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The Role of Psychological Factors and Mindfulness in Fatigue-Related Disability

September 24, 2020
When patients with rheumatic disease, including rheumatoid arthritis and ankylosing spondylitis, are more engaged in their activities and more mindful, they experience less fatigue-related disability.

A PPM Brief

Adults with rheumatoid arthritis or ankylosing spondylitis reported less fatigue-related disability when they engaged in mindfulness or other meaningful activities, based on data from 143 patients.

Fatigue remains a common complaint among individuals with inflammatory arthritis, but medication is not always effective and the causes of fatigue in these patients are often unclear, noted Roisin S.M. Hegarty, MSc, of the University of Otago, New Zealand, and colleagues in their recently published study.

“Psychological models of disability suggest that the experience of fatigue alone is not enough to lead to disability but rather it is patients’ emotional and behavioral reaction to fatigue that influences its impact on daily life,” they wrote. Further, they pointed out that previous research on psychological factors in fatigue-related disability has been mainly retrospective, and studies have not identified the dynamic daily fluctuations in fatigue that occur in arthritis patients.

Study Population and Methods

In their report, 97 adults with rheumatoid arthritis (RA) and 46 with ankylosing spondylitis (AS) participated in a 10-day online diary study in which they completed a questionnaire each evening. The questionnaires measured psychological flexibility, which the team defined as: “the ability to be open and consciously in contact with the present moment, and to change or persist in behavior when doing so serves one’s goals and values.”

Six inter-related processes involved in psychological flexibility were defined and measured as well:

  1. acceptance – a willingness to experience thoughts, emotions, and physical sensations without an attempt to control or avoid them
  2. cognitive defusion – the ability to distance oneself from thoughts and not view them as rules or truths that must be followed
  3. mindfulness – awareness of what is happening both within oneself and the environment
  4. self-as-context – the ability to detach from unhelpful ideas about oneself
  5. values – an understanding of what makes life meaningful
  6. committed action – behavior guided by ones’ personal values and goals, rather than by difficult thoughts, feelings, and physical symptoms.

The patients ranged in age from 24 to 85 years and included 104 women and 39 men. Approximately half (57%) reported at least one comorbidity; the most common were depression and/or anxiety (11.6%), hypertension (10.1%), and asthma (4.8%). A majority of 92% of patients completed 8 or more of 10 daily diaries for a total of 1,317 days of data.

The daily questionnaires asked patients to report on daily fatigue severity, daily fatigue-related disability, daily pain, daily valued activity, daily mindfulness, daily cognitive fusion, and daily fatigue avoidance.

Fatigued manPatients reported less fatigue-related disability on days when they engaged in valued activities or reported more mindfulness after controlling for daily levels of pain and fatigue and for variables including age, sex, and type of arthritis. (Image: iStock)

Results: Cognitive and Behavioral Responses Can Reduce Fatigue Response

Overall, psychological flexibility accounted for 15.6% of variations in daily fatigue-related disability, with the greatest variance explained by valued activity (7.8%), cognitive defusion (4.2%), and mindfulness (3.7%). Patients reported less fatigue-related disability on days when they engaged in valued activities or reported more mindfulness after controlling for daily levels of pain and fatigue and for variables including age, sex, and type of arthritis.

The findings “highlight how inflammatory arthritis patients’ cognitive and behavioral responses to fatigue are related to how disabled they are by their fatigue each day,” the researchers wrote. “The findings indicate that psychological flexibility is a dynamic process that unfolds in the daily lives of people with inflammatory arthritis,” they concluded, adding that, “psychological treatments that combine a focus on improving inflammatory arthritis patients’ engagement in meaningful life goals and teach mindfulness may be particularly useful for reducing fatigue-related disability.”

Noted study limitations included reliance on self-reports and the inability to make conclusions about causality. However, the researchers pointed out that their data were strengthened by repeated measurements of variables over several days.


Practical Takeaways: Biopsychosocial Approach Could Normalize Psychological Factors of Pain and Disability

“Fatigue is a common problem for people with rheumatic disease, and although currently available treatments are effective for some, there is a need for more effective treatment,” lead author Roisin S.M. Hegarty told PPM. “The psychological flexibility model has been the focus of a lot of research in relation to chronic pain, but not so much in terms of fatigue. We thought it would be interesting to explore whether this model is relevant to people with rheumatic disease-related fatigue because if so, treatments based on the psychological flexibility model could be a useful adjunct to existing approaches.”

“One barrier to developing psychological flexibility is a lack of understanding of the important role of psychological factors in chronic illness,” said Hegarty. “Emphasizing the biopsychosocial approach with patients may be useful as it would normalize the role of psychological factors and set the scene for people to develop an understanding of how a wide variety of factors influence outcomes from medical conditions,” she said.

Hegarty said that the findings were in line with her team’s hypotheses. “I expected at least some of the subprocesses of psychological flexibility would be relevant to fatigue-related disability in participants' daily lives,” she noted. “Initially, I was surprised that daily mindfulness was one of the two variables that had a significant daily relationship with fatigue-related disability, but as I thought more about it and discussed it with my co-authors, it made a lot of sense.”

The key clinical point from the study is that when people with rheumatic disease are more engaged in their activities and more mindful, they experience less fatigue-related disability, said Hegarty. However, the direction of the relationship between these variables is unclear. “Because this is a correlational finding, further research is needed to evaluate whether interventions that are designed to increase valued activity and mindfulness are effective at reducing fatigue-related disability,” she emphasized.

Potential next steps for research might examine whether interventions designed to increase valued activity and/or mindfulness lead to reduced fatigue-related disability or improvements in quality of life, she added.

The study was supported by a non-commercial research grant from the Jack Thompson Arthritis Fund charitable trust. Some participants were part of an earlier study funded by an unrestricted educational grant from AbbVie, and one of the study coauthors disclosed personal fees from AbbVie and Janssen unrelated to the study. Lead author Hagerty had no financial conflicts to disclose.



Last updated on: September 24, 2020
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