Commentary
Treatment of chronic fatigue syndrome: How to find a ‘new equilibrium’?

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Introduction

In this issue of Patient Education and Counseling, two interesting papers challenge current evidence-based treatments of chronic fatigue syndrome (CFS). In the first study Goudsmit et al. [1] show that a brief multi-component programme aimed at helping CFS patients cope with their illness, may be as effective as cognitive behavior therapy (CBT). In the second study Jason et al. [2] demonstrate that CFS patients who carefully stayed within their ‘energy envelope’ (measured by a self-monitoring strategy) did better than patients who were less successful in keeping expended energy close to available energy – a finding that challenges basic assumptions of graded exercise therapy (GET).

Both papers highlight ongoing controversies surrounding the treatment of this incapacitating and ill-understood illness. In this context, we will reflect on the use of CBT and GET in CFS, the aim of treatment in CFS patients, the importance of treatment acceptability, and future research.

Section snippets

CBT/GET: what's in a name?

The cognitive-behavioral model of CFS hypothesizes that the illness, independent from its initiating causes, is perpetuated by distorted somatic perceptions as well as by dysfunctional cognitions and behaviors such as exercise phobia and associated physical deconditioning [3], [4].

Although this model still lacks unequivocal empirical support, cognitive behavior therapy (CBT) and graded exercise therapy (GET) are widely used in CFS, since RCT's have shown that these treatments may considerably

Coping or recovery: a faulty dichotomy

There is no consensus about the final treatment goal in CFS [9]. Although few clinicians will assert that the majority of CFS patients can be ‘cured’, some are convinced that ‘full recovery’ is possible (yet, reported percentages depend on the criteria of recovery used, i.e. varying from 20 to more than 70 percent) [10], while others (like the authors of the present papers) [1], [2] think that enhancing coping with the illness is a more realistic and feasible goal.

However, if CFS is

The importance of a ‘common ground’

It should not be overlooked that an astonishing gap exists between the evidence-based treatment literature on CFS, and contrasting opinions voiced by ME/CFS patient support groups and their advocates [see e.g. 13].

Clearly, CFS patients are hypersensitive to any suggestion that their ailment might be related to psychological factors. This hypersensitivity may be due to the ‘invisibility’ of the illness (which may raise suspicion of malingering), the intense frustration of functional limitations

Conclusion

The cause of CFS is undoubtedly complex – even when in the future different subgroups will be identified. Not surprisingly, recent research suggests that a thorough understanding of the pathophysiological mechanisms in CFS will necessitate a system-biological approach [11]. Hence, it is very improbable that a simple (medical or psychological) solution for this illness will ever be found.

Within this line of thinking, current evidence-based treatments (CBT and GET) should not be considered a

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