsing chronic fatigue that is of new or definite onset (i.e., not lifelong); lasts for at least 6 months; is not the result of ongoing exertion; is not substantially alleviated by rest; and results in substantial reduction in previous levels of occupational, educational, social, or personal activities (Fukuda et al., 1994). Several reviews of randomized controlled trials showed that cognitive behavior therapy (CBT) is an effective treatment for CFS (Afari & Buchwald, 2003, Price & Couper, 2000, Reid et al., 2000 and Whiting et al., 2001). In CFS, facilitating, initiating, and perpetuating factors can be distinguished. Somatic factors, such as viruses, are often cited as initiating chronic fatigue. Some prospective studies showed that 10% to 17% of the patients with a viral infection fulfilled CFS criteria after 6 months (Cope et al., 1994 and White et al., 1998). However, patients without a viral infection had the same chance to develop CFS. Although there are some indications that psychosocial problems and life events initiate fatigue (Hatcher & House, 2003, Theorell et al., 1999 and Wessely et al., 1995), convincing evidence is still lacking. The research literature also mentions psychosocial problems as facilitating factors. A prospective study showed that psychological problems are a predictor of chronic fatigue (Wessely et al., 1995). Premorbid overactivity might also facilitate the development of CFS (van Houdenhove, Onghena, Neerinckx, & Hellin, 1995). However, little is known about initiating and facilitating factors in CFS. More evidence is found on the perpetuating factors. According to a model developed by Vercoulen et al. (1998), a strong focus on bodily symptoms, low levels of physical activity, and a poor sense of control contribute to an increase in the severity of fatigue and functional impairment. Strong somatic attributions have an indirect influence on fatigue via lower levels of physical activity. Most factors in this model of perpetuating factors in CFS have been found in other studies as well (e.g., Heijmans, 1998 and Wessely et al., 1998). The cognitive behavioral treatment for CFS is based on the model of perpetuating factors (Prins & Bleijenberg, 1999 and Prins et al., 2001). CBT for CFS is directed at decreasing somatic attributions and the patient's focus on bodily symptoms, increasing the patient's sense of control over his or her symptoms, and restoring balance in activity patterns. One of the randomized controlled trials that demonstrated the effectiveness of CBT for CFS was conducted by Prins et al. (2001). This study showed that the treatment manual used was not appropriate for all CFS patients. It seemed that, based on their activity level, three types of CFS patients could be distinguished: pervasively active, moderately active, and pervasively passive CFS patients (van der Werf, Prins, Vercoulen, van der Meer, & Bleijenberg, 2000). The protocol used in our effect study did not seem to work for the so-called passive CFS patients (Prins et al., 2001), which is about 25% of the CFS population (van der Werf et al., 2000). Based on these results, the treatment manual for passive CFS patients was adjusted. The main difference is that for pervasively active and moderately active (together so-called relatively active) CFS patients, the treatment starts with a focus on a good alternation between rest and activity. For passive CFS patients, the treatment starts with a gradually increasing activity program. This article will begin with a discussion of basic assumptions of the treatment, including what to consider before starting CBT for CFS. Next, we explain how to determine the activity pattern, describe the treatment manuals for relatively active and for passive CFS patients, and provide suggestions for relapse prevention. We conclude with a discussion of variations in treatment (i.e., treating children). The general treatment outline is shown in Table 1.

CBT for CFS as described in this chapter has initially been developed for and tested with adults. CBT is also considered suitable for the treatment of young CFS patients, provided that their individual circumstances are taken into account. Participation of the parents in their child's treatment is a precondition. In a randomized controlled trial Stulemeijer, de Jong, Fiselier, Hoogveld, and Bleijenberg (2005) found that CBT was also effective for CFS in adolescents. CBT for CFS can also take the form of group therapy. In our center several CFS patients were treated in a group setting (Bazelmans, Prins, Lulofs, van der Meer, & Bleijenberg, 2005). Patients may benefit from observing the progress of other group members. Comparing and discussing the participants' individual actometer patterns may help patients realize which direction their activity program should take. Although group therapy for CFS has not yet proven to be effective, it seems most suitable for patients whose functional impairment is moderate. A certain number of CFS patients may also be treated with elements of CBT by their family physician. It seems wise to select those CFS patients who are most likely to benefit from the treatment. This will usually imply CFS patients who are still relatively active and for whom the majority of prognostic factors are favorable (i.e., no comorbidity, a predominantly positive self-efficacy regarding the symptoms, moderate somatic attributions, no repetitive use of medication, and a social environment that has a positive attitude toward the chances of the patient's recovery). Unfortunately, as yet there is only one study in which general practitioners were trained to deliver CBT, but the study suffered from poor recruitment and high dropout, and the treatment had no effects on the patients with CFS (Whitehead & Campion, 2002). In the studies described earlier, therapies provided were always on an outpatient basis. Chalder, Butler, and Wessely (1996) reported an uncontrolled study involving six inpatients of a clinic that specialized in the treatment of CFS. They provide a comprehensive description of the treatment they developed for their patients, whose severity of symptoms necessitated inpatient treatment. Five of the six patients showed considerable improvement, and this effect was still present 3 months after their release from the clinic. Cox and Findley (1998) also described CBT and graded activity of CFS patients in an inpatient setting. They claimed that at 6 months postdischarge 82% of patients increased in level of ability. It has been shown that psychotherapists find CFS patients difficult to treat (Bazelmans, Prins, Hoogveld, & Bleijenberg, 2004). Many problems therapists encounter during CBT for CFS involve the interaction with the patient. Motivating the patient for treatment, handling comorbidity, and realizing work-resumption are particularly difficult aspects. These challenges can best be dealt with by individualizing the treatment, which involves making the specific perpetuating factors of a particular patient concrete and integrating comorbid elements that may be part of the perpetuating factors. It is recommended that therapists willing to treat CFS patients become knowledgeable about the current scientific state of affairs into CFS, and are experienced in CBT as well as treating patients with (unexplained) physical symptoms.