Category: Psychiatry/Psychology

Chronic fatigue syndrome: current perspectives on evaluation and management

Abstract:

OBJECTIVE: To describe clinical and laboratory guidelines for assessment and management of patients presenting with chronic fatigue syndrome(CFS).

DATA SOURCES: Relevant international consensus diagnostic criteria and research literature on the epidemiology, pathophysiology, concurrent medical and psychological disturbance and clinical management of CFS.

CONCLUSIONS: Medical and psychiatric morbidity should be carefully assessed and actively treated, while unnecessary laboratory investigations and extravagant treatment regimens should be avoided. No single infective agent has been demonstrated as the cause of CFS, and immunopathological hypotheses remain speculative. The aetiological role of psychological factors is debated, but they do predict prolonged illness. The rate of spontaneous recovery appears to be high. Effective clinical management requires a multidisciplinary approach, with consideration of the medical, psychological and social factors influencing recovery.

Comment in: Chronic fatigue syndrome: is total body potassium important? [Med J Aust. 1996]

 

Source: Hickie IB, Lloyd AR, Wakefield D. Chronic fatigue syndrome: current perspectives on evaluation and management. Med J Aust. 1995 Sep 18;163(6):314-8. http://www.ncbi.nlm.nih.gov/pubmed/7565238

 

Coping with chronic fatigue syndrome: illness responses and their relationship with fatigue, functional impairment and emotional status

Abstract:

The implications of patients’ approaches to managing chronic fatigue syndrome were examined in a cross-sectional study. With severity of fatigue controlled, attempting to maintain activity was associated with less functional impairment, while accommodating to the illness was positively related to impairment; behavioural disengagement was related not only to higher levels of impairment but also to greater emotional disturbance. Fatigue itself was positively associated with focusing on symptoms and with behavioural disengagement; it was associated also with illness accommodation, but only for illness of longer duration. The causal direction of relationships between coping and fatigue severity is ambiguous, and a follow-up study will address the effects of coping on changes in the illness over time.

 

Source: Ray C, Jefferies S, Weir WR. Coping with chronic fatigue syndrome: illness responses and their relationship with fatigue, functional impairment and emotional status. Psychol Med. 1995 Sep;25(5):937-45. http://www.ncbi.nlm.nih.gov/pubmed/8588012

 

Exercise responses and psychiatric disorder in chronic fatigue syndrome

Comment in: Exercise responses in the chronic fatigue syndrome. Objective assessment of study is difficult without knowledge of data. [BMJ. 1995]

 

Fatigue, exercise intolerance, and myalgia are cardinal symptoms of the chronic fatigue syndrome, but whether they reflect neuromuscular dysfunction or are a manifestation of depression or other psychiatric or psychological disorders diagnosed in a high proportion of fatigued patients in the community is unclear.’ In previous studies patients with the chronic fatigue syndrome showed exercise intolerance in incremental exercise tests, which seemed to be related to an increased perception of effort; also, blood lactate concentrations in some patients tended to increase more rapidly than normal at low work rates, implying inefficient aerobic muscle metabolism.2 We examined venous blood lactate responses to exercise at a work rate below the anaerobic threshold in relation to psychiatric disorder.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2550606/pdf/bmj00607-0028.pdf

 

Source: Lane RJ, Burgess AP, Flint J, Riccio M, Archard LC. Exercise responses and psychiatric disorder in chronic fatigue syndrome. BMJ. 1995 Aug 26;311(7004):544-5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2550606/pdf/bmj00607-0028.pdf

 

“Abnormal” illness behaviour in chronic fatigue syndrome and multiple sclerosis

Abstract:

OBJECTIVE: To investigate the presence of abnormal illness behaviour in patients with a diagnosis of chronic fatigue syndrome.

DESIGN: A cross sectional descriptive study using the illness behaviour questionnaire to compare illness behaviour scores and illness behaviour profiles of patients with chronic fatigue syndrome and patients with multiple sclerosis.

SETTING: A multidisciplinary fatigue clinic and a teaching hospital neurology outpatient clinic.

SUBJECTS: 98 patients satisfying the Oxford criteria for chronic fatigue syndrome and 78 patients with a diagnosis of multiple sclerosis.

MAIN OUTCOME MEASURE: Responses to the 62 item illness behaviour questionnaire.

RESULTS: 90 (92%) patients in the chronic fatigue syndrome group and 70 (90%) in the multiple sclerosis group completed the illness behaviour questionnaire. Both groups had significantly high scores on the general hypochondriasis and disease conviction subscales and significantly low scores on the psychological versus somatic concern subscale, as measured in relation to normative data. There were, however, no significant differences in the subscale scores between the two groups and the two groups had identical illness behaviour profiles.

CONCLUSION: Scores on the illness behaviour questionnaire cannot be taken as evidence that chronic fatigue syndrome is a variety of abnormal illness behaviour, because the same profile occurs in multiple sclerosis. Neither can they be taken as evidence that chronic fatigue and multiple sclerosis share an aetiology. More needs to be known about the origins of illness beliefs in chronic fatigue syndrome, especially as they are important in determining outcome.

Comment in:

Illness behaviour in the chronic fatigue syndrome and multiple sclerosis. Choice of multiple sclerosis as comparison condition was inappropriate.[BMJ. 1995]

Illness behaviour in the chronic fatigue syndrome and multiple sclerosis. Disentangling common characteristics is not so easy. [BMJ. 1995]

 

Source: Trigwell P, Hatcher S, Johnson M, Stanley P, House A. “Abnormal” illness behaviour in chronic fatigue syndrome and multiple sclerosis. BMJ. 1995 Jul 1;311(6996):15-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2550080/pdf/bmj00599-0019.pdf (Full article)

 

Cognitive functioning and magnetic resonance imaging in chronic fatigue

Abstract:

BACKGROUND: This study examines whether cognitive dysfunction in chronic fatigue may be accounted for by depression and anxiety or is due to brain pathology evident on magnetic resonance imaging (MRI).

METHOD: Twenty-six subjects with chronic fatigue, with and without coexisting depression, and 18 age-matched normal controls were recruited from primary care following a presumed viral illness six months previously. Comparison was made with 13 psychiatric controls with depressive illness on standardised cognitive tests. MRI determined the presence of cerebral white-matter lesions.

RESULTS: No substantial differences in performance were shown between subjects with chronic fatigue, most of whom met the criteria for chronic fatigue syndrome, and controls. Subjective cognitive dysfunction increased with psychopathology. White-matter lesions were found in a minority from all groups. Improvement in fatigue and depression coincided with improved performance on cognitive measures.

CONCLUSIONS: Subjective complaints of cognitive impairment are a prominent feature of chronic fatigue, but objective cognitive and MRI abnormalities are not. Such complaints probably reflect psychopathology rather than a post-viral process.

 

Source: Cope H, Pernet A, Kendall B, David A. Cognitive functioning and magnetic resonance imaging in chronic fatigue. Br J Psychiatry. 1995 Jul;167(1):86-94. http://www.ncbi.nlm.nih.gov/pubmed/7551617

 

Does high ‘action-proneness’ make people more vulnerable to chronic fatigue syndrome? A controlled psychometric study

Abstract:

Degree of premorbid ‘action-proneness’ was measured, using a self-administered questionnaire, in 35 patients suffering from chronic fatigue syndrome (CFS), all the members of ‘ME’-self help groups and all those meeting CDC-criteria of CFS. The results were compared with those of 30 chronic idiopathic musculoskeletal pain patients, 34 patients with a chronic organic condition, and 34 neurotic patients without primary somatic complaints. Statistical analysis showed that CFS patients described themselves as significantly more ‘action-prone’ than the last two groups, and to a degree which was comparable with the chronic pain group. The results could not be explained by concomitant depression and are in accordance with anecdotal reports of premorbid hyperactive lifestyle in CFS patients. Further investigations seem worthwhile to test the hypothesis that hyperactivity might be a predisposing factor for chronic illness behaviour in CFS patients.

 

Source: Van Houdenhove B, Onghena P, Neerinckx E, Hellin J. Does high ‘action-proneness’ make people more vulnerable to chronic fatigue syndrome? A controlled psychometric study. J Psychosom Res. 1995 Jul;39(5):633-40. http://www.ncbi.nlm.nih.gov/pubmed/7490698

 

Physical symptoms of chronic fatigue syndrome are exacerbated by the stress of Hurricane Andrew

Abstract:

This study examined the effects of Hurricane Andrew on physical symptoms and functional impairments in a sample of chronic fatigue syndrome(CFS) patients residing in South Florida. In the months after Hurricane Andrew (September 15-December 31, 1992), 49 CFS patients were assessed for psychosocial and physical functioning with questionnaires, interviews, and physical examinations.

This sample was made up of 25 CFS patients living in Dade county, a high impact area, and 24 patients in Broward and Palm Beach counties, areas less affected by the hurricane. Based on our model for stress-related effects on CFS, we tested the hypothesis that the patients who had the greatest exposure to this natural disaster would show the greatest exacerbation in CFS symptoms and related impairments in activities of daily living (illness burden). In support of this hypothesis, we found that the Dade county patients showed significant increases in physician-rated clinical relapses and exacerbations in frequency of several categories of self-reported CFS physical symptoms as compared to the Broward/Palm Beach county patients.

Illness burden, as measured on the Sickness Impact Profile, also showed a significant increase in the Dade county patients. Although extent of disruption due to the storm was a significant factor in predicting relapse, the patient’s posthurricane distress response was the single strongest predictor of the likelihood and severity of relapse and functional impairment.

Additionally, optimism and social support were significantly associated with lower illness burden after the hurricane, above and beyond storm-related disruption and distress responses. These findings provide information on the impact of environmental stressors and psychosocial factors in the exacerbation of CFS symptoms.

 

Source: Lutgendorf SK, Antoni MH, Ironson G, Fletcher MA, Penedo F, Baum A, Schneiderman N, Klimas N. Physical symptoms of chronic fatigue syndrome are exacerbated by the stress of Hurricane Andrew. Psychosom Med. 1995 Jul-Aug;57(4):310-23. http://www.ncbi.nlm.nih.gov/pubmed/7480560

 

A clinical study of chronic fatigue syndrome

Abstract:

BACKGROUND: This study examines the hypothesis that more recently ill patients with chronic fatigue syndrome (CFS) might have different characteristics from more chronic patients in tertiary referral centres.

METHOD: Sixty-four patients who fulfilled strict diagnostic criteria for CFS had detailed medical, viral, immunological and psychiatric assessment. Patients were advised to remain within their energy limits. Patient and doctor monitored progress using a scoring system.

RESULTS: Using the Schedule for Affective Disorders and Schizophrenia, patients were placed into four groups: group A (no psychiatric disorder, 35 patients), group B (psychiatric disorder before onset of CFS, 7 patients), group C (coincident psychiatric disorder and CFS, 11 patients), and group D (psychiatric disorder after onset of CFS, 11 patients). There were no viral or immunological differences between the groups. Patients in groups B, C and D had more severe illness than those in group A (P < 0.05), but patients in group A had more muscle pain (P < 0.05) than patients in group C. Counselling resulted in 52 patients becoming better; nine remained the same and three became worse.

CONCLUSIONS: A lower incidence of psychiatric disorder may characterise patients who are more recently ill, as may the type of associated emotional disorder and better outcome.

Comment in: Chronic fatigue syndrome. [Br J Psychiatry. 1995]

 

Source: Shanks MF, Ho-Yen DO. A clinical study of chronic fatigue syndrome. Br J Psychiatry. 1995 Jun;166(6):798-801. http://www.ncbi.nlm.nih.gov/pubmed/7663831

 

Chronic fatigue syndrome in the community. Prevalence and associations

Abstract:

BACKGROUND: Chronic fatigue syndrome (CFS) is a poorly understood condition, apparently related to both psychiatric disturbance and infectious illness. Little progress has been made in identifying aetiology, owing to a lack of epidemiological studies using case-definition criteria.

METHOD: A community postal survey of a random sample of over 1000 patients registered at a local health centre comprised a fatigue questionnaire and the 12-item General Health Questionnaire (GHQ).

RESULTS: Total fatigue scores were modestly higher in women than men. Fatigue was most frequently attributed to psychosocial factors. Fatigue and GHQ scores were strongly correlated. Two men and two women satisfied British criteria for CFS, a prevalence of 0.56% (95% Cl 0.16-1.47%); three were probable psychiatric cases.

CONCLUSIONS: Previously reported sociodemographic associations of CFS may reflect medical referral patterns. A strong association exists with psychological morbidity, but relabelling CFS as a psychiatric disorder is not justified.

 

Source: Lawrie SM, Pelosi AJ. Chronic fatigue syndrome in the community. Prevalence and associations. Br J Psychiatry. 1995 Jun;166(6):793-7. http://www.ncbi.nlm.nih.gov/pubmed/7663830

 

Chronic fatigue syndrome

Comment on: Chronic fatigue syndrome: a follow up study. [J Neurol Neurosurg Psychiatry. 1994]

 

Chronic fatigue syndrome: a follow up study by Bonner et al’ reported that 47 patients initially diagnosed with “chronic fatigue” were contacted for follow up four years later. The authors indicated that “These patients were initially assessed before the current criteria for chronic fatigue syndrome became available, but most would have satisfied the criteria retrospectively” (p 617). At the outset, all patients were offered cognitive behavioural treatment and some were offered antidepressant medications. Each patient then made a decision to either undergo or decline cognitive behavioural treatment. Four years later, those patients who reported functional improvement were more likely to have elected to receive the cognitive behavioural treatment. Additionally, patients in the group that did not report any functional improvement were more likely to score higher on measures of depression.

The US Centers for Disease Control and Prevention (CDC) case definition,2 the proposed revisions to the CDC case definition,3 and the guidelines for research set forth by Sharpe et al4 were cited, but the researchers did not make it clear as to which criteria were used to diagnose which patients. Thus it is unknown whether uniform criteria were applied to diagnose all patients at the outset. Moreover, the authors did not specify just how many of the initial 47 patients met any of the cited criteria for chronic fatigue syndrome, as opposed to chronic fatigue. In short, they did not differentiate the exact number of chronic fatigue syndrome v chronic fatigue cases.

Only 29 of the original 47 patients (62%) agreed to be interviewed for the follow up. Thus 18 (38%) of the original patients were not included in the outcome data, where 10 subjects reported little or no improvement and 19 subjects reported improvement or recovery. The authors acknowledged that the small patient sample size constituted a methodological shortcoming, but nevertheless concluded “that there is a strong association between successful completion of [cognitive] treatment and the absence of functional disability at the four year follow up” (p 620). They further suggest that costs associated with long term disability could be reduced by the utilisation of cognitive therapy in the treatment of chronic fatigue syndrome. We would like to emphasise that the small patient sample size, together with the lack of availability of almost 40% of the initial patients for interview at follow up, make such conclusions highly inappropriate.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1073573/pdf/jnnpsyc00030-0116.pdf

 

Source: Lipkin DM, Robin R, Vasquez L, Plioplys AV, Plioplys S. Chronic fatigue syndrome. J Neurol Neurosurg Psychiatry. 1995 Jun;58(6):764-5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1073573/