A psychodynamic view of the chronic fatigue syndrome. The role of object relations in etiology and treatment

Abstract:

The chronic fatigue syndrome (CFS) is a constellation of physical and psychological symptoms including incapacitating fatigue associated with a marked reduction in activity. Although the etiology of CFS is unclear, reports in the literature suggest the presence of both physical and psychological dysfunction in this patient population. These findings have led to a debate between those who consider CFS to be primarily organic in origin and those who view CFS as a primary psychiatric disorder characterized by somatic preoccupations.

This debate led the authors to develop a working model for CFS designed to integrate the psychological and physiological findings, based on the hypothesis that early object relations have an etiologic relationship to CFS. This hypothesis then formed the rationale for a psychoanalytic treatment approach which will be described.

There are no published case reports describing psychoanalytic psychotherapy as a primary treatment modality for this patient population. The current paper attempts to fill a void. Two case reports of long-term (> 18 months), intensive (2-3 times per week) psychoanalytic psychotherapy with CFS patients referred by infectious disease specialists at a university teaching hospital will be presented.

The following aspects of the treatment will be highlighted: 1) the unique opportunity afforded by this treatment to view the nature of CFS, namely, the intimate relationship over time of fatigue symptoms to disturbances in object relationships, particularly within the transference; (2) the improvement in symptoms when this relationship is seen and understood by the patient; (3) the importance of the patient-therapist bond as a facilitating medium for clinical improvement; (4) the challenges involved in treating CFS patients with psychotherapy.

Comment in: Childhood abuse, personality disorder and chronic fatigue syndrome. [Gen Hosp Psychiatry. 1998]

 

Source: Taerk G, Gnam W. A psychodynamic view of the chronic fatigue syndrome. The role of object relations in etiology and treatment. Gen Hosp Psychiatry. 1994 Sep;16(5):319-25. http://www.ncbi.nlm.nih.gov/pubmed/7995502

 

Chronic fatigue syndrome

Abstract:

The major and minor diagnostic criteria of the chronic fatigue syndrome are described. The stages of the differential diagnosis, the diagnostic strategies and the controversies, while insisting on certain sleeping disorders are discussed. The cause of the syndrome may be a viral infection, and an anxious-depressive state may increase somatic complaints. Patients with chronic fatigue syndrome did not demonstrate a specific response to therapy. Spontaneous remission after a few years is a typical feature of this syndrome.

 

Source: Sternon J, Decaux G, Hoffmann G. Chronic fatigue syndrome. Rev Med Brux. 1994 Sep-Oct;15(5):311-5. [Article in French] http://www.ncbi.nlm.nih.gov/pubmed/7984848

 

Coming to terms with ME

Abstract:

Myalgic encephalomyelitis (ME) is a chronic, severely disabling condition, but one which is little understood and about which there are many misconceptions. Former health visitor Anne Hoad, diagnosed with ME in her mid-50s, describes her own struggle to come to terms with the illness and the limitations it has placed on her life.

 

Source: Hoad A. Coming to terms with ME. Health Visit. 1994 Sep;67(9):302-3. http://www.ncbi.nlm.nih.gov/pubmed/7960845

 

Human adjuvant disease revisited: a review of eleven post-augmentation mammoplasty patients

Abstract:

OBJECTIVES: We have reviewed 11 women post-augmentation  who were referred to our clinic with diffuse rheumatic complaints. All patients had undergone mammoplasty with silicone gel-filled implants prior to the onset of their locomotor symptoms (mean latency time 7.8 years). One physician interviewed and examined each of these patients following a standardized format for clinical retrieval.

RESULTS: Of the patients reviewed, 6 patients had clinical fibromyalgia based on the ACR criteria, and the remaining 5 patients had symptoms consistent with the “chronic fatigue syndrome.” None of our patients were found to have evidence of a defined connective tissue disease. Antinuclear antibodies were detected in 4 (36%) patients and low level titres of extractable nuclear antigens in only 2 (18%).

CONCLUSIONS: Previously a causal relationship between the use of silicone gel-filled breast implants and the subsequent development of symptoms referred to as human adjuvant disease (HAD) has been proposed. On the basis of currently accepted criteria we have preferred to diagnose our post-mammoplasty patients without specific connective tissue disease, as having chronic fatigue syndrome (CFS), or when tender points are present, as having fibromyalgia (FMS), rather than implying that such cases represent a separate and unique rheumatological disease entity. In the light of our current understanding of CFS and FMS, a relationship between them and the previous silicone mammoplasty seems possible.

 

Source: Fenske TK, Davis P, Aaron SL. Human adjuvant disease revisited: a review of eleven post-augmentation mammoplasty patients. Clin Exp Rheumatol. 1994 Sep-Oct;12(5):477-81. http://www.ncbi.nlm.nih.gov/pubmed/7842527

 

Use of dynamic tests of muscle function and histomorphometry of quadriceps muscle biopsies in the investigation of patients with chronic alcohol misuse and chronic fatigue syndrome

Abstract:

Ischaemic lactate/ammonia tests, serum carnosinase and creatine kinase assays and percutaneous needle muscle biopsies were performed on 10 patients with chronic fatigue syndrome (CFS), and 10 with chronic alcohol misuse complaining of muscular symptoms.

Basal serum lactate levels were significantly elevated in the alcohol misusers compared to the CFS patients, but all were within the reference range. Lactate profiles after ischaemic forearm exercise did not differ significantly for the two patient groups.

In one patient previously diagnosed as having CFS, myoadenylate deaminase deficiency was identified on the basis of a flat ammonia response to ischaemia and absent muscle adenosine monophosphate deaminase activity. In addition, two further patients in the CFS group were subsequently shown to have other disorders: one had polymyositis and one had myopathy with mild type II fibre atrophy of unknown cause.

Histomorphometric examination of muscle needle biopsy in the alcohol misusers showed features of chronic alcohol-induced skeletal myopathy in six patients and polymyositis in one patient. Type II fibre atrophy factors were significantly elevated in the alcohol group but were within the reference range in CFS patients.

Dynamic tests of muscle function and muscle histology are valuable tools in excluding alternative pathology in CFS, whereas muscle histomorphometry is of the greatest value in the diagnosis of chronic alcoholic myopathy.

 

Source: Wassif WS, Sherman D, Salisbury JR, Peters TJ. Use of dynamic tests of muscle function and histomorphometry of quadriceps muscle biopsies in the investigation of patients with chronic alcohol misuse and chronic fatigue syndrome. Ann Clin Biochem. 1994 Sep;31 ( Pt 5):462-8. http://www.ncbi.nlm.nih.gov/pubmed/7832572

 

Normal red cell magnesium concentrations and magnesium loading tests in patients with chronic fatigue syndrome

Abstract:

Red blood cell magnesium concentrations were measured in samples from 89 patients who fulfilled the diagnostic criteria for chronic fatigue syndrome and the results compared to those found in an age and sex matched group selected from the normal population. No significant difference was found. Six patients were further investigated using a magnesium loading test to determine if there was any evidence of magnesium deficiency associated with this disorder. None was found. There is therefore no indication for the use of magnesium therapy in the management of this condition.

 

Source: Hinds G, Bell NP, McMaster D, McCluskey DR. Normal red cell magnesium concentrations and magnesium loading tests in patients with chronic fatigue syndrome. Ann Clin Biochem. 1994 Sep;31 ( Pt 5):459-61. http://www.ncbi.nlm.nih.gov/pubmed/7832571

 

Simultaneous measurement of antibodies to Epstein-Barr virus, human herpesvirus 6, herpes simplex virus types 1 and 2, and 14 enteroviruses in chronic fatigue syndrome: is there evidence of activation of a nonspecific polyclonal immune response?

Abstract:

As a test of the hypothesis that elevated titers of viral antibodies in patients with chronic fatigue syndrome (CFS) are due to a nonspecific polyclonal immune response, antibodies to Epstein-Barr virus (EBV), human herpesvirus 6 (HHV-6), and 14 enteroviruses in 20 patients with CFS and 20 age- and gender-matched controls were simultaneously measured.

Similarly, titers of IgG to herpes simplex virus (HSV) types 1 and 2 were measured in 18 of these cases and in the respective controls. IgG to EBV viral capsid antigen (VCA) was present at titers > or = 1:320 in 55% of cases vs. 15% of controls (P = .02).

The geometric mean titers of early antigen antibody to EBV, HHV-6 IgG, and HSV-1 and HSV-2 IgG were not significantly different among cases and controls. Of the 14 enteroviral antibodies tested for, only those to coxsackieviruses B1 and B4 were present at significant titers (> or = 1:8) in cases vs. controls (P = .02 and P = .001, respectively).

Of the cases, 19 (95%) had either an EBV VCA IgG titer > or = 1:320 or a coxsackievirus B1 or B4 antibody titer > or = 1:8, a percentage significantly higher than that of controls (40%; P = .0004). Titers of EBV VCA IgG and coxsackievirus B1 and B4 antibodies were simultaneously elevated in only 20% of cases.

There was no correlation between elevated titers of EBV VCA IgG and IgG to HHV-6, HSV-1, and HSV-2 or antibody to coxsackieviruses B1 and B4 in the cases. The prevalence of reported allergies to medications or other substances was identical in both groups (60%). These findings suggest that in the majority of cases of CFS, elevation of viral antibody titers is not due to a nonspecific polyclonal immune response.

Comment in: Viral antibodies in chronic fatigue syndrome. [Clin Infect Dis. 1995]

 

Source: Manian FA. Simultaneous measurement of antibodies to Epstein-Barr virus, human herpesvirus 6, herpes simplex virus types 1 and 2, and 14 enteroviruses in chronic fatigue syndrome: is there evidence of activation of a nonspecific polyclonal immune response? Clin Infect Dis. 1994 Sep;19(3):448-53. http://www.ncbi.nlm.nih.gov/pubmed/7811864

 

Cognitive functioning in chronic fatigue syndrome and depression: a preliminary comparison

Abstract:

This study used a brief battery of neuropsychological measures to examine the performance of patients with chronic fatigue syndrome (CFS) (N = 16) and patients in a major depressive episode (N = 23). The overall neuropsychological performance of the CFS group was not significantly different from depressed patients, and both groups scored within normal limits on most measures. Variability of neuropsychologic performance was in general unrelated to level of depressive symptoms. The results are discussed in terms of the validity of the cognitive criterion for the CFS diagnosis. Subjective complaints of cognitive dysfunction by CFS patients in light of the lack of objective evidence for the same are considered in terms of a somatic vigilance hypothesis.

 

Source: Schmaling KB, DiClementi JD, Cullum CM, Jones JF. Cognitive functioning in chronic fatigue syndrome and depression: a preliminary comparison. Psychosom Med. 1994 Sep-Oct;56(5):383-8. http://www.ncbi.nlm.nih.gov/pubmed/7809336

 

Chronic fatigue syndrome: a diagnostic challenge for the laboratory

Abstract:

OBJECTIVE: To review the literature and current research about the causes of chronic fatigue syndrome (CFS).

DATA SOURCES: Recent research articles about CFS and data gathered by the author.

STUDY SELECTION: Performed by the author.

DATA EXTRACTION: Performed by the author.

DATA SYNTHESIS: Chronic fatigue syndrome (CFS) is a disease of pain, excessive fatigue after minor exertion, cognitive difficulties, and other symptoms-all occurring in cycles. While its etiology is unclear, CFS is associated with abnormal results of immune system tests. There is no specific marker for the illness. Treatment is symptomatic, and the long-term outlook for recovery is good.

CONCLUSION: A rational, symptomatic approach to treating CFS patients can be made using the model developed at the author’s institution. Research into the causes of CFS must continue.

Source: Lanham RJ. Chronic fatigue syndrome: a diagnostic challenge for the laboratory. Clin Lab Sci. 1994 Sep-Oct;7(5):279-82. http://www.ncbi.nlm.nih.gov/pubmed/10150382

Serum concentrations of 2′,5′-oligoadenylate synthetase, neopterin, and beta-glucan in patients with chronic fatigue syndrome and in patients with major depression

Chronic fatigue syndrome is characterised by debilitating severe fatigue persisting for more than six months. Furthermore, it is associated with physical symptoms, such as mild fever, sore throat, arthralgia, and myalgia, as well as psychological symptoms such as headache, insomnia, depressive state, and neuropsychiatric symptoms. It has often been claimed that the onset of chronic fatigue syndrome follows an infection or infection-like illness; hence a certain microorganism(s) or virus may cause it. Another possible candidate for inducing chronic fatigue syndrome is cellular or humoral immune dysfunction, which has been found in patients with the disease. There is controversy also as to whether or not chronic fatigue syndrome and major depression (mood disorder) represent different entities.

Mild fever, pharyngitis, and lymphadenopathy, which are suggestive of the existence of inflammation, are often associated with chronic fatigue syndrome, but the peripheral leucocyte count, erythrocyte sedimentation rate, and C-reactive protein concentration are usually normal in patients with chronic fatigue syndrome. Hence, it is possible that certain cytokines may produce the symptoms in patients with chronic fatigue syndrome and, possibly, those with major depression. For example, interferon is known to cause fever, fatigue, and psychoneurological abnormalities. We conducted this study to clarify whether or not 2′,5′-oligoadenylate synthetase (2,5-AS), neopterin, adenosine deaminase, endotoxin, or B-glucan participate in the pathogenesis of chronic fatigue syndrome.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1073106/pdf/jnnpsyc00038-0135b.pdf

 

Source: Matsuda J, Gohchi K, Gotoh N. Serum concentrations of 2′,5′-oligoadenylate synthetase, neopterin, and beta-glucan in patients with chronic fatigue syndrome and in patients with major depression. J Neurol Neurosurg Psychiatry. 1994 Aug;57(8):1015-6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1073106/