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=== Ceiling effects === The subjective fatigue (also called fatigue severity) subscale of the CIS has been the most widely used in the field of ME/CFS.<ref>{{Cite journal | last = Prins | first = Judith B | last2 = Bleijenberg | first2 = Gijs | last3 = Bazelmans | first3 = Ellen | last4 = Elving | first4 = Lammy D | last5 = de Boo | first5 = Theo M | last6 = Severens | first6 = Johan L | last7 = van der Wilt | first7 = Gert Jan | last8 = Spinhoven | first8 = Philip | last9 = van der Meer | first9 = Jos WM | date = Mar 2001 | title = Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial | url = http://dx.doi.org/10.1016/s0140-6736(00)04198-2 | journal = The Lancet | volume = 357 | issue = 9259 | pages = 841–847|doi=10.1016/s0140-6736(00)04198-2|issn=0140-6736}}</ref><ref>{{Cite journal | last = Wiborg | first = Jan F. | last2 = van Bussel | first2 = Jose | last3 = van Dijk | first3 = Agaat | last4 = Bleijenberg | first4 = Gijs | last5 = Knoop | first5 = Hans | date = 2015 | title=Randomised Controlled Trial of Cognitive Behaviour Therapy Delivered in Groups of Patients with Chronic Fatigue Syndrome | url =https://www.karger.com/Article/FullText/438867 | journal = Psychotherapy and Psychosomatics|language=en | volume = 84 | issue = 6 | pages = 368–376|doi=10.1159/000438867|issn=0033-3190}}</ref><ref>{{Cite journal | last = Knoop | first = Hans | last2 = van der Meer | first2 = Jos W.M. | last3 = Bleijenberg | first3 = Gijs | date = Oct 2008 | title = Guided self-instructions for people with chronic fatigue syndrome: randomised controlled trial | url = http://dx.doi.org/10.1192/bjp.bp.108.051292 | journal = British Journal of Psychiatry | volume = 193 | issue = 04 | pages = 340–341|doi=10.1192/bjp.bp.108.051292|issn=0007-1250}}</ref><ref>{{Cite journal | last = Janse | first = A. | last2 = Worm-Smeitink | first2 = M. | last3 = Bleijenberg | first3 = G. | last4 = Donders | first4 = R. | last5 = Knoop | first5 = H. | date = Feb 2018 | title = Efficacy of web-based cognitive–behavioural therapy for chronic fatigue syndrome: randomised controlled trial | url = https://www.cambridge.org/core/product/identifier/S0007125017000228/type/journal_article | journal = The British Journal of Psychiatry|language=en | volume = 212 | issue = 02 | pages = 112–118|doi=10.1192/bjp.2017.22|issn=0007-1250}}</ref> Because this subscale asks general questions about fatigue such as “I “feel tired” or “I feel weak”, ME/CFS often score close to the maximum score.<ref name=":5">{{Cite journal | last = Stouten | first = Bart | date = 2005-05-13 | title = Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution | url =https://www.ncbi.nlm.nih.gov/pubmed/15892882 | journal = BMC health services research | volume = 5 | pages = 37|doi=10.1186/1472-6963-5-37|issn=1472-6963|pmc=1175848|pmid=15892882}}</ref> The fatigue severity subscale asks 8 questions which gives a score from 8 to 56. While healthy persons score on average 17.3 and patients with other chronic conditions usually score below 40, ME/CFS patients easily reach a score above 50. For example, in a study of homebound ME/CFS patients (which included some of the authors of the CIS), it was noted that “The CIS-fatigue score involves an overall rating and in CFS samples easily reaches the extreme end of its scale.”<ref>Van der Werf S, Prins J, Klein-Rouweler E, Alberts M, van der Meer J, Bleijenberg G: Homebound chronic fatigue syndrome patients. Determinants and consequences of experienced fatigue in chronic fatigue syndrome and neurological conditions. PhD thesis 2000:31-41</ref> As a result ME/CFS patients can no longer indicate a worsening of their fatigue, a phenomenon that is called the ceiling effect. This can influence the findings of randomized trials. For example: If ME/CFS patients record the maximum score on the CIS and half of them improves while the other half deteriorates with the same amount during follow-up, then only the improvement will become visible on the questionnaire.<ref>{{Cite web | url = https://www.s4me.info/threads/my-feedback-on-content-of-cdes-fatigue-myalgic-encephalomyelitis-chronic-fatigue-syndrome-me-cfs-cde-public-review.2017/ | title = My feedback on content of CDEs (Fatigue) - Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) CDE Public Review | website = Science for ME|language=en-US|access-date=2019-02-17}}</ref> If such a result were used as a primary outcome in randomized trial, it might overestimate improvements in fatigue and underestimate deterioration or harms by the intervention.<ref>{{Cite web | url = http://senseaboutscienceusa.org/pace-research-sparked-patient-rebellion-challenged-medicine/ | title = PACE: The research that sparked a patient rebellion and challenged medicine | last = sasusa | date = 2016-03-21 | website = Sense About Science USA|language=en-US|access-date=2019-02-17}}</ref> Bart Stouten calculated the lower bounds for the number of items with the maximum score on the CIS fatigue severity subscale. In some studies this was as high as 46%.<ref name=":5" />
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