Trudie Chalder

In-Patient Treatment of Chronic Fatigue Syndrome

Behavioural and Cognitive Psychotherapy, Oct 1, 1996

A cognitive behavioural model for the development of chronic fatigue syndrome (CFS) is outlined. ... more A cognitive behavioural model for the development of chronic fatigue syndrome (CFS) is outlined. Six patients with CFS are described who were treated as in-patients using cognitive behaviour therapy. Treatment consisted of graded consistent exposure to activity and cognitive restructuring. Substantial improvements were made in all but one patient up to three months after discharge.

Cognitive Behavioural Therapy for chronic fatigue and CFS: outcomes from a specialist clinic in the UK

Objectives: Cognitive behavioural therapy is commonly used to treat chronic fatigue syndrome and ... more Objectives: Cognitive behavioural therapy is commonly used to treat chronic fatigue syndrome and has been shown to be effective for reducing fatigue and improving physical functioning. Most of the evidence on the effectiveness of cognitive behavioural therapy for chronic fatigue syndrome is from randomised control trials, but there are only a few studies in naturalistic treatment settings. Our aim was to examine the effectiveness of cognitive behavioural therapy for chronic fatigue syndrome in a naturalistic setting and examine what factors, if any, predicted outcome. Design: Using linear mixed effects analysis, we analysed patients' self-reported symptomology over the course of treatment and at three-month follow-up. Furthermore, we explored what baseline factors were associated with improvement at follow-up. Setting: Data were available for 995 patients receiving cognitive behavioural therapy for chronic fatigue syndrome at an outpatient clinic in the UK. Participants: Participants were referred consecutively to a specialist unit for chronic fatigue or chronic fatigue syndrome. Main outcome measures: Patients were assessed throughout their treatment using self-report measures including the Chalder Fatigue Scale, 36-item Short Form Health Survey, Hospital Anxiety and Depression Scale and Global Improvement and Satisfaction. Results: Patients' fatigue, physical functioning and social adjustment scores significantly improved over the duration of treatment with medium to large effect sizes (jdj ¼ 0.45-0.91). Furthermore, 85% of patients self-reported that they felt an improvement in their fatigue at follow-up and 90% were satisfied with their treatment. None of the regression models convincingly predicted improvement in outcomes with the best model being (R 2 ¼ 0.137). Conclusions: Patients' fatigue, physical functioning and social adjustment all significantly improved following cognitive behavioural therapy for chronic fatigue syndrome in a naturalistic outpatient setting. These findings support the growing evidence from previous randomised control trials and suggest that cognitive behavioural therapy could be an effective treatment in routine treatment settings.

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Management of chronic (post-viral) fatigue syndrome

PubMed, Apr 1, 1989

Management of chronic (post-viral) fatigue syndrome SIMON WESSELY ANTHONY DAVID SUE BUTLER TRUDIE... more Management of chronic (post-viral) fatigue syndrome SIMON WESSELY ANTHONY DAVID SUE BUTLER TRUDIE CHALDER SUMMARY. Simple rehabilitative strategies are proposed to help patients with the chronic fatigue syndrome. A model is outlined of an acute illness giving way to a chronic fatigue state in which symptoms are perpetuated by a cycle of in- activity, deterioration in exercise tolerance and further symp- toms. This is compounded by the depressive illness that is often part of the syndrome The result is a self-perpetuating cycle of exercise avoidance. Effective treatment depends upon an understanding of the interaction between physical and psychological factors. Cognitive behavioural therapy is suggested. Cognitive therapy helps the patient understand how genuine symptoms arise from the frequent combina- tion of physical inactivity and depression, rather than con- tinuing infection, while a behavioural approach enables the treatment of avoidance behaviour and a gradual return to normal physical activity. paper is not a review of the subject,6'9 but is intended to offer treatment guidelines to general practitioners, neurologists, physi- cians and psychiatrists, all of whom may be faced with people with the chronic fatigue syndrome. S. Wessely, MRCP, MRCPsych, senior registrar in psychiatry, S. Butler, senior behaviour therapist and T. Chalder, behaviour therapist, National Hospital for Nervous Diseases, London; A

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Long-Term Outcome of Cognitive Behavior Therapy Versus Relaxation Therapy for Chronic Fatigue Syndrome: A 5-Year Follow-Up Study

American Journal of Psychiatry, Dec 1, 2001

Objective: This study evaluated the longterm outcome of cognitive behavior therapy versus relaxat... more Objective: This study evaluated the longterm outcome of cognitive behavior therapy versus relaxation therapy for patients with chronic fatigue syndrome. Method: Sixty patients who participated in a randomized controlled trial of cognitive behavior therapy versus relaxation therapy for chronic fatigue syndrome were invited to complete self-rated measures and participate in a 5-year follow-up interview with an assessor who was blind to treatment type. Results: Fifty-three patients (88%) participated in the follow-up study: 25 received cognitive behavior therapy and 28 received relaxation therapy. A total of 68% of the patients who received cognitive behavior therapy and 36% who received relaxation therapy rated themselves as "much improved" or "very much improved" at the 5-year follow-up. Significantly more patients receiving cognitive behavior therapy, in relation to those in relaxation therapy,

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The prevalence and morbidity of chronic fatigue and chronic fatigue syndrome: a prospective primary care study

American Journal of Public Health, Sep 1, 1997

opment of chronic fatigue and CFS in this sample of primary care patients.9 In this paper we cons... more opment of chronic fatigue and CFS in this sample of primary care patients.9 In this paper we consider the prevalence of chronic fatigue and CFS. A companion paper considers the role of psychological disorder and somatic symptoms in chronic fatigue and CFS.'I The study design, which has been reported in detail elsewhere,9 is summa- rized in Figure . The study began in 1992 with a large-scale community screening (stage 1). Its purpose was to study the population prevalence of fatigue and psychological morbidity11 and to deter- mine preexposure vulnerability factors for the subsequent development of postinfectious fatigue.9 All adults aged 18 through 45 registered with five general practicestwo urban, two semiurban, and one rural, all located in the south of England-took part. In the following year (1993), all patients attending the participating gen- eral practices and in whom the general

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Cognitive Behavioral Therapy for Chronic Fatigue Syndrome

Clinical Infectious Diseases, Mar 1, 1995

SIR-We were delighted to see that the efficacy of cognitive behavioral therapy was tested on pati... more SIR-We were delighted to see that the efficacy of cognitive behavioral therapy was tested on patients with chronic fatigue syndrome (CFS) [1] but would like to point out that the content of the treatment was radically different from that of the one used by Butler et al. [2] and Lloyd et al. [3], both of whom were cited as influences by Friedberg and Krupp. Overall, the treatment used by Friedberg and Krupp appears to be based on the principle of emotional adjustment to CFS and acceptance of the limitations of the disease. While this would no doubt decrease patients' frustration and emotional distress, it would not assist them in safely overcoming their disability. Procedural differences undoubtedly influenced treatment outcome, and therefore we cannot accept this report as a fair evaluation of the cognitive behavioral approach. The procedural problems were compounded by methodological flaws. In particular, patients who refused treatment were assigned to a no-treatment control group rather than being excluded from the trial. Treated patients were offered either individual or group therapy, although the reasons for this were unclear. In our experience, six sessions is insufficient for the majority of patients, many of whom have formed strongly held beliefs with illness-associated disabilities that have developed over many years. We were surprised that all the patients with CFS, although fulfilling the criteria of Holmes et al. [4] and by definition having had a minimum 50% reduction of activities, were asked to make life-style changes that were compatible with their current

Telephone-based guided self-help for adolescents with chronic fatigue syndrome: A non-randomised cohort study

Behaviour Research and Therapy, May 1, 2012

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Illness beliefs and treatment outcome in chronic fatigue syndrome

Journal of Psychosomatic Research, Jul 1, 1998

Longitudinal studies have shown that physical illness attributions are associated with poor progn... more Longitudinal studies have shown that physical illness attributions are associated with poor prognosis in chronic fatigue syndrome (CFS). Speculation exists over whether such attributions influence treatment outcome. This study reports the effect of illness beliefs on outcome in a randomized controlled trial of cognitive-behavior therapy versus relaxation. Causal attributions and beliefs about exercise, activity, and rest were recorded before and after treatment in 60 CFS patients recruited to the trial. Physical illness attributions were widespread, did not change with treatment, and were not associated with poor outcome in either the cognitive-behavior therapy group or the control group. Beliefs about avoidance of exercise and activity changed in the cognitive behavior therapy group, but not in the control group. This change was associated with improved outcome. These findings suggest that physical illness attributions are less important in determining outcome (at least in treatment studies) than has been previously thought. In this study, good outcome is associated with change in avoidance behavior, and related beliefs, rather than causal attributions.

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Chronic fatigue in the community: ‘A question of attribution’

Psychological Medicine, Jul 1, 1996

SynopsisThirty-eight subjects identified in a large community survey were found to attribute thei... more SynopsisThirty-eight subjects identified in a large community survey were found to attribute their fatigue to ‘myalgic encephalomyelitis’ (ME). They were matched randomly to two other groups of subjects who attributed their fatigue to either psychological or social factors. All three groups were followed up 18 months later and were asked to complete a series of questionnaires that examined fatigue, psychological distress, number of symptoms, attributional style and levels of disability. At onset the ‘ME’ group were found to be more fatigued, had been tired for longer but were less psychologically distressed than the other two groups. At follow-up the ‘ME’ group were more handicapped in relation to home, work, social and private leisure activities, even when controlling for both duration of fatigue and fatigue at time 1, but were less psychologically distressed. The relationships between psychological distress, specific illness attributions, attributional style and their effect on the experience of illness and its prognosis are discussed. Attributing fatigue to social reasons appears to be most protective.

A Comparison of the Characteristics of Chronic Fatigue Syndrome in Primary and Tertiary Care

British Journal of Psychiatry, 1996

To evaluate the characteristics of Chronic Fatigue Syndrome (CFS) in primary and tertiarycare. Me... more To evaluate the characteristics of Chronic Fatigue Syndrome (CFS) in primary and tertiarycare. Method. A comparison of subjects fulfilling criteria for CFS seen in primary care and in a hospital unit specialising in CFS. Subjects were 33 adults fulfilling criteria for CFS, identified as part of a prospective cohort study in primarycare, compared to 79 adults fulfillingthe same criteria referred for treatment to a specialist CFS clinic. Results. Hospital cases were more likelyto belong to upper socio-economic groups, and to have physicalillnessattributions. They had higherlevelsof fatigue and more somatic symptoms, and were more impairedfunctionally, but had less overt psychological morbidity. Women were over-represented in both primary care and hospital groups. Nearly half of those referred to a specialist clinic did not fulfil operational criteria for CFS. Conclusion. The high rates of psychiatric morbidity and female excess that characterise CFS in specialist settings are not due to selection bias. On the other hand higher social class and physical illness attributions may be the result of selection bias and not intrinsic to CFS. The ChronicFatigueSyndrome(CFS) continuesto be regarded as a controversial condition, particularly with regards to competing claims concerning aetiology and treatment. There is little disagreement about what constitutes the classic clinical presentation of this syndrome, and the usual demographic features of the sufferers. Many studies report that CFS sufferers are more likely to be women, to belong to higher social classes (with a particular over-representation of professionals), to be very impaired functionally, have high levelsof psychological distress, hold characteristic illness beliefs, and have a poor prognosis (Wessely &

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Rehabilitative treatments for chronic fatigue syndrome: long-term follow-up from the PACE trial

The Lancet Psychiatry, Dec 1, 2015

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Longitudinal mediation in the PACE randomised clinical trial of rehabilitative treatments for chronic fatigue syndrome: modelling and design considerations

Trials, Nov 16, 2015

Background Clinical trials require large monetary and time commitments and should provide informa... more Background Clinical trials require large monetary and time commitments and should provide information on both whether and how treatments work. Treatment mechanisms can be studied using mediation analysis, allowing refinement of treatments. Mediation studies often use only single contemporaneous measures of mediator and outcome limiting the conclusions that can be drawn. Longitudinally measured mediators and outcomes, such as those in the Pacing, Graded Activity, and Cognitive Behaviour Therapy: A Randomised Evaluation trial (PACE, ISRCTN 54285094) allow for more realistic estimates of mediated effects.

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Cognitive behavioural therapy for chronic fatigue and chronic fatigue syndrome: outcomes from a specialist clinic in the UK

Journal of the Royal Society of Medicine, Sep 15, 2020

Objectives: Cognitive behavioural therapy is commonly used to treat chronic fatigue syndrome and ... more Objectives: Cognitive behavioural therapy is commonly used to treat chronic fatigue syndrome and has been shown to be effective for reducing fatigue and improving physical functioning. Most of the evidence on the effectiveness of cognitive behavioural therapy for chronic fatigue syndrome is from randomised control trials, but there are only a few studies in naturalistic treatment settings. Our aim was to examine the effectiveness of cognitive behavioural therapy for chronic fatigue syndrome in a naturalistic setting and examine what factors, if any, predicted outcome. Design: Using linear mixed effects analysis, we analysed patients' self-reported symptomology over the course of treatment and at three-month follow-up. Furthermore, we explored what baseline factors were associated with improvement at follow-up. Setting: Data were available for 995 patients receiving cognitive behavioural therapy for chronic fatigue syndrome at an outpatient clinic in the UK. Participants: Participants were referred consecutively to a specialist unit for chronic fatigue or chronic fatigue syndrome. Main outcome measures: Patients were assessed throughout their treatment using self-report measures including the Chalder Fatigue Scale, 36-item Short Form Health Survey, Hospital Anxiety and Depression Scale and Global Improvement and Satisfaction. Results: Patients' fatigue, physical functioning and social adjustment scores significantly improved over the duration of treatment with medium to large effect sizes (jdj ¼ 0.45-0.91). Furthermore, 85% of patients self-reported that they felt an improvement in their fatigue at follow-up and 90% were satisfied with their treatment. None of the regression models convincingly predicted improvement in outcomes with the best model being (R 2 ¼ 0.137). Conclusions: Patients' fatigue, physical functioning and social adjustment all significantly improved following cognitive behavioural therapy for chronic fatigue syndrome in a naturalistic outpatient setting. These findings support the growing evidence from previous randomised control trials and suggest that cognitive behavioural therapy could be an effective treatment in routine treatment settings.

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Self-help treatment of chronic fatigue in the community: A randomized controlled trial

British Journal of Health Psychology, Sep 1, 1997

reducing chronic fatigue in a primary care population aged 18-34 years. Design. A randomized cont... more reducing chronic fatigue in a primary care population aged 18-34 years. Design. A randomized controlled trial. Methods. A self-help intervention (N = 70) was compared with no treatment ( N = 80). The main outcome measures were a fatigue questionnaire and the 12-item General Health Questionnaire. Follow-up was completed on 127 patients. Results. The self-help group showed significantly greater improvements in fatigue ( p = .01) and psychological distress ( p < .01) than controls. At follow-up, 63 per cent of the self-help complerers achieved a good outcome (scored less than 4 on the fatigue questionnaire) compared with 39 per cent of the control group. Conclusions. The provision of a self-help booklet and specific advice during a consultation with a research nurse was more effective than no treatment at improving fatigue and psychological distress. General practitioners should be encouraged to use self-help literature in the management of patients with chronic fatigue. To evaluate the efficacy of a self-help booklet and specific advice in Fatigue is a subjective somatic symptom which is common in the community and primary care. Up to 40 per cent of the general population complain of substantial fatigue lasting for more than one month (Pawlikowska, Chalder, Hirsach, Wallace, Wright & Wessely, 1994). As with many other symptoms, fatigue is best viewed on a continuum, with those most severely affected fulfilling the criteria for chronic fatigue syndrome (CFS) (Sharpe, Archnard & Banatvala, 1991). There is a close association between fatigue and *Requests for reprints.

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Cognitive behaviour therapy for chronic fatigue syndrome: Authors' reply, naturalistic outcomes paper

Journal of the Royal Society of Medicine, May 27, 2021

percentage of patients failed to provide follow-up data for this outcome measure? Patients who dr... more percentage of patients failed to provide follow-up data for this outcome measure? Patients who dropped out seem to be more impaired as they had lower physical functioning, higher Work and Social Adjustment Scale scores, and higher depression scores. At baseline, only 52% of patients met Centers for Disease Control and Prevention criteria for chronic fatigue syndrome. It would be interesting to know if these patients were overrepresented in the dropouts, given that dissatisfaction with cognitive behavioural therapy has frequently been reported in the chronic fatigue syndrome patient community. It is unfortunate that this paper only mentions the positive results of cognitive behavioural therapy for chronic fatigue syndrome. This is not an accurate reflection of the literature as there are large-scale randomised trials that found little evidence for the effectiveness of a cognitive-behavioural approach for chronic fatigue syndrome. Finally, the self-reported global improvement scale used in this study had only six instead of seven options, as is usually the case. Could the authors explain why the option ‘much worse’ was not available in this questionnaire?

The PACE trial in chronic fatigue syndrome – Authors' reply

The Lancet, May 1, 2011

We declare that we have no confl icts of interest other than those described in the original paper.

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Cognitive, behavioural and emotional predictors of outcome after CBT for chronic fatigue syndrome in a specialist setting

Comment on: ‘Reports of recovery in chronic fatigue syndrome may present less than meets the eye’

Evidence Based Mental Health, 2016

Dear Editor, Friedberg and Adamowicz reviewed our paper about recovery from chronic fatigue syndr... more Dear Editor, Friedberg and Adamowicz reviewed our paper about recovery from chronic fatigue syndrome (CFS) after treatment in the PACE trial.1–3 We write in order to correct some errors of fact and interpretation in their review. The authors suggest that we did not use any measures of patients’ perceptions of recovery. In fact we used the patient-rated clinical global impression change score of their overall health,4 which included those who rated their overall health as ‘much’ and “very much better”, and which was one of the five criteria …

Rehabilitative therapies for chronic fatigue syndrome: a secondary mediation analysis of the PACE trial

The Lancet Psychiatry, Feb 1, 2015

Cognitive behaviour therapy (CBT) added to specialist medical care (SMC), or graded exercise ther... more Cognitive behaviour therapy (CBT) added to specialist medical care (SMC), or graded exercise therapy (GET) added to SMC, are more effective in reducing fatigue and improving physical function than both adaptive pacing therapy (APT) plus SMC and SMC alone for chronic fatigue syndrome (CFS). This paper investigates putative treatment mechanisms. Mediation was assessed using the product of coefficients method with the 12 week measure of the mediators and the 52 week measure of the outcomes. Confounder covariates were included and treatment by mediator interaction terms were used to examine differences in mediator-outcome relationships by treatment group. The largest mediated effect for both CBT and GET and both outcomes was through fear avoidance beliefs with an effect of larger magnitude for GET (standardised effects times 10, CBT v APT, fatigue -1•22, 95% CI = -0•52 to -1•97, physical function 1•54, CI = 0•86 to 2•31; GET v APT, fatigue -1•86, CI = -0•80 to -2•89, physical function 2•35, CI = 1•35 to 3•39). Increase in exercise tolerance (six minute walk distance) was a potent mediator of the effect of GET (v APT, fatigue -1•37, CI = -0•76 to -2•21, physical function 1•90, CI = 1•10, 2•91), but not CBT. Our main finding was that fear avoidance beliefs were the strongest mediator for both CBT and GET. Changes in both beliefs and behaviour mediated the effects of both CBT and GET, but more so for GET. The results support a treatment model in which both beliefs and behaviour play a role in perpetuating fatigue and disability in CFS.

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The Impact of Covid-19 on Mental Health

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