Table 3 Cognitive behavioural therapy modules and assessment tools used for patient tailoring of fatigue treatment

1. Treatment goals.

Positive and concrete goals of the fatigue treatment are formulated by each patient. The goals consist of activities they would do when no longer severely fatigued.

All patients

2. Sleep and rest.

The importance of a regular sleep–wake cycle and a good sleep hygiene are discussed, and instructions are given how to improve this.

Sickness Impact Profile subscale sleep and rest (scores ≥60) [29, 30]

Sleep log during one week

3. Uncertainty about the (consequences of the) illness and appraisal of MS as threatening.

In case of non-accepting cognitions of having MS and extreme fear of the future, the patient will be helped to gather realistic information about MS, to develop helping cognitions about MS and the personal future and to develop and maintain a more accepting attitude towards the illness and its consequences.

Impact Event Scale (IES ≥20) [31],

subscale Acceptance of the Illness Cognition Questionnaire (ICQ-acceptance ≤12) [32], Beck Depression Inventory-PC (>4) [33],

Fear of Disease progression Questionnaire–short form (FoP-Q-SF ≥34) [34, 35],

The Cognitive behavioural Responses to Symptoms Questionnaire (CBRSQ) [36, 37]:

- Resting behaviour >14.3,

- all-or-nothing behaviour >12.9,

- symptom focusing >15.5,

- Embarrassment >16.4,

- Damage >20.5,

- Fear avoidance >15.3

4. Fatigue-related cognitions.

Sense of control over fatigue symptoms (self-efficacy), fatigue catastrophizing, somatic attributions and other dysfunctional thoughts are assessed [38,39,40,41,42,43]. Patients are helped to change these cognitions in daily life.

modified Self Efficacy Scale for fatigue (≤19),

Jacobson-Fatigue Catastrophizing Scale (≥16) [44]

5. Focusing on fatigue.

Information about and consequences of focusing on fatigue will be discussed. Patients will practice with redirecting the focus of attention (away from the fatigue towards activity and other sensations).

Illness Management Questionnaire (≥4) [45]

6. Physical activity regulation.

Depending on the activity pattern, patients will learn to spread activities more evenly, sometimes to lower activities and followed by a systematical increase of regular physical activity. After patients have increased their physical activity level, they increase other activities in order to reach the goals step by step.

Activity Pattern Interview

7. Regulation of social activity.

The relationship with reduction in social activities as well as the cognitions about these activities and fatigue will be assessed in relation to the set goals. Suggestions how to increase social activities and how to handle the problems that are experienced during social interactions (as a consequence of cognitive impairments or intolerance of noise) are given.

Sickness Impact Profile (≥100) [29]

subscale social functioning of the SF-36 (≤65) [46]

8. Regulation of mental activity.

Patients are supported with regard to practicing and expanding mental activities such as computer use of reading. They learn how to deal with possible cognitive deficits such as concentration and memory problems.

CIS20r concentration subscale (score ≥18) [38]

9. Social support.

The goal of this module is to support emotional independence of others as far as fatigue is concerned. Unrealistic expectations of others and expressing boundaries are discussed.

The Sonderen Social Support Inventory: subscale discrepancy (score ≥50)

subscale negative interactions (score ≥14) [47]

10. Unhelpful thoughts about pain.

Dysfunctional pain cognitions are challenged, and more helpful pain cognitions will be installed.

SF-36 bodily pain subscale (score ≤40)

Pain Catastrophizing Scale (score ≥16) [48]