The central role of cognitive processes in the perpetuation of chronic fatigue syndrome
Expert Centre Chronic Fatigue, Radboud University Nijmegen Medical Centre, 6500 HB Nijmegen, The Netherlands. Journal of psychosomatic research
(Impact Factor: 2.74).
05/2010; 68(5):489-94. DOI: 10.1016/j.jpsychores.2010.01.022
Chronic fatigue syndrome (CFS) is considered to be one of the functional somatic syndromes (FSS). Cognitions and behavior are thought to perpetuate the symptoms of CFS. Behavioral interventions based on the existing models of perpetuating factors are quite successful in reducing fatigue and disabilities. The evidence is reviewed that cognitive processes, particularly those that determine the perception of fatigue and its effect on behavior, play a central role in the maintenance of symptoms.
Findings from treatment studies suggest that cognitive factors mediate the positive effect of behavioral interventions on fatigue. Increased fitness or increased physical activity does not seem to mediate the treatment response. Additional evidence for the role of cognitive processes is found in studies comparing the subjective beliefs patients have of their functioning with their actual performance and in neurobiological research.
Three different cognitive processes may play a role in the perpetuation of CFS symptoms. The first is a general cognitive representation in which fatigue is perceived as something negative and aversive and CFS is seen as an illness that is difficult to influence. The second process involved is the focusing on fatigue. The third element is formed by specific dysfunctional beliefs about activity and fatigue.
Available from: Andreas Schröder
- "Cognitive behavioural therapy (CBT) is the best documented treatment for a wide range of FSS    . However, it is less investigated how, why and when CBT works, and several studies have called for more mediation research within this area    . Currently, a limited number of studies have examined mediators of change in FSS treatments , all of which emphasize the role of illness-related cognitions          . "
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Although there is substantial evidence that cognitive behavioural therapy alleviates symptoms in functional somatic syndromes, the mechanisms of change are less investigated. This study examined whether changes in illness perceptions mediated the effect of cognitive behavioural therapy.
We analysed additional data from a randomised controlled trial comparing completers of cognitive behavioural group therapy (46 patients) to an enhanced usual care group (66 patients). Proposed mediators (illness perceptions) and primary (physical health) and secondary (somatic symptoms and illness worry) outcomes were assessed by means of questionnaires at referral, baseline, end of treatment, and 10 and 16 months after randomisation. Multiple mediation analysis determined whether (1) changes in specific illness perceptions during treatment mediated the effect of cognitive behavioural therapy (primary analysis), and (2) whether changes in illness perceptions during the whole trial period were associated with improved outcome (secondary analysis).
Improvements in illness perceptions during treatment partially mediated the effect of cognitive behavioural therapy on physical health one year after treatment (sum of indirect effects 1.556, BCa 95% CI (0.006; 3.620)). Improving perceived control was particularly important. Changes in illness perceptions from baseline to 16 months after randomisation were associated with clinically meaningful improvements in physical health, somatic symptoms and illness worry during the same period.
Our results suggest that changing patients' illness perceptions is an important process in cognitive behavioural therapy for functional somatic syndromes. Challenging patients' own understanding of their illness may hence be a key element of successful treatment.
Available from: Arno van Dam
- "Volgens een eerste theoretische opvatting, zouden burn-out patiënten hun vermoeidheid op een bepaalde manier beleven. Verschillende auteurs geven aan dat een bepaalde beleving van vermoeidheid bij mensen chronische vermoeidheidsklachten kan leiden tot mindere prestaties (Afari & Buchwald, 2003; Deluca, 2005; Knoop et al., 2010). Door de aandacht te richten op vermoeidheidssignalen en te denken dat inspanning tijdens vermoeidheid schadelijks is of te denken dat inspanning weinig zal opleveren, neemt de bereidheid om zich in te spannen af. "
- "The finding that the subjective and objective measures of cognition were not related in people with CFS is compatible with those of previous studies (Ray et al., 1993;Short et al., 2002;Vercoulen et al., 1998;Wearden & Appleby, 1997). It has been suggested that people with CFS may overestimate their cognitive problems (e.g.,Knoop et al., 2010;Short et al., 2002;Wearden & Appleby, 1996). However, this is not supported by Metzger and Denney (2002), Wearden and Appleby (1997), or the current study, in which the CFS group accurately evaluated their performance on two out of three tests, which was better than the controls. "
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The purpose of this study was to examine the relationship between subjective and objective assessments of memory and attention in people with chronic fatigue syndrome (CFS), using tests that have previously detected deficits in CFS samples and measures of potential confounds.
Fifty people with CFS and 50 healthy controls were compared on subjective (memory and attention symptom severity, Cognitive Failures Questionnaire, Everyday Attention Questionnaires) and objective (California Verbal Learning Test, Rey-Osterreith Complex Figure Test, Paced Auditory Serial Addition Test, Stroop task) measures of memory and attention. Fatigue, sleep, depression, and anxiety were also assessed.
The CFS group reported experiencing more cognitive problems than the controls, but the two groups did not differ on the cognitive tests. Scores on the subjective and objective measures were not correlated in either group. Depression was positively correlated with increased severity of cognitive problems in both the CFS and control groups.
There is little evidence for a relationship between subjective and objective measures of cognitive functioning for both people with CFS and healthy controls, which suggests that they may be capturing different constructs. Problems with memory and attention in everyday life are a significant part of CFS. Depression appears to be related to subjective problems but does not fully explain them.
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