Original article
The central role of cognitive processes in the perpetuation of chronic fatigue syndrome

https://doi.org/10.1016/j.jpsychores.2010.01.022Get rights and content

Abstract

Objective

Chronic fatigue syndrome (CFS) is considered to be one of the functional somatic syndromes (FSS). Cognitions and behavior are thought to perpetuate the symptoms of CFS. Behavioral interventions based on the existing models of perpetuating factors are quite successful in reducing fatigue and disabilities. The evidence is reviewed that cognitive processes, particularly those that determine the perception of fatigue and its effect on behavior, play a central role in the maintenance of symptoms.

Method

Narrative review.

Results

Findings from treatment studies suggest that cognitive factors mediate the positive effect of behavioral interventions on fatigue. Increased fitness or increased physical activity does not seem to mediate the treatment response. Additional evidence for the role of cognitive processes is found in studies comparing the subjective beliefs patients have of their functioning with their actual performance and in neurobiological research.

Conclusion

Three different cognitive processes may play a role in the perpetuation of CFS symptoms. The first is a general cognitive representation in which fatigue is perceived as something negative and aversive and CFS is seen as an illness that is difficult to influence. The second process involved is the focusing on fatigue. The third element is formed by specific dysfunctional beliefs about activity and fatigue.

Section snippets

Background

Chronic fatigue syndrome (CFS) is characterized by severe fatigue lasting longer than 6 months and leading to disability. A somatic explanation for the fatigue is lacking [1]. CFS is often considered to be one of the functional somatic syndromes (FSS) where patients report persistent symptoms while there is no known somatic substrate. All CFS patients have, aside from fatigue, additional symptoms. According to the US Centers for Disease Control criteria for CFS [2], a patient must report four

Models of perpetuating factors in CFS

One of the first models of CFS was developed by Wessely et al. [5]. Somatic attributions, depressive symptoms, and physical inactivity interacted and perpetuated symptoms. The vicious cycle of avoidance of activity in response to the fatigue, and the resulting physical deconditioning, was considered to be an important maintaining factor. It followed from this that patients had to become more physically active to reduce symptoms and disabilities. This became an important element of the

Findings from treatment studies aimed at changing the perpetuating factors

On the basis of the models of perpetuating factors behavioral interventions have been developed. Cognitive behavior therapy (CBT) and graded exercise therapy (GET) are most often used. In GET it is postulated that the graded exercise will improve the physical condition of patients which ameliorates symptoms and will enable patients to become more physically active. CBT is not only aimed at the gradual increase of activity levels but also at changing cognitions [11].

Systematic reviews report

Discrepancies between patients' subjective beliefs about their functioning and their objective performance

Other studies have looked at the role of cognitive processes in CFS by testing the discrepancy between the actual performance or functioning of patients and their own evaluation of this performance. If negative beliefs about symptoms and the ability to be active are indeed central to the perpetuation of CFS, one would expect to see such a discrepancy [7].

Most CFS patients report neuropsychological symptoms including difficulty concentrating and forgetfulness. However, only a small minority of

Neurobiological correlates of CFS and its relationship with perpetuating factors

Although until now no consistent somatic impairment has been found in CFS, a recent and promising line of research has looked at possible neurobiological abnormalities associated with CFS. The findings support the idea of the important role of cognitive processes in CFS. De Lange et al. [35] compared brain activity patterns in patients with CFS and those in healthy controls when they were performing the same tasks. They found that areas in the brain that play a role in evaluating the emotional

Discussion

There is evidence of a disorder in cognitive processes in CFS. We hypothesize that three different cognitive processes play a crucial role in the perpetuation of CFS. The first is a general cognitive representation or schema of the illness that gets activated in a wide range of situations. In this representation fatigue is continuously perceived as something negative and aversive [17]. CFS is seen as an illness with a substantial impact on life that is difficult to influence [37]. This last

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    This article was written while the first author was a visiting staff member of the School of Psychology at the University of Southampton. The working visit was made possible by a grant of the Dutch MSresearch fund (Stichting MSresearch).

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