Category: Psychiatry/Psychology

Clarifying the relationship between unexplained chronic fatigue and psychiatric morbidity: results from a community survey in Great Britain

Abstract:

The study examined the associations between several sociodemographic and psychosocial variables and unexplained chronic fatigue in the community before and after adjustment for psychiatric morbidity and determined the prevalence of fatigue and rate of disability resulting from fatigue in the general population. The study is a secondary analysis of 1993 data from a household survey of psychiatric morbidity conducted by the Office for Population Censuses and Surveys in Great Britain. The survey included 12,730 subjects age 16-64 years. Unexplained chronic fatigue was used as the dependent variable in a logistic regression analysis, with various sociodemographic and psychosocial variables and psychiatric morbidity as the independent variables. Psychiatric morbidity was assessed by using the Revised Clinical Interview Schedule. Fatigue was measured by using the fatigue section of the Revised Clinical Interview Schedule.

A total of 10,108 subjects agreed to cooperate (79.4% participation rate). The prevalence of unexplained chronic fatigue was 9%. Subjects with psychiatric morbidity had higher rates of fatigue. Adjustment for psychiatric morbidity had a minor effect on the associations between sociodemographic factors and chronic fatigue. After adjustment, older subjects, women, and couples with children had higher rates of fatigue. Single subjects, widowed subjects, adults living with parents, and economically inactive subjects had lower rates of fatigue. Fatigue was associated with considerable disability, but the association between fatigue and psychiatric morbidity explained most of this disability. Unexplained chronic fatigue is a common condition, strongly associated with psychiatric morbidity. The close relationship between fatigue and psychiatric morbidity should not obscure the possibility of differences as well as similarities in their aetiologies.

 

Source: Skapinakis P, Lewis G, Meltzer H. Clarifying the relationship between unexplained chronic fatigue and psychiatric morbidity: results from a community survey in Great Britain. Int Rev Psychiatry. 2003 Feb-May;15(1-2):57-64. http://www.ncbi.nlm.nih.gov/pubmed/12745311

 

Psychiatric morbidity in the chronic fatigue syndrome: are patients with personality disorder more physically impaired?

Abstract:

OBJECTIVE: The long-term consequences of chronic fatigue syndrome (CFS) include substantial impairment in physical functioning and high levels of work disability. In the absence of a medical explanation for this impairment, some have speculated that it may be due to comorbid psychiatric illness or personality disorder. We addressed this possibility by comparing the functional status of three CFS groups: no psychiatric diagnosis, psychiatric illness only, psychiatric illness and personality disorder. A second aim of the study was to determine whether a continuous measure of psychological distress could provide a better account of impairment than psychiatric diagnosis.

METHOD: The study sample consisted of 84 consecutive female referrals with CFS. All participants satisfied the case definition and completed an assessment protocol consisting of: physical examination, psychiatric interview and self-report questionnaires.

RESULTS: Psychiatric illness, either alone or in combination with a comorbid personality disorder, was not associated with physical impairment or disability in female participants. A regression model of physical functioning found that psychological distress accounted for 6% and symptom severity for 41% of the variance (P=.06 and <.01, respectively). In the case of disability, the corresponding percentages were 2% and 18% (NS and P<.01, respectively). The modest effects of psychological distress could not be attributed to symptom severity.

CONCLUSIONS: Although psychiatric illness and personality disorder was prevalent, neither could explain the effects of CFS on physical functioning and disability. As yet, there is no psychological or medical explanation for the behavioral consequences of CFS.

 

Source: Ciccone DS, Busichio K, Vickroy M, Natelson BH. Psychiatric morbidity in the chronic fatigue syndrome: are patients with personality disorder more physically impaired? J Psychosom Res. 2003 May;54(5):445-52. http://www.ncbi.nlm.nih.gov/pubmed/12726901

 

Childhood experiences of illness and parenting in adults with chronic fatigue syndrome

Abstract:

OBJECTIVE: There are many similarities between chronic fatigue syndrome (CFS), the somatoform disorders and problems otherwise known as “medically unexplained symptoms.” There is some evidence to suggest that a combination of inadequate parenting and early illness experience may predispose the individual to develop medically unexplained symptoms in adult life. The aim of this investigation was to compare the contributions of childhood experiences of illness and parenting in adults with CFS with a fracture clinic control group.

METHOD: A retrospective case control design was used. Thirty patients with a diagnosis of CFS and 30 patients attending a fracture clinic in an inner London teaching hospital completed questionnaires measuring parental care and protection and were interviewed about childhood experiences of illness.

RESULTS: There were no differences in childhood experience of illness in the two groups. However, logistic regression revealed that maternal overprotection and depression were associated with the diagnosis of CFS.

CONCLUSION: The findings may represent risk factors for the development of CFS in adult life. It is possible that maternal overprotection in particular is related to the formation of belief systems about avoiding activity that operate to adversely influence behaviour in patients with CFS.

 

Source: Fisher L, Chalder T. Childhood experiences of illness and parenting in adults with chronic fatigue syndrome. J Psychosom Res. 2003 May;54(5):439-43. http://www.ncbi.nlm.nih.gov/pubmed/12726900

 

Review: cognitive behavioural interventions may be effective for chronic fatigue syndrome and chronic back pain

Comment on: 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]

 

Psychological disorders have a high financial burden with many indirect costs. Behavioural strategies and cognitive behavioural interventions may be effective for a range of mental disorders, including some of the most chronic, severe and costly mental health problems.1 Very few medical professionals are adequately trained to deliver such treatments, however. This article is both timely and important because it emphasises the need to disseminate cognitive behaviour therapies more widely.

Raine et al conducted a thorough review of the efficacy of psychological treatments for common somatic symptoms: chronic fatigue syndrome, irritable bowel syndrome and chronic back pain. The results were consistent with the findings by the American Psychological Association’s Task Force on Promotion and Dissemination of Psychological Procedures:2 cognitive behaviour interventions and behaviour therapy are effective for treating chronic back pain and chronic fatigue syndrome. Raine et al found that treatment effects were stronger in secondary care compared with primary care settings. Furthermore, antidepressants were effective in both settings for treating irritable bowel syndrome.

The review has some limitations. First, as in all secondary analyses, the review is based only on published studies (that are more likely to report positive outcomes). There may also be problems with how interventions were defined and implemented. The majority of studies did not follow a treatment manual and did not measure adherence to the therapy protocol. The distinction between “behaviour therapy” and “cognitive-behaviour therapy” therefore remains elusive. This leaves important questions unanswered about how and why these treatments work (ie the mechanisms and mediators of change).3

You can read the rest of this comment here: http://ebmh.bmj.com/content/6/2/55.long

 

Source: Hofmann SG. Review: cognitive behavioural interventions may be effective for chronic fatigue syndrome and chronic back pain. Evid Based Ment Health. 2003 May;6(2):55. http://ebmh.bmj.com/content/6/2/55.long (Full article)

 

Comparative study of anxiety, depression, somatization, functional disability, and illness attribution in adolescents with chronic fatigue or migraine

Abstract:

OBJECTIVE: To compare adolescents with migraine, unexplained profound chronic fatigue of >6 months duration, and normal school controls on measures of anxiety, depression, somatization, functional disability, and illness attribution.

METHODS: Adolescents referred to Children’s Hospital and Regional Medical Center for behavioral treatment of migraine (n = 179) or evaluation of chronic fatigue (n = 97) were compared with a group of healthy controls of similar age and sex from a middle school (n = 32). Subjects completed the Spielberger State-Trait Anxiety Inventory-Trait Form, the Children’s Depression Inventory, the Childhood Somatization Inventory, and estimated the number of school days missed in the past 6 months because of illness. Migraine and fatigued subjects completed an illness attribution questionnaire.

RESULTS: Subjects in the 3 groups were 56% to 70% female and ranged from 11 years old to 18 years old with a mean age of 14.0 +/- 2.0. Forty-six of the 97 chronically fatigued adolescents met 1994 Centers for Disease Control and Prevention (CDC) criteria for chronic fatigue syndrome (CDC-CFS), while 51 had idiopathic chronic fatigue syndrome (I-CFS) that did not meet full CDC criteria. Adolescents with migraine had significantly higher anxiety scores than those with I-CFS or controls and higher somatization scores than controls. Adolescents with CDC-CFS had significantly higher anxiety scores than those with I-CFS or controls, and higher depression and somatization scores than all other groups. There were significant differences between all groups for school days missed with CDC-CFS more than I-CFS more than migraine more than controls. Parents of adolescents with unexplained I-CFS had significantly lower attribution scores relating illness to possible psychological or stress factors than parents of adolescents with CDC-CFS or migraine.

CONCLUSIONS: Adolescents referred to an academic center for evaluation of unexplained chronic fatigue had greater rates of school absenteeism than adolescents with migraine or healthy controls. Those meeting CDC-CFS criteria had higher anxiety scores than controls and higher depression and somatization scores than migraineurs or controls. Parents of adolescents with I-CFS were less likely to endorse psychological factors as possibly contributing to their symptoms than parents of adolescents with CDC-CFS or migraine.

 

Source: Smith MS, Martin-Herz SP, Womack WM, Marsigan JL. Comparative study of anxiety, depression, somatization, functional disability, and illness attribution in adolescents with chronic fatigue or migraine. Pediatrics. 2003 Apr;111(4 Pt 1):e376-81. http://www.ncbi.nlm.nih.gov/pubmed/12671155

 

Correlates of illness worry in chronic fatigue syndrome

Abstract:

BACKGROUND: Anxiety about illness leading to restriction of activity and physical deconditioning has been hypothesized to contribute to the chronicity of fatigue. Pathological symptom attributions, personality traits, and depression have all been hypothesized to contribute to illness worry.

METHODS: We compared 45 chronic fatigue syndrome (CFS) and 40 multiple sclerosis (MS) outpatients using a battery of psychometric instruments comprising the 12-item Illness Worry scale, the Symptom Interpretation Questionnaire (SIQ), the NEO Five-Factor Inventory (NEO-FFI), and a modified version of the SCL-90R Depression scale.

RESULTS: There was no difference between the two diagnostic groups on neuroticism, depressive symptoms, as well as the three scales of the SIQ. On the illness worry index, the CFS group had significantly higher scores than the MS group. This difference was due to items tapping vulnerability to illness and the perception that others are not taking their illness seriously. Somatic attributional style, neuroticism, depressive symptoms, and age were all significant predictors of illness worry in both CFS and MS patients.

CONCLUSIONS: Somatic attributions, neuroticism, and depression all contribute to illness worry in chronic illness. However, these factors do not account for the higher levels of illness worry in CFS as opposed to MS, which may be due to other specific cognitive and social interactional processes.

 

Source: Taillefer SS, Kirmayer LJ, Robbins JM, Lasry JC. Correlates of illness worry in chronic fatigue syndrome.  J Psychosom Res. 2003 Apr;54(4):331-7. http://www.ncbi.nlm.nih.gov/pubmed/12670610

 

Does graded activity increase activity? A case study of chronic fatigue syndrome

Abstract:

The reliance on self-report outcome measures in clinical trials of graded activity-oriented cognitive-behavior therapy in chronic fatigue syndrome (CFS) makes it difficult to draw definitive conclusions about actual behavioral change.

The participant in this case study was a 52-year-old married male with CFS who was working full-time. Outcome measures included a step counter to objectively measure physical activity as well as a daily diary measure of exercise activity and in vivo ratings of perceived energy, fatigue, and affect. The following psychometric instruments were also used: the CFS Symptom Inventory, the SF-36, the Beck Depression Inventory, and the Beck Anxiety Inventory. The 26-session graded activity intervention involved gradual increases in physical activity.

From baseline to treatment termination, the patient’s self-reported increase in walk time from 0 to 155 min a week contrasted with a surprising 10.6% decrease in mean weekly step counts. The final follow-up assessment revealed a “much improved” global rating, substantial increases in patient-recorded walk time and weight lifting intensity, yet a relatively modest increment in weekly step counts. It appeared that improvement was associated with mood-enhancing, stress-reducing activities that were substituted for stress-exacerbating activities.

Copyright 2003 Elsevier Science Ltd.

 

Source: Friedberg F. Does graded activity increase activity? A case study of chronic fatigue syndrome.  J Behav Ther Exp Psychiatry. 2002 Sep-Dec;33(3-4):203-15. http://www.ncbi.nlm.nih.gov/pubmed/12628637

 

Psychiatric adjustment in chronic fatigue syndrome of childhood and in juvenile idiopathic arthritis

Abstract:

BACKGROUND: High rates of psychopathology and of personality problems have been reported in children and adolescents with chronic fatigue syndrome (CFS). It is not clear whether this is consequent on the experience of chronic physical ill health. We compare psychiatric adjustment in children with CFS and in children suffering from another chronic physical disorder (juvenile idiopathic arthritis or JIA).

METHOD: Our sample consisted of 28 children with CFS and 30 with JIA attending tertiary paediatric centres (age range, 11 to 18 years, mean 15, S.D. 2.3). In order to assess psychiatric status and functioning, we used the K-SADS psychiatric interviews, CGAS and Harter Self-Esteem Questionnaire with child subjects; behavioural questionnaires (CBCL) and child personality assessment interviews (PAS) with parent informants.

RESULTS: Psychiatric disorders in the year prior to interview had been present significantly more commonly in the CFS group (72% v. 34% in JIA) and were more impairing to them (CGAS scores of 45 v. 77). Most common diagnoses in both groups were depressive and anxiety disorders. Personality problems were also significantly more frequent in CFS subjects (48% disorder and 26% difficulty v. 11% and 11% in JIA). There were few differences between the two groups in self-esteem.

CONCLUSIONS: Psychopathology and personality problems are common in children and adolescents with severe forms of CFS and cannot be explained strictly through the experience of chronic physical illness.

Comment in: Costs, correlates and consequences of fatigue in children and adults. [Psychol Med. 2003]

 

Source: Rangel L, Garralda ME, Hall A, Woodham S. Psychiatric adjustment in chronic fatigue syndrome of childhood and in juvenile idiopathic arthritis. Psychol Med. 2003 Feb;33(2):289-97. http://www.ncbi.nlm.nih.gov/pubmed/12622307

 

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