Fatigue and psychosocial variables in autoimmune rheumatic disease and chronic fatigue syndrome: A cross-sectional comparison

https://doi.org/10.1016/j.jpsychores.2016.11.002Get rights and content

Highlights

  • Patients with ARD show similar cognitive-behavioural responses.

  • Transdiagnostic treatment approaches may be beneficial for fatigue in ARD.

  • Lack of acceptance is associated with fatigue severity in CFS and ARD.

Abstract

Objective

Fatigue is common in autoimmune rheumatic diseases (ARD). This study compared symptom-related cognitions, beliefs, behaviours, quality of sleep, lack of acceptance and distress in participants with ARD such as rheumatoid arthritis (RA), seronegative spondyloarthropathy (SpA), and connective tissue disease (CTD), and participants with chronic fatigue syndrome (CFS).

Methods

303 participants with RA, SpA, CTD and CFS completed questionnaire measures of fatigue, social adjustment, cognitive-behavioural responses, lack of acceptance, distress and quality of sleep. The RA, SpA and CTD groups were first compared with each other. They were then combined into one group and compared with the CFS group.

Results

There were no statistically significant differences between the RA, SpA or CTD groups for any of the measures. The CFS group was more fatigued, reported more distress and sleep disturbance and had worse social adjustment than the ARD group after adjustment for age and illness duration. After adjustment for fatigue, age, and illness duration, the CFS group scored more highly on lack of acceptance and avoidance/resting behaviour while the ARD group showed significantly higher levels of catastrophizing, damage beliefs, and symptom focusing than the CFS group.

Conclusion

Fatigue in rheumatic diseases may be perpetuated by similar underlying transdiagnostic processes. The ARD and CFS groups showed similarities but also key differences in their responses to symptoms. Specific aspects of treatment may need to be tailored towards each group. For example, lack of acceptance and avoidance behaviour may be particularly important in perpetuating fatigue in CFS.

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

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