Chalder – Page 7 – American ME and CFS Society

Recovery from infectious mononucleosis: a case for more than symptomatic therapy? A systematic review

Abstract:

Infectious mononucleosis is usually an acute, transiently incapacitating condition, but for some sufferers it precipitates chronic illness. It is unclear which patients are at risk of a prolonged state of illness following onset of infectious mononucleosis and if there are any useful preventive measures that would facilitate recovery. The aim of this study was to review all cohort studies and intervention trials that provide information on: (a) the longitudinal course of ill health subsequent to the onset of infectious mononucleosis; (b) the relationship between psychosocial and clinical factors and recovery rate; and (c) the effect of interventions on recovery.

A systematic review was conducted, based on a search of the PSYCHINFO, MEDLINE, EMBASE and CINHAL databases up to October 2001, and ISI Science and Social Sciences Citation Indices up to 22 November 2001. Eight papers were identified that gave data on illness following onset of infectious mononucleosis. The best evidence concluded that there is a distinct fatigue syndrome after infectious mononucleosis. Eight papers explored risk factors for prolonged illness following acute infectious mononucleosis.

Results varied on the association of acute illness characteristics and psychological features with prolonged ill health. Poor physical functioning, namely lengthy convalescence and being less fit or active, consistently predicted chronic ill health. Three trials reported on interventions that aimed to shorten the time taken to resolve symptoms after uncomplicated infectious mononucleosis. None of the drug trials found any evidence that drug therapy shortens recovery time. The trial that compared the effect of activity with imposed bed rest, found that those patients allowed out of bed as soon as they felt able reported a quicker recovery. More information is needed on the course of ill health subsequent to the onset of infectious mononucleosis. Certain risk factors associated with delay may be amenable to a simple intervention in primary care.

Source: Candy B, Chalder T, Cleare AJ, Wessely S, White PD, Hotopf M. Recovery from infectious mononucleosis: a case for more than symptomatic therapy? A systematic review. Br J Gen Pract. 2002 Oct;52(483):844-51. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1316091/ (Full article)

Underlying self-esteem in chronic fatigue syndrome

Abstract:

OBJECTIVE: It has been suggested that people with chronic fatigue syndrome (CFS) have low self-esteem; however, this is not necessarily apparent when self-esteem is measured overtly. This study is the first to investigate underlying self-esteem using information-processing measures and overtly administered measures of self-esteem with this population.

METHODS: The study comprised 68 participants (24 CFS, 24 healthy volunteers, and 20 chronic illness volunteers). A Self-Statements Questionnaire (SSQ) and an Emotional Stroop Test (EST) using neutral, positive, and negative trait words were administered.

RESULTS: Participants with CFS reported lower self-esteem than the two comparison groups on overt measures. Overt responses, however, did not fully account for the full extent of the interference effect from the negative word Stroop compared to the positive word Stroop.

CONCLUSION: In contrast to previous studies, participants with CFS reported lower levels of self-esteem on overt measures than two comparison groups. It is suggested, however, that the extent to which participants reported low self-esteem did not fully reflect their underlying low self-esteem and that this may result from the use of rigidly held defence mechanisms. Further use of information-processing measures, in contrast to relying only on self-report measures, is advocated for future research.

Source: Creswell C, Chalder T. Underlying self-esteem in chronic fatigue syndrome. J Psychosom Res. 2002 Sep;53(3):755-61. http://www.ncbi.nlm.nih.gov/pubmed/12217449

Family cognitive behaviour therapy for chronic fatigue syndrome: an uncontrolled study

Abstract:

AIM: To examine the efficacy of family focused cognitive behaviour therapy for 11-18 year olds with chronic fatigue syndrome.

METHODS: Twenty three patients were offered family focused cognitive behaviour therapy. The main outcome was a fatigue score of less than 4 and attendance at school 75% of the time.

RESULTS: Twenty patients completed treatment. Eighteen had completed all measures at six months follow up; 15 of these (83%) improved according to our predetermined criterion. Substantial improvements in social adjustment, depression, and fear were noted.

CONCLUSIONS: Family focused cognitive behaviour therapy was effective in improving functioning and reducing fatigue in 11-18 year olds. Gains were maintained at six months follow up.

Source: Chalder T, Tong J, Deary V. Family cognitive behaviour therapy for chronic fatigue syndrome: an uncontrolled study. Arch Dis Child. 2002 Feb;86(2):95-7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1761081/ (Full article)

Long-term outcome of cognitive behavior therapy versus relaxation therapy for chronic fatigue syndrome: a 5-year follow-up study

Abstract:

OBJECTIVE: This study evaluated the long-term outcome of cognitive behavior therapy versus relaxation therapy for patients with chronic fatigue syndrome.

METHOD: Sixty patients who participated in a randomized controlled trial of cognitive behavior therapy versus relaxation therapy for chronic fatigue syndrome were invited to complete self-rated measures and participate in a 5-year follow-up interview with an assessor who was blind to treatment type.

RESULTS: Fifty-three patients (88%) participated in the follow-up study: 25 received cognitive behavior therapy and 28 received relaxation therapy. A total of 68% of the patients who received cognitive behavior therapy and 36% who received relaxation therapy rated themselves as “much improved” or “very much improved” at the 5-year follow-up. Significantly more patients receiving cognitive behavior therapy, in relation to those in relaxation therapy, met criteria for complete recovery, were free of relapse, and experienced symptoms that had steadily improved or were consistently mild or absent since treatment ended. Similar proportions were employed, but patients in the cognitive behavior therapy group worked significantly more mean hours per week. Few patients crossed the threshold for “normal” fatigue, despite achieving a good outcome on other measures. Cognitive behavior therapy was positively evaluated and was still used by over 80% of the patients.

CONCLUSIONS: Cognitive behavior therapy for chronic fatigue syndrome can produce some lasting benefits but is not a cure. Once therapy ends, some patients have difficulty making further improvements. In the future, attention should be directed toward ensuring that gains are maintained and extended after regular treatment ends.

Source: Deale A, Husain K, Chalder T, Wessely S. Long-term outcome of cognitive behavior therapy versus relaxation therapy for chronic fatigue syndrome: a 5-year follow-up study. Am J Psychiatry. 2001 Dec;158(12):2038-42. http://www.ncbi.nlm.nih.gov/pubmed/11729022

Defensive coping styles in chronic fatigue syndrome

Abstract:

OBJECTIVE: The cognitive-behavioral model of chronic fatigue syndrome (CFS) proposes that rigidly held beliefs act to defend individuals against low self-esteem. This study is the first to investigate the prevalence of a potential mechanism, the Defensive High Anxious coping style, among individuals with CFS.

METHODS: The study comprised 68 participants (24 CFS; 24 healthy volunteers; 20 chronic illness volunteers). Participants completed the Bendig short form of the Taylor Manifest Anxiety Scale (B-MAS) and the Marlowe-Crowne Social Desirability Scale (MC) in order to ascertain the distribution of participants in each group within the four coping styles defined by Weinberger et al. [J. Abnorm. Psychol. 88 (1979) 369].

RESULTS: A greater number of participants in the CFS group (46%) were classified as Defensive High Anxious compared to the two comparison groups [chi(2)(2)=8.84, P=.012].

CONCLUSION: This study provides support for the existence of defensive coping mechanisms as described by the cognitive-behavioral model of CFS. Furthermore, it has been suggested that this particular coping style may impinge directly on physical well being through similar mechanisms as identified in CFS, and further research linking these areas of research is warranted.

Source: Creswell C, Chalder T. Defensive coping styles in chronic fatigue syndrome. J Psychosom Res. 2001 Oct;51(4):607-10. http://www.ncbi.nlm.nih.gov/pubmed/11595249

Chronic fatigue in general practice: is counselling as good as cognitive behaviour therapy? A UK randomised trial

Abstract:

BACKGROUND: Fatigue is a common symptom for which patients consult their doctors in primary care. With usual medical management the majority of patients report that their symptoms persist and become chronic. There is little evidence for the effectiveness of any fatigue management in primary care.

AIM: To compare the effectiveness of cognitive behaviour therapy (CBT) with counselling for patients with chronic fatigue and to describe satisfaction with care.

DESIGN OF STUDY: Randomised trial with parallel group design.

SETTING: Ten general practices located in London and the South Thames region of the United Kingdom recruited patients to the trial between 1996 and 1998. Patients came from a wide range of socioeconomic backgrounds and lived in urban, suburban, and rural areas.

METHOD: Data were collected before randomisation, after treatment, and six months later. Patients were offered six sessions of up to one hour each of either CBT or counselling. Outcomes include: self-report of fatigue symptoms six months later, anxiety and depression, symptom attributions, social adjustment and patients’ satisfaction with care.

RESULTS: One hundred and sixty patients with chronic fatigue entered the trial, 45 (28%) met research criteria for chronic fatigue syndrome; 129 completed follow-up. All patients met Chalder et al’s standard criteria for fatigue. Mean fatigue scores were 23 on entry (at baseline) and 15 at six months’ follow-up. Sixty-one (47%) patients no longer met standard criteria for fatigue after six months. There was no significant difference in effect between the two therapies on fatigue (1.04 [95% CI = -1.7 to 3.7]), anxiety and depression or social adjustment outcomes for all patients and for the subgroup with chronic fatigue syndrome. Use of antidepressants and consultations with the doctor decreased after therapy but there were no differences between groups.

CONCLUSION: Counselling and CBT were equivalent in effect for patients with chronic fatigue in primary care. The choice between therapies can therefore depend on other considerations, such as cost and accessibility.

Comment in:

Chronic fatigue in general practice. [Br J Gen Pract. 2001]

Cognitive behaviour therapy and chronic fatigue syndrome. [Br J Gen Pract. 2001]

Source: Ridsdale L, Godfrey E, Chalder T, Seed P, King M, Wallace P, Wessely S; Fatigue Trialists’ Group. Chronic fatigue in general practice: is counselling as good as cognitive behaviour therapy? A UK randomised trial. Br J Gen Pract. 2001 Jan;51(462):19-24. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313894/ (Full article)

Causal attributions for somatic sensations in patients with chronic fatigue syndrome and their partners

Abstract:

BACKGROUND: Patients with chronic fatigue syndrome (CFS) often make somatic attributions for their illness which has been associated with poor outcome. A tendency to make somatic attributions in general may be a vulnerability factor for the development of CFS.

METHODS: This cross-sectional study based on self-report questionnaire data aimed to investigate the type of attributions for symptoms made by patients with CFS and to compare this to attributions made by their partners. It was hypothesized that patients with CFS would make more somatic attributions for their own symptoms than control subjects and that partners of patients with CFS would make more somatic attributions for their ill relative’s symptoms but would be similar to controls regarding their own symptoms. Fifty patients with CFS were compared to 50 controls from a fracture clinic in the same hospital and 46 relatives living with the patients with CFS. A modified Symptom Interpretation Questionnaire was used to assess causal attributions.

RESULTS: CFS patients were more likely to make somatic attributions for their symptoms. The relatives of patients with CFS made significantly more somatic attributions for symptoms in their ill relative. However, they were like the fracture clinic controls in terms of making predominantly normalizing attributions for their own symptoms.

CONCLUSIONS: The data support modification of existing cognitive behavioural treatments for CFS to investigate whether addressing partners’ attributions for patients’ symptoms improves recovery in the patient. Furthermore, a tendency to make somatic attributions for symptoms may be a vulnerability factor for the development of CFS.

Source: Butler JA, Chalder T, Wessely S. Causal attributions for somatic sensations in patients with chronic fatigue syndrome and their partners. Psychol Med. 2001 Jan;31(1):97-105. http://www.ncbi.nlm.nih.gov/pubmed/11200964

Chronic fatigue syndrome

Definition: Chronic fatigue syndrome is characterised by severe, disabling fatigue and other symptoms, including musculoskeletal pain, sleep disturbance, impaired concentration, and headaches. Two widely used definitions of chronic fatigue syndrome (from the US Centers for Disease Control and Prevention 1 and from Oxford 2—see table) were developed as operational criteria for research. There are two important differences between these definitions. The British criteria insist on the presence of mental fatigue; the American criteria include a requirement for several physical symptoms, reflecting the belief that chronic fatigue syndrome has an underlying immunological or infective pathology.

Incidence/prevalence: Community and primary care based studies have reported the prevalence of chronic fatigue syndrome to be 0.2-2.6%, depending on the criteria used.3 4 Systematic population surveys have found similar rates of the syndrome in people of different socioeconomic status, and in all ethnic groups.4 5 Female sex is the only demographic risk factor (relative risk 1.3 to 1.7 depending on diagnostic criteria used).6

Aetiology: The cause of chronic fatigue syndrome is poorly understood.

Prognosis: Studies of prognosis in chronic fatigue syndrome have focused on people attending specialist clinics, who are likely to have had the condition for longer and to have a poorer outlook. Children with the syndrome seem to have a notably better outcome: 54-94% of children show definite improvement (after up to six years’ follow up); 20-50% of adults show some improvement in the medium term and only 6% return to premorbid levels of functioning.7 Despite the considerable burden of morbidity associated with chronic fatigue syndrome, there is no evidence of increased mortality. Outcome is influenced by the presence of psychiatric disorders and beliefs about causation and treatment.7

Aims: To reduce levels of fatigue and associated symptoms; to increase levels of activity; to improve quality of life.

Outcomes: Severity of symptoms; effects on physical function and quality of life measured in several different ways by: the medical outcomes survey short form general health survey (SF-36), a rating scale measuring limitation of physical functioning caused by ill health 8; the Karnofsky scale, a modified questionnaire originally developed for the rating of quality of life in people undergoing chemotherapy for malignancy 9; the Beck depression inventory 10; the sickness impact profile, a measure of the influence of symptoms on social and physical functioning 11; and self reported severity of symptoms and levels of activity.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117488/

Source: Reid S, Chalder T, Cleare A, Hotopf M, Wessely S. Chronic fatigue syndrome. BMJ : British Medical Journal. 2000;320(7230):292-296. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117488/ (Full article)

Fatigue and psychiatric disorder: different or the same?

Abstract:

BACKGROUND: Fatigue and psychiatric symptoms are common in the community, but their association and outcome are sparsely studied.

METHOD: A total of 1177 patients were recruited from UK primary care on attending their general practitioner. Fatigue and psychiatric disorder was measured at three time points with the 12-item General Health Questionnaire and the 11-item Fatigue Questionnaire.

RESULTS: Total scores for fatigue and psychiatric disorder did not differ between the three time points and were closely correlated (r around 0.6). The association between non-co-morbid (‘pure’) fatigue and developing psychiatric disorder 6 months later was the same as that for being well and subsequent psychiatric disorder. Similarly, having non-co-morbid psychiatric disorder did not predict having fatigue any more than being well 6 months previously. Between 13 and 15% suffered from non-co-morbid fatigue at each time point and 2.5% suffered from fatigue at two time points 6 months apart. Less than 1% of patients suffered from non-co-morbid fatigue at all three time points.

CONCLUSIONS: The data are consistent with the existence of ‘pure’ independent fatigue state. However, this state is unstable and the majority (about three-quarters) of patients become well or a case of psychiatric disorder over 6 months. A persistent, independent fatigue state lasting for 6 months can be identified in the primary-care setting, but it is uncommon of the order of 2.5%. Non-co-morbid (pure) fatigue did not predict subsequent psychiatric disorder.

Source: van der Linden G, Chalder T, Hickie I, Koschera A, Sham P, Wessely S. Fatigue and psychiatric disorder: different or the same? Psychol Med. 1999 Jul;29(4):863-8. http://www.ncbi.nlm.nih.gov/pubmed/10473313

Illness beliefs and treatment outcome in chronic fatigue syndrome

Abstract:

Longitudinal studies have shown that physical illness attributions are associated with poor prognosis in chronic fatigue syndrome (CFS). Speculation exists over whether such attributions influence treatment outcome. This study reports the effect of illness beliefs on outcome in a randomized controlled trial of cognitive-behavior therapy versus relaxation.

Causal attributions and beliefs about exercise, activity, and rest were recorded before and after treatment in 60 CFS patients recruited to the trial. Physical illness attributions were widespread, did not change with treatment, and were not associated with poor outcome in either the cognitive-behavior therapy group or the control group.

Beliefs about avoidance of exercise and activity changed in the cognitive behavior therapy group, but not in the control group. This change was associated with improved outcome. These findings suggest that physical illness attributions are less important in determining outcome (at least in treatment studies) than has been previously thought. In this study, good outcome is associated with change in avoidance behavior, and related beliefs, rather than causal attributions.

Source: Deale A, Chalder T, Wessely S. Illness beliefs and treatment outcome in chronic fatigue syndrome. J Psychosom Res. 1998 Jul;45(1):77-83. http://www.ncbi.nlm.nih.gov/pubmed/9720857