Reader Comments

Post a new comment on this article

A review of interventions for medically unexplained symptoms affirms that cognitive behavior therapy for chronic fatigue syndrome is not effective.

Posted by FrankTwisk on 12 Feb 2019 at 14:58 GMT

A review of interventions for medically unexplained symptoms (1) could raise the impression that cognitive behavior therapy (CBT) and/or graded exercise therapy (GET) are effective treatment options for chronic fatigue syndrome (CFS).

The review includes 8 “studies focusing on CFS” (2,3,4,5,6,7,8,9) . However only one study (2), not two as suggested (1), investigated the effects of behavorial therapies, CBT and Multidisciplinary rehabilitation treatment (MRT), in CFS (10). The other seven studies investigated the effects of CBT, GET and pragmatic rehabilitation (PR) in patients with chronic fatigue (CF), often selected by the Oxford definition (11), a definition which “may impair progress and cause harm” and “must be retired” (12). To be diagnosed as CFS (10) patient, chronic fatigue must be accompanied by at least four out of eight symptoms, e.g. multi-joint pain; muscle pain; substantial impairment in short-term memory or concentration; and post-exertional ‘malaise’. Chronic fatigue is by far insufficient to qualify as CFS (10) patient as illustrated by the finding that “85% of Oxford-defined cases were inappropriately classified as CFS” (13). Some studies (4,5) even suggest to have studied patients with ME. ME (14) is a disease with distinctive muscular and neurological symptoms. ME (14) and CFS (10) are two very distinct clinical entities, with only partial overlap. At present no study investigated or reported the effects of CBT, GET or other therapies in ME (14).

The studies of CBT, GET and other therapies for CF/CFS show that the subjective effects are largely insufficient to achieve ‘normal values’, e.g. for ‘fatigue’ scores. Using objective measures, e.g. time spent working (7), activity levels (7), disability benefits (5), and healthcare costs (5), the effects of CBT, GET et cetera are nihil. Even more, several studies and patient surveys implicate that GET and CBT (essentially CBT/GET) can be potentially harmful (15) for patients with CFS (10) and ME (14).


1. Wortman MSH, Lokkerbol J, van der Wouden JC, Visser B, van der Horst HE, Olde Hartman TC. Cost-effectiveness of interventions for medically unexplained symptoms: A systematic review. PLoS One. 2018;13(10):e0205278. PMID: 30321193. doi: 10.1371/journal.pone.0205278. eCollection 2018.
2. Vos-Vromans D, Evers S, Huijnen I, Köke A, Hitters M, Rijnders N, et al. Economic evaluation of multidisciplinary rehabilitation treatment versus cognitive behavioural therapy for patients with chronic fatigue syndrome: A randomized controlled trial. PLoS One. 2017;12(6):e0177260. PMID: 28574985. doi: 10.1371/journal.pone.0177260.
3. Meng H, Friedberg F, Castora-Binkley M. Cost-effectiveness of chronic fatigue self-management versus usual care: a pilot randomized controlled trial. BMC Fam Pract. 2014;15:184. PMID: 25421363. doi: 10.1186/s12875-014-0184-7.
4. Richardson G, Epstein D, Chew-Graham C, Dowrick C, Bentall RP, Morriss RK, et al. Cost-effectiveness of supported self-management for CFS/ME patients in primary care. BMC Fam Pract. 2013;14:12. PMID: 23327355. doi: 10.1186/1471-2296-14-12.
5. McCrone P, Sharpe M, Chalder T, Knapp M, Johnson AL, Goldsmith KA, et al. Adaptive pacing, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome: a cost-effectiveness analysis. PLoS One. 2012;7(8):e40808. PMID: 22870204. doi: 10.1371/journal.pone.0040808.
Expression of concern: Adaptive pacing, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome: A cost-effectiveness analysis. PLoS One Editors. https://doi.org/10.1371/j....
6. Sabes-Figuera R, McCrone P, Hurley M, King M, Donaldson AN, Ridsdale L. Cost-effectiveness of counselling, graded-exercise and usual care for chronic fatigue: Evidence from a randomised trial in primary care. BMC Health Serv Res. 2012;2:264. PMID: 22906319. doi: 10.1186/1472-6963-12-264.
7. Severens JL, Prins JB, van der Wilt GJ, van der Meer JWM, Bleijenberg G. Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. QJM. 2004;97(3):153-61. PMID: 14976272. doi: 10.1093/qjmed/hch029.
8. McCrone P, Ridsdale L, Darbishire L, Seed P. Cost-effectiveness of cognitive behavioural therapy, graded exercise and usual care for patients with chronic fatigue in primary care. Psychol Med. 2004;34(6):991-9. PMID: 15554570. doi: 10.1017/S0033291704001928.
9. Chisholm D, Godfrey E, Ridsdale L, Chalder T, King M, Seed P, et al. Chronic fatigue in general practice: economic evaluation of counselling versus cognitive behaviour therapy. Br J Gen Pract. 2001;51(462):15-8. PMID: 11271867.
10. Fukuda K, Straus SE, Hickie I, Sharpe M, Dobbins JG, Komaroff AL. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med. 1994;121(12):953-9. PMID: 7978722. doi: 10.7326/0003-4819-121-12-199412150-00009.
11. Sharpe MC, Archard LC, Banatvala JE, Borysiewicz LK, Clare AW, David A, et al. Chronic fatigue syndrome: guidelines for research. J R Soc Med. 1991;84(2):118-21. PMID: 1999813. doi: 10.1177/014107689108400224.
12. Green CR, Cowan P, Elk R, O'Neil KM, Rasmussen AL. National Institutes of Health Pathways to Prevention Workshop: Advancing the research on Myalgic Encephalomyelitis/chronic fatigue syndrome. Ann Intern Med. 2015;162(12):860-5. PMID: 26075757. doi: 10.7326/M15-0338.
13. Baraniuk JN. Chronic fatigue syndrome prevalence is grossly overestimated using Oxford criteria compared to Centers for Disease Control (Fukuda) criteria in a U.S. population study. Fatigue. 2017;5(4):215-230. doi: 10.1080/21641846.2017.1353578.
14. Twisk FNM. Myalgic Encephalomyelitis (ME) or what? An operational definition. Diagnostics (Basel). 2018;8(3):E64. PMID: 30205585. doi: 10.3390/diagnostics8030064.
15. Twisk FNM, Corsius LAMM. Cognitive-behavioural therapy for chronic fatigue syndrome: neither efficacious nor safe. Br J Psychiatry. 2018;213(2):500-1. PMID: 30027882. doi: 10.1192/bjp.2018.136.

No competing interests declared.