The Relationship of Fennell
Phases to Symptoms
Among Patients With
Chronic Fatigue Syndrome
Nadia L. Reynolds
Molly M. Brown
Leonard A. Jason
The Fennell Phase Inventory (FPI) is an instrument designed to measure
phases of the illnesses known as Myalgic Encephalomyelitis/chronic
fatigue syndrome (ME/CFS). The current study explored how the FPI was
related to physical and psychological functioning as well as coping style.
Based on FPI scores, 111 adults with ME/CFS were placed in one of three
groups: crisis, stabilization, or resolution. Results showed that the crisis
group demonstrated significantly worse functioning than at least one other
group for depression, quality of life, mental functioning, anxiety, and self-
efficacy; and utilized less adaptive coping styles. These results indicate that
patients with ME/CFS who are in the crisis phase tend to experience more
severe psychological and physical symptoms and utilize poorer coping
strategies. Those in the resolution phase maintain the most adaptive coping
strategies. Implications for these findings are discussed.
Keywords:chronic fatigue syndrome; Myalgic Encephalomyelitis; Myalgic
Encephalopathy; Fennell Phase Inventory; coping
causes significant impairment in physical and psychological functioning.
Due to the disruption in lifestyle caused by ME/CFS, adjustment and coping
hronic fatigue syndrome (CFS), also known as Myalgic Encephalo-
myelitis or Myalgic Encephalopathy (ME), is a devastating illness that
of Allergy and Infectious Diseases(grantnumbers AI36295 and AI49720). Requestsfor reprints,
for Community Research, 990 W. Fullerton Ave., Suite 3100, Chicago, IL, 60614; e-mail:
the Health Professions
Volume 000 Number 00
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# 2009 SAGE Publications
Eval Health Prof OnlineFirst, published on August 20, 2009 as doi:10.1177/0163278709338558
styles used by patients have been researched in relation to illness severity
(Ax, Gregg, & Jones, 1995). Accurate assessment of coping is crucial to any
investigation in this area.
Despite the vast number of self-report assessments of coping that exist,
many have been developed for specific illnesses and cannot be generalized
across different populations of individuals (Parker & Endler, 1992). In addi-
tion, many coping assessments evaluate specific types of coping, or differ-
ent dimensions of the construct (De Ridder, 1997). For issues such as
chronic illness, it may be important to assess both the extent to which a per-
son has adapted to life changes associated with the illness as well as specific
coping styles used by the patients.
The Fennell Phase Inventory (FPI) is an instrument designed to measure
phases of coping typically experienced by individuals with ME/CFS and
their progression through those phases (Jason, Fennell, Taylor, Fricano,
& Halpert, 2000). The FPI was designed as a tool to measure Fennell’s
four-phase model of coping with ME/CFS (Fennell, 1995; Jason, Fennell,
Klein, Fricano, & Halpert, 1999). According to Fennell, the four phases are
described as follows: Phase I, the crisis phase, is characterized by the indi-
vidual entering into a state of emotional crisis after the initial onset of the
illness; Phase II, the stabilization phase, involves the continuation of emo-
tional turmoil as symptoms begin to stabilize; Phase III, the resolution
phase, is described by the individual accepting the ambiguous and chronic
nature of their illness, and beginning to construct meaning out of their expe-
rience; and Phase IV, the integration phase, occurs when the individual
achieves integration between their pre- and post-illness selves, and may
even reach transcendence (Jason et al., 1999).
Dealing with ME/CFS involves a progression of mental and physical
adaptations and adjustments over time, as the affected individual gradu-
ally learns how to deal with and accept their illness and its limitations.
An important difference between the FPI and other stage models of coping
(e.g., Kubler-Ross, 1969) is the flexibility of phases and progression
sequence. Unlike many other models, the FPI takes into account the relap-
sing and remitting nature of ME/CFS, therefore allowing regression of
phases and/or the possibility of fitting into more than one phase at a time
(Jason et al., 1999), as is common with ME/CFS. Although individuals are
expected to move through these four phases in a fixed sequence, this the-
ory is flexible in that it is possible to relapse into previous phases and be in
more than one phase at any given time (Jason et al., 1999). Research indi-
cates that ME/CFS illness duration does not necessarily predict coping
style among patients (Friedberg, Dechene, McKenzie, & Fontanetta,
2 Evaluation & the Health Professions
2000; McKenzie, Dechene, Friedberg, & Fontanetta, 1995), supporting
the assertion that the ME/CFS experience is not linear due to relapses and
Along with the complicated remitting and relapsing nature of ME/CFS,
the illness is also heterogeneous in terms of illness severity. To reduce the
heterogeneity of ME/CFS, it has been suggested that identifying important
subtypes, or subgroups, of patients may be useful (Jason, Corradi, Torres-
Harding, Taylor, & King, 2005). Subgrouping patients based on Fennell
phase may be one way of identifying patients with more severe ME/CFS
symptomatology. Further, the FPI may be useful in identifying subgroups
of patients in terms of coping style. In doing so, potentially more homoge-
neous samples can be obtained for research and treatment purposes.
Preliminary research has explored the relationship between the four
phases assessed by the FPI and ME/CFS symptomatology. It appears that
the crisis phase is associated with the highest level of ME/CFS symptom
severity in comparison to the other phases (Jason, Fricano, et al., 2000).
Other research has found a trend toward improving psychological function-
ing and lessening symptom severity from the crisis to the resolution phase
within a sample of patients with ME/CFS (Van Hoof, Coomans, Cluydts, &
De Meirleir, 2004). Thus, research suggests that ME/CFS symptom severity
declines once patients progress past the crisis phase.
The purpose of this study is to assess the relationship between the Fen-
nell phases and physical and psychological markers of ME/CFS severity to
determine homogeneous subtypes of patients. Further, the current study will
explore the association between coping styles and the four phases. Based
upon previous research (Jason, Fricano, et al., 2000; Van Hoof et al.,
2004), it is hypothesized that patients with ME/CFS who are in the crisis
phase will display higher levels of illness severity in comparison to the
other phases. It is further hypothesized that participants in the crisis phase
will utilize less adaptive coping strategies than those in the stabilization,
resolution, and integration phases.
Participants were recruited for a larger, longitudinal study on nonphar-
macological interventions for ME/CFS (see Jason et al., 2007) from a
variety of sources, including physician referrals, mailings, phone
Reynolds et al. / Fennell Phases in CFS Symptoms3
communication, and study announcements for new participants were placed
in local newspapers and recruitment offers were made atlocal ME/CFS sup-
port group meetings. All participants were required to be at least 18 years of
age, not pregnant, able to read and speak English, and considered to be phy-
sically capable of attending the scheduled sessions. Persons who used
wheelchairs and those who were bedridden or housebound were excluded
due to the practical difficulties of keeping therapy appointments. Referrals
to local physicians who treat ME/CFS and to support groups were offered to
these individuals. After a consent form was filled out, prospective partici-
pants were initially screened using a structured questionnaire. Because
ME/CFS is a diagnosis of exclusion, prospective participants were screened
for identifiable psychiatric and medical conditions that may explain ME/
CFS-like symptoms. These measures were completed at DePaul University
and took approximately 2 hr. After the initial interview was completed, the
patients’ information was reviewed to ensure that they met all eligibility
requirements. All eligible participants attended a medical appointment with
the study physician to confirm the diagnosis of CFS according to the
Fukuda et al. (1994) criteria.
A total of 114 individuals were found to be eligible for the current study.
Forty-six percent were referred by physicians, 34% were recruited by
media, and 20% stemmed from other sources (heard about the study from
a friend, family member, person in the study, etc.). There were no signifi-
cant demographic differences for patients recruited from these varying
sources. In regard to demographic characteristics, 83.3% of the participants
were females. The average age was 43.8 years. Regarding ethnicity, 87.7%
were Caucasian, 4.4% were African American, 4.4% were Latino, and 3.5%
were Asian American. As for marital status, 49.1% were married/ living
with someone, 33.3% were single, and 17.6% were either divorced or sepa-
rated. In terms of work status, 40.4% were working or full-time students,
and 59.6% were not working or were part-time students. In terms of educa-
tion, 47.4% had earned a standard college degree, 21.8% had a graduate or
professional degree, 21.1% had partial college, and 9.7% had a high school/
General Educational Development (GED) degree or less.
Participants completed the CFS questionnaire to collect demographic,
health status, medication usage, symptom data, and assess the definitional
symptoms of CFS (Fukuda et al., 1994). This screening scale was initially
4Evaluation & the Health Professions
validated by Jason et al. (1997). Hawk, Jason, and Torres-Harding (2006)
revised this CFS questionnaire, and administered the questionnaire to three
groups (those with CFS, major depressive disorder, and healthy controls).
The revised instrument, which was used in the current study, evidences
good test?retest reliability and has good sensitivity and specificity.
The CFS questionnaire was designed to assess the diagnostic criteria for
CFS as specified by Fukuda et al. (1994). For each symptom, participants
were asked to indicate whether the symptom had been present for 6 months
or longer, if the symptom began before the onset of their fatigue or health
problems, and how often (never, seldom, often/usually, or always) the
symptom is experienced. Participants were also asked to rate the intensity
of each symptom they endorsed on a scale of 0 to 100, where 0 ¼ no prob-
lem and 100 ¼ the worst problem possible. This is a numerical rating scale
(NRS), which has been shown to be a consistently valid measure of symp-
tom intensity, particularly for pain intensity (Jensen & Karoly, 1992). To
measure the Fukuda et al. (1994) case definition symptoms, items were
designed to measure the presence of the eight minor symptoms (i.e.,
impaired memory or concentration, sore throat, tender lymph nodes, muscle
pain, multi-joint pain, new headaches, unrefreshing sleep, and post-
exertional malaise) as specified by the case definition of Fukuda et al.
Next, the Structured Clinical Interview for Diagnostic and statistical
manual of mental disorders, fourth edition ([DSM-IV] SCID; First, Spitzer,
Gibbon, & Williams, 1995) was used to establish the presence of axis I psy-
chiatric diagnoses. The professionally administered SCID allows for clini-
cal judgment in the assignment of symptoms to psychiatric or medical
categories, a crucial distinction in the assessment of symptoms that overlap
between CFS and psychiatric disorders, e.g., fatigue, concentration diffi-
culty, and sleep disturbance (Friedberg & Jason, 1998). A psychodiagnostic
study (Taylor & Jason, 1998) validated the use of the SCID in a sample of
CFS patients. Because CFS is a diagnosis of exclusion, prospective partici-
pants were screened for identifiable psychiatric and medical conditions that
may explain CFS-like symptoms. These measures were completed at
DePaul University and took approximately 2 hr. After the initial interview
was completed, the patients’ information was reviewed to ensure that they
met all eligibility requirements. If an individual was eligible for the study, a
medical appointment was set up. Conversely, if an individual was not eligi-
ble, we discussed with him or her alternate treatment options.
Finally, a physician screening evaluation was conducted. It included an
in-depth medical and neurological history, as well as general and neurolo-
gical physical examinations. The evaluation also included a structured
Reynolds et al. / Fennell Phases in CFS Symptoms5
instrument, a modified version of the CFS questionnaire (Komaroff et al.,
1996). This instrument assesses the signs, symptoms, and medical history
to rule out other disorders. Relevant medical information was gathered to
exclude possible other medical causes of chronic fatigue, including expo-
sure histories to tuberculosis, AIDS, and non-AIDS sexually transmitted
diseases. Information on prescribed and illicit drug use was also assessed
and recorded. With adult females, results of recent Pap smears and mammo-
grams were obtained. Finally, the histories of all symptoms related to CFS
Laboratory tests in the battery were the minimum necessary to rule out
other illnesses (Fukuda et al., 1994). Laboratory tests included a chemistry
screen (which assesses liver, renal, and thyroid functioning), complete
blood count with differential and platelet count, erythrocyte sedimentation
rate, arthritic profile (which includes rheumatoid factor and antinuclear
antibody), hepatitis B, Lyme Disease screen, HIV screen and urinalysis.
A tuberculin skin test was also performed. Finally, an anterior-posterior
and lateral chest X-ray was conducted if one had not been obtained within
8 months of the study. The project physician performed a detailed medical
examination to detect evidence of diffuse adenopathy, hepatosplenomegaly,
synovitis, neuropathy, myopathy, cardiac, or pulmonary dysfunction.
FPI. The 20-item FPI was administered to each participant, and each
item was rated on a 6-point scale (1 ¼ definitely do not agree, 5 ¼ very
strongly agree). The FPI was factor analyzed in a previous study (Jason,
Fennell, et al., 2000) using two samples. Three distinct factors emerged that
were consistent with crisis, stabilization, and integration phases of Fennell’s
model. Cronbach’s alpha was found to be in the moderate range for the
three factors (0.63 to 0.83). When these scores were used in a cluster anal-
ysis, four clusters emerged measuring a crisis phase, a stabilization phase, a
resolution phase, and an integration phase (Jason, Fennell, et al., 2000).
To score the FPI and place individuals into one of the four phases, mean
scores are first calculated for the crisis, stabilization and integration groups
using scores for particular FPI items. Specifically, the crisis mean score is
calculated using items 1, 5, 9, and 17; the stabilization mean score is calcu-
lated using items 2, 3, 6, 7, 10, 11, 14, 15, 18, and 19; and the integration
mean score is calculated using items 4, 8, 16, and 20. Next, the mean scores
6 Evaluation & the Health Professions
are compared to the scoring rubric developed by Jason, Fricano, et al.
Medical Outcomes Study-Short Form-36 (MOS-SF-36). The MOS-SF-
36, a 36-item broadly based self-report measure of functional status related
to health, identifies eight health concepts as perceived by the individual.
The concepts include physical functioning, social functioning, role-
physical, role-emotional, bodily pain, general health, vitality, and mental
health (Ware & Sherbourne, 1992). Using the eight items of the MOS-
SF-36, a Physical Component Summary and Mental Component Summary
scales can be calculated, which has appropriate validity and reliability as
well as greater sensitivity and specificity in discriminating the gradations
of health status among groups (Brazier et al., 1992). Higher scores indicate
better health or less negative impact on health or functioning. Test construc-
tion studies for the SF-36 (McHorney, Ware, Lu, & Sherbourne, 1994;
McHorney, Ware, & Raczek, 1993) have shown adequate internal consis-
tency, significant discriminate validity among subscales, and substantial
differences between patient and nonpatient populations in the pattern of
scores. For this study, the Physical Component Summary and Mental Com-
ponent Summary were used to rate global physical and mental impairment.
Fatigue Severity Scale (FSS). FSS of Krupp, LaRocca, Muir-Nash, and
Steinberg (1989) was used to measure fatigue. This scale includes 9 items
rated on 7-point scales and is sensitive to different aspects and gradations of
fatigue severity. Most items in the fatigue scale of Krupp et al. (1989) are
related to behavioral consequences of fatigue. Previous findings have
demonstrated the use of the FSS (Krupp et al., 1989) to discriminate
between individuals with ME/CFS, MS, and primary depression (Pepper,
Krupp, Friedberg, Doscher, & Coyle, 1993). Taylor, Jason, and Torres
(2000) found that within a ME/CFS-like group, the FSS (Krupp et al.,
1989) was more closely associated with severity ratings for the eight
Fukuda et al. (1994) ME/CFS symptoms as well as with functional out-
comes related to fatigue.
Beck Depression Inventory (BDI-II). Because depression is the most
commonly diagnosed psychiatric disorder in ME/CFS (Friedberg, 1996),
a quantitative measure of depression severity was used. Depressive symp-
tomatology was measured with the BDI-II (Beck, Steer, & Brown, 1996),
a 21-item self-report instrument with well-established psychometric proper-
ties. This version of the BDI is more consonant with DSM-IV criteria for
Reynolds et al. / Fennell Phases in CFS Symptoms7
major depressive disorder. The BDI-II is the only depression rating scale to
be empirically tested and interpreted for both depressed and nondepressed
patients with ME/CFS (Johnson, DeLuca, & Natelson, 1996).
Beck Anxiety Inventory (BAI). Anxiety symptoms were measured with
the BAI, a 21-item self-report measure with established and replicated con-
struct validity (Hewitt & Norton, 1993; Steer, Clark, Beck, & Ranieri,
1995). Factor analysis of the BAI and BDI yielded a first-order factor
labeled anxiety that had salient loadings for all 21 items on the BAI, but
only one item on the BDI. In addition, there is a high frequency of anxiety
disorders reported in psychodiagnostic studies of ME/CFS (e.g., Pepper
et al., 1993).
Perceived Stress Scale (PSS). The PSS is a 4-item revised version of a
previous 14-item measure of global perceived stress that measures the per-
ceived stress for the pervious month (Cohen, Kamarck, & Mermelstein,
1983). The authors report a coefficient alpha reliability of .72 for the 4-
item short version. The total score (indication of total stress) was used in
the current study, with scores ranging from 0?16, with higher scores mea-
suring more stress.
Self Efficacy Scale (SES). This is a measure of how much control a per-
son feels with respect to ME/CFS complaints. The ratings from each of the
five questions are added, and higher scores indicate higher levels of self-
efficacy. Cronbach’s alpha reliability range from .70 to .77 (Prins et al.,
Quality of Life Scale (QLS). The QLS measures satisfaction with differ-
ent life activities for individuals with various chronic illnesses (Burckhardt
& Anderson, 2003). The scale consists of 16 items answered on a 1 to 7
scale which measure six conceptual domains of quality of life: material and
physical well-being; relationships with other people; social, community and
civic activities; personal development and fulfillment; recreation; and inde-
pendence. Higher scores mean more overall life satisfaction. This scale
demonstrated high test?retest reliability for this 16-item scale, and conver-
gent and discriminate construct validity in groups of individuals with vari-
ous stable chronic illness, including post ostomy surgery, osteoarthritis,
rheumatoid arthritis, fibromyalgia, COPD, and insulin-dependent diabetes
(Burckhardt & Anderson, 2003).
8 Evaluation & the Health Professions
Brief-COPE (bCOPE). This inventory assesses how participants are cop-
ing with the stress in their lives (Carver, 1997). It is derived from the Coping
Orientation to Problems Experienced Scale (COPE; Carver, Scheier, &
Weintraub, 1989), which consists of conceptually distinct problem-focused
coping and conceptually distinct emotion-focused coping scales. This instru-
ment has been validated and has adequate reliability. There are 28 items con-
cerning ways of coping, and each is rated on a 4-point scale (anchor points
ranging from not engaging in the coping strategy to engaging a lot). There
are 14 coping methods found in these 28 items; the scales are as follows:
self-distraction, active coping, denial, substance use, use of emotional sup-
port, use of instrumental support, behavioral disengagement, venting, posi-
tive reframing, planning, humor, acceptance, religion, and self-blame.
There are 2 items for each of these14 coping methods; the sum of the 2 items
is the score for that particular coping method. Adequate psychometric prop-
erties of this instrument have been found (Carver, 1997).
Brief Pain Inventory (BPI). The BPI (Cleeland & Ryan, 1994) was admi-
nistered to measure the intensity of pain (pain severity) and the interference
of pain in the patient’s life (pain interference). Higher scores indicate more
severe levels of persistent pain and higher levels of interference with func-
tioning. This measure exhibits adequate levels of reliability to assess pain in
noncancer samples, with coefficient alphas of .70 and above, also evidences
good concurrent validity with other generic pain measures, and has been
shown to be sensitive to changes in pain status over time (Keller et al.,
Participants were placed into groups based on which of the four phases
they were found to be in as measured by the FPI. In our sample, we had 32
participants who fell into the crisis phase, 37 in the stabilization phase, 39 in
the resolution phase, and 3 in the integration phase. Due to the limited num-
ber of participants in the Integration group, this group was excluded from
analyses. No significant differences in age, race, gender, marital status, or
duration of ME/CFS illness was found between the three groups. However,
a chi-square analysis revealed a significant difference between the groups for
work status1(working vs. not working) w2(2, N ¼ 108) ¼ 6.52, p ¼ .04.
Reynolds et al. / Fennell Phases in CFS Symptoms9
The stabilization group had the highest percentage of participants who were
working (54.1%), followed by the crisis group (43.8%), and the resolution
Using one-way analysis of variance (ANOVA) and Bonferroni post hoc
analyses for multiple comparisons, the scores on the mental, physical, and
coping measures were compared across the crisis, stabilization and resolu-
tion groups. Due to the large number of dependent variables in the current
study, we considered using multivariate analysis of variance (MANOVA).
However, the inter-correlations among our dependent variables were not
sufficiently correlated to warrant the use of MANOVA. Thus, multiple
one-way ANOVAs were used, with a cutoff of p < .01 to indicate significant
effects to control for type I error.
Physical and Psychological Measures. One-way ANOVAs revealed sig-
nificant overall effects for the BDI, F(2, 107) ¼ 12.16, p < .001, the Mental
Component Summary (of the SF-36), F(2, 105) ¼ 11.48, p < .001, and the
Quality of Life Scale, F(2, 99) ¼ 9.38, p < .001. Table 1 shows the results
from the Bonferroni post hoc analyses such that significant differences
Means (and Standard Deviations) for Physical and Psychological
(n ¼ 32)
(n ¼ 37)
(n ¼ 39)
Beck Depression Inventorya
Beck Anxiety Inventorya
Physical Component Summaryb
Mental Component Summaryb
Fatigue Severity Scalea
Perceived Stress Scalea
Quality of Life Scaleb
Brief Pain Inventory-Severitya
Brief Pain Inventory-Interferencea
aLower numbers are better.
bHigher numbers are better.
cSuperscript indicates a significant difference between the crisis and stabilization phases.
dSuperscript indicates a significant difference between the crisis and resolution phases.
eSuperscript indicates a significant difference between the stabilization and resolution phases.
10 Evaluation & the Health Professions
between groups are denoted with the same superscript. Results from the
post hoc analyses revealed the crisis group demonstrated significantly
worse scores on these measures compared to both the stabilization and res-
olution groups. Overall significant differences were found for the BAI, F(2,
107) ¼ 6.84, p < .001 and the Self-Efficacy Scale, F(2, 107) ¼ 7.26, p <
.001. The crisis group evidenced significantly more anxiety than the stabi-
lization group. In addition, the crisis group evidenced significantly lower
self-efficacy than the resolution group. A significant overall effect across
groups was found for the Physical Component Summary (of the SF-36),
F(2, 105) ¼ 4.91, p ¼ .01, and post hoc analyses revealed the stabilization
group demonstrated significantly higher scores on this measure than the res-
olution group. Scores on the Perceived Stress Scale approached an overall
significant effect, F(2, 107) ¼ 3.93, p ¼ .02, with the resolution group scor-
ing higher than the stabilization group on this scale. The BPI-Interference
scale approached an overall significant effect, F(2, 101) ¼ 4.16, p ¼ .02,
with the resolution group reporting more pain interference than the stabili-
zation group. However, findings for the Perceived Stress Scale and BPI
were not significant at the p < .01 level. There were no significant overall
effects on the Fatigue Severity Scale, F(2, 107) ¼ 1.83, p ¼ .17 or the
BPI-Severity scale, F(2, 102) ¼ 2.11, p ¼ .13.
The Brief COPE scales. A series of one-way ANOVAs revealed signif-
icant differences for the following bCOPE subscales: denial, F(2, 105) ¼
11.32, p < .001, behavioral disengagement, F(2, 104) ¼ 5.73, p < .001, and
acceptance, F(2, 105) ¼ 10.87, p < .001 (See Table 2). Bonferroni post hoc
analyses revealed the crisis group performed significantly worse than both
the stabilization and resolution groups on these subscales. An overall effect
was also found for emotional support, F(2, 105) ¼ 5.08, p ¼ .01, in which
the crisis group was found to have obtained significantly lower scores than
the resolution group. Overall significant effects were also revealed for the
following five subscales: self-distraction, F(2, 105) ¼ 6.78, p < .001,
active-coping, F(2, 105) ¼ 6.09, p < .001, instrumental support, F(2,
105) ¼ 8.70, p < .001, positive-reframing, F(2, 105) ¼ 17.72, p < .001, and
planning, F(2, 105) ¼ 8.78, p < .001. For these subscales, the resolution
group demonstrated significantly higher scores than both the crisis and sta-
bilization groups. Trends toward significant effects were found for humor,
F(2, 105) ¼ 3.46, p ¼ .04, in which the crisis group was found to have
obtained lower scores than the resolution group; and for self-blame F(2,
105) ¼ 3.97, p ¼ .02, in which the crisis group showed higher scores than
the resolution group for this subscale. There was no overall significant
Reynolds et al. / Fennell Phases in CFS Symptoms 11
effects for the following subscales: substance use, F(2, 104) ¼ .34, p ¼ .73,
venting, F(2, 105) ¼ 2.83, p ¼ .06, or religion, F(2, 105) ¼ .80, p ¼ .45.
Findings indicate that the FPI is a valuable tool in ME/CFS assessment.
As hypothesized, the crisis group demonstrated the poorest functioning for
depression, anxiety, the Mental Component Summary of the SF-36, self-
efficacy, and quality of life. However, despite differences in psychological
functioning, the groups did not significantly differ in terms of perceived
stress. Interestingly, fatigue severity and pain (interference and severity),
two integral parts of the ME/CFS process, did not demonstrate significant
differences between any of the Fennell groups. This finding may suggest
that fatigue is a symptom that is relatively stable throughout the four phases,
and pain severity and interference remains relatively high throughout the
various stages, perhaps being mitigated by different factors, unrelated to
Means (and Standard Deviations) for Coping Measuresa
Crisis (n ¼ 32)
Stabilization (n ¼ 37) Resolution (n ¼ 39)
aHigher numbers indicate more use of coping strategy.
bSuperscript indicates a significant difference between the crisis and resolution phases.
cSuperscript indicates a significant difference between the stabilization and resolution phases.
dSuperscript indicates a significant difference between the crisis and stabilization phases.
12 Evaluation & the Health Professions
Alternatively, the FPI may simply be a better measure of psychological
adaptation to ME/CFS than physical adaptation. While our results showed
the crisis group having poorer overall psychological functioning compared
to the other two groups, the crisis group did not reveal increased physical
disability in terms of fatigue, pain, or overall physical functioning. There-
fore, our results demonstrate that physical limitations of the illness are not
necessarily related to Fennell phase.
However, we did find that scores on the Physical Component Summary,
which measures the level of physical functioning, were significantly better
for those in the stabilization phase than the resolution phase. This finding is
consistent with previous research reporting that those in the stabilization
group revealed the highest level of functioning across the four Fennell
groups (Jason, Fricano, et al., 2000). The stabilization group also had the
highest percentage of participants who were working. Patients with ME/
CFS often experience remission and relapse of symptoms, and the FPI
appears to measure how they will respond psychologically to the inconsis-
tent and unpredictable nature of their illness. It is possible that patients in
the stabilization phase perceive improved physical ability after experien-
cing a period of crisis and are attempting to regain normalcy in their lives
by returning to work. In contrast, those in the Resolution phase are at a point
where they have accepted the ambiguous and chronic nature of their illness
and have begun to psychologically adapt to their physical limitations. It
should be noted that even though the stabilization group demonstrated
higher scores on the Physical Component Summary than the resolution
group, scores on this measure were significantly low across all groups
(ranging from 24.52 to 29.86, out of a possible 100), indicating that those
in the stabilization group were still highly disabled.
In terms of coping style, most of the bCOPE subscales demonstrated sig-
nificant differences between the three Fennell groups. Our hypothesis that
individuals in the crisis phase would utilize less adaptive coping strategies
wassupported, asthisgroup ofparticipants was found to use denialand beha-
vioral disengagement significantly more often than both of the other groups.
In addition, a trend was found for the crisis group utilizing significantly more
self-blame than those in the resolution group. Further, in comparison to at
least one of the other two groups, the crisis group demonstrated significantly
lower use of coping strategies that are considered to be more adaptive includ-
ing active coping, emotional and instrumental support, positive reframing,
planning, and acceptance. Thus, it appears that individuals who are assessed
to be in the crisis phase of illness adjustment use different coping strategies
than those who are in the stabilization or resolution phases.
Reynolds et al. / Fennell Phases in CFS Symptoms 13
Despite our results showing that individuals in the stabilization phase
have higher levels of physical functioning in comparison to the resolution
group, our findings demonstrate that individuals in the latter group display
more adaptive coping strategies than the former. The resolution group used
significantly more active coping, instrumental support, positive reframing,
and planning than the stabilization group. This finding is consistent with
previous research indicating that individuals in the resolution group may
often be in a relapse phase of ME/CFS but are better able to cope with their
symptoms (Jason, Fricano, et al., 2000). Work status may be an additional
indicator that more individuals in the resolution group may be experiencing
relapse, as our results showed that the resolution group had the lowest fre-
quency of employment. However, previous research indicates that patients
with ME/CFS who use better coping strategies tend to make accommoda-
tions to their illness, such as reducing or removing the burden of employ-
ment (Friedberg et al., 2000). The enhanced coping abilities found in the
resolution group is consistent with the conceptualization of this group as
better psychologically adapted to the ME/CFS illness process.
One limitation of this study was the small number of participants who
fell into the integration group. However, this is consistent with previous
research demonstrating that few individuals with ME/CFS are in the inte-
gration phase of illness (Jason, Fricano, et al., 2000; Van Hoof et al.,
2004). Consistent with these previous studies, we removed the integration
group from analysis. It has been suggested that participant recruitment from
primary or tertiary care facilities may be responsible for the difficulty
recruiting participants in the integration phase, as patients who have
advanced to the integration phase may be less likely to be actively seeking
treatment for ME/CFS (Jason, Fricano, et al., 2000; Van Hoof et al., 2004).
In addition, this is a cross-sectional analysis of individuals in different
phases of the ME/CFS illness experience, and how individuals cope over
time was not explored, but would be a valuable future direction for research
in this area.
Findings from this study indicate that there may be differences in how
people with ME/CFS experience and cope with their illness when in differ-
ent phases of adjustment to the illness. Further, we replicated previous
research suggesting individuals in the crisis phase experience more severe
psychological symptoms (Jason, Fricano, et al., 2000). Understanding cop-
ing and illness characteristics is vital to the assessment and treatment of
ME/CFS. Additional research is warranted to determine how physical dis-
ability is experienced by individuals in different FPI phases. Further under-
standing these phases will have important clinical implications for
14 Evaluation & the Health Professions
treatment because patients in different phases may respond better to inter-
ventions tailored to their phase. Research in treatment development will
benefit from subgrouping patients based on Fennell phase because more
homogeneous groups can be identified and analyzed. ME/CFS is a complex
illness to assess and treat based on the variety of symptoms experienced and
the progression of the illness itself, and it is important to have a more com-
plete picture of coping capabilities of the patient to appropriately develop
treatment strategies for individuals in various phases of ME/CFS.
1. All analyses were conducted with work status as a covariate. All significant outcome
variables remained significant at the p < .05 level, with the exception of the physical compo-
nent summary, F(2, 105) ¼ 2.96, p ¼ .06, when work status was included as a covariate. We
did not include work status as a covariate for the main report of our analyses because work
status may, in fact, represent an outcome variable rather than a covariate.
Ax, S., Gregg, V. H., & Jones, D. (2002). Coping and illness cognitions: Chronic fatigue syn-
drome. Clinical Psychology Review, 21, 161-182.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-
II. San Antonio, TX: Psychological Corporation.
Brazier, J. E., Harper, R., Jones, N. M. B., O’Cathain, A., Thomas, K. J., Usherwood, T., et al.
(1992). Validating the SF-36 Health Survey Questionnaire. Quality of Life Research, 2,
Burckhardt, C. S., & Anderson, K. L. (2003). The Quality of Life Scale (QOLS): Reliability,
validity, and utilization. Health and Quality of Life Outcomes, 1, 60.
Carver, C. S. (1997). If you want to measure coping but your protocol’s too long: Consider the
brief COPE. International Journal of Behavioral Medicine, 4, 92-100.
Carver, C. S., Scheier, M. F., & Weintraub, J. K. (1989). Assessing coping strategies: A the-
oretically based approach. Journal of Personality and Social Psychology, 56, 267-283.
Cleeland, C. S., & Ryan, K. M. (1994). Pain assessment: Global use of the Brief Pain Inven-
tory. Annals of the Academy of Medicine, Singapore, 23, 129-138.
Cohen, S., Kamark, T., & Mermelstein, R. (1983). A global measure of perceived stress. Jour-
nal of Health and Social Behavior, 37, 147-153.
De Ridder, D. (1997). What is wrong with coping assessment? A review of conceptual and
methodological issues. Psychology and Health, 12, 417-431.
Fennell,P. A. (1995).The four progressive stages of the ME/CFSexperience: A coping tool for
patients. Journal of Chronic Fatigue Syndrome, 1, 69-79.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995). Structured clinical inter-
view for DSM-IV axis i disorders, clinician version (SCID-CV). Washington, DC: Amer-
ican Psychiatric Press.
Reynolds et al. / Fennell Phases in CFS Symptoms 15
Friedberg, F. (1996). Chronic fatigue syndrome: A new clinical application. Professional Psy-
chology: Research and Practice, 27, 487-494.
Friedberg, F., Dechene, L., McKenzie M. II & Fontanetta, R, (2000). Symptom patterns in
long-duration chronic fatigue syndrome. Journal of Psychosomatic Research, 48, 59-68.
Friedberg, F., & Jason, L. A. (1998). Chronic fatigue syndrome and fibromyalgia: Clinical
assessment and treatment. Journal of Clinical Psychology, 57, 433-455.
Fukuda, K., Straus, S. E., Hickie, I., Sharpe, M. C., Dobbins, J. G., & Komaroff, A. (1994). The
chronic fatigue syndrome: A comprehensive approach to its definition and study. Annals of
Internal Medicine, 121, 953-959.
Hawk, C., Jason, L. A., & Torres-Harding, S. (2006). Differential diagnosis of chronic fatigue
syndrome and major depressive disorder. International Journal of Behavioral Medicine,
Hewitt, P. L., & Norton, G. R. (1993). The Beck Anxiety Inventory: A psychometric analysis.
Psychological Assessment, 5, 408-412.
Jason, L. A., Corradi, K., Torres-Harding, S., Taylor, R. R., & King, C. (2005). Chronic fatigue
syndrome: The need for subtypes. Neuropsychology Review, 15, 29-58.
Jason, L. A., Fennell, P. A., Klein, S., Fricano, G., & Halpert, J. (1999). An investigation
of the different phases of the ME/CFS illness. Journal of Chronic Fatigue Syndrome,
Jason, L. A., Fennell, P. A., Taylor, R. R., Fricano, G., & Halpert, J. (2000). An empirical
verification of the Fennell phases of the ME/CFS illness. Journal of Chronic Fatigue Syn-
drome, 6, 47-56.
Jason, L. A., Fricano, G., Taylor, R., Halpert, J., Fennell, P. A., Klein, S., et al. (2000). Chronic
fatigue syndrome: Anexamination ofthe phases. Journal of Clinical Psychology, 56,1497-
Jason, L. A., Ropacki, J. A., Santoro, N. B., Richman, J. A., Heatherly, W., Taylor, R., et al.
(1997). A screening scale for chronic fatigue syndrome: Reliability and validity. Journal of
Chronic Fatigue Syndrome, 3, 39-59.
Jason, L. A., Torres-Harding, S., Friedberg, F., Corradi, K., Njoku, M. G., Donalek, J., et al.
(2007). Non-pharmacologic interventions for ME/CFS: A randomized trial. Journal of
Clinical Psychology in Medical Settings, 275-296.
Jensen, M., & Karoly, P. (1992). Self report scales and procedures for assessing pain in adults.
In D. C. Turk, & R. Meizack (Eds.), Handbook of pain assessment (pp. 135-151). New
York: The Guilford Press.
Johnson, S. K., DeLuca, J., & Natelson, B. (1996). Depression in fatiguing illness: Comparing
patients with chronic fatigue syndrome, multiple sclerosis and depression. Journal of
Affective Disorders, 39, 21-30.
Keller, S., Bann, C., Dodd, S., Schein, J., Mendoza, T. R., & Cleeland, C. (2004). Validity of
the Brief Pain Inventory for use in documenting the outcomes of patients with noncancer
pain. Clinical Journal of Pain, 20, 309-318.
Komaroff, A. L., Fagioli, L. R., Geiger, A. M., Doolittle, T. H., Lee, J., Kornish, J., et al.
(1996). An examination of the working case definition of chronic fatigue syndrome. Amer-
ican Journal of Medicine, 100, 56-64.
Krupp, L. B., LaRocca, N. G., Muir-Nash, J. & Steinberg, A. D. (1989). The Fatigue Severity
Scale: Application to patients with multiple sclerosis and systemic Lupus erythematosus.
Archives of Neurology, 46, 1121-1123.
Kubler-Ross, E. (1969). On death and dying. New York: Macmillan.
16Evaluation & the Health Professions
McHorney, C. A., Ware, J. E., & Raczek, A. E. (1993). The MOS 36-Item Short-Form Health Download full-text
Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and
mental health constructs. Medical Care, 31, 247-263.
McHorney, C. A., Ware, J. E., Lu, A. W., & Sherbourne, C. D. (1994). The MOS 36-item
Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and
reliability across diverse patient groups. Medical Care, 32, 40-66.
McKenzie M. II, Dechene, L, Friedberg, F., & Fontanetta, R. (1995). Coping reports ofpatients
with long-term chronic fatigue syndrome. Journal of Chronic Fatigue Syndrome, 1, 59-67.
Parker, J. D., & Endler, N. S. (1992). Coping with coping assessment: A critical review. Eur-
opean Journal of Personality, 6, 321-344.
Pepper, C. M., Krupp, L. B., Friedberg, F., Doscher, C., & Coyle, P. K. (1993). A comparison
of neuropsychiatric characteristics in chronic fatigue syndrome, multiple sclerosis, and
major depression. The Journal of Neuropsychiatry and Clinical Neurosciences, 5, 200-205.
Prins, J. B., Bleijenberg, G., Bazelmans, E., Elving, L. D., De Boo, T. M., Severens, J. L., et al.
(2001). Cognitive behaviour therapy for chronic fatigue syndrome: A multicenter rando-
mized controlled trial. Lancet, 357, 841-847.
Steer, R. A., Clark, D. A., Beck, A. T., & Ranieri, W. F. (1995). Common and specific dimen-
sions of self-reported anxiety and depression: A replication. Journal of Abnormal Psychol-
ogy, 104, 542-545.
Taylor, R. R., & Jason, L. A. (1998). Comparing the DIS with the SCID: Chronic fatigue syn-
drome and psychiatric comorbidity. Psychology and Health, 13, 1087-1104.
Taylor, R. R., Jason, L. A., & Torres, S. (2000). Fatigue rating scales: an empirical comparison.
Psychological Medicine, 30, 849-856.
Van Hoof, E., Coomans, D., Cluydts, R., & De Meirleir, K. (2004). Association between Fen-
nell Phase Inventory scores and immune and RNase-L parameters in chronic fatigue syn-
drome. Journal of Chronic Fatigue Syndrome, 12, 19-34.
Ware, J. E., & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey. Medical
Care, 30, 473-483.
Reynolds et al. / Fennell Phases in CFS Symptoms 17