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Participant attributions for global change ratings in unexplained chronic fatigue and chronic fatigu

Bob

Senior Member
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England (south coast)
Another paper from Friedberg.

Participant attributions for global change ratings in unexplained chronic fatigue and chronic fatigue syndrome
Friedberg F, Coronel J, Seva V, Adamowicz JL, Napoli A.
8 Jun 2014
J Health Psychol.
pii: 1359105314535458. [Epub ahead of print]
http://hpq.sagepub.com/content/early/2014/05/29/1359105314535458.abstract

Abstract

The purpose of this mixed methods study was to identify participants’ attributions for their global impression of change ratings in a behavioral intervention for unexplained chronic fatigue and chronic fatigue syndrome. At 3-month follow-up, participants (N = 67) were asked “Why do you think you are (improved, unchanged, worse)?” Improved patients pointed to specific behavioral changes, unchanged patients referred to a lack of change in lifestyle, and worsened patients invoked stress and/or specific life events. Identifying patient perceptions of behaviors associated with patient global impression of change–rated improvement and non-improvement may assist in developing more effective management strategies in clinical care.
 

biophile

Places I'd rather be.
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It gives the sole impression that improvement is a direct result of behavioural changes. Maybe it is for some patients with chronic fatigue, but still I'm skeptical about the overall value of this study.
 
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A.B.

Senior Member
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3,780
It gives the sole impression that improvement is a direct result of behavioural changes. Maybe it does for some patients with chronic fatigue, but still I'm skeptical about the overall value of this study.

It can also be interpreted in this way:

Patients interpret changes in illness severity according to their beliefs. In this study, patients were taught to attribute changes in illness to behaviour. Unsurprisingly, they did indeed interpret changes in illness severity in terms of behaviour.

Of course this is a bit premature because the abstract is vague and the paper not available. Behaviour could mean many different things, but I'm guessing it means "catastrophizing" and "positive thinking" and the usual.
 

WillowJ

คภภเє ɠรค๓թєl
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WA, USA
alternately, the 'behavior' discussed could be overdoing things (depending on one's life circumstances this can sometimes be inevitable).

Depending on what kind of intervention they had. Some CBT/similar seem to teach acceptance of illness and learning to work with it: modifying things to make them more ergonomic, doing things in smaller bits, deciding what might be unnecessary and could be left undone, as well as sleep hygeine and positive reframing.
 

xchocoholic

Senior Member
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2,947
Location
Florida
I recently saw a doctor who concluded that since I'd learned that being supine made me feel better (treating OI) that somehow my problems were solved. I assured him that laying on the couch isn't the lifestyle I want.

His conclusion seemed completely irrational to me. But seems to fall in line with what was concluded here.

Tc ... x
 

Dolphin

Senior Member
Messages
17,567
alternately, the 'behavior' discussed could be overdoing things (depending on one's life circumstances this can sometimes be inevitable).

Depending on what kind of intervention they had. Some CBT/similar seem to teach acceptance of illness and learning to work with it: modifying things to make them more ergonomic, doing things in smaller bits, deciding what might be unnecessary and could be left undone, as well as sleep hygeine and positive reframing.
Yes, Fred Friedberg's interventions are more like that.

It's the COG intervention in this trial: http://www.cfids-cab.org/cfs-inform/CFStreatment/jason.etal07.pdf

COG is based on pacing and did a little better than King's College London-type CBT (i.e. Chalder-/Wessely-type CBT).



Here's a description of COG which Friedberg et al. said was a basis for this trial:

Cognitive Therapy Treatment (COG)

This condition, formulated and supervised by Fred Friedberg, a clinical psychologist, incorporated a broad-based cognitive approach that focused on developing cognitive strategies to better tolerate and reduce stress and symptoms, and to lessen self-criticism. Cognitive changes were linked, in principle, to achieving a healthy balance between activity, rest, and leisure.

COG training was focused on treating maladaptive beliefs associated with illness-related depression, anxiety, and anger. It is a credible condition because it involves actively listening to participant’s complaints, as well as teaching coping and stress reduction skills. In comparison to CBT and ACT, the COG condition does not include structured schedules of increasing activity or exercise (Deale et al., 1997; Fulcher & White, 1997; Sharpe et al., 1996). Rather, this approach emphasizes pacing activities, which involves trying to remain as active as possible while avoiding over-exertion. Low effort activities that are not associated with symptom flare-ups are selectively increased while symptom-producing activities are decreased or managed more effectively. For instance, activity pacing was applied to completing job or household tasks in energy-conserving small steps that were less likely to produce symptom flare-ups. In a more narrowly focused early version of this protocol (Friedberg & Krupp,1994), a trend toward reduced depression scores and significant reductions in maladaptive illness beliefs were found. However, there were no changes in functional status. The 13-session COG protocol is summarized below.

Sessions 1–3. During the initial session, the therapist explained the purpose and goals of the intervention. Because of numerous encounters with physicians and others who have treated patients with CFS with condescension and even ridicule (McKenzie, Dechene, Friedberg, & Fontanetta,1995), rapport building was a critical aspect of the treatment regimen (Deale et al., 1997). As an initial intervention, the participant’s personal account of his/her illness, including CFS symptoms and their effects on vocational functioning, marital satisfaction, social relationships, and physical exercise was placed in the context of the four stage progressive model of chronic illness (Fennell, 1995). The model serves as a coping tool that allows the participant to view his/her reactions to the illness as understandable adjustments to an unpredictable, disabling condition. It also allowed the therapist to better target and individualize the coping techniques presented below.

Sessions 4–8. These sessions focused on stress reduction techniques for intrusive illness symptoms and limitations, as well as emotional distress. Initially, relaxation exercises were demonstrated and rehearsed in session. They were later prescribed for home use with audiocassette tapes. Cue-controlled relaxation was then introduced to create an association between the self-instructed relaxation and the feeling state of being relaxed. Specific relaxation benefits were addressed to the participant so that active use of relaxation as a coping skill (Ost, 1987) was clearly explained. In addition, cognitive coping statements were formulated and prescribed to counteract (1) catastrophic thinking about illness limitations and its vocational and social consequences; (2) symptom-exacerbating selfdemands for high achievement; and (3) intolerance of illness symptoms. To encourage practice of these coping skills, daily stress and fatigue records were reviewed to identify stress/symptom associations and then to prescribe relaxation and cognitive coping techniques to ameliorate these symptoms.

Sessions 9–13. As participants incorporated stress management and cognitive coping strategies into their daily routine, the imagery technique of pleasant mood induction was introduced as a method of alleviating depressed mood and uplifting mood in general. Pleasant mood induction involved visualizing enjoyable activities and events that could be performed by the participant, given the limitations of his or her illness. If the imagery exercises succeeded in elevating mood, they were incorporated into daily relaxation practice. The quality of social support was discussed in order to identify maladaptive beliefs that were detrimental to marital, family, and other significant relationships. Once identified, these maladaptive beliefs were used to generate cognitive coping statements that were intended to ameliorate relationship-damaging beliefs. These individually constructed coping statements were assigned as daily homework and were designed to counteract maladaptive thinking about relationships. Such sessions were devoted to the identification of specific cognitive difficulties and exposure to memory compensation and cognitive retraining techniques. For instance, to reduce debilitating feelings of cognitive overload, the participant was encouraged to (1) allow extra time to complete activities, (2) minimize distractions, and (3) watch for signs of increased mental fatigue and take necessary rest breaks. During the final session, the therapist and participant reviewed the course of therapy, including specific coping techniques that were learned and utilized. Improvements were also assessed in light of the four stage progressive model of CFS. Finally, a plan was developed to maintain the effective coping skills gained.

Jason et al 2007 Table 1 part 1 larger.png

Jason et al 2007 Table 1 part 2 larger.png
 

Dolphin

Senior Member
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17,567
Across the three study conditions, common themes emerged that distinguished improved, unchanged, and worsened patients. Almost ¾ of improved patients (17/23) pointed to one or more personally directed behavioral changes to account for their improvement. These behavioral changes included multiple responses (in parentheses) for the following categories: increased awareness of fatigue and behavior (12), increased use of relaxation and better coping (10), reduced activity/increased rest (7) (e.g. more rest, less exercise, less work, pacing), increased physical activity (7), improved sleep hygiene (5) (e.g. better sleeping habits, less naps), and increased involvement in pleasant activities (4). Apart from these behaviors, specific life events (5), improved medical problems (2), and effective dietary supplements (2) were also given as reasons for improvement.

For “unchanged” patients, 32 percent (9/28) explained their status as due to unchanged lifestyle, frequently referring to a lack of exercise. lack of resources, time, or motivation. Eight participants (29%) simply offered a more general response that everything was the same without explanation or that they were not taught anything. Eight participants also cited “stress” as a reason for their unchanged status, while six pointed to specific events (e.g. new job; season change; divorce). Five indicated that nothing would help them because lifestyle change would not work, the problem is physical, or no one understands the problem. The following responses were also given: a bad knee that prevented more activity, a medication change, and a bad memory for the reason for lack of change.

Patients with worsened ratings most often attributed their decline to “stress” (44%; 7/16) and/or specific events (38%; 6/16) including menopause, job loss, or a car accident. Four participants said they did not know why they The lack of change was often attributed to a were worse. Symptom flare-ups (dizziness, headaches, and back pain) were offered by three respondents as the reason for their worsened condition. No participant referred to personal behaviors in explaining their deterioration.
 

Dolphin

Senior Member
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17,567
I actually found some of this paper quite interesting e.g.

Related to locus of control is the concept of self-serving attribution biases, the tendency for successes (such as illness improvement) to be attributed to internal factors and failures (such as illness worsening) to be attributed to external factors (Miller and Ross, 1975). A meta-analysis of self-threat and self-serving attributions (Campbell and Sedikides, 1999) found that the self-serving bias was significantly stronger in individuals with an external locus of control. Thus, if more negative events happen than positive ones, attributing negative events to outside forces may be self-protective (Twenge et al., 2004). Relevant to this point, Lefcourt (1991) described externality as a “failure to act in one’s own behalf in trying to remedy an unpleasant situation, in the face of potential stress, or in trying to bring about rewarding outcomes” (p. 413). It appears that making non-self-serving attributions, that is, viewing personal behavior, rather than uncontrollable events as influencing worsened outcomes, requires more deliberate cognitive control of attributions (Krusemark et al., 2008).
 

Dolphin

Senior Member
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17,567
I thought this was good to see:
One possible alternate explanation of the findings is that demand characteristics helped to create the consistency of response themes within improvement and non-improvement categories (Anderson and Strupp, 1996). Specifically, participants may have supplied answers that were perceived to be “expected” by the interviewer in accordance with their assigned study condition. For instance, participants in the active intervention condition might have provided an “improved” PGIC rating attributable to performing the self-management activities that they agreed to do during the two intervention visits. Responding in this expected manner might reflect the influence of demand characteristics, rather than the participant’s actual perceptions of his or her PGIC rating and the accompanying “real” reasons to explain it. Conversely, an “expected” reason for nonimprovement might be the lack of particular self-management activities that all participants, intervention and controls, may have been aware of from the consent form signed at the beginning of the study
 

Dolphin

Senior Member
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17,567
The authors briefly discuss recovery claims:

The findings of this study may have implications for the interpretation of outcomes in behavioral intervention studies in UCF and CFS. In reviews of behavioral treatment trials, improvements in fatigue or functioning to the normative range have been interpreted as evidence for illness recovery (e.g. Knoop et al., 2007; White et al., 2013). Given the controversy over the interpretation of such positive outcomes in CFS (Kindlon, 2011), patient feedback on the personal significance of putative recovery level outcomes may help to evaluate the validity of such characterizations.