Category: Psychiatry/Psychology

Psychological symptoms in chronic fatigue and juvenile rheumatoid arthritis

Abstract:

OBJECTIVE: To determine if psychological morbidity in youth with chronic fatigue is caused by the stress of coping with a chronic illness.

STUDY DESIGN: Case-control study comparing pediatric patients with debilitating chronic fatigue and matched subjects with juvenile rheumatoid arthritis, a chronic medical illness with similar functional sequelae.

SETTING: Pediatric Infectious Diseases Clinic and Juvenile Rheumatoid Arthritis Clinic of Kosair Children’s Hospital.

PARTICIPANTS: Nineteen children and adolescents with debilitating chronic fatigue and 19 age- and sex-matched peers with juvenile rheumatoid arthritis. Outcome. Structured Interview, Kaufman Brief Intelligence Test, Child Behavior Checklist, and Youth Self-Report.

RESULTS: Intellectual functioning on the Kaufman Brief Intelligence Test Composite was average (103, standard score) for both groups. Pediatric patients with chronic fatigue had higher levels of internalizing psychological distress than patients suffering from juvenile rheumatoid arthritis, despite the fact that both groups had a similar pattern of decline in social and physical activities. Duration of illness did not explain the difference in psychological symptoms.

CONCLUSIONS: Psychological factors may play a more active role in debilitating chronic fatigue in pediatric patients than can be explained by the stress of coping with a similar chronic, non-life-threatening illness.

 

Source: Carter BD, Kronenberger WG, Edwards JF, Marshall GS, Schikler KN, Causey DL. Psychological symptoms in chronic fatigue and juvenile rheumatoid arthritis. Pediatrics. 1999 May;103(5 Pt 1):975-9. http://www.ncbi.nlm.nih.gov/pubmed/10224175

 

The persistence of fatigue in chronic fatigue syndrome and multiple sclerosis: development of a model

Abstract:

The cause of chronic fatigue syndrome (CFS) is unknown. With respect to factors perpetuating fatigue, on the other hand, a model has been postulated in the literature in which behavioral, cognitive, and affective factors play a role in perpetuating fatigue. In the present study, this hypothesized model was tested on patients with CFS and on fatigued patients with multiple sclerosis (MS).

The model was formulated in terms of cause-and-effect relationships and an integral test of this model was performed by the statistical technique, “structural equation modeling,” in 51 patients with chronic fatigue syndrome and 50 patients with multiple sclerosis matched for age, gender, and education. Attributing complaints to a somatic cause produced low levels of physical activity, which in turn had a causal effect on fatigue severity. Depression had to be deleted from the model.

Sense of control over symptoms and focusing on bodily symptoms each had a direct causal effect on fatigue. The model showed an excellent fit for CFS patients, but was rejected for MS patients. Therefore, a new model for MS patients had to be developed in which sense of control had a causal effect on fatigue. In the MS model, no causal relationship was found between the physical state as measured by the Expanded Disability Status Score (EDSS) and fatigue or functional impairment.

The present study shows that cognitive and behavioral factors are involved in the persistence of fatigue. Treatment should be directed at these factors. The processes involved in the subjective experience of fatigue in CFS were different from the processes related to fatigue in MS.

 

Source: Vercoulen JH, Swanink CM, Galama JM, Fennis JF, Jongen PJ, Hommes OR, van der Meer JW, Bleijenberg G. The persistence of fatigue in chronic fatigue syndrome and multiple sclerosis: development of a model. J Psychosom Res. 1998 Dec;45(6):507-17. http://www.ncbi.nlm.nih.gov/pubmed/9859853

 

Assessing illness representations of chronic illness: explorations of their disease-specific nature

Abstract:

Elaborating on the five-dimensional structure of illness representation, as described in the self-regulation model of Leventhal (1980), the present study is aimed at identifying the relevance of this generic structure for two chronic illnesses: chronic fatigue syndrome (CFS) and Addison’s disease (AD).

Factor analyses showed the importance of the five dimensions identity, time-line, control/cure, cause, and consequences to differ according to the type of disease. That is, the items representing the five dimensions merged together for CFS patients and AD patients in a different manner and thereby produced different factor solutions for the two patient groups.

In CFS patients, a four-factor solution was identified with manageability, seriousness, personal responsibility, and external cause as the factors. In AD patients a four-factor solution was also identified but with seriousness, cause, chronicity, and controllability as the factors. The value of these findings for our understanding of the disease-specific nature of illness representation is discussed.

 

Source: Heijmans M, de Ridder D. Assessing illness representations of chronic illness: explorations of their disease-specific nature. J Behav Med. 1998 Oct;21(5):485-503. http://www.ncbi.nlm.nih.gov/pubmed/9836133

 

Exploring the validity of the Chalder Fatigue scale in chronic fatigue syndrome

Abstract:

The Chalder fatigue scale is widely used to measure physical and mental fatigue in chronic fatigue syndrome patients, but the constructs of the scale have not been examined in this patient sample. We examined the constructs of the 14-item fatigue scale in a sample of 136 chronic fatigue syndrome patients through principal components analysis, followed by correlations with measures of subjective and objective cognitive performance, physiological measures of strength and functional work capacity, depression, anxiety, and subjective sleep difficulties.

There were four factors of fatigue explaining 67% of the total variance. Factor 1 was correlated with subjective everyday cognitive difficulties, concentration difficulties, and a deficit in paired associate learning. Factor 2 was correlated with difficulties in maintaining sleep. Factor 3 was inversely correlated with grip strength, peak VO2, peak heart rate, and peak functional work capacity. Factor 4 was correlated with interview and self-rated measures of depression.

The results support the validity of mental and physical fatigue subscales and the dropping of the “loss of interest” item in the 11-item version of the fatigue scale.

 

Source: Morriss RK, Wearden AJ, Mullis R. Exploring the validity of the Chalder Fatigue scale in chronic fatigue syndrome. J Psychosom Res. 1998 Nov;45(5):411-7. http://www.ncbi.nlm.nih.gov/pubmed/9835234

 

Cognitive behavior therapy for chronic fatigue syndrome: efficacy and implications

Abstract:

Cognitive behavior therapy (CBT) is a form of non-pharmacologic treatment. It is based on a model of chronic fatigue syndrome (CFS) that hypothesizes that certain cognitions and behavior may perpetuate symptoms and disability–that is, act as obstacles to recovery. Treatment emphasizes self-help and aims to help the patient to recover by changing these unhelpful cognitions and behavior.

There is now good evidence from 2 independent randomized clinical trials to support the efficacy of CBT in patients with CFS. The treatment effect is substantial, although few patients are cured. The urgent clinical need is to make this form of treatment available to patients with CFS. One approach is to incorporate the principles of CBT into routine clinical practice. The preliminary evaluation of these simpler forms of CBT are promising, although the results of controlled trials are awaited. At present, intensive individual CBT administered by a skilled therapist remains the treatment of choice for patients with CFS.

 

Source: Sharpe M. Cognitive behavior therapy for chronic fatigue syndrome: efficacy and implications. Am J Med. 1998 Sep 28;105(3A):104S-109S. http://www.ncbi.nlm.nih.gov/pubmed/9790491

 

Self-efficacy as a psychological moderator of chronic fatigue syndrome

Abstract:

Chronic fatigue syndrome (CFS) is characterized by debilitating fatigue and a variety of somatic symptoms. Few studies have examined psychological aspects of CFS. In the present study, self-efficacy is shown to be a significant predictor of CFS symptoms beyond the variance accounted for by demographic variables and distress. Further psychological CFS research is encouraged by (1) identifying dimensions that are salient in the experience and study of CFS, (2) providing preliminary psychometric data for measures of those dimensions, and (3) identifying psychological variables that serve as moderators of the experience of CFS.

 

Source: Findley JC, Kerns R, Weinberg LD, Rosenberg R. Self-efficacy as a psychological moderator of chronic fatigue syndrome. J Behav Med. 1998 Aug;21(4):351-62. http://www.ncbi.nlm.nih.gov/pubmed/9789165

 

A naturalistic study of the chronic fatigue syndrome among women in primary care

Abstract:

Chronic fatigue syndrome (CFS), a controversial illness without clear etiology, causes profound debilitation in its sufferers. This study explored subjects’ perceptions of the variables that mediated the course of their illness and identified coping strategies in 15 women with CFS referred from the practice of a primary care physician.

Exploratory semistructured interviews were adapted from Kleinman’s Illness Narratives. Four instruments were used: the Beck Depression Inventory, the Sickness Impact Profile, a modified Karnofsky scale, and the Defense Mechanism Rating Scale. Of the 15 women, 60% reported improvement and/or recovery at the time of the interview.

Improvement was associated with social support and lower levels of depressive symptoms. Health status was influenced by how subjects perceived their illness, their future, and the doctor’s prognosis; and by the physician’s early diagnosis, validation of the CFS, and intensive medical follow-up. Obsessional and healthy neurotic defense levels predominated, which differs from historical comparison groups with dysthymia and panic disorder.

Psychological adaptation to CFS is similar to adaptive coping in other chronic illnesses: subjective perceptions of health status can predict functional status. Physician validation is particularly important given the controversial status of CFS. Maintaining relationships with others–doctor, work, family, and group/spiritual activities reflected healthy coping strategies that promoted hope and attitudinal shifts.

The finding of a mixture of neurotic and healthy defenses and a low proportion of defenses associated with personality disorders has not been previously reported in the CFS literature and warrants further investigation.

 

Source: Saltzstein BJ, Wyshak G, Hubbuch JT, Perry JC. A naturalistic study of the chronic fatigue syndrome among women in primary care. Gen Hosp Psychiatry. 1998 Sep;20(5):307-16. http://www.ncbi.nlm.nih.gov/pubmed/9788031

 

Screening instruments for psychiatric morbidity in chronic fatigue syndrome

Abstract:

Physicians require a screening instrument to detect psychiatric disorders in patients with chronic fatigue syndrome (CFS). Different threshold scores on the Hospital Anxiety and Depression scale (HAD) and the mental health scale of the Medical Outcome Survey (MOS) were compared with two gold standards for the presence or absence of psychiatric disorder, standard diagnostic criteria (DSM-III-R) and a threshold score for the number of psychiatric symptoms at a standardized psychiatric interview (Revised Clinical Interview Schedule total cut-off score of 11/12). They were compared by use of validating coefficients and receiver operating characteristics in 136 consecutive CFS medical outpatients.

The HAD scale at cut-off of 9/10 was a valid and efficient screening instrument for anxiety and depression by comparison with both gold standards. The MOS mental health scale at its recommended cut-off score of 67/68 yielded too many false-positives to be recommended as a psychiatric screening instrument in CFS patients.

 

Source: Morriss RK, Wearden AJ. Screening instruments for psychiatric morbidity in chronic fatigue syndrome. J R Soc Med. 1998 Jul;91(7):365-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1296809/ (Full article)

 

Structure and Determinants of Illness Representations in Chronic Disease: A Comparison of Addison’s Disease and Chronic Fatigue Syndrome

Abstract:

Although the clinical relevance of illness representations has been demonstrated in several studies, research on the structure and determinants of illness representations is rare. This article examines the illness representations of chronically ill patients, using a structured interview technique and taking chronic fatigue syndrome (CFS) and Addison’s disease (AD) as examples.

Considerable differences were found between the group of CFS patients (n = 98) and the group of AD patients (n = 63) with regard to their ideas about the identity, time line, control/cure , and consequences of their illness. Despite these differences, the pattern of correlations among these four dimensions of illness representation was found to be similar for the two groups. Moreover, the strength of the correlations points to the coherent nature of illness representations. The relations between the illness representations, personal variables, and disease- related variables were also explored.

Regression analyses showed the dimensions of illness representation to be explained rather well by personal and disease-related variables. Disease-related variables were the most important predictors for the dimensions of identity and consequences; personal variables showed strong associations with time line and control/cure.

 

Source: Heijmans M, De Ridder D. Structure and Determinants of Illness Representations in Chronic Disease: A Comparison of Addison’s Disease and Chronic Fatigue Syndrome. J Health Psychol. 1998 Oct;3(4):523-37. Doi: 10.1177/135910539800300406. http://www.ncbi.nlm.nih.gov/pubmed/22021411

 

Chronic fatigue syndrome: identification of distinct subgroups on the basis of allergy and psychologic variables

Abstract:

BACKGROUND: We investigated a role for allergic inflammation and psychologic parameters in the development of chronic fatigue syndrome (CFS).

METHODS: The design was a comparison between subjects with CFS and age- and sex-matched control cohorts. Studies were performed on CFS subjects (n = 18) and control cohorts consisting of normal subjects (n = 11), allergic subjects (n = 14), and individuals with primary depression (n = 12). We quantified cytokines at baseline as cell-associated immunoreactive peptides and as transcripts evaluated by means of semiquantitative RNA-based polymerase chain reactions. Psychologic evaluations included administration of the Diagnostic Interview Schedule, the Structured Clinical Interview, and the Symptom Checklist 90-Revised.

RESULTS: Increases in tumor necrosis factor (TNF)-alpha were identified in individual subjects with CFS (50.1 +/- 14.4 pg TNF-alpha per 10(7) peripheral blood mononuclear cells [PBMCs]; mean +/- SEM) and allergic subjects (41.6 +/- 7.6) in comparison with normal subjects (13.1 +/- 8.8) (P < .01 and P < .05, respectively). Similar trends were observed for interferon (IFN)-alpha in allergic subjects (3.0 +/- 1.7 pg/10(7) PBMCs) and subjects with CFS (6.4 +/- 3.4) compared with normal subjects (1.9 +/- 1.4). A significant increase (P < .05) in TNF-alpha transcripts was demonstrated between subjects with CFS and depressed subjects. In contrast to these proinflammatory cytokines, both subjects with CFS (2.6 +/- 1.8 pg/10(7) PBMCs) and allergic subjects (3.4 +/- 2.8) were associated with a statistically significant (P < .01) decrease in IL-10 concentrations compared with normal subjects (60.2 +/- 18.2). As shown in other studies, most of our subjects with CFS were allergic (15 of 18) and therefore presumably demonstrated cytokine gene activation on that basis. The seasonal exacerbation of allergy was associated with a further increase in cellular IFN-alpha (from 2.1 +/- 1.2 to 14.2 +/- 4.5 pg/107 PBMCs; P < .05) but no further modulation of TNF-alpha or IL-10. Similarly, self-reported exacerbations of CFS were associated with a further increase in IFN-alpha (from 2.5 +/- 1.0 to 21.9 +/- 7.8; P < .05) and occurred at times of seasonal exposures to allergens. This linkage does not permit making any definitive conclusions regarding a causative influence of either seasonal allergies or the increase in cellular IFN-alpha with the increase in CFS symptoms. The close association between atopy and CFS led us to speculate that CFS may arise from an abnormal psychologic response to the disordered expression of these proinflammatory and antiinflammatory cytokines. Psychologic variables were predictive of immune status within the CFS sample (65.9% of the variance in immune status; F (3,10) = 6.44, P < .05). Specifically, the absence of a personality disorder but greater endorsement of global psychiatric symptoms was predictive of immune activation.

CONCLUSIONS: Most of our subjects with CFS were allergic, and the CFS and allergy cohorts were similar in terms of their immune status. However, the CFS subjects could be discriminated by the distinct psychologic profiles among subjects with and without immune activation. We propose that in at least a large subgroup of subjects with CFS who had allergies, the concomitant influences of immune activation brought on by allergic inflammation in an individual with the appropriate psychologic profile may interact to produce the symptoms of CFS. In a psychologically predisposed individual, symptoms associated with allergic inflammation are recognized as illness.

 

Source: Borish L, Schmaling K, DiClementi JD, Streib J, Negri J, Jones JF. Chronic fatigue syndrome: identification of distinct subgroups on the basis of allergy and psychologic variables. J Allergy Clin Immunol. 1998 Aug;102(2):222-30. http://www.ncbi.nlm.nih.gov/pubmed/9723665