380 Chronic Fatigue Syndrome
increasing cortisol and alleviating symptoms (Scott & Dinan,
1999). In addition, a negative relationship between “tness
and impairment appears to exist (Bazelmans, Bleijenberg,
van der Meer, & Folgering, 2001).
Cognitive behavioral interventions have many features
similar to stress-management trials, and both types of inter-
ventions deal with cognitive restructuring, coping skills, pro-
vision of psychological support, and illness education. It is
still unclear whether these types of interventions in”uence
the immune system (see a recent meta-analysis by Miller &
Cohen, 2001). Miller and Cohen have proposed that patients
evaluate stressful experiences as signi“cant threats and ex-
ceeding coping resources, and this might elicit negative
emotional responses. They also cited studies suggesting that
these negative emotional responses cause distressed patients
to engage in behaviors (e.g., tobacco use, decreasing physical
activity, altering sleep patterns) that conceivably modify im-
mune responses. In addition, negative emotional states might
also activate the sympathetic division, whose “bers descend
from the brain to lymphoid tissues (bone marrow, thymus,
spleen, etc.), and these “bers could release substances that in-
”uence immune responses. Distress also can activate the
HPA axis, and hormonal products from these systems
can dysregulate the immune system. Psychological interven-
tions might modify the way stressful circumstances are ap-
praised and diminish the way negative emotional responses
in”uence immune dysregulation. Relaxation, emotional-
regulation training, and learning more adaptive coping re-
sponses might also decrease negative emotions.
As mentioned previously, over the past few years, re-
search conducted in Europe by three independent groups has
suggested that cognitive behavior therapy is an effective
treatment approach for those with CFS. While cognitive be-
havior therapy has been applied to several medical problems
from pain to “bromyalgia, its application to CFS has been
more controversial. This is due in part to several of the com-
ponents of cognitive behavior therapy, as practiced by the
British investigators, that involve the following notions:
Resting is not helpful, increasing levels of exercising is criti-
cal, and patients need to be convinced that the disorder does
not have a viral or medical etiology. Because the “ndings of
the British studies have been disseminated widely, it is not
uncommon for medical practitioners today to encourage pa-
tients with CFS to begin an exercise program and for patients
to be challenged about their beliefs about the medical etiol-
ogy of their disorder. Many patient groups have been critical
of these cognitive behavioral studies because they have been
used to dispute either the severity or biological nature of their
illness. The studies conducted to date on this topic have had
serious methodological problems including, for example,
heterogeneous patient groups that may have encompassed
subjects manifesting purely psychiatric disorders. Consider-
able data indicates that cognitive behavioral interventions are
very effective for individuals with depression; therefore, it
remains unclear as to which population or subgroups of
patients actually bene“t from this type of treatment.Medical UtilizationBecause most prior research has consisted of medically re-
ferred samples, it has been unclear what medical services
have been used by the population of individuals with CFS
and what proportion of individuals suffering from CFS have
gone untreated or have been treated for other illnesses. In
a study of individuals with chronic fatigue, CFS, and “-
bromyalgia from a university-based chronic fatigue clinic
(Bombardier & Buchwald, 1996), individuals were found to
access health care services, both allopathic and alternative, at
a rate higher than the average, possibly indicating simultane-
ous and uncoordinated use of services. This may be indica-
tive of the lack of diagnostic or treatment satisfaction among
individuals seeking care for fatiguing illnesses such as CFS.
Related to this “nding, Lane, Matthews, and Manu (1990)
found that in individuals accessing physical examinations
and laboratory investigations for a chief complaint of fatigue,
diagnostic information was produced in only 2% of physical
examinations and 5% of laboratory investigations. These
investigations indicate that perhaps due to the nature of
fatigue-related physical complaints, individuals with fatigue
in general and CFS in particular are subject to inaccurate di-
agnoses and dissatisfaction with health care practitioners.
In a recent community-based study of CFS, Jason, Taylor,
Kennedy, Song, et al. (2000) found that the majority of indi-
viduals diagnosed with CFS had consulted a physician re-
garding their fatigue (65.6%), but only 10% to 15% of them
had been previously diagnosed with CFS. This is important
for two reasons. First, over one-third of people with CFS
have never been seen by a physician for their fatigue. This
“nding may be attributable, in part, to limited social and eco-
nomic resources among many of the individuals with CFS in
our sample (Jason, Richman, et al., 1999) and a resulting de-
creased tendency for those individuals to seek appropriate
medical care. Second, of those who had been seen by a physi-
cian, very few had been appropriately diagnosed with CFS.
This suggests that there may be inadequacies in medical
awareness of diagnostic criteria and/or biases in medical
perceptions of fatigue-related illness that prevent individuals
from receiving appropriate diagnosis and treatment.
Findings for high levels of dissatisfaction with traditional
medical care among individuals with CFS (Anderson &