Trudie Chalder

Trudie Chalder, R.M.N., M.Sc., (born March 1960) is a Professor of cognitive behavioural psychotherapy at the Institute of Psychiatry, King's College London. She has worked as director of the South London and Maudsley NHS Foundation Trust’s Chronic Fatigue Service and is currently director of the Persistent Physical Symptoms Research and Treatment Unit at Kings College London. From 2012 to 2014 Chalder was president of the British Association for Behavioural and Cognitive Psychotherapies.

Chalders’ research focuses on psychosocial and behavioral aspects of persistent physical symptoms. She has helped develop cognitive behavioral interventions for chronic fatigue syndrome, irritable bowel syndrome , multiple sclerosis , and psychogenic nonepileptic seizures , often based on the fear-avoidance model. Her research, however, has been criticized for overemphasizing psychological factors and characterizing patients’ symptoms as unhelpful cognitive responses. As one of the principal investigators of the PACE trial, Chalder was criticized for misrepresenting the study’s findings in favor of cognitive behavioral therapy and graded exercise therapy.

The cognitive behavioral model
In collaboration with colleagues such as Simon Wessely, Chalder helped develop the cognitive behavioral model (CBM) of chronic fatigue syndrome (CFS). This model supposes that “unhelpful catastrophic interpretations of symptoms and excessive focus on symptoms are central in driving disability and symptom severity.” With cognitive behavioral therapy (CBT) patients are encouraged to take on more optimistic interpretations of symptoms and to gradually increase their activity levels without responding to symptom flares with resting behavior.

Chalder has conducted several randomized trials which reported that CBT improves fatigue and physical function in patients with CFS. She has studied the effectiveness of a family-focused version of CBT for patients with CFS and shorter telephone  -and guided self-help versions to reduce costs of the intervention. According to Chalder, the evidence indicates that CBT is an effective treatment for CFS and “the idea that nothing can be done to help people with CFS must surely be challenged.” Chalder has claimed that CFS patients can fully recover with CBT, even that even severe and homebound CFS patients improve with a family focused rehabilitation treatment.

The methodology of trials of CBT for CFS, however, has been questioned and some reviews have concluded that the lack of improvement on objective outcomes demonstrate that CBT is not effective in CFS. Chalder has criticized articles that “underestimate” the benefits of CBT for CFS and has claimed that “therapeutic nihilism, the idea that nothing can be done, may act as a self- fulfilling prophecy…”

Development of Questionnaires
During her career, Chalder helped develop or validate various questionnaires to evaluate psychosocial factors suspected to perpetuate disability in chronic illnesses. She has studied the work and social adjustment scale, the cognitive behavioural responses questionnaire, and the beliefs about emotions scale and helped develop the irritable bowel syndrome-behavioral responses questionnaire , the behavioural responses to illness questionnaire and the Chalder fatigue scale (CFQ). The latter is a brief questionnaire assessing symptoms of fatigue which has been frequently used in research into CFS and has been translated into multiple languages. The CFQ, however, has been criticized for having ceiling effects and other operational flaws.

Psychosocial factors
Chalders research has focused on the psychosocial factors which, according to the cognitive behavioral model, perpetuate the symptoms of CFS. These include defensive coping styles, somatic attributions , unhealthy perfectionism , high expectations , low self-esteem , lack of acceptance and personality measures such as neuroticism. According to Chalder’s research, CFS participants show significant attentional bias for fatigue-related words and are “more likely to interpret ambiguous information in a somatic way." Other studies of Chalders team claimed that CFS patients have lower emotional expression, which the authors thought to be a learned response to unsympathetic response towards expression of negative emotions in early life. Another prominent element in the CBM for CFS is fear avoidance. Chalder has stated that while “avoidant coping strategies may help in the short term, the long-term consequences are potentially extremely unhelpful” and may lead to deconditioning.  Others have questioned Chalders assessment of avoidant behavior in ME/CFS as it uses descriptions such as ‘physical activity makes my symptoms worse’, that overlap with post-exertional malaise, a core symptom of the illness.

Research in other illnesses
Chalder has developed cognitive-behavioral interventions - often based on the fear-avoidance model - to treat fatigue in other conditions such as multiple sclerosis, low back pain , rheumatoid arthritis and fatigue following cancer or a stroke. She has developed a cognitive behavioral model for medically unexplained symptoms and has conducted randomized trials of CBT for irritable bowel syndrome and dissociative non-epileptic seizures. Chalder was for example coauthor of ACTIB, a large study which reported that web-based and telephone-delivered CBT are more effective in treating irritable bowel syndrome than treatment as usual. She has also studied psychological factors in patients with a diabetic foot ulcer, muscle disease , and ADHD. Chalder helped develop a web-based stress management intervention for occupational support workers and The Practitioner Health Programme (PHP), a service set up to help doctors with mental health problems.

The PACE trial
Trudie Chalder was one of the principal investigators of the PACE trial, a 5 million pound study that investigated the effectiveness of cognitive behavioral therapy (CBT), graded exercise therapy (GET) and adaptive pacing therapy (APT) in a sample of more than 600 CFS patients. While the reported findings indicated that CBT and GET were effective treatments for CFS, the authors have been criticized for misrepresenting the trials’ results.

At the press conference for the 2011 Lancet paper that reported the main results of the PACE trial, Chalder said that twice as many people in the CBT and GET groups as in the other groups “got back to normal”, a conclusion that was not supported by the data presented but was taken over by news outlets.

The PACE authors have been criticized for deviating from the methods specified in their protocol, without explaining these changes in full in their publications or how the changes impacted the reported findings. Following inconsistencies in the economic analysis of the PACE trial, Professor James Coyne filed a request to the journal PLOS ONE to access the data of the trial, a request that was dismissed as vexatious by Kings College London. PLOS ONE has since issued an expression of concern about the publications in question.

The PACE authors have refused to share the trial's data for independent reanalysis due to concerns that “patients might be personally identified by releasing their data.”  During a 2015 first tribunal hearing on the release of the PACE trial data, expert witness Professor Ross Anderson defended the PACE authors’ decision by making “wild speculations” about “young men, borderline sociopathic or psychopathic” being attached to criticism of the PACE trial. The tribunal considered these claims to be unfounded: it found no evidence of "direct threats", and only evidence of harassment provided was Prof. Chalder's testimony that she was once hackled in a seminar.  The tribunal rejected the appeal by the PACE investigators and ordered the release of some of the anonymised data of the trial. An independent reanalysis showed that the PACE authors had inflated improvement and recovery rates threefold. Three PACE authors, including Chalder, responded that they preferred their revised version of recovery over the one specified in the protocol, as it gives “absolute rates more consistent both with the literature and with our clinical experience.” An open letter signed by more than 100 prominent ME/CFS experts including researchers, clinicians, and MPs has called for “an independent re-analysis of the individual-level trial data, with appropriate sensitivity analyses.”

The role of the parents
Chalder has written a self-help guide for young people struggling with chronic fatigue syndrome, although she has made some strong statements about this subject. She has written that “emotional involvement with the child’s problem might have the unintended result of placing an excessive emphasis on physical symptoms and rewarding their continuation.” Elsewhere Chalder has stated that in her clinical experience “mothers fear of symptoms and the consequences of them lead them to encourage their children to reduce activities, thereby inadvertently reinforcing the vicious circle of symptoms and disability.” According to Chalder parents can be helpful by encouraging their ill children “to continue with their activity programme despite their symptoms.”

Patient surveys have indicated that a significant portion of participants report having worsened following a graded activity program. In a review on treatments for CFS, however, Chalder emphasizes that “it is normal to experience a temporary increase in symptoms that this doesn’t mean patients are have caused harm or will relapse, and “the symptoms will pass as they get fitter.” According to Chalder, “parents should be reassured about the safety of the approach and should be given support in encouraging their child to engage in rehabilitation.”

Conflicts of interest
In her publications, Chalder declared conflicts of interest which include consultancy work for insurance companies, payments for workshops and speeches on “evidence-based treatments for persistent physical symptoms” and royalties for the self-help books on chronic fatigue syndrome she has published.

From 2003 to 2019 Chalder was a director of WESTSIDE PROPERTY (MANAGEMENT) LIMITED (02067823). She was also an officer of OneHealth (Company number 04364122) from 2002 to 15 June 2010. Co-author of the PACE-trial, Peter Denton White was also an officer of Onehealth. Onehealth was dissolved on 15 June 2010. The memorandum of association stated that the purpose is to promote the biopsychosocial model of illness. These conflicts of interest have not been declared in her publications.

Prominent Studies

 * 1993, Development of a fatigue scale
 * 1997, Chronic fatigue syndrome. A practical guide to assessment and management
 * 2011, Adolescents with severe chronic fatigue syndrome can make a full recovery
 * 2012, Experiences of young people who have undergone the Lightning Process to treat chronic fatigue syndrome/myalgic encephalomyelitis
 * 2013, Recent stressful events contribute to the development of fatigue and depression in patients receiving Interferon-α treatment - (Abstract)


 * 2013: The planning, implementation and publication of a complex intervention trial for chronic fatigue syndrome: the PACE trial


 * 2014, Childhood stressors in the development of fatigue syndromes: a review of the past 20 years of research - (Abstract)
 * 2016, An attention and interpretation bias for illness-specific information in chronic fatigue syndrome
 * 2016, Cognitive behaviour therapy for chronic fatigue syndrome: Differences in treatment outcome between a tertiary treatment centre in the United Kingdom and the Netherlands
 * 2016, Complementary and alternative healthcare use by participants in the PACE trial of treatments for chronic fatigue syndrome
 * 2016, Mortality of people with chronic fatigue syndrome: a retrospective cohort study in England and Wales from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Clinical Record Interactive Search (CRIS) Register
 * The study has been criticized by James Coyne.
 * 2017, The presence of co-morbid mental health problems in a cohort of adolescents with chronic fatigue syndrome
 * 2017, Response to: "Do more people recover from chronic fatigue syndrome with cognitive behaviour therapy or graded exercise therapy than with other treatments?"
 * 2018, Illness beliefs of adolescents with CFS and their parents: the perceived causes of illness and beliefs about recovery
 * 2018, Home-based family focused rehabilitation for adolescents with severe Chronic Fatigue Syndrome
 * 2018, Does fatigue and distress in a clinical cohort of adolescents with chronic fatigue syndrome correlate with fatigue and distress in their parents?
 * 2019, Persistent fatigue induced by interferon-alpha: a novel, inflammation-based, proxy model of chronic fatigue syndrome - (Full text)
 * 2019, Psychological and demographic factors associated with fatigue and social adjustment in young people with severe chronic fatigue syndrome/myalgic encephalomyelitis: A preliminary mixed-methods study.


 * 2019, The PACE trial of treatments for chronic fatigue syndrome: a response to WILSHIRE et al - (Full text)
 * 2019, Cognitive and behavioural responses to symptoms in adolescents with chronic fatigue syndrome: A case-control study nested within a cohort - (Abstract)
 * 2019, Perfectionism and beliefs about emotions in adolescents with chronic fatigue syndrome and their parents: a preliminary investigation in a case control study nested within a cohort - (Abstract)
 * 2020, Cognitive behavioural therapy for chronic fatigue and chronic fatigue syndrome: outcomes from a specialist clinic in the UK - (Full text)

Books

 * Chalder, Trudie (1995), Coping with chronic fatigue, Overcoming common problems.
 * Chalder, Trudie; Hussain, Kaneez (2002), Self help for chronic fatigue syndrome : a guide for young people.
 * Burgess, Mary; Chalder, Trudie (2005), Overcoming chronic fatigue : a self-help guide using cognitive behavioral techniques.
 * Rimes, Katherine; Chalder, Trudie (2010), Overcoming Chronic Fatigue in Young People, A cognitive-behavioral self-help guide.

Talks and interviews

 * Trudie Chalder interview, undated (YouTube)
 * 2011, Trudie Chalder interview (YouTube)
 * 2016, Slide from talk claiming "It is possible to recover from CFS"
 * 2018, Chalder is quoted in an article as saying "“There are groups of people who perceive all such trials negatively; I’m not sure why. Perhaps they think we are suggesting the problem is psychological. We’re not. This is simply a rehabilitative treatment to help manage the symptoms more effectively.”

Learn more

 * Wikipedia - Trudie Chalder
 * 2013, Wiley - Chronic Fatigue Syndrome Part Two. Specific Disorders