Original Articles
Illness beliefs and treatment outcome in chronic fatigue syndrome

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Abstract

Longitudinal studies have shown that physical illness attributions are associated with poor prognosis in chronic fatigue syndrome (CFS). Speculation exists over whether such attributions influence treatment outcome. This study reports the effect of illness beliefs on outcome in a randomized controlled trial of cognitive-behavior therapy versus relaxation. Causal attributions and beliefs about exercise, activity, and rest were recorded before and after treatment in 60 CFS patients recruited to the trial. Physical illness attributions were widespread, did not change with treatment, and were not associated with poor outcome in either the cognitive-behavior therapy group or the control group. Beliefs about avoidance of exercise and activity changed in the cognitive behavior therapy group, but not in the control group. This change was associated with improved outcome. These findings suggest that physical illness attributions are less important in determining outcome (at least in treatment studies) than has been previously thought. In this study, good outcome is associated with change in avoidance behavior, and related beliefs, rather than causal attributions.

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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