# CBT for CFS



## trbell (Nov 1, 2000)

Thinking through chronic fatigue24 March 2003 18:00 GMTby Henry Nicholls Glasgow, UK - Asking patients to change their behavior and the way they think can reverse the hormonal disturbance that characterizes some forms of chronic fatigue syndrome (CFS), says a leading psychiatrist. Some patients with CFS have a disturbance to the hypothalamic-pituitary-adrenal (HPA) axis that lowers the level of cortisol in their blood. But, says Anthony Cleare of the Institute of Psychiatry in London, UK, this hormonal deficit can be corrected by cognitive behavioral therapy (CBT) aimed at gradually improving the physical and mental well being of the patient.The term CFS describes patients presenting several debilitating symptoms, including severe fatigue, headaches, poor concentration, muscle and joint pains and sleep disturbance. The mechanisms that underlie such a collection of subjective symptoms are poorly understood, but recent research suggests that hormones could play a part in the long-term persistence of the syndrome."They're one piece of the jigsaw," said Cleare, who is studying the effects of CBT - the most effective and widely used treatment for CFS - on the HPA axis. "We have now shown that this therapy is also effective at increasing cortisol levels and reversing HPA axis changes," he said.This suggests to Cleare that the HPA axis becomes disturbed as a result of CFS, rather than being the primary cause of the condition. However, once the HPA axis has become unbalanced, it could be a factor that keeps patients in a state of fatigue, says Cleare. "HPA axis disturbance may be a significant perpetuating factor in fatigue chronicity," he said.Cleare spoke here today at a well-attended session of the 22nd joint meeting of the British Endocrine Societies that promised to explore the endocrine basis for CFS. As many as 20% of the population experience fatigue, but only a small proportion of these consider their lethargy sufficiently severe that it affects their physical and mental health.About half of the studies that have measured cortisol levels in CFS patients have found that levels are reduced compared with those in control subjects. Hydrocortisone replacement therapy can also reduce fatigue. However, it is not known whether the low cortisol levels are a consequence of a problem in the hypothalamus, the pituitary or the adrenal gland, or anywhere in-between.Because of this inability to pinpoint a mechanism that links CFS to the HPA axis, it is uncertain whether this research will change the way that endocrinologists treat this enigmatic condition. Stephen Shalet, a clinical endocrinologist at Christie Hospital in Manchester, UK, expressed regret that Cleare's talk had not offered any new insights into the management of CFS."I can't see where the shaft of light will come from," said Shalet. There is evidence of a subtly abnormal production of cortisol in some patients, he says, "but the evidence is very thin indeed."Cleare agrees that low cortisol is only part of the problem for only some CFS patients. Nevertheless, Michael Sharpe, of the School of Molecular and Clinical Medicine at the University of Edinburgh, UK, is optimistic that Cleare's reductionist approach can begin to scratch away at the surface of complex disorders like CFS. "Modern neuroscience is reminding us that symptoms do have a physiological basis," he said, "and these are explanations that patients find more acceptable." tom


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