Depression, chronic fatigue syndrome, and the adolescent

Abstract:

To summarize, CFS and depression present very real problems for adolescent patients, their families, and their physicians. The wealth of symptoms presented may signal the presence of any number of psychiatric or physiologic disorders. As part of the evaluation to rule out other maladies, the physician must identify the developmental issues and life stress events with which patients or their families are struggling. Helping patients to accept psychiatric referral to address these issues is indicated if it is thought that they may be contributing to the onset or maintenance of the symptoms. Referral is also indicated if a protracted clinical course evolves and the patient’s normal course of growth and development appears to be in jeopardy.

 

Source: Strickland MC. Depression, chronic fatigue syndrome, and the adolescent. Prim Care. 1991 Jun;18(2):259-70. http://www.ncbi.nlm.nih.gov/pubmed/1876612

 

Postviral fatigue syndrome

Comment onPostviral fatigue syndrome. [BMJ. 1991]

 

SIR, In his letter Dr Anthony Knudsen comments (1) on the recent paper by Dr J W Gow and colleagues on the postviral fatigue syndrome.(2) Dr Knudsen refers to the fact that the aetiology of the syndrome has not been established and to the dearth of definitive pathological findings. Though he does not directly express an opinion, he mentions “the view held by some that the condition is stress related and of psychological origin.”

The body of opinion that holds that the postviral fatigue syndrome has a physical, organic origin seems often to be criticised because it cannot produce “the evidence.” Yet these critics seem quite sanguine about putting forward the hypothesis that the syndrome is of psychological or psychiatric origin without a hint of an opinion regarding the basis of this hypothesis, far less evidence to support it.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1669836/pdf/bmj00125-0065d.pdf

 

Source: M L Sweeney. Postviral fatigue syndrome. BMJ. 1991 May 11; 302(6785): 1153–1154. PMCID: PMC1669836 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1669836/

 

Postinfectious chronic fatigue syndrome: case history of thirty-five patients in Germany

Abstract:

Thirty-five patients with chronic fatigue syndrome according to the criteria of Holmes were followed for periods of up to eight years. The most frequent symptoms were severe fatigue, arthralgias and myalgias, recurrent oropharyngitis and various psychiatric disorders.

More than half of the patients suffered from neuropathy, lymphadenopathy, gastrointestinal complaints and recurrent low-grade fever. Recurrent or persistent activity of human herpesvirus -6 infection was seen in 73% of the patients and of Epstein-Barr virus in 34.4%. In addition, various other infections were diagnosed at lower frequency.

Initial routine immunologic screening revealed various types of deficiencies, these were yet inconsistent and variable when different patients were compared with each other. Tentative treatments included in immunoglobulins, nonspecific immunostimulation and virostatic drugs. No consistently positive results were obtained with any treatment schedule although immunoglobulins appeared the most efficient measure. In addition, psychologic care of the patients is indicated, since disturbances in the psycho-neuroimmunologic regulation may play a significant role in the pathogenesis of the disease.

 

Source: Hilgers A, Krueger GR, Lembke U, Ramon A. Postinfectious chronic fatigue syndrome: case history of thirty-five patients in Germany. In Vivo. 1991 May-Jun;5(3):201-5. http://www.ncbi.nlm.nih.gov/pubmed/1893076

 

Psychiatric symptoms, personality and ways of coping in chronic fatigue syndrome

Abstract:

This study aimed to investigate the psychological characteristics of chronic fatigue syndrome (CFS: Holmes et al. 1988).

A battery of psychometric instruments comprising the General Health Questionnaire (GHQ), the Beck Depression Inventory (BDI), the Minnesota Multiphasic Personality Inventory (MMPI) and the Lazarus Ways of Coping (WoC) inventory, was administered to a sample of clinically-defined CFS sufferers (N = 58), to a comparison group of chronic pain (CP) patients (N = 81) and to a group of healthy controls matched for sex and age with the CFS sample (N = 104).

Considerable overlap was found between CFS and CP patients at the level of both physical and psychological symptoms. This raises the possibility that CFS sufferers are a sub-population of CP patients. However, while there was some commonality between CFS and CP patients in terms of personality traits, particularly the MMPI ‘neurotic triad’ (hypochondriasis, depression and hysteria),

CFS patients showed more deviant personality traits reflecting raised levels on the first MMPI factor, emotionality. Moreover, results were not consistent with the raised emotionality being a reaction to the illness, but rather were consistent with the hypothesis that emotionality is a predisposing factor for CFS.

The majority of CFS patients fell within four personality types, each characterized by the two highest MMPI scale scores. One type (N = 20) reported a lack of psychological symptoms or emotional disturbance contrary to the overall trend for the CFS sample. This group conformed to the ICD-10 classification of neurasthenia.

 

Source: Blakely AA, Howard RC, Sosich RM, Murdoch JC, Menkes DB, Spears GF. Psychiatric symptoms, personality and ways of coping in chronic fatigue syndrome. Psychol Med. 1991 May;21(2):347-62. http://www.ncbi.nlm.nih.gov/pubmed/1876640

 

Panic disorder among patients with chronic fatigue

Abstract:

Among 200 adults with a chief complaint of chronic fatigue evaluated in an internal medicine practice, currently active panic disorder was diagnosed in 26 patients (13%), a frequency tenfold greater than that in the general population. Panic disorder preceded or was coincidental with the onset of chronic fatigue in 21 of these patients.

In comparison with the rest of the study cohort, significantly more patients with panic disorder had a history of severe depression, including persistent thoughts of death or suicide. Moreover, more patients with panic disorder showed a lifetime tendency to have physical symptoms that remained unexplained after medical evaluation.

Our findings suggest that treatable panic disorder is an important contributor not only to major depression and somatization, but also to the etiology and clinical presentation of chronic fatigue in patients in an outpatient practice.

 

Source: Manu P, Matthews DA, Lane TJ. Panic disorder among patients with chronic fatigue. South Med J. 1991 Apr;84(4):451-6. http://www.ncbi.nlm.nih.gov/pubmed/2014428

 

A practical approach to chronic fatigue syndrome

Abstract:

Chronic fatigue may have several physical causes, but a psychiatric condition is often involved. A substantial minority of patients are not diagnosed by conventional tests and do not respond to antidepressant therapy. These patients should be referred for psychiatric opinion or observed for new developments. Extensive virologic testing and unorthodox treatment approaches have no scientific basis at present. Claims of dramatic new diagnostic tests or therapy should be treated with caution because of the long history of unsuccessful attempts to categorize chronic fatigue into one diagnosis and the strong placebo effect shown in controlled trials.

 

Source: Hayden SP. A practical approach to chronic fatigue syndrome. Cleve Clin J Med. 1991 Mar-Apr;58(2):116-20. http://www.ncbi.nlm.nih.gov/pubmed/2025913

 

Myalgic encephalomyelitis

Comment in: Myalgic encephalomyelitis. [J R Soc Med. 1991]

Comment on: Myalgic encephalomyelitis: an alternative theory. [J R Soc Med. 1990]

 

I am pleased that Dr Wilson (August 1990 JRSM, p481) has paid me the compliment of giving my article on the vexed topic of ‘myalgic encephalomyelitis’ (April 1989 JRSM, p 215) serious attention, and echoes our call’ for a ‘new approach’ to the problem, based on an absence of prejudice and a sound clinical and social history. He also notes the parallels between neurasthenia and ‘ME’, although the former was not, as he writes, first described in 18842. However, I only wish I could follow the rest of his arguments so clearly:

Dr Wilson states that I failed to realize that ‘about 100%’ of patients have an allergic diathesis and an allergic family history. I was indeed unaware of this remarkable finding. Unfortunately, I have been unable to trace the two sources cited for this observation, one an American paperback, the other a society newsletter. Similarly, I am afraid that neither I nor any of my colleagues have ever met anyone suffering from ‘Alternate Multiple Personality’. Perhaps this was because I was again unaware of the relevant literature. However, in my defence I would not otherwise have known that the two references quoted, namely Dr Wilson’s paper on allergic disease, multiple personality and dowsing, and his paper on possession and multiple personality, are actually about chronic fatigue syndrome. Similarly, I would not have known that an article in the Christian Parapsychologist called ‘Deliverance and dowsing’ is on the psychopathology of allergy and ME, nor that information on treatment of ME would be published in a series of titles beginning with ‘Current theological perspectives on possession. It is becoming harder to keep up with the relevant literature.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293160/pdf/jrsocmed00126-0074c.pdf

 

See the article “Myalgic encephalomyelitis: an alternative theory.” in volume 83 on page 481.

See letter “Myalgic encephalomyelitis.” on page 633.

See the reply “The author replies” on page 183a.

 

Source: Wessely S. Myalgic encephalomyelitis. J R Soc Med. 1991 Mar;84(3):182-3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293160/

 

Cognitive behaviour therapy in chronic fatigue syndrome

Abstract:

Fifty patients fulfilling operational criteria for the chronic fatigue syndrome (CFS), and who had been ill for a mean of five years, were offered cognitive behaviour therapy in an open trial. Those fulfilling operational criteria for depressive illness were also offered tricyclic antidepressants. The rationale was that a distinction be drawn between factors that precipitate the illness and those that perpetuate it.

Among the latter are cognitive factors such as the belief that physical symptoms always imply tissue damage, and behavioural factors such as persistent avoidance of activities associated with an increase in symptoms. Therapy led to substantial improvements in overall disability, fatigue, somatic and psychiatric symptoms. The principal problems encountered were a high refusal rate and difficulties in treating affective disorders. Outcome depended more on the strength of the initial attribution of symptoms to exclusively physical causes, and was not influenced by length of illness.

These results suggest that current views on both treatment and prognosis in CFS are unnecessarily pessimistic. It is also suggested that advice currently offered to chronic patients, to avoid physical and mental activity, is counterproductive.

 

Source: Butler S, Chalder T, Ron M, Wessely S. Cognitive behaviour therapy in chronic fatigue syndrome. J Neurol Neurosurg Psychiatry. 1991 Feb;54(2):153-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1014351/

 

A supplemental interview for forms of “affective spectrum disorder”

Abstract:

OBJECTIVE: Recent evidence suggests that a number of psychiatric and medical conditions may be members or candidate members of a larger family of conditions, which we have termed “affective spectrum disorder (ASD).” In order to facilitate further research into this concept, we drafted seven interview modules, using the format of the Structured Clinical Interview for DSM-III-R (SCID), designed to diagnose the following psychiatric and medical disorders: irritable bowel syndrome, narcolepsy, Tourette’s disorder, migraine, fibromyalgia, chronic fatigue syndrome, and kleptomania.

METHOD: Published operational diagnostic criteria for these seven disorders were sought in the literature. Questions in SCID format were then drafted in accordance with these operational criteria. Draft modules were then sent to experts familiar with each of the disorders and suggestions and revisions from these experts incorporated into the final modules.

RESULTS: The complete supplemental interview is presented with this report. Preliminary experience with this interview in more than 100 patients tentatively suggests that it is reliable for diagnosing the disorders in question; however, a formal test-retest reliability assessment is still required.

CONCLUSIONS: It is hoped that this supplemental interview, used in conjunction with the SCID, will be helpful in further studies of the epidemiology, pathogenesis, and treatment of these possible forms of affective spectrum disorder.

 

Source: Pope HG Jr, Hudson JI. A supplemental interview for forms of “affective spectrum disorder”. Int J Psychiatry Med. 1991;21(3):205-32. http://www.ncbi.nlm.nih.gov/pubmed/1955274

 

Cognitive and mood-state changes in patients with chronic fatigue syndrome

Abstract:

In this paper the cognitive and psychiatric impairments associated with chronic fatigue syndrome (CFS) and related disorders are reviewed. It is concluded that while acute mononucleosis and infection with Epstein-Barr virus occasionally result in impaired cognition, such changes have not yet been objectively verified in patients with CFS.

However, when patients with CFS are carefully studied, concurrent or premorbid psychiatric disorders are revealed at a greater than chance level. Finally, some suggestions are offered regarding improved neuropsychological assessment of fatigue, concentration, and attention for patients with CFS. The findings to date, while suggesting that psychological predisposition may play a role in the expression of CFS, are still inconclusive regarding the etiology of CFS.

 

Source: Grafman J, Johnson R Jr, Scheffers M. Cognitive and mood-state changes in patients with chronic fatigue syndrome. Rev Infect Dis. 1991 Jan-Feb;13 Suppl 1:S45-52. http://www.ncbi.nlm.nih.gov/pubmed/1850543