Practitioner review: chronic fatigue syndrome in childhood

Abstract:

BACKGROUND: Chronic fatigue syndrome (CFS) is being increasingly recognized in children and adolescents. Yet comparatively little attention has been given in the literature to management.

METHODS: Description of the main features of the disorder, precipitating and maintaining factors and diagnostic assessment. Outline of different views on the nature and treatment of CFS in childhood. Description of a rehabilitation program based on cognitive behavior therapy and graded activity.

RESULTS: Using adult research criteria, CFS can be diagnosed in children and adolescents. In its severe form it is often triggered by infectious illness episodes. It is commonly associated with mood disorders in the child and with mental distress and high levels of emotional involvement in parents. A number of patient support groups hold the view that CFS is a medical disorder, contest a psychiatric contribution and advocate ‘pacing’ as an approach to rehabilitation which includes avoiding activities. To date there is no empirical evidence for the efficacy of this approach. Research in adults, open and clinical reports in children support the use of graded activity and family cognitive behavior therapy. The main aim is to enable children, with the help of their family, to carry out their own rehabilitation with some support and guidance from a health professional. Engaging the child and family in treatment and forming a therapeutic alliance is a continual process and a crucial aspect of management, as many families view the condition as a medical disorder and are initially ambivalent towards this approach.

CONCLUSIONS: There is controversy about the nature and management of CFS in childhood but a rehabilitation program based on family cognitive behavior therapy can be implemented and seems to hold most promise in the management of children with CFS. Family engagement is a crucial aspect of management.

 

Source: Elena Garralda M, Chalder T. Practitioner review: chronic fatigue syndrome in childhood. J Child Psychol Psychiatry. 2005 Nov;46(11):1143-51. http://www.ncbi.nlm.nih.gov/pubmed/16238661

 

Chronic fatigue syndrome: an overview

Medically unexplained symptoms (MUS) – those lacking identifiable underlying physical disease – are common in all levels of the health care system, and can be associated with severe disability and distress to patients and high cost to health services. Common MUS include pain (including back, chest, abdominal pain, and headache), fatigue, dizziness and ENT (Ear, Nose and Throat) symptoms. Similarly, functional somatic syndromes refer to groups of symptoms lacking disease-specific, demonstrable abnormalities of structure, and are usually defined by specialty or organ system.1 They include irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, multiple chemical sensitivity, chronic pelvic pain, temporomandibular joint dysfunction and more recently Gulf War syndrome. These conditions overlap in their symptoms, aetiology and treatment; prompting some to point out that the similarities outweigh differences between them and that there is utility in considering them collectively rather than separately.2

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Source: Cho HJ, Wessely S. Chronic fatigue syndrome: an overview. Rev Bras Psiquiatr. 2005 Sep;27(3):174-5. Epub 2005 Oct 4. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-44462005000300003&lng=en&nrm=iso&tlng=en (Full article)

 

Impact of a maximal exercise test on symptoms and activity in chronic fatigue syndrome

Abstract:

OBJECTIVE: This study examined the effects of exercise on symptoms and activity in chronic fatigue syndrome (CFS).

METHODS: Twenty CFS patients and 20 neighborhood controls performed an incremental exercise test until exhaustion. Fatigue, muscle pain, minutes spent resting, and the level of physical activity were assessed with a self-observation list. Physical activity was assessed with an actometer as well. Data were obtained 3 days before the maximal exercise test (MET) up to 5 days thereafter.

RESULTS: For CFS patients, daily observed fatigue was increased up to 2 days after the exercise test. For controls, self-observed fatigue returned to baseline after 2 h. Both CFS patients and controls spent more minutes resting on the day before and on the day after the MET. For CFS patients, self-observed minutes resting increased on the day of the exercise test. For neither group, a decrease of actometer recorded or self-observed physical activity after exercise was found.

CONCLUSION: Fatigue in CFS patients increased after exercise, but the level of actual physical activity remained unchanged.

 

Source: Bazelmans E, Bleijenberg G, Voeten MJ, van der Meer JW, Folgering H. Impact of a maximal exercise test on symptoms and activity in chronic fatigue syndrome. J Psychosom Res. 2005 Oct;59(4):201-8. http://www.ncbi.nlm.nih.gov/pubmed/16223622

 

Children and adolescents with Chronic Fatigue Syndrome in non-specialist settings: beliefs, functional impairment and psychiatric disturbance

Abstract:

BACKGROUND: Adolescents with Chronic Fatigue Syndrome (CFS) seen in specialist centres have substantial psychological and functional impairment. Beliefs about activity levels may be important in the development of CFS.

METHOD: The aim was to investigate psychological and functional impairment, and beliefs in children and adolescents with CFS recruited from non-specialist services. A total of 30 such individuals participated, and 30 young people with Inflammatory Bowel Disease (IBD) formed the comparison group.

RESULTS: Emotional symptoms and disorder were high in both groups. In all, 50% of those with CFS and 30% with IBD reached the threshold for emotional disorder according to the Strengths and Difficulties Questionnaire (SDQ) parent report, although this difference did not reach statistical significance. Participants with CFS scored statistically significantly higher on measures of functional impairment, including school non-attendance, compared to those with IBD. According to questionnaire responses, those with CFS were statistically significantly more likely to favour rest rather than exercise compared to those with IBD. Comparison of parental beliefs did not show such a difference.

CONCLUSIONS: These young people with CFS were at high risk of psychiatric disorder. They were substantially disabled when compared to individuals with a known chronic illness. Also, as a group, they were characterised by a preference for rest rather than exercise.

 

Source: Richards J, Turk J, White S. Children and adolescents with Chronic Fatigue Syndrome in non-specialist settings: beliefs, functional impairment and psychiatric disturbance. Eur Child Adolesc Psychiatry. 2005 Sep;14(6):310-8. http://www.ncbi.nlm.nih.gov/pubmed/16220215

 

37-Kilodalton/83-kilodalton RNase L isoform ratio in peripheral blood mononuclear cells: analytical performance and relevance for chronic fatigue syndrome

Comment on: RNase L levels in peripheral blood mononuclear cells: 37-kilodalton/83-kilodalton isoform ratio is a potential test for chronic fatigue syndrome.[Clin Diagn Lab Immunol. 2003]

 

A French group has reported results (5) supporting the use of the RNase L 37-kDa/83-kDa ratio (37/83 R) in peripheral blood mononuclear cells (PBMC) as a diagnostic test for chronic fatigue syndrome (CFS). More recently (6), the same group cautioned about the diagnostic value of the 37/83 R, based on a small patient follow-up study which was likely to indicate analytical variability among duplicate assays, lack of reproducibility over time, and a weak correlation with the multidimensional fatigue inventory (MFI) score. Because of our long-term experience with this assay, we would like to offer some comments.

First, we tested the analytical performance of the 37/83 R assay according to CLSI (formerly NCCLS) procedure EP5-A (4), with control samples at three different levels made of extracts of the monocytic U937 cell line spiked with various concentrations of recombinant RNase L. The guideline protocol involves assaying the samples in duplicate twice daily over a total period of 20 days. The results summarized in Table Table11 indicate that both within- and between-run variation does not exceed 13%. In another series of experiments, we assayed eight patient samples in duplicate (average 37/83 R ranging from 0.5 to 245). Although in accordance with the NCCLS protocol results, the variation did not exceed 12% for samples with 37/83 R levels up to 20, and it rose significantly to 30% and more for samples with 37/83 R levels above 20. This should be expected, because beyond this level, more than 70% of the 83-kDa isoform is cleaved, and consequently, the faint 83-kDa band is difficult to scan with accuracy. Thus, in our opinion, the lower level of correlation between the duplicate assay results observed with the CFS group versus those with the controls (6) reflects the prevalence of high 37/83 R levels in the CFS group rather than a low test reproducibility as claimed by these authors. This is further supported by the good correlation found for the control group (r = 0.95). During validation, the lowest detectable ratio measured with a sample containing the 83-kDa isoform only was estimated (3 independent experiments with 26 replicates each) to be 0.13 ± 0.06 (average ± three standard deviations). Thus, the clinical cutoff ratio of 0.4 found by the authors (5, 6) to best discriminate CFS patients from controls falls within the measurable range.

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Source: Frémont M, Vaeyens F, Herst CV, De Meirleir K, Englebienne P. 37-Kilodalton/83-kilodalton RNase L isoform ratio in peripheral blood mononuclear cells: analytical performance and relevance for chronic fatigue syndrome. Clin Diagn Lab Immunol. 2005 Oct;12(10):1259-60; author reply 1260. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1247842/ (Full article)

 

Use of depression rating scales in chronic fatigue syndrome

Abstract:

OBJECTIVE: The aim of this study was to examine the performance of three commonly used depression rating scales in a hospital sample of patients with chronic fatigue syndrome (CFS).

METHODS: Sixty-one patients with CDC criteria for CFS completed the General Health Questionnaire (GHQ), the Hamilton Depression Scale (HAM-D) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D). Current psychiatric status was assessed using the Structured Clinical Interview for DSM-III-R. DISORDERS: Patient version (SCID-P). Receiver operating curves were drawn for each of the depression rating scales.

RESULTS: Thirty-one percent of the patients were depressed according to the SCID-P. Using the standard cut-offs, both GHQ and HAM-D overestimated the number of depressed patients, whilst the HADS-D underestimated the number. The receiver operating curves suggest that the optimum cut-offs for GHQ, HAM-D and HADS-D in this population are 7/8, 13/14 and 8/9, respectively.

CONCLUSIONS: Standard cutoffs may not be appropriate when using depression rating scales in CFS patients in a tertiary care setting.

 

Source: Henderson M, Tannock C. Use of depression rating scales in chronic fatigue syndrome. J Psychosom Res. 2005 Sep;59(3):181-4. http://www.ncbi.nlm.nih.gov/pubmed/16198192

 

The relationships among coping styles and fatigue in an ethnically diverse sample

Abstract:

The present study focused on coping strategies among African Americans, Latinos, and European Americans with chronic fatigue syndrome (CFS) and idiopathic chronic fatigue (ICF). The coping strategies examined were measured by using the COPE Scales, which assess Seeking Emotional Social Support, Positive Reinterpretation and Growth, Acceptance, Denial, Turning to Religion, Behavioral Disengagement, and Focusing on and Venting Emotions. In addition, the four coping strategies specifically designed for people with CFS, including maintaining activity, accommodating to the illness, focusing on symptoms, and information-seeking, were used in this study. It was hypothesized that African Americans and Latinos in comparison to European Americans would be more likely to use religious coping, behavioral disengagement, and denial.

As predicted, African Americans were significantly more likely to turn to religion than European Americans, and Latinos and African Americans used denial significantly more often than European Americans. An additional finding was that focusing on symptoms was associated with greater fatigue and more physical disability among African Americans. Within the Latino sample, acceptance was related to greater fatigue and less physical disability, and greater optimism predicted less mental disability. Among European American participants, maintaining activity was related to less mental disability, whereas accommodating to the illness predicted more physical disability.

These results indicate that coping varies among various ethnic groups with CFS and ICF; however, denial is consistently related to less adaptive outcomes. Therefore, healthcare professionals should find ways to reduce patient use of denial and promote alternative strategies for managing life events.

 

Source: Njoku MG, Jason LA, Torres-Harding SR. The relationships among coping styles and fatigue in an ethnically diverse sample. Ethn Health. 2005 Nov;10(4):263-78 http://www.ncbi.nlm.nih.gov/pubmed/16191727

 

Exercise and cognitive performance in chronic fatigue syndrome

Abstract:

PURPOSE: To determine the effect of submaximal steady-state exercise on cognitive performance in patients with chronic fatigue syndrome (CFS) alone, CFS with comorbid fibromyalgia FM (CFS + FM), and sedentary healthy controls (CON).

METHODS: Twenty CFS-only patients, 19 CFS + FM, and 26 CON completed a battery of cognitive tests designed to assess speed of information processing, variability, and efficiency. Tests were performed at baseline, immediately before, and twice following 25 min of either cycle ergometry set at 40% of peak oxygen capacity or quiet rest.

RESULTS: There were no group differences in average percentage of peak oxygen consumption during exercise (CFS = 45%; CFS + FM = 47%; Control = 43%: P = 0.2). There were no significant effects of acute exercise on cognitive performance for any group. At baseline, one-way ANOVA indicated that CFS patients displayed deficits in speed of processing, performance variability, and task efficiency during several cognitive tests compared with healthy controls. However, the CFS + FM patients were not different than controls. Repeated measures ANOVA indicated that across all tests (pre- and postexercise) CFS, but not CFS + FM, were significantly less consistent (F2,59 = 3.7, P = 0.03) and less efficient (F2,59 = 4.6, P = 0.01) than controls.

CONCLUSION: CFS patients without comorbid FM exhibit subtle cognitive deficits in terms of speed, consistency, and efficiency that are not improved or exacerbated by light exercise. Importantly, our data suggest that CFS + FM patients do not exhibit cognitive deficits either pre- or postexercise. These results highlight the importance of disease heterogeneity in studies determining acute exercise and cognitive function in CFS.

 

Source: Cook DB, Nagelkirk PR, Peckerman A, Poluri A, Mores J, Natelson BH. Exercise and cognitive performance in chronic fatigue syndrome. Med Sci Sports Exerc. 2005 Sep;37(9):1460-7. http://www.ncbi.nlm.nih.gov/pubmed/16177595

 

Chronic fatigue in a population sample: definitions and heterogeneity

Abstract:

BACKGROUND: Numerous nosological decisions are made when moving from the common human symptom of unusual fatigue to the rare chronic fatigue syndrome (CFS). These decisions have infrequently been subjected to rigorous evaluation.

METHOD: We obtained telephone interview data on fatiguing symptoms from 31406 individuals twins in the Swedish Twin Registry aged 42-64 years; 5330 subjects who endorsed fatigue and possessed no exclusionary condition formed the analytic group. We evaluated the definition and classification of CFS-like illness using graphical methods, regression models, and latent class analysis.

RESULTS: Our results raise fundamental questions about the 1994 Centers for Disease Control criteria as (1) there was no empirical support for the requirement of four of eight cardinal CFS symptoms; (2) these eight symptoms were not equivalent in their capacity to predict fatigue; and (3) no combination of symptoms was markedly more heritable. Critically, latent class analysis identified a syndrome strongly resembling CFS-like illness.

CONCLUSIONS: Our data are consistent with the ‘existence’ of CFS-like illness although the dominant nosological approach captures population-level variation poorly. We suggest that studying a more parsimonious case definition – impairing chronic fatigue not due to a known cause – would represent a way forward.

 

Source: Sullivan PF, Pedersen NL, Jacks A, Evengård B. Chronic fatigue in a population sample: definitions and heterogeneity. Psychol Med. 2005 Sep;35(9):1337-48. http://www.ncbi.nlm.nih.gov/pubmed/16168156

 

Twin analyses of chronic fatigue in a Swedish national sample

Abstract:

BACKGROUND: Chronic fatigue has infrequently been studied in twins. Data from twin studies can inform clinical and research approaches to the management and etiology of human complex traits.

METHOD: The authors obtained telephone interview data on current chronic fatigue from 31406 individuals twins in the Swedish Twin Registry (aged 42-64 years, 75.68% response rate), from both members of 12407 pairs and from one member of 6592 pairs. Of the complete pairs, 3269 pairs were monozygotic, 9010 pairs dizygotic, and 128 pairs of unknown zygosity. Structural equation twin modeling was used to estimate the latent genetic architecture of varying definitions of fatiguing illness.

RESULTS: Estimates of additive genetic effects, shared environmental effects, and individual-specific environmental effects were similar in males and females. No definition of current fatiguing illness (ranging from any fatigue to CFS-like illness) was strikingly distinctive. Individual-specific effects were the predominant source of variation, followed by modest genetic influences. We could not exclude a small but conceptually important contribution of shared environmental effects.

CONCLUSIONS: Current fatiguing illness appears to be a complex trait resulting from both environmental and genetic sources of variation without pronounced differences by gender.

 

Source: Sullivan PF, Evengård B, Jacks A, Pedersen NL. Twin analyses of chronic fatigue in a Swedish national sample. Psychol Med. 2005 Sep;35(9):1327-36. http://www.ncbi.nlm.nih.gov/pubmed/16168155