This study captured the common and unique aspects of fatigue from a cognitive-behavioural perspective in individuals with HCV infection and clinically significant fatigue.
Interviews were gathered from fourteen participants with HCV, (64% women; age >18 years)
The fatigue definitely is: How do I feel at this moment? It's a day to day thing. I do make the plans and of course when that time comes if I can't do it, I just don't do it.
(Female, age 48, living with HCV infection for 8 years)
I'm not overweight. I have no blood pressure problems, I'm not diabetic. I have nothing. I have no illnesses whatsoever other than hep C. That's the only problem I have and that's the only thing that's doing this to my body.
(Female, age 61, living with HCV for 20 years)
I think I can regulate it in the sense that I know I'm limited with what I can do so I don't try to push myself before I get started. I say I'm going to do this much, this much I feel like I accomplish and I can. And so it allows me to be in control rather than let the situation control me.
(Male, age 57, living with HCV infection for 3 years)
Abstract with Discussion provided below, view original full text article, here.
British Journal of Health Psychology
Volume 21, Issue 1
February 2016
Pages 157–172
Dora Zalai1,*, Colleen E. Carney1, Morris Sherman2, Colin M. Shapiro3,4 andKelly McShane
Article first published online: 6 AUG 2015 DOI: 10.1111/bjhp.12155 © 2015 The British Psychological Society
Abstract
Objectives
Fatigue is a leading concern of patients with chronic hepatitis C virus (HCV) infection. Despite its clinical significance, fatigue in HCV is poorly understood and therefore invariably under-treated. A cognitive-behavioural approach offers a framework to understand and treat fatigue, but the characteristics of fatigue in chronic HCV infection have not been documented from a cognitive-behavioural perspective. This study captured the common and unique aspects of fatigue from a cognitive-behavioural perspective in individuals with HCV infection and clinically significant fatigue.
Objectives
Fatigue is a leading concern of patients with chronic hepatitis C virus (HCV) infection. Despite its clinical significance, fatigue in HCV is poorly understood and therefore invariably under-treated. A cognitive-behavioural approach offers a framework to understand and treat fatigue, but the characteristics of fatigue in chronic HCV infection have not been documented from a cognitive-behavioural perspective. This study captured the common and unique aspects of fatigue from a cognitive-behavioural perspective in individuals with HCV infection and clinically significant fatigue.
Design
Cross-sectional, qualitative using a critical realism approach.
Methods
Fourteen individuals (64% women; age >18 years) participated in semi-structured interviews. The interviews documented the features, course, and perceived antecedents of fatigue; fatigue-specific cognitions; fatigue management behaviours; and the functional impact of fatigue.
Results
Participants' descriptions included the aspects of fatigue that have been targets of cognitive-behavioural therapy in other medical conditions, including attributing fatigue to the illness; expectation of chronicity; low control; and fatigue-driven coping. There were also components of fatigue experience that appear to be unique characteristics of fatigue related to HCV, including predominantly physical fatigue; high acceptance of fatigue; and liver-protective diet as a fatigue management behaviour.
Conclusions
This was the first study to document the experience of fatigue in chronic HCV infection in a cognitive-behavioural framework. The findings suggest that the cognitive-behavioural approach can be applied to fatigue in chronic HCV infection. This would open an avenue to alleviate fatigue and thus improve the primary patient-reported outcome of the disease.
Discussion ONLY
Download Complete Article:
This is the first study documenting the experience of fatigue in chronic HCV infection from a cognitive-behavioural perspective. Patients' descriptions revealed clinically important components of the fatigue experience which appear to overlap with that of other conditions and could be seen as specific treatment targets (Table 4). The patient interviews also highlighted the aspects of fatigue that appear to be unique to HCV infection compared to other health conditions, and this will need to be considered when designing interventions for patients with chronic HCV infection (Table 4). The results indicate that fatigue in HCV can be conceptualized within a cognitive-behavioural framework and suggest that CBT may be applied for the treatment of fatigue in chronic HCV infection.
A number of clinically important cognitions and behaviours were discussed in the interviews that have been shown to amplify fatigue and lead to adverse fatigue outcome in previous research. These include attributing fatigue to the infection; perception and expectations of chronicity; low control beliefs; excessive passive rest; and fatigue-driven coping.This is the first study documenting the experience of fatigue in chronic HCV infection from a cognitive-behavioural perspective. Patients' descriptions revealed clinically important components of the fatigue experience which appear to overlap with that of other conditions and could be seen as specific treatment targets (Table 4). The patient interviews also highlighted the aspects of fatigue that appear to be unique to HCV infection compared to other health conditions, and this will need to be considered when designing interventions for patients with chronic HCV infection (Table 4). The results indicate that fatigue in HCV can be conceptualized within a cognitive-behavioural framework and suggest that CBT may be applied for the treatment of fatigue in chronic HCV infection.
The association between somatic fatigue attributions and intense fatigue is consistent with research in chronic fatigue syndrome, cancer, and multiple sclerosis (Bol, Duits, Hupperts, Vlaeyen, & Verhey, 2009; Servaes, Verhagen, & Bleijenberg, 2002; Sharpe, 1997). Attributing fatigue to the infection is a central issue because it fuels other non-adaptive fatigue cognitions. One of these cognitions is patients' expectations that their fatigue will be chronic and worsening, in parallel with the course of their disease. Indeed, expectations of chronicity of fatigue symptoms, even in a context of a benign virus infection, predict the development of chronic fatigue within 6 months (Moss-Morris, Spence, & Hou, 2011).
In addition to expectations about chronicity, attributing fatigue to the disease also increases fatigue via emotional pathways. A previous qualitative study in HCV, as well as evidence in cancer, multiple sclerosis, and chronic fatigue syndrome, has also shown that being fatigued may become emotionally threatening and distressing if patients believe fatigue is a sign of disease progression/recurrence/flare-up (Bol et al., 2009; Glacken, Coates, Kernohan, & Hegarty, 2003; Servaes et al., 2002; Sharpe, 1997). There is evidence to support the idea that negative emotions can amplify unpleasant physical sensations (e.g., fatigue) because they increase self-focused attention and monitoring (Mor & Winquist, 2002).
A further example of clinically important, non-adaptive cognitions was participants' beliefs that they had little control over their fatigue. Participants with low control beliefs preferred predominantly fatigue-driven, passive coping behaviours, including excessive rest and avoidance of activities. This behavioural adaptation to fatigue characterizes and amplifies other chronic fatigue conditions and has been the primary treatment target in CBT for chronic fatigue syndrome (Bol et al., 2010; Leeuw et al., 2007).
In addition to the fatigue-specific cognitive-behavioural factors that appear to be similar to what has been found in other disorders, patients' descriptions also revealed the following unique categories: Predominantly physical fatigue; high acceptance; cognitive avoidance; positive thinking; active rest; and engaging in physical and pleasurable activities.
In relation to describing fatigue as a physical sensation, this study is consistent with a previous qualitative study on HCV infection (Glackenet al., 2003). In contradistinction, patients with cancer and multiple sclerosis see physical and mental fatigue as equally salient (Ford, Trigwell, & Johnson, 1998; de Raaf, de Klerk, & van der Rijt, 2013). An adaptation of CBT for fatigue in chronic HCV infection will need to take this difference into consideration, perhaps by incorporating a treatment component that targets physical fatigue (e.g., graded exercise or muscle relaxation). It is important to be aware when implementing these interventions that a unique antecedent of fatigue was ‘bending’, which could be related to physical discomfort caused by an enlarged liver.
A second characteristic aspect of fatigue in this study was high acceptance. Acceptance of fatigue has been observed in some medical conditions in which patients accept fatigue as belonging to the illness, whereas acceptance is less typical in other medical conditions (e.g., chronic insomnia and chronic fatigue syndrome). Acceptance of unpleasant physical sensations is generally adaptive in chronic conditions that cannot be cured by routine medical interventions, for example in chronic pain conditions or in chronic fatigue syndrome (Brooks, Rimes, & Chalder, 2011; McCracken & Vowles, 2008; Van Damme, Grombez, Van Houdenhove, Mariman, & Michielsen, 2006). In the situation when fatigue is caused by treatable a condition, for example by an undiagnosed sleep disorder (which is common in chronic HCV infection), accepting chronic fatigue as an inevitable part of the infection is non-adaptive. Encouraging patients to adopt behaviours that promote sleep (e.g., avoiding excessive time in bed and stimulus control) should be a part of CBT for patients with poor sleep and high fatigue.
Finally, participants in this study described diet as a typical coping behaviour, which also appears to be specific for this illness. Being on a liver-protective or ‘anti-inflammatory’ diet in particular appears to be a logical attempt to fight fatigue in a condition that patients associate with accumulation of toxins in the body. From a behavioural perspective, however, this coping strategy was non-adaptive as it did not combat chronic fatigue; instead, it confirmed patients' beliefs that fatigue was uncontrollable. Instead of pursuing non-adaptive behaviours, for example ‘antitoxic diet’, CBT can help patients to acquire and practise new behaviours that are effective in reducing the sensation and the impact of fatigue.
A minority of participants indicated a self-discovery of such behaviours in the current study, for instance regular physical activity, engaging in pleasurable activities, and ‘active rest’. Indeed, physical activity (particularly graded exercise) has been successfully applied for the treatment of fatigue in cancer and in chronic fatigue syndrome (Jacobsen, Donovan, Vadaparampil, & Small, 2007; White et al., 2011). It remains to be evaluated whether gradually re-introducing pleasurable activities and scheduling active, instead of passive rest could be an active treatment component of HCV-related fatigue.
As the above findings indicate, there are a number of cognitions and behaviours that can be incorporated into a cognitive treatment of fatigue in chronic HCV infection. For example, fatigue attributions can be modified in a single session with a simple, cognitive intervention (Harris & Carney, 2012). Educating patients to recognize a range of modifiable contributors of fatigue (e.g., excessive rest, fatigue-driven coping, feeling upset and guilty when being tired, giving up pleasurable activities) allows them to actively take steps to successfully control their fatigue, instead of accepting it as an inevitable, uncontrollable ‘symptom’ of the illness. Planning activities and following through with the plan, instead of making decisions based on momentary fatigue level, has been the central component of the cognitive-behavioural treatment for fatigue and could be recommended for patients with fatigue-driven coping. Focusing on the physical aspects of fatigue and planning physical activities that do not require bending should be disease-specific themes in CBT for fatigue in patients with HCV infection.
It is noteworthy that some patients attributed their fatigue to comorbid medical conditions (including sleep problems) in addition to the hepatitis infection. These attributions and the contribution of comorbidities to the fatigue experience of patients should be taken into account in fatigue assessment and treatment. There was a variability in the daytime course of fatigue in this study, with some individuals reported that fatigue started early, while for others fatigue became noticable later, during the day. Participants describing that their fatigue started in the morning also experienced sleep problems in this study. Sleep problems, in particular insomnia and obstructive sleep apnoea, are common in chronic medical conditions and cause non-restorative sleep, which patients may describe as morning fatigue (Budhiraja, Roth, Hudgel, Budhiraja, & Drake, 2011; Young, Skatrud, & Peppard, 2004). It is therefore imperative to assess sleep disorders in individuals with chronic medical conditions and high fatigue. For patients with insomnia, CBT is the front-line treatment approach, and sleep-focused CBT for insomnia has been shown to reduce fatigue in medical populations, for example in patients with cancer (Espie et al.,2008; Ritterband et al., 2012). Sleep- and fatigue-focused CBT can also be combined to enhance fatigue outcomes.
The study has refined the CBT model of fatigue as it has captured features of fatigue, cognitions, and behaviours that has not been identified or related to the CBT model in previous research. Notwithstanding the value of using the CBT approach, the authors recognize that their orientation in behavioural medicine and in CBT made a mark on the research questions, the research objectives, and the research design, and by taking a CBT lens, they did not explore fatigue from other (e.g., cultural discourses, environmental, and social) perspectives. A limitation of the data collection was a possible selection bias, as only those willing to discuss their fatigue volunteered to participate. At the same time, these were the individuals for whom fatigue was a pressing issue, and therefore, they may be the ones who would benefit most from fatigue interventions. The inclusion of quotes that contradicted the main findings (e.g., patients' views that chronic fatigue does not always cause functional impairment) reflects the researchers' attempt to demonstrate the validity of the findings (Binderet al., 2012). Using an interview schedule and collecting data until saturation increased the probability that crucially important information relating specifically to the research questions was not missed. The unique strength of the qualitative approach was that it allowed the emergence of themes that could not have been captured with existing questionnaires. Future studies should expand these findings by developing the items identified into a quantitative format and applying it in larger samples.
In conclusion, this study documents for the first time the fatigue experience of patients with chronic HCV infection using a cognitive-behavioural framework. The findings suggest that a cognitive-behavioural conceptualization and treatment could be applied to fatigue in chronic HCV infection. However, the specific aspects of fatigue experience need to be taken into account in the CTB for fatigue in this condition. The key clinical implication of the findings is that CTB would open a new treatment avenue to alleviate fatigue and thus improve the primary patient-reported outcome of chronic HCV infection.
Continue reading..
No comments:
Post a Comment