General Health Questionnaire – American ME and CFS Society

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

Screening for psychiatric disorders in chronic fatigue and chronic fatigue syndrome

Abstract:

Psychiatric disorders are common in chronic fatigue (CF) and chronic fatigue syndrome (CFS). To determine the usefulness of the General Health Questionnaire (GHQ), a self-report measure of psychological distress, in identifying those with psychiatric illnesses, a structured psychiatric interview and the GHQ were administered to 120 CF and 161 CFS patients seen in a referral clinic.

Overall, 87 (35%) patients had a current and 210 (82%) a lifetime psychiatric disorder. Compared to patients without psychiatric disorders, GHQ scores above the threshold (> or = 12) were more frequent among patients with current (p < 0.001) and lifetime (p < 0.05) diagnoses; scores among patients with CF and CFS were similar.

Longer illness duration, greater fatigue severity, and current psychiatric disorders were significant predictors of the GHQ score. In CF and CFS, the best sensitivity (0.69-0.76) and specificity (0.51-0.62) were achieved for current psychiatric diagnoses using a threshold score of > or = 12. Thus, patients scoring < 12 on the GHQ are significantly less likely to have a psychiatric disorder.

Source: Buchwald D, Pearlman T, Kith P, Katon W, Schmaling K. Screening for psychiatric disorders in chronic fatigue and chronic fatigue syndrome. J Psychosom Res. 1997 Jan;42(1):87-94. http://www.ncbi.nlm.nih.gov/pubmed/9055216

Chronic fatigue and minor psychiatric morbidity after viral meningitis: a controlled study

Abstract:

OBJECTIVE: To test the hypotheses that patients exposed to viral meningitis would be at an increased risk of developing chronic fatigue syndrome and would have an excess of neurological symptoms and physical impairment.

METHODS: Eighty three patients were followed up 6-24 months after viral meningitis and a postal questionnaire was used to compare outcome with 76 controls who had had non-enteroviral, non-CNS viral infections.

RESULTS: For the 159 patients and controls the prevalence of chronic fatigue syndrome was 12.6%, a rate higher than previously reported from primary care attenders, suggesting that moderate to severe viral infections may play a part in the aetiology of some fatigue states. Those with a history of meningitis showed a slight, non-significant increase in prevalence of chronic fatigue syndrome (OR 1.4; 95% CI 0.5-3.6) which disappeared when logistic regression and analysis was used to correct for age, sex, and duration of follow up (OR 1.0; 95% CI 0.3-2.8). Controls showed marginally higher psychiatric morbidity measured on the general health questionnaire-12 (adjusted OR 0.6; 95% CI 0.3-1.3) Both groups had similar rates of neurological symptoms and physical impairment. The best predictor of chronic fatigue was a prolonged duration time of off work after the illness (OR 4.93, 95% CI 1.3-18.8). The best predictor of severe chronic fatigue syndrome diagnosed by Center for Disease Control criteria was past psychiatric illness (OR 7.82, 95% CI 1.8-34.3). Duration of viral illness, as defined by days in hospital, did not predict chronic fatigue syndrome.

CONCLUSIONS: (1) The prevalence of chronic fatigue syndrome is higher than expected for the range of viral illnesses examined; (2) enteroviral infection is unlikely to be a specific risk factor for its development; (3) onset of chronic fatigue syndrome after a viral infection is predicted by psychiatric morbidity and prolonged convalescence, rather than by the severity of the viral illness itself.

Source: Hotopf M, Noah N, Wessely S. Chronic fatigue and minor psychiatric morbidity after viral meningitis: a controlled study. J Neurol Neurosurg Psychiatry. 1996 May;60(5):504-9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC486361/ (Full article)

Screening for psychiatric morbidity in subjects presenting with chronic fatigue syndrome

Abstract:

BACKGROUND: There is a need for a valid self-rating questionnaire to screen for psychiatric morbidity in patients with chronic fatigue syndrome (CFS). This study had the aim of assessing the utility and validity of two commonly used measures.

METHOD: Scores obtained on the General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) were compared with various diagnostic and severity ratings obtained via a validating clinical interview, the Schedules for the Clinical Assessment of Neuropsychiatry (SCAN) in 95 consecutively referred subjects at a medical out-patient clinic who fulfilled standard criteria for CFS, and 48 healthy controls. Outcome measures were validating coefficients and receiver operating characteristics (ROC) for different thresholds and scoring on GHQ and BDI and index of definition (ID) as measured by SCAN; and Pearson and point by serial correlation coefficients for different diagnostic groups derived via SCAN and defined according to ICD-10 and DSM-III-R.

RESULTS: GHQ and BDI perform poorly as screeners of psychiatric morbidity in CFS subjects when compared with various SCAN derived ratings although results for controls are comparable with other studies.

CONCLUSIONS: Neither the GHQ nor BDI alone can be recommended as screeners for psychiatric morbidity in CFS subjects.

Source: Farmer A, Chubb H, Jones I, Hillier J, Smith A, Borysiewicz L. Screening for psychiatric morbidity in subjects presenting with chronic fatigue syndrome. Br J Psychiatry. 1996 Mar;168(3):354-8. http://www.ncbi.nlm.nih.gov/pubmed/8833692

Chronic fatigue syndrome in the community. Prevalence and associations

Abstract:

BACKGROUND: Chronic fatigue syndrome (CFS) is a poorly understood condition, apparently related to both psychiatric disturbance and infectious illness. Little progress has been made in identifying aetiology, owing to a lack of epidemiological studies using case-definition criteria.

METHOD: A community postal survey of a random sample of over 1000 patients registered at a local health centre comprised a fatigue questionnaire and the 12-item General Health Questionnaire (GHQ).

RESULTS: Total fatigue scores were modestly higher in women than men. Fatigue was most frequently attributed to psychosocial factors. Fatigue and GHQ scores were strongly correlated. Two men and two women satisfied British criteria for CFS, a prevalence of 0.56% (95% Cl 0.16-1.47%); three were probable psychiatric cases.

CONCLUSIONS: Previously reported sociodemographic associations of CFS may reflect medical referral patterns. A strong association exists with psychological morbidity, but relabelling CFS as a psychiatric disorder is not justified.

Source: Lawrie SM, Pelosi AJ. Chronic fatigue syndrome in the community. Prevalence and associations. Br J Psychiatry. 1995 Jun;166(6):793-7. http://www.ncbi.nlm.nih.gov/pubmed/7663830

Post-hepatitis syndrome revisited

Abstract:

To examine the role of acute hepatitis A and B infection in the aetiology of chronic fatigue syndrome and psychiatric morbidity we studied 40 patients with acute viral hepatitis A or B consecutively admitted to an infectious diseases unit and studied at least 6 months after recovery.

Liver function tests (LFT) had returned to normal in each case. Forty-seven patients with other infectious diseases, of which 12 were presumed viral, admitted immediately after each hepatitis patient during the same period acted as controls. The main outcome measures were scores on a fatigue and muscle pain questionnaire, general health questionnaire (GHQ-12) and supplementary questions.

The hepatitis cases scored significantly higher fatigue scores, GHQ-12 scores and muscle pain scores. Length of time since recovery from illness, age and sex were not confounding factors. Hepatitis cases were also less energetic, had greater weight change, had altered alcohol tolerance, had less exercise tolerance and felt less fit than the control group and compared with their premorbid state.

Hence fatigue is more common after recovery in patients hospitalized for hepatitis A and B up to 30 months post-infection compared with matched controls hospitalized for other infectious diseases. Hepatitis A and B infection is a risk factor for post-infection fatigue, intermittent fatigue, as well as for psychiatric morbidity.

Source: Berelowitz GJ, Burgess AP, Thanabalasingham T, Murray-Lyon IM, Wright DJ. Post-hepatitis syndrome revisited. J Viral Hepat. 1995;2(3):133-8. http://www.ncbi.nlm.nih.gov/pubmed/7493307

Gender differences in patients with chronic fatigue syndrome

Abstract:

OBJECTIVE: To determine whether there are differences between men and women patients who have chronic fatigue syndrome (CFS) and, if so, to ascertain whether a gender-related pattern exists.

DESIGN: A descriptive study of demographic, clinical, and psychosocial measures, the results of which were prospectively collected for patients who had CFS.

SETTING: A university-based referral clinic devoted to the evaluation and management of chronic fatigue.

PATIENTS: 348 CFS patients who had undergone complete medical evaluations.

MEASURES: Clinical variables included symptoms, physical examination findings, and laboratory results. Psychosocial assessment consisted of a structured psychiatric interview, the Medical Outcomes Study Short-form General Health Survey to assess functional status, the General Health Questionnaire to ascertain psychological distress, the Multidimensional Health Locus of Control, and measures of attribution, social support, and coping.

MAIN RESULTS: Overall, few gender-related differences were identified. Women had a higher frequency of tender or enlarged lymph nodes (60% versus 33%, p < or = 0.01) and fibromyalgia (36% versus 12%, p < or = 0.001) and lower scores on the physical functioning subscale of the Medical Outcomes Study Short-form General Health Survey (37.6 versus 52.2, p < 0.01); men more often had pharyngeal inflammation (42% versus 22%, p < or = 0.001) and reported a higher lifetime prevalence of alcoholism (20% versus 9%, p < or = 0.01).

CONCLUSIONS: In general, demographic, clinical, and psychosocial factors do not distinguish men from women CFS patients.

Source: Buchwald D, Pearlman T, Kith P, Schmaling K. Gender differences in patients with chronic fatigue syndrome. J Gen Intern Med. 1994 Jul;9(7):397-401. http://www.ncbi.nlm.nih.gov/pubmed/7931750

Population based study of fatigue and psychological distress

Abstract:

OBJECTIVES: To determine the prevalence of fatigue in the general population and the factors associated with fatigue.

DESIGN: Postal survey.

SETTING: Six general practices in southern England.

SUBJECTS: 31,651 men and women aged 18-45 years registered with the practices.

MAIN OUTCOME MEASURES: Responses to the 12 item general health questionnaire and a fatigue questionnaire which included self reported measures of duration, severity, and causes of fatigue.

RESULTS: 15,283 valid questionnaires were returned, giving a response rate of 48.3%, (64% after adjustment for inaccuracies in the practice registers). 2798 (18.3%) of respondents reported substantial fatigue lasting six months or longer. Fatigue and psychological morbidity were moderately correlated (r = 0.62). Women were more likely to complain of fatigue than men, even after adjustment for psychological distress. The commonest cited reasons for fatigue were psychosocial (40% of patients). Of 2798 patients with excessive tiredness, only 38 (1.4%) attributed this to the chronic fatigue syndrome.

CONCLUSION: Fatigue is distributed as a continuous variable in the community and is closely associated with psychological morbidity.

Comment in:

Patients with a self diagnosis of myalgic encephalomyelitis. [BMJ. 1995]

Twists in the tale of impossible means. The reviewer shows that the gremlins might have attacked on several fronts. [BMJ. 2000]

Twists in the tale of impossible means. In which a copy of the original manuscript is found safe in Norway. [BMJ. 2000]

Fatigue and psychological distress. Statistics are improbable. [BMJ. 2000]

Source: Pawlikowska T, Chalder T, Hirsch SR, Wallace P, Wright DJ, Wessely SC. Population based study of fatigue and psychological distress. BMJ. 1994 Mar 19;308(6931):763-6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2539651/

You can read the full article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2539651/pdf/bmj00432-0041.pdf

Illness behaviour of patients with chronic fatigue syndrome

Abstract:

The study examines the illness behaviour of patients with Chronic Fatigue Syndrome (CFS). The Illness Behaviour Questionnaire (IBQ), the twenty-eight version of the General Health Questionnaire (GHQ-28), and the Beck Depression Inventory (BDI) were administered to forty patients with a diagnosis of CFS. The results revealed that CFS patients in comparison with general practice patients, scored significantly higher on the IBQ sub-scales of General Hypochonriasis, t(188) = 5.2, p < 0.001 and Disease Conviction, t(188) = 13.28, p < 0.001 but lower on the Psychological/Somatic sub-scale, t(188) = -5.88, p < 0.001. The CFS and psychiatric patients did not differ significantly on the general hypochondriasis sub-scale. Results of the GHQ-28 revealed 66.7% of the CFS patients scored above the cut-off for psychiatric morbidity. In comparison to a previous study of CFS patients [1], the current findings indicate a significantly higher score on general hypochondriasis. The implications of these findings are discussed.

Source: Schweitzer R, Robertson DL, Kelly B, Whiting J. Illness behaviour of patients with chronic fatigue syndrome. J Psychosom Res. 1994 Jan;38(1):41-9. http://www.ncbi.nlm.nih.gov/pubmed/8126689

Postviral syndrome

Note: This letter appeared in the Journal of the Royal Society of Medicine, Volume 83, July 1990.

We read with interest the paper by Bowman (December 1989 JRSM, p 712) which suggests that the positive monospot test may only be present within the first four weeks of the illness. They also questioned the specificity of V P-I antigen, a view recently supported by Lynch and Seth. (1)

We are, however, interested in their comment that the General Health Questionnaire (GHQ) is having a limited usefulness in the context, of postviral syndrome. They have used an older version of the GHQ which includes 60 questions. There is a 30 item GHQ which was derived from the GHQ-60 by excluding symptoms that were commonly present in subjects with entirely physical illness thus the GHQ-30 could be regarded as a measure of more purely psychological or psychosocial symptoms (2). Another difficulty with postviral syndrome patients is that by definition they suffer from chronic symptoms. By using the GHQ as a screening instrument, it is likely that there will be a number of cases that will not be detected by GHQ (false negatives). It has been suggested that false negatives largely result from the relative insensitivity of the GHQ for chronic disorders (3,4). To overcome this problem Goodchild and Duncan-Jones have proposed a new scoring procedure (C-GHQ) to eliminate the insensitivity of the GHQ for chronic complaints (5).

Further investigation on this showed that the new scoring method was better with regard to both the GHQ at the measure of severity and GHQ with the screening instrument (6,7). We therefore suggest that in future investigation of the psychological well being of patients with postviral syndrome the shorter version of the GHQ with the revised scoring methods is to be used.

~B T FARID Consultant Psychiatrist

~A CHANDRA Registrar in Psychiatry New Cross Hospital Wolverhampton WV10 0QP

References

1 Lynch S, Seth R. Postviral fatigue syndrome and the V P-I antigen. Lancet 1989;ii.1160-1

2 Huppert FA, et al. The factor structure of the General Health Questionnaire (GHQ-30). Br J Psychiatry 1989; 155:178-85

3 BenJamin S, elm P, Haran D. Community screening for mental illness: A validity study of the General Health Questionnaire. Br J Psychiatry 1982;140:174-80

4 Finlay-Jones RA, Murphy E. Severity of psychiatric disorder and the 30-item GHQ. Br J Psychiatry 1979; 134:609-16

5 Goodchild ME, Duncan-Jones P. Chronicity and the General Health Questionnaire. Br J Psychiatry 1985; 146:55-62

6 Koetar MWJ, Van Den Brink W, Ormel J. Chronic psychiatric complaints and the General Health Questionnaire. Br J Psychiary 1989;155:186-90.

7 Surtees PG. Psychiatric disorder in the community and the General Health Questionnaire. Br J Psychiatry 1987;150:828-35

Source: B T Farid and A Chandra. Postviral syndrome. J R Soc Med. 1990 Jul; 83(7): 476. PMCID: PMC1292747 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292747/