A longitudinal study of the relationship between psychological distress and recurrence of upper respiratory tract infections in chronic fatigue syndrome

Abstract:

OBJECTIVES: Previous research has found that chronic fatigue syndrome (CFS) patients report increased susceptibility to upper respiratory tract illnesses (URTIs) when compared with healthy volunteers. This study aimed to replicate and extend this research by investigating the role of psychological distress (stress and negative mood) in the recurrence of URTIs in CFS patients as well as its role in the recurrence of CFS symptoms.

DESIGN: A 15-week diary study.

METHODS: Measures of psychological stress, negative mood, recurrence of URTIs and symptoms were recorded each week for a 15-week period. CFS patients (N=21), who had been assessed and diagnosed according to the Oxford criteria, were recruited from the Cardiff Chronic Fatigue Clinic and compared with a matched group of healthy controls (N=18). Frequency of occurrence of infectious illness and the relationship between psychological stress/negative mood and occurrence of illness were assessed.

RESULTS: CFS patients reported more URTIs than the controls. Stress scores (and negative mood) were significantly higher in the week prior to the occurrence of URTIs than in weeks when no subsequent illness occurred. High levels of psychological stress also preceded the severity of reported symptoms of fatigue in the CFS group.

CONCLUSIONS: CFS patients reported more frequent URTIs than healthy controls and these recurrences were preceded by high levels of psychological stress. High levels of stress were also associated with greater subsequent fatigue. Possible explanations of these results are discussed.

 

Source: Faulkner S, Smith A. A longitudinal study of the relationship between psychological distress and recurrence of upper respiratory tract infections in chronic fatigue syndrome. Br J Health Psychol. 2008 Feb;13(Pt 1):177-86. https://www.ncbi.nlm.nih.gov/pubmed/17535488

 

A follow-up study of chronic fatigue syndrome in children and adolescents: symptom persistence and school absenteeism

Abstract:

This is a follow-up study of 28 young people aged between 7 and 17 meeting the Oxford criteria for the diagnosis of chronic fatigue syndrome treated in a specialist paediatric/psychiatric service. Retrospective case note analysis revealed a wide range and duration of symptoms together with high levels of school absenteeism prior to the diagnosis. The mean follow-up interval after discharge from the specialist service was 3 years and although most of the young people regarded themselves as fully recovered by this time, improvement was variable and about one third were still experiencing disabling symptoms.

The illness had impacted on the education or career plans of all the young people to some extent with 15 experiencing difficulty returning to school. This article highlights the need for early recognition and diagnosis of chronic fatigue syndrome in young people and the importance of continuing paediatric support to reduce symptom persistence in the sensitive recovery period. Maintaining school attendance by close liaison between health and education services both before and after diagnosis and treatment is also vital if long-term morbidity is to be reduced.

 

Source: Sankey A, Hill CM, Brown J, Quinn L, Fletcher A. A follow-up study of chronic fatigue syndrome in children and adolescents: symptom persistence and school absenteeism. Clin Child Psychol Psychiatry. 2006 Jan;11(1):126-38. https://www.ncbi.nlm.nih.gov/pubmed/17087490

 

Fatigue Intervention by Nurses Evaluation–the FINE Trial. A randomised controlled trial of nurse led self-help treatment for patients in primary care with chronic fatigue syndrome: study protocol.[ISRCTN74156610]

Abstract:

BACKGROUND: Chronic fatigue syndrome, also known as ME (CFS/ME), is a condition characterised primarily by severe, disabling fatigue, of unknown origin, which has a poor prognosis and serious personal and economic consequences. Evidence for the effectiveness of any treatment for CFS/ME in primary care, where most patients are seen, is sparse. Recently, a brief, pragmatic treatment for CFS/ME, based on a physiological dysregulation model of the condition, was shown to be successful in improving fatigue and physical functioning in patients in secondary care. The treatment involves providing patients with a readily understandable explanation of their symptoms, from which flows the rationale for a graded rehabilitative plan, developed collaboratively with the therapist. The present trial will test the effectiveness and cost-effectiveness of pragmatic rehabilitation when delivered by specially trained general nurses in primary care. We selected a client-centred counselling intervention, called supportive listening, as a comparison treatment. Counselling has been shown to be as effective as cognitive behaviour therapy for treating fatigue in primary care, is more readily available, and controls for supportive therapist contact time. Our control condition is treatment as usual by the general practitioner (GP).

METHODS AND DESIGN: This study protocol describes the design of an ongoing, single-blind, pragmatic randomized controlled trial of a brief (18 week) self-help treatment, pragmatic rehabilitation, delivered by specially trained nurse-therapists in patients’ homes, compared with nurse-therapist delivered supportive listening and treatment as usual by the GP. An economic evaluation, taking a societal viewpoint, is being carried out alongside the clinical trial. Three adult general nurses were trained over a six month period to deliver the two interventions. Patients aged over 18 and fulfilling the Oxford criteria for CFS are assessed at baseline, after the intervention, and again one year later. Primary outcomes are self-reported physical functioning and fatigue at one year, and will be analysed on an intention-to-treat basis. A qualitative study will examine the interventions’ mechanisms of change, and also GPs’ drivers and barriers towards referral.

 

Source: Wearden AJ, Riste L, Dowrick C, Chew-Graham C, Bentall RP, Morriss RK, Peters S, Dunn G, Richardson G, Lovell K, Powell P. Fatigue Intervention by Nurses Evaluation–the FINE Trial. A randomised controlled trial of nurse led self-help treatment for patients in primary care with chronic fatigue syndrome: study protocol. [ISRCTN74156610]. BMC Med. 2006 Apr 7;4:9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1456982/ (Full article)

 

The management of children with chronic fatigue syndrome-like illness in primary care: a cross-sectional study

Abstract:

BACKGROUND: Most studies on children with chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (ME) have been undertaken in tertiary care and little is known about their management in primary care.

AIM: To describe the characteristics of patients aged 5-19 years with CFS-like illness in primary care and to examine how GPs investigate and manage patients.

DESIGN OF STUDY: Descriptive retrospective questionnaire study.

SETTING: Sixty-two UK GP practices in the MRC General Practice Research Framework (GPRF).

METHOD: One hundred and twenty-two practices were approached; 62 identified 116 patients consulting a GP with severe fatigue lasting over 3 months. Practice nurses and GPs completed questionnaires from medical notes and patients completed postal questionnaires.

RESULTS: Ninety-four patients were considered by a clinical panel, blind to diagnosis, to meet the Oxford CFS criteria with a fatigue duration of 3 months. Seventy-three per cent were girls, 94% white, mean age was 12.9 years and median illness duration 3.3 years. GPs had principal responsibility for 62%. A diagnosis of CFS/ME was made in 55%, 30% of these within 6 months. Fifty per cent had a moderate illness severity. Paediatric referrals were made in 82% and psychiatric referrals in 46% (median time of 2 and 13 months respectively). Advice given included setting activity goals, pacing, rest and graded exercise.

CONCLUSIONS: Patient characteristics are comparable to those reported in tertiary care, although fewer are severe cases. GPs have responsibility for the majority of patients, are diagnosing CFS/ME within a short time and applying a range of referral and advice strategies.

 

Source: Saidi G, Haines L. The management of children with chronic fatigue syndrome-like illness in primary care: a cross-sectional study. Br J Gen Pract. 2006 Jan;56(522):43-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1821410/ (Full article)

 

Subjective quality of life in patients with chronic fatigue syndrome

Abstract:

The aim of this study was to (1) assess Subjective Quality of Life (SQOL) of patients with Chronic Fatigue Syndrome (CFS) using a generic concept and to compare the findings with those in groups with mental disorders and healthy subjects, and (2) investigate whether and, if so, to what extent socio-demographic and clinical variables predict SQOL in CFS patients.

Seventy-three patients diagnosed with CFS were randomly selected and interviewed from two specialised clinics. CFS was diagnosed using the Oxford Criteria. SQOL was assessed on the Manchester Short Assessment of Quality of Life (MANSA) and Health-Related Quality of Life (HRQOL) on the Medical Outcome Study Short-Form 36 (MOS) SF-36. A battery of mood and symptom questionnaires, including the Symptom Checklist Questionnaire (SCL-90-R), was administered to assess various aspects of symptomatology as potential predictor variables.

Multiple regression analyses were conducted to identify predictors of SQOL. Overall, SQOL was low in CFS patients and less favourable than in groups with mental disorders and healthy subjects. Satisfaction was particularly low with life as a whole, leisure activities and financial situation. Whilst SQOL was only moderately correlated with HRQOL, the SCL-90-R score, especially SCL-90-R Depression scale score, was the best predictor of SQOL explaining 35% of the variance. HRQOL and generic SQOL appear distinct despite some overlap.

The findings underline that SQOL is significantly disrupted in CFS patients. Depressive symptoms are statistically the strongest ‘predictor’ of SQOL, although the direction of the relationship is not established. These data suggest that treatment of depression associated with CFS, regardless of causation, could help to improve SQOL in CFS patients.

 

Source: Rakib A, White PD, Pinching AJ, Hedge B, Newbery N, Fakhoury WK, Priebe S. Subjective quality of life in patients with chronic fatigue syndrome. Qual Life Res. 2005 Feb;14(1):11-9. http://www.ncbi.nlm.nih.gov/pubmed/15789937

 

Chronic fatigue syndrome: a clinical and laboratory study with a well-matched control group

Comment on: Chronic fatigue syndrome: a clinical and laboratory study with a well matched control group. [J Intern Med. 1995]

 

Dear Sir,

It is an ongoing debate whether concurrent occurrence of particular additional symptoms should be part of the definition of chronic fatigue syndrome (CFS) [1–5] or not. Studies on the similarities and differences between patients satisfying the various definitions are indispensable to solve this dispute.

Swanink et al. [6] studied CFS patients satisfying the criteria described by Sharpe et al. [3], i.e. additional symptoms may be present but are not required. Part of the group also satisfied the more stringent CFS criteria by the Centers for Disease Control (CDC) [1], which require the additional presence of at least eight specific symptoms. When the number of complaints was included as the covariate, no significant differences on fatigue severity, depression and functional impairment were found between CFS patients who fulfilled the CDC criteria and who did not. Furthermore, the authors remarked that the sole effect of applying the CDC symptom criteria to their study group is separating patients with few symptoms from patients with many symptoms.

These results are very misleading and have often been misinterpreted. The authors’ analysis of variance (anova) yielded a lot of significant differences between CDC–CFS and non-CDC–CFS patients. That these were lost in their subsequent analysis of covariance (ancova) is because the level of the covariate and the treatment (fulfilment of the CDC criteria) are highly dependent, as fulfilment of the CDC criteria requires the presence of at least nine symptoms (fatigue included). Because the ancova assumption that the covariate is statistically independent of the treatment is not met, the ancova results are artificial and have little practical meaning [7, 8].

What happened* is illustrated in Fig. 1. anova checks whether CDC–CFS and non-CDC–CFS patients have equal test score means  and inline image and inline image. ancova, however, checks the equality of adjusted test score means  and inline image and inline image. These are obtained by transporting inline image and inline image from the treatment covariate means  inline image and inline image and  along parallel regression lines to the grand covariate mean inline image. Thus ancova predicts if test score means of CDC–CFS and non-CDC–CFS patients would have been equal if both groups had exactly the same mean number of complaints. It provides an answer to a question that has no relevance – the mean number of complaints is inherently different for these two groups. In particular, Table 1 of the article learns that the grand covariate mean as reported with the standardized questionnaire equals  = 674/88 = 7.66: the adjusted mean  corresponds to a group of CDC–CFS patients that does not even exist in reality!

Figure 1.

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Difference between analysis of variance (anova) and analysis of covariance (ancova).anova compares the treatment means  and , whereas ancova compares the adjusted treatment means  and  corresponding to the same level of the covariate for both groups. Note that the grand covariate mean corresponds to a group of CDC–CFS patients that does not exist in reality.

Although their ancova was inappropriate, the authors’anova did result in valuable information.anova of CDC–CFS versus non-CDC–CFS yielded significant differences (at least P < 0.05) in concentration, activity, sleep and rest, ambulation, alertness behaviour, and recreation and pastimes, which according to the authors means that CDC–CFS patients are significantly more impaired in daily functioning. As the subjective fatigue subscale of the checklist individual strength (CIS-fatigue) easily reaches the extreme end of its scale in CFS samples (see e.g. [9, 10]), it is obvious that no significant differences in fatigue severity as measured by CIS-fatigue could be found. Generally speaking, assessing fatigue severity using a scale without this flaw may well result in different outcomes (see e.g. [10]).

Because the inadequate ancova made it appear that there are no clinical differences between CDC–CFS and non-CDC–CFS patients, this study has often been cited to permit leaving out additional symptom criteria when considering CDC–CFS. This has had major consequences for scientific research as well as for clinical practice. In scientific literature, non-CDC–CFS patients are labelled as having ‘a diagnosis of CFS according to the CDC criteria’ [10] or fulfilling ‘the CDC criteria for CFS’ [11], although other sources by the same authors explicitly state that they do not [12, 13]. In a large randomized study on cognitive behaviour therapy for CFS [14], one of the two reasons that patients without the required number of additional symptoms were included is that ‘patients who fulfilled the CDC-criteria did not differ concerning the severity of the complaints from patients who did not satisfy the CDC criteria’ [13]. The CFS definition used for clinical practice in large parts of the Netherlands [15] is based on CDC criteria, but patients without the required additional symptoms are also diagnosed CFS because ‘clinically this distinction has no meaning, as it has turned out from Dutch research’ [16]. This means that if the mistakes above would have been noted at an earlier stage, literally thousands of chronically fatigued patients might have had a different diagnosis in the Netherlands.

Apparently [13] the incorrect results of the article have also been presented during a recent meeting held for revising the latest CDC–CFS definition (presentation Bleijenberg, CDC consensus meeting, Atlanta 2000). To prevent more scientific research on CDC–CFS that disregards additional symptoms and more CFS definitions that are based on statistical errors rather than on data, it is important that the mistakes in the article are corrected as soon as possible.

You can read the rest of this comment here: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2004.01378.x/full

 

Source: Stouten B. Chronic fatigue syndrome: a clinical and laboratory study with a well-matched control group. J Intern Med. 2004 Sep;256(3):265-7; author reply 268-9. http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2004.01378.x/full (Full article)

 

Cognitive behaviour therapy and chronic fatigue syndrome

Comment on: Chronic fatigue in general practice: is counselling as good as cognitive behaviour therapy? A UK randomised trial. [Br J Gen Pract. 2001]

 

Ridsdale and colleagues state that there is evidence that cognitive behaviour therapy (CBT) is effective for patients with chronic fatigue syndrome (CFS), but fail to point out that such evidence derives only from studies performed in the United Kingdom, where CFS is diagnosed on the basis of the Oxford criteria. There is no evidence that CBT is beneficial to patients fulfilling the Australian criteria for CFS or the American ones, namely, the original criteria of the Centers for Disease Control.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313986/pdf/11458489.pdf

 

Source: Baschetti R. Cognitive behaviour therapy and chronic fatigue syndrome. Br J Gen Pract. 2001 Apr;51(465):316-7. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313986/ (Full comment)

 

Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome

Abstract:

OBJECTIVE: To assess the efficacy of an educational intervention explaining symptoms to encourage graded exercise in patients with chronic fatigue syndrome.

DESIGN: Randomised controlled trial.

SETTING: Chronic fatigue clinic and infectious diseases outpatient clinic.

SUBJECTS: 148 consecutively referred patients fulfilling Oxford criteria for chronic fatigue syndrome.

INTERVENTIONS: Patients randomised to the control group received standardised medical care. Patients randomised to intervention received two individual treatment sessions and two telephone follow up calls, supported by a comprehensive educational pack, describing the role of disrupted physiological regulation in fatigue symptoms and encouraging home based graded exercise. The minimum intervention group had no further treatment, but the telephone intervention group received an additional seven follow up calls and the maximum intervention group an additional seven face to face sessions over four months.

MAIN OUTCOME MEASURE: A score of >/=25 or an increase of >/=10 on the SF-36 physical functioning subscale (range 10 to 30) 12 months after randomisation.

RESULTS: 21 patients dropped out, mainly from the intervention groups. Intention to treat analysis showed 79 (69%) of patients in the intervention groups achieved a satisfactory outcome in physical functioning compared with two (6%) of controls, who received standardised medical care (P<0.0001). Similar improvements were observed in fatigue, sleep, disability, and mood. No significant differences were found between the three intervention groups.

CONCLUSIONS: Treatment incorporating evidence based physiological explanations for symptoms was effective in encouraging self managed graded exercise. This resulted in substantial improvement compared with standardised medical care.

Comment in:

Patient education to encourage graded exercise in chronic fatigue syndrome. Trial has too many shortcomings. [BMJ. 2001]

ACP J Club. 2001 Sep-Oct;135(2):46.

 

Source: Powell P, Bentall RP, Nye FJ, Edwards RH. Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome. BMJ. 2001 Feb 17;322(7283):387-90. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC26565/ (Full article)

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 herehttp://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)

 

Prediction of peak oxygen uptake in chronic fatigue syndrome

Abstract:

OBJECTIVES: To establish a simple, valid, and acceptable method of predicting peak oxygen uptake (VO2peak) in patients with chronic fatigue syndrome (CFS), which could provide a basis for subsequent exercise prescription at an appropriate intensity as part of a clinical rehabilitation programme.

METHODS: A total of 130 patients who met UK research criteria for CFS were taken from consecutive referrals for chronic fatigue to the University Department of Medicine at Withington Hospital, Manchester. VO2peak was determined using an incremental graded exercise test to exhaustion. Respiratory gas exchange, work rate, and heart rate were monitored throughout.

RESULTS: In all patients, VO2peak was found to correlate strongly and significantly with peak work rate (WRpeak) during testing (r2 = 0.88, p<0.001). In patients who exercised for longer than two minutes (n = 119), regression analysis established the relation as Vo2peak = 13.1 x WRPpeak + 284, where VO2 is given in ml/min and WR in W. The mean error between the measured VO2peak and the predicted value was 10.7%. The relation between increase in work rate and oxygen uptake across the group was highly significant (r2 = 0.87, p<0.001), and given as VO2increase = 12.0 x WRincrease, this value being similar to that expected for healthy individuals. Almost all (97%) subjects reported no exacerbation of symptoms after maximal exercise testing.

CONCLUSIONS: Using a simple to administer maximal exercise test on a cycle ergometer, it is possible to predict accurately the VO2peak of a patient with CFS from peak work rate alone. This value can then be used as an aid to setting appropriate exercise intensity for a rehabilitation programme. The increase in VO2 per unit increase in workload was consistent with that expected in healthy individuals, suggesting that the physiological response of the patients measured here was not abnormal. Contrary to the belief of many patients, maximal exercise testing to the point of subjective exhaustion proved to be harmless, with no subjects suffering any lasting deterioration in their condition after assessment.

 

Source: Mullis R, Campbell IT, Wearden AJ, Morriss RK, Pearson DJ. Prediction of peak oxygen uptake in chronic fatigue syndrome. Br J Sports Med. 1999 Oct;33(5):352-6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756205/ (Full article)