Category: Psychiatry/Psychology

Possible influence of defenses and negative life events on patients with chronic fatigue syndrome: a pilot study

Abstract:

13 patients with a diagnosis of chronic fatigue syndrome and two contrast groups of conversion disorder patients (n = 19) and healthy controls (n = 13) were assessed using the projective perceptual Defense Mechanism Test to investigate if specific defense patterns are associated with chronic fatigue syndrome. Another objective was to assess the possible influence of perceived negative life events prior the onset of the illness. The overall results showed significant differences in defensive strategies among groups represented by two significant dimensions in a Partial Least Squares analysis. Compared to the contrast groups the patients with chronic fatigue syndrome were distinguished by a defense pattern of different distortions of aggressive affect, induced by an interpersonal anxiety-provoking stimulus picture with short exposures.

Their responses suggested the conversion group was characterized by a nonemotionally adapted pattern and specific constellations of defenses, associated with interior reality orientation compared to the patients with chronic fatigue syndrome and the healthy controls. Rated retrospectively, the group with chronic fatigue syndrome reported significantly more negative life events prior to the onset of their illness than healthy controls. For instance, 5 of the 13 patients reported sexual assault or physical battery as children or teenagers compared to none of the healthy controls. A significant association was found between defense pattern and frequency of reported negative life events. However, these retrospective reports might be confounded to some extent by the experience of the patients’ illness; for example, the reports may be interpreted in terms of present negative affect.

 

Source: Sundbom E, Henningsson M, Holm U, Söderbergh S, Evengård B. Possible influence of defenses and negative life events on patients with chronic fatigue syndrome: a pilot study. Psychol Rep. 2002 Dec;91(3 Pt 1):963-78. http://www.ncbi.nlm.nih.gov/pubmed/12530752

 

Chronic fatigue syndrome/ME

Comment on: Chronic fatigue syndrome/myalgic encephalitis. [Br J Gen Pract. 2002]

 

In previous correspondence,1 I challenged the trivialisation of chronic fatigue syndrome (CFS), and the generalisation and speculation in an editorial on chronic fatigue.2 The authors dismissed my arguments as, in their opinion, I had not demonstrated that I ‘was prepared and able accurately to read and interpret a scientific article’.3 I consider this remark to be unfair and unjustified.

I shall discuss each of their points in turn. First, they denied that by referring to the illness as ‘fatigue or its synonyms’, they were trivialising ‘the suffering of patients with PUPS (persistent unexplained physical symptoms)’. The authors must be aware of the controversy surrounding the word ‘fatigue’. As one affected surgeon wrote: ‘there is nothing in your experience in medical school, residency, or practice with its gruelling hours and sleep deprivation that even approaches the fatigue you feel with this illness. Fatigue is the most pathetically inadequate term’.4 Other writers on the subject recognise this, which is probably why most tend to describe the main symptom as profound, debilitating or disabling fatigue. But this was not the case here. The authors clearly equated CFS with (normal) tiredness and chronic fatigue. Elsewhere, they referred to ‘commonplace symptoms’ and in their response, again wrote about ‘fatigue and its synonyms’

You can read the full comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314477/pdf/12528593.pdf

 

Source: Goudsmit E. Chronic fatigue syndrome/ME. Br J Gen Pract. 2002 Dec;52(485):1023-4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314477/pdf/12528593.pdf

 

Psychological correlates of functional status in chronic fatigue syndrome

Abstract:

BACKGROUND: The present study was designed to test a cognitive model of impairment in chronic fatigue syndrome (CFS) in which disability is a function of severity of fatigue and depressive symptoms, generalized somatic symptom attributions and generalized illness worry.

METHODS: We compared 45 CFS and 40 multiple sclerosis (MS) outpatients on measures of functional ability, fatigue severity, depressive symptoms, somatic symptom attribution and illness worry.

RESULTS: The results confirmed previous findings of lower levels of functional status and greater fatigue among CFS patients compared to a group of patients with MS. Fatigue severity was found to be a significant predictor of physical functioning but not of psychosocial functioning in both groups. In CFS, when level of fatigue was controlled, making more somatic attributions was associated with worse physical functioning, and both illness worry and depressive symptoms were associated with worse psychosocial functioning.

CONCLUSIONS: Our findings support the role of depression and illness cognitions in disability in CFS sufferers. Different cognitive factors account for physical and psychosocial disability in CFS and MS. The SF-36 may be sensitive to symptom attributions, suggesting caution in its interpretation when used with patients with ill-defined medical conditions.

 

Source: Taillefer SS, Kirmayer LJ, Robbins JM, Lasry JC. Psychological correlates of functional status in chronic fatigue syndrome. J Psychosom Res. 2002 Dec;53(6):1097-106. http://www.ncbi.nlm.nih.gov/pubmed/12479992

 

Women experienced chronic fatigue syndrome and fibromyalgia as stigmatising

Comment on: Women’s experiences of stigma in relation to chronic fatigue syndrome and fibromyalgia. [Qual Health Res. 2002]

 

Any clinician who has taken the trouble to get to know a patient with fibromyalgia or CFS will recognise the basic finding of the study by Åsbring and Närvänen — patients attending specialist clinics with either condition (the similarities between the 2 outweigh the differences) feel acutely a sense of discrimination and stigmatisation. Many describe negative interactions with the medical profession.1 This is most acute when doctors are perceived to be “psychologising” the condition. Indeed, patients in this study found the act of prescribing antidepressants to be “violating”. This is regrettable because evidence exists that antidepressants can reduce pain, fatigue, and sleep disturbances in patients with fibromyalgia,2 although similar evidence does not exist for patients with CFS.

You can read the rest of this comment here: http://ebmh.bmj.com/content/5/4/127.long

 

Source: Wessely S. Women experienced chronic fatigue syndrome and fibromyalgia as stigmatising. Evid Based Ment Health. 2002 Nov;5(4):127. http://ebmh.bmj.com/content/5/4/127.long (Full comment)

 

Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care?

Abstract:

OBJECTIVES: To determine the strength of evidence for the effectiveness of mental health interventions for patients with three common somatic conditions (chronic fatigue syndrome, irritable bowel syndrome, and chronic back pain). To assess whether results obtained in secondary care can be extrapolated to primary care and suggest how future trials should be designed to provide more rigorous evidence.

DESIGN: Systematic review.

DATA SOURCES: Five electronic databases, key texts, references in the articles identified, and citations from expert clinicians.

STUDY SELECTION: Randomised controlled trials including participants with one of the three conditions for which no physical cause could be found. Two reviewers screened sources and independently extracted data and assessed quality.

RESULTS: Sixty one studies were identified; 20 were classified as primary care and 41 as secondary care. For some interventions, such as brief psychodynamic interpersonal therapy, little research was identified. However, results of meta-analyses and of randomised controlled trials suggest that cognitive behaviour therapy and behaviour therapy are effective for chronic back pain and chronic fatigue syndrome and that antidepressants are effective for irritable bowel syndrome. Cognitive behaviour therapy and behaviour therapy were effective in both primary and secondary care in patients with back pain, although the evidence is more consistent and the effect size larger for secondary care. Antidepressants seem effective in irritable bowel syndrome in both settings but ineffective in chronic fatigue syndrome.

CONCLUSIONS: Treatment seems to be more effective in patients in secondary care than in primary care. This may be because secondary care patients have more severe disease, they receive a different treatment regimen, or the intervention is more closely supervised. However, conclusions of effectiveness should be considered in the light of the methodological weaknesses of the studies. Large pragmatic trials are needed of interventions delivered in primary care by appropriately trained primary care staff.

Comment in: Review: cognitive behavioural interventions may be effective for chronic fatigue syndrome and chronic back pain. [Evid Based Ment Health. 2003]

 

Source: Raine R, Haines A, Sensky T, Hutchings A, Larkin K, Black N. Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care? BMJ. 2002 Nov 9;325(7372):1082. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC131187/ (Full article)

 

On the history of the concept neurasthenia and its modern variants chronic-fatigue-syndrome, fibromyalgia and multiple chemical sensitivities

Abstract:

This article deals with the history of the terminological and nosological development of the concept neurasthenia introduced in 1869 by George Miller Beard and in particular with its reappearance in western medicine in the 1980 s. Beginning with its predecessors in antiquity and continuing with hypochondria, which became a fashionable disease in the 18 th century, the concept neurasthenia reached a high point and world-wide medical acceptance at the end of the 19 th/beginning of the 20 th century. However, between the 1930 s and 1960 s it declined in popularity and gradually disappeared until finally it only had a rudimentary nosological role in the term “pseudoneurasthenia”. In the countries of the Far East, on the contrary, the concept of neurasthenia has been in continual use since its importation in the first decades of the last century. In the 1980 s, when an interest in the symptoms of chronic fatigue was reawakened in western medicine, the concept neurasthenia reappeared, this time to define the particular form of a neurotic disorder.

Parallel to these developments increasing importance was attached to clinical descriptions of illnesses which on account of their similarity to the symptoms of neurasthenia could be termed modern variants of the concept neurasthenia. These are “Chronic-Fatigue-Syndrome”, “Fibromyalgia” and “Multiple Chemical Sensitivities” which have more or less adopted the organic inheritance of Beard’s former concept of neurasthenia, despite the fact that so far the question of organicity could not be decisively answered in a single case. In order to clarify possible influences on the development of the concept neurasthenia and its variants, the theories and ideas of E. Shorter, medical historian at the University of Toronto, are discussed in the final part of the article, whereby the particular cultural background in each case has a decisive influence on the manifestation of the psychosomatic symptoms.

 

Source: Schäfer ML. On the history of the concept neurasthenia and its modern variants chronic-fatigue-syndrome, fibromyalgia and multiple chemical sensitivities. Fortschr Neurol Psychiatr. 2002 Nov;70(11):570-82. [Article in German] http://www.ncbi.nlm.nih.gov/pubmed/12410427

 

Birth order and its association with the onset of chronic fatigue syndrome

Abstract:

Chronic fatigue syndrome (CFS) is a medically unexplained illness that is diagnosed on the basis of a clinical case definition; so it probably is an illness with multiple causes producing the same clinical picture. One way of dealing with this heterogeneity is to stratify patients based on illness onset. We hypothesized that either the whole group of CFS patients or that group which developed CFS gradually would show a relation with birth order, while patients who developed CFS suddenly, probably due to a viral illness, would not show such a relation. We hypothesized the birth order effect in the gradual onset group because those patients have more psychological problems, and birth order effects have been shown for psychological characteristics.

We compared birth order in our CFS patients to that in a comparison group derived from U.S. demographic data. We found a tendency that did not reach formal statistical significance for a birth order effect in the gradual onset group, but not in either the sudden onset or combined total group. However, the birth order effect we found was due to relatively increased rates of CFS in second-born children; prior birth order studies of personality characteristics have found such effects to be skewed toward first-born children. Thus, our data do support a birth order effect in a subset of patients with CFS. The results of this study should encourage a larger multicenter study to further explore and understand this relation.

Comment in: Response to Brimacombe et al., birth order and its association with the onset of chronic fatigue syndrome. [Hum Biol. 2003]

 

Source: Brimacombe M, Helmer DA, Natelson BH. Birth order and its association with the onset of chronic fatigue syndrome. Hum Biol. 2002 Aug;74(4):615-20. http://www.ncbi.nlm.nih.gov/pubmed/12371687

 

Chronic fatigue syndrome or neurasthenia?

Comment on: Neurasthenia: prevalence, disability and health care characteristics in the Australian community. [Br J Psychiatry. 2002]

 

The interesting study reported by Hickie et al (2002) draws attention to the prevalence of ICD-10 neurasthenia (World Health Organization, 1992) in a large sample of the Australian general population. The authors’ findings are of the utmost importance for clinicians concerned with the disabling effects of fatigue but also provide food for thought in the wake of the CFS/ME Working Group (2002) report to the Chief Medical Officer. In this report, the term chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is used as an ‘umbrella term’ because of the ‘need for patients and clinicians to agree a satisfactory term as a means of communication’ but the concept of neurasthenia is not used. The report’s authors state that CFS is ‘widely used among clinicians’ and seem to consider it to be a disorder more physical than psychiatric. Equally, CFS/ME is not included in DSM-IV (American Psychiatric Association, 1994) or ICD-10. On the other hand, neurasthenia as defined in the ICD-10 is a psychiatric disorder whose main feature is ‘persistent and distressing complaints of increased fatigue after mental effort, or persistent and distressing complaints of bodily weakness and exhaustion after minimal effort’. This fatigue could be associated with muscular aches, dizziness, tension headaches, sleep disturbances, irritability, dyspepsia and inability to relax. Neurasthenia includes ‘fatigue syndrome’ but excludes ‘post viral fatigue syndrome’. Using ICD-10 criteria in the general population, Hickie et al (2002) found that 1.5% of the 10 641 people who participated in the study met the criteria for neurasthenia in the past year. For females aged between 18 and 24 years, the 12-month prevalence rises to 2.4%.

You can read the rest of this comment here: http://bjp.rcpsych.org/content/181/4/350.2.long

 

Source: Bailly L. Chronic fatigue syndrome or neurasthenia?  Br J Psychiatry. 2002 Oct;181:350-1. http://bjp.rcpsych.org/content/181/4/350.2.long (Full article)

 

Physicians’ diagnoses of psychiatric disorders for people with chronic fatigue syndrome

Abstract:

OBJECTIVE: To examine rates of psychiatric diagnoses given by patients’ primary or regular physicians to persons with chronic fatigue syndrome(CFS), persons with psychiatrically explained fatigue, and a control group. Physicians’ psychiatric diagnosis and participants’ self-reported psychiatric diagnoses were compared to lifetime psychiatric diagnoses as measured by a structured psychiatric interview.

METHOD: Participants were recruited as part of a community-based epidemiology study of chronic fatigue syndrome. Medical records of 23 persons with chronic fatigue syndrome, 25 persons with psychiatrically explained chronic fatigue, and 19 persons without chronic fatigue (controls) were examined to determine whether their physician had given a diagnosis of mood, anxiety, somatoform, or psychotic disorder. Lifetime psychiatric status was measured using the Structured Clinical Interview for the DSM-IV (SCID). Participants’ self reports of specific psychiatric disorders were assessed as part of a detailed medical questionnaire.

RESULTS: Physicians’ diagnosis of a psychiatric illness when at least one psychiatric disorder was present ranged from 40 percent in the psychiatrically explained group, 50 percent in the control group, and 64.3 percent in the CFS group. Participants in the psychiatrically explained group were more accurate than physicians in reporting the presence of a psychiatric disorder, and in accurately reporting the presence of a mood or anxiety disorder.

CONCLUSIONS: The present investigation found underrecognition of psychiatric illness by physicians, with relatively little misdiagnosis of psychiatric illness. Physicians had particular difficulty assessing psychiatric disorder in those patients whose chronic fatigue was fully explained by a psychiatric disorder. Results emphasized the importance of using participant self report as a screening for psychiatric disorder.

 

Source: Torres-Harding SR, Jason LA, Cane V, Carrico A, Taylor RR. Physicians’ diagnoses of psychiatric disorders for people with chronic fatigue syndrome. Int J Psychiatry Med. 2002;32(2):109-24. http://www.ncbi.nlm.nih.gov/pubmed/12269593

 

Chronic fatigue syndrome/myalgic encephalitis

Comment in: Chronic fatigue syndrome/ME. [Br J Gen Pract. 2002]

Comment on: Doctors and social epidemics: the problem of persistent unexplained physical symptoms, including chronic fatigue. [Br J Gen Pract. 2002]

 

In their editorial (Journal, May 2002), Stanley et al argued that chronic fatigue should be categorised under ‘persistent unexplained physical symptoms’, and that these are often the result of the somatisation of ‘unhappiness’ and the misinterpretation of ‘normal functioning’. However, their analysis contained some notable flaws.

Firstly, there is more to chronic fatigue syndrome (CFS) than ‘tiredness and its synonyms’ and to ignore symptoms, such as vertigo, nausea, and photophobia, both misrepresents and trivialises this illness.

Secondly, the authors alluded to widespread somatisation, despite the lack of evidence that this is a major problem in relation to CFS. The suggestion that this is a homogeneous population of unhappy, prejudiced, attention-seekers is difficult to reconcile with evidence-based medicine, and the subtle accusations of mass exaggeration are stigmatising and unhelpful.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314419/pdf/12236282.pdf

 

Source: Goudsmit E. Chronic fatigue syndrome/myalgic encephalitis. Br J Gen Pract. 2002 Sep;52(482):763; author reply 763-4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1314419/pdf/12236282.pdf (Full article)