Treatment 379to even small doses of the medications described herein (par-
ticularly antidepressants) are not unusual among individuals
with these conditions (Friedberg, 1996; Verrillo & Gellman,
1997). Some suggest that physicians who prescribe medica-
tions for patients with CFS should start at lower than normal
dosages and increase slowly only if the drug is well tolerated
(Taylor, Friedberg, & Jason, 2001).
Nonpharmacological Interventions
Cognitive behavior therapy (CBT) with graded exercise con-
stitutes a popular form of treatment for CFS. This approach to
psychotherapy challenges patients• attributions of CFS symp-
toms as resulting from physical disease, such as viral or
immunological problems (Sharpe et al., 1996). Rather, it en-
courages patients to attribute their symptoms to social and
psychological factors. According to this approach, individu-
als with CFS are encouraged to engage in gradual and con-
sistent increases in activity and to try strategies other than
activity avoidance as modes for managing their symptoms.
Other components of this treatment include modifying exces-
sive perfectionism and self-criticism and maintaining an ac-
tive problem-solving approach in coping with interpersonal
and occupational dif“culties. Results of short-term studies
that have employed cognitive behavior therapy with graded
exercise suggest that this form of treatment is more effective
in improving physical functioning than relaxation training
(Deale, Chalder, Marks, & Wessely, 1997). Another study
also using this form of cognitive behavior therapy (Sharpe
et al., 1996) also reported signi“cant ef fects. However, in a
four-year follow-up differences decreased between the
cognitive-behavior therapy and a control group (Sharpe,
1998).
In an effort to generalize these “ndings to less specialized
settings using newly trained therapists, Prins et al. (2001)
found that CBT was more effective than guided support
groups, but there was a lower percentage of improved pa-
tients than the other CBT trials that had used highly skilled
therapists. Powell, Bentall, Nye, and Edwards (2001) com-
pared four conditions: two CBT treatment sessions plus two
telephone follow-up calls, a similar intervention plus an addi-
tional seven follow-up calls, and a third intervention that
included the prior interventions plus an additional seven
face-to-face sessions. No signi“cant dif ferences were found
between the three treatment conditions (69% achieved a
satisfactory outcome in physical functioning), but patients
receiving any of the treatments did signi“cantly better than a
control group receiving standardized medical care. (Among
controls, only 6% achieved a satisfactory outcome.) Fulcher
and White (1997) compared graded aerobic exercise to
”exibility/relaxation training, and those in the exercise group
were more likely to rate themselves improved than those in
the ”exibility/relaxation group (52% versus 27%), but there
was a high drop-out rate (29%). In addition, in a recent trial
comparing CBT to counseling, the CBT group did not im-
prove compared to CFS patients in the counseling group with
respect to fatigue and social functioning (Ridsdale et al.,
2001).
Other approaches to psychotherapy, including cognitive
coping skills therapy (Friedberg & Krupp, 1994) and enve-
lope theory (Jason, Melrose, et al., 1999), offer alternative
ways of treating CFS patients. Cognitive coping skills ther-
apy, for example, focuses on the identi“cation of symptom
relapse triggers and encourages activity moderation to
minimize setbacks. This therapy also emphasizes cognitive
and behavioral coping skills, stress reduction techniques, and
social support in an attempt to promote self-regulation
and management of CFS symptoms. Unlike some forms of
cognitive behavioral therapy (Sharpe et al., 1996), cognitive
coping skills therapy does not challenge or question patients•
beliefs in a medical cause for CFS. Instead, practitioners
using this approach are encouraged to respond to patients•
symptom accounts with complete empathy and validation for
the illness.
Envelope theory (Jason, Melrose, et al., 1999) assumes a
similar perspective and does not challenge patients• beliefs in
a medical cause for CFS. Instead, envelope theory recom-
mends that patients with CFS pace their activity according to
their available energy resources. In this approach, the phrase,
•staying within the envelope,Ž is used to designate a com-
fortable range of energy expenditure in which an individual
avoids both overexertion and underexertion, maintaining an
optimal level of activity over time. If a comfortable level of
activity is maintained over time, the functional and health
status of individuals with CFS will slowly improve, and indi-
viduals with CFS will “nd themselves able to engage in in-
creasing levels of activity. Jason, Melrose, and associates
(1999), King, Jason, Frankenberry, and Jordan (1997), and
Pesek, Jason, and Taylor (2000) presented data on the use
of this theory during interventions involving repeated self-
ratings of perceived and expended energy over time.
Findings indicated that when the participants• perceived and
expended energy levels were maintained within proximity
(within the envelope), the participants experienced decreases
in fatigue over time. Advocates of this approach do not chal-
lenge a patient•s belief in the medical cause of CFS, but
rather point to positive medical bene“ts of exercise. If the
HPA axis is implicated in the etiology of CFS, exercise is one
of the more potent activators of the HPA, and employment of
gradual increases in activity might activate the HPA, thereby