The effects of CBT and GET on patients with Myalgic Encephalomyelitis looks at the physical effects of CBT and GET on patients with M.E.

This page features the full-length version of this text. A shorter/condensed version of this text is also available, see: The effects of CBT and GET – Condensed.

No evidence exists which shows that cognitive behavioural therapy (CBT) or graded exercise therapy (GET) are appropriate, useful or safe treatments for Myalgic Encephalomyelitis (or ICD-CFS) patients.

Studies involving miscellaneous psychiatric and non-psychiatric ‘fatigue’ sufferers, and their response to these treatments, have no more relevance to M.E. sufferers than they do to diabetes patients, cancer patients, patients with multiple sclerosis or any other illness. Thus, patients with M.E. are being prescribed these treatments on what amounts to a ‘random’ basis medically and so the questions need to be asked:

As (bad) luck would have it, graded exercise programs are probably the single most inappropriate treatment that a M.E. sufferer could be recommended to undertake. This is because one of the unique features of authentic M.E. is exercise intolerance – that patients worsen with even trivial levels of activity or exercise.

Exercise or exertion intolerance is one of the many things which separates Myalgic Encephalomyelitis so distinctly from various post-viral fatigue states or other illnesses involving 'chronic fatigue' as the defining or primary feature. People with M.E. do not improve with exercise. They cannot; exercise intolerance is a large and essential part of what M.E. is. Veteran M.E. expert Dr Ramsay explained that this unique characteristic: ‘is virtually a sheet-anchor in the diagnosis of Myalgic Encephalomyelitis and without it a diagnosis should not be made.’ (1986, [Online]).

This essential feature of M.E. is characterised by a unique form of paralytic muscle weakness whereby muscles perform normally to begin with but after even a minor degree of physical effort; three, four or five days, or longer, elapse before full muscle power is restored. This is quite distinct from the ‘chronic fatigue’ seen in many other illnesses. This paralytic muscle weakness in M.E. affects all muscles including the heart and causes what is commonly known as exercise intolerance; that patients relapse with physical and mental exertion. These features are a core part of what M.E. is as they are responsible for causing much of the symptomatology and disability associated with the illness. (Ramsay 1986, [Online]) (Hyde 2003, [Online]) (Hyde 1992 p. xi) (Hyde & Jain 1992 pp. 38 - 43) (Dowsett 2001, 2000, 1999.b, b [Online])

a. Dr Melvin Ramsay M.D., a UK doctor who specialised in M.E. for more than thirty years, from the Royal Free Hospital M.E. outbreak of 1955 until his death in 1990, and who is credited with having written some of the most accurate description of the illness to date, explains; ‘The degree of physical incapacity varies greatly, but the [level of severity] is directly related to the length of time the patient persists in physical effort after its onset; put in another way, those patients who are given a period of enforced rest from the onset have the best prognosis. Since the limitations which the disease imposes vary considerably from case to case, the responsibility for determining these rests upon the patient. Once these are ascertained the patient is advised to fashion a pattern of living that comes well within them.’ (Ramsay 1986, [Online])

b. Dr. Elizabeth Dowsett, explains: ‘There is ample evidence that M.E. is primarily a neurological illness although non neurological complications affecting the liver, cardiac and skeletal muscle, endocrine and lymphoid tissues are also recognised. Apart from secondary infection, the commonest causes of relapse in this illness are physical or mental over exertion’ and ‘Prompt recognition and advice to avoid over-exertion is mandatory’ and ‘The prescription of increasing exercise can only be counter-productive.’ She also states that; ‘20% have progressive and frequently undiagnosed degeneration of cardiac muscle which has led to sudden death following exercise.’ (Dowsett & Ramsay et al. 1990) (Dowsett 2000, [Online]) (Dowsett a, [Online])

c. Dr Byron Hyde MD, explains that: ’I have some ME patients with a circulating red blood cell volume less than 50% of expected and a very large number with the range of 60% to 70%. What this test means is that blood is pooling somewhere in the body and that this blood is probably not available for the brain. When blood flow to the heart decreases sufficiently, the organism has an increased risk of death. Accordingly, the human body operates in part with pressoreceptors that protect and maintain heart blood supply. When blood flow decreases, pressoreceptors decrease blood flow to noncardiac organs and shunt blood to the heart to maintain life. This, of course, robs those areas of the body that are not essential for maintaining life and means the brain, muscles, and peripheral circulation are placed in physiological difficulty.’ This physiological difficulty is exacerbated by physical and mental activity and orthostatic stress. Dr Byron Hyde goes on to say that: ‘In MRI spectography of arm muscle of ME patients, it has been shown that because of an abnormal buildup of normal metabolites, the muscle cell actually shuts down to prevent cell death.’ Dr Hyde explains that this is what is happening to the true M.E. patient’s cell physiology in the brain, and in muscle as a result of certain levels of physical and mental activity; there is ‘cell field shutdown’ to prevent the death of the cell. (Hyde 2003, [Online])

d. Dr. Paul Cheney explains that when disabled M.E. patients stand up, they are on the edge of organ failure due to extremely low cardiac output as their Q drops to 3.7 litres per minute (a 50% drop from the normal of 7 litres per minute). Without exception, according to Cheney, every disabled M.E. patient ‘is in heart failure’ and the disability level is exactly proportional to the severity of their Q defect, without exception and with scientific precision. (Marshall & Williams 2005, [Online].) Findings which showed mitochondrial metabolic dysfunction similar to mitochondrial encephalomyopathy also led Dr Cheney to comment, ‘The most important thing about exercise is not to have [patients with ME] do aerobic exercise. I believe that even progressive aerobic exercise is counter-productive. If you have a defect in mitochondrial function and you push the mitochondria by exercise, you kill the DNA.’ (Williams 2004, [Online]).

As these comments show, the adverse response to physical activity in M.E. patients is not ‘medically unexplained’ – research has found a number of sound medical reasons why M.E. sufferers are so physically disabled and unable to maintain an upright posture. These include; evidence of damage to the central nervous system (and autonomic and sympathetic nervous systems), damage to cardiac muscle (and many other cardiac and cardiovascular abnormalities), abnormalities and damage to muscle, immune system abnormalities, respiratory abnormalities and also a variety of abnormalities at a cellular level (eg. mitochondrial defects). It is also worth noting that none of these abnormalities can be explained by so-called ‘deconditioning’ – the supposed reason for the recommendation of therapies such as GET. (MESA [Online])

• To read more articles, research and books by these authors (and others) which explain these abnormalities in more detail see: Articles sorted by Author and Myalgic Encephalomyelitis Research and Articles. For more information on why exercise programs are so dangerous for M.E. patients see the medical overviews given in: Profits Before Patients? CRITICAL CONSIDERATIONS and Science or Psychology? by Eileen Marshall and Margaret Williams.

Surveys of M.E. patients on the effects of GET illustrate the accuracy of these findings only too well:

• In 1998 a survey of over 3000 UK M.E. patients found that the single most harmful strategy was graded exercise therapy. 50% of respondents who had tried GET indicated that graded exercise had made their condition worse. This was the highest negative rating of any of the pharmacological, non-pharmacological and alternate approaches of management covered in the questionnaire. The most helpful strategies were: a) Pacing activity with rest: 90% b) Bed rest: 89% (Jones 1998, [Online].)
• In 2004 a survey of severely affected M.E. sufferers (conducted by the 25% M.E. Group) again found that graded exercise was by far the single most harmful treatment of any of the pharmacological, non-pharmacological and alternate approaches of management covered in the questionnaire. 95% of those that had tried GET said that graded exercise was ‘unhelpful’ while a shocking 82% reported that it had made their condition worse.’ A significant number of those surveyed indicated that they were not severely affected before GET. (25% M.E. Group 2004, [Online])

• This (slightly modified) chart is taken from an article written by patient advocate Marjorie van de Sande in 2003 (See the reference list). See Testing for M.E. for more information about exercise testing in M.E.

When people with M.E. are physically or mentally active (or experience orthostatic or sensory stress) beyond their individual limits, they experience:

A combination of: profound cognitive dysfunctions (and various other neurological disturbances), muscle weakness (or paralysis), burning eye pain, subnormal temperature or low-grade fever, sore throat or painful lymph nodes (and/or other signs of inappropriate immune system activation), faintness or vertigo, loss of co-ordination, dyspnea, an explosion of sensory phenomena, cardiac and/or blood pressure disturbances, facial pallor and/or a slack facial expression, widespread severe pain, nausea or feeling as if ‘poisoned,’ feeling cold and shivering one minute and hot and sweating the next, anxiety or even terror (as an organic part of the attack itself rather than as a reaction to it) and hypoglycaemia. Often the patient will feel an urgent need to retreat from all homeostatic pressures. The types of symptoms triggered vary widely from patient to patient, but some combination of these is common. There may also be an accompanying exacerbation of other symptoms. These symptoms combine to create an indescribable and overwhelming experience of terrible illness that is unique to M.E, and can be profoundly incapacitating. At its most severe, the patient feels as if they are about to die. (Bassett, 2005 [Online])

Strong evidence exists to show that exercise can have extremely harmful effects on M.E. patients; permanent damage may be caused, as well as disease progression. Patient accounts of leaving exercise programs much more severely ill than when they began them; wheelchair-bound or bed-bound or needing intensive care or cardiac care units, are common. The damage caused is often very severe and may be either long-term or permanent. In addition to the risk of relapse, sudden deaths have also been reported in a small percentage of M.E. patients following exercise. As Dr. Elizabeth Dowsett, explains; ‘20% have progressive and frequently undiagnosed degeneration of cardiac muscle which has led to sudden death following exercise.’ Dr Dowsett has estimated the death rate of M.E. to be 3% . (This figure however also includes other causes of death including organ failure, another common cause of death in M.E. patients). (2000, [Online]) (2001, [Online).

Other characteristics of the unique form of exercise intolerance in M.E. include:

a. The level of physical (or mental) activity needed to cause the symptom complex outlined above varies from patient to patient, but is often trivial compared to a patient’s pre-illness tolerances and abilities. The severity level of the symptoms produced varies widely between patients and ranges from mild to very severe (to life-threatening).

b. 25% of M.E. sufferers are severely affected and wheelchair-bound, bed-bound and/or housebound and need help with all personal care tasks. Many must be tube-fed. For the most severely affected (and most disabled) sufferers there is virtually no ‘safe’ level of physical or mental activity, no level which does not produce a worsening of symptoms (and perhaps also contribute to disease progression). Even the most basic actions – speaking a few words, being exposed to bright light or moderate noise for a few minutes, sitting or standing for a few seconds or minutes, turning over in bed, having hair or body washed in bed by a carer or chewing and swallowing food – cause severe and extended symptom exacerbations in such patients.

c. The onset of these symptoms may be sometimes be acute but often symptoms will not peak until 24 – 48 hours (or more) afterward. Symptoms will then persist for hours, weeks or many months afterward or the relapse may be permanent, (or lead to death in a small percentage of cases).

d. The symptomatic expression of these effects from exercise can also be delayed and accumulate over time (usually days or weeks but sometimes months) until they are realised in a ‘crash,’ a period of intense worsening of the overall condition followed by a gradual return to the patient’s base level of illness. When the body is forced to be physically active beyond the patient’s individual limits severely and/or repeatedly over time however, these effects can also become cumulative in the long term; the patient becomes unable to return to their base level of illness at all (long-term or permanent worsening of the overall severity of the condition is caused). Thus some patients are still dealing with the severe physical effects of inappropriate advice to exercise 5, 10, 15 or more YEARS afterward. For some patients this damage appears to be permanent. (Bassett 2005, [Online])

e. In addition to physical and mental activity, M.E. patients will also relapse in response to orthostatic stress. Patients relapse if encouraged (or forced) to sit or stand upright for longer than they are able to cope with; this may be seconds, minutes or hours at a time depending on the severity of the illness. Neurally mediated hypotension and postural orthostatic hypotension (NMH and POTS) are common in M.E. Heart-rates may climb to 150 beats-per-minute (or higher) in response to maintaining an upright posture and there is often an accompanying fall in blood pressure. Blood pressure as low as 84/48 has been recorded in M.E. (Hooper et al. 2001, [Online]) In some patients these effects are immediate while in others there is a 10 minute or so delay in onset (delayed NMH or POTS). As with physical exercise, these effects may last for many days or weeks (or longer) and be very severe (or life-threatening). Recent research has shown that postural stress (as well as exercise) exacerbates cardiac insufficiency in this disease. (MESA [Online]) Again, see Testing for M.E. for more information about the series of tests which can be used to confirm a suspected M.E. diagnosis (including tests of orthostatic intolerance, and of the heart-rate using tilt-table testing and Holter monitors.) (Bassett 2005, [Online]) (Bassett 2006, [Online])

It is sometimes claimed that while exercise programs are not safe or appropriate for the severely affected, that mild or moderately affected M.E. sufferers can benefit from such interventions. But this assertion is NOT supported by the evidence. Some ‘fatigue’ sufferers have been shown to benefit from GET, but the results of these studies are no more relevant to mild M.E. sufferers than they are to severe M.E. sufferers; people with ‘fatigue’ do NOT have mild M.E. any more than they have mild multiple sclerosis, or mild cancer or any other illness. They are an entirely unrelated patient group. Thus graded exercise programs may help some fatigue sufferers but this is irrelevant to those who have M.E. Recent studies have shown that graded exercise programs are the actual reason many with M.E. are so severely affected ie. they were not severely affected before they were given advice to exercise or enrolled in formal GET programs. Thus GET should not be considered safe for M.E. sufferers of any severity. (25% M.E. Group 2004, [Online])

It is vital that M.E. patients avoid physical over-exertion and are never encouraged to exercise (or be mentally active, or cause orthostatic stress) beyond their individual limits particularly in the early and acute stages of the illness, but also at any stage of the illness as this can greatly damage a patients chances for future improvement or recovery. Graded exercise cannot improve authentic M.E.; disabled patients who improve with exercise do not qualify for a diagnosis of authentic M.E. There is nothing to be gained by people with M.E. pushing themselves beyond their individual physical limits; this can only result in unnecessary and sometimes very severe and prolonged relapses, disease progression, or even death, and so be counterproductive. (Ramsay 1986, [Online]) (Hyde 2003, [Online]) (Hyde 1992 p. xi) (Hyde & Jain 1992 pp. 38 - 43) (Dowsett 2001, 2000, 1999.b, b [Online])

• For more information on why exercise programs are so dangerous for M.E. patients see the medical overviews given in: Profits Before Patients? CRITICAL CONSIDERATIONS and Science or Psychology? by Eileen Marshall and Margaret Williams.
• In M.E., the body/brain no longer responds appropriately to homeostatic pressures including (to varying extents): physical activity, cognitive exertion, sensory input, orthostatic stress, emotional stress and infectious stress. Thus relapse is not caused solely by physical activity. See Myalgic Encephalomyelitis: The Medical Facts for more information.
• See Testing for M.E. for more information about the series of tests which can be used to confirm a suspected M.E. diagnosis.
• If you have M.E. see Treating Myalgic Encephalomyelitis - The Basics and Treating Myalgic Encephalomyelitis - Avoiding Overexertion for more on the importance of avoiding over-exertion.

Compared to the physical devastation caused by GET, CBT would seem at first glance to be the softer option of the two; but this is not always the case. There are two different types of CBT that M.E. sufferers may be given and the effect on patients varies greatly depending on which type is used:

1. The first type of CBT respects that there is an organic illness present which is largely irreversible (and which cannot be improved by CBT), but aims to help a patient cope better with the limitations caused by their illness. This type of CBT is also given to patients with cancer and a wide array of other chronic illnesses. (Carruthers et al. 2003, [Online])
2. The second type of CBT is based on the premise that the patient's impairments are entirely due to ‘wrong thinking’ and that the pathophysiology of the illness is entirely reversible and perpetuated solely by a patient’s ‘false illness beliefs.’ ie. ‘Patients are sick only because they believe they are sick.’ According to this theory of CBT, this therapy is potentially curative. (Carruthers et al. 2003, [Online])

Surveys of M.E. patients on the effects of cognitive behavioural therapy found:

• The (aforementioned) 1998 survey of over 3000 UK M.E. patients found that CBT was the least effective treatment of any of the pharmacological, non-pharmacological and alternate approaches of management covered in the questionnaire. Of those who had tried CBT, 55% indicated that the treatment had made no difference while 22% indicated that they had been made worse by CBT. (Jones 1998, [Online].)
• The (aforementioned) 2004 survey of severely affected M.E. sufferers (conducted by the 25% M.E. Group) also found that cognitive behavioural therapy was one of the most unhelpful treatments for M.E. Fully 93% of those who had tried CBT said that it was unhelpful (the only treatment with a worse rating was GET). (25% M.E. Group 2004, [Online])

The hypothesis behind the first type of CBT is reasonable. This type of CBT will likely do the vast majority of mild - moderately affected sufferers little harm (if also very little good), while a small percentage may find it useful in improving the way they cope with the illness emotionally. A significant percentage of patients will also be made worse by CBT. As with other chronic illnesses, the indications are that this type of CBT should be recommended or provided on a patient by patient basis only to those patients who have a specific need for such an intervention. CBT should not be considered essential for all – or even most – M.E. patients.

The hypothesis behind the second type of CBT however, is far from reasonable. Despite the large body of research which compellingly and conclusively disproves this hypothesis, the assumption of its truth by some has led to this treatment being forced on many M.E. sufferers particularly in the UK, The Netherlands and to a lesser extent, Australia. This unscientific and unethical form of CBT (which ignores the demonstrated biological pathology of the illness) seeks to disregard the patient’s autonomy and experience of their illness. It tells them to ignore their symptoms. When, inevitably, this causes significant physical relapse, patients are told that this is entirely their own fault; that they must not be trying hard enough to get well and must still not be thinking ‘correctly’ about their illness. Patients are blamed entirely for their illness and accused of ‘choosing’ to remain unwell because they are supposedly ‘enjoying the sick role’ too much. (Carruthers et al. 2003, [Online])

CBT to convince a physically ill person that he/she does not have a physical disorder is disrespectful, inappropriate and cruel. It places an additional (and bogus) psychological burden on a person already suffering with severe physical illness, and can cause significant psychological harm.

M.E. expert Dr. Elizabeth Dowsett explains about CBT: ‘Whereas any regime which can encourage patients with depression to discard or distract their damaging unrealistic morbid thoughts is helpful, patients with ME are usually capable of greater insight and understanding about their illness. Unfortunately, ME sufferers are too often denied care in our society, so it is essential that they should remain as well informed as possible about treatment options and not ‘brainwashed’ into disbelieving their own symptoms.’ (b [Online])

It is undoubtedly children with M.E. and their families who pay the highest price where CBT is involved however. Children with M.E. are not exempt from such ‘therapy’ and this is often far more detrimental to children as compared to adults. As M.E. authors Verillo and Gellman explain:

Misdiagnosing [M.E.] as school phobia, depression, or separation anxiety or chalking it up to family problems places the blame squarely on the shoulders of he child. When adults experience this kind of scepticism, they usually are able to defend themselves against the mistaken ideas of others. Children are unable to do so; they depend on adults for information, explanations, sympathy and advice. To throw disbelief in the face of a child who not only has all the symptoms of [M.E.] but is terribly frightened and in profound need of reassurance is not only cruel, it is detrimental to the child's future emotional growth. (Verillo & Gellman 1997 p. 327)

Equally concerning is the fact that because it is harder to pin the blame for the illness on depression or anxiety with children, the parents are often blamed instead. The ‘family dynamic’ may be blamed for causing the child’s illness and parents of these ill children have actually been charged with neglect or accused of actually making their children ill themselves (Munchausens by proxy). Some parents have lost custody and their children have been placed in foster care. Children have also been forcibly removed from the home and forced to undergo CBT and GET (and worse). All of this while the child continues to be seriously physically ill and not receive any sort of appropriate medical care.

• For more information about forced exercise and other ‘treatments’ used on M.E. children see: Children with M.E., The case of Ean Proctor and Sara Bass's Testimony

This medically unsupportable and abusive form of CBT can undoubtedly cause significant psychological harm, but it is these additional associated burdens; physical relapse, the withholding of basic medical care, the removal of children from their parents and parents being falsely charged with making their children ill themselves (etc.) which combine to make this form of CBT so harmful. Thus the negative effects of CBT can sometimes be equally as devastating as those of GET, or in some cases, worse (for sufferers and their families).

Clearly, CBT and GET are at best useless and at worst extremely harmful for M.E. patients. Despite this, people with M.E. are routinely being recommended these treatments while also being assured that they are completely safe. These treatments are also not just being offered to M.E. patients solely on a voluntary basis; many have been treated as psychiatric patients against their will. (Or against the will of the parents of children with M.E., as described previously). It is also of great concern that many M.E. patients are ONLY offered ‘treatments’ such as CBT and GET – while access to even basic appropriate medical care is withheld.

See the paper Smoke and Mirrors for information on why patients with M.E. are being treated based on theories motivated by financial and political considerations as opposed to the available medical evidence. This text forms the introduction to a 100 page + CBT and GET database. The database contains excerpts and links to literally hundreds of articles and research studies which expose the lack of scientific legitimacy (and the hidden financial and political motivations) underlying the 'behavioural' paradigm of M.E. and the use of CBT and GET on M.E. patients – as well as a large number of patient accounts of CBT and GET.

To print or save a copy of this text (or the entire database) in a printer-friendly Word or PDF format, see the Printer-friendly versions/Downloads section. A shorter/condensed version of this text is also available: The effects of CBT and GET – Condensed.

Permission is given for this document to be freely redistributed by e-mail or in print for any not-for-profit purpose provided that the entire text (including this notice and the author’s attribution) is reproduced in full and without alteration.

References (and recommended further reading list)

• Bassett, Jodi 2006. Testing for M.E. [Online], Available: http://www.ahummingbirdsguide.com/testingforme.htm
• Bassett, Jodi 2005. The Ultra-Comprehensive M.E. Symptom List [Online], Available: http://www.ahummingbirdsguide.com/themesymptomlist.htm
• Carruthers, Bruce M. Dr. et al 2003 Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Haworth Medical Press, New York
• Dowsett, Elizabeth MBChB. 2001, THE LATE EFFECTS OF ME Can they be distinguished from the Post-polio syndrome? [Online], Available: http://www.ott.zynet.co.uk/polio/lincolnshire/library/dowsett/lateeffectsme.html
• Dowsett, Elizabeth MBChB. 2000, Mobility problems in ME [Online], Available: http://www.25megroup.org/Information/Medical/dowsett's/mobility%20problems.htm
• Dowsett, Elizabeth MBChB. 1999 (a), Redefinitions of ME [Online], Available: http://www.25megroup.org/Information/Medical/dowsett’s/Redefinitions%20of%20ME.htm
• Dowsett, Elizabeth MBChB. 1999 (b) Research into ME 1988 - 1998 Too much PHILOSOPHY and too little BASIC SCIENCE!, [Online], Available: http://www.25megroup.org/Information/Medical/dowsett's/Research%20into%20ME.CFS%201988-98.htm
• Dowsett, Elizabeth MBChB. Undated (a), Time to put the exercise cure to rest, [Online], Available: http://25megroup.org/Information/Medical/dowsett’s/exercise%20cure%20to%20rest.htm
• Dowsett, Elizabeth MBChB. Undated (b), Differences between ME and CFS, [Online], Available: http://25megroup.org/Information/Medical/dowsett’s/me%20and%20cfs.htm
• Dowsett, Elizabeth MBChB. Undated (c), Is stress more than a modern buzzword? [Online], Available: www.25megroup.org/Information/Medical/dowsett's/Is%20stress%20more%20than%20a%20modern%20buzz%20word.htm
• Dowsett EG, Ramsay AM, McCartney RA, Bell EJ. 1990 Myalgic encephalomyelitis--a persistent enteroviral infection? Basildon Hospital, Essex, UK.
• Hooper, M. Marshall E.P. & Williams, M. 2001, What is ME? What is CFS? Information for Clinicians and Lawyers, [Online], Available: http://www.ahummingbirdsguide.com/wmarwillhoopwimewicfs.htm
• Hyde, Byron M.D. 2003, The Complexities of Diagnosis in (ed) Jason, Leonard at et al. 2003 Handbook of Chronic Fatigue Syndrome by Ross Wiley and Sons, USA
• Hyde, Byron M.D. 1992, Preface in Hyde, Byron M.D. (ed) 1992, The Clinical and Scientific Basis of Myalgic Encephalomyelitis / Chronic Fatigue Syndrome, Nightingale Research Foundation, Ottawa
• Hyde, Byron M.D., Bastien, Sheila M.D. & Anil Jain M.D. 1992, General Information: Post Infectious, Acute Onset M.E./CFS in Hyde, Byron M.D. (ed) 1992, The Clinical and Scientific Basis of Myalgic Encephalomyelitis / Chronic Fatigue Syndrome, Nightingale Research Foundation, Ottawa
• Hyde, Byron M.D. & Anil Jain M.D. 1992, Clinical Observations of Central Nervous System Dysfunction in Post Infectious, Acute Onset M.E./CFS in Hyde, Byron M.D. (ed) 1992, The Clinical and Scientific Basis of Myalgic Encephalomyelitis / Chronic Fatigue Syndrome, Nightingale Research Foundation, Ottawa
• Jones, Doris M. MSc. 1998, SOME FACTS AND FIGURES ON CBT, GET AND OTHER APPROACHES Directly from the 'Horses' Mouths [Online]. Available: (link in title)
• Marshall, Eileen & Williams, Margaret. 2005 Profits before Patients? [Online], Available: http://www.ahummingbirdsguide.com/wmarwillpbp.htm
• Ramsay, Melvin A. 1986 MYALGIC ENCEPHALOMYELITIS : A Baffling Syndrome With a Tragic Aftermath. [Online], Available: http://www.meactionuk.org.uk/ramsey.html
• The ME Society of America website, [Online], Available: http://www.cfids-cab.org/MESA/framework.html
• The 25% M.E. Group. 2004, SEVERELY AFFECTED ME (MYALGIC ENCEPHALOMYELITIS) ANALYSIS REPORT ON QUESTIONNAIRE [Online]. Available: (link in title)
• van de Sande, Marjorie M.Ed, Grad. Dip. Ed 2003, 2003 ME/CFS Post-Exertional Malaise and Exercise [Online]. Available: (link in title)
• Verillo, Erica F & Gellman, Lauren M 1997, Chronic Fatigue Syndrome - A Treatment Guide, St. Martin's Griffin, New York
• Williams, Margaret. Critical considerations 2004, [Online], Available: http://www.ahummingbirdsguide.com/wmarwillcc.htm