All-or-Nothing Behavior and Catastrophic Thinking Predict Fatigue in Inflammatory Bowel Disease: A Prospective Cohort Study 2023 Moulton Chalder et al

[Andy]

Lay Summary
Patients with inflammatory bowel disease (IBD) often report fatigue. However, the reasons for this are poorly understood. In this study of people with IBD, we demonstrate that all-or-nothing behavior (being very active then needing to resting a while) and catastrophic thinking (making very negative assumptions about outcomes) both predict worsening in fatigue over time.

Introduction
Fatigue affects 80% of patients with active inflammatory bowel disease (IBD) and 40% to 50% in remission of IBD, typically running a persistent course.1 However, owing to a lack of prospective research, there is limited understanding of the behavioral patterns that precipitate fatigue in IBD.

In people with chronic fatigue syndrome, a common pattern is all-or-nothing behavior.2 On days when fatigue is better, patients may try to catch up on lost productivity, thereby cramming activities and exerting themselves much more than normal. However, this leads to marked worsening in fatigue for subsequent days, precipitating a persistent boom-and-bust pattern of fatigue. Cognitive behavioral therapy (CBT) in chronic fatigue syndrome addresses all-or-nothing behavior and promotes graded increases in activity, producing significant improvements in fatigue.2 Although all-or-nothing behavior has been observed in irritable bowel syndrome,3 no study has tested the behavioral predictors of worsening fatigue in patients with IBD, including the role of all-or-nothing behavior. This is important because there are multiple competing pathways to fatigue in IBD, while IBD clinicians—who are frustrated at having few treatments for fatigue4—would benefit from clear psychoeducational advice to offer patients.

In this prospective observational study, we tested the hypothesis that all-or-nothing behavior is associated with increased risk of fatigue in people with IBD. We further tested other cognitive and behavioral predictors of fatigue in IBD.

Open access, https://academic.oup.com/ibdjournal/advance-article/doi/10.1093/ibd/izad193/7250330

 

[Sly Saint]

In people with chronic fatigue syndrome, a common pattern is all-or-nothing behavior.2

ref2: The PACE trial

 

[Hoopoe]

What they mean with "predict" is probably that it "occurs together with".

Another paper coming out of the paper mill. This isn't even worth studying, let alone publishing. The spin to make normal behavior in ill people look like a serious psychological anomaly is also nauseating.

So my reading of this is that people with IBD are fatigued, and try to catch up on their daily activities when they can (labelled "all-or-nothing behavior"), and they also suffer from the illness (labelled "catastrophizing").

I'm sure CBT can turn all this around by teaching patients to imitate normal behavior and thinking. Just like building imitation airplanes and landing strips out of wood on pacific islands will result in cargo planes bringing many valuable goods to the lucky inhabitants.

 

[Hutan]

Oh Trudie, to have been thinking about these things for so long, and yet still not getting the difference between correlation and causation.

(cross post with Hoopoe)

 

[duncan]

That lot wears hyperbole like a bad toupee.

 

[Sly Saint]

Cognitive behavioral therapy (CBT) in chronic fatigue syndrome addresses all-or-nothing behavior and promotes graded increases in activity, producing significant improvements in fatigue.2

goes against current NICE guidelines. again citing PACE.

 

[bobbler]

I'm sorry but I can't help but assume there is a lot of 'priming and seeking out phrases and leading horses to water' involved with claims of 'all-or-nothing behaviour', particularly when it is being used by certain people as an explanation for why someone has worse x than others.

I highly doubt there is a methodology that can measure this fake concept properly. So that would just make it another manifesto of suggestion backed up by fake pretend fallacial 'evidence' which isn't actually evidence just 'claims' or 'things that are made to sound feasible to those who are gullible or choosing to be gullible because they want to believe' wouldn't it?

 

[Kitty]

Ach, come on you lot.

These people staked their whole careers on an all-or-nothing outlook: you think up one bunco, and keep working it on different people.

It's hardly surprising they're preoccupied with it.

 

[Trish]

Sigh.

They might as well say there's an assocation between all or nothing behaviour and fatigue in professional sports people too. Have you ever watched a long tennis match, a marathon, a 200km cycling road race. Surprise surprise, the athletes are fatigued after competing, some so badly they can't walk after the event and have to be helped away.

 

[Andy]

In this study of people with IBD, we demonstrate that all-or-nothing behavior (being very active then needing to resting a while) and catastrophic thinking (making very negative assumptions about outcomes) both predict worsening in fatigue over time.

It seems to me that all they are demonstrating is that pacing (in the way that pwME use the term) is a useful symptom management strategy, and that patients are accurate judges of their symptoms.

 

[Hoopoe]

It seems to me that all they are demonstrating is that pacing (in the way that pwME use the term) is a useful symptom management strategy, and that patients are accurate judges of their symptoms.

But in order to make money with CBT, there has to a be disorder of thought and behavior in the patients that is causing illness.

 

[Amw66]

How long before " predictive coding" becomes part of this teams' vocabulary?

 

[dave30th]

What they mean with "predict" is probably that it "occurs together with".

Yes, "predict" in this sense is a misnomer--it sounds causative but is just an association.

 

[rvallee]

They're using "predict" out of correlational data that is mostly arbitrary labeling. They decide to frame this as "all or nothing" or "catastrophizing", it's not a thing in itself. They're simply moralizing out of observations that are banal in themselves. Disabled people have limited energy. They may as well call poor people spending what little money they have "splurging on luxuries" when they buy $30 of groceries. It's dripping with a moralistic sense of superiority.

They're really claiming a predictive effect out of correlational data. Is there really no one who can actually stand up to what they know is clearly invalid? How does this pass a whole series of steps, including peer review, making claims that are clearly not scientifically valid?

There is a freaking reason why statistics students are reminded constantly that correlation is not causation, damnit. They may as well be claiming that falling to the ground causes tripping on something, FFS.

 

[Obermann]

Another way of phrasing “catastrophic thinking predicts fatigue in IBD” is “negative thoughts because you have a chronic illness with distressing symptoms is correlated with having distressing symptoms because you have a chronic illness”. Wow! This is groundbreaking research!

 

[rvallee]

Another way of phrasing “catastrophic thinking predicts fatigue in IBD” is “negative thoughts because you have a chronic illness with distressing symptoms is correlated with having distressing symptoms because you have a chronic illness”. Wow! This is groundbreaking research!

In a sense, they want delusional thinking, or think that it would work best. They want people suffering from an illness to be in denial about their illness and its impacts. It makes zero sense, and reminds me more of poverty piety in some religion, in trying to glorify destitution as some test of life that one should bear with a smile and feelings of gratitude. It's so damn creepy.

There really is a full separation between disease and illness in modern medicine. Disease is a real thing that doctors can look at and understand, something that patients cannot feel or know anything about. Illness, including symptoms, is just some experience that you can ignore, like closing the windows to shut out noise outside the house. Only disease matters, illness is a state of mind. Or whatever. It's extremely creepy as all hell.

 

[Evergreen]

In people with chronic fatigue syndrome, a common pattern is all-or-nothing behavior.

A commonly hypothesised pattern is boom-bust. The PACE crew found that 30% of PACE participants showed what they considered a boom-bust pattern on accelerometer data. Here are a few details from King E, Beynon M, Chalder T, Sharpe M, White PD. Patterns of daytime physical activity in patients with chronic fatigue syndrome. J Psychosom Res. 2020 Aug;135:110154. doi: 10.1016/j.jpsychores.2020.110154.

King et al's Results: 124 (21%) of the participants were classified as pervasively inactive, 65 (11%) as pervasively active, 172 (30%) showed a 'boom and bust' pattern of activity, and 218 (38%) had an indeterminate pattern.

King et al. defined boom and bust as

Boom and Bust (BB) (all or nothing): In order to empirically classify this clinically
recognised group, four possible patterns of activity were considered before examining the
data:
1. Lowest activity levels on the first complete day – The participant had come to the
hospital to have their Actiwatch fitted on the previous day making this a high activity
day. A participant showing a boom and bust pattern of activity might follow this by a
day of low activity, making the first completed day of actigraphy data particularly
low.
2. Range larger than average – Because these participants were likely to exhibit more
extreme activity levels, the range between their highest and lowest days of activity
were likely to be higher than average.
3. Most active day followed by least active day – This assumed that if a BB participant
had a day of high activity, the following day the participant would be inactive as they
had exhausted their energy.
4. Most active day followed by day of <50% that activity – This simply assumes that
following a day of highest activity, a BB participant’s activity levels would drop
dramatically.

They then broke this down further to be numbers 2 and 4 only (people whose brains are working better than mine today might want to look into this):

the criteria which best defined BB participants were the
range of activity being over the average, and most active day followed by a day of less than
50% of this activity (table 1, table 2). 172 (30%) participants were found to have ‘boom and
bust’ pattern of activity, using these two criteria (figure 2).

 

[bobbler]

we demonstrate that all-or-nothing behavior (being very active then needing to resting a while) and catastrophic thinking (making very negative assumptions about outcomes) both predict worsening in fatigue over time.

So they didn't check whether those 'negative assumptions about outcomes' were actually accurate to the same people 'having negative outcomes' - which would mean that it had nothing to do with thinking.

In fact it is probably pretty hard to manage a condition like IBD without learning to be accurate about cause-and-effect as one will look to chain themselves to a toilet for just the right amount of time, no more than they have to of their life, but disastrous if they get blase thinking they can stay stood in the middle of the office and just meditate the urgency away and it doesn't work. In fact if they wanted to prove whether someone's thinking was catastrophic they almost certainly had the perfect symptom area for taking objective measures to if it was actually 'accurate thinking'. ... and 'a measure of illness'

I think the authors were very foolish to include their weak concept of catastrophic thinking therefore, except that is basically what their course is on so what is the point if you can't sell your wares without having to tweak it?

Goodness knows how they garbled it in their own heads to explain 'all-or-nothing behaviour'

In this prospective observational study, we tested the hypothesis that all-or-nothing behavior is associated with increased risk of fatigue in people with IBD. We further tested other cognitive and behavioral predictors of fatigue in IBD.

In people with chronic fatigue syndrome, a common pattern is all-or-nothing behavior.2 On days when fatigue is better, patients may try to catch up on lost productivity, thereby cramming activities and exerting themselves much more than normal. However, this leads to marked worsening in fatigue for subsequent days, precipitating a persistent boom-and-bust pattern of fatigue.

Noting that this is IBD and not IBS, so could include people with acknowledged very serious biomedical bowel issues and that whilst you'd hope had been checked out thoroughly when presenting with fatigue for e.g. absorption issues or other problems they mightn't be fixable always or beyond a certain threshold so will be including people even the authors know is very medically-related.

And it is interesting therefore that 'CFS' is used as the comparator so maybe in this instance the authors acknowledge how ill with genuine reasons for the energy-depletion pwme really are, just for the instance of comparing us to IBD, but not enough to look back at all the work they've done and realise it therefore makes no sense and is harmful.

One might be conned with sly language into thinking this is trying to help rather than a therapy trying to sell itself as having a use by distorting another set of patient's truth. But it seems like a classic switch-and-bait (instead of the solution being 'these people need adjustments and support' doing the opposite and telling those who might provide these to blame the patient's behaviour 'on good days' even if said good days meant 'showering' or 'work' vs bed-bound), even if 'all-or-nothing' did have anything to do with the issue. Of course I suspect that - as should be banned and result in being struck off for trickery - the language, introduction and questions of that questionnaire did not differentiate it from someone having to describe their 'lived experience' of what they have to do whilst being given no informed consent that this would be twisted into 'attitude'.

What I find really pathetic though is the fact that the authors seem to think they have no requirement to suggest that pacing, nevermind GET is either possible or good or makes an iota of difference if they are just measuring fluctuating conditions. And if the pacing/GET in itself showed whether it was in certain groups useful to pace then why not test pacing and measure objectively without all the nonsense? They haven't even tested whether the very thing they claim they are encouraging 'works' - and I suspect it is because it is a massive fishing expedition.

Look at the 'fear avoidance' line on the results table as it moves across the different models removing the confounders (drop-outs) from p<0.001 to insignificant by model 3 for fatigue but not so for functional impairment where it was more significant than both 'catastrophizing' and 'all-or-nothing behaviour' were. In fact if you went by that 'functional impairment' measure it was 'fear avoidance' and 'resting behaviour' that was correlated. Why use a second measure if you are then going to ignore it in favour of your fatigue scale?

 

[Hubris]

Interesting that the whole psychosomatic/catastrophism theory basically starts with the premise that you don't do things even if you could, and when you find evidence of the opposite (patients desperately trying to do a lot of things in a short time to catch up on life when they feel better) it somehow confirms your belief.

 

[bobbler]

Interesting that the whole psychosomatic/catastrophism theory basically starts with the premise that you don't do things even if you could, and when you find evidence of the opposite (patients desperately trying to do a lot of things in a short time to catch up on life when they feel better) it somehow confirms your belief.

Yep it is as irrational and illogical in train of thought as a box of frogs. And the entire introduction a lesson in using rhetoric rather than academic literature as inferences of connections seemingly must be inferred just by them putting the lines next to each other - when did that become OK? THe one punchline it was always going to end on being that disabled people just need someone who knows nothing about their condition to help them think better, and somehow it is their fault/responsibilty. Well the real punchline is hidden right in there early on at the bottom of a para:

This is important because there are multiple competing pathways to fatigue in IBD, while IBD clinicians—who are frustrated at having few treatments for fatigue4—would benefit from clear psychoeducational advice to offer patients.

The one reference they decided to wait until the discussion to note existed:

Previous understanding of the behavioral correlates of IBD fatigue has been limited by a lack of prospective research. In one cross-sectional study, all-or-nothing behavior was not associated with fatigue severity but was associated with increased fatigue impact, while catastrophizing was not associated with fatigue severity or impact.10 However, the cross-sectional design of this study precludes any inference of causality. In chronic fatigue syndrome research, all-or-nothing behavior and catastrophic thinking patterns are both associated with worse fatigue.11 Our findings advance the literature by extending these findings to IBD in a prospective study.

To me, this says how did you get funded or permission to do this. They've had to jam in debunked research in a condition they'd normally claim was very different to IBD to feign some precedent that makes it worth doing.

And it also suggests that previous studies were done and found no association but said authors thought 'they just weren't doing it right to get the right results.....what you need is a cross-sectional design that precludes any inference of causality'

So how dare they use any phrases like predict or any terms that infer causality, when even after their little fishing exercise the literature clearly says 'no' because they didn't test causality. In fact, given causality that way has been ruled out any decent research would be ensuring it wasn't in the other direction and feeling a lot of weight to use any exploratory research (not closed-down to only the topics they want to consider/offer) to check for that potential underlying linkage causing both. Which is almost certainly explained by the symptom manual for the diseases

Anyway, the referenced paper is Artom et al (2016):

https://onlinelibrary.wiley.com/doi/full/10.1111/apt.13870

And I thought it was rather interesting to look at with quite different, more straightforward language even if it is looking at 'all the dimensions of biopsychosocial' vs what we tend to see with Chalder and the like.

Perhaps unsurprisingly (although should there really be a difference) this paper used very different measures - different fatigue scales and a different secondary measure. I'm going to paste this bit because a few things jump out at me from it (relevant to this, but to an issue I have with BPS approach to pwme in general in research):

The primary outcome was fatigue, as measured by the IBD-Fatigue (IBD-F) Scale53 and the Multidimensional Fatigue Inventory (MFI).54 The IBD-F Scale was selected as it was specifically developed to measure IBD-specific fatigue. Higher scores indicate higher fatigue severity and greater impact of fatigue.

Data assessing frequency and severity of fatigue from Section 1 (IBD-F1: five questions), and impact of fatigue on individuals’ lives from Section 2 (IBD-F2: 30 questions) were included in the analysis. Total scores for Section 1 and 2 are calculated separately.

Questions in Section 2 are scored on a 0–4 Likert scale, with the possible total score range from 0 to 20. Questions in Section 2 are scored on a 0–4 Likert scale, with the possible total score range from 0 to 120.

The MFI was chosen to be used in conjunction with the newly developed IBD-F scale, as it is the most frequently used scale to measure fatigue in IBD.9 It is a 20-item self-assessment instrument designed to measure the severity of multiple dimensions of fatigue (physical, mental and general fatigue, reduced activity and motivation). When a single score on fatigue severity is required results of the General fatigue subscale is recommended by the authors.54, 55

Indeed, the General fatigue subscale has been shown to have the highest correlation with general scales assessing fatigue severity in other long-term conditions.56, 57 Higher scores indicate higher fatigue. Due to the moderate sample size, continuous raw scores were utilised for both scales instead of categorical cut-offs (fatigued/nonfatigued).58

The secondary outcome measure was health-related QoL as measured by the Inflammatory Bowel Disease Questionnaire (IBDQ).59 The IBDQ is a disease-specific measure of overall physical, mental and social well-being in patients with CD and UC. The scale has 32 items scored on a 7-point Likert scale, higher scores signify better QoL.

I've broken up the first para to make it more readable for those on here.

My main point is in relation to the use of the Chalder Fatigue scale even for an IBD study where e.g. the previous research clearly shows there are preferable and more specific scales for various reasons. Indeed the paper on its [EDIT: th IBD-F scale] development is interesting and I don't know whether such patient input was used for the CFQ: https://www.sciencedirect.com/science/article/pii/S1873994614001585

I'd like to look into these further if there are comparators with the CFQ to note where it is 'transforming data' or any weak points. But why would someone switch to generic scales for both when there were disease-specific? I'm quite impressed by the IBD-F the first section with 5 questions are like the 'overall score' I've seen floated re: what to measure, except it asks for the last 2 weeks: the worst, best, ave and what is the fatigue level right now plus how much of waking time have they felt fatigued in last 2 weeks. The second part is much more specific questions (vs CFQ) such as 'because of fatigue': I had to nap during day, work affected, social affected, couldn't wash and dress, made mistakes, had difficulty sleeping, and so on for 30 questions.

My second point is these IBD-F scales were separated and that e.g. a 5 question part for the fatigue itself but 30 questions for impact. Which are totalled separately. vs Chalder Fatigue scale's 11, which somewhat rolls these separated concepts together. Which is interesting given this paper notes that the Artom et al (2016) paper found no correlation for fatigue but it did for impact. Both the IBD-F and CFQ use a Likert scale 1-4

And then this paper has chosen the Work and Social Adjustment Scale as its secondary measure rather than the IBDQ