بدرفتاری در دوران کودکی و واکنش به رفتاردرمانی شناختی برای سندرم خستگی مزمن

Objective To examine the relationship between a history of childhood maltreatment and the treatment response to cognitive behavior therapy for chronic fatigue syndrome (CFS). Methods A cohort study in a tertiary care clinic with a referred sample of 216 adult patients meeting the Centers for Disease Control and Prevention criteria for CFS, and starting cognitive behavior therapy. Main outcome measures changes between pre- and post therapy in fatigue (Checklist Individual Strength fatigue subscale), disabilities (Sickness Impact Profile total score), physical functioning (short form 36 health survey subscale) and psychological distress (Symptom checklist 90 total score). Results At baseline, patients with a history of childhood maltreatment had significantly more limitations and a higher level of psychological distress, but were not more severely fatigued. Change scores on the outcome measures after cognitive behavior therapy did not differ significantly between patients with or without a history of childhood maltreatment, or between the different types of childhood maltreatment. However, patients with a history of childhood maltreatment still experienced more limitations and a higher level of psychological distress after CBT. Conclusions A history of childhood maltreatment was not related to the treatment response of cognitive behavior therapy for CFS. In patients with a history of childhood maltreatment CFS symptoms can be treated with CBT just as well as those without.

Chronic fatigue syndrome (CFS) is an often long-lasting condition [1], that has profound impact on the daily life of patients [2]. The diagnostic criteria for CFS, as defined by the Centers for Disease Control and Prevention (CDC), include the experience of severe and medically unexplained fatigue for more than six months that causes cause severe impairment in daily functioning [3] and [4]. Previous studies have found an increased prevalence of childhood maltreatment in both patients with CFS and chronic fatigue (i.e. any fatigue lasting longer than 6 months but not meeting full CDC criteria). Most of them were nested case–control studies in the general population [5], [6], [7], [8] and [9], except for one small case–control study conducted in a specialist clinic [10]. Two studies did not find an increased prevalence of childhood maltreatment in CFS patients [11] and [12], although one of them did find an increased prevalence in patients with chronic fatigue not meeting CDC criteria. In addition, two studies found that the risk of being a CFS patient increased with a higher exposure to childhood maltreatment [5] and [6]. So childhood maltreatment seems to make a person more vulnerable to become chronically fatigued. Cognitive behavior therapy (CBT) is an evidence based intervention for CFS that leads to a significant reduction in fatigue and impairment, as has been shown by two meta-analyses [13] and [14]. A subgroup of CFS patients shows a complete recovery following CBT [15]. CBT is based on a model that encompasses different fatigue related cognitions and behaviors, thought to perpetuate symptoms in CFS patients [16] and [17]. These include attributing complaints to a somatic cause, low levels of physical activity, low sense of control over symptoms and focusing on bodily symptoms. During CBT the therapist helps the patient to change these perpetuating factors to become less fatigued and disabled. Childhood maltreatment seems to predispose patients to develop CFS. According to the model underlying CBT for CFS, predisposing factors only play a role in the development of CFS, not in the continuation of symptoms. It would therefore, at first sight, not seem likely that exposure to childhood maltreatment would have an effect on the response to CBT. However, there are several possible pathways as to how a history of childhood maltreatment could have a negative effect on CBT for CFS. First, childhood maltreatment has been related to psychological distress (e.g. depression, anxiety) in later life [7], [18], [19] and [20]. This has also been found in CFS patients [5], [6], [7] and [10]. Psychological distress might impede changes in fatigue related cognitions during therapy and thus result in a poor therapy response. Second, childhood maltreatment may result in interpersonal problems later in life, such as sensitivity to rejection, unstable or chaotic relationships and problems trusting others [21] and [22]. These interpersonal problems may also impede the psychotherapeutic relationship between patient and therapist, and thereby the therapy response. Third, Roberts et al. showed that CFS patients with hypocortisolism, i.e. low levels of the stress-related hormone cortisol, do show a poorer response to CBT [23]. Hypocortisolism has been related to childhood maltreatment [24], and Roberts et al. hypothesized that it might be a symptom perpetuating factor in CFS patients. A poor therapy response of CFS patients with a history of childhood maltreatment could have clinical implications, like adding specific interventions aimed at reducing the level of psychological distress to the currently used treatment protocol to improve outcome for this subgroup. The aim of the current study is to determine whether the treatment response to CBT for CFS is impaired in patients with a history of childhood abuse. As McMahon et al. reported [25], the effect of childhood maltreatment may not appear in the direct treatment response, but rather in long-term results. The factors that lead to a greater vulnerability to become chronically fatigued, might also lead to a greater vulnerability to relapse after successful therapy. So in an exploratory analysis we also included 6-month follow-up data in our study.

Concluding, childhood maltreatment is not related to the direct treatment response of CBT for CFS, so in patients with a history of childhood maltreatment CFS symptoms can be treated with CBT just as well as in patients without such a history.