1. Tired all the time: The role of acceptance in Chronic Fatigue Syndrome Kevin E. Vowles, Ph.D. University of Bath Association for Contextual Behavioral Science 01 July 2009

2. Background There are clinical and conceptual parallels between chronic pain and chronic fatigue.There are clinical and conceptual parallels between chronic pain and chronic fatigue. In ACT, there is an assumption that common processes exist across the spectrum of human problems.In ACT, there is an assumption that common processes exist across the spectrum of human problems.

3. 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.

4. Some quick stats: It is a diagnosis of exclusion.It is a diagnosis of exclusion. 50%+ are depressed50%+ are depressed There is no reliably effective medical interventionThere is no reliably effective medical intervention –CBT and Graded exercise seem to work ok according to meta-analyses.

5. What do we know from chronic pain (& other chronic conditions too!) Less struggling with (insert your bad stuff) is associated with better functioning.Less struggling with (insert your bad stuff) is associated with better functioning. More engagement in (insert what makes you tick) is associated with better functioning.More engagement in (insert what makes you tick) is associated with better functioning.

6. What, then, does “acceptance” of chronic pain look like? Participation in important activities of living while pain is present.Participation in important activities of living while pain is present. –Activity Engagement “I am getting on with the business of living no matter what my level of pain is.” Allowing pain to be present without attempts to avoid or control it, especially when such attempts inhibit the above.Allowing pain to be present without attempts to avoid or control it, especially when such attempts inhibit the above. –Pain Willingness “I have to struggle to do things when I have pain” The Chronic Pain Acceptance Questionnaire (20 Items; 2 subscales)

7. “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 Fatigue Acceptance Questionnaire (20 Items)

8. Two statistical questions: Does the FAQ have the same subscales (i.e., factor structure) as the CPAQ?Does the FAQ have the same subscales (i.e., factor structure) as the CPAQ? Do scores on the FAQ account for variance in functioning above and beyond fatigue?Do scores on the FAQ account for variance in functioning above and beyond fatigue?

9. 187 Participants Assessment Clinic, Tertiary care settingAssessment Clinic, Tertiary care setting 75% women75% women Mean age 40 yrs (+ 13)Mean age 40 yrs (+ 13) 97% white97% white Symptom duration – 3.8 yrs (median), 6.5 yrs (mean)Symptom duration – 3.8 yrs (median), 6.5 yrs (mean) Diagnoses included CFS (59%), ME (20%), & Post-viral fatigue (12%)Diagnoses included CFS (59%), ME (20%), & Post-viral fatigue (12%) 87% had pain87% had pain 87% reported altered sleep87% reported altered sleep 61% unemployed61% unemployed

10. Factor Analysis Range of factor structures evaluated (2 – 4 factors) 2 factors: Activity Engagement ( α = 0.87) Fatigue Willingness ( α = 0.70) Scale content identical to CPAQ, with the exception of 2 items which switched.

11. Measures Fatigue SeverityFatigue Severity DisabilityDisability –Physical –Psychosocial DepressionDepression Anxiety “Sensitivity”Anxiety “Sensitivity” Usual Pain Intensity Average Daily Uptime Work Status Values Success

12. Regression If we knew about acceptance, would we know more about how one is functioning than if we only knew fatigue alone?If we knew about acceptance, would we know more about how one is functioning than if we only knew fatigue alone? –Controlled for gender, age, symptom duration. –Entered fatigue severity. –Entered both acceptance subscale scores.

13. Physical Disability

14. Psychosocial Disability

15. Depression

16. Usual Pain

17. Anxiety Sensitivity

18. Daily Uptime (hrs)

19. Work (yes/no)

20. Values Success

21. More questions? Can we define the “problem” of CFS as a problem of behavior (and not of fatigue)?Can we define the “problem” of CFS as a problem of behavior (and not of fatigue)? Is it possible that control efforts directed at meaningful living will contribute to different results than efforts direct towards fatigue reduction?Is it possible that control efforts directed at meaningful living will contribute to different results than efforts direct towards fatigue reduction?

22. Thanks for your attention k.vowles@bath.ac.uk www.bath.ac.uk/pain-management/