Category: Psychiatry/Psychology

Coniunctio–in bodily and psychic modes: dissociation, devitalization and integration in a case of chronic fatigue syndrome

Abstract:

Three years of analytical psychotherapy with a professional woman in mid-life, suffering from chronic fatigue syndrome (CFS), is described. Gradual recovery merged into mid-life changes; marriage, along with a new balance of maternal and paternal imagos, enabled her to trust enough to become pregnant-coniunctio in the most primal bodily and psychic modes. Her life-long, schizoid type pattern, “the pendulum of closeness and isolation’, with its extreme of psycho-physical collapse and devitalization, was replayed in therapy.

The analyst’s symbolic attitude is emphasized, containing the patient’s initial affective explosion and validating the physicality of her condition. Mirroring and steady rhythmic attunement became a new, pre-verbal, source of trust-vitalization; differentiation and separation replaced defensive splitting and dissociation. Then the overwhelmingly powerful bodily/maternal could be counterbalanced by the masculine, and a transitional space emerged for symbolic work. Both the regressive and the dynamic aspects of CFS are located in the earliest undifferentiated, archetypal, bodily/psychic modes, when the frustration of primary needs evokes the defences of the self.

It is argued that our psychodynamic understanding can contribute to the stalemate in seeing chronic fatigue syndrome as either an organic illness or depression, and that a new linking of the somatic and psychic calls for a new professional collaboration.

 

Source: Holland P. Coniunctio–in bodily and psychic modes: dissociation, devitalization and integration in a case of chronic fatigue syndrome. J Anal Psychol. 1997 Apr;42(2):217-36. http://www.ncbi.nlm.nih.gov/pubmed/9161122

A body with chronic fatigue syndrome as a battleground for the fight to separate from the mother

Abstract:

I describe the therapy of a 20-year-old women who believed that her difficulties in concentrating and remembering were caused by her “ME’ (Myalgic encephalomyelitis, Chronic fatigue syndrome, or CFS). She had been fathered by a man who never left his own wife. Work with her dreams revealed a within-body drama in which she was locked in an unspeakable fight to the death with her mother. Her symptoms improved after parallels between a dream and an accident showed her own self-destructive hand in her story.

Another dream, reflecting her first ‘incestuous’ affair, showed her search for her original father-self as someone separate from mother, and a later affair provided a between-body drama, helping her to own the arrogant and abject traits she had before seen only as her mother’s. I show how we worked in the area of Winnicott’s first ‘primitive agony’ as experienced by a somatizing patient, stuck in a too-close destructive relationship with her mother-body. I discuss how analytical work can be done with the primitive affects and conflicts against which the ME symptoms may be defending.

 

Source: Simpson M. A body with chronic fatigue syndrome as a battleground for the fight to separate from the mother. J Anal Psychol. 1997 Apr;42(2):201-16. http://www.ncbi.nlm.nih.gov/pubmed/9161121

 

Chronic fatigue syndrome/myalgic encephalomyelitis as a twentieth-century disease: analytic challenges

Abstract:

The challenges of chronic fatigue syndrome (often called myalgic encephalomyelitis, especially in the UK) (CFS/ME) to analytical and medical approaches are connected with our inability to understand its distressing somatic symptoms in terms of a single identifiable and understandable disease entity. The evidence for the roles of viral aetiologies remains inconclusive, as does our understanding of the involvement of the immune system.

The history and social context of CFS/ME, and its relation to neurasthenia and psychasthenia are sketched. A symbolic attitude to the condition may need to be rooted in an awareness of psychoid levels of operation, and the expression and spread of CFS/ME may sometimes be aided by the ravages of projective identification. Psychic denial, sometimes violent, in sufferers (especially children and adolescents) and their families may be important in the aetiology of CFS/ME. We draw out common threads from psychodynamic work with five cases, four showing some symptomatic improvement, analytic discussions of three cases being presented elsewhere in this issue of JAP.

 

Source: Simpson M, Bennett A, Holland P. Chronic fatigue syndrome/myalgic encephalomyelitis as a twentieth-century disease: analytic challenges. J Anal Psychol. 1997 Apr;42(2):191-9. http://www.ncbi.nlm.nih.gov/pubmed/9161120

 

The prognosis of chronic fatigue and chronic fatigue syndrome: a systematic review

Abstract:

The prognosis of chronic fatigue syndrome and chronic fatigue has been studied in numerous small case series. We performed a systematic review of all studies to determine the proportion of individuals with the conditions who recovered at follow-up, the risk of developing alternative physical diagnoses, and the risk factors for poor prognosis.

A literature search of all published studies which included a follow-up of patients with chronic fatigue syndrome or chronic fatigue were performed. Of 26 studies identified, four studied fatigue in children, and found that 54-94% of children recovered over the periods of follow-up. Another five studies operationally defined chronic fatigue syndrome in adults and found that < 10% of subjects return to pre-morbid levels of functioning, and the majority remain significantly impaired. The remaining studies used less stringent criteria to define their cohorts. Among patients in primary care with fatigue lasting < 6 months, at least 40% of patients improved.

As the definition becomes more stringent the prognosis appears to worsen. Consistently reported risk factors for poor prognosis are older age, more chronic illness, having a comorbid psychiatric disorder and holding a belief that the illness is due to physical causes.

Comment in:

Chronic fatigue syndrome. [QJM. 1997]

Chronic fatigue syndrome. [QJM. 1997]

 

Source: Joyce J, Hotopf M, Wessely S. The prognosis of chronic fatigue and chronic fatigue syndrome: a systematic review. QJM. 1997 Mar;90(3):223-33. http://qjmed.oxfordjournals.org/content/90/3/223.long (Full article)

 

Cognitive behavior therapy for chronic fatigue syndrome: a randomized controlled trial

Abstract:

OBJECTIVE: Cognitive behavior therapy for chronic fatigue syndrome was compared with relaxation in a randomized controlled trial.

METHODS: Sixty patients with chronic fatigue syndrome were randomly assigned to 13 sessions of either cognitive behavior therapy (graded activity and cognitive restructuring) or relaxation. Outcome was evaluated by using measures of functional impairment, fatigue, mood, and global improvement.

RESULTS: Treatment was completed by 53 patients. Functional impairment and fatigue improved more in the group that received cognitive behavior therapy. At final follow-up, 70% of the completers in the cognitive behavior therapy group achieved good outcomes (substantial improvement in physical functioning) compared with 19% of those in the relaxation group who completed treatment.

CONCLUSIONS: Cognitive behavior therapy was more effective than a relaxation control in the management of patients with chronic fatigue syndrome. Improvements were sustained over 6 months of follow-up.

Comment in: Cognitive behavior therapy for chronic fatigue syndrome. [Am J Psychiatry. 1998]

 

Source: Deale A, Chalder T, Marks I, Wessely S. Cognitive behavior therapy for chronic fatigue syndrome: a randomized controlled trial. Am J Psychiatry. 1997 Mar;154(3):408-14. http://www.ncbi.nlm.nih.gov/pubmed/9054791

 

Cognitive functioning is impaired in patients with chronic fatigue syndrome devoid of psychiatric disease

Abstract:

OBJECTIVE: To examine the effect of the presence or absence of psychiatric disease on cognitive functioning in chronic fatigue syndrome.

METHODS: Thirty six patients with chronic fatigue syndrome and 31 healthy controls who did not exercise regularly were studied. Subgroups within the chronic fatigue syndrome sample were formed based on the presence or absence of comorbid axis I psychiatric disorders. Patients with psychiatric disorders preceding the onset chronic fatigue syndrome were excluded. Subjects were administered a battery of standardised neuropsychological tests as well as a structured psychiatric interview.

RESULTS: Patients with chronic fatigue syndrome without psychiatric comorbidity were impaired relative to controls and patients with chronic fatigue syndrome with concurrent psychiatric disease on tests of memory, attention, and information processing.

CONCLUSION: Impaired cognition in chronic fatigue syndrome cannot be explained solely by the presence of a psychiatric condition.

 

Source: DeLuca J, Johnson SK, Ellis SP, Natelson BH. Cognitive functioning is impaired in patients with chronic fatigue syndrome devoid of psychiatric disease. J Neurol Neurosurg Psychiatry. 1997 Feb;62(2):151-5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC486726/ (Full article)

 

Chronic fatigue syndrome: a 20th century illness?

Abstract:

The chronic fatigue syndrome has become the fin de siècle illness, now getting similar attention to that of neurasthenia, which dominated medical thinking at the turn of the century.

Myalgic encephalomyelitis was an early term introduced in the United Kingdom in 1957 for this state, but it had little or no public or professional prominence. Until then “chronic fatigue had become invisible”, with “no name, no known etiology, no case illustrations or clinical accounts in the medical textbook, no ongoing research activity–nothing to relate it to current medical knowledge”.

The reconstruction of chronic fatigue began in the mid-1980s, with the emergence of “chronic Epstein-Barr virus syndrome”, which was later converted to chronic fatigue syndrome. The former term, which first emerged in the mid-1980s, is now regarded as a misnomer and should be abandoned.

In the popular American literature the term “chronic fatigue and immune deficiency syndrome” is preferred by the most active of the patient lobbies, while myalgic encephalomyelitis continues to be the usual label in the United Kingdom.

The relevant research linking chronic fatigue syndrome with somatization is reviewed in this article. Understanding the nature of somatization can still shed some light on the meaning of chronic fatigue at the end of the 20th century.

 

Source: Wessely S. Chronic fatigue syndrome: a 20th century illness? Scand J Work Environ Health. 1997;23 Suppl 3:17-34. http://www.sjweh.fi/show_abstract.php?abstract_id=239 (Full article)

 

Sudden vs gradual onset of chronic fatigue syndrome differentiates individuals on cognitive and psychiatric measures

Abstract:

To examine the influence of mode of illness onset on psychiatric status and neuropsychological performance, 36 patients with CFS were divided into two groups: sudden vs gradual onset of symptoms.

These two CFS subgroups were compared to each other and to sedentary healthy controls on standardized neuropsychological tests of attention/concentration, information processing efficiency, memory, and higher cortical functions. In addition, the distribution of comorbid Axis I psychiatric disease between the two CFS groups was examined.

The rate of concurrent psychiatric disease was significantly greater in the CFS-gradual group relative to the CFS-sudden group. While both CFS groups showed a significant reduction in information processing ability relative to controls, impairment in memory was more severe in the CFS-sudden group. Because of the significant heterogeneity of the CFS population, the need for subgroup analysis is discussed.

 

Source: DeLuca J, Johnson SK, Ellis SP, Natelson BH. Sudden vs gradual onset of chronic fatigue syndrome differentiates individuals on cognitive and psychiatric measures. J Psychiatr Res. 1997 Jan-Feb;31(1):83-90. http://www.ncbi.nlm.nih.gov/pubmed/9201650

 

Neuropsychological and psychological functioning in chronic fatigue syndrome

Abstract:

Although patients with chronic fatigue syndrome (CFS) typically present subjective complaints of cognitive and psychological difficulties, studies to date have provided mixed objective support for the existence of specific cognitive deficits. The present study was designed to examine differences in performance between individuals diagnosed with CFS and matched controls with respect to sustained attention, processing efficiency, learning, and memory.

Subjects included 17 patients meeting Centers for Disease Control research criteria for CFS and 17 control subjects. Subjects were administered six measures assessing attention, memory, and word-finding ability and two measures assessing psychological distress.

For the most part, the two groups did not differ on measures of neurocognitive functioning. Significant group differences were found on a single measure of attention and incidental memory. However, CFS patients differed markedly from controls with respect to reported psychological distress.

The results support previous findings of notable levels of psychological distress among CFS patients. They also suggest the need for alternative research paradigms to assess the cognitive abilities of CFS patients.

 

Source: Kane RL, Gantz NM, DiPino RK. Neuropsychological and psychological functioning in chronic fatigue syndrome. Neuropsychiatry Neuropsychol Behav Neurol. 1997 Jan;10(1):25-31. http://www.ncbi.nlm.nih.gov/pubmed/9118194

 

Screening for psychiatric disorders in chronic fatigue and chronic fatigue syndrome

Abstract:

Psychiatric disorders are common in chronic fatigue (CF) and chronic fatigue syndrome (CFS). To determine the usefulness of the General Health Questionnaire (GHQ), a self-report measure of psychological distress, in identifying those with psychiatric illnesses, a structured psychiatric interview and the GHQ were administered to 120 CF and 161 CFS patients seen in a referral clinic.

Overall, 87 (35%) patients had a current and 210 (82%) a lifetime psychiatric disorder. Compared to patients without psychiatric disorders, GHQ scores above the threshold (> or = 12) were more frequent among patients with current (p < 0.001) and lifetime (p < 0.05) diagnoses; scores among patients with CF and CFS were similar.

Longer illness duration, greater fatigue severity, and current psychiatric disorders were significant predictors of the GHQ score. In CF and CFS, the best sensitivity (0.69-0.76) and specificity (0.51-0.62) were achieved for current psychiatric diagnoses using a threshold score of > or = 12. Thus, patients scoring < 12 on the GHQ are significantly less likely to have a psychiatric disorder.

 

Source: Buchwald D, Pearlman T, Kith P, Katon W, Schmaling K. Screening for psychiatric disorders in chronic fatigue and chronic fatigue syndrome. J Psychosom Res. 1997 Jan;42(1):87-94. http://www.ncbi.nlm.nih.gov/pubmed/9055216