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Reexamination of Cognitive Behavioral Model of CFS: Investigating Cogency of Model’s Behavioral Path

Dolphin

Senior Member
Messages
17,567
From: Dr. Marc-Alexander Fluks


Source: DePaul University

Date: July 26, 2016; online: February 8, 2017

URL: http://via.library.depaul.edu/csh_etd/193/

http://via.library.depaul.edu/cgi/viewcontent.cgi?article=1200&context=csh_etd



A reexamination of the Cognitive Behavioral Model of Chronic Fatigue Syndrome: Investigating the cogency of the model's behavioral pathway

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Madison Lindsay Sunnquist

- Department of Psychology, College of Science and Health, DePaul University, Chicago, Illinois, USA. Email: madison.sunnquist@gmail.com



Abstract


Cognitive behavioral theories of chronic fatigue syndrome (CFS) assert that cognitions and behaviors perpetuate the fatigue and impairment that individuals with CFS experience (Wessely, Butler, Chalder, & David, 1991).

Vercoulen and colleagues (1998) utilized structural equation modeling to empirically develop a cognitive behavioral model of CFS.

The resulting model indicated that attributing symptoms to a physical cause, focusing on symptoms, and feeling less control over symptoms were associated with increased fatigue.

Additionally, individuals who attributed symptoms to a physical cause reported lower activity levels and more fatigue and impairment.

However, in an attempt to replicate this model, Song and Jason (2005) demonstrated that the model displayed inadequate fit statistics for a well-characterized group of individuals with CFS; the model resulted in appropriate fit for individuals with chronic fatigue from psychiatric conditions.

Despite uncertainty surrounding the model's validity, it continues to be cited to support the application of cognitive behavioral and graded exercise therapies to individuals with CFS (White et al., 2011).

The current study utilized second-stage conditional process modeling (i.e., moderated mediation) to reexamine the behavioral pathway of the Vercoulen et al. (1998) model.

This pathway is characterized by the association among causal attribution for symptoms, activity level, and fatigue and impairment.

The use of a large sample allowed for a robust examination of the pathway, and moderators isolated potential factors that contributed to previous studies' discrepant results.

Findings were generally inconsistent with the Vercoulen et al. (1998) model.

Results indicated that individuals did not reduce their activity level due to illness beliefs.

Although activity level and impairment were significantly correlated, this correlation decreased as case definition stringency increased.

Furthermore, a canonical correlation analysis demonstrated that activity level, impairment, and fatigue could be conceptualized as indicators of illness severity.

Rather than implicating activity level as the cause of fatigue and impairment, the relation among these variables may be due to their shared association with the latent construct of illness severity.

This study represents the second attempt to replicate the Vercoulen et al. (1998) model; neither the Song and Jason (2005) nor the current study resulted in findings consistent with the original model.

As this model provides the theoretical foundation for cognitive behavioral and graded exercise treatments for ME and CFS, these failed replication attempts support patient-expressed concerns about the appropriateness and efficacy of these treatments.


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(c) 2016, 2017 DePaul University
 
Messages
2,158
Wow, this is brilliant. BPS model disproved again! As I understand it, they are saying that it is illness severity that causes impairment, fatigue and low activity level. They show that beliefs have nothing to do with any of these factors.

Severity of symptoms is not caused by false illness beliefs or by low activity levels. CBT and GET are not appropriate or effective treatments.

Good to see them clearly demarcating the difference between chronic fatigue syndrome, and chronic fatigue as a symptom caused by depression.

Another nail in Wessely and PACE's coffins.

Made my day, especially after Wessely's ghastly self satisfied preening on the radio this morning.

'these failed replication attempts support patient-expressed concerns about the appropriateness and efficacy of these treatments.'

Such a contrast to Wessely's talk of being threatened by disgruntled patients.
 

Hutan

Senior Member
Messages
1,099
Location
New Zealand
The whole document is worth a read if you are in to this sort of thing.

The Vercoulen model (that found that faulty illness beliefs was the problem) is slammed beautifully from page 6:

Broad inclusion criteria - Oxford definition, just more than 6 months unexplained fatigue

Measurement selection - I was amazed at how limited the measures of impairment and activity levels used by Vercoulen were. For example for 'Impairment', it seems that they used only two questions:
  • I have given up taking care of personal or household business affairs (e.g., paying bills, banking, working on budget);
  • I am doing less of the regular daily work around the house than I usually do.

Now, since I and my children became ill I have stopped work and so I actually do more of the household business affairs than I used to. We can't afford a cleaner anymore and my son and I are home virtually all of the time, so there is more housework and food preparation to do and I do more of it than I used to. But I don't do my demanding, satisfying paid work anymore.

So, using the Vercoulen measure of impairment, I was actually more impaired when I was a busy executive who frequently worked overseas in cultures quite different to my own and could do complex abstract thinking for long periods than I am now, a housewife whose major challenge is getting to the supermarket, remembering what I went there for and getting home again.

As Sunnquist says:
Moreover, household tasks represent just one potential area of impairment; individuals could also experience impairment in social, occupational, or cognitive functioning. Given these limitations, this measure appears to lack both sensitivity and specificity, as it does not represent a precise, nor comprehensive measure of impairment. A more valid measure of impairment might have resulted in different model pathways.

It seems to me as though Vercoulen et al specifically picked measures out of a whole range of possibilities that gave them the answer they wanted.

Sample size: Too small

Causal claims: Basically, it is all very well finding an association between attribution of illness to a physical cause, low activity levels and fatigue, but that in itself says nothing about causation.

Sunnquist says:
In describing the final model, the article <<Vercoulen>> states, “Attributing complaints to a somatic cause produced low levels of physical activity, which in turn had a causal effect on fatigue severity.”

Though SEM could be used as a tool to demonstrate causality in a highly-controlled, prospective, longitudinal experimental design, the Vercoulen et al. (1998) study does not demonstrate three requisite tenets of causality: temporal precedence of cause from effect, covariance of cause and effect variables, and rejection of all plausible alternative causes for the effect (Shadish, Cook, & Campbell, 2002).

That's as far as I have got. But I'm impressed. Well done Madison Sunnquist and thank you.
 

barbc56

Senior Member
Messages
3,657
Yes! Over the years, DePaul has come out with some good research.

My rheumatologist in Chicago worked half time in a physician practice and half time research on Fibromyalgia. It would be interesting to fiind out if they've done studies that include both me/cfs and FM.
 

A.B.

Senior Member
Messages
3,780
the Vercoulen et al. (1998) study does not demonstrate three requisite tenets of causality: temporal precedence of cause from effect, covariance of cause and effect variables, and rejection of all plausible alternative causes for the effect.

They have never made any serious attempt to reject alternative explanations, and typically don't even mention that alternative explanations might exist. The modus operandi appears to be: can I construct a psychosocial narrative from this correlation? Not "is a psychosocial narrative the best fit for the data?"
 

HowToEscape?

Senior Member
Messages
626
The whole document is worth a read if you are in to this sort of thing.

Measurement selection - I was amazed at how limited the measures of impairment and activity levels used by Vercoulen were. For example for 'Impairment', it seems that they used only two questions:
  • I have given up taking care of personal or household business affairs (e.g., paying bills, banking, working on budget);
  • I am doing less of the regular daily work around the house than I usually do.

......

I'm confused. I can't determine whether the researchers intended the above as a joke cast upon the patients, as an insult, or as a means to evade acknowledging that our illness exists.
 

RogerBlack

Senior Member
Messages
902
I'm confused. I can't determine whether the researchers intended the above as a joke cast upon the patients, as an insult, or as a means to evade acknowledging that our illness exists.

These are not phrases chosen by the researchers, but specific research questionaires that attempt to measure disability, there are several, and most are terrible.
This is the SIP.

They are commonly used scales of disability in research,so it's a little different problem than the researchers picking bad questions themselves.
 

HowToEscape?

Senior Member
Messages
626
These are not phrases chosen by the researchers, but specific research questionaires that attempt to measure disability, there are several, and most are terrible.
This is the SIP.

They are commonly used scales of disability in research,so it's a little different problem than the researchers picking bad questions themselves.

Ouch. It seems those authoritatively compiled questions wete written by people with no knowledge of the subject matter, and no interest in gaining it.