Cognitive Behavioral Therapy—An Effective Aid in the Management of Chronic Fatigue Syndrome and Fibromyalgia

Research now supports cognitive behavioral therapy (CBT) as an effective adjunct in the management of both Chronic Fatigue Syndrome (CFS) and Fibromyalgia (FM). This treatment entails the use of gradually increased exercise and activity and thus a big commitment from patients. Nevertheless, the efforts are worthwhile, since two thirds of the patients who stick with therapy realize significant symptom reduction as well as a substantial increase in ability to function.

What is Cognitive Behavioral Therapy?

A British doctor, Michael Sharpe, MA, MB, MRCP, MRCPsych, has studied cognitive behavior therapy and its implications for CFS extensively. He explains that CBT is “based upon the hypothesis that inaccurate and unhelpful beliefs, ineffective coping behavior, negative mood states, social problems, and pathophysiological processes all interact to perpetuate illness. Treatment aims at helping patients re-evaluate their understanding of the illness and to adopt more effective coping behaviors.”

CBT is particularly helpful for hard to treat medical conditions. It has been beneficial in a range of psychological problems such as panic disorder, obsessive-compulsive disorder and post-traumatic distress syndrome. However, it is often used for other conditions too, such as insomnia or chronic pain associated with rheumatoid arthritis, back problems and cancer.

What negative thinking or unhelpful beliefs, which complicate CFS or FM, could stand some readjustment? Many patients are so afraid of symptoms acutely worsening in reaction to exertion that they have come to believe activity must be harmful for them and thus they refrain from it as much as possible. As a result their immobility and deconditioning worsens and their symptoms are generally unremitting. Others worry about insomnia and get so upset about it that they only increase their sleeping difficulties. Yet others’ fear of anxiety and panic attacks aggravates this condition as well. Negative emotional reactions to pain can also serve to magnify this symptom.

What is involved in CBT treatment?

CBT treatment for CFS first consists of helping patients to recognize how such negative mental states can amplify and further perpetuate their condition. Patients learn strategies for dealing with unhelpful or distressing thoughts, including fears about treatment, symptoms, perfectionism, self-criticism, guilt and performance expectations. They are trained in an active problem solving approach to interpersonal and occupational difficulties.

Factors to Consider in Treatment:

* Insurance coverage for CBT varies according to condition being treated; can be expensive

* It is important to find a therapist the patient trusts and feels comfortable with; could consult National Association of Cognitive-Behavioral Therapists, (800) 853-1135

* Therapist must understand CFS or FM well

* CBT protocols specific to CFS/FM must be followed (general CBT protocols used for CFS/FM have not met with success)

* Treatment must be specifically tailored for the individual patient’s needs

* Patient must be committed to diligent follow-through

Homework is outlined where patients keep diaries of their activity, rest and fatigue as well as their emotional reactions. Practice sessions focus on dealing with particular difficulties. After careful collaboration between the therapist and patient, activity is gradually increased and rest is reduced slowly but surely as tolerance improves. A sleep routine is established with set times for retiring and rising. Finally, strategies are taught for continuing the newly learned thoughts and practices, and for dealing with setbacks after completion of the treatment.

CBT Benefits CFS

For CFS a number of published reports, but in particular two controlled trials performed in England, have established the usefulness of cognitive behavior therapy. Alicia Deale, M.Sc., and her associates conducted a trial in London involving 53 people with CFS who either received 13 sessions of cognitive behavior therapy or relaxation therapy over a period of four to six months. Deale reported in 1997 that 70% of those in the CBT group achieved good outcomes including “substantial improvement in physical functioning” compared with only 19% of those in the relaxation therapy group.

Another benefit received by a majority in the CBT group was substantial reduction of fatigue. In fact Deale noted that the improvement in physical functioning and fatigue was such that after the trial more than half of the cognitive behavior therapy group no longer fulfilled the diagnostic criteria for CFS. Additionally because of the training they received, most were able to maintain these benefits 6 months after the treatment had ended.

A year before the London trial was published, the British Medical Journal reported on a CBT/CFS study in Oxford, England, conducted by Michael Sharpe, MA, MB, MRCP, MRCPsych. This trial compared 30 CFS patients who received standard medical care alone with 30 patients who received 16 one-hour CBT sessions over the course of six months in addition to receiving standard medical care. Although no patients had a complete resolution of their symptoms Sharpe reports that “the overall treatment effect was substantial.”

Because patients in the Oxford trial who underwent CBT treatment were helped to change their illness beliefs and coping behavior, most enjoyed a significant increase in their daily functioning. In fact 63% improved in their work status in comparison with 20% in the medical care only group. The benefits for CBT in the Oxford trial also included reduced fatigue and depression.

Almost two-thirds in the CBT group rated their improvement as “much improved” or “very much improved” as opposed to only one fifth of the medical care group who felt the same. Overall 73% of those who received CBT improved satisfactorily as opposed to only 27% who received medical care alone.

Similar to the Oxford trial, a Canadian study evaluated the treatment of 51 CFS patients with both cognitive behavior therapy and optimal medical care. The CFS patients were all severely ill such that they were unable to work. After treatment, which averaged 6 months in length, 31 patients returned to gainful employment, mostly full-time. Another 14 functioned at a level capable of full-time work, but because of reasons other than health were not employed. A follow-up on the average of 33 months later with a subset of these improved patients showed that they had been able to maintain the benefits of treatment.

CBT Benefits FM

Studies testing CBT’s use in fibromyalgia have also found it beneficial. When used for three weeks on 30 hospital in-patients, a significant reduction of perceived pain was experienced. The patients also experienced more functionality, reduced helplessness, and better control over their lives. These benefits persisted even 30 months after treatment. Similar results were found in another study of 20 patients where CBT was combined with an exercise regime.

In an eight-week pilot study done in Baltimore 20 FM patient were treated with CBT which focused on relaxation techniques, controlled movements and breath control. The researchers involved reported that their patients “showed significant reduction in pain, fatigue, and sleeplessness, and improved function, mood state, and general health.”

Not Proof of Psychological Cause of CFS

The success of CBT in the care of CFS by no means indicates that CFS patients’ problems are all psychological. Dr. Sharp explains that his group has “been at pains to point out that the relative effectiveness of cognitive behavior therapy does not mean that the illness is all in the mind.” A 1996 British review of cognitive behavior therapy benefits in CFS care echoes these sentiments. The review states that “it is important to stress that CBT does not involve a shift from an exclusively physical view of CFS to an exclusively psychological model.” However, until an actual treatable, physical cause of CFS is conclusively found, it only makes sense to encourage the best management of what can be a very distressing illness.

Rather than proving a psychological cause of CFS, cognitive behavior therapy’s success emphasizes the importance of treating the whole person and in this regard is similar to mind/body medicine. The brain is not a separate entity from the physical being. To the contrary the interrelation of mental activity and physical health is quite complicated. And the fact remains that many potential causes of CFS now being researched involve the nervous system, which is controlled by the brain. Further doctors have learned that deliberate changes in thinking and behavior can have positive effects on the nervous system and other related systems. This highlights the reasonableness of cognitive behavior therapy for CFS.


Cognitive behavior therapy can be described as an adjunct for CFS or FM since it can accompany other treatment plans. The strong desire for recovery in most patients with these conditions is advantageous since CBT requires long-term commitment. Actually, CBT empowers patients by giving them an active roll in the treatment process. Empowerment, and the opportunity to regain control of one’s life through increased functioning and reduced symptoms all make cognitive behavior therapy worth investigating for patients with CFS and FM.

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