The Hijacking of Fatigue by CBT To Foster Expansionism


A just published paper by Picariello et al 2023 singles out fatigue across 5  disorders, suggesting that certain cognitions and behaviours  play a pivotal role in the worsening or maintaining  of this symptom. In addition it is suggested that targeting such cognitions and behaviours would   make a clinically significant difference to associated low mood and anxiety. The cognitions and behaviours are enshrined in the authors Cognitive and Behavioural  response to Symptoms Questionnaire  (CBRSQ-SF) short form.  The authors posit that the scale could be a therapeutic aid, indicating treatment targets. Further they suggest  that it may facilitate the development of a low intensity treatment for these conditions.


But the data Picariello et al 2023  present is all correlational, it does not establish causation. To establish causation it would be necessary to demonstrate that amongst those who had remitted from the conditions a high score on the CBRQ-SF was predictive of fatigue score, controlling first for the effect of mood. [Dysfuntional attitudes are known to be correlated with mood].  The partial correlation analysis would then need to be repeated with low mood and anxiety as the dependent variables. The danger is that the CBRQ-SF is promoted on the basis of its face validity and used to justify the expansion of psychological therapy into the Long Term Conditions Arena. Given that 43% the  population of England have at least one LTC there is the prospect of rich pickings for service providers, such as the Improving Access to Psychological Therapies Service. One of the authors of the Picariello et al 2023 Trudie Chalder is a regular presenter to IAPT staff on the treatment of LTC’s.

Unfortunately it is unlikely that IAPT and its fellow travellers will take note of the study by Serfaty et al  (2020) on the efficacy of CBT for the treatment of depression in patients with advanced cancer, which used  IAPT therapists and revealed no difference to treatment as usual. Claims for the efficacy of CBT with LTCs rest on studies using self-report measures and without blind assessment. 

Returning to the Picariello et al (2023) study  although 5 populations are considered (chronic fatigue syndrome, multiple sclerosis, hemodialysis, irritable bowel disease and chronic dizziness) the focus was on a particular aspect of these disorders, fatigue. Thus, at best, targeting the dysfunctional attitudes and behaviours enshrined in the instrument would at most have a circumscribed impact on these disorders. With the possible exception of CFS sufferers, it is unlikely that most people with these disorders/difficulties would see fatigue as their primary issue.   It could equally plausibly be suggested that irritability and low mood are accompaniments of these disorders and also of Long Covid. But there is no evidence to suggest that targeting CBRQ-SF items would have a clinically significant impact on this diffuse array of symptoms across a wide range of long term conditions, despite the intimation of Picariello et al 2023.  Arguably the fatigue, low mood, anxiety and irritability are an epiphenomenon of these conditions. The elevation of fatigue to the status of a cardinal symptom of long-term conditions is without  foundation. It is a heuristic designed to short circuit  the assessment of multi-faceted disorders, accuracy is sacrificed for speed.                                  

A pinch of salt is required for the claim of Picariello et al 2023that it is a ‘transdiagnostic measure of cognitive interpretations of symptoms, and related behaviours which are associated with the experience of more severe and disabling symptoms, low mood and anxiety’ and from a treatment perspective ‘the focus and content of therapeutic techniques may vary depending on the coping procedures employed by a client (avoidance/resting versus all-or-nothing behaviour); or developing lower-intensity interventions while retaining key therapeutic techniques in line with stepped-care treatment models’.  

My thanks to Joan Crawford for help with this blog .

Dr Mike Scott