Uplifts And Hassles Are Related To Worsening in Chronic Fatigue Syndrome A Prospective Study Part 2

Discussion

In this six-month observational study of individuals with CFS involving 26 weekly assessments, only a few clear differences were found between self-report worsened as compared to improved subjects on the dimensions of behavioral uplifts and hassles. The worsened group showed an increasing pattern of non-social hassles, while the improved group evidenced a decreasing pattern. In addition, the frequency of social uplifts significantly decreased in all three groups across the six-month assessment interval. However, only the worsened group showed a significant decrease in non-social uplift frequency.

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Uplifts Defi cits and Worsening

Our finding of a downtrend in the frequency of specifically “non-social” uplifts in the worsened group may have some overlap with our earlier study [13] in which a lower intensity of uplifts predicted self-report non-improvement (unchanged and worsened) in individuals with CFS. Perhaps non-social activities are more salutary as they are more readily available, more manageable, and potentially less energy-depleting than socially positive interactions [28]. In general, excessive fatigue is triggered in CFS in response to even minor activities [29], regardless of valence, and thus it may be challenging for patients to thread the needle to eventual illness improvement via greater uplifts, fewer hassles, and other positive self-management activities. Even if successful, relatively small improvements in illness symptoms may result, as suggested by the modest 15% downward trend of weekly fatigue ratings in the CFS improver group recorded over six months in the primary study [13]. Not surprisingly, in the current observational study, a far lower percentage of individuals rated themselves as improved as compared to two previous behavioral self-management trials in CFS [24, 30].

Speculatively, these findings could reflect an ongoing change process, only partially captured in this six-month study that may inform specific behavioral pathways to worsening and improvement. Fewer pleasant experiences in CFS have been associated with higher fatigue and lower functioning over 18  months [3]. In addition, our data revealed that the intensity of non-social hassles increased in worsened subjects and decreased in improved subjects (Fig. 1). More broadly, negative social events have been associated with higher daily fatigue in chronically fatiguing illnesses, e.g., fibromyalgia, rheumatic arthritis [8], suggesting that social interactions may play a role in determining the magnitude of ongoing fatigue experienced by those with chronic fatigue and pain [9].

As compared to the primary study [13], our expanded range of significant findings regarding uplifts and hassles as possible outcome predictors may be explained in part by several design changes in the present study: (1) the unit of analysis was weekly scores on the CHUS, rather than single 26-week means used for each subject in the primary study; (2) the use of separate categories for unchanged and worsened outcomes rather than the more generic non-improvement construct; and (3) the subdivision of hassles and uplifts into social and social sub-categories. Overall, the current analysis represents a fine-grained examination of hassles and uplifts in the experiences of individuals with CFS, which was likely to identify more precise and potentially more informative outcome predictors.

Clinical Implications

Although the salient illness variable of fatigue was not assessed as an outcome variable in this study, a critical element of improved outcomes in CFS is based on the patients' efforts to effectively manage their illnesses such that well-being and functioning are maximized. In the absence of curative treatments, this is perhaps the most beneficial type of outcome that can be realistically achieved. In addition, perceived global improvement in CFS, even if modest, has been associated with significantly reduced fatigue and higher functioning over a two-year observational period [23]. Perhaps a clinical focus on selectively assigning uplifts and limiting hassles, as suggested by our findings, could be utilized as a straightforward approach to facilitating improvement in CFS. Potential therapeutic changes in target areas, as suggested by our hassles and uplift findings, do not necessarily have to be of a high magnitude to result in overall improvement.

Although not an intervention or controlled trial, clinically relevant findings in this observational study suggest the potential importance of uplifts to perceived global improvement in this difficult-to-treat illness. Uplifts can be a focus of behavioral management [12] if the clinician collaboratively identifies with the patient pleasant, enjoyable, low-effort activities that are often lacking in the lives of individuals with debilitating CFS [31, 32]. This may have relevance to CFS pathophysiology given that a large biobehavioral study in healthy adults suggested that the absence of positivity in daily life may be particularly consequential for inflammation [6].

Examples of positive events that could be applied clinically in CFS include listening to an inspirational speaker, going to a concert, watching ducks on a pond, sharing a special moment with a spouse or friend, or any other moderately pleasant activity that does not trigger long-duration symptom worsening. To generate ideas, the patient can be asked to make a list of 10 pleasant low-effort activities. Once these possibilities are identified, a flexible schedule is developed so that the patients can participate in pleasant activities at least several times a week. Although illness-related restrictions may have reduced opportunities to engage in pleasant experiences [12], about 1/3 of our (often homebound) study participants were able to engage in uplifting activities and reduce the intensity of their hassles over several months to the point where they rated themselves as "improved."

Our findings regarding worsening illness in association with fewer non-social uplifts are also consistent with developing beneficial treatment targets in two evidenced-based therapies, Behavioral Activation and Acceptance and Commitment Therapy. Although not described as “uplifts”, both treatments consist of helping patients to identify and clarify chosen values [33, 34], such as who is important to them (e.g., friends, family), what is important to them (e.g., physical and mental health, companionship) and what qualities of action they want to embody (e.g., loyalty, trustworthy, kindness). Once values are identified, clinicians help patients start to behave in ways in line with the chosen values in pursuing the most rewarding or intense socially uplifting activities by identifying who (i.e., spending time with grandchildren) or what (non-social) is in that category rather than participating in social gatherings that do not have the same valence (i.e., spending time with an acquaintance).

Furthermore, by encouraging patients to focus on chosen values, they may also be less likely to be bothered by hassles, which were significantly greater in our worsened subjects. Both Behavioral Activation and Acceptance and Commitment Therapy have also been found to be associated with improved well-being [35, 36]. This may explain why in the current study, improved subjects experienced significantly less intense non-social hassles than their worsened counterparts. Future work should continue to examine the effect of improving the frequency of uplifts, or values, in patients with CFS on physical and emotional well-being.

Limitations

As this study was not a randomized treatment trial, clinical approaches to illness improvement may be suggested but not definitively recommended. Also, participant demographics heavily favored white females with long-term illness. Furthermore, weekly trajectories of uplifts and hassles were grouped and analyzed by global change categories which may have obscured potentially important individual patterns. Despite these limitations, the between-group distinctions were particularly notable given the opposing directions of change for hassles and uplifts evidenced in the longitudinal patterns of improved and worsened patients which are potentially of clinical relevance.

Conclusions

Given the controversies regarding the efficacy of well-publicized graded activity interventions in CFS [37], our alternate or perhaps complementary focus on behavioral uplifts and hassles as possible improvement predictors may be clinically useful. For instance, one path to behavioral improvement in CFS that is supported by our findings may be through the scheduling of more frequent non-social uplifts, and perhaps reducing the emotional impact of intense hassles (cf., [11]). These commonly experienced minor events can be voluntarily modified and therapeutically managed, with less potential adverse consequence than standard behavioral approaches in the service of improving well-being and outcomes in CFS.

Declarations

Ethical approval and consent to participate. All procedures performed in studies involving human participants were by the ethical standards of the institution and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. This study was approved by the Stony Brook University Committee on Research Involving Human Subjects and all participants provided informed consent for participation and publication.

Consent for publication. Not applicable. 

Conflict of Interest Declaration. The authors declare that they have no conflict of interest.

Funding. The project described was supported by National Institutes of Health Grant R01NR015850; (National Institute of Nursing Research; Principal Investigator: F. Friedberg). The work was also supported in part by the National Institute of Health T32 pre-doctoral training grant: T32GM108540 (trainee: J.L.A.) The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health.

Author contributions: FF conceived the original research study. JLA and SR collected data. FF, JLA, PB, MM, XZ, and JY critically reviewed the paper and were involved in data interpretation. XZ and JY conducted the data analysis. FF and JLA co-led the writing of the paper. All authors reviewed and approved the final versions.

Acknowledgements. We thank Daniel Gordon, Marie Codella, Sydney Zhang, and Samantha Vasquez for their invaluable assistance in carrying out the essential support tasks involved in conducting this study.

Data availability statement: The data that support the findings of this study are available from the corresponding author (FF), upon reasonable request.

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Figures

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