CENTER ON BEHAVIORAL MEDICINE

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EFFECTIVE TREATMENTS

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Effective Treatments Index

Chronic Fatigue


Permission graciously given by the author to reproduce this paper.

Chronic Fatigue

Lisa Cook
2005

The most consistent aspect related to both research and discussions connected with Chronic Fatigue Syndrome (CFS) is controversy. This controversy is based upon the unknown etiology of CFS (Craig, D.O., & Kakumanu, A., 2002; Dobbins, & Komaroff, 1994).  The United States Center for Disease Control and Prevention (CDC) has established specific criteria necessary to substantiate the diagnosis of Chronic Fatigue Syndrome (Craig, D.O., & Kakumanu, A., 2002; Dobbins, & Komaroff, 1994).  A patient is required to exhibit, provide documented evidence and/or personal reports (Dobbins, & Komaroff, 1994 of a set of specific somatic symptoms to meet the diagnostic criteria with CFS (Fakuda, Strauss, Hickie, Sharpe, Dobbins, & Komaroff, 1994; Gregg, V.H. & Jones, D.).  CFS is characterized by debilitating fatigue with associated myalgias (tenderness/pain in muscles), tender lymph nodes, arthralgias (joint pain), chills, feverish feelings, and postexertional malaise (Fakuda, Strauss, Hickie, Sharpe, Dobbins, & Komaroff, 1994; Gregg, V.H. & Jones, D., 2001).  Patients can also experience psychiatric symptoms such as depression and mood lability (Gregg, V.H. & Jones, D., 2001; Fakuda, Strauss, Hickie, Sharpe, Dobbins, & Komaroff, 1994).  CFS can also produce cognitive deficits in memory, concentration and speech (Fakuda, Strauss, Hickie, Sharpe, Dobbins, & Komaroff, 1994; Gregg, V.H. & Jones, D.).   The symptoms of CFS can fluctuate throughout the disease progression, which can further obstruct the treatment of CFS (Gregg, V.H. & Jones, D., 2001; Fakuda, Strauss, Hickie, Sharpe, Dobbins, & Komaroff, 1994).

The diagnosis of CFS is primarily determined by the exclusion of other possible somatic derivatives because, currently, there is no exclusive diagnostic medical test available to make a definitive diagnosis (Gregg, V.H. & Jones, D., 2001). Medical researchers continue to examine the many possible etiologic agents that may cause CFS.  While the origin of CFS remains elusive, the etiological agents that are being investigated include infection, immunological, neurological, and psychiatric. (Fakuda, Strauss, Hickie, Sharpe, Dobbins, & Komaroff, 1994; Gregg, V.H. & Jones, D., 2001). 

It is known that CFS is a heterogeneous disorder possibly involving an interaction of the biological systems (Landay, Jessop, Lennette, & Levy, 1991; Lloyd, Hickie, Wilson, & Wakefield, 1994; Tirelli, Marotta, Improta, & Pinto, 1994). Similarities with fibromyalgia exist and concomitant illnesses include irritable bowel syndrome, depression, and headaches (Landay, Jessop, Lennette, & Levy, 1991; Lloyd, Hickie, Wilson, & Wakefield, 1994).   Therefore, treatment of CFS may be just one somatic variable in the patient’s presentation and diagnostic evaluation (Landay, Jessop, Lennette, & Levy, 1991; Lloyd, Hickie, Wilson, & Wakefield, 1994; Tirelli, Marotta, Improta, & Pinto, 1994). 

Researchers have suggested that a multi-disciplinary treatment approach is the most suitable treatment approach for a CFS patient (Burns, J., Kubilus, A., Bruehl, S., Harden, R., Norman, R., & Lofland, K., 2003; Leibing, E., Pfingsten, M., Bartmann U., Rueger, U., & Schuessler, G., 1999). Researchers recommend that the multi-disciplinary team should include individualized treatment plans to accommodate the medical and psychological needs of each specific patient (Landay, Jessop, Lennette, & Levy, 1991; Lloyd, Hickie, Wilson, & Wakefield, 1994; Tirelli, Marotta, Improta, & Pinto, 1994). Researchers suggest that the treatment of CFS should include exercise, diet, appropriate sleep hygiene, antidepressants, and adjunct medications, depending on the patient’s idiosyncratic presentations (Craig, D.O. & Sujani, K., 2002; Landay, Jessop, Lennette, & Levy, 1991; Lloyd, Hickie, Wilson, & Wakefield, 1994).

The psychological therapy modality identified to be the most effective intervention in the treatment of CFS patients and his or her somatic involvement and possible related psychiatric symptoms is Cognitive/Behavioral Therapy (CBT) (Burns, J., Kubilus, A., Bruehl, S., Harden, R., Norman, R., & Lofland, K., 2003; Leibing, E., Pfingsten, M., Bartmann U., Rueger, U., & Schuessler, G., 1999). Researchers have concluded that cognitive interpretations and perceptions of pain and a related chronic medical conditions potentially influence the development of either adaptive or maladaptive coping skills (Bradley, L., McKendree-Smith, N., & Cianfrini, L., 2003;Williams, D., 2003; Leibing, E., Pfingsten, M., Bartmann U., Rueger, U., & Schuessler, G., 1999).  CBT interventions have can be utilized to alter the existence or possible development of cognitive maladaptive and/or counterproductive perceptions and possibly subsequently disadvantageous behaviors (Burns, J., Kubilus, A., Bruehl, S., Harden, R., Norman, R., & Lofland, K., 2003; Leibing, E., Pfingsten, M., Bartmann U., Rueger, U., & Schuessler, G., 1999). The primary cognitive factors that can be targeted by CBT are catastrophizing, perceived helplessness, depletion of supportive resources, disability, depression, and anxiety  (Burns, J., Kubilus, A., Bruehl, S., Harden, R., Norman, R., & Lofland, K., 2003; Leibing, E., Pfingsten, M., Bartmann U., Rueger, U., & Schuessler, G., 1999; Bradley, L., McKendree-Smith, N., & Cianfrini, L., 2003;Williams, D., 2003; Leibing, E., Pfingsten, M., Bartmann U., Rueger, U., & Schuessler, G., 1999). 

Bradley, Mckendree-Smith and Cianfrini hypothesize that there are five primary assumptions that underlie CBT interventions.  The first assumption is the individual’s method of  processing information related to events and internal/ external stimuli. The individual has preconceived perceptions concerning the alteration of his or her physical status and can project outcomes based on these perceptions.  The second assumption is that cognitions interact with emotional and physiological reactions as well as with behavior.  The individual will possibly make assumptions based upon his or her physiological and emotional status and interpret the situation or event in a destructive framework.  This technique can possibly result in catastrophizing the medical diagnosis, and experience episodes of depression and/or anxiety. 

The third assumption is that behavioral responses may be influenced by environmental responses.  The influence and actions of providers, support network and societal stigmas may impact behavioral responses to a chronic medical condition.  The fourth assumption of CBT interventions is a holistic approach.  The CBT interventions address the emotional, cognitive and behavioral facets of the patient.  CBT offers the patient an opportunity to identify and define his or her reactions and belief system related to the presenting medical diagnosis.  The fifth assumption is that CBT interventions provide a realistic venue for the individual to become an active participant in developing adaptive coping skills to manage his or her illness.  The adaptive skills have the potential to empower the individual to develop and activate positive new strategies to cope and manage his or her pain and related symptoms associated with the diagnosed medical condition.

The treatment components of cognitive/behavioral interventions as they relate to the treatment of CFS are: (1) education; (2) acquisition of skills; (3) rehearsal of reframed cognitive/behavioral responses and reactions; and (4) generalization and maintenance (Burns, J., Kubilus, A., Bruehl, S., Harden, R., Norman, R., & Lofland, K., 2003; Leibing, E., Pfingsten, M., Bartmann U., Rueger, U., & Schuessler, G., 1999; Bradley, L., McKendree-Smith, N., &  Cianfrini, L., 2003;Williams, D., 2003; Leibing, E., Pfingsten, M., Bartmann U., Rueger, U., & Schuessler, G., 1999). CBT can be an effective therapeutic intervention for individuals diagnosed with CFS.  The provision of accurate clinical medical information related to CFS can help reduce the likelihood of the patient to catastrophize the impact of a CFS diagnosis(Gregg, V.H. & Jones, D., 2001; Fakuda, Strauss, Hickie, Sharpe, Dobbins, & Komaroff, 1994).  Accurate information can also preempt probable depressive and anxious responses commonly found in patients once the CFS becomes a definitive diagnosis (Hiroko, A., Klimes, I., & Bass, C., 2001). CFS has numerous physical, cognitive and psychiatric symptoms which can immobilize and disempower a patient.  The ability to develop strategies to compensate for the symptomology of CFS is essential in maintaining a level of quality and productivity in his or her life.  These strategies empower the patient’s sense of control as well as enhance his or her possible fragile sense of confidence (Hiroko, A., Klimes, I., & Bass, C., 2001; Gregg, V.H. & Jones, D., 2001; Fakuda, Strauss, Hickie, Sharpe, Dobbins, & Komaroff, 1994).  The daily practice and inclusion of these newly acquired skills can reinforce and substantiate the individual’s purpose and ability to actively participate in living rather than becoming a passive participant in life.

A chronic medical condition has the potential to destroy an individual’s life and reinforce his or her sense of victimization.  This same chronic medical condition also has the potential to empower and challenge the individual to reach new heights of personal development.  My experience,  as a disabled therapist, has exposed me to both types of patients.  The characteralogical implications of victimization are debilitating. These individuals are defined by his or her illness. Those individuals who strive to develop adaptive strategies become empowered and self-defining and are able to identify his or her illness rather than be identified by it! CBT offers a patient the therapeutic clinical techniques to make the latter come to fruition. 

Reference

Akagi, H., Klimes, I., & Bass, C., (2001). Cognitive behavioral therapy for chronic
 Fatigue syndrome in a general hospital- feasible and effective.  General
 Hospital Psychiatry, 23, 254-260.  Retrieved December 24, 2004, from  www.elsevier.com

Blakely, A.A., Howard, R., Sosich, R., Murdocj, J., Menkes, D., & Spears, G.,
 (1991). Psychiatric symptoms, personality and ways of coping in
 Chronic fatigue syndrome. Psychological Medicine, 21, 347-362  Retrieved December 29, 2004. From  www.sciencedirect.com

Bradley, L., Mekendree-Smith, N., & Cianfrini, L, (2003).  Cognitive- Behavioral  Therapy Interventions for Pain Associated with Chronic Illness.  Seminars
 In Pain Medicine, 1(2), 44-54.  Retrieved December 24, 2004,  from 
 www.sciencedirect.com

Burns, J., Johnson, B., Mahoney, N., Devine, J., & Prawl, R. (1998).  Cognitive
 And physical capacity process variables predict long-term outcome
 Following treatment of chronic pain.  Journal of Consulting and Physical
 Psychology, 66, 434-439. Retrieved January 7, 2005, 
 from www.elsevier.com

Craig, T., & Kakumanu,S., (2002).  Chronic Fatigue Syndrome: Evaluation 
 And Treatment.  American Family Physician, 65, 1083-1095. 
 Retrieved Decenber 28, 2004, from www.sciencediret.com

Fakuda, K., Strauss, S., Hickie, L., Sharpe, M., Dobbins, J., & Komaroff, A.,
 (1994). The chronic fatigue syndrome: a comprehensive approach
 to its definition and study.  Annal of Internal Medicine, 121, 953-959.
 Retrieved December 24, 2004, from www.sciencedirect.com

Gregg, V., & Jones, D., (2001).  Coping and Illness Cognitions: Chronic Fatigue
 Syndrome.  Clinical Psychology Review, 21(2). 161-182. Retrieved January  3, 2005, from www.elsevier.com

Hollen, S., (1998).  What is cognitive behavioural therapy and does it work? 
 Neurobology, 8, 289-292.  Retrieved December 24, 2004, from  www.elsevier.com

Price, J., (2000).  Managing physical symptoms: The clinical assessment as
 Treatment.  Journal of Psychosomatic Research. 48, 1-10.  Retrieved   November 26, 2004, from  www.elsevier.com

Sharp, T., (2001).  Chronic pain: a formulation of the cognitive-behavioural  model.  Behaviour Research Therapy, 39, 787-800.  Retrieved  January  01, 2005,from www.sciencedirect.com

Williams, D., (2003).  Psychological and behavioral therapies in fibromyalgia and
 Related syndromes.  Best Practice & Research Clinical Rheumatology,  17(4), 649-665.  Retrieved December 16, 2004, from  www.scienceddirect.com