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brief in reactie op

analyse lange termijn-effect


binnen een uur

afgewezen voor publicatie








Onderstaande brief aan de hoofredacteur van Journal of Psychosomatic Research,

in reactie op een analyse van de lange termijn-effecten van CGT/GET in Nederlandse studies,

werd (binnen één uur) afgewezen voor publicatie door de hoofdredacteur,

omdat het volgens de hoofdredacteur "niet geschikt is voor publicatie in zijn tijdschrift".


De analyse van Janse en collega's, waaronder een ver familielid (?),

bevestigt de conclusies die ook op basis van de PACE-trial getrokken kunnen worden:

  • het subjectieve effect is bescheiden en op langere termijn uitgewerkt,
  • het subjectieve effect is onvoldoende om 'normale waarden' te bereiken, en
  • er is geen enkel effect als we uitsluitend naar objectieve maatstaven kijken.

De analyse van Janse e.a. bevestigt 'het failliet van het (bio)psychosociale verklaringsmodel'.


Een nauwgezette analyse van studies, waarvan de meeste afkomstig zijn van het NKCV,

is kennelijk 'niet geschikt' voor het 'clubblaadje' van 'psychomatiek-geloofsgenoten'.


De redactie acht het 'wel geschikt' dat enkele 'geloofsgenoten' stellen dat een grote groepen

CVS-patiënten 'normale waarden' bereiken t.a.v. vermoeidheid en fysieke beperkingen na CGT/GET.

Dit terwijl die 'normale waarden' bij lange na niet 'normaal' zijn volgens andere NKCV-studies.




Long-term follow-up confirms:

Cognitive behaviour therapy (CBT)/graded exercise study (GET)

is not an effective therapy for chronic fatigue syndrome (CFS).



A recently published study [1] analysed

the long-term effects of cognitive behaviour therapy (CBT) [2-5]

on fatigue severity (CIS F) and physical functioning (SF-36 PF)

in chronic fatigue syndrome (CFS).


As the authors acknowledge: "sustainment of treatment effects is not self-evident" [1],

even when subjective measures are considered.


This is confirmed by

the observation that the difference between groups

was not significant for fatigue at short-term follow up and

the fact that the improvement in physical functioning post-treatment partly vanished.


"At long-term follow-up

fatigue severity significantly increased [..] and

physical functioning significantly decreased [..]

compared to posttreatment assessment." [1].


Despite this the authors report that

"[S]till 37% of the participants had fatigue scores in the normal range and

70% were not impaired in physical functioning." [1].


However a minimal improvement is sufficient to achieve 'normal levels'

(e.g. an improvement of CIS F from 35 to 34).


Oddly enough, the improvement of the SIP8 score,

one of the two criteria to qualify as 'CFS' patient,

wasn't analysed or reported.


Other studies by the same investigators [6] showed that

the effect on SIP8 wasn't by far sufficient to achieve 'normal levels'.


The cut-off criteria used in the analysis [1]

are also largely insufficient to qualify as 'normal'.


In one of the studies analysed [4],

the cut-off threshold for

a "level of fatigue comparable to healthy people" (mean + 1 SD) is ≤27,

while 'no physical disability" implied a SF-36 PF ≥80.


According to a large-scale study in the UK [7]

even the latter cut-off criterion

could be considered insufficient to achieve normal levels.


All in all, the impressive results reported by the authors

are based on 'normal levels'

which don't qualify as normal and can be achieved by very minor improvements.


When objective measures are considered,

the effects of CBT/GET are non-existent.


Studies by the same group showed that

CBT/GET doesn't result in an increase of the activity levels [8],

which are extremely low in CFS,

cognitive test scores [9], or number of hours worked [10].


Only one study reported an objective improvement:

a decrease of school absence [11].


However, another study [12] found that

school absence wasn't correlated with the deterioration of the IQ

compared to peers of the same school level,

despite the fact that a substantial number of patients

had already switched to a lower school level due to their illness.


The analysis by Janse et al. [1]

confirms the findings of the PACE trial [13],

which observed minor improvements of fatigue and physical functioning.


The long-term follow-up [14] showed

no significant effect on subjective measures.


More importantly CGT and GET

had no effect on all objective measures [13,15].


In conclusion,

the analysis by Janse et al. [1] reaffirms that

CBT and GET have only modest effects on subjective measures,

which seem to evaporate over time, and

no effect at objective measures.


CBT and GET certainly don't qualify as effective therapies [16] and

can have detrimental effects on the health status [17].






  1. Janse, A., et al.,
  2. Long-term follow-up after cognitive behaviour therapy for chronic fatigue syndrome.

    J Psychosom Res, 2017.

    doi: 10.1016/j.jpsychores.2017.03.016.

  3. Heins, M.J., et al., G.,
  4. The process of cognitive behaviour therapy for chronic fatigue syndrome:

    which changes in perpetuating cognitions and behaviour are related to a reduction in fatigue?

    J Psychosom Res, 2013. 75(3): 235-41.

    doi: 10.1016/j.jpsychores.2013.06.034.

  5. Wiborg, J.F., et al.,
  6. Randomised controlled trial of cognitive behaviour therapy

    delivered in groups of patients with chronic fatigue syndrome.

    Psychother Psychosom, 2015. 84(6): 368-6.

    doi: 10.1159/000438867.

  7. Knoop, H., et al.,
  8. Is a full recovery possible after cognitive behavioural therapy for chronic fatigue syndrome?

    Psychother Psychosom, 2007. 76(3): 71-176.

    doi: 10.1159/000099844.

  9. Tummers, M., Knoop, H., Bleijenberg,
  10. G., Effectiveness of stepped care for chronic fatigue syndrome:

    a randomized noninferiority trial.

    J Consult Clin Psychol, 2010. 78(5): 724-31.

    doi: 10.1037/a0020052.

  11. Bazelmans, E., et al.,
  12. Cognitive behaviour group therapy for chronic fatigue syndrome:

    a non-randomised waiting list controlled study.

    Psychother Psychosom, 2005. 74(4): 218-24.

    doi: 10.1159/000085145.

  13. Bowling, A., et al.,
  14. Short Form 36 (SF-36) Health Survey questionnaire: which normative data should be used?

    Comparisons between the norms provided by the Omnibus Survey in Britain,

    the Health Survey for England and the Oxford Healthy Life Survey.

    J Public Health Med, 1999. 21(3): 255-70.

    doi: 10.1093/pubmed/21.3.255.

  15. Wiborg, J.F., et al.,
  16. How does cognitive behaviour therapy reduce fatigue in patients with chronic fatigue syndrome?

    The role of physical activity.

    Psychol Med, 2010. 40(8): 1281-7.

    doi: 10.1017/S0033291709992212.

  17. Knoop, H., et al.,
  18. The effect of cognitive behaviour therapy for chronic fatigue syndrome on

    self-reported cognitive impairments and neuropsychological test performance.

    J Neurol Neurosurg, 2007. 78(4): 434-6.

    doi: 10.1136/jnnp.2006.100974.

  19. Prins, J.B., et al.,
  20. Cognitive behaviour therapy for chronic fatigue syndrome:

    a multicentre randomised controlled trial.

    Lancet, 2001. 357(9259): 841-7.

    doi: 10.1016/S0140-6736(00)04198-2.

  21. Nijhof, S.L., et al.,
  22. Effectiveness of internet-based cognitive behavioural treatment for adolescents

    with chronic fatigue syndrome (FITNET): a randomised controlled trial.

    Lancet, 2012. 379(9824): 1412-8.

    doi: 10.1016/S0140-6736(12)60025-7.

  23. Nijhof, L.N., et al.,
  24. The impact of chronic fatigue syndrome on cognitive functioning in adolescents.

    Eur J Pediatr, 2016. 175(2): 245-52.

    doi: 10.1007/s00431-015-2626-1.

  25. White, P.D., et al.,
  26. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy,

    and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial.

    Lancet, 2011. 377(9768): 823-36.

    doi: 10.1016/S0140-6736(11)60096-2.

  27. Sharpe, M., et al.,
  28. Rehabilitative treatments for chronic fatigue syndrome:

    long-term follow-up from the PACE trial.

    Lancet Psychiatry, 2015. 2(12): 1067-74.

    doi: 10.1016/S2215-0366(15)00317-X.

  29. McCrone, P., et al.,
  30. Adaptive pacing, cognitive behaviour therapy, graded exercise, and

    specialist medical care for chronic fatigue syndrome: a cost-effectiveness analysis.

    PLoS One, 2012. 7(8): e40808.

    doi: 10.1371/journal.pone.0040808.

  31. Twisk, F.N.M., PACE: CBT and GET are not rehabilitative therapies.
  32. Lancet Psychiatry, 2016. 3(2): e6.

    doi: 10.1016/S2215-0366(15)00554-4.

  33. Twisk, F.N.M. and Arnoldus, R.J.W.,
  34. Graded exercise therapy (GET)/cognitive behavioural therapy (CBT)

    is often counterproductive in myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS).

    Eur J Clin Invest. 2012. 42(11): 1255-6.

    doi: 10.1111/j.13652362.2012.02718.x.