شیوع و عوامل بهبودی سندرم خستگی مزمن در عملکرد بالینی معمول

Cognitive behavioural therapy (CBT) is one of the treatments of choice for patients with chronic fatigue syndrome (CFS). However, the factors that predict recovery are unknown. The objective of this study was to ascertain the recovery rate among CFS patients receiving CBT in routine practice and to explore possible predictors of recovery. Recovery was defined as no longer meeting Oxford or CDC criteria for CFS measured at 6 months follow-up. A composite score representing full recovery additionally included the perception of improvement, and normal population levels of fatigue and of physical functioning. Logistic regression was used to examine predictors of recovery. Predictors included age, gender, cognitive and behavioural responses to symptoms, work and social adjustment, beliefs about emotions, perfectionism, anxiety and depression at baseline. At 6 months follow-up 37.5% of the patients no longer met either the Oxford or the CDC criteria for CFS while 18.3% were fully recovered. Multivariate analyses showed that worse scores on the work and social adjustment scale, unhelpful beliefs about emotions, high levels of depression and older age were associated with reduced odds for recovery. Recovery rates in this routine practice were comparable to previous RCTs. There was a wide spectrum of significant predictors for recovery. Gadget timed out while loading

Chronic fatigue syndrome (CFS) is a heterogeneous and multi-factorial condition, characterised by fatigue and disability. Two commonly used criteria are; the Oxford criteria (Sharpe et al., 1991), and the US Center for Disease Control (CDC) criteria (Fukuda et al., 1994). While these two criteria are similar, there is not a complete overlap in terms of included symptoms. The CDC criteria necessitate the presence of several discrete symptoms. The Oxford criteria are less “detailed” in this respect but require the presence of both physical and mental fatigue for 6 months or more. The aetiology is still much debated with some focused on finding a specific cause (Cairns & Hotopf, 2005). Since CFS does not have pathognomonic manifestations, the diagnostics of CFS remains a clinical endeavour, and suggests that the condition may be multi-factorial. Our original cognitive behavioural model of CFS suggested that an initial trigger such as a virus may contribute to a vicious cycle in which the individual avoids activity for fear of making symptoms worse (Butler, Chalder, Ron, & Wessely, 1991). In an effort to manage symptoms people become hypervigilant and this so called symptom focussing can exacerbate symptoms (Chalder, Butler, & Wessely, 1996). Surawy and colleagues subsequently added to the model by suggesting that pre-morbid characteristics such as conscientiousness and perfectionism contributed to individuals becoming vulnerable. In addition, patients with CFS were more likely to hold the belief that showing emotions was unacceptable (Surawy, Hackmann, Hawton, & Sharpe, 1995). Cognitive behavioural therapy (CBT) addresses these factors but in particular focuses on encouraging patients to become more consistent in engaging in activity before increasing activity thereby challenging fearful cognitions such as fear avoidance beliefs and catastrophising whilst simultaneously addressing symptom focussing. CBT and graded exercise therapy (GET) have proven to be the most effective treatments for CFS with significant improvements in fatigue and disability (Chambers et al., 2006 and White et al., 2011). However, reduction in symptoms and improvement from disability does not necessarily entail recovery. Recovery as an outcome has rarely been investigated in CFS patients. Recovery involves several conditions such as perception of improvement, perception of symptom reduction and perception of improvement of fatigue impact. More objectively, recovery entails no longer meeting the Oxford and the CDC CFS criteria. To recover may represent a return to premorbid levels of health and wellbeing. When previously defining recovery from CFS, studies have used the normal population statistics as a guide. However, for some CFS patients recovery as defined by the population mean may entail a level of good health they did not have before their CFS started. Likewise, “healthy” individuals could regard themselves as fully functional and still be under the population mean on health questionnaires. Some studies have thus set the cut-off for recovery at 1 standard deviation (SD) from the population mean (Deale et al., 2001 and Knoop et al., 2007). Early studies found that up to a quarter of people with CFS who receive CBT in the context of a randomized controlled trial (RCT) make a full recovery (Deale et al., 2001 and Knoop et al., 2007). Although Deale and colleagues found that patients recovered there was a slight downward trajectory from the 1 to 5 year follow-up (Deale et al., 2001). More recently a large multi-centred four-arm RCT found that 22% of patients in secondary care recovered after CBT, 22% after GET, 8% after adaptive pacing therapy (APT) and 7% after specialist medical care (White, Goldsmith, Johnson, Chalder, & Sharpe, 2013). The odds for recovery after CBT or GET were 3.36 and 3.38 respectively when compared to APT. This study confirmed that recovery from CFS was possible. Outside the confines of an RCT clinical follow-ups have found that between 0% and 31% of the CFS patients show full recovery depending on the setting (Cairns & Hotopf, 2005). In Cairns and Hotopf (2005) systematic review covering various clinical follow-ups, they found a median of 5% showing full recovery and 39.5% showing improvement (Cairns & Hotopf, 2005). However, the studies used different inclusion criteria. Some were conducted in primary care whereas others were secondary care studies. Some of the highest recovery rates were found in primary care settings, possibly involving lower levels of severity or chronicity than those treated in secondary care. In addition, the studies involved different types of treatment many of which were not recorded systematically. The variation in recovery rates in different studies is likely to be affected by the inclusion criteria used. Furthermore, the recovery rate will be influenced by the operationalization of “full recovery” and the timing of follow-ups in the different studies.

In conclusion, we found recovery rates in line with previous studies on recovery from CFS. Different predictors were related to recovery in terms of official criteria, subjective improvement, reduced fatigue symptomatology and reduced physical impairment. This suggests that a broad therapeutic focus is necessary to improve all facets of CFS, and to facilitate total recovery. CBT has this broad focus but the number of sessions may need to be increased to facilitate a full recovery.