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The relation between cognitive-behavioural responses to symptoms in patients with long term medical conditions and the outcome of cognitive behavioural therapy for fatigue – A secondary analysis of four RCTs

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M de Gier, Federica Picariello, M Slot, A Janse, S Keijmel, Department Medical Psychology, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, the Netherlands, M. Worm-Smeitink, H Beckerman, V de Groot, Rona Moss-Morris, Hans Knoop

Original languageEnglish
Article number104243
Number of pages9
JournalBehaviour Research and Therapy
Issue number161
Early online date22 Dec 2022
Accepted/In press12 Dec 2022
E-pub ahead of print22 Dec 2022
PublishedFeb 2023

Bibliographical note

Funding Information: The TREFAMS-CBT was funded by the Fonds NutsOhra ( ZonMw 89000005 VG ). The Qure study was funded by The Netherlands Organization for Health Research and Development (ID ZonMw 50-51800-98-006 ) and received additional funding from Q-support (ID UMCN140410-01). The DiaFit study was funded by the Dutch Diabetes Research Foundation ( 2012.00.1483 ). This study was made possible by a grant from MS Research (16–937). Publisher Copyright: © 2022 The Authors

King's Authors


Cognitive behavioural therapy (CBT) is effective in reducing fatigue across long-term conditions (LTCs). This study evaluated whether cognitive and behavioural responses to symptoms: 1) differ between LTCs and 2) moderate and/or mediate the effect of CBT on fatigue.

Data were used from four Randomized Controlled Trials testing the efficacy of CBT for fatigue in Chronic Fatigue Syndrome/ME (N = 240), Multiple Sclerosis (N = 90), Type 1 Diabetes Mellitus (N = 120) and Q-fever fatigue syndrome (N = 155). Fatigue severity, assessed with the Checklist Individual Strength, was the primary outcome. Differences in fatigue perpetuating factors, assessed with the Cognitive Behavioural Responses to Symptoms Questionnaire (CBRQ), between diagnostic groups were tested using ANCOVAs. Linear regression and mediation analyses were used to investigate moderation and mediation by CBRQ scores of the treatment effect.

There were small to moderate differences in CBRQ scores between LTCs. Patients with higher scores on the subscales damage beliefs and avoidance/resting behaviour at baseline showed less improvement following CBT, irrespective of diagnosis. Reduction in fear avoidance, catastrophising and avoidance/resting behaviour mediated the positive effect of CBT on fatigue across diagnostic groups.

The same cognitive-behavioural responses to fatigue moderate and mediate treatment outcome across conditions, supporting a transdiagnostic approach to fatigue.

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