Background: Cognitive behaviour therapy (CBT) for chronic fatigue syndrome (CFS) can decrease the level of fatigue and disabilities, but it has been suggested that during therapy some patients experience a deterioration of their symptoms rather than an improvement. The aim of this study is to examine the frequency and severity of symptom deterioration during CBT for CFS. Methods: Data from 3 randomised controlled trials on CBT for CFS were pooled and reanalysed. Symptom deterioration during the trial was rated by patients and measured as deterioration in fatigue, pain, functional impairment and psychological distress. Both the frequency and severity of deterioration in these domains were compared between the patients receiving CBT and those in the control group. Predictors of symptom deterioration were identified by comparing their means in patients with and without an increase in fatigue. Statistically significant predictors were then combined in a logistic regression model. Results: The frequency of symptom deterioration varied from 2 to 12% in patients receiving CBT and from 7 to 17% in the control group. None of the measures showed a significantly higher frequency of symptom deterioration in the CBT group. The severity of deterioration was also comparable in the CBT and in the control group. No predictors of symptom deterioration specific to CBT were found. Conclusion: Patients receiving CBT do not experience more frequent or more severe symptom deterioration than untreated patients. The reported deterioration during CBT seems to reflect the natural variation in symptoms. Thus, CBT is not only a helpful, but also a safe treatment for CFS.

Jason LA, Richman JA, Rademaker AW, Jordan KM, Plioplys AV, Taylor RR, McCready W, Huang CF, Plioplys S: A community-based study of chronic fatigue syndrome. Arch Intern Med 1999;159:2129–2137.
Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A: 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.
Behan P, Hannifah H: 5-HT reuptake inhibitors in CFS. EOS (Rome, Italy) 1995;15:66–69.
Kaslow JE, Rucker L, Onishi R: Liver extract-folic acid-cyanocobalamin versus placebo for chronic fatigue syndrome. Arch Intern Med 1989;149:2501–2503.
Vercoulen JH, Swanink CM, Zitman FG, Vreden SG, Hoofs MP, Fennis JF, Galama JM, van der Meer JW, Bleijenberg G: Randomised, double-blind, placebo-controlled study of fluoxetine in chronic fatigue syndrome. Lancet 1996;347:858–861.
Walach H, Bosch H, Lewith G, Naumann J, Schwarzer B, Falk S, Kohls N, Haraldsson E, Wiesendanger H, Nordmann A, Tomasson H, Prescott P, Bucher HC: Effectiveness of distant healing for patients with chronic fatigue syndrome: a randomised controlled partially blinded trial (EUHEALS). Psychother Psychosom 2008;77:158–166.
Warren G, McKendrick M, Peet M: The role of essential fatty acids in chronic fatigue syndrome: a case-controlled study of red-cell membrane essential fatty acids (EFA) and a placebo-controlled treatment study with high dose of EFA. Acta Neurol Scand 1999;99:112–116.
Wearden AJ, Morriss RK, Mullis R, Strickland PL, Pearson DJ, Appleby L, Campbell IT, Morris JA: Randomised, double-blind, placebo-controlled treatment trial of fluoxetine and graded exercise for chronic fatigue syndrome. Br J Psychiatry 1998;172:485–490.
Price JR, Mitchell E, Tidy E, Hunot V: Cognitive behaviour therapy for chronic fatigue syndrome in adults. Cochrane Database Syst Rev 2008;4:CD001027.
Knoop H, Bleijenberg G, Gielissen MF, van der Meer JW, White PD: Is a full recovery possible after cognitive behavioural therapy for chronic fatigue syndrome? Psychother Psychosom 2007;76:171–176.
Fava GA: The intellectual crisis of psychiatric research. Psychother Psychosom 2006;75:202–208.
Chouinard G, Chouinard VA: Atypical antipsychotics: CATIE study, drug-induced movement disorder and resulting iatrogenic psychiatric-like symptoms, supersensitivity rebound psychosis and withdrawal discontinuation syndromes. Psychother Psychosom 2008;77:69–77.
Yoshiuchi K, Cook DB, Ohashi K, Kumano H, Kuboki T, Yamamoto Y, Natelson BH: A real-time assessment of the effect of exercise in chronic fatigue syndrome. Physiol Behav 2007;92:963–968.
Bazelmans E, Bleijenberg G, Voeten MJ, van der Meer JW, Folgering H: Impact of a maximal exercise test on symptoms and activity in chronic fatigue syndrome. J Psychosom Res 2005;59:201–208.
Whiteside A, Hansen S, Chaudhuri A: Exercise lowers pain threshold in chronic fatigue syndrome. Pain 2004;109:497–499.
Working Group on CFS/ME (Chronic Fatigue Syndrome/Myalgic Encephalomyelitis): A Report of the CFS/ME Working Group. London, Department of Health, 2002.
Action for ME/Association of Young People with ME: ME 2008: what progress? Initial findings of a national survey of over 2,760 people with ME focusing on their health and welfare. 2008. (last ed July 29, 2009).
Cairns R, Hotopf M: A systematic review describing the prognosis of chronic fatigue syndrome. Occup Med (Lond) 2005;55:20–31.
Knoop H, van der Meer JW, Bleijenberg G: Guided self-instructions for people with chronic fatigue syndrome: randomised controlled trial. Br J Psychiatry 2008;193:340–341.
Prins JB, Bleijenberg G, Bazelmans E, Elving LD, de Boo TM, Severens JL, van der Wilt GJ, Spinhoven P, van der Meer JW: Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial. Lancet 2001;357:841–847.
Stulemeijer M, de Jong LW, Fiselier TJ, Hoogveld SW, Bleijenberg G: Cognitive behaviour therapy for adolescents with chronic fatigue syndrome: randomised controlled trial. BMJ 2005;330:14.
Knoop H, Stulemeijer M, Prins JB, van der Meer JW, Bleijenberg G: Is cognitive behaviour therapy for chronic fatigue syndrome also effective for pain symptoms? Behav Res Ther 2007;45:2034–2043.
van Dulmen AM, Fennis JF, Mokkink HG, van der Velden HG, Bleijenberg G: Persisting improvement in complaint-related cognitions initiated during medical consultations in functional abdominal complaints. Psychol Med 1997;27:725–729.
Vercoulen JH, Swanink CM, Fennis JF, Galama JM, van der Meer JW, Bleijenberg G: Prognosis in chronic fatigue syndrome: a prospective study on the natural course. J Neurol Neurosurg Psychiatry 1996;60:489–494.
Vercoulen JH, Bazelmans E, Swanink CM, Fennis JF, Galama JM, Jongen PJ, Hommes O, van der Meer JW, Bleijenberg G: Physical activity in chronic fatigue syndrome: assessment and its role in fatigue. J Psychiatr Res 1997;31:661–673.
Bergner M, Bobbitt RA, Pollard WE, Martin DP, Gilson BS: The sickness impact profile: validation of a health status measure. Med Care 1976;14:57–67.
Pollard WE, Bobbitt RA, Bergner M, Martin DP, Gilson BS: The sickness impact profile: reliability of a health status measure. Med Care 1976;14:146–155.
Jacobs HM, Luttik A, Touw-Otten FW, de Melker RA: The Sickness Impact Profile: results of an evaluation study of the Dutch version (in Dutch). Ned Tijdschr Geneeskd 1990;134:1950–1954.
Stewart AL, Hays RD, Ware JE Jr: The MOS short-form general health survey: reliability and validity in a patient population. Med Care 1988;26:724–735.
Arrindell WA, Ettema JHM: SCL-90. Handleiding bij een Multidimensionele Psychopathologie-Indicator. Lisse, Swets & Zeitlinger BV, 1986.
Vercoulen JH, Swanink CM, Fennis JF, Galama JM, van der Meer JW, Bleijenberg G: Dimensional assessment of chronic fatigue syndrome. J Psychosom Res 1994;38:383–392.
Dempster ALN, Rubin D: Likelihood from incomplete data via the EM algorithm. J R Stat Soc Series B Stat Methodol 1977;39:1–38.
Jacobson NS, Truax P: Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. J Consult Clin Psychol 1991;59:12–19.
Sharpe M, Hawton K, Simkin S, Surawy C, Hackmann A, Klimes I, Peto T, Warrell D, Seagroatt V: Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial. BMJ 1996;312:22–26.
Mohr DC, Spring B, Freedland KE, Beckner V, Arean P, Hollon SD, Ockene J, Kaplan R: The selection and design of control conditions for randomized controlled trials of psychological interventions. Psychother Psychosom 2009;78:275–284.
Elliott SA, Brown JS: What are we doing to waiting list controls? Behav Res Ther 2002;40:1047–1052.
Bentall RP, Powell P, Nye FJ, Edwards RH: Predictors of response to treatment for chronic fatigue syndrome. Br J Psychiatry 2002;181:248–252.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.