Fatigue and psychosocial variables in autoimmune rheumatic disease and chronic fatigue syndrome: A cross-sectional comparison
Introduction
Transdiagnostic theory proposes that heterogeneous illnesses share similar underlying emotional, cognitive and behavioural processes, and that the same treatment can be used across different diagnoses [1], [2]. This approach can be applied to fatigue in chronic illnesses.
Fatigue is common in the general population, with 18.3% of the general population reporting substantial fatigue for six months or longer [3]. It is a significant feature of CFS (chronic fatigue syndrome). Fatigue is also a ubiquitous symptom of many chronic diseases [4], including ARD (autoimmune rheumatic diseases). From a transdiagnostic perspective, the cognitive and behavioural responses to fatigue may be similar across different rheumatic diseases and CFS, and may respond to similar treatment approaches regardless of the specific diagnosis.
CFS is characterised by long-standing fatigue and includes physical and mental symptoms such as muscle pain and concentration difficulties, which can impact on physical and social functioning [5], [6]. Moreover, patients often report sleep disturbance and distress [7], [8], [9], [10]. In ARD such as rheumatoid arthritis (RA), seronegative spondyloarthropathy (SpA) and connective tissue diseases (CTD), fatigue is a pervasive symptom which affects every day functioning, and has been associated with decreased quality of life and increased disease burden [11], [12], [13], [14], [15], [16], [17], [18], [19]. Fatigue often persists even after disease activity has been managed with disease-modifying medication [20].
There is some evidence that fatigue in ARD could be associated with cognitive and behavioural factors. For example, cognitive factors such as self-efficacy and pain catastrophizing have been shown to correlate with fatigue and distress in both SLE (systemic lupus erythematosus) [21] and Sjögren's syndrome [22]. In RA a systematic review of psychological correlates of fatigue [23] found evidence that RA-related unhelpful cognitions such as lower arthritis self-efficacy were associated with higher levels of fatigue [24], [25].
Similarly, research suggests that fatigue in CFS may also be maintained by a complex interplay of cognitive, behavioural and physiological factors. According to the cognitive-behavioural model of fatigue in CFS, unhelpful beliefs about physical activity can perpetuate fatigue severity, and an individual may reduce or avoid certain activities for fear of worsening symptoms. This can lead to a vicious cycle of negative beliefs about activity, avoidance of activity, prolonged rest, and worsening symptoms, along with a reinforced belief that activity is harmful [26], [27]. This model is supported by Petrie et al.'s finding that catastrophic beliefs were associated with worse fatigue and functioning in patients with CFS [28]. Another view is that lack of acceptance, or a desire to control symptoms, may cause distress and impaired functioning. Research suggests that a lack of acceptance of symptoms is associated with higher levels of fatigue and disability, and in turn higher levels of acceptance are associated with better psychological well-being [29], [30].
We know of only one study to date which has compared the illness-related cognitions of patients with CFS and those with a rheumatic disease. Moss-Morris and Chalder [31] compared illness-related cognitions of RA patients with cognitions of patients with CFS, and found that the patients with CFS had more negative illness beliefs than patients with RA as well as more negative beliefs about the course and prognosis of their illness. This may be due to differences in the way that CFS and RA are defined and diagnosed. For example, rheumatoid arthritis includes objective manifestations of disease such as joint swelling or damage as well as subjective symptoms such as pain, whereas the diagnosis of chronic fatigue syndrome relies largely on subjective self-reports of symptomatology [31]. Patients with CFS report experiencing stigma and scepticism from health professionals, and difficulties with obtaining a diagnosis [32], [33]. Therefore their experiences may differ from those of RA patients.
In this paper, we suggest that the processes that maintain fatigue in the context of CFS, which is defined by fatigue, may be similar to the processes that perpetuate fatigue in chronic diseases such as autoimmune rheumatic diseases (ARD). The purpose of the current study was to examine the levels of fatigue, disability, distress and sleep problems in participants with ARD such as RA, CTD and SpA. We also sought to examine the symptom-related cognitive and behavioural responses of these participants. We hypothesised that there would be no differences between the three ARD groups on the cognitive and behavioural responses subscales. Another aim of the study was to compare the fatigue, cognitions and behaviours of participants with CFS and a heterogeneous group of participants with ARD. It was hypothesised that the CFS group would show higher levels of fatigue and disability than the ARD group. Also, given the previous research showing differences between participants with CFS and RA in terms of illness-related cognitions [31], we hypothesised that participants with CFS would show more extreme cognitive behavioural responses and a higher lack of acceptance than participants with ARD.
Section snippets
Participants and procedure
This cross-sectional questionnaire study compared the questionnaire data of participants with rheumatoid arthritis (RA), seronegative spondyloarthropathy (SpA) and connective tissue diseases (CTD). These ARD groups were subsequently compared with a group of participants with CFS. Data was collected in accordance with the ethical principles of the Declaration of Helsinki. Data collection for the participants with ARD was approved by the London Dulwich Research Ethics Committee; REC reference
Demographics
A total of 303 participants were included in the final analysis. The demographic characteristics of study participants are shown in Table 1.
Of 232 patients from the rheumatology clinic who were assessed for eligibility for the study, 70 were excluded because they did not have a clinician-verified diagnosis of a disease that could be classified under the groups of RA, CTD, or SpA. Therefore 162 patients were included in the final analysis. In this group, 56 patients had a diagnosis of RA, 69 had
Summary of findings
This study investigated the symptom-related beliefs and behavioural responses of participants with ARD such as RA, CTD and SpA, and participants with CFS.
To our knowledge, this is the first study to measure these psychological constructs in a sample of people with varied rheumatological diagnoses and to show that the results were similar regardless of the specific diagnosis.
As hypothesised, results showed that the three ARD groups did not differ from each other for fatigue, social adjustment,
Conclusion
The results of this study suggest that although cognitive behavioural approaches may be suitable for both CFS and ARD, there are specific variables that might need to be targeted in each of the illnesses. For example, lack of acceptance and avoidance behaviour, which appears to be important in CFS, could be addressed with acceptance and commitment therapy which targets these processes specifically with valued based goals or mindfulness-based treatment approaches.
Fatigue continues to be a
Competing interest statement
All authors have completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf and we declare that one of the authors (TC) received support from the National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) for the submitted work and (2) has TC has authored self-help books for chronic fatigue and has received royalties in the past three years, that could be perceived to constitute a conflict of interest. The remaining authors have no competing
Acknowledgements
We would like to thank the patients who gave their time to take part in this study. We also thank Ms. Suzanne Roche, Ms. Barbara Bowman, Dr. Mary Burgess, Dr. Antonia Dittner, Dr. Caroline Stokes, Ms. Radka Chura, Mr. Putu Khorisantono, Mr. James Gwinnutt, Ms. Fatma Mehmet, and Ms. Egli Ioannou for their assistance with gathering data for this study. We would like to thank Dr. Kimberley Goldsmith for statistical advice.
FM and TC receive salary support from the National Institute for Health
References (66)
- et al.
Toward a unified treatment for emotional disorders
Behav. Ther.
(2004) - et al.
Fatigue, health-related quality of life and other patient-reported outcomes in systemic lupus erythematosus
Best Pract. Res. Clin. Rheumatol.
(2013) - et al.
Fatigue as experienced by patients with rheumatoid arthritis (RA): a qualitative study
Int. J. Nurs. Stud.
(2008) - et al.
Fatigue in systemic lupus erythematosus and rheumatoid arthritis
PM R
(2010) - et al.
Psychological correlates of fatigue in rheumatoid arthritis: a systematic review
Clin. Psychol. Rev.
(2015) - et al.
Educational preferences, psychological well-being and self-efficacy among people with rheumatoid arthritis
Patient Educ. Couns.
(2002) - et al.
Chronic fatigue syndrome: a cognitive approach
Behav. Res. Ther.
(1995) - et al.
The central role of cognitive processes in the perpetuation of chronic fatigue syndrome
J. Psychosom. Res.
(2010) - et al.
The impact of catastrophic beliefs on functioning in chronic fatigue syndrome
J. Psychosom. Res.
(1995) - et al.
Well-being in patients with chronic fatigue syndrome: the role of acceptance
J. Psychosom. Res.
(2006)
The role of acceptance in chronic fatigue syndrome
J. Psychosom. Res.
Illness perceptions and levels of disability in patients with chronic fatigue syndrome and rheumatoid arthritis
J. Psychosom. Res.
Measuring fatigue in clinical and community settings
J. Psychosom. Res.
Development of a fatigue scale
J. Psychosom. Res.
Fatigue and social impairment in multiple sclerosis: the role of patients' cognitive and behavioral responses to their symptoms
J. Psychosom. Res.
Measuring disability in patients with chronic fatigue syndrome: reliability and validity of the work and social adjustment scale
J. Psychosom. Res.
A scale for the estimation of sleep problems in clinical research
J. Clin. Epidemiol.
Acceptance of chronic pain: component analysis and a revised assessment method
Pain
The Chronic Pain Acceptance Questionnaire: confirmatory factor analysis and identification of patient subgroups
Pain
Tailored cognitive-behavioral therapy in early rheumatoid arthritis for patients at risk: a randomized controlled trial
Pain
Acceptance-based treatment for persons with complex, long standing chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase
Behav. Res. Ther.
Cognitive Behavioural Processes across Psychological Disorders: A Transdiagnostic Approach to Research and Treatment
Population based study of fatigue and psychological distress
Br. Med. J.
Fatigue in chronic disease
Clin. Sci.
The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group
Ann. Intern. Med.
A report-chronic fatigue syndrome: guidelines for research
J. R. Soc. Med.
Sleep quality and psychological adjustment in chronic fatigue syndrome
J. Behav. Med.
Cognitions, behaviours and co-morbid psychiatric diagnoses in patients with chronic fatigue syndrome
Psychol. Med.
Mood and anxiety disorders in chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome: results from the LifeLines cohort study
Psychosom. Med.
A community-based study of chronic fatigue syndrome
Arch. Intern. Med.
Assessment of fatigue in patients with ankylosing spondylitis: a psychometric analysis
Arthritis Rheum.
A systematic review of quality of life in adults with muscle disease
J. Neurol.
Comparison of self-reported fatigue in rheumatoid arthritis and controls
J. Rheumatol.
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