Treatment expectations influence the outcome of multidisciplinary rehabilitation treatment in patients with CFS
Introduction
Chronic Fatigue Syndrome (CFS) is a condition characterised by persistent fatigue which often leads to a substantial limitation in function, activities and participation [1]. Cognitive behavioural therapy (CBT), a monodisciplinary treatment with a psychotherapeutic approach focusing on the perpetuating factors (cognitions and behaviour) of the CFS, has shown to be an effective, evidence based treatment for patients with CFS [2]. Recently, a new, innovative multidisciplinary rehabilitation treatment (MRT) has been developed and compared with CBT in a randomized controlled trial. MRT is a multidisciplinary treatment in which different interventions (for example CBT, gradual increasing activity and body awareness) can be combined to treat the patient depending on the modifiable components and personal aims of the patient [3]. Results of the randomized trial comparing MRT and CBT showed that immediately post-treatment (26 weeks after start of treatment) both treatments showed significant reduction of fatigue and increase of quality of life, however the between group differences were not significant. At 52 weeks follow-up, MRT was more effective in reducing fatigue and equally effective in improving quality of life [4]. To understand the working mechanisms of these interventions and to find out how to increase their effectiveness, it is important to study factors that influence the outcome of treatment. A factor that might influence important treatment outcomes such as fatigue and quality of life, is the expectancy of the patient. Expectations or predicted expectations are what the patient believes will occur after following treatment [5]. Heins et al. (2013) [6] were the first to investigate whether outcome expectations contribute to the reduction in fatigue during CBT for patients with CFS. Twenty-five percent of the variance in post-treatment fatigue was jointly explained by outcome expectations and agreement between therapist and patient on the content of treatment and how to achieve the patient's goals [6]. It is postulated that these factors exert their positive effect through a change in fatigue perpetuating factors. In patients with chronic low back pain, similar results were found regarding the influence of expectations on the outcome. Expectations explained 1–8% of the variance in the equation of four different outcome variables after CBT, namely: motor behaviour, pain coping and control, negative effect and QoL [7]. Whether expectations influence the outcome after MRT in patients with CFS needs to be evaluated.
Another factor, which might influence treatment outcomes is credibility. Credibility is how believable, convincing and logical the treatment seems to the patient. In patients with chronic low back pain, credibility was a significant predictor for global perceived effect in patients following a rehabilitation treatment, which combined active physical therapy with CBT [8]. In patients with CFS, the association between credibility and outcome of treatment has never been studied before. If expectancy and/or credibility influence the treatment effects, interventions could be designed to increase these concepts, which might increase effectiveness of the treatment. To influence the expectancy and/or credibility it is worthwhile studying factors that are associated with these concepts. Age, internal control over symptoms, self-efficacy, depression, duration of complaints and severity of symptoms have been proposed as factors influencing expectations before treatment [8], [9], [10]. Whether these factors influence the expectancy or credibility in patients with CFS referred for treatment needs to be studied.
The purpose of this study was two-fold: first, to assess the association of patients' treatment expectancy and credibility on the outcome of treatment (change in fatigue severity and quality of life), and whether these associations are different for MRT and CBT respectively. Second, to study the effect of age, treatment centre, type of treatment allocation, self-efficacy, symptoms of depression and duration of complaints at baseline on treatment expectancy and credibility.
Section snippets
Methods
This study is part of the FatiGo trial, a multi-centre, pragmatic two-arm randomized controlled trial (ISRCTN77567702) of which the methods and results are described previously [3], [4]. The main aim of the FatiGo trial was to analyse the difference in treatment effect between MRT and CBT for patients with CFS.
Baseline characteristics
Overall, 364 patients were referred to the participating rehabilitation centres with a major complaint of fatigue. The most common reasons for exclusion were unwillingness to participate (54 patients), not meeting the CDC-94 criteria (34 patients), and other diagnosis explaining the presence of fatigue or fatigue was not the primary complaint (34 patients). Finally, 60 patients completed the baseline assessment and were randomized to CBT and 62 to MRT. In the MRT group 57 (95%) patients
Discussion
Patients with higher expectancy at the beginning of treatment who receive MRT improve more in terms of fatigue and physical QoL than those that receive CBT. Expectations did not influence treatment response on the outcome of mental QoL.
The mechanism by which patients with higher expectations respond better to MRT than CBT is unknown and was not investigated in this study. It is possible that the rationale of MRT is more in line with what patients think will help them in achieving a positive
Competing interest statement
The authors have no competing interests to report.
Acknowledgements
We thank all the participants who took part in the FatiGo trial and all the professionals, support staff and management of the participating rehabilitation centres. The FatiGo trial was funded by the Netherlands Organisation for Health Research and Development (ZonMw) grant number 56100007, Rehabilitation Fund (the Netherlands) 2007176/sw, Foundation Nutsohra, grant number 0801-06 and the ME/CVS Stichting Nederland. The funders had no role in study design, data collection and analysis, decision
References (29)
- et al.
The role of the therapeutic relationship in cognitive behaviour therapy for chronic fatigue syndrome
Behav. Res. Ther.
(Jul 2013) - et al.
Prevalence and predictors of recovery from chronic fatigue syndrome in a routine clinical practice
Behav. Res. Ther.
(Dec 2014) - et al.
Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial
Lancet
(Mar 17 2001) - et al.
Dimensional assessment of chronic fatigue syndrome
J. Psychosom. Res.
(Jul 1994) - et al.
Psychometric properties of the credibility/expectancy questionnaire
J. Behav. Ther. Exp. Psychiatry
(Jun 2000) - et al.
The persistence of fatigue in chronic fatigue syndrome and multiple sclerosis: development of a model
J. Psychosom. Res.
(Dec 1998) - et al.
Cognitive behavioural treatment for chronic fatigue syndrome in a rehabilitation setting: effectiveness and predictors of outcome
Behav. Res. Ther.
(Dec 2011) - et al.
Predictors of outcome in a multi-component treatment program for chronic fatigue syndrome
J. Affect. Disord.
(2010 Oct) - et al.
The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group
Ann. Intern. Med.
(Dec 15 1994) - et al.
Cognitive behaviour therapy for chronic fatigue syndrome in adults
Cochrane Database Syst. Rev.
(2008)
Cognitive behavioural therapy versus multidisciplinary rehabilitation treatment for patients with chronic fatigue syndrome: study protocol for a randomized controlled trial (FatiGo)
Trials
Multidisciplinary rehabilitation treatment versus cognitive behavioural therapy for patients with chronic fatigue syndrome: a randomized controled trial
J. Intern. Med.
Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain
Phys. Ther.
Treatment expectancy affects the outcome of cognitive-behavioral interventions in chronic pain
Clin. J. Pain
Cited by (10)
Using clinical patient characteristics to predict treatment outcome of cognitive behavior therapies for individuals with medically unexplained symptoms: A systematic review and meta-analysis
2022, General Hospital PsychiatryCitation Excerpt :Another moderator analysis (I2study quality = 92.20%) demonstrated a significant effect in studies of high and moderate methodological quality (moderate quality: r = 0.39; 95%-CI: 0.17, 0.58; high quality: r = 0.43; 95%-CI: 0.12, 0.67), but not in low quality studies (p = 0.213). Two studies [54,55] of our systematic review did not provide sufficient data to be included to the meta-analysis. Consistent with the meta-analytic findings, both studies demonstrated a positive association between individuals' symptom intensity at baseline and symptom intensity at the end of therapy.
“Understand your illness and your needs”: Assessment-informed patient education for people with multiple functional somatic syndromes
2019, Patient Education and CounselingCitation Excerpt :Expectancy for further treatment was high compared to other studies testing psychological treatment for patients with FSS [49,50]. High treatment expectations have been associated with better treatment outcomes among patients with somatoform pain conditions and chronic fatigue syndrome 50–53]. "Understand your illness and your needs" seems to successfully create hope, positive expectation, and motivation to enter psychotherapy.
Patients’ outcome expectations and their fulfilment in multidisciplinary stroke rehabilitation
2019, Annals of Physical and Rehabilitation MedicineCitation Excerpt :No determinants were identified for outcome expectations, but expectation fulfilment was associated with low baseline expectations and improved HRQoL. The median score on the CEQ Expectancy scale was 21.6, which is higher than in a previous study of stroke patients (mean 20.0) [11] and higher than for patients undergoing treatment for chronic low back pain (mean 16.4) [17] and fatigue (mean 17.5) [25]. After rehabilitation, the CEQ Expectancy-Follow up scores were somewhat lower than the baseline CEQ Expectancy scores, although not significantly.
Guided Self-Help for Patients with Chronic Fatigue Syndrome Prior to Starting Cognitive Behavioural Therapy: A Cohort Study
2017, Behavioural and Cognitive Psychotherapy