illness attribution – Page 3 – American ME and CFS Society

Attributions and chronic fatigue

Abstract:

It was recently suggested that chronic fatigue is merely a question of attribution. Attribution clearly contributes to the course of chronic fatigue syndrome (CFS) but is not its sole determinant. The presence of strong somatic attributions appears to be one of the perpetuating factors in CFS but not the only one.

Many CFS patients present a self-diagnosis, e.g. myalgic encephalomyelitis. Communication problems between patient and doctor easily arise because of different attributions of the complaints. At the start of fatigue somatic attributions are of less importance than later on in the course of the complaints. In this process an iatrogenic factor might be involved. On the other hand doctors are able to influence these attributions actively in a favourable direction.

Comment in:

Chronic fatigue syndrome. Ned Tijdschr Geneeskd. 1997

Source: Bleijenberg G. Attributions and chronic fatigue. Ned Tijdschr Geneeskd. 1997 Aug 2;141(31):1510-2. [Article in Dutch] http://www.ncbi.nlm.nih.gov/pubmed/9543736

The prognosis of chronic fatigue and chronic fatigue syndrome: a systematic review

Abstract:

The prognosis of chronic fatigue syndrome and chronic fatigue has been studied in numerous small case series. We performed a systematic review of all studies to determine the proportion of individuals with the conditions who recovered at follow-up, the risk of developing alternative physical diagnoses, and the risk factors for poor prognosis.

A literature search of all published studies which included a follow-up of patients with chronic fatigue syndrome or chronic fatigue were performed. Of 26 studies identified, four studied fatigue in children, and found that 54-94% of children recovered over the periods of follow-up. Another five studies operationally defined chronic fatigue syndrome in adults and found that < 10% of subjects return to pre-morbid levels of functioning, and the majority remain significantly impaired. The remaining studies used less stringent criteria to define their cohorts. Among patients in primary care with fatigue lasting < 6 months, at least 40% of patients improved.

As the definition becomes more stringent the prognosis appears to worsen. Consistently reported risk factors for poor prognosis are older age, more chronic illness, having a comorbid psychiatric disorder and holding a belief that the illness is due to physical causes.

Comment in:

Chronic fatigue syndrome. [QJM. 1997]

Source: Joyce J, Hotopf M, Wessely S. The prognosis of chronic fatigue and chronic fatigue syndrome: a systematic review. QJM. 1997 Mar;90(3):223-33. http://qjmed.oxfordjournals.org/content/90/3/223.long (Full article)

Psychosocial risk factors for chronic fatigue and chronic fatigue syndrome following presumed viral illness: a case-control study

Abstract:

This study investigated psychosocial morbidity, coping styles and health locus of control in 64 cases with and without chronic fatigue identified from a cohort of primary care patients recruited 6 months previously with a presumed, clinically diagnosed viral illness. A significant association between chronic fatigue and psychosocial morbidity, somatic symptoms and escape-avoidance coping styles was shown.

Chronic fatigue cases were significantly more likely to have a past psychiatric history and a current psychiatric diagnosis based on a standardized clinical interview. Twenty-three of the cases fulfilled criteria for chronic fatigue syndrome (CFS). Such cases were significantly more fatigued than those not fulfilling criteria, but had little excess psychiatric disorder.

A principal components analysis provided some evidence for chronic fatigue being separable from general psychosocial morbidity but not from the tendency to have other somatic complaints. Past psychiatric history and psychological distress at the time of the viral illness were risk factors for psychiatric ‘caseness’ 6 months later, while presence of fatigue, psychologising attributional style and sick certification were significant risk factors for CFS. These findings extend a previous questionnaire study of predictors of chronic ‘post-viral’ fatigue.

Source: Cope H, Mann A, Pelosi A, David A. Psychosocial risk factors for chronic fatigue and chronic fatigue syndrome following presumed viral illness: a case-control study. Psychol Med. 1996 Nov;26(6):1197-209. http://www.ncbi.nlm.nih.gov/pubmed/8931166

Chronic fatigue in the community: ‘a question of attribution’

Abstract:

Thirty-eight subjects identified in a large community survey were found to attribute their fatigue to ‘myalgic encephalomyelitis’ (ME). They were matched randomly to two other groups of subjects who attributed their fatigue to either psychological or social factors. All three groups were followed up 18 months later and were asked to complete a series of questionnaires that examined fatigue, psychological distress, number of symptoms, attributional style and levels of disability.

At onset the ‘ME’ group were found to be more fatigued, had been tired for longer but were less psychologically distressed than the other two groups. At follow-up the ‘ME’ group were more handicapped in relation to home, work, social and private leisure activities, even when controlling for both duration of fatigue and fatigue at time 1, but were less psychologically distressed.

The relationships between psychological distress, specific illness attributions, attributional style and their effect on the experience of illness and its prognosis are discussed. Attributing fatigue to social reasons appears to be most protective.

Source: Chalder T, Power MJ, Wessely S. Chronic fatigue in the community: ‘a question of attribution’. Psychol Med. 1996 Jul;26(4):791-800. http://www.ncbi.nlm.nih.gov/pubmed/8817714

Prognosis in chronic fatigue syndrome: a prospective study on the natural course

Abstract:

OBJECTIVE: To determine spontaneous improvement after a follow up interval of 18 months in patients with chronic fatigue syndrome and to identify factors that predict improvement.

METHODS: A longitudinal study was used. Of 298 initially assessed self referred patients fulfilling criteria for chronic fatigue syndrome, 246 patients completed self report questionnaires at follow up (response rate 83%). A multidimensional assessment method was used, measuring behavioural, emotional, cognitive, and social functioning. Comparison data from 53 healthy subjects matched for age, sex, and educational level were available.

RESULTS: Three per cent of patients reported complete recovery and 17% reported improvement. At follow up, there were considerable problems at work and consumption of medication was high. Subjective improvement was confirmed by dimensional change: at follow up recovered patients had similar scores to healthy subjects and improved patients showed significant improvement on four out of seven outcome measures and had higher scores than healthy subjects in all dimensions. Sociodemographic variables or treatment by specialists and alternative practitioners did not predict improvement. Predictors of improvement were: subjective sense of control over symptoms, less fatigue, shorter duration of complaints, and a relative absence of physical attributions.

CONCLUSION: The improvement rate in patients with a relatively long duration of complaints is small. Psychological factors are related to improvement, especially cognitive factors.

Source: Vercoulen JH, Swanink CM, Fennis JF, Galama JM, van der Meer JW, Bleijenberg G. Prognosis in chronic fatigue syndrome: a prospective study on the natural course. J Neurol Neurosurg Psychiatry. 1996 May;60(5):489-94. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC486359/ (Full article)

Correlates of somatic causal attributions in primary care patients with fatigue

Abstract:

Researchers in the field of chronic fatigue in tertiary care found that patients’ somatic (e.g. viral) explanations for their condition may lead to chronicity of symptoms. We studied the influence of a somatic attributional bias on outcome and reported symptoms in primary care patients with fatigue.

We compared fatigue scores on a specific scale, and number of presented symptoms, in two groups of primary care patients with ‘functional’ fatigue: 75 with a high score on the somatic subscale of the Fatigue Attribution Scale (S-FAS), and 95 with a low score on the S-FAS. At the index visit, patients with low and high scores on the S-FAS were not different for age, sex, fatigue scores, and levels of depressive symptoms.

Patients with high scores on the S-FAS presented significantly more somatic and psychological symptoms-a total of 36 symptoms for 24 patients (25.3%) in the low-score group, and a total of 52 symptoms for 31 patients (41.3%) in the high-score group.

Forty-two days later, at the follow-up visit, the fatigue scores were similar in both groups. In primary care patients with fatigue not due to somatic illness or major depression, the tendency to attribute fatigue to somatic causes is not associated with a worse outcome, but with a higher number of reported symptoms.

Source: Cathébras P, Jacquin L, le Gal M, Fayol C, Bouchou K, Rousset H. Correlates of somatic causal attributions in primary care patients with fatigue. Psychother Psychosom. 1995;63(3-4):174-80. http://www.ncbi.nlm.nih.gov/pubmed/7624463

Predictors of chronic “postviral” fatigue

Abstract:

We set out to determine the relation between a general practitioner (GP) diagnosis of viral illness and development of chronic fatigue 6 months later. 618 subjects who attended GPs clinics in London, south, and southwest England and who received a diagnosis of viral illness were followed prospectively and fatigue was assessed by questionnaire after 6 months. At presentation, GPs recorded fatigue in 62.6% of subjects, usually since the onset of symptoms. 502 (81.2%) subjects completed the 6-month questionnaire, of whom 88 (17.5%) met criteria for chronic fatigue and 65 (12.9%) had no reported fatigue before the viral illness.

Compared with a similar group of non-postviral GP attenders, the risk ratio for chronic fatigue in the present cohort was 1.45 (95% CI 1.14-2.04). Infective symptoms did not predict fatigue 6 months later. Psychiatric morbidity, belief in vulnerability to viruses, and attributional style at initial presentation were all associated with self-designated postviral fatigue.

Logistic regression showed that somatic attributional style, less definite diagnosis by the GP, and sick certification were the only significant predictors of chronic fatigue after viral infection when other factors were controlled for. Chronic severe fatigue 6 months after GP-diagnosed viral illness is related to symptom-attributional style and doctor behaviour, rather than to features of the viral illness. Some subjects with apparent postviral fatigue had complained of tiredness before their presentation with a viral illness.

Comment in:

Chronic fatigue syndrome. [Lancet. 1994]

Source: Cope H, David A, Pelosi A, Mann A. Predictors of chronic “postviral” fatigue. Lancet. 1994 Sep 24;344(8926):864-8. http://www.ncbi.nlm.nih.gov/pubmed/7916407

Dimensional assessment of chronic fatigue syndrome

Abstract:

The absence of laboratory tests and clear criteria to identify homogeneous (sub)groups in patients presenting with unexplained fatigue, and to assess clinical status and disability in these patients, calls for further assessment methods. In the present study, a multi-dimensional approach to the assessment of chronic fatigue syndrome (CFS) is evaluated.

Two-hundred and ninety-eight patients with CFS completed a set of postal questionnaires that assessed the behavioural, emotional, social, and cognitive aspects of CFS. By means of statistical analyses nine relatively independent dimensions of CFS were identified along which CFS-assessment and CFS-research can be directed.

These dimensions were named: psychological well-being, functional impairment in daily life, sleep disturbances, avoidance of physical activity, neuropsychological impairment, causal attributions related to the complaints, social functioning, self-efficacy expectations, and subjective experience of the personal situation. A description of the study sample on these dimensions is presented.

Source: Vercoulen JH, Swanink CM, Fennis JF, Galama JM, van der Meer JW, Bleijenberg G. Dimensional assessment of chronic fatigue syndrome. J Psychosom Res. 1994 Jul;38(5):383-92. http://www.ncbi.nlm.nih.gov/pubmed/7965927

Chronic fatigue syndrome. Role of psychological factors overemphasised

Comment in: Chronic fatigue syndrome and myalgic encephalomyelitis. [BMJ. 1994]

Comment on: Longitudinal study of outcome of chronic fatigue syndrome. [BMJ. 1994]

Editor,-In concluding that psychological factors are more important than immunological ones in determining the long term outcome of myalgic encephalomyelitis or the chronic fatigue syndrome Andrew Wilson and colleagues seem overconfident of the validity of their findings. Although the use of self rated measures of outcome is necessary, the validity of the investigators’ treatment of such data is questionable. For example, the five point self rated global illness outcome was dichotomised such that an original response of “not improved at all” was recorded to “worsened”-a decision the investigators fail to justify. It is also dubious whether patients’ recall of their own premorbid psychological state is accurate, given that the average onset was 9 years before recall and the finding that memory of an event is affected by subsequent events.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2540179/pdf/bmj00440-0053a.pdf

Source: Blatch C, Blatt T. Chronic fatigue syndrome. Role of psychological factors overemphasised. BMJ. 1994 May 14;308(6939):1297. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2540179/

Chronic fatigue syndrome: a follow up study

Abstract:

Forty-six of 47 patients diagnosed as having chronic fatigue and offered treatment four years previously were followed up. Twenty-nine patients were interviewed, three patients refused an interview, and information on the remaining 14 was obtained from their general practitioners. All the instruments used at interview had been used in the initial study. The long-term prognosis for patients with chronic fatigue syndrome who have initially responded to treatment is good. Spontaneous recovery in those who declined or who did not benefit from treatment is unlikely. Patients who continue to fulfil the criteria for chronic fatigue syndrome four years after they were initially diagnosed are likely to have had more somatic disorders, to have been more fatigued, and to have had a previous psychiatric history when they were initially assessed.

Comment in: Chronic fatigue syndrome. [J Neurol Neurosurg Psychiatry. 1995]

Source: Bonner D, Ron M, Chalder T, Butler S, Wessely S. Chronic fatigue syndrome: a follow up study. J Neurol Neurosurg Psychiatry. 1994 May;57(5):617-21. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1072927/

You can read the full article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1072927/pdf/jnnpsyc00035-0089.pdf