Illness Attributions Research Articles

Black identity and internal health attributions of second generation black immigrant women

ABSTRACT Objective Despite second generation Black immigrants being a rapidly growing population, they are often overlooked in health attribution research that treats Black populations as a monolithic group. Very few studies focus on how discrimination, societal pressure, and racial identity play a role in the health attributions of Black immigrant women. Even fewer studies have examined this relationship solely with second generation Black immigrant women. Research has shown, however, that increased racial and ethnic identity but decreased experiences with racism are related to higher internal health attributions in Black populations. Thus, we addressed this dearth in research in the current study by examining the relationship between racial centrality, racism stress, and internal health attributions in a sample of 123 second generation Black immigrant women. Design Health attributions were assessed using the Illness Attribution Scale, racism stress using the Schedule of Racist Events, and racial centrality using the Multidimensional Inventory of Black Identity. Multiple regression analyses were conducted to test the hypotheses that lower levels of racism stress, but higher ratings of racial centrality would relate to higher scores of internal health attributions. Results A positive relationship was found between racial centrality and internal health attributions but not racism stress. Conclusion The results indicated that stronger affirmations with Black identity are associated with a greater importance of the causes of illness to be within one’s perceived control for second generation Black immigrant women, which highlights the importance of examining wthin-group differences via collective identity measures to better explain health attribution behavioirs.

Personhood Disrupted: An Ethnography of Social Practices and the Attribution of Mental Illness in Abeokuta, Nigeria.

This paper explores the intricate interplay between living with mental illness and the processes of identifying mental illness in Abeokuta, Nigeria. With a particular focus on the contextual understanding of personhood, this study reveals how sociocultural backgrounds modulate the understanding of mental illness and its treatments within the Yoruba context. Through nine months of ethnographic fieldwork and discursive narrative analysis, the research revealed that becoming a mentally ill person is deeply intertwined with the everyday social life in the study site. The analysis highlights the multifaceted nature of personhood, encompassing various aspects such as parenthood, friendship, employment, and financial freedom. These facets of personhood are shaped by specific social practices and embedded within complex webs of social relations, often becoming more pronounced when these relationships are disrupted, leading to certain behaviours being categorised as mental illness. This paper underscores the significance of recognising and acknowledging the contextual notion and understanding of mental illness to ensure the provision of acceptable and effective care and recovery strategies.

Why did this happen to me? Causal attributions of illness and cultural health capital

This study examines how conversations between patients and clinicians about the causes of their health conditions relate to patient engagement in care. Leveraging cultural health capital (CHC) theory, we find that patient-physician discussions of health attributions are one mechanism to build patient understanding and activate engagement. We present a qualitative interpretive analysis of data collected in three phases with adult home health care patients: phone interviews (n = 28), field observations (n = 61), and semi-structured field interviews (n = 38). We find that engaging in discussions of causal health attributions with clinicians enables patients to overcome uncertainty, envision preventive actions, and engage in setting future goals. Such discussions must be supported by acknowledgement of the co-responsibility of individual factors and structural factors such as social determinants of health. These discussions are not easy to navigate but they can potentially help patients transition from a mindset of treating the disease (pathogenic approach) to an awareness of their available capabilities to improve health (salutogenic approach). This study contributes to research on attribution theory and cultural health capital theory by demonstrating how discussing causes for poor health can enable patients resolve doubts and accrue instrumental and symbolic resources that facilitate healing.

Parental Depression and Self-Stigma Among Chinese Young People Living With Depression: A Qualitative Study.

Self-stigma is detrimental to psychosocial well-being and the recovery journey among people living with depression. However, there has been limited research exploring the experience of stigma internalization when depression runs in families. This study aims to address this gap by (1) characterizing the manifestations of self-stigma among individuals living with depression whose parent(s) also have depression and (2) exploring the potential mechanisms underlying the impact of parental depression on self-stigma. Essential principles of the constructivist grounded theory approach were adopted to collect data through in-depth interviews with 27 participants aged 15-30, living in Mainland China. Many participants perceived depression running in their family as an endless disaster and an incurable illness. These beliefs further led to stigmatizing emotions (such as suppression, anger, and guilt) and behaviors (such as concealment and social withdrawal). Participants also highlighted ambivalent intergenerational relationships, tense family atmospheres, lower parental emotional involvement and support, and a lack of family flexibility due to parental depression. Furthermore, parental depression impacted participants' self-stigma by interfering with family relationships, family functioning, and parenting styles. It also shaped their perceptions of family, illness attribution, and public stigma. Additionally, parental depression had an impact on participants' social functioning, self-esteem, and personality, making them more susceptible to self-stigma. This study emphasizes the crucial role that the family plays in the internalization of stigma among individuals living with depression. It suggests that family dynamics, rather than family structure or economic backgrounds alone, shape this process.

I don't feel sick: Cognitive and affective processing of self-health associations using the Implicit Association Test.

Measuring implicit associations of self-concept with health or illness attributes may offer valuable insight into the mechanisms entailing the perception of one's own health, as explicit measures of self-reported health are usually influenced by social desirability or response bias. In this study, healthy participants performed a modified version of the implicit association test (IAT) investigating implicit associations between the self and either health or illness related representations. Behaviorally, implicit associations dominated for self-health pairing, and their strength was inversely correlated with depressive traits. Neurally, concomitant EEG recording showed significant modulations of the P1, LPP, and N4 components evoked by such pairings, suggesting a facilitation of sensory responses to self-related stimuli and differential emotional processes engaged to integrate health versus illness information into self-related representations. These data offer new clues to better understand the cognitive and affective mechanisms underlying unrealistic optimism and pathological awareness of health conditions in various clinical populations.

Diagnosing mental disorders in diverse cultures

Abstract Our goal is to highlight challenges clinicians encounter in achieving valid psychiatric diagnoses in linguistically and culturally diverse patients. These challenges often arise from language barriers, misinterpretation of nuanced expressions of distress, and a lack of consideration for the patient’s unique experiences and perspectives regarding their illness, leading to potential misdiagnoses. In this context, we explore the strategies to address these diagnostic issues. To illustrate these challenges, clinical examples of culturally diverse patients are presented. These cases offer insights into the cultural nuances of expressing distress and attributing illness to the external factors such as cosmic influences and spiritual afflictions, often employed as a way to conceal underlying causes. To achieve culturally appropriate diagnoses, clinicians need to be mindful of their patients’ cultural and spiritual beliefs, establish trust and rapport, and approach patient narratives with empathy. This empathetic approach allows clinicians to gain a deeper understanding of the patient’s cultural expressions of distress and their perspectives on illness attribution, often tied to supernatural influences. Importantly, effective communication is a key to uncovering the concealed causes of the patient’s condition.

Causal Explanations, Treatability, and Mental Illness Stigma: Experimental Study.

The purpose of this study was to test the effects of causal explanations, information about treatability, and type of psychiatric diagnosis on how the public reacts to an individual described as having a specific mental illness versus subclinical distress. A 5 (mental health condition) × 2 (treatability) × 4 (causal explanation) vignette experiment was embedded in an online survey, followed by assessments of prognostic optimism and desire to maintain social distance from the vignette character. Data were collected, in late 2022, from a probability sample (N=1,607) representative of the U.S. adult population. Ordinary least-squares regression was used to estimate the effects of the experimental conditions, covariates, and interactions on respondents' desire for social distance and their prognostic optimism. Attribution of mental illness to a genetic predisposition (vs. no attribution) significantly (p<0.001) predicted unwillingness to socially interact with the vignette character, regardless of the character's psychiatric diagnosis. Describing the illness as treatable with medication or psychotherapy (vs. no treatability information) also reduced willingness to socially interact, yet it also increased optimism for recovery. Desire for social distance and prognostic pessimism were greater for alcohol use disorder, opioid use disorder, or schizophrenia compared with major depression or subclinical distress. Attributing mental illness solely to genetics predicts social rejection of people diagnosed as having psychiatric disorders. Efforts to reduce stigma, increase social acceptance, and protect the mental health of individuals diagnosed as having a mental illness should include not framing mental illness exclusively in genetic terms.

Representations of Mental Illness in a Ga Community in Southern Ghana

This study explored lay concepts about and attributions of mental illness in a Ga community in southern Ghana. The study’s sample consisted of 11 Ga men and 12 Ga women, ranging in age from 30-81. Participants completed one-on-one interviews. Participants ascribed to polyphasic attributions of mental illness including biomedical and spiritual explanations. Attributions informed understandings of help-seeking behavior. Stigma was recognized as an important factor in the lived experience of people with mental illness. The recognition of individual distress as a marker of mental illness seemed less prominent than social indicators. Our interviewees’ narratives highlighted the importance of the social context in identifying and making meaning of mental illness in the community of study.

Nature and/or Nurture: Causal Attributions of Mental Illness and Stigma

Most medical researchers and social scientists concur that mental illness is caused by “nature” and “nurture,” yet efforts to reduce stigma tend to focus on biomedical causes. This study analyzed original survey data collected from 1,849 respondents in 2021–2022 who were randomly assigned to 16 experimental vignette conditions. Each vignette portrayed a man and varied according to which psychiatric diagnosis his situation resembled (alcohol dependence, depression, or schizophrenia) and what caused it: genetics (nature), environmental stress (nurture), or both. Control conditions included subclinical distress and no explanation. Exposure to the environmental explanation (vs. no explanation) predicted identifying mental illness, reduced expectation of violence toward others, increased willingness to socially interact, and optimism for recovery with treatment. Exposure to the nature and nurture explanation (vs. no explanation) predicted reduced desire for social distance. Implications of these findings for future research and for contact-based anti-stigma efforts are presented.

An Overview of Foodborne Sample-Initiated Retrospective Outbreak Investigations and Interagency Collaboration in the United States

Foodborne outbreak investigations have traditionally included the detection of a cluster of illnesses first, followed by an epidemiologic investigation to identify a food of interest. The increasing use of whole genome sequencing (WGS) subtyping technology for clinical, environmental, and food isolates of foodborne pathogens, and the ability to share and compare the data on public platforms, present new opportunities to identify earlier links between illnesses and their potential sources. We describe a process called sample-initiated retrospective outbreak investigations (SIROIs) used by federal public health and regulatory partners in the United States. SIROIs begin with an evaluation of the genomic similarity between bacterial isolates recovered from food or environmental samples and clusters of clinical isolates while subsequent and parallel epidemiologic and traceback investigations are initiated to corroborate their connection. SIROIs allow for earlier hypothesis generation, followed by targeted collection of information about food exposures and the foods and manufacturer of interest, to confirm a link between the illnesses and their source. This often leads to earlier action that could reduce the breadth and burden of foodborne illness outbreaks. We describe two case studies of recent SIROIs and present the benefits and challenges. Benefits include insight into foodborne illness attribution, international collaboration, and opportunities for enhanced food safety efforts in the food industry. Challenges include resource intensiveness, variability of epidemiologic and traceback data, and an increasingly complex food supply chain. SIROIs are valuable in identifying connections among small numbers of illnesses that may span significant time periods; detecting early signals for larger outbreaks or food safety issues associated with manufacturers; improving our understanding of the scope of contamination of foods; and identifying novel pathogen/commodity pairs.

Pathways to care in first-episode psychosis in low-resource settings: Implications for policy and practice.

Developing countries such as India face a major mental health care gap. Delayed or inadequate care can have a profound impact on treatment outcomes. We compared pathways to care in first episode psychosis (FEP) between North and South India to inform solutions to bridge the treatment gap. Cross-sectional observation study of 'untreated' FEP patients (n=177) visiting a psychiatry department in two sites in India (AIIMS, New Delhi and SCARF, Chennai). We compared duration of untreated psychosis (DUP), first service encounters, illness attributions and socio-demographic factors between patients from North and South India. Correlates of DUP were explored using logistic regression analysis (DUP ≥ 6 months) and generalised linear models (DUP in weeks). Patients in North India had experienced longer DUP than patients in South India (β=17.68, p<0.05). The most common first encounter in North India was with a faith healer (45.7%), however, this contact was not significantly associated with longer DUP. Visiting a faith healer was the second most common first contact in South India (23.6%) and was significantly associated with longer DUP (Odds Ratio: 6.84; 95% Confidence Interval: 1.77, 26.49). Being in paid employment was significantly associated with shorter DUP across both sites. Implementing early intervention strategies in a diverse country like India requires careful attention to local population demographics; one size may not fit all. A collaborative relationship between faith healers and mental health professionals could help with educational initiatives and to provide more accessible care.

Role of Mosque Communities in Supporting Muslims with Mental Illness: Results of CBPR-oriented Focus Groups in the Bay Area, California.

Objective The purpose of this study was to explore perspectives of Muslims residing in the Bay Area, California on the role of the mosque community in supporting community members' mental health needs and barriers to mental health care for members who experience mental health challenges. Methods This study employed a CBPR-focused qualitative approach in the form of content analysis of three focus group discussions organized and conducted with the help of a Community Advisory Board made up of members of the Muslim Community Association. Results Two major themes were identified upon examination of the data: services needed in the mosque community and barriers to addressing mental health issues in the mosque community. Specifically, participants reported wanting support groups within the mosque space, mosque-based activities, virtual support, community social workers, and family-oriented services. Barriers reported included community stigma, lack of cultural awareness of race-ethnic minorities within the community, attribution of mental illness to lack of faith or supernatural causes, and specific barriers unique to vulnerable/special subgroups within the community. Conclusion These findings highlight the need for developing mental health-related services and social support initiatives within the mosque space, specifically for those Muslim Americans living in the Bay Area in California. Furthermore, special attention needs to be placed on the barriers to accessing these services as identified by the community members.

Towards definitions of critical illness and critical care using concept analysis

ObjectiveAs ‘critical illness’ and ‘critical care’ lack consensus definitions, this study aimed to explore how the concepts’ are used, describe their defining attributes, and propose potential definitions.Design and methodsWe used...

Can a negative religious causal attribution of mental illness affect the phenomenon of public stigma?

ABSTRACT This study assessed, through an exploratory approach, how religion-based negative causal attributions of mental illness may be associated to stigmatising attitudes and behaviours that contribute to public stigma in an Italian convenience sample. All participants (N = 311; average age = 33 years, 38.6% male) completed a set of three questionnaires: Religious Beliefs and Mental Illness Stigma Scale, the Attribution Questionnaire 27 and the Mental Health Knowledge Schedule. The study found support for two specific models. The Responsibility model involved four key predictors: participant age, the influence of religious beliefs in everyday choices, religious beliefs about the connection between morality/sin and mental illness and having participated in seminars about mental illness stigma. The Dangerousness model involved three exogenous variables: participating in mental illness stigma seminars, religious beliefs about morality/sin and mental illness, and participant age. This study allows the identification of variables that seem to activate or attenuate the models of “Personal Responsibility” and “Dangerousness”.

Microbial Antagonism in Food-Enrichment Culture: Inhibition of Shiga Toxin-Producing Escherichia coli and Shigella Species.

Bacterial pathogens, such as Shiga toxin-producing Escherichia coli (STEC) and Shigella spp., are important causes of foodborne illness internationally. Recovery of these organisms from foods is critical for food safety investigations to support attribution of illnesses to specific food commodities; however, isolation of bacterial cultures can be challenging. Methods for the isolation of STEC and Shigella spp. from foods typically require enrichment to amplify target organisms to detectable levels. Yet, during enrichment, target organisms can be outcompeted by other bacteria in food matrices due to faster growth rates, or through production of antimicrobial agents such as bacteriocins or bacteriophages. The purpose of this study was to evaluate the occurrence of Shigella and STEC inhibitors produced by food microbiota. The production of antimicrobial compounds in cell-free extracts from 200 bacterial strains and 332 food-enrichment broths was assessed. Cell-free extracts produced by 23 (11.5%) of the strains tested inhibited growth of at least one of the five Shigella and seven STEC indicator strains used in this study. Of the 332 enrichment broths tested, cell-free extracts from 25 (7.5%) samples inhibited growth of at least one of the indicator strains tested. Inhibition was most commonly associated with E. coli recovered from meat products. Most of the inhibiting compounds were determined to be proteinaceous (34 of the 48 positive samples, 71%; including 17 strains, 17 foods) based on inactivation by proteolytic enzymes, indicating presence of bacteriocins. The cell-free extracts from 13 samples (27%, eight strains, five foods) were determined to contain bacteriophages based on the observation of plaques in diluted extracts and/or resistance to proteolytic enzymes. These results indicate that the production of inhibitors by food microbiota may be an important challenge for the recovery of foodborne pathogens, particularly for Shigella sonnei. The performance of enrichment media for recovery of Shigella and STEC could be improved by mitigating the impact of inhibitors produced by food microbiota during the enrichment process.

What stops Korean immigrants from accessing child and adolescent mental health services?

BackgroundAccess to child and adolescent mental health services by ethnic minorities has been poorly studied. Despite rapid growth of the immigrant Korean population, evidence indicates that few Korean families utilise these services in New Zealand. Those that do tend to present late and with significant morbidity. We sought to understand barriers to service access from Korean parents’ perspectives.MethodSeven focus groups were undertaken with 31 Korean parents of children aged 18 and under. The focus groups were semi-structured, held in the Korean language and utilised two case scenarios of common childhood/adolescent mental illnesses around which a set of broad, open-ended questions were posed. All conversations were audiorecorded, transcribed and translated into English. Thematic analysis was conducted using NVivo software.ResultsBoth attitudinal and structural barriers were identified. Attitudinal barriers included attribution of mental illness to external stressors or parenting problems, social stigma, denial or normalization of children’s behaviour, fear of family disempowerment, and mistrust of public mental health services. Structural barriers included parents’ lack of information regarding available services, logistical difficulties in access, communication difficulties, concerns over the quality of translators, and cultural competence of service providers.ConclusionSignificant barriers prevent Korean immigrant families from accessing child and adolescent mental health services in New Zealand. Measures to improve access, for example by countering stigma, are urgently required.

Perspectives of university health care students on mental health stigma in Nigeria: Qualitative analysis.

Mental illness is a significant public health burden in low- and middle-income countries. A wide treatment gap in mental health care exists within the Nigerian health care system and this gap is worsened by the presence of stigma associated with mental illness, which leads to delay in treatment or acts as a barrier to any care. In this study, our aim was to understand the factors that underlie mental illness stigma in order to inform the design of effective stigma-reducing interventions among health care students in Nigeria. We conducted four focus groups among university health care students in March 2019 in Nigeria. The students included nursing, pharmacy, and medical trainees from a university teaching hospital. We used an inductive-driven thematic analysis to identify codes and themes related to mental health stigma and conceptualization of mental health within the study group. Among the 40 participants, we identified how specific interpretations of religious and spiritual beliefs may be associated with stigmatizing behaviors such as social distancing and discrimination. Conceptualization of mental illness as a communicable disease and the attribution of mental illness to a moral failing contributed to stigma mechanisms. Overall, eight themes associated with mental health stigma and mental health-related concepts were found: spirituality, discrimination and devaluation, conceptualization of mental health, attribution theories, methods to reduce stigma, shortage of resources, violence and dangerousness, and maltreatment. We found that the co-existence of spiritual beliefs and biomedical and psychological models of mental health is a key factor to consider in the design of effective stigma-reducing interventions among university health students in Nigeria.

Explanatory models, illness, and treatment experiences of patients with psychosis using the services of traditional and faith healers in three African countries: Similarities and discontinuities.

As part of formative studies to design a program of collaborative care for persons with psychosis, we explored personal experience and lay attributions of illness as well as treatment among persons who had recently received care at traditional and faith healers' (TFHs) facilities in three cultural groups in Sub-Saharan Africa. A purposive sample of 85 individuals in Ibadan (Nigeria), Kumasi (Ghana), and Nairobi (Kenya) were interviewed. Data was inductively explored for themes and analysis was informed by the Framework Method. Across the three sites, illness experiences featured suffering and disability in different life domains. Predominant causal attribution was supernatural, even when biological causation was also acknowledged. Prayer and rituals, steeped in traditional spiritual beliefs, were prominent both in traditional faith healing settings as well as those of Christianity and Islam. Concurrent or consecutive use of TFHs and conventional medical services was common. TFHs provided services that appear to meet the therapeutic goals of their patients even when harmful treatment practices were employed. Cultural and linguistic differences did not obscure the commonality of a core set of beliefs and practices across these three groups. This similarity of core worldviews across diverse cultural settings means that a collaborative approach designed in one cultural group would, with adaptations to reflect differences in context, be applicable in another cultural group. Studies of patients' experience of illness and care are useful in designing and implementing collaborations between biomedical and TFH services as a way of scaling up services and improving the outcome of psychosis.

Sustained improvement with mindfulness-based therapy for psychogenic nonepileptic seizures

BackgroundWe previously reported on the efficacy of a manualized 12-session mindfulness-based therapy (MBT) for psychogenic nonepileptic seizures (PNES). Completion of MBT provided improvements in weekly PNES frequency and self-rated intensity. ObjectivesIn this study, we aimed to determine sustainability of improvement of seizure-related measures at 3- to 6-month follow-up after treatment completion. We also examined changes at treatment end and at follow-up on therapeutic targets of the MBT program. MethodsPatients with documented PNES were recruited from 2014 to 2018. Baseline measures were collected at time of diagnosis (T0) and at first follow-up post-diagnosis (T1). Outcomes are reported at MBT treatment completion (T3) and 3- to 6-month follow-up (T4). The Wilcoxon signed-rank test was used for pair-wise comparisons of PNES frequency; linear mixed models were used for other outcomes. ResultsFourteen of the 26 MBT completers (54%) attended follow-up (median 147.5 days between T3 and T4). PNES frequency, intensity, and number of days/week with PNES remained reduced at T4 (p < 0.01 for all; median frequency reduction 1.3/week from T1). Illness perception and feeling understood remained improved at T4 (p < 0.001 for both) as did worry about PNES (p < 0.05). Illness attribution (physical, mental or both) changed from T0 to T3 (p < 0.01), but not to T4. Psychological flexibility did not change over time. ConclusionPreviously reported improvements in seizure-related measures with MBT at treatment conclusion were maintained at 3- to 6-month follow-up. There were sustained improvements in some underlying processes (illness perception, feeling understood, and symptom worry) over the course of treatment and at follow-up. Long-term benefits of MBT need to be established with randomized controlled trials.

Is Cognitive Change Necessary to Alleviate Symptoms in Patients With Functional Somatic Syndrome?

What has been included under the umbrella term “Functional somatic syndromes” (FSS) has varied over the years. Diagnoses such as “somatoform” and “somatic symptom disorders,” as well as “medically unexplained symptoms,” have been included in FSS (1). Although there is no complete consensus, FSS usually comprise of conditions such as fibromyalgia, irritable bowel syndrome (IBS), and chronic fatigue syndrome (CFS) (2). A characteristic of FSS is persistent physical symptoms that lead to impairment or disability and that disrupt the capacity to take part in daily life. Although FSS are believed to be caused by a complex interaction of biological and psychosocial factors (3), the conditions are not medically explained in terms of well-Understood or established pathophysiological mechanisms. Cognitive behavioral therapy (CBT) has become the gold standard psychological treatment for FSS. Several meta-analyses have shown a small to moderate effect in patients with FSS (4–7). Even though the small to moderate effect is robust, in the sense that results have been replicated both within and across conditions, there is limited research on treatment mechanisms (8). That is, CBT has an effect, but why the effect takes place is not firmly established. Traditional CBT rests on the idea that changing cognitions and behaviors in FSS will decrease somatic symptoms (9). Specifically, changing so-called dysfunctional illness beliefs “are of paramount importance for treatment (success)” (10). According to a review of Windgassen et al. (11), there is a “clear indication” that “cognitive change is important for reducing symptom severity.” Put simply, a patient who, for example, believes that “something is wrong with my body” or claims a physical attribution such as “I have a chronic infection, that is why I feel fatigued,” will not easily get well. There are some merits to this position. In a review of CBT for IBS, four out of five studies found cognitions to mediate the effect of treatment on symptom severity (11). In another review of CBT for CFS, three different types of illness perceptions (fatigue as something aversive, activity as potentially dangerous to health, and a symptom preoccupation with fatigue) were found to potentially perpetuate CFS symptoms (12). Although there is a value in the position that changing cognition is of “paramount importance” to reduce symptoms in FSS, we argue that this idea is a simplification and leaves several questions unanswered. In the following, we provide two major arguments against this position. Counterargument 1: Patients With FSS Hold Complex Illness Beliefs or Attributions Patients with FSS have been assumed to hold strong beliefs that the cause of their symptoms is a physical disease (10). It has been suggested that they inflexibly hold assumptions like “something is wrong with my body” or “there is nothing I can do except waiting for a medical cure.” While it might be true that there is a tendency among certain patients with FSS to hold such beliefs (13, 14), some research speaks to the fact that patients with FSS either do not hold clear causal attributions or have a plethora of quite complex illness attributions. For example, in a study of 104 patients with fibromyalgia, over two-thirds of the patients endorsed the statement that “I cannot understand at all the cause of my pain (the reason I have pain)” (15). In these patients, there simply are no dysfunctional illness beliefs to change, as they do not understand the reason for why they have pain. In a study of 66 patients with chronic fatigue syndrome, half of the sample believed that stress had played a role in the development of their illness (16). In another qualitative study based on nine adolescents with CFS, three out of nine participants had a multi-causal understanding of their illness, believing that the illness had both physical and psychological origins (17). It is not clear how a patient who holds a psychological attribution fits with the idea of changing dysfunctional illness beliefs about the illness as a pervasive and uncontrollable physical disease.