Explaining fatigue: an examination of patient causal attributions and their (in)congruence with family doctors' initial causal attributions.

BACKGROUND: General practitioners (GPs) and patients can have different ideas about the causes of fatigue, which may hinder management of fatigue. OBJECTIVE: To investigate the causal attributions of patients and their GPs for fatigue, their level of agreement, and the association between patients' attributions, and fatigue characteristics and other illness perceptions. METHODS: Baseline data, collected between 2004 and 2006, of a prospective cohort study among 642 adult patients presenting to Dutch primary care practices (n = 147) with a main symptom of fatigue, were used. Patient causal attributions and illness perceptions were measured using the revised illness perception questionnaire (fatigue version). GP causal attributions were measured with an open question included in the form that was completed at the end of the patient's visit. Fatigue severity was measured using the checklist individual strength. RESULTS: Psychosocial causes were among the most often reported causal attributions by both patients and GPs. In 33% of 519 cases, the GP had no idea about the cause whereas the patient did. Overall, the agreement between the first reported causal attribution of patients and GPs was low. Qualitative differences in the labelling of causes were also found. Type of attribution (physical vs psychosocial/psychological) was associated with duration of fatigue (40 vs 25 months), and personal control (score 17.4 vs. 18.9). CONCLUSION: Most patients and GPs had ideas about the causes of fatigue, but differences were found in the first reported causes and the labelling of causes. The findings may provide leads for optimizing communication about fatigue.

Symptom attribution and presentation in general practice after an extreme life event.

BACKGROUND: A serious life event is likely to shape attributions relating to symptoms experienced afterwards. While they may play an important role in prognosis and seeking care, such perceptions have hardly been studied among survivors of a disaster. OBJECTIVE: To investigate the association between self-reported health problems that have been attributed to an extreme life event and the symptoms presented to GPs. METHODS: A two-wave longitudinal survey (2-3 weeks and 18 months) among survivors of a fireworks disaster was combined with a continuous morbidity surveillance in general practice. Symptoms attributed to the disaster reported in an open-ended question in the two waves were analysed using descriptive statistics. Differences in presented symptoms over time were analysed using logistic multilevel analysis. RESULTS: More than half of the respondents reported health problems, which were, in their opinion, related to the disaster. Psychological problems were most frequently reported in association with the disaster, and in contrast to physical attributed symptoms, presentation of these problems in general practice decreased over time. In the total sample, musculoskeletal symptoms were less frequently presented in the longer term. Survivors who attributed symptoms to the disaster at both waves or after 18 months only most often presented such symptoms to the GP. CONCLUSION: Survivors attributed psychological problems and physical symptoms to the disaster at short-term and midterm post-disaster. Most of these survivors presented such symptoms to the GP. Attribution of symptoms to an extreme life event such as a disaster may therefore require special attention from the GP.

Fatigue in primary care: longitudinal associations with pain.

So far, most studies on the association between pain and fatigue have used cross-sectional data. We analysed the possibilities for a temporal relationship between pain and fatigue in a cohort study of patients presenting with fatigue in primary care. Of 856 recruited patients, 642 (75%) completed postal questionnaires after the consultation, and at one, four, eight and 12 months follow-up, with completion rates ranging from 82% to 88%. Pain was measured using the Short-Form health survey (SF-36) and fatigue using the severity scale of the Checklist Individual Strength (CIS). Longitudinal associations were analysed using generalised estimated equations (GEE). We used three different models assessing possible relationships between the symptoms in time, either in the same intervals or with a time-lag, suggesting either a synchronous or temporal association. The regression coefficients were strongest in the model assessing synchronous change, indicating that a one-point improvement in pain was associated with a 0.25 improvement in fatigue in the same time interval (adjusted for potential confounding). Baseline duration of fatigue and expectations of its future course significantly modified the association in this model, with stronger associations between changes in pain and fatigue found in patients with a shorter duration of fatigue or more positive expectations. The models using a time lag showed a significant but inverse association between changes in pain and subsequent changes in fatigue. The results indicate that changes in pain and fatigue are directly related in time, rather than showing temporal associations.

Co-occurrence and associations of pain and fatigue in a community sample of Dutch adults.

Widespread pain and chronic fatigue are common in the general population. Previous research has demonstrated co-occurrence of syndromes that are associated with pain and fatigue (fibromyalgia and chronic fatigue syndrome), but there is limited existing data on the co-occurrence of these symptoms in general. This study investigates the co-occurrence of pain and fatigue, and characterises people with these symptoms individually, and in combination. A postal questionnaire was sent to a random sample of 4741 community dwelling Dutch adults registered with five general practices. There were 2447 participants (adjusted response=53.5%). Persistent fatigue was reported by 60% of the 451 subjects with chronic widespread pain. Chronic widespread pain was reported by 33% of the 809 responders with persistent fatigue. Anxiety and depression were more common in subjects who reported both symptoms than those who reported either one or neither. Participants who had chronic disease, high body mass index, low activity levels or did not perceive ability to influence health had higher adjusted odds of reporting both symptoms (but not one alone) than subjects not having these characteristics. Pain and fatigue occur more often than would be expected by chance and there are a number of reasons for this. Clinicians should be aware that co-occurrence of the symptoms is common, especially in people who have high BMI or chronic disease, and that people with both symptoms are often anxious or depressed. Further work should address longitudinal associations of pain and fatigue.

Diagnoses during follow-up of patients presenting with fatigue in primary care.

BACKGROUND: Little is known about the distribution of diagnoses that account for fatigue in patients in primary care. We evaluated the diagnoses established within 1 year after presentation with fatigue in primary care that were possibly associated with the fatigue. METHODS: We conducted a prospective observational cohort study with 1-year follow-up. We included adult patients who presented with a new episode of fatigue between June 2004 and January 2006. We extracted data on diagnoses during the follow-up period from the patients' medical records as well as data on pre-existing chronic diseases. RESULTS: Of the 571 patients for whom diagnostic data were available, 268 (46.9%) had received one or more diagnoses that could be associated with fatigue. The diagnoses were diverse and mostly included symptom diagnoses, with main categories being musculoskeletal (19.4%) and psychological problems (16.5%). Clear somatic pathology was diagnosed in 47 (8.2%) of the patients. Most diagnoses were not made during the consultation when fatigue was presented. INTERPRETATION: Only a minority of patients were diagnosed with serious pathology. Half of the patients did not receive any diagnosis that could explain their fatigue. Nevertheless, because of the wide range of conditions and symptoms that may explain or co-occur with the fatigue, fatigue is a complex problem that deserves attention not only as a symptom of underlying specific disease.

Prediction of outcome in patients presenting with fatigue in primary care.

BACKGROUND: Although fatigue is a common problem presenting to primary care, few prospective studies have examined the contribution of a wide range of prognostic factors. AIM: To determine the combination of factors most strongly associated with a favourable or unfavourable course of fatigue, when fatigue is presented as a main symptom in primary care. DESIGN OF STUDY: Prospective, observational cohort study with a 1-year follow-up. SETTING: A total of 147 primary care practices in the Netherlands. METHOD: Patients presenting with fatigue as a main symptom completed questionnaires at baseline, and 1, 4, 8, and 12 months later. The prognostic value of potential predictors was assessed by applying multivariable logistic regression analysis. The outcome was severity of fatigue, defined as a combination of dichotomised scores on several repeated measurements with the Checklist Individual Strength. Separate models were used to predict either a favourable or an unfavourable course of fatigue. RESULTS: Baseline severity of fatigue and patient expectations of chronicity consistently predicted a poor outcome. Additional factors predicting a chronic course were baseline pain intensity and less social support. Baseline characteristics predicting a fast recovery were: male sex, not providing care for others (for example, for older people), better perceived health, and fewer (serious) prolonged difficulties. Both models had good reliability and discriminative validity (area under the receiver operating characteristic curve after internal validation: 0.78 and 0.79). CONCLUSION: The identified combination of predictors reflects the multidimensionality of fatigue, with a significant contribution of patient expectations of chronicity in the prediction of a poor prognosis. These negative perceptions are modifiable, and should receive more attention in the initial assessment of patients presenting with fatigue.

Prognosis of fatigue and functioning in primary care: a 1-year follow-up study.

PURPOSE: Although fatigue is a common presenting symptom in primary care and its course and outcomes often remain unclear, cohort studies among patients seeking care for fatigue are scarce. We therefore aimed to investigate patterns in the course of fatigue and relevant secondary outcomes in a large cohort of patients who sought care for a main symptom of fatigue. METHODS: We performed an observational cohort study in 147 primary care practices. Patients consulting their general practitioner for a new episode of fatigue were sent questionnaires at 1, 4, 8, and 12 months after baseline. We collected measures of fatigue, perceived health and functioning, absenteeism, psychological symptoms, and sleep using the Checklist Individual Strength, the 36-Item Short Form Health Survey, the Four-Dimensional Symptoms Questionnaire, and the Pittsburgh Sleep Questionnaire Inventory. Patients were classified into 4 subgroups based on fatigue severity scores over time. We assessed patterns in the course of all outcomes in these subgroups and in the total population, and tested changes over time and differences between subgroups. RESULTS: A total of 642 patients were enrolled in the study. Response rates during follow-up ranged between 82% and 88%. For 75% of the patients, 4 distinct groups could be discerned: 26% of patients had continuously high scores for fatigue, 17% had a fast recovery, 25% had a slow recovery, and 32% initially improved but then had a recurrence of fatigue. Patterns for the secondary outcomes of symptoms and functioning were all similar to the pattern for fatigue within each of the subgroups. CONCLUSIONS: The findings of this study suggest a longitudinal relationship between the severity of fatigue, impaired functioning, psychological symptoms, and poor sleep. Physicians should be aware that a substantial proportion of patients seeking care for fatigue have these additional health and psychosocial problems.

Prognosis of fatigue. A systematic review.

OBJECTIVE: The objective of the study was to summarize evidence on the course and prognostic factors of fatigue in primary care patients and in the community. METHODS: Two reviewers independently screened identified citations, discussed eligible studies, and assessed methodological quality of selected studies. Data concerning study population, duration of follow-up, measurement of fatigue, outcome, and prognostic factors were extracted. Studies with populations selected by a specific disease or postpartum condition were excluded. RESULTS: We selected 21 articles reporting on 11 (partly) primary care cohorts and six community cohorts. Follow-up was up to 1 year in primary care and up to 4 years in the community, and in most studies that presented duration of fatigue, participants were chronically fatigued. Because of wide heterogeneity of studies, a qualitative analysis was performed. Recovery of fatigue varied widely, but no differences were found between settings. Sufficient evidence for an association with recovery was found for lower severity of fatigue, and limited evidence was found for good self-reported health, mental health, and psychological attributions. A major deficit in methodological quality of most studies was a potential bias due to low or selective response or loss to follow-up. CONCLUSION: Most studies on fatigue included patients with long symptom duration at baseline, making it difficult to study prognosis early in the course of fatigue. To provide clear evidence on prognosis in fatigued persons, prognostic studies should use an optimal design including selection of an inception cohort with limited duration of fatigue at baseline, a sufficient sample size, and information on rates and selectivity of response and loss to follow-up.