Twisk, Frank N M, Maes, Michael · Neuro endocrinology letters · 2009
This review challenges the common medical recommendation to treat ME/CFS with cognitive behavioral therapy (CBT) and graded exercise therapy (GET). The authors argue that these treatments are not effective for ME/CFS and may actually harm many patients by worsening their symptoms, particularly through exercise-induced post-exertional malaise—a characteristic crash that occurs after physical activity. Instead, the review suggests that ME/CFS has biological causes that make intense exercise potentially dangerous rather than therapeutic.
This review is important because it directly challenges widely-recommended treatments, providing validation for patients who have experienced harm from CBT/GET and supporting the emerging biological understanding of ME/CFS. It contributes to a critical re-evaluation of treatment paradigms and has influenced clinical guidelines and patient advocacy efforts to reject exercise-based rehabilitation for ME/CFS.
This review does not prove that CBT/GET is harmful in all cases or that psychological support is never helpful for ME/CFS patients. It does not establish the precise mechanisms by which exercise worsens ME/CFS, nor does it definitively rule out all potential benefits of carefully-designed cognitive or behavioral interventions tailored to the disease's biological nature. The review's conclusions are based on synthesized evidence rather than new original data.
About the PEM badge: “PEM required” means post-exertional malaise was an explicit required diagnostic criterion for participant inclusion in this study — not that PEM was studied, observed, or discussed. Studies using criteria that do not require PEM (e.g. Fukuda, Oxford) are tagged “PEM not required”. How the atlas works →
The first block is for the primary paper and is the citation you should use in research work. The atlas-snapshot line only applies if you are specifically referring to this atlas’s reading of the paper on the date shown.
Primary citation
Twisk, Frank N M & Maes, Michael (2009). A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS.. Neuro endocrinology letters. https://pubmed.ncbi.nlm.nih.gov/19855350/
BibTeX
@article{mecfsatlas-twisk-2009-review-cognitive,
author = {Twisk, Frank N M and Maes, Michael},
title = {A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET) in myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS.},
journal = {Neuro endocrinology letters},
year = {2009},
note = {PubMed: 19855350},
url = {https://www.mecfsatlas.com/evidence/twisk-2009-review-cognitive},
}Atlas snapshot reference
ME/CFS Atlas. Generator v1 / Scanner v1.4 / policy v0.1. Accessed 2026-05-25. https://www.mecfsatlas.com/evidence/twisk-2009-review-cognitive
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