Tag: dysthymia

Dysthymia: clinical picture, extent of overlap with chronic fatigue syndrome, neuropharmacological considerations, and new therapeutic vistas

Abstract:

Dysthymia, as defined in the American Psychiatric Association and International Classification of Mental Disorders, refers to a prevalent form of subthreshold depressive pathology with gloominess, anhedonia, low drive and energy, low self-esteem and pessimistic outlook. Although comorbidity with panic, social phobic, and alcohol use disorders has been described, the most significant association is with major depressive episodes.

Family history is loaded with affective, including bipolar, disorders. The latter finding explains why dysthymia, especially when onset is in childhood, can lead to hypomanic switches, both spontaneously and upon pharmacologic challenge in as many as 30%.

Indeed, antidepressants from different classes -tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), reversible inhibitors of monoamine oxidase A (RIMAs), selective serotonin-reuptake inhibitors (SSRIs) and, more recently, amisulpride, and spanning noradrenergic, serotonergic as well as dopaminergic mechanisms of action – have been shown to be effective against dysthymia in an average of 65% of cases. This is a promising development because social and characterologic disturbances so pervasive in dysthymia often, though not always, recede with continued pharmacotherapy beyond acute treatment.

Despite symptomatic overlap of dysthymia with chronic fatigue syndrome – especially with respect to the cluster of symptoms consisting of low drive, lethargy, lassitude and poor concentration – neither the psychopathologic status, nor the pharmacologic response profile of the latter syndrome is presently understood. Chronic fatigue today is where dysthymia was two decades ago.

We submit that the basic science – clinical paradigm that has proven so successful in dysthymia could, before too long, crack down the conundrum of chronic fatigue as well. At a more practical level, we raise the possibility that a subgroup within the chronic fatigue group represents a variant of dysthymia.

 

Source: Brunello N, Akiskal H, Boyer P, Gessa GL, Howland RH, Langer SZ, Mendlewicz J, Paes de Souza M, Placidi GF, Racagni G, Wessely S. Dysthymia: clinical picture, extent of overlap with chronic fatigue syndrome, neuropharmacological considerations, and new therapeutic vistas. J Affect Disord. 1999 Jan-Mar;52(1-3):275-90. http://www.ncbi.nlm.nih.gov/pubmed/10357046

 

Cognitive slowing and working memory difficulties in chronic fatigue syndrome

Abstract:

OBJECTIVE: Patients with chronic fatigue syndrome (CFS) commonly report problems with attention, memory, learning, and speed of cognitive processing. This study attempted to evaluate these complaints using objective test criteria.

METHOD: A test battery composed of six tests assessing these cognitive functions was given on two consecutive days. Twenty CFS patients were compared with 20 healthy control subjects and 14 patients with a history of major depression or dysthymia matched by age, intelligence, education level, and sex.

RESULTS: Compared with control subjects, CFS patients consistently scored lower on tests in which motor and cognitive processing speeds were a critical factor, eg, reaction-time tasks. They also had more difficulty on working-memory tests in which rapid cognitive processing speed is also an important factor. The effort made on the first day of testing did not result in a decline in cognitive function on the following day. CFS patients did not qualify as having affective disorder by several different diagnostic criteria. Nonetheless, CFS patients’ test performances did not differ from patients with a history of major depression or dysthymia.

CONCLUSIONS: It is concluded that, although CFS and major depression and dysthymia have distinct clinical features, these disorders have slowed motor and cognitive processing speed in common.

Comment in: Cognitive slowing in chronic fatigue syndrome (CFS) [Psychosom Med. 1997]

 

Source: Marshall PS, Forstot M, Callies A, Peterson PK, Schenck CH. Cognitive slowing and working memory difficulties in chronic fatigue syndrome. Psychosom Med. 1997 Jan-Feb;59(1):58-66. http://www.ncbi.nlm.nih.gov/pubmed/9021867

 

Reducing heterogeneity in chronic fatigue syndrome: a comparison with depression and multiple sclerosis

Abstract:

Chronic fatigue syndrome (CFS) is a heterogeneous illness characterized by a high prevalence of psychiatric problems. We reasoned that we could reduce heterogeneity by excluding patients with psychiatric problems preceding CFS.

We compared the functional status, mood, fatigue level, and psychiatric status of this more homogeneous group of CFS patients with the same parameters in patients with mild multiple sclerosis and in patients with major depression or dysthymia.

Patients with CFS and those with multiple sclerosis were similar in terms of level of anger, severity of depression, level of anxiety, and frequency of current psychiatric diagnoses. Patients with CFS resembled depressed patients in having impaired vigor and experiencing substantial fatigue and confusion–problems constituting part of the case definition of CFS.

The group with CFS was not psychologically vulnerable before the development of this condition and maintained adequate networks of social support despite disabling illness.

Stratification to exclude patients with prior psychiatric disease and those with mild CFS allowed us to define a group of patients with CFS who more resembled patients with mild MS than patients with major depression or dysthymia and thus were more likely to have illness with an infectious or immunologic cause. Use of such a stratification strategy should prove important in testing of the viral/immunologic hypothesis of the etiology of CFS.

 

Source: Natelson BH, Johnson SK, DeLuca J, Sisto S, Ellis SP, Hill N, Bergen MT. Reducing heterogeneity in chronic fatigue syndrome: a comparison with depression and multiple sclerosis. Clin Infect Dis. 1995 Nov;21(5):1204-10. http://www.ncbi.nlm.nih.gov/pubmed/8589144

 

Outcome and prognosis of patients with chronic fatigue vs chronic fatigue syndrome

Abstract:

BACKGROUND: There are few data on the natural history and prognosis of persons with chronic fatigue (CF) or CF syndrome (CFS). Therefore, we compared functional outcomes in patients with each condition and tested the validity of various prognostic indicators.

METHODS: Four hundred forty-five (89%) of 498 consecutive referral patients were surveyed an average of 1.5 years after an initial evaluation. Data from the initial evaluation were used to predict outcomes.

RESULTS: Sixty-four percent of all patients reported improvement, but only 2% reported complete resolution of symptoms. Patients initially diagnosed as having CFS reported greater symptom severity and lower level of functioning at follow-up than did patients with CF. Major depression predicted unemployment in the CF group. Older age, longer duration of illness, and a lifetime history of dysthymia predicted less improvement in the CF group. Current dysthymia predicted less improvement for the CFS group.

CONCLUSIONS: The case definition of CFS according to the Centers for Disease Control and Prevention identifies chronically fatigued patients with poorer prognosis. In a tertiary care setting, recovery from CF or CFS is rare, but improvement is common. Prognostic indicators vary for the two groups, but the coexistence of dysthymia suggests poorer outcomes generally.

 

Source: Bombardier CH, Buchwald D. Outcome and prognosis of patients with chronic fatigue vs chronic fatigue syndrome. Arch Intern Med. 1995 Oct 23;155(19):2105-10. http://www.ncbi.nlm.nih.gov/pubmed/7575071

Chronic fatigue: risk factors for symptom persistence in a 2 1/2-year follow-up study

Abstract:

BACKGROUND: The prolonged disability of patients suffering from chronic fatigue may be due to sustaining factors that are independent of the cause and subject to intervention. This study reexamined a cohort of patients with chronic fatigue to define medical and psychiatric predictors of persistent symptoms.

METHODS: Seventy-eight patients with chronic fatigue present for 6 months or more (not required to meet the Centers for Disease Control case definition for chronic fatigue syndrome [CFS]) completed a self-report, follow-up questionnaire to measure the overall improvement or worsening of their condition at a mean of 2.5 years after their initial examination. At the time of initial evaluation, patients underwent a structured psychiatric examination, physical examination, laboratory studies, and self-report measures of psychological distress and functional disability. The psychiatric examination queried the patient about 28 somatic symptoms that are separate from those associated with CFS. Discriminant analysis was used to determine which variables present at the initial examination were significant predictors of persistent symptoms and disability at 2.5 years.

RESULTS: The factors most important at the time of initial presentation in predicting persistent illness were: (1) more than eight medically unexplained physical symptoms separate from those associated with CFS case definition; (2) lifetime history of dysthymia; (3) duration of chronic fatigue symptoms greater than 1.5 years; (4) less than 16 years of formal education; and (5) age older than 38 years. None of the results of the initial physical examination, or immunologic, general laboratory, or viral antibody measurements were significant in predicting persistence of symptoms. Recovery rates for those who met the criteria for CFS by either of two case definitions were lower than the rate of noncases, but the differences were not statistically significant. The five aforementioned variables formed a significant discriminative function, correctly classifying 78% of those who recovered and 74% of those with persistent symptoms.

CONCLUSIONS: At initial examination, patients with chronic fatigue, more than eight medically unexplained physical symptoms (excluding symptoms in the case criteria for CFS), a lifetime history of dysthymic disorder, longer than 1.5 years of chronic fatigue, less than 16 years of formal education, and who were older than 38 years were the most likely to have persistence of symptoms of chronic fatigue at the 2.5-year follow-up.

 

Source: Clark MR, Katon W, Russo J, Kith P, Sintay M, Buchwald D. Chronic fatigue: risk factors for symptom persistence in a 2 1/2-year follow-up study. Am J Med. 1995 Feb;98(2):187-95. http://www.ncbi.nlm.nih.gov/pubmed/7847436

 

Research about fatigue in France over the past 20 years

Abstract:

The author reported the works of the “Fatigue Studies Group” founded 20 years ago to explore the different dimensions of “fatigue” complaint. The emphasis is placed on the asthenic syndromes evaluation instrument created by the group, which takes into account the socio-demographic data of the patient, clinical signs and their severity as well as the potential etiological factors. Its first version (GEF-3) enabled to isolate 4 groups of asthenia (overworking, somatic, psychosomatic and psychic), each of them requesting a specific treatment. An ulterior version (GEF-4) has been elaborated to describe better the psychiatric semeiology. Finally, a simplified version (GEF-10) was used as an evaluation instrument in different therapeutic researches. At the same time, the group continued its researches on the fatigue psychosocial dimensions and its nosographic status, especially in comparison with dysthymic disorders.

 

Source: Crocq L. Research about fatigue in France over the past 20 years. Encephale. 1994 Nov;20 Spec No 3:615-8. [Article in French] http://www.ncbi.nlm.nih.gov/pubmed/7843059