Psychiatry/Psychology – Page 34 – American ME and CFS Society

Chronic fatigue and indicators of long-term employment disability in psychosomatic inpatients

Abstract:

The major goal of this study was to determine indictors of long-term disability for psychosomatic inpatients with chronic fatigue syndrome. To this end, a cross-sectional study was performed with a random sample of patients (n=1000, response rate: 83.9%) at a psychosomatic inpatient clinic. 51.1% of the patients (n=429) reported intensely persistent exhaustion that had no logical relation to actual exertion. 159 (37.1%) patients in this group were disabled from working and these comprised the main target group of this study.

Significantly more patients in the target group worked part time, were disabled for a disproportionately long period of time (50.9% of all were disabled for more than 6 months in the previous year), and felt stressed because of conflicts with their superiors and/or colleagues (in each case, P<0.01). While more frequent psychological comorbidity was not found, they reported physical complaints more often. It was not the patients fit for work who felt more burdened with chronic fatigue, but rather the employment-disabled, who were actually exposed to fewer demands.

These patients had, in comparison with those fit to work, a stronger fixation on somatic complaints, inadequate perception of physical and psychic sensations, difficulties getting along with other people and in coping with a regular job (in each case, P<0.01). Prospective examination of these indicators could help detect predictor variables for long-term disability in chronic fatigue. Such predictors could contribute to timely social-medical assessment and treatment.

Source: Tritt K, Nickel M, Mitterlehner F, Nickel C, Forthuber P, Leiberich P, Rother W, Loew T. Chronic fatigue and indicators of long-term employment disability in psychosomatic inpatients. Wien Klin Wochenschr. 2004 Mar 31;116(5-6):182-9. http://www.ncbi.nlm.nih.gov/pubmed/15088993

Impairment and coping in children and adolescents with chronic fatigue syndrome: a comparative study with other paediatric disorders

Abstract:

BACKGROUND: Functional impairment is a key feature of chronic fatigue syndrome (CFS) of childhood.

AIM: To compare impairment, illness attitudes and coping mechanisms in childhood CFS and in other paediatric disorders.

METHOD: Participants were 28 children and adolescents with CFS, 30 with juvenile idiopathic arthritis (JIA) and 27 with emotional disorders (ED). The measures used were interviews with children and parents, with detailed enquiry on impairment, including the Functional Disability Inventory (FDI), Illness Attitudes Scales (IAS), and Kidcope to measure coping styles in relation to common problems, illness and disability.

RESULTS: Children with CFS reported significantly more illness impairment, especially in school attendance, than those with JIA and ED. They had higher ‘worry about illness’ scores on the IAS. On the Kidcope they named school issues (work, expectations, attendance) as illness- or disability-related problems more than the other two groups. Fewer CFS participants reported using problem solving as a strategy to cope with illness and disability than with other problems in their lives. More in the CFS than in the JIA group used emotional regulation to cope with illness and disability. Fewer in the CFS than in the ED groups used social withdrawal to cope with illness and self-criticism for disability, but more used resignation to cope with disability.

CONCLUSION: Severe illness-related impairment, particularly through school non-attendance, and high levels of illness-related school concerns appear specific to CFS. CFS may also have characteristically high levels of generalised illness worry and particular styles of coping with illness and disability.

Source: Garralda ME, Rangel L. Impairment and coping in children and adolescents with chronic fatigue syndrome: a comparative study with other paediatric disorders. J Child Psychol Psychiatry. 2004 Mar;45(3):543-52. http://www.ncbi.nlm.nih.gov/pubmed/15055373

Objective assessment of personality disorder in chronic fatigue syndrome

Abstract:

OBJECTIVES: This study aims to objectively assess the prevalence and nature of personality disorders in depressed and nondepressed chronic fatigue syndrome (CFS) patients and compare this to depressed and healthy control groups.

METHODS: Sixty-one patients attending a tertiary referral clinic with chronic fatigue syndrome, 40 psychiatric inpatients with depressive disorder and 45 healthy medical students completed the Structured Clinical Interview for DSM-III-R Diagnoses (SCID-II) in addition to providing routine clinical and demographic information.

RESULTS: Thirty-nine percent of the CFS group, 73% of the depressed group and 4% of the healthy group were diagnosed with personality disorders. Cluster C disorders were the most common in both the CFS and depressed group. The depressed CFS patients had more Cluster B personality disorders than nondepressed CFS patients. Overall for CFS patients there was no association between mood state and personality disorder.

CONCLUSIONS: High levels of personality disorder are found on objective assessment of CFS patients attending a teaching hospital clinic. This cannot be accounted for by comorbid depression.

Source: Henderson M, Tannock C. Objective assessment of personality disorder in chronic fatigue syndrome. J Psychosom Res. 2004 Feb;56(2):251-4. http://www.ncbi.nlm.nih.gov/pubmed/15016586

Efficacy of cognitive-behavioural therapy by general practitioners for unexplained fatigue among employees: Randomised controlled trial

Abstract:

BACKGROUND: Fatigue is a common complaint that may lead to long-term sick leave and work disability.

AIMS: To assess the efficacy of cognitive-behavioural therapy by general practitioners for unexplained, persistent fatigue among employees.

METHOD: A randomised controlled trial, using a pre-randomisation design in primary care, investigated 151 employees on sick leave with fatigue. Participants in the experimental group were offered five to seven 30 min sessions of cognitive-behavioural therapy by a general practitioner; those in the control group were offered no treatment. Main outcome measures (fatigue severity, self-reported absenteeism, registered absenteeism and clinical recovery) were assessed at 4 months, 8 months and 12 months.

RESULTS: At baseline, 44% of the patients already met research criteria for chronic fatigue syndrome. There was no significant difference between the experimental group and the control group on primary or secondary outcomes at any point.

CONCLUSIONS: Cognitive-behavioural therapy by general practitioners for unexplained, persistent fatigue did not prove to be an effective intervention. Since these doctors were unable to deliver this therapy effectively under ideal circumstances, it is unlikely that doctors in routine practice would be more successful in doing so.

Source: Huibers MJ, Beurskens AJ, Van Schayck CP, Bazelmans E, Metsemakers JF, Knottnerus JA, Bleijenberg G. Efficacy of cognitive-behavioural therapy by general practitioners for unexplained fatigue among employees: Randomised controlled trial. Br J Psychiatry. 2004 Mar;184:240-6. http://bjp.rcpsych.org/content/184/3/240.long (Full article)

Chronic fatigue syndrome in a cognitive perspective. A therapeutic model

Abstract:

The cognitive approach to the treatment of chronic fatigue syndrome (CSF) is based on a multifactor etiological hypothesis, i.e. inaccurate beliefs and attitudes to the illness interact with pathophysiological processes, ineffective coping behaviours, negative states of mood, social problem, to perpetuate the illness. Patients suffering from CFS are supposed to be hypervigilant to somatic sensations and to interpret them as signs of impending physical catastrophe.

The aim of the this paper is to describe the clinical implementation of principles of cognitive therapy in the treatment of CFS. Basic to the treatment approach is a collaborative, listening and empathic attitude, sensitive to the patient’s personal beliefs and potential threats to self-esteem. The aim is to develop more useful, functional, formulations of the illness. The patient and the therapist work together to look at how the patient thinks about herself/himself and the illness, detect unhelpful attitudes, thoughts and mental images about the illness, and to make them accessible to Socratic reasoning. Graded behavioural interventions are planned in order to disconfirm unhelpful beliefs and reverse the spiral of tiredness, demoralization and reduced activity. The treatment is structured according to the general principles of cognitive therapy.

Source: d’Elia G. Chronic fatigue syndrome in a cognitive perspective. A therapeutic model. Lakartidningen. 2004 Jan 29;101(5):358-64. [Article in Swedish] http://www.ncbi.nlm.nih.gov/pubmed/14986443

Post-traumatic stress disorder among patients with chronic pain and chronic fatigue

Abstract:

BACKGROUND: Fibromyalgia (FM), a chronic pain condition of unknown aetiology often develops following a traumatic event. FM has been associated with post-traumatic stress disorder (PTSD) and major depression disorder (MDD).

METHOD: Patients seen in a referral clinic (N=571) were evaluated for FM and chronic fatigue syndrome (CFS) criteria. Patients completed questionnaires, and underwent a physical examination and a structured psychiatric evaluation. Critical components of the diagnostic criteria of FM (tender points and diffuse pain) and CFS (persistent debilitating fatigue and four of eight associated symptoms) were examined for their relationship with PTSD.

RESULTS: The prevalence of lifetime PTSD was 20% and lifetime MDD was 42%. Patients who had both tender points and diffuse pain had a higher prevalence of PTSD (OR=3.4, 95% CI 2.0-5.8) compared with those who had neither of these FM criteria. Stratification by MDD and adjustment for sociodemographic factors and chronic fatigue revealed that the association of PTSD with FM criteria was confined to those with MDD. Patients with MDD who met both components of the FM criteria had a three-fold increase in the prevalence of PTSD (95% CI 1.5-7.1); conversely, FM patients without MDD showed no increase in PTSD (OR=1.3, 95% CI 0.5-3.2). The components of the CFS criteria were not significantly associated with PTSD.

CONCLUSION: Optimal clinical care for patients with FM should include an assessment of trauma in general, and PTSD in particular. This study highlights the importance of considering co-morbid MDD as an effect modifier in analyses that explore PTSD in patients with FM.

Source: Roy-Byrne P, Smith WR, Goldberg J, Afari N, Buchwald D. Post-traumatic stress disorder among patients with chronic pain and chronic fatigue. Psychol Med. 2004 Feb;34(2):363-8. http://www.ncbi.nlm.nih.gov/pubmed/14982142

Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome

Abstract:

BACKGROUND: There is some evidence that cognitive behaviour therapy (CBT) is efficacious in chronic fatigue syndrome (CFS), but little data on its cost-effectiveness.

DESIGN: Prospective economic analysis alongside a randomized clinical trial.

METHODS: CFS patients were randomly assigned to CBT, guided support groups (SG), or the ‘natural course’ (NC, no protocol-based interventions). Patients were treated for 8 months and followed-up for another 6 months. Costs per patient showing clinically significant improvement, based on the CIS fatigue scale, and costs per quality-adjusted life year, were determined for a time period of 14 months.

RESULTS: Data were available for 171 patients at 8 months and for 128 at 14 months. At 8 and 14 months, the percentages of improved patients were 31% and 27% for CBT, 9% and 11% for SG, and 12% and 20% for NC. Mean QALYs gained at 14 months were, for CBT, SG and NC, respectively, 0.0737, -0.0018 and 0.0458. CBT and SG mean treatment costs were euro1490 and euro424. Other medical costs for CBT, SG, and NC, respectively, were euro324, euro623 and euro412 for the first period, and euro232, euro561 and euro378 for the second period. Non-medical costs for these periods for CBT, SG and NC were euro262, euro550, euro427 and euro226, euro439, euro287, respectively. Productivity costs were considerable, but not significantly different between groups.

DISCUSSION: CBT was less costly and more effective than SG. Compared to NC, the baseline incremental cost-effectiveness of CBT was euro20 516 per CFS patient showing clinically significant improvement, and euro21 375 per QALY. The bootstrap ratios showed considerable uncertainty regarding the results. Future research should focus on productivity costs, and follow patients prospectively over a longer period.

Comment in:

Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. [QJM. 2004]

Source: Severens JL, Prins JB, van der Wilt GJ, van der Meer JW, Bleijenberg G. Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. QJM. 2004 Mar;97(3):153-61. http://qjmed.oxfordjournals.org/content/97/3/153.long (Full article)

Is graded exercise better than cognitive behaviour therapy for fatigue? A UK randomized trial in primary care

Abstract:

BACKGROUND: Patients frequently present with unexplained fatigue in primary care, but there have been few treatment trials in this context. We aimed to test cognitive behaviour therapy (CBT) and graded exercise therapy (GET) for patients presenting to their family doctor with fatigue. Secondly, we described the outcome for a cohort of patients who presented to the same doctors with fatigue, who received standard care, plus a booklet.

METHOD: This was a randomized trial, followed by a prospective cohort study. Twenty-two practices in SE England referred 144 patients aged 16 to 75 years with over 3 months of unexplained fatigue. Self-rated fatigue score, the hospital anxiety and depression rating scale, functional impairment, physical step-test performance and causal attributions were measured. In the trial six sessions of CBT or GET were randomly allocated.

RESULTS: In the therapy groups the mean fatigue score decreased by 10 points (95% confidence interval (CI) = -25 to -15), with no significant difference between groups (mean difference = -1.3; CI = -3.9 to 1.3). Fewer patients attended for GET. At outcome one-half of patients had clinically important fatigue in both randomized groups, but patients in the group offered CBT were less anxious. Twenty-seven per cent of the patients met criteria for CFS at baseline. Only 25% of this subgroup recovered, compared to 60% of the subgroup that did not meet criteria for CFS.

CONCLUSIONS: Short courses of GET were not superior to CBT for patients consulting with fatigue of over 3 months in primary care. CBT was easier ‘to sell’. Low recovery in the CFS subgroup suggests that brief treatment is too short.

Source: Ridsdale L, Darbishire L, Seed PT. Is graded exercise better than cognitive behaviour therapy for fatigue? A UK randomized trial in primary care. Psychol Med. 2004 Jan;34(1):37-49. http://www.ncbi.nlm.nih.gov/pubmed/14971625

Prospective study of the prognosis of unexplained chronic fatigue in a clinic-based cohort

Abstract:

OBJECTIVES: To determine prospective changes in clinical status related to chronic fatigue over an 18-month period, and to test demographic and clinical predictors of outcome.

METHODS: A cohort of 100 patients with unexplained chronic fatigue (UCF), which encompasses both chronic fatigue syndrome (CFS) and idiopathic chronic fatigue (ICF), completed questionnaire measures and medical and psychiatric evaluations on four occasions, each six months apart.

RESULTS: Approximately 21% of the sample did not meet criteria for either CFS or ICF at their last research appointment 1.5 years after their index visit. Vitality increased over time, and physical functioning tended to improve, but UCF symptoms did not decrease significantly. Less education, being unemployed, worse mental health, more use of sedating and antidepressant medications, and more somatic attributions for their symptoms were associated with worsening symptom severity over time. Older age, current depression, and more somatic attributions predicted worsening physical functioning. Better mental health, less use of sedating medications, and fewer somatic attributions for illness were significant predictors of increases in vitality.

CONCLUSIONS: Demographic and clinical variables predict outcomes over time among a cohort of patients with unexplained chronic fatigue.

Source: Schmaling KB, Fiedelak JI, Katon WJ, Bader JO, Buchwald DS. Prospective study of the prognosis of unexplained chronic fatigue in a clinic-based cohort. Psychosom Med. 2003 Nov-Dec;65(6):1047-54. http://www.ncbi.nlm.nih.gov/pubmed/14645784

Psychosocial factors in chronic fatigue syndrome among Chinese Americans: a longitudinal community-based study

Abstract:

Chronic fatigue syndrome (CFS) is a relatively new condition of unknown etiology. Research suggests that psychosocial factors such as perceived social support, life stress, and acculturation may significantly influence individuals who are prone to CFS. For 57 Chinese American individuals initially diagnosed with CFS, those who recovered after one year reported lower levels of life stress than those who did not recover. Effects of changes in perceived social support also appeared to be mediated by life stress.

Source: Lim BR, Tan SY, Zheng YP, Lin KM, Park BC, Turk AA. Psychosocial factors in chronic fatigue syndrome among Chinese Americans: a longitudinal community-based study. Transcult Psychiatry. 2003 Sep;40(3):429-41. http://www.ncbi.nlm.nih.gov/pubmed/14649853