Psychosomatics 49:470-477, November-December 2008
doi: 10.1176/appi.psy.49.6.470
© 2008 Academy of Psychosomatic Medicine
Customizing Treatment of Chronic Fatigue Syndrome and Fibromyalgia: The Role of Perpetuating Factors
Boudewijn Van Houdenhove, M.D., Ph.D., and
Patrick Luyten, Ph.D.
Received October 4, 2007; revised December 13, 2007; accepted January 2, 2008. From Dienst Liaisonpsychiatrie, UZ Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium. Send correspondence and reprint requests to Dr. Boudewijn Van Houdenhove. e-mail: boudewijn.vanhoudenhove{at}uz.kuleuven.ac.be
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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BACKGROUND: Syndromes characterized by chronic, medically unexplained fatigue, effort- and stress-intolerance, and widespread pain are highly prevalent in medicine. RESULTS: In chronic fatigue syndrome (CFS) and fibromyalgia (FM), various perpetuating factors may impair patients’ quality of life and functioning and impede recovery. Although cognitive-behavioral and graded-exercise therapy are evidence-based treatments, the effectiveness and acceptability of therapeutic interventions in CFS/FM may largely depend on a customized approach taking the heterogeneity of perpetuating factors into account. CONCLUSION: Further research should clarify the aim and outcome of different treatment strategies in CFS/FM, as well as the underlying mechanisms of change, including those facilitating neurobiological recovery.
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INTRODUCTION
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Syndromes characterized by chronic, medically unexplained fatigue, effort- and stress intolerance, and widespread pain are highly prevalent in medicine, from general practice to several medical specialties. Such syndromes cause much individual and family suffering, and are often associated with serious physical, mental, and social/professional disability.1
Operational criteria have been formulated, defining these symptom-pictures as chronic fatigue syndrome (CFS)2 and fibromyalgia (FM;3 Table 1). However, since both syndromes largely overlap, some authors ("lumpers") argue that CFS and FM should be merged under the broad umbrella of "functional somatic syndromes," whereas others ("splitters") plead for maintaining CFS and FM as discrete entities.4 Although the scientific literature on CFS and FM still follows distinct paths, there are increasing tendencies toward an integrative approach of these and other stress-related somatic syndromes.5–7 In this article, we will assume the "lumper" point of view by using the abbreviation CFS/FM.
On the other hand, it has become evident that patients with a CFS/FM diagnosis are a heterogeneous group. In this respect, different subgroups have been proposed, for example, depending on type of onset (sudden or gradual, initiating infection or not, etc.),8 activity patterns (passive or relatively active),9 or putative biological mechanisms,10 but no consensus has been reached on this issue.
Current evidence-based treatments for CFS/FM mainly consist of cognitive-behavioral therapy (CBT) and graded-exercise therapy (GET).1 However, despite positive results in randomized, controlled trials (see metaanalyses11–13), the use of these treatments in routine clinical practice is still problematic—as, for example, reflected on websites of patient-support groups.14 Moreover, many questions remain about the therapeutic aim, strategies, and outcome, as well as mediating and moderating processes underlying mechanisms of change in CFS/FM treatment.15,16 Also, little attention has been paid to the role of perpetuating factors in explaining heterogeneity among CFS/FM patients and to the way in which this hetero-geneity may influence treatment results.
Hence, the main aim of this article is to clarify the rationale of CFS/FM treatment in light of the heterogeneity of perpetuating factors. We will first outline a biopsychosocial model of the etiology and pathogenesis of CFS/FM. Subsequently, we will review recent empirical evidence about the role of perpetuating factors in the illness. Finally, we will argue that, in clinical practice, the effectiveness and acceptability of therapeutic strategies in CFS/FM may largely depend on customizing interventions to the patient’s personal set of perpetuating factors.
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THE BIOPSYCHOSOCIAL MODEL
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Etiological Factors
Although the etiology of CFS/FM is still uncertain, various precipitating, predisposing, and perpetuating factors have been identified, suggesting that multiple pathways may lead to the causation and persistence of the illness (Figure 1).1,17
More concretely, a whole range of physical and psychosocial stressors seem to play a precipitating role; familial-genetic factors, traumatic experiences, personality/lifestyle factors, and previous episodes of depression may increase vulnerability to CFS/FM, and various physical, perceptual-cognitive, affective, personality-related, behavioral, social, and iatrogenic factors may perpetuate the illness.1,17
Pathophysiological Hypothesis
The exact pathophysiology of CFS/FM remains unclear, yet it has become very probable that the illness has a neurobiological substrate including subtle disturbances in physiological regulatory systems; notably, the neurohormonal stress system, different neurotransmitter systems, the immune system, and the central pain-processing system.1,17
Most neurobiological findings point to a hypo-(re)activity of the hypothalamic–pituitary–adrenal (HPA) axis, which may not only impede a normal stress response, but also foster abnormal inflammatory activity.17–19 Also, the widespread pain and pain hypersensitivity of CFS/FM patients (allodynia) may be based on central sensitization, in which cytokine-mediated inflammation, as well as genetically-determined disturbances in neurotransmitter balance, lead to decreased central pain inhibition.17–20
Many questions remain, however, about the causal significance of these neurobiological findings.1,21,22 Nonetheless, the illness-narrative of most CFS/FM patients,23 as well as retrospective studies,1,17 suggest that a dysfunction of the stress system may be the primum movens of the illness, whereby, after a long period of overburdening, a "switch" from hyper- to hypofunctioning might take place, which, in turn might provoke a cascade of further neuronal, neurohormonal, and immunological dysregulations. This hypothesis nicely fits within McEwen’s "allostatic load" paradigm,24 and it has recently received preliminary support from a metaanalysis25 and a population-based study.26
Finally, perpetuating factors may—often via vicious circles—not only reinforce symptoms and disability, but presumably also impede recovery by interacting with the pathophysiological basis of the illness, and/or negatively influencing the patient’s associated illness-perceptions and illness-behavior. These factors, listed in Table 2, will be discussed below.
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PERPETUATING FACTORS
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Physical Factors
Deterioration of CFS/FM patients’ physical condition logically results from their decreased activity due to fatigue and pain. In turn, loss of muscle power and endurance (cardiopulmonary functioning) reinforces and perpetuates symptoms and makes daily functioning still more problematic.27
However, research findings about the precise role of physical deconditioning in CFS/FM are equivocal. Taken together, findings converge to suggest that the degree of physical deconditioning varies significantly among patients and that—in contrast with previous theories—this factor does not seem to play a specific pathophysiological role in the illness.27
Furthermore, persistent sleep problems may make symptoms and functional limitations in CFS/FM patients worse, often also through circular interactions. Nonetheless, the perpetuating role of disturbed sleep in CFS/FM and the contribution of perceptual factors in this respect remain unclear.28–30
Also, some biologically-oriented researchers have proposed that CFS/FM patients frequently suffer from opportunistic infections (e.g., chlamydia and mycoplasma microorganisms), which may be at least partly responsible for the persistence of some symptoms.10 At this moment, however, there is no evidence either for the validity of this hypothesis or for the pharmacological therapy based on it (see, for example, the results of a large antibiotic trial in patients with Gulf-War syndrome who showed CFS-like symptoms.31)
Perceptual-Cognitive Factors
Many CFS/FM patients are badly informed about their illness or lose their way in the labyrinth of diverse theories and opinions (for example, on the Internet). This uncertainty not only causes much stress, but also makes symptoms and disability worse, and hinders efficient coping.32 Some patients focus excessively on even minimal signs of physical distress (somatic hypervigilance).33 Others show a tendency toward rigid somatic attributions while vigorously rejecting psychological or psychiatric explanations,1 or remain preoccupied with their functional limitations or catastrophize about the prognosis of their illness.34 Such perceptual-cognitive biases may play an illness-perpetuating role by making patients feel helpless, leading to decreased self-efficacy.
Affective Factors
Chronic pain and fatigue are frequently associated with depression and anxiety, and there are indications of neurobiological and familial-genetic links between these different sets of symptoms and syndromes.35–37 Most frequent are feelings of demoralization and frustration, in response to the loss of earlier capabilities, but some CFS/FM patients show manifest major depression, panic disorder, or posttraumatic stress disorder.38,39
Although the relationship between depression and chronic physical illness has been much studied in recent years,40 the exact nature, prevalence, and therapeutic implications of comorbidity between depression and CFS/FM are still a matter of debate.40–42 Nonetheless, it can be assumed that additional depressive symptoms in these patients may perpetuate the illness by reinforcing symptoms and increasing the risk of patients’ negatively spiralling into more severe functional limitations.
To what degree fear of movement and associated activity-avoidance may play a perpetuating role in CFS/FM is unclear, but it seems fair to state that only a minority of patients are really "kinesiophobic."43,44
Finally it should be mentioned that, particularly in patients with FM, not only high levels of negative affect have been demonstrated,45 but even more pronounced deficits in positive affects, increasing the risk of depression in response to illness-related stressors.46
Personality Factors
The role of personality in CFS/FM is largely terra incognita. Experienced clinicians have described CFS patients as conscientious, hard-working, somewhat "neurotic," and introverted individuals with high personal standards, a strong wish for social acceptance, and a life-history that is often characterized by exceeding physical limitations.23
However, systematic research on the role of personality in hampering adaptation to the illness—and thus perpetuating it—is still in its infancy.47 Interesting research topics in this context would be the following: links between personality and comorbid depression in CFS/FM;48 emotion regulation related to alexithymia,49,50 including biological measures such as salivary cortisol;51 the way in which some CFS/FM patients may create their own stress, for example, by being too perfectionistic;52 and the role such personality and lifestyle factors may play in the prognosis of CFS/FM and other functional somatic syndromes.53
Behavioral Factors
CFS/FM patients who do not accept their limitations or have difficulty adapting are not only more emotionally distressed but may unintentionally perpetuate their illness. Indeed, as soon as they feel somewhat less fatigued, they may engage in inappropriate activities, putting their disturbed stress mechanisms under severe pressure and making recovery less probable. Patients with a history of an overactive lifestyle may be particularly prone to this "boom-and-bust" activity pattern.54
In chronic-pain patients55 as well as in patients with a CFS diagnosis,56 it has been found that "nonacceptance" is correlated with lower quality of life and more associated psychiatric symptoms, but whether this also results in a less favorable outcome of CFS/FM remains to be studied.
Social Factors
Lack of recognition and understanding is a perpetuating factor that cannot be overestimated. Concretely, many CFS/FM patients complain of a skeptical attitude or even disbelief from their family members ("You don’t look ill!"), as well as from private or governmental insurance agencies ("[This illness] does not exist!").57–60 Such reactions not only cause extra stress for the patient and diminish his or her quality of life, but may also encourage illness-behavior: in the words of Hadler:61 "when you have to prove you are ill, you cannot get well."
Some CFS/FM patients—like other chronically ill patients—welcome the sickness status because it provides them with a range of advantages, such as a solicitous partner.62 In classical terms, this has been called "secondary gain," but this illness-reinforcing mechanism can also be formulated in terms of operant conditioning.63
Opinions differ as to whether membership in a CFS or FM patient-support group might play a role in the prognosis of the illness. Nevertheless, a recent investigation found that active—as compared with nonactive—support-group members had more serious symptoms and showed a less favorable illness outcome.64
Iatrogenic Factors
A final perpetuating factor may be the inadequate treatment behavior of doctors and therapists.65 Some practitioners seduce the patient into undergoing various investigations (e.g., sophisticated immunological tests) or interventions with dubious benefit (among them, the replacement of dental amalgam fillings or long-lasting treatment with antibiotics or nutritional supplements). Others impose unfounded beliefs onto patients, making them catastrophize even more ("Your immune system is a total loss!"). Such messages may decrease patients’ self-efficacy beliefs and active coping efforts, which, as studies discussed below demonstrate, are crucial requirements for recovery.
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FROM PERPETUATING FACTORS TO THERAPY
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Aims, Strategies, and Outcome
The rationale of current treatment interventions in CFS/FM can be formulated as follows: since the pathophysiology underlying the illness cannot be actively (e.g., pharmacologically) corrected, treatment should aim at creating optimal conditions for "natural" stress-system recovery by tackling illness-perpetuating factors.
In this respect, cognitive-behavioral therapy (CBT) and graded-exercise therapy (GET) have shown moderate efficacy in CFS/FM via randomized, controlled trials (RCTs).11–13 However, the effect sizes for individual CBT are significantly higher than those for CBT-based group programs.66,67 This may, at least partly, be due to the heterogeneity of perpetuating factors, implying that individual treatment may be better able to address this heterogeneity. Also, therapeutic effects are not always maintained in the long-term, and drop-out rates are fairly high,11,68,69 which may also be related to insufficiently individualized treatment. Furthermore, we cannot ignore the resistance of some researchers and patient organizations to CBT and GET—particularly when they follow a fixed protocol.10,14
It seems crucial, therefore, that the clinical application of CBT/GET should not be based on a "one-size-fits-all" approach, but should be carefully tailored to the patient’s personal needs.1,68 The recently-published NICE (British National Institute for Health and Clinical Excellence) guidelines for CFS/ME, similarly, recommend a customized therapy.70
Finally, opinions differ as to what might be an attainable therapeutic outcome in CFS/FM. Should these patients, in the first place, accept their ailment and learn to cope optimally with symptoms and functional limitations, or should they strive for real recovery? And, in the latter case, how should "recovery" be defined? Should patients, after a symptomatic and functional improvement, stop defining themselves as CFS or FM patients, or should they take account of their—possibly lifelong—vulnerability? These are questions for which no definitive answer has yet been given. (Several investigators15,16,71 have offered more extensive discussions.)
THERAPEUTIC PROCESSES
There is a manifest lack of knowledge about factors that could account for and predict successful treatment in CFS/FM.1,68 What are the core therapeutic ingredients of CBT and GET in these patients? Is therapeutic success initially dependent on correcting cognitive-perceptual errors and behavioral adaptation, or are there more fundamental factors at work, such as changes in emotional processing?72 Are some perpetuating factors more difficult to influence than others? Are there contraindications for these treatment strategies ? How can these treatments lead to enduring adjustments of personality traits, lifestyle, and life goals—rather than producing only temporary changes, such as a deactivation of maladaptive cognitive-affective schemas that could easily be reactivated by new stressors?73
Such questions—which are crucial in view of individualizing therapy—should be studied via process-outcome studies, focusing on putative mechanisms of change. In this respect, the question "what works, and for whom?"1,68 could be best addressed by using a conceptual framework distinguishing between predictors, mediators, and moderators.74
Today, such studies are still scarce. In FM, cognitive behavior and exercise treatments have been shown to be most effective in distressed patients in which the disorder has had a high impact on their daily life.68 In CFS, some of the perpetuating factors discussed above (such as membership of a self-help group, receipt of sickness-benefits, low sense of control, strong focus on symptoms, emotional problems, and passivity) have been found to predict negative treatment-outcome of CBT,1 whereas a decrease in symptom-focusing predicted a positive outcome for GET.75 These findings are congruent with studies in chronic low-back pain showing that changes in catastrophizing and self-efficacy/helplessness in part mediated the effects of a multidisciplinary rehabilitation program.76–78
Finally, although it has been suggested that a favorable therapeutic outcome in CFS/FM might be paralleled by positive changes in the neurobiological substrate of the illness,1 in line with recent evidence that CBT and exercise may increase resiliency of the HPA axis,79–81 no definitive proof of such effects in CFS/FM patients has been given until now.
Therapeutic Practice
In the clinical setting, individualized treatment should consist of three components: First, adequate therapy of possible comorbid depression, anxiety, and sleep disturbances, as well as optimal pain control, should be carried out, to minimize patients’ emotional and physical distress.82 Although antidepressants certainly have a role to play in this respect,35 it remains controversial whether these medications might also lead to lower levels of fatigue.42
Second, the patient should be offered a plausible illness theory that can be the starting-point for translating the therapeutic rationale into concrete practice. In accordance with the presumed pathophysiology of CFS/FM, a formulation in terms of "loss of stress-system resilience" could be useful, since it points to real, although subtle, biologically-based disturbances; it links physical and psychological factors, and has a nonstigmatizing and "nonpsychiatric" character, implying multiple "handles" for therapeutic change.
Third, we should discuss with patients which perpetuating factors will be concretely targeted during the therapy and what, in his or her particular case, might be realistic objectives. For most CFS/FM patients, it will be helpful to learn to pace their activities, instead of periodically exceeding their limits and provoking repeated setbacks manifesting as post-exertional malaise.71 Also, some patients must be assisted to rebuild their physical condition, by overcoming "fear of movement," while, at the same time, respecting their dysfunctional recovery mechanisms.27 Other persons must be confronted, for example, by means of a "Socratic dialogue," to abandon their erroneous or unfruitful illness-beliefs that foster catastrophizing and undermine self-efficacy, replacing them by more helpful approaches.1 For some patients, stress-management techniques such as relaxation training may be useful, as well as counseling focused on acceptance-based55,56,83 or affect-regulation46,72 principles. Some patients should be treated together with their partner in order to find a common modus vivendi adapted to intended life-changes. Still others need active coaching in their efforts for progressive professional reintegration or search for medical/social compensation.84 Also, many CFS/FM patients may benefit from gaining insight into personality and lifestyle factors that have contributed to their illness, since a better understanding of the past can help keep future stress levels within acceptable limits and help find a new equilibrium.52,72
It logically follows from the above that results of randomized, controlled trials in CFS/FM (such as the current therapeutic trial in the U.K. comparing CBT, GET, and pacing85) can guide, but never be simply translated into, clinical practice.86 Thus, future process-outcome studies should randomize different subtypes of CFS/FM patients to different treatment conditions that should be customized in turn to individual patterns of perpetuating factors.
Finally, it may be expected that a more personalized therapeutic approach may foster the openness of patients and researchers to a pragmatic management of symptoms and functional limitations, and counteract perceptions of psychological or rehabilitative treatments as being inflexible and dogmatic.10,14
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CONCLUSION
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Next to precipitating and predisposing factors, various perpetuating factors seem to play a role in CFS/FM by interacting with neurobiological dysfunction and associated perceptual and behavioral disturbances.
From a therapeutic point of view, CBT and GET (as well as other interventions) should start from a plausible illness theory and focus on perpetuating factors in a tailored, patient-centered way. Under these conditions, psychological and rehabilitative treatments may improve quality of life and functioning in CFS/FM patients and optimize their chances of recovery.
Nonetheless, many uncertainties remain about the therapeutic aim, strategies, and outcome, as well as the mechanisms of change underlying the above-mentioned treatments, particularly with regard to the recovery of stress-system functioning. Long-term follow-up studies are needed to provide answers to these unsolved questions.
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REFERENCES
|
- Prins JB, van der Meer JW, Bleijenberg G: Chronic fatigue syndrome. Lancet 2006; 367:346–355[CrossRef][Medline]
- Fukuda K, Straus SE, Hickie I, et al: The chronic fatigue syndrome: a comprehensive approach to its definition and study. international chronic fatigue syndrome study group. Ann Intern Med 1994; 121:953–959[Abstract/Free Full Text]
- Wolfe F, Smythe HA, Yunus MB, et al: The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia: Report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33:160–172[Medline]
- Wessely S, White PD: Debate: there is only one functional somatic syndrome. Br J Psychiatry 2004; 185:95–96[Free Full Text]
- Fink P, Hansen MS, Ornbol E, et al: Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medicine, neurological, and primary-care patients. Psychosom Med 2007; 69:30–39[Abstract/Free Full Text]
- Schur EA, Afari N, Furberg H, et al: Feeling bad in more ways than one: comorbidity patterns of medically unexplained and psychiatric conditions. J Gen Intern Med 2007; 22:818–821[Medline]
- Yunus MB: Fibromyalgia and overlapping disorders: the unifying concept of central sensitivity syndromes. Semin Arthritis Rheum 2007; 36:339–356[CrossRef][Medline]
- Jason LA, Corradi K, Torres-Harding S, et al: Chronic fatigue syndrome: the need for subtypes. Neuropsychol Rev 2005; 15:29–58[CrossRef][Medline]
- Van der Werf SP, Prins JB, Vercoulen JH, et al: Identifying physical activity patterns in chronic fatigue syndrome using actigraphic assessment. J Psychosom Res 2000; 49:373–379[CrossRef][Medline]
- Hooper M: Myalgic encephalomyelitis: a review with emphasis on key findings in biomedical research. J Clin Pathol 2007; 60:466–471[Abstract/Free Full Text]
- Malouff JM, Thorsteinsson EB, Rooke SE, et al: Efficacy of cognitive-behavioral therapy for chronic fatigue syndrome: a meta-analysis. Clin Psychol Rev 2008; 28:736–745[CrossRef][Medline]
- Edmonds M, McGuire H, Price J: Exercise therapy for chronic fatigue syndrome. Cochrane Database Syst Rev 2004; 3: CD003200
- Busch AJ, Barber KA, Overend TJ, et al: Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev 2007; 4: CD003786
- http://meagenda.wordpress.com/2007/09/07/nice-cfs-me-guideline-statement-by-the-me-association-07-Sept-2007
- Van Houdenhove B: What is the aim of cognitive-behaviour therapy in patients with chronic fatigue syndrome? Psychother Psychosom 2006; 75:396–397[CrossRef][Medline]
- Knoop H, Bleijenberg G, Gielissen MF, et al: Is a full recovery possible after cognitive-behavioural therapy for chronic fatigue syndrome? Psychother Psychosom 2007; 76:171–176[CrossRef][Medline]
- Van Houdenhove B, Egle UT: Fibromyalgia: a stress disorder ? piecing the biopsychosocial puzzle together. Psychother Psychosom 2004; 73:267–275[CrossRef][Medline]
- Abeles AM, Pillinger MH, Solitar BM, et al: Narrative review: the pathophysiology of fibromyalgia. Ann Intern Med 2007; 146:726–734[Abstract/Free Full Text]
- Fries E, Hesse J, Hellhammer J, et al: A new view on hypocortisolism. Psychoneuroendocrinology 2005; 30:1010–1016[CrossRef][Medline]
- Meeus M, Nijs J: Central sensitization: a biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clin Rheumatol 2007; 26:465–473[CrossRef][Medline]
- White PD: What causes chronic fatigue syndrome? BMJ 2004; 329:928–929[Free Full Text]
- Maes M, Mihaylova I, Bosmans E: Not in the mind of neurasthenic lazybones but in the cell nucleus: patients with chronic fatigue syndrome have increased production of nuclear factor kappa beta. Neuro Endocrinol Lett 2007; 28:456–462[Medline]
- Van Houdenhove B: Listening to CFS: Why we should pay more attention to the story of the patient. J Psychosom Res 2002; 52:495–499[CrossRef][Medline]
- McEwen BS: Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev 2007; 87:873–904[Abstract/Free Full Text]
- Miller GE, Chen E, Zhou ES: If it goes up, must it come down? chronic stress and the hypothalamic-pituitary-adrenocortical axis in humans. Psychol Bull 2007; 133:25–45[CrossRef][Medline]
- Maloney EM, Gurbaxani BM, Jones JF, et al: Chronic fatigue syndrome and high allostatic load. Pharmacogenomics 2006; 7:467–473[CrossRef][Medline]
- Van Houdenhove B, Verheyen L, Pardaens K, et al: Decreased motor performance in patients with chronic fatigue syndrome: should we treat low effort capacity or reduced effort tolerance? Clin Rehabil 2007; 21:1121–1142[Abstract/Free Full Text]
- Armitage R, Landis C, Hoffmann R, et al: The impact of a 4-hour sleep-delay on slow-wave activity in twins discordant for chronic fatigue syndrome. Sleep 2007; 30:657–662[Medline]
- Majer M, Jones JF, Unger ER, et al: Perception versus polysomnographic assessment of sleep in CFS and non-fatigued control subjects: results from a population-based study. BMC Neurol 2007; 7:40[Medline]
- Lavigne G, Sessle B, Choinière M, et al (eds): Sleep and Pain. Seattle, WA, IASP Press, 2007
- Donta ST, Engel CC Jr, Collins JF, et al: Benefits and harms of doxycycline treatment for Gulf War veterans’ illnesses: a randomized, double-blind, placebo-controlled trial. Ann Intern Med 2004; 141:85–94[Abstract/Free Full Text]
- Johnson LM, Zautra AJ, Davis MC: The role of illness-uncertainty in coping with fibromyalgia symptoms. Health Psychol 2006; 25:696–703[Medline]
- Carrillo-de-la-Pena MT, Vallet M, Perez MI, et al: Intensity dependence of auditory-evoked cortical potentials in fibromyalgia patients: a test of the generalized hypervigilance hypothesis. J Pain 2005; 115:316–321
- Edwards RR, Bingham CO 3rd, Bathon J, et al: Catastrophizing and pain in arthritis, fibromyalgia, and other rheumatic diseases. Arthritis Rheum 2006; 55:325–332[Medline]
- Bair MJ, Robinson RL, Katon W, et al: Depression and pain comorbidity: a literature review. Arch Intern Med 2003; 163:2433–2445[Abstract/Free Full Text]
- Raphael KG, Janal MN, Nayak S, et al: Familial aggregation of depression in fibromyalgia: a community-based test of alternate hypotheses. Pain 2004; 110:449–460[CrossRef][Medline]
- Hammen C: Stress and depression. Annu Rev Clin Psychol 2005; 1:239–319
- Prins J, Bleijenberg G, Rouweler EK, et al: Effect of psychiatric disorders on outcome of cognitive-behavioural therapy for chronic fatigue syndrome. Br J Psychiatry 2005; 187:184–185[Abstract/Free Full Text]
- Van Houdenhove B: Psychiatric comorbidity and chronic fatigue syndrome. Br J Psychiatry 2006; 88:395
- Steptoe A (ed): Depression and Physical Illness. Cambridge, UK, Cambridge University Press, 2006
- Henningsen P, Zimmermann T, Sattel H: Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosom Med 2003; 65:528–533[Abstract/Free Full Text]
- Thomas MA, Smith AP: An investigation of the long-term benefits of antidepressant medication in the recovery of patients with chronic fatigue syndrome. Hum Psychopharmacol 2006; 21:503–509[CrossRef][Medline]
- Nijs J, Vanherberghen K, Duquet W, et al: Chronic fatigue syndrome: lack of association between pain-related fear of movement and exercise capacity and disability. Phys Ther 2004; 84:696–705[Abstract/Free Full Text]
- Gallagher AM, Coldrick AR, Hedge B, et al: Is the chronic fatigue syndrome an exercise phobia? a case-control study. J Psychosom Res 2005; 58:367–373[CrossRef][Medline]
- Geenen R, van Middendorp H: The ostrich strategy toward affective issues in alexithymic patients with fibromyalgia. Patient Educ Couns 60; 97-99: 2006
- Zautra AJ, Fasman R, Reich JW, et al: Fibromyalgia: evidence for deficits in positive affect regulation. Psychosom Med 2005; 67:147–155[Abstract/Free Full Text]
- Van Geelen SM, Sinnema G, Hermans HJ, et al: Personality and chronic fatigue syndrome: methodological and conceptual issues. Clin Psychol Rev 2007; 27:885–903[Medline]
- Nordahl HM, Stiles TC: Personality styles in patients with fibromyalgia, major depression, and healthy controls. Ann Gen Psychiatry 2007; 6:9[Medline]
- Friedberg F, Quick J: Alexithymia in chronic fatigue syndrome: associations with momentary, recall, and retrospective measures of somatic complaints and emotions. Psychosom Med 2007; 69:54–60[Abstract/Free Full Text]
- Van Heule S, Vandenbergen J, Desmet M, et al: Alexithymia and core conflictual relationship themes: a study in a chronically fatigued primary-care population. Int J Psychiatry Med 2007; 37:87–98[Medline]
- Finset A, Graugaard PK, Holgersen K: Salivary cortisol response after a medical interview: the impact of physician communication behaviour, depressed affect, and alexithymia. Patient Educ Couns 2006; 60:115–124[Medline]
- Luyten P, Cosyns N, Van Houdenhove B, et al: Are patients with chronic fatigue syndrome perfectionistic, or were they? a case-control study. Pers Indiv Diff 2006; 40:1473–1483
- Creed F: Cognitive-behavioural model of irritable bowel syndrome. Gut 2007; 56:1039–1041[Free Full Text]
- Van Houdenhove B, Neerinckx E, Onghena P, et al: Premorbid "overactive" lifestyle in chronic fatigue syndrome and fibromyalgia: an etiological factor or proof of good citizenship? J Psychosom Res 2001; 51:571–576[CrossRef][Medline]
- Viane I, Crombez G, Eccleston C, et al: Acceptance of pain is an independent predictor of mental well-being in patients with chronic pain: empirical evidence and reappraisal. Pain 2003; 106:65–72[CrossRef][Medline]
- Van Damme S, Crombez G, Van Houdenhove B, et al: Quality of life in patients with chronic fatigue syndrome: the role of acceptance. J Psychosom Res 2006; 61:595–599[Medline]
- Undeland M, Malterud K: The fibromyalgia diagnosis: hardly helpful for the patients? Scand J Prim Health Care 2007; 25:250–255[Medline]
- Prins JB, Bos E, Huibers M, et al: Social support and the persistence of complaints in chronic fatigue syndrome. Psychother Psychosom 2004; 73:174–182[CrossRef][Medline]
- Page LA, Wessely S: Medically unexplained symptoms: exacerbating factors in the doctor-patient encounter. J R Soc Med 2003; 96:223–227[Free Full Text]
- Larun L, Malterud K: Identity and coping experiences in chronic fatigue syndrome: a synthesis of qualitative studies. Patient Educ Counsel 2007; 69:20–28[Medline]
- Hadler NM: If you have to prove you are ill, you can’t get well: the object lesson of fibromyalgia. Spine 1996; 21:2397–2400[CrossRef][Medline]
- Schmaling KB, Smith WR, Buchwald DS: Significant-other responses are associated with fatigue and functional status among patients with chronic fatigue syndrome. Psychosom Med 2000; 62:444–450[Abstract/Free Full Text]
- Thieme K, Turk DC, Flor H: Responder criteria for operant and cognitive-behavioral treatment of fibromyalgia syndrome. Arthritis Rheum 2007; 57:830–836[Medline]
- Friedberg F, Leung DW, Quick J: Do support groups help people with chronic fatigue syndrome and fibromyalgia? a comparison of active and inactive members. J Rheumatol 2005; 32:2416–2420[Abstract/Free Full Text]
- Salmon P: The potentially somatizing effect of clinical consultation. CNS Spectr 2006; 11:190–200[Medline]
- Bazelmans E, Prins JB, Lulofs R, et al: Cognitive-behavioural group therapy for chronic fatigue syndrome: a non-randomised, waiting-list, controlled study. Psychother Psychosom 2005; 74:218–224[CrossRef][Medline]
- Pardaens K, Haagdorens L, Van Wambeke P, et al: How relevant are exercise-capacity measures for evaluating treatment effects in chronic fatigue syndrome? results from a prospective, multidisciplinary outcome study. Clin Rehabil 2006; 20:56–66[Abstract/Free Full Text]
- van Koulil S, Effting M, Kraaimaat FW, et al: Cognitive-behavioural therapies and exercise programmes for patients with fibromyalgia: state of the art and future directions. Ann Rheum Dis 2007; 66:571–581[Abstract/Free Full Text]
- Deale A, Husain K, Chalder T, et al: Long-term outcome of cognitive-behavioral therapy versus relaxation therapy for chronic fatigue syndrome: a 5-year follow-up study. Am J Psychiatry 2001; 158:2038–2042[Abstract/Free Full Text]
- www.nice.org.uk/CG53
- Van Houdenhove B, Bruyninckx K, Luyten P: In search of a new balance: can high "action-proneness" in patients with chronic fatigue syndrome be changed by a multidisciplinary group treatment? J Psychosom Res 2006; 60:623–625[CrossRef][Medline]
- Godfrey E, Chalder T, Ridsdale L, et al: Investigating the "active ingredients" of cognitive-behavioural therapy and counselling for patients with chronic fatigue in primary care: developing a new process measure to assess treatment fidelity and predict outcome. Br J Clin Psychol 2007; 46:253–272[CrossRef][Medline]
- Luyten P, Blatt SJ, Van Houdenhove B, et al: Depression research and treatment: are we skating to where the puck is going to be? Clin Psychol Rev 2006; 26:985–999[CrossRef][Medline]
- Kraemer HC, Stice E, Kazdin A, et al: How do risk factors work together? mediators, moderators, and independent, overlapping, and proxy risk factors. Am J Psychiatry 2001; 158:848–856[Abstract/Free Full Text]
- Moss-Morris R, Sharon C, Tobin R, et al: Randomized, controlled, graded exercise trial for chronic fatigue syndrome: outcomes and mechanisms of change. J Health Psychol 2005; 10:245–259[Abstract/Free Full Text]
- Spinhoven P, Ter Kuile M, Kole-Snijders AM, et al: Catastrophizing and internal pain control as mediators of outcome in the multidisciplinary treatment of chronic low-back pain. Eur J Pain 2004; 8:211–219[CrossRef][Medline]
- Smeets RJ, Vlaeyen JW, Kester AD, et al: Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low-back pain. J Pain 2006; 7:261–271[CrossRef][Medline]
- Woby SR, Urmston M, Watson P: Self-efficacy mediates the relation between pain-related fear and outcome in chronic low-back pain patients. Eur J Pain 2007; 11:711–718[Medline]
- Bonifazi M, Suman AL, Cambiaggi C, et al: Changes in salivary cortisol and corticosteroid receptor-
 mRNA expression following a 3-week multidisciplinary treatment program in patients with fibromyalgia. Psychoneuroendocrinology 2006; 31:1076–1086[Medline]
- Gaab J, Sonderegger L, Scherrer S, et al: Psychoneuroendrocrine effects of cognitive-behavioral stress management in a naturalistic setting: a randomized, controlled trial. Psychoneuroendocrinology 2006; 31:428–438[Medline]
- Hammerfald K, Eberle C, Grau M, et al: Persistent effects of cognitive-behavioral stress management on cortisol responses to acute stress in healthy subjects: a randomized clinical trial. Psychoneuroendocrinology 2006; 31:333–339[CrossRef][Medline]
- Rooks DS: Fibromyalgia treatment update. Curr Opin Rheumatol 2007; 19:111–117[Medline]
- Grossman P, Tiefenthaler-Gilmer U, Raysz A, et al: Mindfulness training as an intervention for fibromyalgia: evidence of post-intervention and 3-year follow-up benefits in well-being. Psychother Psychosom 2007; 76:226–233[Medline]
- Patel S, Greasly K, Watson PJ: Barriers to rehabilitation and return to work for unemployed chronic pain patients: a qualitative study. Eur J Pain 2007; 11:831–840[Medline]
- White PD, Sharpe MC, Chalder T, PACE Trial Group: Protocol for the PACE trial, et al: A randomised, controlled trial of adaptive pacing, cognitive-behavioural therapy, and graded exercise, as supplements to standardised specialist medical care versus standardised specialist medical care-alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy. BMC Neurol 2007; 7:6[Medline]
- Quarmby L, Rimes KA, Deale A, et al: Cognitive-behavioural therapy for chronic fatigue syndrome: comparison of outcomes within and outside the confines of a randomised controlled trial. Behav Res Ther 2007; 45:1085–1094[CrossRef][Medline]
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ABSTRACT
INTRODUCTION
