In search of a new balance. Can high “action-proneness” in patients with chronic fatigue syndrome be changed by a multidisciplinary group treatment?

doi:10.1016/j.jpsychores.2005.12.006

Journal of Psychosomatic Research

Volume 60, Issue 6, June 2006, Pages 623-625

https://doi.org/10.1016/j.jpsychores.2005.12.006 Get rights and content

Abstract

Objective

The purpose of this study is to investigate changes in action-proneness (a cognitive and behavioral tendency toward direct action) after a multidisciplinary group intervention, including cognitive behaviour therapy (CBT) and graded exercise therapy (GET).

Methods

Patients with chronic fatigue syndrome (n=62) completed three versions of a Dutch self-report questionnaire evaluating action-proneness retrospectively that is (1) before illness onset, (2) before treatment and (3) after treatment. Significant others (n=62) also gave their opinion about the patients' action-proneness at time points 1 and 2.

Results

Premorbid action-proneness levels considerably dropped after illness onset. After treatment, action-proneness levels significantly increased again, although levels remained below premorbid levels.

Conclusion

High action-proneness retrospectively reported by CFS patients can be adaptively modified by a multidisciplinary group treatment including CBT and GET.

Introduction

Chronic fatigue syndrome (CFS) is a distressing and potentially disabling illness characterized by persistent medically unexplained fatigue, muscular and articular pains, postexertional malaise, and other nonspecific symptoms [1]. A clear cause of the condition is not established, although the pathophysiology of CFS (and the largely overlapping fibromyalgia syndrome) may be based on subtle stress system malfunctions [2].

Many authors believe that since a direct curative treatment for CFS is not available, recovery may be facilitated when patients realistically adapt to their current limitations, at the same time, trying to progressively increase their physical and mental effort tolerance [2]. In a systematic review, both cognitive behavior therapy (CBT) and graded exercise therapy (GET) have been considered evidence-based methods to obtain these goals [3].

In our previous research, we investigated the possible etiopathogenetic role of an “overactive” lifestyle in CFS, which we operationalized as high “action-proneness,” that is, a cognitive and behavioral tendency toward direct action [4]. Maladaptive overactivity patterns may not only precede the illness but may persist after illness onset (e.g., periodic outbursts of activity followed by prolonged periods of rest), constituting an important perpetuating factor [5].

The aim of the present study was to investigate whether, and to which degree, adaptive changes in beliefs, attitudes, and intentions concerning (over)activity occur in CFS patients participating in a multidisciplinary CBT- and GET-based treatment program. The study was part of a larger outcome study, the results of which are reported elsewhere [6].

Section snippets

Participants

Sixty-two consecutively admitted patients (55 female and 7 male, mean age=39.03 years, S.D.=8.61) participated in the study. The majority (87%) had at least higher secondary education, and 80% were married or living together. Only two patients dropped out before the end of the treatment.

Each patient was sent to our CFS Reference Centre at the University Hospitals Leuven by his/her general practitioner. At the end of the multidisciplinary diagnostic screening, a CFS diagnosis was based on the

Results

As shown in Table 1, Table 2, the patients' pretreatment action-proneness levels (M=17.75, S.D.=6.21) were significantly lower than premorbid levels (M=38.27, S.D.=6.65, P<.001). On the other hand, posttreatment action-proneness levels (M=20.23, S.D.=4.65) were significantly higher than pretreatment levels (P=.03) but still significantly lower than premorbid levels (P<.001).

The SOs scored the patients' pretreatment action-proneness also as lower (M=19.95, S.D.=6.97) than the patients' premorbid

Discussion

First, the results of this study are in line with our previous findings that CFS patients describe themselves, before illness onset, as highly “action-prone” [4]. Moreover, as in our former research [5], patients' self-descriptions were paralleled by the opinion of their SOs.

Second, after illness onset, patients' reported action-proneness levels strongly decreased—an expected finding that could be considered a consequence of symptoms and illness-related functional limitations.

Third, when at the

Acknowledgment

The authors thank the team members of the CFS Reference Centre of the University Hospitals Leuven for their help in the collection of data.

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Self-criticism is increasingly conceptualized as a transdiagnostic factor that may play a key role in explaining the high comorbidity between depressive symptoms and FSS [36,37]. Specifically, self-criticism has been shown to be associated with a pattern of over-activity and persistence [38–41], which may lead to a crash of the stress system, typical of both depression [42–45] and functional somatic disorders [38,46–49], because of the ‘wear and tear’ caused by chronic stress and over-activity. In this regard it is also important to consider that self-criticism and both depressive symptoms and FSS share important environmental factors, such as early childhood adversity [50–53] and dysfunctional (e.g., cold and controlling) parenting [54–56].
Coping with fibromyalgia using cognitive-behavioral therapy: Clinical case study "mrs L."
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Les patients souffrant de fibromyalgie rapportent avoir eu un style de vie prémorbide comme « très dynamique, avec des journées très remplies, avec l’impossibilité de s’arrêter et le besoin d’aller jusqu’à l’épuisement en dépassant leurs limites ». Cette propension excessive à l’action (« ergomanie » ou « workaholism ») constitue à la fois un facteur de risque, facteur précipitant et un facteur d’entretien de la douleur fibromyalgique, entraînant fatigue et incapacité fonctionnelle. Ainsi, les patients fibromyalgiques peuvent finir par éviter toute activité physique de peur d’accroître leurs douleurs et la fatigue. L’objectif est de rendre compte d’un cas clinique qui présente une propension excessive à l’action traitée avec une thérapie comportementale et cognitive de groupe pour la gestion de la fibromyalgie au centre d’évaluation et traitement de la douleur de l’hôpital Saint-Antoine, Paris. Les résultats de cette étude corroborent ceux de la littérature sur l’efficacité de certaines techniques comportementales et cognitives telles que le « pacing ». Toutefois, ils méritent d’être approfondis pour proposer des stratégies efficaces pour apprendre aux patients à réguler leur comportement de propension excessive à l’action, augmenter leurs capacités physiques et leur bien-être et ainsi arriver à « mieux vivre avec la fibromyalgie ».
Cognitive Behavioral Therapy (CBT) now has a place in the treatment of chronic pain (Williams et al., 2012 [28]) and, in particular, fibromyalgia (Bernardy et al., 2010 [29]). This debilitating pathology is characterized by chronic widespread pain associated with functional disability, fatigue, sleep disturbance, cognitive disorders and psychological distress. (Wolf et al., 2011 [1]). Patients suffering from fibromyalgia often report having a hectic lifestyle before falling ill, a tendency to exhaustion and exceeding limits. This high action-proneness, (“ergomania” or “workaholism”) is both a risk factor (Aguerre et al., 2008 [7]), a precipitating factor (“premorbid personality”) and a maintaining factor of fibromyalgic pain and its impact on life quality, through fatigue and functional disability. Patients with fibromyalgia eventually try to avoid all physical activity through fear of increasing their pain (Vlaeyen et al., 2000 [12]). The aim of our work is to suggest behavioral and cognitive strategies such as “pacing” (McCracken et al., 2007 [14]) to help patients with fibromyalgia regulate their physical activity gradually, step by step, taking into consideration their bodily sensations, their emotions, their limits, (Jammet and Laroche, 2012 [10]) and also to improve their general well-being.
Clinical case: Mrs L., 52 years old, lives with her retired husband. Their adult children have left home. Currently on sick leave, with the diagnosis of “fibromyalgia in a context of anxiety and depression”, she would like to return to work, but feels exhausted. She reported a difficult and isolated childhood, and mental and physical trauma. She describes alternating periods of hyperactivity and exhaustion prohibiting any activity, which matches “high action proneness” behavior. Assessment: This took place at three separate intervals: before and after the program, then nine months following the end of the CBT. The parameters assessed were: quality of life (questionnaire on the impact of fibromyalgia [QIF]), anxiety and depression (HAD), pain intensity (EVA), coping strategies (CSQ) and willingness to change (PSOCQ). Therapeutic proposal: inclusion in a cognitive-behavioral group program “Coping with fibromyalgia”, involving eight weekly two-hour sessions (Jammet and Laroche, 2012 [10]), with four individual sessions and follow-up after the end of the therapy. Therapeutic procedure: The program implemented several strategies: information on and awareness of the psychological aspect of pain, cognitive restructuring, “pacing”, gradual return to physical and enjoyable activities, learning of coping strategies, stress management and emotion regulation techniques (Jacobson's progressive relaxation, work on “mindfulness” style body awareness).
The assessments showed the acquisition of new coping strategies by our patient, notably with regard to activity and physical effort. She was able to plan her activities and take pauses (breathing, relaxation, distraction). Nine months after the program, there was a decrease in depressive signs (−80%), anxiety levels (46%) and dramatization (−60%). The intensity of pain over the last seven days had reduced by 40%, the score of the impact of fibromyalgia had decreased by 50%. Mrs L. has gone back to work fulltime.
These results confirm the literature supporting the efficiency of certain behavioral and cognitive strategies in the treatment of fibromyalgia, notably “pacing” to reduce action proneness. The specific features, benefits and limits of this therapy will be discussed in the context of this case study which is a prototype of cognitive-behavioral treatment of a fibromyalgia group in the centre d’évaluation et traitement de la douleur “François-Boureau” at the hôpital Saint-Antoine in Paris.
The prevalence and impact of early childhood trauma in Chronic Fatigue Syndrome
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Early childhood trauma may also have important effects on personality and lifestyle. For instance, we and others have hypothesized that high levels of “action-proneness” and self-critical perfectionism that have been identified in at least a subgroup of CFS patients (Kempke et al., 2011b, in press; Van Houdenhove, Bruyninckx, and Luyten, 2006), may reflect attempts to compensate for feelings of worthlessness and inferiority associated with (emotional) adverse childhood experiences in order to regain a positive sense of self (Kempke et al., 2011a; Van Houdenhove, 1986, 2005; Van Houdenhove and Neerinckx, 1999; Van Houdenhove et al., 2001; Van Houdenhove, Stans, and Verstraeten, 1987). Although this study has a number of strengths, including the diary method approach, several limitations need to be considered.
Although some studies have found high rates of early childhood trauma in Chronic Fatigue Syndrome (CFS), the role of early trauma in this condition remains controversial.
This study examined the prevalence of early childhood trauma and its impact on daily fatigue and pain levels over a 14-day period in a sample of 90 carefully screened CFS patients using a diary method approach. Data were analyzed using multilevel analysis.
More than half of the patients (54.4%) had experienced at least one type of early trauma, with the majority of these patients reporting multiple traumas. Prevalence rates were particularly high for emotional trauma (i.e., emotional abuse and/or emotional neglect) (46.7%). Moreover, total trauma scores and emotional abuse significantly predicted higher levels of daily fatigue and pain over the 14-day period, even when controlling for demographic features and depressed mood.
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The role of acceptance in chronic fatigue syndrome
2011, Journal of Psychosomatic Research
Citation Excerpt :
Systematic reviews have shown CBT to be effective in improving functioning and reducing fatigue in CFS patients [5]. CBT, along with Graded Exercise Therapy, has also been shown in a non randomised trial to significantly improve “action-proneness” (cognitive and behavioural tendency towards direct action), although not to pre-morbid levels [6]. Research on patients with chronic pain has suggested that attempting to control pain which is uncontrollable (lack of acceptance) is associated with distress and frustration [7,8], reduced physical functioning [9], higher pain identity and more serious perceived consequences [10].
In this paper we consider the role that acceptance plays in fatigue and physical and social functioning. We predicted that lack of acceptance would be positively correlated with fatigue and impairment in functioning; that there would be a significant relationship between perfectionism and acceptance; and cognitive behavioural therapy (CBT) would increase acceptance.
Two hundred and fifty nine patients with chronic fatigue syndrome (CFS) completed questionnaires measuring fatigue, physical functioning, work and social adjustment, lack of acceptance, perfectionism and depression. Ninety consecutive attenders received a course of CBT and completed further questionnaires at discharge and 3 months post-treatment. Correlations and multiple hierarchical regressions were used to determine relationships between acceptance, perfectionism and clinical outcome variables.
At baseline, lack of acceptance was the key factor associated with impaired physical functioning and work and social adjustment. Lack of acceptance and doubts about actions were associated with fatigue in a multiple regression analysis. At discharge and follow-up patients showed significantly increased acceptance, as well as reduced Concern over Mistakes, less fatigue and impairment of physical functioning, and improved work and social adjustment.
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Unraveling the role of perfectionism in chronic fatigue syndrome: Is there a distinction between adaptive and maladaptive perfectionism?
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In the current study, we investigated whether the distinction between adaptive (i.e. high personal standards) and maladaptive (i.e. concern over mistakes and doubt about actions) perfectionism that has been found in the literature, is also valid in patients with chronic fatigue syndrome (CFS). We hypothesized that maladaptive, but not adaptive, perfectionism would be significantly and positively related to severity of fatigue and depression in CFS. We examined this hypothesis in a sample of 192 CFS patients using structural equation modelling (SEM). Although the two perfectionism dimensions were related to each other, results supported a model in which only maladaptive perfectionism was positively related to severity of fatigue and depression. Further, we found that depression fully mediated the effect of maladaptive perfectionism on fatigue. The results suggest that adaptive and maladaptive perfectionism are two distinct, albeit related, dimensions in CFS. Findings of this study have important implications for theory and treatment of CFS, particularly for cognitive–behavioral treatment.
Predictors of outcome in a multi-component treatment program for chronic fatigue syndrome
2010, Journal of Affective Disorders
Little is known about factors predicting treatment outcome in chronic fatigue syndrome (CFS).
Based on Vercoulen et al.'s (1998) cognitive–behavioral model of perpetuating factors in CFS, the predictive value of the following patient characteristics were examined in a sample of 178 CFS patients who followed a multi-component treatment program: (1) somatic attributions, (2) psychological attributions, (3) sense of control over symptoms, (4) physical activity, (5) functional impairment, (6) somatic focus, and (7) severity of depression.
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Short communicationIn search of a new balance. Can high “action-proneness” in patients with chronic fatigue syndrome be changed by a multidisciplinary group treatment?

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Participants

Results

Discussion

Acknowledgment

J Psychosom Res

J Psychosom Res

The chronic fatigue syndrome: a comprehensive approach to its definition and study

Ann Intern Med

Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together

Psychother Psychosom

Interventions for the treatment and management of chronic fatigue syndrome: a systematic review

JAMA

Short communication
In search of a new balance. Can high “action-proneness” in patients with chronic fatigue syndrome be changed by a multidisciplinary group treatment?