Illness beliefs:
The literature on the role of illness beliefs/attributions on the part of both patients and health care professionals is widely divided and some have gone as far as suggesting that chronic fatigue is merely a question of attribution.1–3 The findings in a study4 of 60 CFS patients suggested that physical illness attributions were less important in determining outcome (at least in treatment studies), and that good outcome was associated with change in avoidance behavior and related beliefs, rather than causal attributions. Another study5 of 137 CFS patients concluded that the belief that one’s actions can influence outcomes modified the relationship between illness accommodation and both fatigue and impairment; adverse outcomes were associated with accommodating to illness only in the context of lower levels of perceived control. It was suggested, therefore, that interventions that either discourage avoidance of activity or enhance perceived control could benefit the course of the illness. A series of regression analyses in one study6 showed illness representations to be stronger predictors of adaptive outcome than coping scores.
Some studies emphasize the patient’s attributions of disease as the cause for symptomatology. For instance, a study7 of 153 women from the Toronto area who were attending a women’s health symposium yielded an overwhelming endorsement of social determinants as the cause of their persistent fatigue. Although depression and anxiety formed the most robust associations with persistent fatigue in primary care and community studies, women in this sample ranked these factors in seventh place in their attributions. Similarly, although physicians often assume physical causes for fatigue, women rank physical health low in their own attributions. A study8 comparing medical records of 133 CFS and 75 multiple sclerosis permanent health insurance claimants and 162 nonclaimant controls cases showed that CFS patients recorded significantly more illnesses at time of proposal for insurance than the two control groups, and had significantly more claims between proposal and diagnosis of their disorder. These observations led the authors to conclude that there is no support for a specific viral or immunological explanation for CFS and that abnormal illness behavior is of great importance.
Other studies have emphasized the role of the physician in disease perpetuation. For instance, a study9 of 2,097 individuals in the Netherlands found that more psychosocially attributed fatigue was found to correlate with consultations characterized by less physical examination, more diagnostic procedures to reassure, fewer diagnostic procedures to discover underlying pathology, more counseling, less medical treatment, less prescription, and a longer duration than consultations with more somatically attributed fatigue. The study concluded that general practitioners do not discriminate between social groups when attributing fatigue to either somatic or psychosocial causes. The presence and character of other complaints and underlying diseases/problems, rather, relate to the general practitioners’ somatic psychosocial attributions, which are then associated with particular aspects of the consultation. Research in one study10 of 609 CFS patients suggested several patterns of relationships between doctors and patients, and attitudes to health and illness, which may alert doctors to patients’ perceptions, beliefs, encoded constructs, and patterns of relating that affect responses to treatment. The study suggested that more attention from doctors to patients who are experiencing the stress of chronic illness is indicated. The latter view is reinforced by another study11 that found that CFS patients complained about insufficient informational as well as emotional support from their doctors and, as a consequence, most opted for alternative or complementary forms of treatment. In addition, disagreements over illness etiology and treatment precluded effective cooperation.
Some studies have addressed the influence of illness attributions by family members on the disease process. A study12 of adolescents with CFS in the Netherlands concluded that factors contributing to the persistence of fatigue are somatic attributions, illness-enhancing cognitions, and behavior of parents as well as physical inactivity. The role of the physician and the role of parents can enhance the problems. The treatment should focus on decreasing the somatic attributions, on reinforcement by the parents of healthy adolescent behavior, on the gradual increase of physical activity, and on decreasing attention (including medical attention) for the somatic complaints. A women’s study13 showed that some women respondents were able to identify specific ways in which family and important others could help them to decrease or prevent their fatigue. However, many expressed the belief that significant others were unconcerned and unwilling to assist them in any substantive way. Analysis of responses in one study14 of 66 CFS participants indicated that, whereas the most commonly described explanation for the illness was a physical one, more than half the patients also believed “stress” had played a role. Patients believed that they could partially control the symptoms by reducing activity, but felt helpless to influence the physical disease process and hence the course of the illness. Patients reported that they had arrived at these beliefs about the illness after prolonged reflection on their own experiences combined with the reading of media reports, self-help books, and patient group literature. The views of health professionals played a relatively small role.
In conclusion, attribution contributes to the course of CFS, but it is not its sole determinant.15 The presence of strong somatic attributions appears to be one of the perpetuating factors in CFS, but not the only one. Many CFS patients present a self-diagnosis. Communication problems...
