Original ArticlesIllness beliefs and treatment outcome in chronic fatigue syndrome
Introduction
Chronic fatigue syndrome (CFS) is a disabling condition of unknown origin. Despite medical uncertainty over cause, most CFS sufferers seen in specialist clinics believe themselves to have a physical illness caused by a virus 1, 2, 3, 4, 5, 6, 7, 8, 9. Such attributions are of interest because they have been associated with poor prognosis in several longitudinal and naturalistic studies of CFS 7, 8, 9, 10.
If physical illness attributions are associated with worse outcome, there may be a case for altering physical illness attributions through treatments such as cognitive-behavioral therapy [9]. A randomized, controlled trial, which found brief graded activity to be ineffective for CFS [11] has been criticized for failing to challenge physical illness attributions [12]. In contrast, another randomized, controlled trial found CBT (cognitive restructuring with graded activity) to be superior to standard medical care [13]. The efficacy of treatment in this study was ascribed to its emphasis on reevaluating illness beliefs. Others have questioned this interpretation, arguing that the attributions of patients in the study did not actually change substantially, and the essential therapeutic ingredient was altering avoidance behavior [14].
This study reports the role of physical illness attributions and beliefs about avoidance of exertion in outcome for CFS patients enrolled in a randomized, controlled trial of CBT versus relaxation [15]. The hypotheses were that: (a) physical illness attributions would not change with treatment, and would not affect outcome; (b) beliefs about avoidance would change more in the CBT group than in the control group, and such changes would be associated with good outcome.
Section snippets
Subjects and procedures
Sixty patients attending a fatigue clinic who met criteria for CFS 16, 17 were randomized to 13 sessions of either CBT or a control treatment of relaxation (30 patients per group). Twenty-seven CBT patients and 26 relaxation patients completed treatment, and were followed-up for 6 months after treatment ended. Subjects were typical of CFS patients seen in specialist settings, with long illness duration, marked fatigue, and disability. Full details of the trial have been published elsewhere [15].
Causal attributions before and after treatment
Answers to the open-ended question, “What do you think caused your illness?” were grouped into the categories shown in Table I. At pre- and posttreatment, around three-fourths of the entire group held physical illness attributions. Some cited a viral illness alone; others cited a virus combined with other factors: failure to rest, stress, overwork, overactivity, and/or lifestyle. One tenth of the group attributed their illness to stress, overactivity, or lifestyle alone. One fifth either did
Discussion
The main findings of this study were:
- 1.
Physical illness attributions did not change, and did not affect outcome in either the CBT or the relaxation group.
- 2.
Nonphysical attributions were just as likely to be associated with beliefs about avoidance as physical illness attributions. At pretreatment, beliefs about avoidance of exercise and reduction of activity were widely held, irrespective of causal attribution.
- 3.
At posttreatment, fewer CBT than relaxation patients agreed that they should avoid
Acknowledgements
Acknowledgments—This study was funded by South East Thames Regional Health Authority Locally Organised Research Scheme. The authors thank Dr. T. Hedrick for her helpful comments.
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