Source: Journal of Psychosomatic Research Vol. 60, #6, pp 623-625 Date: June 2006 URL: http://www.sciencedirect.com/science/journal/00223999 [Short communication] In search of a new balance. Can high 'action-proneness' in patients with chronic fatigue syndrome be changed by a multidisciplinary group treatment? Boudewijn Van Houdenhovea(a,*), Karolien Bruyninckx(b), Patrick Luyten(b,c) a Chronic Fatigue Reference Centre, University Hospitals, K.U. Leuven, Leuven, Belgium b Department of Psychology, K.U. Leuven, Leuven, Belgium c Postdoctoral Fellow Research Fund, K.U. Leuven, Leuven, Belgium * Corresponding author. University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium. E-mail address: boudewijn.vanhoudenhove@uz.kuleuven.ac.be Received 21 June 2005; received in revised form 28 November 2005; accepted 13 December 2005 Abstract Objective The purpose of this study is to investigate changes in 'action-proneness' (a cognitive and behavioral tendency toward direct action) after a multidisciplinary group intervention, including cognitive behaviour therapy (CBT) and graded exercise therapy (GET). Methods Patients with chronic fatigue syndrome (n=62) completed three versions of a Dutch self-report questionnaire evaluating action-proneness retrospec- tively that is (1) before illness onset, (2) before treatment and (3) after treatment. Significant others (n=62) also gave their opinion about the patients' action-proneness at time points 1 and 2. Results Premorbid action-proneness levels considerably dropped after illness onset. After treatment, action-proneness levels significantly increased again, although levels remained below premorbid levels. Conclusion High action-proneness retrospectively reported by CFS patients can be adaptively modified by a multidisciplinary group treatment including CBT and GET. Keywords Action-proneness; Chronic fatigue syndrome; Lifestyle; Multidisciplinary treatment; Outcome study; Overactivity Introduction Chronic fatigue syndrome (CFS) is a distressing and potentially disabling illness characterized by persistent medically unexplained fatigue, muscular and articular pains, postexertional malaise, and other nonspecific symptoms [1]. A clear cause of the condition is not established, although the pathophysiology of CFS (and the largely overlapping fibromyalgia syndrome) may be based on subtle stress system malfunctions [2]. Many authors believe that since a direct curative treatment for CFS is not available, recovery may be facilitated when patients realistically adapt to their current limitations, at the same time, trying to progressively increase their physical and mental effort tolerance [2]. In a systematic review, both cognitive behavior therapy (CBT) and graded exercise therapy (GET) have been considered evidencebased methods to obtain these goals [3]. In our previous research, we investigated the possible etiopathogenetic role of an 'overactive' lifestyle in CFS, which we operationalized as high 'action-proneness,' that is, a cognitive and behavioral tendency toward direct action [4]. Maladaptive overactivity patterns may not only precede the illness but may persist after illness onset (e.g., periodic outbursts of activity followed by prolonged periods of rest), constituting an important perpetuating factor [5]. The aim of the present study was to investigate whether, and to which degree, adaptive changes in beliefs, attitudes, and intentions concerning (over)activity occur in CFS patients participating in a multidisciplinary CBT- and GET-based treatment program. The study was part of a larger outcome study, the results of which are reported elsewhere [6]. Methods Participants Sixty-two consecutively admitted patients (55 female and 7 male, mean age=39.03 years, S.D.=8.61) participated in the study. The majority (87%) had at least higher secondary education, and 80% were married or living together. Only two patients dropped out before the end of the treatment. Each patient was sent to our CFS Reference Centre at the University Hospitals Leuven by his/her general practitioner. At the end of the multidisciplinary diagnostic screening, a CFS diagnosis was based on the CDC criteria [1] and the patient was informed about our therapeutic approach. It was notably explained that amelioration could be obtained by 'the search for a new physical and mental equilibrium' - implying an optimal balance between doing too little and doing too much - as a basic condition for long-term recovery [7]. When the patient agreed with this approach, he/she gave written consent and entered the program. No other selection criterion was used, except the impossibility of attending an outpatient setting (e.g., because of geographical reasons). Besides the CFS group, the patients' significant others (SO) (n=62, in 70% the partners) also participated in the study. Therapeutic intervention The treatment lasted 6 months. During the first month, it took 2 days a week (4h a day) and was then gradually reduced to 1 day in a month. For an extensive description of the therapeutic program, see Ref. [6]. In line with the therapeutic rationale, the cognitive-behavioral therapist placed much emphasis on discussing concrete modalities of activity pacing, while at the same time, encouraging patients to improve their physical condition as much as possible. Graded exercise therapy consisted of 1-h sessions, with an initial training intensity corresponding to the work load at 60% of the heart rate reserve, calculated on the basis of a maximum exercise test. Starting from Week 3, all participants were asked to exercise three times a week (including at home). The training program was adjusted to a slower pace when deemed necessary, after discussion with the patient. Instruments The 'Vragenlijst voor Habituele Actiebereidheid' (Questionnaire for Habitual Action-proneness) (HAB) was used to measure the degree of action-proneness [8]. This is a well-validated Dutch questionnaire consisting of 50 items (to be answered as 'correct' or 'incorrect'), capturing beliefs, attitudes, and tendencies with respect to physical as well as mental activity. To evaluate possible changes in action-proneness, we administered the HAB questionnaire to the patients in three different forms at different time points. HAB1 items retrospectively focused on premorbid action-proneness, for example, 'Before I got ill... I didn't need much time to think before making a decision.' HAB2 items focused on current (i.e., pretreatment) action-proneness, for example, 'I enjoy exerting myself to the limit.' Finally, HAB3 items focused on posttreatment action-proneness (or activity- related intentions), for example, 'From now on... no effort is too much for me.' The SOs were also instructed to give their opinion about the patient's action-proneness, for example, 'Before he/she got ill... he/she took any job, if only to have something to do' (premorbid HAB-SO1), and, 'If he/she had a choice, he/she would sleep far into the day' (pretreatment HAB-SO2). Procedure A naturalistic pre/post design was used. At the start of the program, patients were asked to fill in HAB1 and HAB2. The SOs were asked to fill in HAB-SO1 and HAB-SO2 at the same time point. Immediately after the last treatment session, patients filled in HAB3. Full anonymity and confidentiality were guaranteed to both patients and SOs. Statistical analyses To compare premorbid, pretreatment and posttreatment action-proneness scores, we used paired t tests. All statistics were carried out with the software program Statistica [9]. Results As shown in Tables 1 and 2, the patients' pretreatment action-proneness levels (M=17.75, S.D.=6.21) were significantly lower than premorbid levels (M=38.27, S.D.=6.65, P<.001). On the other hand, posttreatment action- proneness levels (M=20.23, S.D.=4.65) were significantly higher than pretreatment levels (P=.03) but still significantly lower than premorbid levels (P<.001). The SOs scored the patients' pretreatment action-proneness also as lower (M=19.95, S.D.=6.97) than the patients' premorbid action-proneness (M=35.03, S.D.=7.80, P<.001). Discussion First, the results of this study are in line with our previous findings that CFS patients describe themselves, before illness onset, as highly 'action-prone' [4]. Moreover, as in our former research [5], patients' self-descriptions were paralleled by the opinion of their SOs. Second, after illness onset, patients' reported action-proneness levels strongly decreased - an expected finding that could be considered a consequence of symptoms and illness-related functional limitations. Third, when at the end of the treatment patients were asked to describe their activity-related intentions, their action-proneness levels increased again, but without reaching retrospectively reported premorbid levels. Together with the fact that our treatment program led to a significant amelioration of the patients' reported global physical and mental functioning, and an increase of their psychological attributions and self-efficacy (see Ref. [6] for more details), the results of the present study may be interpreted as the patients' readiness for adaptive activity management and realistic adjustment of lifestyle and life goals. However, the following methodological limitations should be taken into account. Both patients' and SOs' reports might be retrospectively biased [10]. In addition, we cannot be sure that the patients' intentions would lead to actual changes in their daily life. Also, our multidisciplinary setting does not indicate which therapeutic ingredients are necessary or sufficient for the desired behavior modifications. Finally, the present study was uncontrolled - although the results of our larger outcome study [6] make it plausible that action-proneness changes were due to the therapeutic intervention. Taken together, controlled prospective research using objective measures of physical and psychosocial functioning is necessary to ascertain whether these preliminary therapeutic findings in CFS patients reflect a real shift 'toward a new balance.' Acknowledgment The authors thank the team members of the CFS Reference Centre of the University Hospitals Leuven for their help in the collection of data. Tables Table 1. Means and S.D.'s for the HAB questionnaires at different time points in CFS patients and SOs ------------------------------------------------------------------------ CFS patients SOs ------------------------------ ------------------------ HAB1 HAB2 HAB3 HAB-SO1 HAB-SO2 (n=62) (n=58) (n=56) (n=62) (n=62) ------------------------------------------------------------------------ Mean 38.27 17.75 20.23 35.03 19.95 S.D. 6.65 6.21 4.65 7.80 6.97 ------------------------------------------------------------------------ HAB1: patients, premorbid; HAB2: patients, pretreatment; HAB3: patients, posttreatment; HAB-SO1: SOs, premorbid; HAB-SO2: SOs, pretreatment. Table 2. Paired sample statistics for the HAB questionnaires at different time points in CFS patients and SOs ------------------------------------------------------------------------ HAB1 vs. HAB2 vs. HAB1 vs. HAB-SO1 vs. HAB2 HAB3 HAB3 HAB-SO2 ------------------------------------------------------------------------ t=19.22 t=-2.19 t=17.09 t=10.89 P<.001 P=.03 P<.001 P<.001 ------------------------------------------------------------------------ HAB1: patients, premorbid; HAB2: patients, pretreatment; HAB3: patients, posttreatment; HAB-SO1: SOs, premorbid; HAB-SO2: SOs, pretreatment. References [1] Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;121:953-9. [2] Van Houdenhove B, Egle UT. Fibromyalgia: a stress disorder? Piecing the biopsychosocial puzzle together. Psychother Psychosom 2004;73:267-75. [3] Whiting P, Bagnall AM, Sowden AL, Cornell JE, Mulrow CD, Ramirez G. 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Vragenlijst voor Habituele Actiebereidheid [Questionnaire for Habitual Action-proneness]. Groningen: Swets & Zeitlinger, 1979. [9] Statistica for Windows [Computer Program Manual]. Tulsa, OK, 2001. [10] Riley MS, O'Brien CJ, McCluskey DR, Bell NP, Nicholls DP. Aerobic work capacity in patients with chronic fatigue syndrome. BMJ 1990;301:953-6. (c) 2006 Elsevier/ScienceDirect