A Biopsychosocial Approach to HIV Fatigue: A Cross-Sectional and Prospective Analysis to Identify Key Modifiable Factors.

This study aimed to identify the prevalence and predictors of current fatigue and fatigue at 1-year follow-up, in people with HIV. Participants were recruited from HIV outpatient clinics in London, England. We explored a range of bio-psychosocial factors associated with current fatigue severity, identifying the most salient factors in a multifactorial model. A prospective study explored the predictive value of specific psychological and behavioral factors in predicting fatigue severity at one year. Sixty-four of 131 (49%) participants met the criteria for clinically significant fatigue at baseline. Psychological and behavioral variables, but not immune-virologic markers or antiretroviral treatment, were associated with current fatigue severity. In the multifactorial model, catastrophizing and distress independently predicted current fatigue severity. Higher levels of fatigue at 1 year was predicted by baseline catastrophizing, symptom focusing, distress and sleep quality, when controlling for baseline fatigue, clinical and demographic variables. These findings suggest psychological and behavioral factors are important in the maintenance of fatigue in people with HIV and identify potential opportunities for treatment. Future interventions for fatigue in HIV should not only address anxiety, depression and distress but could be optimized by targeting psychological processes such as catastrophic thinking styles and symptom focusing.

Attentional Processing and Interpretative Bias in Functional Neurological Disorder.

OBJECTIVE: Altered attentional processing (automatically attending to negative or illness-relevant information) and interpretative biases (interpreting ambiguous information as negative or illness relevant) may be mechanistically involved in functional neurological disorder (FND). Common mechanisms between FND and chronic fatigue syndrome (CFS) have been proposed but not compared experimentally. METHODS: We compared the cognitive task performance of FND, CFS, and healthy control (HC) groups. The tasks assessed attentional bias toward illness-relevant stimuli (visual probe task), attentional control (attention network task), and somatic interpretations (interpretative bias task), alongside self-reported depression, anxiety, fatigue, and general health. RESULTS: Thirty-seven participants diagnosed with FND, 52 participants diagnosed with CFS, and 51 HC participants were included. Although participants with CFS showed attentional bias for illness-relevant stimuli relative to HC (t = -3.13, p = .002, d = 0.624), individuals with FND did not (t = -1.59, p = .118, d = 0.379). Both the FND (t = 3.08, p = .003, d = 0.759) and CFS (t = 2.74, p = .007, d = 0.548) groups displayed worse attentional control than did the HC group. Similarly, the FND (t = 3.63, p < .001, d = 0.801) and CFS groups (t = 4.58, p < .001, d = 0.909) showed more somatic interpretative bias than did the HC group. CONCLUSIONS: Similar attentional control deficits and somatic interpretative bias in individuals with FND and CFS support potential shared mechanisms underlying symptoms. Interpretative bias toward somatic and illness-relevant stimuli in functional disorders may prove a therapeutic target.

Cross-Cultural Study of Information Processing Biases in Chronic Fatigue Syndrome: Comparison of Dutch and UK Chronic Fatigue Patients.

PURPOSE: This study aims to replicate a UK study, with a Dutch sample to explore whether attention and interpretation biases and general attentional control deficits in chronic fatigue syndrome (CFS) are similar across populations and cultures. METHOD: Thirty eight Dutch CFS participants were compared to 52 CFS and 51 healthy participants recruited from the UK. Participants completed self-report measures of symptoms, functioning, and mood, as well as three experimental tasks (i) visual-probe task measuring attentional bias to illness (somatic symptoms and disability) versus neutral words, (ii) interpretive bias task measuring positive versus somatic interpretations of ambiguous information, and (iii) the Attention Network Test measuring general attentional control. RESULTS: Compared to controls, Dutch and UK participants with CFS showed a significant attentional bias for illness-related words and were significantly more likely to interpret ambiguous information in a somatic way. These effects were not moderated by attentional control. There were no significant differences between the Dutch and UK CFS groups on attentional bias, interpretation bias, or attentional control scores. CONCLUSION: This study replicated the main findings of the UK study, with a Dutch CFS population, indicating that across these two cultures, people with CFS demonstrate biases in how somatic information is attended to and interpreted. These illness-specific biases appear to be unrelated to general attentional control deficits.

A pilot study examining the effects of priming headache illness schema on attentional engagement towards pain relief medication, in those with high and low medication treatment beliefs.

Few studies have assessed the underlying theoretical components of the Common Sense Model. Past studies have found, through implicit priming, that coping strategies are embedded within illness schema. Our aim was to evaluate the effect priming 'headache' illness schema upon attentional engagement to pain relief medication and to examine the interaction with illness treatment beliefs. Attentional engagement to the pain relief medication ('Paracetamol') was assessed using a 2 (primed vs. control) × 2 (strong belief in medication efficacy vs. weak belief in medication efficacy) design. During a grammatical decision task (identifying verbs/non-verbs), participants were randomised to receive a headache prime or a control. Response latency to the target word, 'Paracetamol' was the dependent variable. 'Paracetamol' treatment beliefs were determined using the brief illness perception questionnaire. Sixty-three participants completed the experiment. There was a significant interaction between illness-primed vs. control and high vs. low treatment efficacy of Paracetamol (p < .001), suggesting an attentional disengagement effect to the coping strategy in illness-primed participants whom held stronger treatment beliefs regarding the efficacy of Paracetamol. In summary, implicit illness schema activation may simultaneously activate embedded coping strategies, which appears to be moderated by specific illness beliefs.

The presence of attentional and interpretation biases in patients with severe MS-related fatigue.

OBJECTIVE: Severe fatigue is a prevalent and disabling symptom in multiple sclerosis (MS). This study tested if a fatigue- and physical activity-related attentional bias (AB) and a somatic interpretation bias (IB) are present in severely fatigued patients with MS. Biases were compared to healthy controls and patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). METHOD: Severely fatigued patients with MS or ME/CFS and healthy controls completed a Visual Probe Task (VPT) assessing fatigue- and physical activity-related AB and an IB task that assesses the tendency to interpret ambiguous information in either a somatically threatening way or in a more neutral manner. The VPT was completed by 38 MS patients, 44 ME/CFS patients, and 46 healthy controls; the IB task was completed by 156, 40 and 46 participants respectively. RESULTS: ANOVA showed no statistically significant group differences in a fatigue-related AB or physical activity-related AB (omnibus test of interaction between topic × condition: F2,125 = 1.87; p = .159). Both patient groups showed a tendency to interpret ambiguous information in a somatically threatening way compared to healthy controls (F1,2 = 27.61, p < .001). This IB was significantly stronger in MS patients compared to ME/CFS patients. IB was significantly correlated with cognitive responses to symptoms in MS patients. CONCLUSION: MS patients tend to interpret ambiguous information in a somatically threatening way. This may feed into unhelpful ways of dealing with symptoms, possibly contributing to the perpetuation of severe fatigue in MS.

The role of attention bias malleability in experiencing pain and associated disability.

Background: Attentional processing of pain has been theorized to play a key role in the severity of pain and associated disability. In particular attentional bias towards pain information, resulting in poor pain outcomes, has been extensively researched. Recently, the idea was put forward that attention bias malleability (AM), i.e., the readiness to acquire an attentional bias irrespective of its direction, may be key in predicting poor pain outcomes. We tested this hypothesis in two studies. Methods: In Study 1, 55 healthy participants completed an AM paradigm, followed by an experimental heat pain paradigm probing pain experience and pain-related task interference. In Study 2, 71 people with chronic pain completed an AM paradigm and questionnaires probing pain experience and associated disability. Results: In Study 1, including healthy participants, no relationship was found between AM indices and experimental pain outcomes. In Study 2, including chronic pain patients, results indicated that higher levels of overall AM were related to higher levels of pain experience and disability. Conclusion: This study partially supports the hypotheses that the degree to which individuals can adapt their attentional preference in line with changing environmental conditions is associated with poor pain outcomes. However, future research is needed to clarify inconsistent findings between healthy volunteers and chronic pain patients as well as to determine the causal status of AM in poor pain outcomes.

Attentional bias malleability as a predictor of daily pain interference.

ABSTRACT: Despite a preponderance of pain-related attentional bias research, little is known about how these biases arise and change over time. We tested whether the degree of attentional bias malleability , that is, ability to acquire and relinquish patterns of selective attention towards pain information, predicts daily pain interference. Individuals with chronic pain (N = 66) completed a novel attentional bias malleability procedure based on a modified dot-probe paradigm. Participants received a contingency that encouraged an attentional preference toward and away from pain words across 2 counterbalanced blocks, and attentional bias was assessed before and after each contingency block. Participants then completed a daily diary for 7 days, including the Patient-Reported Outcomes Measurement Information System-29 pain severity and interference. Multilevel modelling was conducted to predict daily pain interference from attentional bias malleability constructs, controlling for pain severity and demographic factors. Greater attentional bias (F 1,391 = 3.97, P = 0.047), greater readiness to acquire an attentional bias (F 1,389 = 4.92, P = 0.027), and less readiness to lose an acquired attentional bias toward pain (F 1,354 = 5.18, P = 0.024) all predicted less pain interference. There was also an interaction between pain severity and overall attentional bias malleability (F 1,62 = 5.48, P = 0.023), such that as pain severity increased, those who showed greater attentional bias malleability showed less corresponding increase in their pain interference than those who showed less attentional bias malleability. This study adds new thinking to the dynamic nature of attentional bias and how such biases might arise and influence pain outcomes.

Cancer-related fatigue and functional impairment - Towards an understanding of cognitive and behavioural factors.

OBJECTIVE: Fatigue is a highly prevalent and debilitating problem in women with breast cancer. This study investigated the cognitive, behavioural, interpersonal and affective responses associated with fatigue and functional impairment for women with breast cancer undergoing chemotherapy. A nested prospective study examined factors predictive of cancer-related fatigue after three cycles of chemotherapy. METHOD: 159 women with breast cancer who were about to begin or undergoing chemotherapy completed a range of measures. Correlational and multiple regression analyses explored associations between fatigue severity, functioning and a range of psychological, behavioural, demographic and clinical variables. Forty-two patients were followed-up prospectively to examine the relationship between psychosocial variables, fatigue and functioning after three cycles of chemotherapy. RESULTS: A range of cognitive, behavioural and affective variables were associated with increased fatigue severity and poorer functioning. Key cognitive and behavioural correlates included, all-or-nothing behaviour, avoidance behaviour, cancer-related catastrophising and critical/punishing responses from others. For the women in the nested prospective study, fatigue significantly increased after three cycles of chemotherapy. Increased fatigue was predicted by increased anxiety before starting chemotherapy. CONCLUSIONS: Behavioural factors and cancer-specific cognitions make important contributions to cancer-related fatigue and associated impairments. Such factors are potentially amenable to change within the context of cognitive behavioural therapy.

Psychometric properties of the Positive and Negative Affect Scale for Children (PANAS-C) in children with anxiety disorders.

This study investigated the psychometric properties of the Positive and Negative Affect Scale for Children (PANAS-C) (Laurent et al. Psychol Asses 1: 326-338, 1999) in a sample of 139 children (ages 7-14 years) diagnosed with a principal anxiety disorder. Results from this study provided support for the convergent validity of the PANAS-C with established measures of childhood anxiety and depression. As predicted, negative affect was significantly associated with measures of anxiety and depression whereas positive affect was associated with depression. However, weaknesses in discriminant validity were found, most notably with regard to social anxiety. Consistent with previous research, social anxiety was significantly associated with low levels of positive affect (PA). Furthermore, results from regression analyses indicated that PA made a significant unique contribution to the prediction of social anxiety as well as depression scores. Findings are discussed with regard to the usefulness of the PANAS-C to differentiate anxiety and depression in children with anxiety disorders.

Anxiety, mood, and substance use disorders in parents of children with anxiety disorders.

Examined the prevalence of anxiety, mood, and substance use disorders in the parents of anxiety disordered (AD) children relative to children with no psychological disorder (NPD). The specificity of relationships between child and parent anxiety disorders was also investigated. Results revealed higher prevalence rates of anxiety disorders in parents of AD children relative to NPD children. Specific child-mother relationships were found between child separation anxiety and panic disorder and maternal panic disorder, as were child and maternal social phobia, obsessive compulsive disorder, and specific phobias. Findings are discussed with reference to theory, clinical implications, and future research needs.

Effect of a positive emotional state on interpretation bias for threat in children with anxiety disorders.

The authors examined the effect of a positive emotional state on interpretation bias for threat in children with anxiety disorders. Participants were 34 children with anxiety disorders and 34 children without any psychological disorders who were randomly assigned to either a positive or neutral emotion induction condition. Consistent with the broaden-and-build theory, children with anxiety disorders exhibited an interpretation bias for threat, but not when they were in a positive emotional state. Furthermore, results indicated that positive emotional state made a unique prediction of interpretation bias score, whereas state anxiety did not. Findings are discussed with reference to theory, clinical implications, and suggestions for future research.

Family functioning in families of children with anxiety disorders.

The authors examined maternal and paternal reports of family functioning and their relationship with child outcomes as well as the association between anxiety and depression in family members and family functioning. Results reveal that maternal and paternal reports of family functioning were both significantly associated with worse child outcomes, including child anxiety disorder (AD) severity, anxiety symptoms, and child global functioning. Maternal and paternal anxiety and depression predicted worse family functioning, whereas child report of anxiety and depression did not. Parents of children with ADs reported significantly worse family functioning and behavior control, but only fathers reported worse problem solving and affective involvement compared with fathers of children with no psychological disorders. Findings from this study suggest that paternal as well as maternal anxiety and depression play a role in worse family functioning in children with ADs and that unhealthier family functioning is associated with worse child outcomes in this population.

Somatic complaints in children with anxiety disorders and their unique prediction of poorer academic performance.

The present study aimed to examine somatic complaints in children with anxiety disorders compared to non-anxious control children and whether somatic complaints predict poorer academic performance. The sample consisted of 108 children and adolescents (aged 8-14 years) assessed by a structured diagnostic interview: 69 with a principal (i.e., most severe and/or interfering) anxiety disorder diagnosis and 39 non-anxious community controls. Established child and parent report measure of somatic complaints, anxiety, and internalizing symptoms were completed. The participants' primary teacher was used to assess academic performance. Findings indicated that children with anxiety disorders reported more somatic complaints than the non-anxious community controls. Furthermore, a greater frequency of somatic complaints uniquely predicted poorer academic performance beyond that accounted for by anxiety and internalizing symptoms based on both child and parent report measures. Knowledge about somatic complaints in children with anxiety disorders and their relation to academic functioning may allow for early identification and prevent academic problems.

Relations of the factors of the tripartite model of anxiety and depression to types of social anxiety.

Our primary goal was to examine the relations of the specific components of the tripartite model of anxiety and depression [Clark, L. A., Watson, D. (1991). Tripartite model of anxiety and depression: Psychometric evidence and taxonomic implications. Journal of Abnormal Psychology, 100, 316-336] to two types of social anxiety (social interaction anxiety and performance anxiety) in 148 individuals with social phobia. In line with previous research, overall social anxiety was more closely related to the anhedonic depression (AD) or low positive affect factor of the tripartite model than to the physiological hyerarousal factor, controlling for general distress. However, as hypothesized, performance anxiety was more closely associated with the physiological hyerarousal factor, whereas social interaction anxiety was more closely associated with the AD or low positive affect factor. We also examined the convergent and discriminant validity of the Mood and Anxiety Symptom Questionnaire (MASQ; [Watson, D., Clark, L. A. (1991). The mood and anxiety symptom questionnaire. Unpublished manuscript, University of Iowa City]). Intercorrelations of the MASQ subscales were as expected, but correlations with measures of social anxiety, nonsocial anxiety, and depression provided only modest support for convergent and discriminant validity. Findings from this study provide a more detailed account of the specific components of the tripartite model that characterize the diversity of symptoms subsumed by social phobia.

Attentional and interpretive bias towards illness-related information in chronic fatigue syndrome: A systematic review.

PURPOSE: Chronic fatigue syndrome (CFS) is characterized by severe and debilitating fatigue. Studies based on self-report measures suggest negative illness representations, related symptom interpretations, and heightened symptom focusing are maintaining factors of fatigue. This study reviews studies which have investigated these cognitive biases using experimental methods, to (1) review the evidence for information processing biases in CFS; (2) determine the nature of these biases, that is the stages cognitive biases occur and for what type of stimuli; and (3) provide directions for future methodologies in this area. METHODS: Studies were included that measured attention and interpretation bias towards negative and illness-related information in people with CFS and in a comparison group of healthy controls. PubMed, Ovid, CINAHL, PsycINFO, Web of Science, and EThOS were searched until December 2014. RESULTS: The evidence for cognitive biases was dependent on the methodology employed as well as the type and duration of the stimuli presented. Modified Stroop studies found weak evidence of an attentional bias in CFS populations, whereas visual-probe studies consistently found an attentional bias in CFS groups for health-threatening information presented for 500 ms or longer. Interpretative bias studies which required elaborative processing, as opposed to a spontaneous response, found an illness-related interpretive bias in the CFS group compared to controls. CONCLUSIONS: Some people with CFS have biases in the way they attend to and interpret somatic information. Such cognitive processing biases may maintain illness beliefs and symptoms in people with CFS. This review highlights methodological issues in experimental design and makes recommendations to aid future research to forge a consistent approach in cognitive processing research. Statement of contribution What is already known on this subject? Studies based on self-report measures suggest negative illness representations, related symptom interpretations, and heightened symptom focusing contribute to the maintenance of chronic fatigue. Experimental studies in other clinical populations, such as patients with anxiety, depression, and chronic pain, have identified illness-specific biases in how information is implicitly attended to and interpreted, which has a causal role in these conditions. What does this study add? This is the first review of implicit cognitive processes in chronic fatigue syndrome (CFS). Sustained attention and negative interpretations of somatic information may reinforce negative illness beliefs. Cognitive processes have a role to play in the cognitive behavioural model of CFS.

Potential treatment mechanisms in a mindfulness-based intervention for people with progressive multiple sclerosis.

OBJECTIVES: To explore putative mediators of a mindfulness-based intervention to decrease distress in people with multiple sclerosis (MS) and to explore the patients' perspectives on this intervention. DESIGN: We used an explanatory mixed methods design incorporating quantitative data from a pilot randomized control trial and a qualitative interview study with people who completed the mindfulness intervention. METHODS: People with MS (n = 40) completed standardized measures of distress (outcome), and acceptance, decentring, self-compassion, and self-efficacy (potential mediators). Semi-structured interviews (n = 15) of patients' experiences of the mindfulness intervention were analysed deductively and inductively. RESULTS: Decentring post-intervention explained 13% of the 3-month change in distress and between 27% and 31% of concurrent changes in distress. Acceptance changed only slightly, and as a result, the indirect effect accounts for only 2% of future distress and between 3% and 11% of concurrent distress. Qualitative data showed that acceptance and self-compassion needed more time to develop, whereas decentring could be implemented readily after being introduced in the sessions. Self-efficacy also had a large mediating effect. Participants in their interviews talked about group dynamics and prior expectations as essential elements that determine their engagement with the course and their level of satisfaction. CONCLUSIONS: Mindfulness interventions for people with a chronic progressive condition may benefit from focusing on helping them to accept daily challenges and teach them to recognize their thoughts and feelings, allowing time for acceptance and self-compassion to develop. Group dynamics also play a fundamental role in the success of the mindfulness interventions. Statement of Contribution What is already known on this subject? Mindfulness courses improve psychological well-being for people with chronic conditions. Mindfulness courses have been successful in improving psychological well-being and symptom management for people with multiple sclerosis but we do not know how these courses work. What does this study add? Decentering and self-efficacy appear to be key mechanisms leading to reduced distress. Acceptance and self-compassion may need more time and practice to develop. Group dynamics and expectations of the mindfulness courses were also important elements of mindfulness.

Maximizing potential impact of experimental research into cognitive processes in health psychology: A systematic approach to material development.

BACKGROUND: There is an abundance of research into cognitive processing biases in clinical psychology including the potential for applying cognitive bias modification techniques to assess the causal role of biases in maintaining anxiety and depression. Within the health psychology field, there is burgeoning interest in applying these experimental methods to assess potential cognitive biases in relation to physical health conditions and health-related behaviours. Experimental research in these areas could inform theoretical development by enabling measurement of implicit cognitive processes that may underlie unhelpful illness beliefs and help drive health-related behaviours. However, to date, there has been no systematic approach to adapting existing experimental paradigms for use within physical health research. Many studies fail to report how materials were developed for the population of interest or have used untested materials developed ad hoc. The lack of protocol for developing stimuli specificity has contributed to large heterogeneity in methodologies and findings. PURPOSE: In this article, we emphasize the need for standardized methods for stimuli development and replication in experimental work, particularly as it extends beyond its original anxiety and depression scope to other physical conditions. METHOD: We briefly describe the paradigms commonly used to assess cognitive biases in attention and interpretation and then describe the steps involved in comprehensive/robust stimuli development for attention and interpretation paradigms using illustrative examples from two conditions: chronic fatigue syndrome and breast cancer. CONCLUSIONS: This article highlights the value of preforming rigorous stimuli development and provides tools to aid researchers engage in this process. We believe this work is worthwhile to establish a body of high-quality and replicable experimental research within the health psychology literature. Statement of contribution What is already known on this subject? Cognitive biases (e.g., tendencies to attend to negative information and/or interpret ambiguous information in negative ways) have a causal role in maintaining anxiety and depression. There is mixed evidence of cognitive biases in physical health conditions and chronic illness; one reason for this may be the heterogeneous stimuli used to assess attention and interpretation biases in these conditions. What does this study add? Steps for comprehensive/robust stimuli development for attention and interpretation paradigms are presented. Illustrative examples are provided from two conditions: chronic fatigue syndrome and breast cancer. We provide tools to help researchers develop condition-specific materials for experimental studies.

In-session exposure tasks and therapeutic alliance across the treatment of childhood anxiety disorders.

The study examined the shape of therapeutic alliance using latent growth curve modeling and data from multiple informants (therapist, child, mother, father). Children (n = 86) with anxiety disorders were randomized to family-based cognitive-behavioral treatment (FCBT; N = 47) with exposure tasks or to family education, support, and attention (FESA; N = 39). Children in FCBT engaged in exposure tasks in Sessions 9-16, whereas FESA participants did not. Alliance growth curves of FCBT and FESA youths were compared to examine the impact of exposure tasks on the shape of the alliance (between-subjects). Within FCBT, the shape of alliance prior to exposure tasks was compared with the shape of alliance following exposure tasks (within-subjects). Therapist, child, mother, and father alliance ratings indicated significant growth in the alliance across treatment sessions. Initial alliance growth was steep and subsequently slowed over time, regardless of the use of exposure tasks. Data did not indicate a rupture in the therapeutic alliance following the introduction of in-session exposures. Results are discussed in relation to the processes, mediators, and ingredients of efficacious interventions as well as in terms of the dissemination of empirically supported treatments.