Tired all the time:Tired all the time:The role of acceptance in The role of acceptance in

Chronic Fatigue SyndromeChronic Fatigue Syndrome

Kevin E. Vowles, Ph.D.Kevin E. Vowles, Ph.D.University of BathUniversity of Bath

Association for Contextual Behavioral Association for Contextual Behavioral ScienceScience

01 July 200901 July 2009

BackgroundBackground

• There are clinical and conceptual There are clinical and conceptual parallels between chronic pain and parallels between chronic pain and chronic fatigue.chronic fatigue.

• In ACT, there is an assumption that In ACT, there is an assumption that common processes exist across the common processes exist across the spectrum of human problems.spectrum of human problems.

What is CFS(/ME)?What is CFS(/ME)?

• Persistent fatiguePersistent fatigue• ““Brain fog”Brain fog”• Post-exertional malaisePost-exertional malaise• Sleep is not refreshingSleep is not refreshing• Pain is very commonPain is very common• Flu-like symptoms very commonFlu-like symptoms very common• Often lots of worry, sadness, etc.Often lots of worry, sadness, etc.

Some quick stats:Some quick stats:

• It is a diagnosis of It is a diagnosis of exclusionexclusion..

• 50%+ are depressed50%+ are depressed

• There is no reliably effective medical There is no reliably effective medical interventionintervention– CBT and Graded exercise seem to work CBT and Graded exercise seem to work

ok according to meta-analyses.ok according to meta-analyses.

What do we know from chronic What do we know from chronic pain (& other chronic conditions pain (& other chronic conditions

too!)too!)• Less struggling with (Less struggling with (insert your bad insert your bad

stuff)stuff) is associated with better is associated with better functioning.functioning.

• More engagement in (More engagement in (insert what insert what makes you tickmakes you tick) is associated with ) is associated with better functioning.better functioning.

What, then, does What, then, does “acceptance” of chronic “acceptance” of chronic

pain look like?pain look like?• Participation in important activities of Participation in important activities of living while pain is present.living while pain is present.– Activity EngagementActivity Engagement

•“I am getting on with the business of living no matter what my level of pain is.”

• Allowing pain to be present without Allowing pain to be present without attempts to avoid or control it, attempts to avoid or control it, especially especially when such attempts inhibit the above.when such attempts inhibit the above.– Pain Willingness Pain Willingness

•“I have to struggle to do things when I have pain”

The Chronic Pain The Chronic Pain Acceptance QuestionnaireAcceptance Questionnaire

(20 Items; 2 subscales)(20 Items; 2 subscales)

•“I am getting on with the business of living regardless of my level of fatigue.”

•“I have to struggle to do things when I am fatigued”

The The Fatigue Fatigue Acceptance Acceptance QuestionnaireQuestionnaire

(20 Items)(20 Items)

Two statistical Two statistical questions:questions:

• Does the FAQ have the same Does the FAQ have the same subscales (i.e., factor structure) as subscales (i.e., factor structure) as the CPAQ?the CPAQ?

• Do scores on the FAQ account for Do scores on the FAQ account for variance in functioning above and variance in functioning above and beyond fatigue?beyond fatigue?

187 Participants187 Participants

• Assessment Clinic, Tertiary care settingAssessment Clinic, Tertiary care setting• 75% women75% women• Mean age 40 yrs (Mean age 40 yrs (++ 13) 13)• 97% white97% white

• Symptom duration – 3.8 yrs (median), 6.5 yrs Symptom duration – 3.8 yrs (median), 6.5 yrs (mean)(mean)

• Diagnoses included CFS (59%), ME (20%), & Post-Diagnoses included CFS (59%), ME (20%), & Post-viral fatigue (12%)viral fatigue (12%)

• 87% had pain87% had pain• 87% reported altered sleep87% reported altered sleep• 61% unemployed61% unemployed

Factor AnalysisFactor Analysis

Range of factor structures evaluated Range of factor structures evaluated

(2 – 4 factors)(2 – 4 factors)

2 factors:2 factors:

Activity Engagement (Activity Engagement (αα = 0.87) = 0.87)

Fatigue Willingness (Fatigue Willingness (αα = 0.70) = 0.70)

Scale content identical to CPAQ, with the Scale content identical to CPAQ, with the exception of 2 items which switched.exception of 2 items which switched.

MeasuresMeasures• Fatigue SeverityFatigue Severity

• DisabilityDisability– PhysicalPhysical– PsychosocialPsychosocial

• DepressionDepression

• Anxiety Anxiety “Sensitivity”“Sensitivity”

• Usual Pain Usual Pain IntensityIntensity

• Average Daily Average Daily UptimeUptime

• Work StatusWork Status

• Values SuccessValues Success

RegressionRegression

• If we knew about acceptance, would If we knew about acceptance, would we know more about how one is we know more about how one is functioning than if we only knew functioning than if we only knew fatigue alone?fatigue alone?

– Controlled for gender, age, symptom Controlled for gender, age, symptom duration.duration.

– Entered fatigue severity.Entered fatigue severity.– Entered both acceptance subscale scores.Entered both acceptance subscale scores.

Physical DisabilityPhysical Disability

24%

7%

69%

Fatigue

Acceptance

Unknown

Psychosocial DisabilityPsychosocial Disability

25%

11%

64%

Fatigue

Acceptance

Unknown

DepressionDepression

17%

18%

65%

Fatigue

Acceptance

Unknown

Usual PainUsual Pain8%

4%

88%

Fatigue

Acceptance

Unknown

Anxiety SensitivityAnxiety Sensitivity3%

15%

82%

Fatigue

Acceptance

Unknown

Daily Uptime (hrs)Daily Uptime (hrs)9%

12%

79%

Fatigue

Acceptance

Unknown

Work (yes/no)Work (yes/no)4%

5%

91%

Fatigue

Acceptance

Unknown

Values SuccessValues Success14%

21%

65%

Fatigue

Acceptance

Unknown

More questions?More questions?

• Can we define the “problem” of CFS Can we define the “problem” of CFS as a problem of behavior (and not of as a problem of behavior (and not of fatigue)?fatigue)?

• Is it possible that control efforts Is it possible that control efforts directed at meaningful living will directed at meaningful living will contribute to different results than contribute to different results than efforts direct towards fatigue efforts direct towards fatigue reduction?reduction?

Thanks for your Thanks for your attentionattention

k.vowles@bath.ac.uk

www.bath.ac.uk/pain-management/