From the Journal of Psychosomatic Research, published online on 18 January 2011.
A pilot study of cognitive behavioral stress management effects on stress, quality of life, and symptoms in persons with chronic fatigue syndrome☆
Corina Lopez, Michael Antoni, Frank Penedo, Donna Weiss, Stacy Cruess, Mary-Catherine Segotas, Lynn Helder, Scott Siegel, Nancy Klimas, Mary Ann Fletcher
Received 21 September 2010; received in revised form 26 November 2010; accepted 29 November 2010. published online 18 January 2011.
Corrected Proof
Abstract
Objective
The present pilot study was designed to test the effects of a 12-week group-based cognitive behavioral stress management (CBSM) intervention on stress, quality of life, and symptoms in chronic fatigue syndrome (CFS). We hypothesized that participants randomized to CBSM would report improvements in perceived stress, mood, quality of life, and CFS symptomatology from pre- to postintervention compared to those receiving a psychoeducational (PE) seminar control.
Method
We recruited 69 persons with a bona fide diagnosis of CFS and randomized 44 to CBSM and 25 to PE. Participants completed the Perceived Stress Scale (PSS), Profile of Mood States (POMS), Quality of Life Inventory (QOLI), and a Centers for Disease Control (CDC)-based CFS symptom checklist pre- and postintervention.
Results
Repeated measures analysis of variance revealed a significant Group×Time interaction for PSS, POMS–total mood disturbance (TMD), and QOLI scores, such that participants in CBSM evidenced greater improvements than those in PE. Participants in CBSM also reported decreases in severity of CFS symptoms vs. those in PE.
Conclusions
Results suggest that CBSM is beneficial for managing distress, improving quality of life, and alleviating CFS symptom severity.
Keywords: CDC symptoms, Chronic fatigue syndrome, Quality of life, Stress, Stress management
University of Miami, Miami, FL, USA
Corresponding author. Department of Psychology, 5665 Ponce DeLeon Blvd., Coral Gables, FL 33124, USA.
☆ This study was funded by the National Institutes of Health (NIH) (1 U01 AI45940 and 1R01 NS055672-01).
PII: S0022-3999(10)00447-2
doi:10.1016/j.jpsychores.2010.11.010
© 2010 Elsevier Inc. All rights reserved.
I was recently accepted into a Mindfulness NHS trial here in my county for stress management among those with serious health issues.
To early to give a fair verdict as I have had only the orientation session.
The fact that I am still there though is testimony I guess to my realisation that I am willing to try and improve my quality of life.
Mindfulness is not about ‘alleviating CFS symtom severity’ or any other illness severity.
The above study though seems to imply its own methods which are not detailed in any way having an effect on CFS symtoms.
That I would have an issue with although as I say there is no indication as to what exactly those methods were.
If ‘stress’ is a symptom then I guess its’ reduction would show a positive result. But that is hardly fair is it?
What i cant understand is why Nancy Klimas a coauthor of the CCC guidelines would not ensure that the people enrolled in her trials at least had the marker that their symptoms were worsened by excercse. At least that would ensure a homogenous cohort even under the beady eyes of the CDC.In that way she could appear to be on the side of the people giving her grants but still be producing useful research
I also cant understand her allowing the CDC CFS symptom inventory to be used where post exertional fatigue (which is a normal response to excercise or the product of deconditioning) has been inserted and the worsening of symptoms following excercise PEM has been taken out
I find this even more surprising because this CDC inventory is 6 months old a creation of Bill reeves and unvalidated
The design of this study is such that cause and effect cannot be established
IT is impossible to tell whether their version of CFS is caused by stress or whether the disability creates stress
So people who believe that ME is a psychiatric disorder can point to the study as a source as proof of their position
I cant understand why a proponent of organic causation would allow such a design in one of her studies
In fact every one of Nancy Klimas’s studies suffer from this flaw
I find this gross departure from the basic requirement of any scientific study puzzling in the extreme
Finally these patients were recruited using telephone canvasing using a personality questionaire -Why?
It seems to me that this study omits the ‘so what?’ question.
Hans Selye first described ‘stress’ as a concept. We are all ‘stressed’ – as he said, ‘the only person who is not stressed is a dead person’. However, sometimes ‘stressors’ (that which causes the stress) exceed our ability to cope. Answer? Remove the stressor.
In this study, people with a ‘bona fide diagnosis of CFS’ were chosen. To remove their stressors, which are physical according to the WHO CDI, you have to remove the cause. The cause is physical; the effect is neurological.
So this study finds that it can help people to cope. So what! That hardly even touches the surface for many people. Put the research money where it matters – in the physical realm – and stop confusing psychosomatic symptoms with neurological ones.
Hans Selye added one further thought that this study failed to address. An organism – be it animal or human – if the stressor continues for too long, will give up. It dies. That is what we find happening to patients when they are made to exercise. Remember Sophia Mirza who died because psychiatrists thought her illness was psychosomatic, and stop putting finances into meaningless studies.
http://www.investinme.org/Article-050%20Sophia%20Wilson%2001-RIP.HTM
Dr White challenged me in a meeting a year ago saying nothing else had been published to deny this finding. SO now you have a publication, written by a psychologist and well regarded CBT expert to use when you want to argue that CBT helps people with this illness (as it does in every chronic disease model ever tested) but does not cure the illness.
It is easy to pick apart any study after the fact, but put this in the context of the time (2001 when it was written) and place (the US where we were absolutely obliged to use the CDC case definition if we hoped for funding at the time.)
I am very proud to work with a multidisciplinary team that includes experts in autonomic function, immunology, cell biology, psychoneuroimmunology, genomics, systems biology, nutrition, measurement illness state… the list goes on. Its a very exciting time and the team is very much jazzed and wants to see the work we do in all of these areas lead to both a clear understanding of the illness at the cellular level and then to effective treatments. You are going to see many papers this year from the different members of the team and taken separately you may fail to see the big picture. Don’t get sucked into too narrow a view. Wait and see… some amazing science is underway.
moderator – the post dropped my first few sentences.
I had said that I had pressed Dr Antoni to get this study published in large part to rebut Dr White’s claim to cure 25% of ME/CFS patients with CBT. Dr Antoni’s study shows that while CBT helps people with the illness as it does in every chronic disease model ever tested, it does not cure the illness.
kind of key first line – right?
Thanks for that, Nancy.
The CBT that Prof. White referred to would take a different form to what was in the Lopez et al. study.
I think their (Knoop et al’s) claims of showing the patients were “fully recovered” are a joke.
I wish I was more on the ball at the time and it could have been challenged at the time.
The paper does not stand up to scrutiny.
Knoop H, Bleijenberg G, Gielissen MF, van der Meer JW, White PD. Is a full recovery possible after cognitive behavioural therapy for chronic fatigue syndrome?Psychother Psychosom. 2007;76(3):171-6. PMID: 17426416
your study claims that cbt stress therapy reduces the symptoms of CFS when a close examination of the study reveals that these symptoms are not core symptoms of CFS unless you agree that the patients deemed to have symptoms ME,cfs by the CDC in their wichita study of 2000 actually had ME/cfs despite never been diagnosed as such by a qualified physician
so far dr Klimas research has produced one testable hypothesis re the cause of ME.
while that may be to narrow a view for you it is a scientific one
I think we may have had enough of “exiting” research that leads nowhere
We would like research to actually be scientific research which strictly adheres to the scientific method.
your CBT stress study sadly falls way short of the required standard
The study references a study from 2005, so how can it have been written in 2001? Is that a mistake?
Dear Prof Klimas,
A study that uses self reported measures for a therapy that teaches people to “think” differently about how they feel is not in the least bit valid scientifically. I am seriously concerned that you continue to believe that this study proves anything other that people say they feel better when told to say that they feel better!
If you really wanted to rebut Peter White, perhaps it would be better to ask patients to do cycle ergometry and measure cytokines – then after CBT get them to do exactly the same and measure cytokines again.
I put it to you that the result would be rather different – that CBT has no objective impact on ME/CFS at all, and that patients may report feeling better but this is only because you have conned them into saying it – it is a complete farce.
From the Klimas CBT paper (currently In Press in Journal of Psychosomatics).
Abstract:
http://www.jpsychores.com/article/S0022-3999(10)00447-2/abstract
[…]
“Selection
“Potential participants underwent a phone screening and a psychiatric screening assessment to determine eligibility. At baseline (T1), participants completed the informed consent, psychosocial questionnaires, and the symptom checklist on a scale from 0 (never) to 4 (very often). Sample questions include “How often have you felt nervous and “stressed?” “How often have you found yourself thinking about things that you have to accomplish?” and “How often have you felt that things were going your way?”. Positive items were reverse scored so that higher scores on this scale indicate greater levels of perceived stress. Also administered was the Profile of Mood States (POMS [27]) to measure overall mood disturbance. The POMS is a 65-adjective checklist used to assess total mood disturbance (TMD) as well as seven mood states: tension/anxiety, depression/dejection, anger/hostility, vigor/activity, fatigue/inertia, confusion–bewilderment, and friendliness [27]. Each item is rated on a five-point scale from 0=not at all to 4=extremely.
“A TMD score was obtained by adding the negative mood factors of tension–anxiety,depression–dejection, anger–hostility, fatigue–inertia, and confusion–bewilderment, and subtracting the sum of the positive mood factors of vigor–activity and friendliness.”
This is the study we need more of these like a hole in the head
A Critique of
“A pilot study of cognitive behavioral stress management effects on stress, quality of life, and symptoms in persons with chronic fatigue syndrome” (1)
The paper states:
Quote
” Distress reactions may further disregulate the immune system since distress/depressive states are related to several immunoregulatory cytokines possibly via alterations in hypothalamic-pituitary-adrenal (HPA) axis hormones such as cortisol [12]. This is salient given the work showing that HPA axis functioning is altered in CFS patients [13].”
” Because distress reactions (increased perceived stress and mood disturbance) appear to be a possible common denominator contributing to neuroimmune changes and symptom exacerbation, we have reasoned that effective treatment would need to focus on reducing the patients’ distress reactions by changing psychological response processes [14]. Indeed, a recent review [15] showed that out of 15 studies, CBT was more successful in alleviating fatigue, depression, physical functioning, and more when compared to usual care”
[12] Demitrack M. Neuroendocrine correlates of chronic fatigue syndrome: a brief review. J Psychiatr Res 1997;31:69–82.
[13] Torres-Harding S, Sorenson M, Jason LA, Reynolds N, Brown M,
Maher K, et al. The associations between basal salivary cortisol levels
and illness symptomatology in chronic fatigue syndrome. J Appl
Biobehav Res 2009;13:157–60.
[14] Weiss D, Helder L, Antoni MH. Development of the SMARTENERGY program. In: Jason L, Fenell P, Taylor R, editors. Handbook of Chronic Fatigue Syndrome and Fatiguing Illnesses. New York: John Wiley & Sons, 2003. p. 546–60.
[15] Price J, Mitchell E, Tidy E, Hunot V. Cognitive behavior therapy for
chronic fatigue syndrome in adults. Cochrane Database Syst Rev 2008:
1–55.
The implication here is that the HPA axis abnormalities in people with ME/CFS are the same as those caused by stress and depression and that changing a sufferers psychological responses will alleviate their immune abnormalities. They actually speculate that perceived stress and mood disturbances are the only possible cause of neuroimmune changes. They do not say that neuroimmune abnormalities can cause mood disturbances and perceived stress.
This sets the scene for the flaws which then pervade the study. The authors also do not state that in patients with ME/CFS display under-activation of the HPA axis while people with depression display an activated or dysregulated HPA axis. This is crucial information as it enables a differential diagnosis to be made. Given that information their hypothesis is not scientific, as reducing stress would not reduce symptoms associated with this HPA axis abnormality. The premise of this study is based on a belief and moreover this study is designed to gather evidence in support of this belief. From this point in objective terms the scientific method is abandoned. A hypotheis must be capable of explaining all observations and should be challenged by actively excluding all people with any evidence of psychological abnormalities known to cause dysregulation of the HPA axis from the trial to eliminate ,or at least reduce the impact of, confounding variables. Instead the inclusion of people with psychological abnormalities is a natural and direct consequence of the selection methods used
Quote
Selection
Potential participants underwent a phone screening and a psychiatric screening assessment to determine eligibility. At baseline (T1), participants completed the informed consent, psychosocial questionnaires, and the symptom checklist on a scale from 0 (never) to 4 (very often). Sample questions include “How often have you felt nervous and “stressed?” “How often have you found yourself thinking about things that you have to accomplish?” and “How often have you felt that things were going your way?”. Positive items were reverse scored so that higher scores on this scale indicate greater levels of perceived stress. Also administered was the Profile of Mood States (POMS [27]) to measure overall mood disturbance. The POMS is a 65-adjective checklist used to assess total mood disturbance (TMD) as well as seven mood states: tension/anxiety, depression/dejection, anger/hostility, vigor/activity, fatigue/inertia, confusion–bewilderment, and friendliness [27]. Each item is rated on a five-point scale from 0=not at all to 4=extremely.
A TMD score was obtained by adding the negative mood factors of tension–anxiety,depression–dejection, anger–hostility, fatigue–inertia, and confusion–bewilderment, and subtracting the sum of the positive mood factors of vigor–activity and friendliness.
Patients were thus enrolled on the basis that they has psychological abnormalities as assessed by telephone interview. Hence the authors were in total control of who was included in the trial. Repeated studies have demonstrated that these parameters are no more of an issue with people with ME/CFS than they are for any chronic disabling disease such as MS. In view of this information why the authors would seek to actively include people with psychological symptoms is unfathomable. This is especially true because (despite several studies attempting to prove psychological causation) such symptoms are not core symptoms of the illness.
By selecting people in this manner the authors ensure a study population with an abnormally high proportion of psychological symptoms and thus could not possibly be representative of the population of CFS patients as a whole. The study also contains no patients displaying post exertional malaise (post exertional fatigue is not the same parameter). There is thus no objective marker which can differentiate these patients with a genuine neuroimmune disease from those whose symptoms are the result of anxiety and depression. Hence this design is not capable of producing scientific information but produces interpretive conclusions which cannot be proved or disproved. This reviewer invites the reader to examine the questions asked closely.
Sample items include, “How often have you felt nervous and “stressed?” “How often have you found yourself thinking about things
that you have to accomplish?” and “How often have you felt that things were going your way?”
How would a person suffering for years with a chronic disabling disease with no treatment faced with a hostile medical profession answer those questions. The authors describe the stress of patients enduring such conditions as perceived rather than real. This selection approach will clearly produce a highly biased trial population as anyone familiar with this disease or indeed any chronic disabling disease would know.
Quote
Quality of Life
Quality of life was measured with the Quality of Life Inventory (QOLI [28]), which is a quality-of-life indicator that assesses the importance and satisfaction in 17 life areas. A subscale score was derived for each domain and scores were computed by multiplying the importance rating (0=not important to 2=extremely important) by the satisfaction rating (−3=very dissatisfied to 3=very satisfied).
The total overall raw score was composed by the sum of the non-zero products of the importance and satisfaction scores. Raw scores were converted to T scores as well. Higher raw and T scores reflect greater quality of life, while lower overall QOLI category reflects a greater quality of life (1=high, 2=average, 3=low, 4=very low). The QOLI has been shown to have good test reliability and to correlate highly with other well-being measures [28,29].
28] Frisch MB. Quality of Life Inventory: Manual and Treatment Guide.
Minneapolis, MN: NCS Pearson, 1994.
[29] Frisch MB, Cornell J, Villanueva M, Retzlaff PJ. Clinical validation of
the Quality of Life Inventory: a measure of life satisfaction for use in treatment planning and outcome assessment. Psychol Assess 1992;4:92-101
The authors are actually stating that a questionnaire created by Frisch has been validated in a study led by Frisch!
That is not scientifically acceptable as independent validation has not taken place. From this point a study which lacked a scientifically valid hypothesis, using recruitment questionnaires which were not disease specific, becomes meaningless. The authors are entitled to express their opinion that the survey is validated but their opinion is not scientific fact.
Let us look more closely at the CDC symptom inventory score and its use in the study of Lopez and others as quoted below
Quote
” Frequency and severity of CFS symptoms
On the CDC Symptom Inventory for Chronic Fatigue Syndrome [30](2), patients were asked to rate the frequency (1=some of the time to 5=all of the time) and severity (1=very mild to 5=very severe) of 19 CFS-related symptoms during the past month.”
19 related CFS symptoms . There is no objective scientific evidence that there are 19 CFS related symptoms.These symptoms are clearly not disease specific as the authors imply
The study referenced by Lopez et al as [30] which is referenced in this work as (2) will be henceforth called the 2005 Reeves study
This study is in turn an extension of a study involving a telephone study carried out in 2000 by the CDC henceforth called the Witchita study (3)
This is the quality of the study that produced the symptom inventory used in the study by Lopez et al et al. Note none of the participants had ever received a formal diagnosis of CFS from any qualified physician. This is the famous (or infamous) “Wichita study”(3) quoted below
Quote
“A surveillance cohort of 3,528 adults who reported fatigue of at least 1-month duration and 3,634 non-fatigued persons completed a detailed telephone interview and eligible subjects were clinically evaluated to assess CFS. A subset of the cohort was followed at 12-, 24-and 36-months with a telephone interview and clinical evaluation. Fatigued participants in the present study were a subset of the 659 fatigued adults identified during surveillance who were classified as CFS by 1994 research case definition criteria [1] or unexplained chronic fatigue not meeting criteria for CFS (ISF). Non-fatigued controls were randomly selected from the cohort who participated in all telephone interviews at baseline, 12-, 24-, and 36-month follow-up periods, who had never reported fatigue of at least 1-month duration, and who had never been identified with medical or psychiatric conditions exclusionary for CFS.”
“We also defined a Case Definition score as the sum of the 8 individual CFS case-definition symptom scores and an Other Symptoms score by considering only the 11 non-CFS symptoms.”
Therefore it is the total score which decides whether a patient has CFS or not and the other symptoms are also considered to be symptoms of the disease
Quote
” We also defined a Case Definition score as the sum of the 8 individual CFS case-definition symptom scores and an Other Symptoms score by considering only the 11 non-CFS symptoms.”
The following is another quote from Lopez et al.
Quote
“We recruited 69 persons with a bona fide diagnosis of CFS.”
Hence Lopez et al consider the use of this questionaire as a Bone Fide method of diagnosing people as having Chronic Fatigue Syndrome
This means having a bone fide diagnosis of CFS according to the CDC inventory list shown. Thus Lopez et al make their diagnosis in all good faith and sincerity. The question remains however as to whether this method has any reliability or validity when it comes to producing an accurate diagnosis of Chronic Fatigue Syndrome which one of the authors (Dr Nancy Klimas) has gone repeatedly on record as being a neuroimmune disease. This will be investigated after describing the details of the questionaire below.
The authors of the 2005 study report that there is a high convergent validity of the symptom inventory with the MFI, SFI and the Chalder (5) fatigue subscales. While this is indeed so, none of those scales have been demonstrated as valid accurate tools for diagnosing CFS. The authors also point to a high construct validity because the questionnaire (perhaps unsurprisingly given its mode of construction) can distinguish between those classified as having idiopathic chronic fatigue or Chronic fatigue syndrome in the “Wichita” study. Unfortunately none of the people labelled with the latter term received a formal diagnosis from a qualified physician let alone one experienced in diagnosing the disease.
When examining the relability of the inventory the flaws become even more overt.
Quote
Cronbach’s alpha coefficients were 0.89 for general fatigue, 0.82 for physical fatigue, 0.90 for reduced activity, 0.77 for reduced motivation, and 0.92 for mental fatigue. These findings are similar to those of Smets and colleagues [6].
So it is (again unsurprisingly) a reliable measure of fatigue.The Cronbach alpha scores are objectively good (0.9 or above is considered excellent).
However if the reader cares to examine the Cronbach alpha scales of the individual symptoms above none are even good measures of reliably diagnosing Chronic Fatigue syndrome. Depression for example at .52 is not a reliable measure neither is shortness of breath or sensitivity to light. The values of feverishness, stomach pain and diarrhea are totally without meaning. In summary while the inventory may be a reliable and valid method for determining fatigue it is demonstrably not a reliable method for diagnosing Chronic fatigue syndrome! Hence the symptoms reported by the patients enrolled by people enrolled in the study of Lopez et all are not CFS specific at all despite the claims of the authors.
This is from the 2005 study
Quote
” At least one important limitation must be considered. Although study subjects were recruited from the community and do not reflect the strong biases inherent of clinic patient populations, they did not represent the general population; rather they comprised a sample of people with and without unexplained fatiguing illnesses. Thus, the excellent psychometric properties of the Symptom Inventory cannot be generalized to the general population. To further validate and evaluate the Symptom Inventory, additional testing in a larger population-based sample not stratified by fatigue is required. There is also a need to determine the test-retest-reliability and stability of the Symptom Inventory. The present study provides preliminary results to encourage researchers to administer the Symptom Inventory along with other standardized questionnaires measuring fatigue and functional impairment in studies of CFS and other fatiguing illnesses.”
It is therefore impossible to understand that with no further work of any kind how the questionaires mentioned in this study now form the diagnostic protocols for the contraversial and, according to many, infamous “Reeves” criteria for diagnosing Chronic Fatigue syndrome.(3)
This is a somewhat complex chain to follow therefore a summary would be advisable at this point.
The CDC carried out a telephone survey in Witchita in 2000. People who self reported a certain range of symptoms were classified as having CFS according to the Fukuda definition of 1994. None of the participants received a formal diagnosis of CFS from a qualified physician. The range of symptoms reported by these people were recorded and formed the basis of the CDC symptom inventory.
In 2005 a study involving Reeves and Unger (2) proposed this symptom inventory as a method of diagnosing chronic fatigue syndrome based on the severity and frequency of the symptoms reported. In essence once a certain ”points score“ is achieved the person is deemed to have CFS. A reliability analysis revealed revealed a significant correlation with the Chalder fatigue scale (3).
In the study under review therefore the authors used a diagnostic method deemed bone fide by the the producers of the CDC 2005 study.
So when the authors of Lopez et al state “This measure provides a reliable and broad indicator of CFS symptomatology [30](2)” they do not say that this diagnostic approach is either objective or accurate. Indeed this methodology is incapable of producing a homogenous cohort which could enable research to move forward.
Lopez and others state that their patients reported “Unusual fatigue after exertion”. It is highly unlikely that this is a direct report. It is a term used in the CDC symptom questionnaire. There must therefore be some definition of an unusual response and whether it is from the perspective of the patient or the researcher. This information is not supplied. Without this information the study cannot be replicated. Hence this study would not have survived a rigorous peer review.
It is also worth noting that this term does not describe Post Exertional Malaise which is a worsening of symptoms following mental or physical activity which is often delayed by 24 or 48 hours following such activity. Using a diagnostic protocol which does not include the one characteristic which separates this disease from all others bizarre considering that this study purports to evaluate the efficacy of a treatment for the disease.
Taking all matters into account the conclusions arrived at by Lopez and others are unjustifiable.
Quote
” Our findings suggest that CBSM may reduce CFS symptoms in parallel with improvements in perceived stress, negative mood, and quality of life. A full-scale trial should next test whether CBSM produces parallel changes in symptoms and neuroimmunologic processes that might explain its stress reducing effects on symptom reports. In view of other work showing that CBT combined with exercise training may be beneficial for CFS, it is reasonable also to conduct comparative effectiveness trials testing a stress management approach (e.g., CBSM) vs. CBT approaches targeting physical reconditioning.”
Our findings show a non significant reduction in symptoms in people deemed to have CFS using an unvalidated diagnostic questionnaire would be a more accurate statement. “The symptoms reported by the patients are not specific for CFS although we believed them to be” should be added.
The researchers can be demonstrated to hold sincere beliefs but unfortunately those beliefs are (ironically) erroneous ones.
I would also suggest the following:
Before more money is spent comparing this approach to another approach which has not shown to reduce the symptoms of any neuroimmune disease (CBT and exercise training) the blood of these trial subjects should be tested to discover whether they actually had a neuroimmune disease to begin with. Stress, anxiety and depression produce characteristic immune disturbances and high levels of oxidative stress. There are relatively simple blood tests that could eliminate people suffering from these extremely serious but different conditions from trial populations before the start of such a trial investigating the efficacy of a psychological treatment on people with a neuroimmune disorder.
This review ends with a quote from one of the authors of the 2005 CDC paper
Quote
” One might question the possibility of circular logic – defining an illness by its symptoms then assessing psychometric properties of a scale that measures the same symptoms.”
Yes indeed one must also question the competence of anyone using such a questionaire to diagnose a neuroimmune illness.
1) C Lopez, M Antoni, F Penedo, D Weiss, S Cruess, M-C Segotas, L Helder, S Siegel, N Klimas and MA Fletcher; A pilot study of cognitive behavioral stress management effects on stress, quality of life, and symptoms in persons with chronic fatigue syndrome; Journal of Psychosomatic Research Available online 15 January 2011 doi:10.1016/j.jpsychores.2010.11.010
2) D Wagner, R Nisenbaum, C Heim, JF Jones, ER Unger and WC Reeves; Psychometric properties of the CDC Symptom Inventory for assessment of Chronic Fatigue Syndrome; Popul Health Metr. 2005; 3: 8.
3) Reyes M, Nisenbaum R, Hoaglin DC, Unger ER, Emmons C, Randall B, Stewart JA, Abbey S, Jones JF, Gantz N, Minden S, Reeves WC: Prevalence and incidence of chronic fatigue syndrome in Wichita, Kansas. Arch Int Med 2003 , 163:1530-1536.
4) WC Reeves, D Wagner, R Nisenbaum, JF Jones, B Gurbaxani, L Solomon, DA Papanicolaou, ER Unger, SD Vernon and C Heim; Chronic Fatigue Syndrome – A clinically empirical approach to its definition and study; BMC Medicine 2005, 3:19doi:10.1186/1741-7015-3-19
5) T Chalder, G Berelowitz, T Pawlikowska, L Watts, S. Wessely, D Wright and EP Wallace; Development of a fatigue scale; Journal of Psychosomatic Research Volume 37, Issue 2, February 1993, Pages 147-153
Dr Klimas has a 25 years experience with treating ME/CFS. She is compassionate and truly understands the disease and will fight the patients doctors to death. She has volunteered on a number of committees like CFSAC and has a number of relationships with key people in the community to help ME/CFS patients. For that I say thank you.
Instead of tarnishing the reputation of one of our rare, awesome doctors, one would be better off trying to be an advocate for our cause.
I agree Anon although I confess that I am unable at present to fully understand the ramifications or indeed content of the post preceeding your own.
It’s only going to help people like White, and they had no proof they were studying ME/CFS. No evidence of post exertional malaise in cohort (PEM).
An analysis of a study should not be taken as a personal attack on the researchers involved. There is no difference between this and comment that appear in a journal.