Cognitive behaviour therapy for adolescents with chronic fatigue syndr
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《英国医生杂志》
1 Expert Centre Chronic Fatigue, University Medical Centre Nijmegen, PO Box 9101, 6500 HB, Netherlands, 2 Department of Medical Psychology, University Medical Centre Nijmegen, 3 Department of Paediatrics, University Medical Centre Nijmegen
Correspondence to: G Bleijenberg G.Bleijenberg@nkcv.umcn.nl
Abstract
Patients with chronic fatigue syndrome have debilitating unexplained severe fatigue that is not the result of an organic disease or ongoing exertion and is not alleviated by rest. Symptoms last for at least six months and are accompanied by other symptoms like muscle pain and unrefreshing sleep.1 2 This condition can occur in adults and adolescents.3
Several randomised controlled trials have shown that cognitive behaviour therapy is effective in adults.4 5 To date, however, there have been no published controlled studies on such therapy for adolescents, though one uncontrolled study suggested that such a behavioural approach can reduce fatigue in adolescents.6 Development of potentially effective interventions is especially important in young people to avoid prolonged absence from school and restricted social activities, which threaten healthy development.7-9
Methods
The figure shows the trial profile. Seventy one patients were randomly allocated to either immediate therapy (n = 36) or to remain on the waiting list (n = 35). After randomisation we excluded two patients (one from each group) because the diagnosis of chronic fatigue syndrome was incorrect. Analyses were based on the 69 remaining patients. Of those, 29 in the immediate therapy group and 33 from the waiting list completed the assessment at five months. Six patients dropped out during the course of treatment, three of them did not finish the second assessment. Table 1 shows the baseline characteristics of both groups.
Trial profile
Table 1 Baseline characteristics of study participants. Values are means (SD) unless stated otherwise
Effect of intervention
Primary outcome—Patients in the immediate therapy group reported a significantly greater decrease in fatigue severity (difference in decrease on checklist individual strength 14.5, 95% confidence interval 7.4 to 21.6) and functional impairment (difference in increase on SF-36 physical functioning 17.3, 6.2 to 28.4) than patients on the waiting list. School attendance also increased significantly more in the therapy group (difference in increase in school attendance 18.2, 0.8 to 35.5) (table 2).
Table 2 Effect of cognitive behaviour therapy on fatigue severity, functional impairment, and school attendance
Other outcomes—At five months the participants in the therapy group reported a significantly greater decrease in how often they felt ill after exercise, impaired concentration, unrefreshing sleep, muscle pain, and headache (table 3). Patients on the waiting list reported increased prevalence of impaired concentration, unrefreshing sleep, and muscle pain.
Clinically significant improvement—For all primary outcome variables as well as for self rated improvement the proportion of patients with clinically significant improvements was greatest among those in the therapy group (table 4).
Table 4 Clinically significant improvement at five months in fatigue severity (checklist individual strength), functional impairment (SF-36), and school attendance (mean percentage) and self rated improvement by treatment group
Two treatment protocols—There were no significant differences in all primary outcomes between adolescents who were treated with the protocol designed for patients with a passive physical activity pattern and those who were treated with the protocol for more active patients (table 5).
Table 5 Treatment effects on fatigue severity (checklist individual strength), functional impairment (SF-36), and school attendance (mean percentage) by activity pattern in patients assigned to cognitive behaviour therapy
Discussion
Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;121: 953-9.
Reeves WC, Lloyd A, Vernon SD, Klimas N, Jason LA, Bleijenberg G, et al. Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution. BMC Health Serv Res 2003;3: 25-33.
Chalder T, Goodman, R, Wessely, S, Hotopf M, Meltzer H. Epidemiology of chronic fatigue syndrome and self reported myalgic encephalomyelitis in 5-15 year olds: cross sectional study. BMJ 2003;327: 654-5.
Prins JB, Bleijenberg G, Bazelmans E, Elving LD, de Boo Th, Severens JL, et al. Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial. Lancet 2001;357: 841-7.
Whiting P, Bagnall, A, Sowden AJ, Cornell JE, Mulrow CD, Ramirez G. Interventions for the treatment and management of CFS. JAMA 2001;286: 1360-8.
Chalder T, Tong J, Deary V. Family cognitive behaviour therapy for chronic fatigue syndrome: an uncontrolled study. Arch Dis Child 2002;86: 95-7.
Garralda ME, Rangel L. Annotation: chronic fatigue syndrome in children and adolescents. J Child Psychol Psychiatry 2002;43: 169-76.
Carter BD, Edwards JF, Kronenberger WG, Michalczyk L, Marshall GS. Case control study of chronic fatigue in pediatric patients. Pediatrics 1995;95: 179-86.
Fritz U, McQuaid EL. Chronic medical conditions. Impact on development. In: Sameroff AJ, Lewis M, Miller SM, eds. Handbook of developmental psychopathology. New York: Kluwer, 2000.
Van der Werf SP, Prins JB, Vercoulen JHMM, van der Meer JWM, Bleijenberg G. Identifying physical activity patterns in chronic fatigue syndrome using actigraphic assessment. J Psychosom Res 2000;49: 372-9.
Bleijenberg G, Prins J, Bazelmans E. Cognitive-behavioral therapies. In: Jason LA, Fennel PA, Taylor RR, eds. Handbook of chronic fatigue syndrome. New Jersey: John Wiley, 2003.
Vercoulen JHHM, Swanink CMA, Galama JMD, Fennis JFM, van der Meer JWM, Bleijenberg G. Dimensional assessment in chronic fatigue syndrome. J Psychosom Res 1994;38: 383-92.
Beurskens AJHM, Bültmann U, Kant IJ, Vercoulen JHMM, Bleijenberg G, Swaen GMH. Fatigue amongst working people: validity of a questionnaire. Occup Environm Med 2000;57: 353-7.
Steward AL, Hays RD, Ware JE Jr. The MOS short form general health survey: reliability and validity in a patient population. Med Care 1998;26: 724-35.
Bell DS, Jordan K, Robinson M. Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome. Pediatrics 2001;107: 994-8.
Vercoulen JHHM, Swanink CMA, Zitman FG, Vreden SGS, Hoofs MPE, Fennis JFM, et al. A randomised, double-blind, placebo controlled study of fluoxentine in chronic fatigue syndrome. Lancet 1996;347: 858-61.
Vercoulen JHHM, Bazelmans E, Swanink CMA, Fennis JFM, Galama JMD, Jongen PJH, et al. Physical activity in the chronic fatigue syndrome: assessment and its role in fatigue. J Psychiatr Res 1997;31: 661-73.
Faul F, Erdfelder E, Gpower: a priori, post-hoc, and compromise power analyses for MS-DOS . Bonn, FRG: Bonn University, Department of Psychology, 1992.
Jacobsen NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy. J Cons Clin Psychol 1991;59: 12-9.
Powell P, Bentall R, Nye F, Edwards RH. Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome. BMJ 2001;322: 387-90.
Bell DS, Jordan K, Robinson M. Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome. Pediatrics 2001;107: 994-8.
Gill AC, Dosen A, Ziegler JB. Chronic fatigue in adolescents: a follow-up study. Arch Pediatr Adolesc Med 2004;158: 225-9.(Maja Stulemeijer, junior researcher1, Li)
Correspondence to: G Bleijenberg G.Bleijenberg@nkcv.umcn.nl
Abstract
Patients with chronic fatigue syndrome have debilitating unexplained severe fatigue that is not the result of an organic disease or ongoing exertion and is not alleviated by rest. Symptoms last for at least six months and are accompanied by other symptoms like muscle pain and unrefreshing sleep.1 2 This condition can occur in adults and adolescents.3
Several randomised controlled trials have shown that cognitive behaviour therapy is effective in adults.4 5 To date, however, there have been no published controlled studies on such therapy for adolescents, though one uncontrolled study suggested that such a behavioural approach can reduce fatigue in adolescents.6 Development of potentially effective interventions is especially important in young people to avoid prolonged absence from school and restricted social activities, which threaten healthy development.7-9
Methods
The figure shows the trial profile. Seventy one patients were randomly allocated to either immediate therapy (n = 36) or to remain on the waiting list (n = 35). After randomisation we excluded two patients (one from each group) because the diagnosis of chronic fatigue syndrome was incorrect. Analyses were based on the 69 remaining patients. Of those, 29 in the immediate therapy group and 33 from the waiting list completed the assessment at five months. Six patients dropped out during the course of treatment, three of them did not finish the second assessment. Table 1 shows the baseline characteristics of both groups.
Trial profile
Table 1 Baseline characteristics of study participants. Values are means (SD) unless stated otherwise
Effect of intervention
Primary outcome—Patients in the immediate therapy group reported a significantly greater decrease in fatigue severity (difference in decrease on checklist individual strength 14.5, 95% confidence interval 7.4 to 21.6) and functional impairment (difference in increase on SF-36 physical functioning 17.3, 6.2 to 28.4) than patients on the waiting list. School attendance also increased significantly more in the therapy group (difference in increase in school attendance 18.2, 0.8 to 35.5) (table 2).
Table 2 Effect of cognitive behaviour therapy on fatigue severity, functional impairment, and school attendance
Other outcomes—At five months the participants in the therapy group reported a significantly greater decrease in how often they felt ill after exercise, impaired concentration, unrefreshing sleep, muscle pain, and headache (table 3). Patients on the waiting list reported increased prevalence of impaired concentration, unrefreshing sleep, and muscle pain.
Clinically significant improvement—For all primary outcome variables as well as for self rated improvement the proportion of patients with clinically significant improvements was greatest among those in the therapy group (table 4).
Table 4 Clinically significant improvement at five months in fatigue severity (checklist individual strength), functional impairment (SF-36), and school attendance (mean percentage) and self rated improvement by treatment group
Two treatment protocols—There were no significant differences in all primary outcomes between adolescents who were treated with the protocol designed for patients with a passive physical activity pattern and those who were treated with the protocol for more active patients (table 5).
Table 5 Treatment effects on fatigue severity (checklist individual strength), functional impairment (SF-36), and school attendance (mean percentage) by activity pattern in patients assigned to cognitive behaviour therapy
Discussion
Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;121: 953-9.
Reeves WC, Lloyd A, Vernon SD, Klimas N, Jason LA, Bleijenberg G, et al. Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution. BMC Health Serv Res 2003;3: 25-33.
Chalder T, Goodman, R, Wessely, S, Hotopf M, Meltzer H. Epidemiology of chronic fatigue syndrome and self reported myalgic encephalomyelitis in 5-15 year olds: cross sectional study. BMJ 2003;327: 654-5.
Prins JB, Bleijenberg G, Bazelmans E, Elving LD, de Boo Th, Severens JL, et al. Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial. Lancet 2001;357: 841-7.
Whiting P, Bagnall, A, Sowden AJ, Cornell JE, Mulrow CD, Ramirez G. Interventions for the treatment and management of CFS. JAMA 2001;286: 1360-8.
Chalder T, Tong J, Deary V. Family cognitive behaviour therapy for chronic fatigue syndrome: an uncontrolled study. Arch Dis Child 2002;86: 95-7.
Garralda ME, Rangel L. Annotation: chronic fatigue syndrome in children and adolescents. J Child Psychol Psychiatry 2002;43: 169-76.
Carter BD, Edwards JF, Kronenberger WG, Michalczyk L, Marshall GS. Case control study of chronic fatigue in pediatric patients. Pediatrics 1995;95: 179-86.
Fritz U, McQuaid EL. Chronic medical conditions. Impact on development. In: Sameroff AJ, Lewis M, Miller SM, eds. Handbook of developmental psychopathology. New York: Kluwer, 2000.
Van der Werf SP, Prins JB, Vercoulen JHMM, van der Meer JWM, Bleijenberg G. Identifying physical activity patterns in chronic fatigue syndrome using actigraphic assessment. J Psychosom Res 2000;49: 372-9.
Bleijenberg G, Prins J, Bazelmans E. Cognitive-behavioral therapies. In: Jason LA, Fennel PA, Taylor RR, eds. Handbook of chronic fatigue syndrome. New Jersey: John Wiley, 2003.
Vercoulen JHHM, Swanink CMA, Galama JMD, Fennis JFM, van der Meer JWM, Bleijenberg G. Dimensional assessment in chronic fatigue syndrome. J Psychosom Res 1994;38: 383-92.
Beurskens AJHM, Bültmann U, Kant IJ, Vercoulen JHMM, Bleijenberg G, Swaen GMH. Fatigue amongst working people: validity of a questionnaire. Occup Environm Med 2000;57: 353-7.
Steward AL, Hays RD, Ware JE Jr. The MOS short form general health survey: reliability and validity in a patient population. Med Care 1998;26: 724-35.
Bell DS, Jordan K, Robinson M. Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome. Pediatrics 2001;107: 994-8.
Vercoulen JHHM, Swanink CMA, Zitman FG, Vreden SGS, Hoofs MPE, Fennis JFM, et al. A randomised, double-blind, placebo controlled study of fluoxentine in chronic fatigue syndrome. Lancet 1996;347: 858-61.
Vercoulen JHHM, Bazelmans E, Swanink CMA, Fennis JFM, Galama JMD, Jongen PJH, et al. Physical activity in the chronic fatigue syndrome: assessment and its role in fatigue. J Psychiatr Res 1997;31: 661-73.
Faul F, Erdfelder E, Gpower: a priori, post-hoc, and compromise power analyses for MS-DOS . Bonn, FRG: Bonn University, Department of Psychology, 1992.
Jacobsen NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy. J Cons Clin Psychol 1991;59: 12-9.
Powell P, Bentall R, Nye F, Edwards RH. Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome. BMJ 2001;322: 387-90.
Bell DS, Jordan K, Robinson M. Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome. Pediatrics 2001;107: 994-8.
Gill AC, Dosen A, Ziegler JB. Chronic fatigue in adolescents: a follow-up study. Arch Pediatr Adolesc Med 2004;158: 225-9.(Maja Stulemeijer, junior researcher1, Li)