Illness behaviors in patients with unexplained chronic fatigue are associated with significant other responses

  • Joan M. RomanoEmail author
  • Mark P. Jensen
  • Karen B. Schmaling
  • Hyman Hops
  • Dedra S. Buchwald


Chronic fatigue syndrome (CFS) and unexplained chronic fatigue (CF) are characterized by compromised functional status and physical disability. Prior research on chronic pain has suggested that social factors may contribute to disability. This study examined the relationship between significant other responses and patient outcomes in patients with unexplained CF. Questionnaire data were collected from 117 patients on physical function, fatigue, pain, illness behaviors and responses of significant others to them, and depression. Ninety-four SOs reported their perceptions of patient illness behavior and their responses. Thirty-seven of these dyads also completed a series of household activities while being videotaped. Dyadic interactions were coded and analyzed. Both reported and observed solicitous responses by the significant other were associated with reported and observed patient illness behavior. Negative responses to patient illness behavior by significant others were associated with higher levels of patient depressive symptoms. The findings provide support for the role of operant behavioral factors in the context of chronic fatigue. They also suggest that further research on the relationship between dysfunction and significant other responses in patients with CFS or CF appears warranted and may have implications for treatment development.


Chronic fatigue Significant other responses Solicitousness Observational assessment 



Funding for this study was through NIH U19 A138429 (Joan M. Romano, Ph.D., Project Principal Investigator) as part of the NIH Chronic Fatigue Syndrome Research Center at the University of Washington (Dedra Buchwald, M.D., Principal Investigator). The authors wish to acknowledge with gratitude the contributions of the Chronic Fatigue Syndrome Research Center Staff, particularly Bethany Rubens, who provided invaluable assistance in data collection.


  1. Aaron, L. A., Burke, M. M., & Buchwald, D. (2000). Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder. Archives of Internal Medicine, 160(2), 221–227.CrossRefPubMedGoogle Scholar
  2. Afari, N., & Buchwald, D. (2003). Chronic fatigue syndrome: A review. American Journal of Psychiatry, 160(2), 221–236.CrossRefPubMedGoogle Scholar
  3. Allison, P. D., & Liker, J. K. (1982). Analyzing sequential categorical data on dyadic interaction: A comment on Gottman. Psychological Bulletin, 91(2), 393–403.CrossRefGoogle Scholar
  4. Bakeman, R., & Gottman, J. N. (1997). Observing interaction: An introduction to sequential analysis. New York: Cambridge Univ. Press.Google Scholar
  5. Belza, B. L., Henke, C. J., Yelin, E. H., Epstein, W. V., & Gilliss, C. L. (1993). Correlates of fatigue in older adults with rheumatoid arthritis. Nursing Research, 42(2), 93–99.CrossRefPubMedGoogle Scholar
  6. Biglan, A. (1985). Problem-solving interactions of depressed women and their husbands. Behavior Therapy, 16(5), 431–451.CrossRefGoogle Scholar
  7. Buchwald, D., Pearlman, T., Umali, J., Schmaling, K., & Katon, W. (1996). Functional status in patients with chronic fatigue syndrome, other fatiguing illnesses, and healthy individuals. The American Journal of Medicine, 101, 364–370.CrossRefPubMedGoogle Scholar
  8. Christensen, A., & Hazzard, A. (1983). Reactive effects during naturalistic observation of families. Behavioral Assessment, 5, 349–362.Google Scholar
  9. Ciccone, D. S., & Natelson, B. H. (2003). Comorbid illness in women with chronic fatigue syndrome: A test of the single syndrome hypothesis. Psychosomatic Medicine, 65(2), 268–275.CrossRefPubMedGoogle Scholar
  10. Davis, B., Hops, H., Alpert, A., & Sheeber, L. (1998). Child responses to parental conflict and their effect on adjustment: A study of triadic relations. Journal of Family Psychology, 12, 163–177.CrossRefGoogle Scholar
  11. Davis, B., Sheeber, L., Hops, H., & Tildesley, E. (2000). Adolescent responses to depressive parental behaviors in problem-solving interactions: Implications for depressive symptoms. Journal of Abnormal Child Psychology, 28, 451–465.CrossRefPubMedGoogle Scholar
  12. Epstein, S. A., Kay, G., Clauw, D., Heaton, R., Klein, D., Krupp, L., et al. (1999). Psychiatric disorders in patients with fibromyalgia: A multicenter investigation. Psychosomatics, 40(1), 57–63.PubMedGoogle Scholar
  13. Fleiss, J. L. (1981). Statistical methods for rates and proportions (2nd ed.). New York: Wiley.Google Scholar
  14. Flor, H., Kerns, R. D., & Turk, D. C. (1987). The role of spouse reinforcement, perceived pain, and activity levels of chronic pain patients. Journal of Psychosomatic Research, 31, 251–259.CrossRefPubMedGoogle Scholar
  15. Fordyce, W. E. (1976). Behavioral methods for chronic pain and illness. St. Louis: C. V. Mosby.Google Scholar
  16. Fukuda, K., Straus, S. E., Hickie, I., Sharpe, M. C., Dobbins, J. G., & Komaroff, A. (1994). The chronic fatigue syndrome: A comprehensive approach to its definition and study. Annals of Internal Medicine, 121, 953–959.PubMedGoogle Scholar
  17. Gatchel, R. J., Mayer, T., Dersh, J., Robinson, R., & Polatin, P. (1999). The association of the SF-36 health status survey with 1-year socioeconomic outcomes in a chronically disabled spinal disorder population. Spine, 24, 2162–2170.CrossRefPubMedGoogle Scholar
  18. Gatchel, R. J., Polatin, P. B., Mayer, T. G., Robinson, R., & Dersh, J. (1998). Use of the SF-36 health status survey with a chronically disabled back pain population: Strengths and limitations. Journal of Occupational Rehabilitation, 8, 237–245.CrossRefGoogle Scholar
  19. Geisser, M. E., Roth, R. S., & Robinson, M. E. (1997). Assessing depression among persons with chronic pain using the center for epidemiological studies-depression scale and the Beck Depression Inventory: A comparative analysis. The Clinical Journal of Pain, 13(2), 163–170.CrossRefPubMedGoogle Scholar
  20. Gottman, J., Markman, H., & Notarius, C. (1977). The topography of marital conflict: A sequential analysis of verbal and nonverbal behavior. Journal of Marriage and the Family, 39, 461–477.CrossRefGoogle Scholar
  21. Herrell, R., Goldberg, J., Hartman, S., Belcourt, M., Schmaling, K., & Buchwald, D. (2002). Chronic fatigue and chronic fatigue syndrome: A co-twin control study of functional status. Quality of Life Research, 11(5), 463–471.CrossRefPubMedGoogle Scholar
  22. Hooten, W. M., Townsend, C. O., Sietten, C. D., Bruce, B. K., & Rome, J. D. (2007). Treatment outcomes after multidisciplinary pain rehabilitation with analgesic medication withdrawal for patients with fibromyalgia. Pain Medicine, 8(1), 8–16.CrossRefPubMedGoogle Scholar
  23. Hops, H., Biglan, A., Tolman, A., Arthur, J., & Longoria, N. (1995a). Living in family environments (LIFE) coding system: Manual for coders (Rev ed.). Eugene, OR: Oregon Research Institute.Google Scholar
  24. Hops, H., Davis, B., Leve, C., & Sheeber, L. (2003). Cross-generational transmission of aggressive parent behavior: A prospective, mediational examination. Journal of Abnormal Child Psychology, 31, 161–169.CrossRefPubMedGoogle Scholar
  25. Hops, H., Davis, B., & Longoria, N. (1995b). Methodological issues in direct observation: Illustrations with the Living in Family Environments (LIFE) coding system. Journal of Clinical Child Psychology, 24, 193–203.CrossRefGoogle Scholar
  26. Jensen, M. P., & Karoly, P. (2001). Self-report scales and procedures for assessing pain in adults. In D. C. Turk & R. Melzack (Eds.), Handbook of pain assessment (2nd ed., pp. 15–34). New York: Guilford Publications.Google Scholar
  27. Kerns, R. D., Haythornthwaite, J., Rosenberg, R., Southwick, S., Giller, E. L., & Jacob, M. C. (1991). The pain behavior check list (PBCL): Factor structure and psychometric properties. Journal of Behavioral Medicine, 14(2), 155–167.CrossRefPubMedGoogle Scholar
  28. Kerns, R. D., Haythornthwaite, J., Southwick, S., & Giller, E. L. (1990). The role of marital interaction in chronic pain and depressive symptom severity. Journal of Psychosomatic Research, 34, 401–408.CrossRefPubMedGoogle Scholar
  29. Kerns, R. D., Turk, D. C., & Rudy, T. E. (1985). The West Haven-Yale multidimensional pain inventory (WHYMPI). Pain, 23, 345–356.CrossRefPubMedGoogle Scholar
  30. Komaroff, A. L., Fagioli, L. R., Doolittle, T. H., Gandek, B., Gleit, M. A., Guerriero, R. T., et al. (1996). Health status in patients with chronic fatigue syndrome and in general population and disease comparison groups. American Journal of Medicine, 101(3), 281–290.CrossRefPubMedGoogle Scholar
  31. Landis, J. R., & Koch, G. G. (1977). The measurement of observer agreement for categorical data. Biometrics, 33, 159–174.CrossRefPubMedGoogle Scholar
  32. Margolin, G., & Wampold, B. E. (1981). Sequential analysis of conflict and accord in distressed and nondistressed marital partners. Journal of Consulting and Clinical Psychology, 49, 554–567.CrossRefPubMedGoogle Scholar
  33. Radloff, L. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychosocial Measurement, 1, 385–401.CrossRefGoogle Scholar
  34. Romano, J. M., Jensen, M. P., Turner, J. A., Good, A. B., & Hops, H. (2000). Chronic pain patient-partner interactions: Further support for a behavioral model of chronic pain. Behavior Therapy, 31, 415–440.CrossRefGoogle Scholar
  35. Romano, J. M., & Schmaling, K. B. (2001). Assessment of couples and families with chronic pain. In D. C. Turk & R. Melzack (Eds.), Handbook of pain assessment (2nd ed., pp. 346–361). New York: The Guilford Press.Google Scholar
  36. Romano, J. M., Turner, J. A., Friedman, L. S., Bulcroft, R. A., Jensen, M. P., & Hops, H. (1991). Observational assessment of chronic pain patient-spouse behavioral interactions. Behavior Therapy, 11, 549–567.CrossRefGoogle Scholar
  37. Romano, J. M., Turner, J. A., Friedman, L. S., Bulcroft, R. A., Jensen, M. P., Hops, H., et al. (1992). Sequential analysis of chronic pain behaviors and spouse responses. Journal of Consulting and Clinical Psychology, 60, 777–782.CrossRefPubMedGoogle Scholar
  38. Romano, J. M., Turner, J. A., Jensen, M. P., Friedman, L. S., Bulcroft, R. A., Hops, H., et al. (1995). Chronic pain patient-spouse behavioral interactions predict patient disability. Pain, 63, 353–360.CrossRefPubMedGoogle Scholar
  39. Schmaling, K. B., Smith, W. R., & Buchwald, D. S. (2000). Significant other responses are associated with fatigue and functional status among patients with chronic fatigue syndrome. Psychosomatic Medicine, 62(3), 444–450.PubMedGoogle Scholar
  40. Schwartz, L., Slater, M. A., & Birchler, G. R. (1996). The role of pain behaviors in the modulation of marital conflict in chronic pain couples. Pain, 65, 227–233.CrossRefPubMedGoogle Scholar
  41. Sharpley, C. F., & Rogers, H. J. (1984). Preliminary validation of the abbreviated Spanier dyadic adjustment scale: Some psychometric data regarding a screening test of marital adjustment. Educational and Psychological Measurement, 44(4), 1045–1049.CrossRefGoogle Scholar
  42. Sheeber, L. B., Davis, B., Leve, C., Hops, H., & Tildesley, E. (2007). Adolescents’ relationships with their mothers and fathers: Associations with depressive disorder and subdiagnostic symptomatology. Journal of Abnormal Psychology, 116(1), 144–154.CrossRefPubMedGoogle Scholar
  43. Sheeber, L. B., Hops, H., Andrews, J., Alpert, A., & Davis, B. (1998). Interactional processes in families with depressed and nondepressed adolescents: Reinforcement of depressive behavior. Behavior Research and Therapy, 36, 417–427.CrossRefGoogle Scholar
  44. Tack, B. (1990). A measure of fatigue in rheumatoid arthritis (abstract). Arthritis Care and Research, 3, S13.Google Scholar
  45. Turk, D. C., Flor, H., & Rudy, T. E. (1987). Pain and families. I. Etiology, maintenance, and psychosocial impact. Pain, 30, 3–28.CrossRefPubMedGoogle Scholar
  46. Turk, D. C., Kerns, R. D., & Rosenberg, R. (1992). Effects of marital interaction on chronic pain and disability: Examining the down side of social support. Rehabilitation Psychology, 37, 259–274.CrossRefGoogle Scholar
  47. Turk, D. C., & Okifuji, A. (1994). Detecting depression in chronic pain patients: Adequacy of self-reports. Behaviour Research and Therapy, 32(1), 9–16.CrossRefPubMedGoogle Scholar
  48. Turk, D. C., Wack, J. T., & Kerns, R. D. (1985). An empirical examination of the “pain-behavior” construct. Journal of Behavioral Medicine, 8, 119–130.CrossRefPubMedGoogle Scholar
  49. Turner, J. A., & Romano, J. M. (2001). Psychological and psychosocial evaluation. In J. Loeser (Ed.), Bonica’s management of pain (3rd ed., pp. 329–341). Baltimore: Lippincott.Google Scholar
  50. Ware, J. E., Jr., & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care, 30, 473–483.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Joan M. Romano
    • 1
    Email author
  • Mark P. Jensen
    • 1
  • Karen B. Schmaling
    • 2
  • Hyman Hops
    • 3
  • Dedra S. Buchwald
    • 4
  1. 1.Department of Psychiatry and Behavioral SciencesUniversity of WashingtonSeattleUSA
  2. 2.Department of Public Health SciencesUniversity of North Carolina at CharlotteCharlotteUSA
  3. 3.Oregon Research InstituteEugeneUSA
  4. 4.Division of General Internal MedicineUniversity of WashingtonSeattleUSA

Personalised recommendations