The quality of life of persons with chronic fatigue syndrome

Causes of death among patients with chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a debilitating illness affecting thousands of individuals. At the present time, there are few studies that have investigated causes of death for those with this syndrome. The authors analyzed a memorial list tabulated by the National CFIDS Foundation of 166 deceased individuals who had had CFS. There were approximately three times more women than men on the list. The three most prevalent causes of death were heart failure, suicide, and cancer, which accounted for 59.6% of all deaths. The mean age of those who died from cancer and suicide was 47.8 and 39.3 years, respectively, which is considerably younger than those who died from cancer and suicide in the general population. The implications of these findings are discussed.

Well-being in patients with chronic fatigue syndrome: the role of acceptance

OBJECTIVE

Research in chronic pain patients has shown that accepting the chronic nature of their illness is positively related to quality of life. The aim of this study was to investigate whether acceptance is also associated with better well-being in patients suffering from chronic fatigue syndrome (CFS).

METHODS

Ninety-seven patients completed a battery of questionnaires measuring fatigue, functional impairment, psychological distress, and acceptance.

RESULTS

Results indicated that acceptance has a positive effect upon fatigue and psychological aspects of well-being. More specifically, acceptance was related to more emotional stability and less psychological distress, beyond the effects of demographic variables, and fatigue severity.

CONCLUSION

We suggest that promoting acceptance in patients with CFS may often be more beneficial than trying to control largely uncontrollable symptoms.

Fatigue and physical activity in patients undergoing hematopoietic stem cell transplant

PURPOSE/OBJECTIVES

To examine the patterns of fatigue, physical activity, health status, and quality of life before and after high-dose chemotherapy and hematopoietic stem cell transplantation (HSCT) and to examine the feasibility of obtaining real-time fatigue and physical activity data.

DESIGN

Prospective, repeated measures.

SETTING

Two midwestern academic medical centers.

SAMPLE

Convenience sample of autologous or allogeneic patients undergoing HSCT (N = 20 baseline, N = 17 post-transplant).

METHODS

Subjects were assessed over a five-day period before and after HSCT for a total of 10 days. Subjects rated fatigue intensity three times daily and wore a wrist actigraph to measure physical activity. At the end of both five-day periods, subjects completed measures of perceived health status (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30) and life satisfaction Quality of Life Index).

MAIN RESEARCH VARIABLES

Fatigue, physical activity, perceived health status, and quality of life.

FINDINGS

Study results indicate that fatigue significantly increased and physical activity decreased following high-dose chemotherapy and HSCT. The decline coincided with diminished physical, emotional, role, and cognitive functioning. The symptoms that patients experienced (i.e., fatigue, pain, nausea and vomiting, sleep disturbances, appetite loss, and diarrhea) increased during the acute post-transplant period. No significant changes in life satisfaction were found.

CONCLUSIONS

The study findings suggest that patients receiving high-dose chemotherapy followed by HSCT experience increased fatigue, reduced physical activity, diminished functioning, and poorer quality of life immediately after transplant. Findings demonstrate that real-time fatigue and physical activity data can feasibly be collected in acutely ill patients.

IMPLICATIONS FOR NURSING

Patients undergoing HSCT require considerable supportive nursing care immediately following transplant. Clinicians and researchers need to strive for effective symptom management to improve the likelihood of successful outcomes.

Linkages between goal attainment and quality of life for individuals with chronic fatigue syndrome

Goal setting was the cornerstone of a rehabilitation program for people with chronic fatigue syndrome. This study examines the relationship between goal attainment and quality of life. Participants (N = 47) set goals over eight supportive and educational group sessions. Group members reported goal progress and confidence level for goal attainment. Using a forward, stepwise linear regression analysis, goal attainment emerged as the only significant predictor of quality of life improvement (B = 0.234, 95% CI for B: 0.050 to 0.419, SE = 0.091, β = 0.372, p <. 05) independently of fatigue severity, symptom severity, and comorbid psychiatric diagnosis.

The Chronic Fatigue Syndrome Activities and Participation Questionnaire (CFS-APQ): An overview

Chronic fatigue syndrome (CFS) is characterized by severe fatigue and a reduction in activity levels. The purpose of this study was to provide an overview of design, reliability, and validity of the CFS Activities and Participation Questionnaire (CFS-APQ). The CFS-APQ was constructed based on a retrospective analysis of the Karnofsky Performance Status Questionnaire and the Activities of Daily Living Questionnaire (n = 141). In a reliability study of 34 participants the test-retest reliability coefficient of the CFS-APQ was 0.95. In two different studies, the Cronbach alpha coefficient for internal consistency varied between 0.87 (n = 88) and 0.94 (n = 47). The CFS-APQ was administered to 47 patients who listed 183 activities that had become difficult due to their chronic symptoms, and 157 (85.8%) answers matched the content of the CFS-APQ. The outcome of a cross-sectional study (n = 88) studying the correlations between the Medical Outcomes Short Form 36 Health Status Survey subscale scores and the CFS-APQ supported the validity of the CFS-APQ. The CFS-APQ scores correlated with a behavioural assessment of the patients' performance of activities encompassed by the questionnaire (r = 0.29-0.55; n = 63), and correlated with exercise capacity parameters (r = 0.26-0.39; n = 77) obtained during a maximal exercise capacity stress test. Finally, the CFS-APQ correlated with visual analogue scales for pain (r = 0.51) and fatigue (r = 0.50; n = 47). It is concluded that the CFS-APQ generates reliable and valid data, and can be used as a clinical measure of disease severity in patients with CFS. Future studies should aim at examining the sensitivity of the CFS-APQ.

Generalized Joint Hypermobility Is More Common in Chronic Fatigue Syndrome Than in Healthy Control Subjects

OBJECTIVES

This study aimed at (1) comparing the prevalence of generalized hypermobility in patients with chronic fatigue syndrome (CFS) and healthy volunteers, (2) examining the clinical importance of generalized hypermobility in patients with CFS, and (3) examining whether knee proprioception is associated with hypermobility in patients with CFS.

METHODS

Sixty-eight patients with CFS filled out two self-reported measures (for the assessment of symptom severity and disability), were questioned about muscle and joint pain, and were screened for generalized hypermobility. Afterward, the patients performed a knee repositioning test (assessment of knee proprioception), and it was examined whether or not they fulfilled the criteria for benign joint hypermobility syndrome (BJHS). Sixty-nine age- and sex-matched healthy volunteers were screened for generalized joint hypermobility and performed the same knee repositioning test.

RESULTS

Compared with the healthy volunteers (4.3%, 3/68), significantly more patients with CFS (20.6%, 14/69) fulfilled the criteria for generalized joint hypermobility (Fisher exact test, P < .004). No associations were found between generalized joint hypermobility and the self-reported measures (including pain severity) or knee proprioception (Spearman correlation analysis). Knee proprioception was similar in both groups (Mann-Whitney U = 1961, z = -1.745, P = .81). Forty patients with CFS (58.8%) fulfilled the criteria for BJHS.

CONCLUSIONS

These data indicate that a subgroup of patients with CFS present with generalized joint hypermobility and most patients with of CFS fulfill the diagnostic criteria for BJHS. There appears to be no association between musculoskeletal pain and joint hypermobility in patients with CFS.

The effects of short-term and long-term pulmonary rehabilitation on functional capacity, perceived dyspnea, and quality of life

STUDY OBJECTIVES

The purposes of this study were as follows: (1) to determine whether physical performance, quality of life, and dyspnea with activities of daily living improved following both short-term and long-term pulmonary rehabilitation (PR) across multiple hospital outpatient programs; (2) to examine the differences in these parameters between men and women; and (3) to determine what relationships existed between the psychosocial parameters and the results of the 6-min walk (6MW) test performance across programs.

DESIGN

Non-experimental, prospective, and comparative.

SETTING

Seven outpatient hospital PR programs from urban and rural settings across North Carolina.

PARTICIPANTS

Three hundred nine women and 281 men who were 20 to 93 years of age (mean [+/- SD] age, 66.7 +/- 11.1 years) with chronic lung disease.

INTERVENTIONS

All 6MW tests and health surveys were administered prior to and immediately following 12 and 24 weeks of supervised PR participation. Scores from the 6MW tests, the Ferrans and Powers quality of life index-pulmonary version III (QLI), the Medical Outcomes Study 36-item short form (SF-36), and the University of California at San Diego shortness of breath questionnaire (SOBQ) were compared at PR entry, at 12 weeks, and at 24 weeks for differences by gender with repeated-measures analysis of variance. The study entry and follow-up SF-36 physical and mental component summary scores, the QLI health/function and overall scores, and the SOBQ scores were also compared to the 6MW test scores with Pearson correlation coefficient analysis.

RESULTS

The mean summary scores on the SF-36 and the QLI increased after 12 weeks of PR (p < 0.05), and improvements were maintained by 24 weeks of PR participation (p < 0.05). Scores on the SOBQ improved after 12 weeks (p < 0.001) among the short-term participants, but not until after 24 weeks among the long-term participants (p = 0.009). The 6MW test performance improved after 12 weeks (p < 0.001) and again from 12 to 24 weeks (p = 0.002) in the long-term participants. No relevant correlational relationships were found between 6MW scores and the summary scores of the administered surveys (r = -0.43 to 0.36).

CONCLUSIONS

Physical performance, as measured by the 6MW test, continued to improve with up to 24 weeks of PR participation. Quality-of-life measures and the perception of dyspnea improved after 12 weeks of PR participation, with improvements maintained by 24 weeks of PR participation. It is recommended that PR patients participate in supervised PR for at least 24 weeks to gain and maintain optimal health benefits.

Subjective quality of life in patients with chronic fatigue syndrome

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.

Disability-induced identity changes in persons with multiple chemical sensitivity

In this qualitative study, the authors asked respondents with multiple chemical sensitivity (MCS) in an open-ended question how having the condition affected their identities. Authors then examined responses for themes, which they discuss within the framework of critical theory. Emergent themes included loss of a stable, familiar personality, loss of self-positioning, emotional suppression to meet others' expectations, redesigning the planned life, forced growth, struggling with support, discovering the spiritual self, and identity reconsolidation. The authors compare findings with published works on adjustment to chronic illness and other delegitimized illnesses, find them to be fairly congruent, and then discuss problems regarding cultural acceptance of MCS as a condition caused by chemical exposure.

Postoperative quality of life among patients with thyroid cancer

BACKGROUND

Thyroid cancer patients have a survival rate of over 90% after thyroidectomy. However, quality of life with a generic focus has rarely been studied in thyroid cancer survivors.

AIM

This paper reports a study to examine and describe factors associated with quality of life among patients with thyroid cancer after operation.

METHODS

Adult patients who had a thyroidectomy for cancer between January 1999 and June 2001 in a Taiwan city participated in the study. Telephone interviews was completed with 146 (67%) of those 218 eligible, asking about sociodemographic variables, disease/treatment characteristics and social support. Quality of life was measured by the Chinese version of the Quality of Life Index. Multivariate analyses were performed using multiple linear regressions.

RESULT

The regression model showed that patients at 19-36 months after operation had lower quality of life compared with those within 18 months of operation. Current symptoms of fatigue and chills were negatively associated with quality of life. Those who rated the impact of operational scar on activities as 'high' had lower quality of life scores. Social support from families and friends had positive effects on quality of life. The model r2 was 48.1%.

CONCLUSIONS

Nurses could improve quality of life among patients with thyroid cancer by strengthening their social support and educating them in self-management of uncomfortable symptoms. Surgeons should consider types of operation in which the scar would be less likely to influence the patients' activities.

Kinesiophobia in chronic fatigue syndrome: Assessment and associations with disability11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To investigate aspects of the validity of the total scores of the Tampa Scale for Kinesiophobia (TSK), Dutch Version, which was modified to make it an appropriate questionnaire for the assessment of kinesiophobia (fear of movement) in chronic fatigue syndrome (CFS) patients (the Dutch TSK-CFS), and, using this assessment tool, to examine the associations between kinesiophobia, exercise capacity, and activity limitations and participation restrictions in patients with CFS.

DESIGN

Prospective observational studies.

SETTING

An outpatient fatigue clinic.

PARTICIPANTS

In the first study, 40 patients fulfilling the 1994 US Centers for Disease Control and Prevention (CDC) criteria for CFS were enrolled. The sample of the second study consisted of 51 CDC-defined patients with CSF.

INTERVENTIONS

Not applicable. Main outcome measures Study 1: Subjects completed a set of questionnaires; the Utrechtse Coping List (UCL), the Dutch TSK-CFS, and the Dutch Baecke Questionnaire of Habitual Physical Activity. Study 2: All patients completed 2 questionnaires (Chronic Fatigue Syndrome Activities and Participation Questionnaire [CFS-APQ], Dutch TSK-CFS) and performed a maximal exercise stress test on a bicycle ergometer. The heart rate was monitored continuously by use of an electrocardiograph. Metabolic and ventilatory parameters were measured through spirometry.

RESULTS

Study 1: The Cronbach alpha coefficient for the individual item scores on the TSK-CFS was .80. The total scores on the Dutch TSK-CFS showed a statistically significant correlation with both the avoidance/abide subscale of the UCL (Spearman rho=.35, P=.029) and the total score of the Baecke Questionnaire (rho=-.45, P=.004). Study 2: The total scores on the Dutch TSK-CFS showed a statistically significant correlation with the total scores on the CFS-APQ (rho=.39, P=.004). No statistically significant associations were observed between the exercise capacity parameters and the total scores on the Dutch TSK-CFS.

CONCLUSIONS

These results provide evidence for the internal consistency and the convergent and congruent validity of the scores obtained by use of the Dutch TSK-CFS. Kinesiophobia appears to be associated with activity limitations/participation restrictions but not with exercise capacity in patients with CFS.

Social support and the persistence of complaints in chronic fatigue syndrome

BACKGROUND

Several studies suggested that the surroundings of chronic fatigue syndrome (CFS) patients are of importance in the persistence of complaints. Contrary to what was expected, participation in support groups has not led to clinical improvement. The purpose of the present study was to describe social support in CFS patients as compared with other fatigued and non-fatigued groups. Further, changes in social support and the influence of social support on the course of CFS over a period of more than 1 year were studied in patients with and without treatment.

METHODS

Baseline data were assessed in 270 CFS patients, 150 disease-free breast cancer patients, 151 fatigued employees on sick-leave and 108 healthy subjects using the Social Support List and Significant Others Scale. CFS patients were followed in cognitive behaviour therapy (CBT), guided support groups and natural course at 8 and 14 months.

RESULTS

CFS patients and fatigued employees reported more negative interactions and insufficiency of supporting interactions than cancer patients and healthy controls. No differences in frequency of supporting interactions were found. Negative interactions decreased significantly after treatment with CBT, but did not change in support groups or natural course. In the natural course, higher fatigue severity at 8 months was predicted by more negative interactions at baseline.

CONCLUSIONS

In CFS patients and fatigued employees, social support is worse than in disease-free cancer patients and healthy controls. Lack of social support was identified as a new factor in the model of perpetuating factors of fatigue severity and functional impairment in CFS.

Evaluation and management of medically unexplained physical symptoms

BACKGROUND

Medically unexplained physical symptoms (MUPS) and related syndromes are common in medical care and the general population, are associated with extensive morbidity, and have a large impact on functioning. Much of medical practice emphasizes specific pharmacological and surgical intervention for discrete disease states. Medical science, with its emphasis on identifying etiologically meaningful diseases comprised of homogeneous groups of patients, has split MUPS into a number of diagnostic entities or syndromes, each with its own hypothesized pathogenesis. However, research suggests these syndromes may be more similar than different, sharing extensive phenomenological overlap and similar risk factors, treatments, associated morbidities, and prognoses. Examples of syndromes consisting of MUPS include chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivities, somatoform disorders, and 'Gulf War Syndrome.'

REVIEW SUMMARY

This paper is a narrative review of the increasing body of evidence suggesting that MUPS and related syndromes are common, disabling, and costly. It emphasizes that MUPS occur along a continuum of symptom count, severity, and duration and may be divided into acute, subacute (or recurrent), and chronic types. Predisposing, precipitating, and perpetuating factors influence the natural history of MUPS.

CONCLUSIONS

Effective symptom management involves collaborative doctor-patient approaches for identification of problems based on a combination of medical importance and patient readiness to initiate behavioral change, negotiated treatment goals and outcomes, gradual physical activation and exercise prescription. Additionally, efforts should be made to teach and support active rather than passive coping with the symptoms.

Chronic fatigue and indicators of long-term employment disability in psychosomatic inpatients

The major goal of this study was to determine indictors of long-term disability for psychosomatic inpatients with chronic fatigue syndrome. To this end, a cross-sectional study was performed with a random sample of patients (n=1000, response rate: 83.9%) at a psychosomatic inpatient clinic. 51.1% of the patients (n=429) reported intensely persistent exhaustion that had no logical relation to actual exertion. 159 (37.1%) patients in this group were disabled from working and these comprised the main target group of this study. Significantly more patients in the target group worked part time, were disabled for a disproportionately long period of time (50.9% of all were disabled for more than 6 months in the previous year), and felt stressed because of conflicts with their superiors and/or colleagues (in each case, P<0.01). While more frequent psychological comorbidity was not found, they reported physical complaints more often. It was not the patients fit for work who felt more burdened with chronic fatigue, but rather the employment-disabled, who were actually exposed to fewer demands. These patients had, in comparison with those fit to work, a stronger fixation on somatic complaints, inadequate perception of physical and psychic sensations, difficulties getting along with other people and in coping with a regular job (in each case, P<0.01). Prospective examination of these indicators could help detect predictor variables for long-term disability in chronic fatigue. Such predictors could contribute to timely social-medical assessment and treatment.

Illness and disability in Danish Chronic Fatigue Syndrome patients at diagnosis and 5-year follow-up

OBJECTIVE

Evaluation of the life impact of Chronic Fatigue Syndrome (CFS) over 5 years.

METHODS

Thirty-three adult patients meeting 1988 and 1994 CDC case criteria answered identical questionnaires at diagnosis and 5 years later, when a retrospective questionnaire was also completed.

RESULTS

Work disability was very high and increased further, social isolation remained high, emotional adjustment improved. There were increased problems with reading and with allergies. Two measures of improvement were used: The relation between these measures was weak. Length of illness, extent of disability and emotional adjustment were poorly related to measures of improvement. Average illness scores were unchanged, but most individuals improved in some ways while worsening or remaining the same in others. Only one participant (3%) neared recovery, one other was substantially better but still severely disabled.

CONCLUSION

CFS patients exhibit severe, long-term functional impairment. Substantial improvement is uncommon, less than 6%. Allergies and aspects of cognition may worsen, emotional adjustment often improves.

Cognitive Processing in Monozygotic Twins Discordant for Chronic Fatigue Syndrome

Twenty-one pairs of monozygotic twins discordant for chronic fatigue syndrome (CFS) and 21 matched healthy control (HC) subjects were assessed with 5 untimed tests and 5 timed tests from the computer-based NeuroCognitive Assessment Battery (R. K. Mahurin, 1993). Random effects regression showed no difference between CFS and healthy twins on any of the cognitive tests. Further, the twin groups did not differ from the HC group on any content-dependent measure. In contrast, both sets of twins performed worse than the HC group on all speed-dependent tests except Finger Tapping. Self-rated fatigue and dysphoric mood were only weakly correlated with cognitive performance. These data point toward a shared genetic trait related to information processing that is manifest in the CFS context. The findings have implications for differentiating genetic and acquired vulnerability in the symptomatic expression of the disorder. ((c) 2004 APA, all rights reserved)

Functional status of persons with chronic fatigue syndrome in the Wichita, Kansas, population

Background

Scant research has adequately addressed the impact of chronic fatigue syndrome on patients' daily activities and quality of life. Enumerating specific problems related to quality of life in chronic fatigue syndrome patients can help us to better understand and manage this illness. This study addresses issues of functional status in persons with chronic fatigue syndrome and other fatiguing illnesses in a population based sample, which can be generalized to all persons with chronic fatigue.

Methods

We conducted a random telephone survey in Wichita, Kansas to identify persons with chronic fatigue syndrome and other fatiguing illnesses. Respondents reporting severe fatigue of at least 1 month's duration and randomly selected non-fatigued respondents were asked to participate in a detailed telephone interview. Participants were asked about symptoms, medical and psychiatric illnesses, and about physical, social, and recreational functioning. Those meeting the 1994 chronic fatigue syndrome case definition, as determined on the basis of their telephone responses, were invited for clinical evaluation to confirm a diagnosis of chronic fatigue syndrome. For this analysis, we evaluated unemployment due to fatigue, number of hours per week spent on work, chores, and other activities (currently and prior to the onset of fatigue), and energy level.

Results

There was no difference between persons with chronic fatigue syndrome and persons with a chronic fatigue syndrome-like illness that could be explained by a medical or psychiatric condition for any of the outcomes we measured except for unemployment due to fatigue (15% vs. 40%, P < .01). Persons with chronic fatigue syndrome and other fatiguing illnesses had substantially less energy and spent less time on hobbies, schooling, or volunteer work than did non-fatigued controls (P < .01).

Conclusions

Persons with chronic fatigue syndrome are as impaired as persons whose fatigue could be explained by a medical or psychiatric condition, and they have less energy than non-fatigued controls.

Quality of life immediately after peripheral blood stem cell transplantation

This prospective, longitudinal study investigated the quality of life among patients immediately after undergoing peripheral blood stem cell transplantation. The patients were assessed before transplantation (n = 16), immediately before hospital discharge (n = 10), 2 weeks after hospital discharge (n = 10), and 6 weeks after hospital discharge (n = 8). Patients completed the European Organization for Research and Training Quality of Life Questionnaire-Core 30 and the Ferrans and Powers Quality of Life Index at each assessment point. A brief telephone interview was conducted 6 weeks after hospitalization (n = 7). The study results indicate that patients undergoing peripheral blood stem cell transplantation experience significant appetite loss (P <.01), diarrhea (P <.05), nausea and vomiting (P <.05), and sleep disturbances (P <.01) during the acute posttransplantation period. Other clinically important changes also were identified, so that a general pattern of recovery emerged. These patients reported diminished functional ability, increased symptoms, and poorer quality of life immediately before hospital discharge, with a return to pretransplantation levels by 6 weeks after hospitalization. In contrast, life satisfaction continued to decline 2 weeks after hospitalization, but did improve by 6 weeks. The qualitative data provide further support for this trend.

Living with achondroplasia in an average-sized world: an assessment of quality of life

Mutations in the gene encoding fibroblast growth factor receptor 3 cause achondroplasia, the most common form of inherited skeletal dysplasia. Although there are more than 10,000 individuals with achondroplasia living in the United States, there has been little study of their quality of life (QOL). For this study, surveys were collected from 189 individuals affected with achondroplasia (ACH) and 136 unaffected first-degree relatives (FDRs) of affected individuals. Individuals affected with achondroplasia had lower annual income, less education, and were less likely to be married than FDRs. They also differed significantly in their perceptions of achondroplasia, with FDRs believing that achondroplasia is a more serious condition. Total QOL indices and indices in each of four QOL subdomains were significantly lower in affected individuals than in relatives. When controlling for demographic characteristics and affected status, having lower self-esteem scores and perceiving achondroplasia as more serious were the independent factors most highly associated with lower QOL. A qualitative analysis of open responses to questions about the advantages and disadvantages of achondroplasia revealed that individuals were as likely to cite disadvantages relating to social barriers as they were to cite those relating to health and functioning. We interpret the low QOL scores to reflect the social challenges that individuals with achondroplasia regularly experience in the average-sized world. Genetics professionals should consider sources of lower QOL for affected individuals in their counseling sessions to acknowledge the relative importance of non-medical contributions.

Functional status, neuropsychological functioning, and mood in chronic fatigue syndrome (CFS): relationship to psychiatric disorder

Individuals with chronic fatigue syndrome (CFS) face chronic physical debilitation, reduced neuropsychological functioning, and changes in emotional well-being that significantly detract from quality of life. The role of psychiatric disturbance in reducing quality of life in CFS remains unclear. In the current investigation, the role of psychiatric status in reducing health-related quality of life in CFS was examined. Four subject groups were compared on measures of functional well-being, mood, and neuropsychological status: individuals with CFS and no history of psychiatric illness, individuals who had current symptoms of psychiatric illness that began after their CFS diagnosis, individuals who had current symptoms of psychiatric illness that began before their CFS diagnosis, and a healthy sedentary control group. Overall, it was found that individuals with CFS suffer from profound physical impairment. Concurrent psychiatric illness, however, did not adversely affect physical functional capacity. Physical functional capacity was not worse in individuals with a concurrent psychiatric illness. As expected, concurrent psychiatric illness was found to reduce emotional well-being. Moreover, individuals with a psychiatric illness that predated the onset of CFS suffered the greatest emotional distress. Thus, an individual's psychiatric history should be considered when attempting to understand the factors maintaining disability in CFS.

Chronic fatigue syndrome: symptom subtypes in a community based sample

Most studies of Chronic Fatigue Syndrome (CFS) have been based on patients recruited from primary or tertiary care settings. Patients from such settings might not be typical of patients in the general population. The present investigation involved examining individuals with CFS from a community-based study. A random sample of 18,675 respondents in Chicago were first interviewed by telephone. A group of individuals with chronic fatigue accompanied by at least four Fukuda et al. (1994) symptoms associated with CFS were given medical and psychiatric examinations. From this sample, a physician review group diagnosed individuals with CFS. Those diagnosed with CFS were subclassified based on frequency of symptoms. Important differences emerged on measures of sociodemographics and disability. The implications of these findings and others are discussed.

Six-minute walk performance and quality of life comparisons in North Carolina cardiac rehabilitation programs

OBJECTIVE

The purposes of this study were (1). to determine if six-minute walk (6MW) performance improved after short-term cardiac rehabilitation (CR) across multiple outpatient programs; (2). to examine differences in 6MW performance by patient age, sex, and race; and (3). to determine what relationships existed, if any, between 6MW performance and subscales of the Ferrans and Powers' Quality of Life Index-Cardiac Version III (QOLI).

DESIGN

Study design was nonexperimental, prospective, and comparative.

SETTING

Study setting included 14 outpatient CR programs from urban and rural settings across North Carolina.

PATIENTS

Adults aged 40 to 89 years (N = 630; men = 424 [67%], women = 206 [33%]; mean age, 61 +/- 10.32 years) with medically or surgically treated coronary heart disease enrolled in outpatient CR.

OUTCOME MEASURES

Study measures included scores on the QOLI and distance walked (feet) on the 6MW test.

RESULTS

Six-minute walk tests and QOLI surveys were administered before and immediately after short-term CR participation. Six-minute walk distance increased for all patients in all age categories across programs after CR (P <.0001). As a group, women improved 6MW distance by 15% (1243.9 +/- 301.2 to 1435.3 +/- 298.1; P <.001). Men also improved 6MW distance by 15% (1463.3 +/- 339.5 to 1683.7 +/- 346.9; P <.001) and walked farther than women on both the initial and follow-up 6MW tests (P <.0001). By age, there were no differences in 6MW scores between men and women aged 40 to 49 years (n = 58) and 50 to 59 years (n = 140; P = 0.54). Both of these age groups had greater initial and discharge 6MW scores than those aged 70 to 79 years (n = 183) and 80 to 89 years (n = 22; P <.001). Those aged 60 to 69 years (n = 227) had lower 6MW scores than those aged 40 to 49 years (P = 0.001) and 50 to 59 years (P <.05), and greater scores than those aged 70 to 79 years (P <.05) and 80 to 89 years (P <.05). Those aged 70 to 79 years had greater initial and follow-up 6MW scores than those aged 80 to 89 years(P <.001). Overall improvements in 6MW performance were found in both white subjects (n = 575; P <.001) and African-Americans (n = 54; P <.001). There were no apparent relationships between 6MW performance and overall or Health and Function QOLI scores (r <.21).

CONCLUSIONS

Participation in short-term outpatient CR improved 6MW performance in patients aged 40 to 89 years across 14 programs in North Carolina. No relationships were found between 6MW performance and any domain of the QOLI, including the Health and Function domain.

Psychological correlates of functional status in chronic fatigue syndrome

BACKGROUND

The present study was designed to test a cognitive model of impairment in chronic fatigue syndrome (CFS) in which disability is a function of severity of fatigue and depressive symptoms, generalized somatic symptom attributions and generalized illness worry.

METHODS

We compared 45 CFS and 40 multiple sclerosis (MS) outpatients on measures of functional ability, fatigue severity, depressive symptoms, somatic symptom attribution and illness worry.

RESULTS

The results confirmed previous findings of lower levels of functional status and greater fatigue among CFS patients compared to a group of patients with MS. Fatigue severity was found to be a significant predictor of physical functioning but not of psychosocial functioning in both groups. In CFS, when level of fatigue was controlled, making more somatic attributions was associated with worse physical functioning, and both illness worry and depressive symptoms were associated with worse psychosocial functioning.

CONCLUSIONS

Our findings support the role of depression and illness cognitions in disability in CFS sufferers. Different cognitive factors account for physical and psychosocial disability in CFS and MS. The SF-36 may be sensitive to symptom attributions, suggesting caution in its interpretation when used with patients with ill-defined medical conditions.

Chronic fatigue, abuse-related traumatization, and psychiatric disorders in a community-based sample

The relationship between sexual and physical abuse history and negative health effects has been well-documented in medical facility samples. Few studies have examined the role of abuse history and its relationship with chronic fatigue and psychiatric disorders in a diverse, randomly selected community-based sample. The present study compared rates of different types of abuse events in individuals with chronic fatigue and non-symptomatic controls. Relationships between specific types of abuse and psychiatric disorders commonly associated with chronic fatigue were also explored. A stratified random sample of 18,675 adults residing in ethnically and socioeconomically diverse neighborhoods in Chicago first completed a telephone screening questionnaire. A control group and a group of individuals with chronic fatigue symptomatology were identified and administered a semi-structured psychiatric interview assessing DSM-IV Axis I psychiatric disorders and a sexual and physical abuse history questionnaire. Controlling for sociodemographic differences, fatigue outcome was significantly predicted by childhood sexual abuse and the total number of different childhood abuse events. Within the chronic fatigue group, diagnosis of posttraumatic stress disorder (PTSD) was significantly predicted by childhood sexual abuse, childhood death threat, the total number of childhood abuse events, and lifetime abuse events. Sexual abuse during adolescence or adulthood significantly predicted other anxiety disorders among individuals with chronic fatigue. These findings suggest that a history of abuse, particularly during childhood, may play a role in the development and perpetuation of a wide range of disorders involving chronic fatigue. Among individuals with chronic fatigue, PTSD and other anxiety disorders appear to demonstrate the strongest association with abuse history. The implications of these findings are discussed.

Measuring quality of life of persons with spinal cord injury: substantive and structural validation

The purpose of this study was to evaluate the substantive and structural validity of an existing measure of quality of life (QOL), the spinal cord injury (SCI) version of the Ferrans and Powers quality of life index (QLI). To evaluate substantive validity, 11 individuals with a SCI participated in 'think aloud' interviews to determine meaningfulness of the QLI items and to identify areas requiring modification. Free sort and ranking exercises of the items were used to evaluate the structural validity of the domains and scoring rubric. Content analysis of the interview comments resulted in the addition of two items and wording revision to three items. The free sort exercise revealed that the domains as perceived by the participants differed somewhat from those of the test developer. The contribution of the satisfaction and importance sections proposed by the scoring model was not completely supported by the data from the ranking exercise. It is concluded that the modified version of the QLI reflects the perspectives of persons with SCI spinal cord injury as represented by the participants of this study. The structural validity evaluation has implications for the use of domain subscores and weighted vs. section scores. Further evaluation of the modified version is necessary before widespread use with this patient population.

Assessing attitudes toward new names for chronic fatigue syndrome

A questionnaire was distributed at the American Association of Chronic Fatigue Syndrome's biannual convention in Washington in January 2001 as well as through various Internet Web sites and listserves during early February and March of 2001. The sample consisted of 432 respondents. Most respondents (86%) indicated they wanted a name change, although more patients than scientists were in favor of this change. It was also apparent that the patients and physicians were clearly split between adopting a name such as myalgic encephalopathy versus one such as neuro-endocrine immune disorder. Also, among those respondents who selected either of these two choices for a new name, less than 30% of them supported the other name. Although the majority of respondents feel the name should be changed at this time, this survey suggests there are different stakeholders involved in the name-change process, each with strong and sometimes disparate feelings about changing the name.

The Family Response Questionnaire: a new scale to assess the responses of family members to people with chronic fatigue syndrome

OBJECTIVE

Family responses to patients with chronic fatigue syndrome (CFS) may influence the course of the disorder and family members themselves are likely to be adversely affected. However, the beliefs and responses of relatives of CFS patients have been under-researched. The aim of this study was to produce an easy-to-administer questionnaire to assess the responses of family members to people with CFS.

METHODS

Seventy-eight people, all close relatives of (physician-diagnosed) CFS sufferers, completed the first version of the Family Response Questionnaire (FRQ).

RESULTS

Examination of the correlation matrix and a cluster analysis of the items support four scales rather than the original five. The four response scales were labelled: sympathetic-empathic, active engagement, rejecting-hostile, and concern with self. Measures of test-retest and internal reliability were high. Participants found the items both comprehensible and relevant to their experiences of living with people with CFS.

CONCLUSION

The new version of the FRQ will be useful in further examination of the responses of CFS on individuals and their families.

Health-related quality of life in patients with chronic fatigue syndrome: an international study

OBJECTIVE

Chronic fatigue syndrome (CFS) has been reported worldwide. Our objectives were to determine if patients from different countries have similar profiles of impairments.

METHODS

Health-related quality of life (HRQoL) was assessed in 740 CFS patients in the US, 82 in the UK, and 65 in Germany using the eight subscales of the Short-Form General Health Survey (SF-36). To examine the internal structure, factor analyses were performed.

RESULTS

Overall, there was a remarkable similarity in HRQoL among all CFS patients, regardless of location. Patients scored two to three standard deviations below normal on six subscales and one standard deviation below normal on the other two subscales. Factor analysis suggested a two-factor model where the same six subscales constitute the first factor and the two others the second factor.

CONCLUSION

HRQoL is poor in CFS patients from three countries. This study is a first step towards conducting further comparative cross-cultural and international studies.

Chronic illness -- a disruption in life: identity-transformation among women with chronic fatigue syndrome and fibromyalgia

BACKGROUND

People with chronic illnesses often suffer from identity-loss. Empirical research concerning patients with chronic fatigue syndrome (CFS) or fibromyalgia has not, however, adequately addressed the consequences of these illnesses for identity.

AIM

The aim of this article is to describe how women with CFS and fibromyalgia create new concepts of identity after the onset of illness, and how they come to terms with their newly arisen identities. I aim to illuminate the biographical work done by these individuals, which includes a re-evaluation of their former identity and life. This process is illustrated by the following themes: An earlier identity partly lost and Coming to terms with a new identity.

METHOD

The study is based on interviews with 25 women in Sweden, 12 with the diagnosis of CFS and 13 diagnosed with fibromyalgia. A grounded theory orientated approach was used when collecting and analysing the data.

FINDINGS

The main findings are that: (1) the illnesses can involve a radical disruption in the women's biography that has profound consequences for their identity, particularly in relation to work and social life, (2) biographical disruptions are partial rather than total, calling for different degrees of identity transformation, (3) many of the women also experience illness gains in relation to the new identity.

CONCLUSIONS

Thus, the biographical disruption and illness experience comprised both losses and illness gains that had consequences for identity.

Coping and illness cognitions: chronic fatigue syndrome

The chronic fatigue syndrome (CFS) is described, and research on coping with this illness reviewed and analysed. CFS is a severely disabling illness of unknown etiology, which has occurred in epidemic forms all over the world. However, the number of sufferers has dramatically increased over previous years. The heterogeneous symptomatology of CFS was reviewed, and diagnostic criteria were discussed. The difficulty in establishing causality was emphasized. An interaction of factors appears most likely to be associated with illness onset and maintenance. As the mediating factor could be sufferers' coping behavior, the existing coping literature was reviewed. There might be an association between coping and physical and psychological well-being. Finally, recommendations are made for longitudinal research on coping and coping effectiveness, and for the development of therapeutic interventions.

Quality of life measures and gender comparisons in North Carolina Cardiac Rehabilitation Programs

BACKGROUND

Quality of life (QOL) is an important health-related outcome measure in patients with cardiovascular disease. The North Carolina Cardiopulmonary Rehabilitation Association (NCCRA) is a coalition of 72 state-certified, multidisciplinary cardiac rehabilitation (CR) programs. In 1997, the NCCRA Executive Board and Research Committee agreed to collect ongoing data to assess QOL changes following CR participation using the Ferrans & Powers QOL Index Cardiac Version III. The purpose of this study was to determine if changes were present in QOL scores after 12 weeks of CR in men and women from multiple outpatient centers.

METHODS

Data were analyzed from 420 patients from 19 Phase II early outpatient CR programs who completed the QOL index survey within the first week of program entry and upon discharge. The four QOL index domains measured were health/function, psychological/spiritual status, socioeconomic status, and family interaction. Overall QOL was tabulated as the aggregate score from the four domains. Each domain, as well as overall QOL, was compared pre- and post-CR participation with a repeated measures analysis of variance.

RESULTS

Across programs, statistically significant improvements in QOL indices were observed following 12 weeks of CR in each of the four domains and on the overall score in all patients. Men reported greater CR entry and discharge scores than women on the health/function, family interaction, and overall scores. Women showed a greater positive change in scores than men on the socioeconomic, family interaction, and overall scores.

CONCLUSIONS

Patients who participated in Phase II multidisciplinary North Carolina CR programs and completed the protocol improved QOL parameters. While men had higher physical function and overall QOL scores both pre- and post-CR, women showed greater improvements in overall scores, as well as in family and socioeconomic parameters. These findings suggest that North Carolina CR patients experience a positive change in QOL following short-term participation in CR. Further study with a larger number of patients benchmarked with programs from other regions with comparisons to patients who do not participate in formalized CR programs is indicated from this investigation.

Chronic fatigue syndrome: an examination of the phases

The present study examined the Fennell Phase Inventory, an instrument designed to measure the phases typically experienced by individuals with chronic fatigue syndrome (CFS). This inventory yields three factor scores of Crisis, Stabilization, and Integration. These factor scores have been employed in a cluster analysis, yielding four clusters that matched the four phases predicted by Fennell: Crisis, Stabilization, Resolution, and Integration. The present study represents a partial replication study of a prior investigation of the Fennell Phase Inventory by Jason et al. (in press), but that earlier study did not have an independent physician examination to diagnose patients with CFS. In the present study, 65 patients diagnosed with chronic fatigue syndrome by a physician were recruited and administered the Fennell Phase Inventory and other measures assessing CFS-related symptoms, disability, and coping. Each of the 65 patients was classified into one of four predefined clusters measuring a Crisis phase, a Stabilization phase, a Resolution phase, and an Integration phase. Relationships were explored between three of these cluster groupings and measures of symptoms, disability, and coping. Results confirmed Fennell's model, revealing significant differences between the three clusters in terms of levels of disability and modes of coping. Results suggest that the Fennell Phase Inventory accurately differentiates phases of adaptation to illness experienced by individuals with CFS.

Chronic fatigue syndrome: sociodemographic subtypes in a community-based sample

Most chronic fatigue syndrome (CFS) studies are based on information about patients from primary or tertiary care settings. These patients might not be typical of patients in the general population. This investigation involved examinations of individuals with CFS from a community-based study. A random sample of 18,675 in Chicago was interviewed by telephone. Individuals with chronic fatigue and at least four minor symptoms associated with CFS were given medical and psychiatric examinations. A group of physicians then diagnosed individuals with CFS, who were then subclassified based on three sociodemographic categories--gender, ethnicity, and work status. Sociodemographic subgroups were analyzed in terms of symptom severity, functional disability, coping, optimism, perceived stress, and psychiatric comorbidity. Women, minorities, and nonworking individuals with CFS reported greater levels of functional disability, symptom severity, and poorer psychosocial functioning than men, Caucasians, and working individuals, suggesting sociodemographic characteristics may be associated with poorer outcomes in urban, community-based samples of CFS individuals.

Chronic fatigue syndrome: occupation, medical utilization, and subtypes in a community-based sample

Most studies of chronic fatigue syndrome (CFS) have been based on patients recruited from primary or tertiary care settings. Patients from such settings might not be typical of patients in the general population. The present investigation involved examining individuals with CFS from a community-based study. A random sample of 18,675 respondents in Chicago was first interviewed by telephone. A group of individuals with chronic fatigue accompanied by at least four minor symptoms associated with CFS were given medical and psychiatric examinations. From this sample, a physician review group diagnosed individuals with CFS. Those diagnosed with CFS were subclassified based on a variety of categories, including duration of illness, mode of illness onset, and presence or absence of a stressful life event directly preceding onset. In addition, we examined medical utilization among those diagnosed with CFS, as well as whether individuals with CFS were disproportionately represented in health care professions. Important differences emerged on measures of sociodemographics, symptoms, and functional disability. The implications of these findings and others are discussed.

Characterization of pituitary function with emphasis on GH secretion in the chronic fatigue syndrome

OBJECTIVE

Previous studies have revealed that hormonal disturbances may accompany the chronic fatigue syndrome (CFS). Changes in the secretion of the pituitary-adrenal axis have been demonstrated, as well as abnormalities in the GH-IGF-I axis. However, data have not always been well characterized and were sometimes conflicting. The small number of CFS patients investigated in earlier studies may have played a role in the interpretation of the results.

SUBJECTS AND DESIGN

Hormonal testing was performed in 73 nonobese CFS patients and nonobese 21 age-and gender-matched healthy controls. We investigated GH, ACTH and cortisol responses to insulin-induced hypoglycaemia. In a subgroup of patients arginine and clonidine stimulation for GH was also performed. Nocturnal secretion of GH, ACTH and cortisol were determined. Serum levels of IGF-I, prolactin, TSH, and free thyroxine were also measured. Visceral fat mass was assessed by CT scanning.

RESULTS

GH response to insulin induced hypoglycaemia assessed by peak value (17.0 +/- 13.1 microg/l vs. 22. 1 +/- 9.8 microg/l; P = 0.01) and by AUC (450.0 +/- 361.3 microg/l vs. 672.3 +/- 393.0 microg/l; P = 0.002) was significantly decreased in CFS patients vs. controls. Nocturnal GH secretion assessed by GH peak value (5.4 +/- 3.7 vs. 9.0 +/- 5.1 microg/l; P = 0.44) and by AUC (34.4 +/- 20.2 vs. 67.4 +/- 43.1; P = 0.045) was also significantly impaired in CFS patients. Arginine and clonidine administration showed no differences in GH secretion between CFS patients and controls. In the CFS group, GH peak values were significantly higher after ITT than after arginine (P = 0.017) or clonidine (P = 0.001). No differences in serum IGF-I levels were found between CFS patients and controls. Except for a significantly lower nocturnal cortisol peak value, no differences were found in ACTH and cortisol secretion between CFS patients and controls. Significantly higher serum prolactin levels (7.4 +/- 4.7 microg/l vs. 4.4 +/- 1.3 microg/l; P = 0.004) and significantly higher serum TSH levels (1.6 +/- 1.0 mU/l vs. 1.0 +/- 0.4 mU/l; P = 0.011) were found in CFS patients. Serum free thyroxine was comparable in both groups. Visceral fat mass was significantly higher in CFS patients (86.6 +/- 34.9 cm2 vs. 51.5 +/- 15.7 cm2; P < 0.001).

CONCLUSIONS

We observed a significant impairment of GH response during insulin-induced hypoglycaemia and a low nocturnal GH secretion in CFS patients. These changes did, however, not lead to different concentrations in serum IGF-I. The clinical expression of this inadequate GH secretion can thus be questioned, although the alteration in body composition may be related to this relative GH deficiency. Significantly increased prolactin and TSH levels were found when compared to controls. These findings give support to the hypothesis of a decreased dopaminergic tone in CFS. Further investigations are required in order to identify specific adaptations within the neurotransmitter system in CFS and to determine the clinical importance of the impaired GH homeostasis.

Topical capsaicin in the management of HIV-associated peripheral neuropathy

Distal symmetrical peripheral neuropathy (DSPN) is a particularly distressing pain syndrome associated with human immunodeficiency virus (HIV) disease. Capsaicin has been found to be effective in relieving pain associated with other neuropathic pain syndromes, and is mentioned as a possible topical adjuvant analgesic for the relief of DSPN. This multicenter, controlled, randomized, double-masked clinical trial studied patients with HIV-associated DSPN and compared measures of pain intensity, pain relief, sensory perception, quality of life, mood, and function for patients who received topical capsaicin to the corresponding measures for patients who received the vehicle only. Twenty-six subjects were enrolled in the study. At the end of 1 week, subjects receiving capsaicin tended to report higher current pain scores than did subjects receiving the vehicle (Mann-Whitney test; P = 0.042). The dropout rate was higher for the capsaicin group (67%) than for the vehicle group (18%) (chi 2 test of association; P = 0.014). There were no other statistically significant differences between the capsaicin and vehicle groups with respect to current pain, worst pain, pain relief, sensory perception, quality of life, mood, or function at study entry or at any time during the 4-week trial. These results suggest capsaicin is ineffective in relieving pain associated with HIV-associated DSPN.

Symptom patterns in long-duration chronic fatigue syndrome

OBJECTIVE

Our objective was to evaluate symptom patterns in patients with chronic fatigue syndrome (CFS) who were ill for 10 or more years.

METHODS

This cross-sectional self-report study compared patient groups with long-duration (median = 18 years; n = 258) and short-duration (median = 3 years; n = 28) CFS to a group of healthy significant others (n = 79) on symptomatic, neurocognitive, and psychological variables. Data were gathered from a 574-item postal questionnaire.

RESULTS

A principal-components analysis of CFS symptom data yielded a three-factor solution: cognitive problems; flu-like symptoms; and neurologic symptoms. Compared with the short-duration CFS group, the long-duration group had significantly higher CFS symptom severity scores (p < 0.04), largely attributable to increased cognitive difficulties. A subgroup comparison of subjects ill for < 3 years versus those ill 4-7 years suggested that denial coping strategies were more likely in those participants with the shorter illness duration. Significant differences between both CFS groups and healthy controls were found in a number of comorbid disorders. Participants with CFS most often endorsed immune/viral abnormalities and persistent stress as important perceived causes of their illness.

CONCLUSION

Participants with long-duration CFS reported a large number of specific cognitive difficulties that were greater in severity than those reported by participants with short-duration CFS. The pattern of comorbid disorders in the CFS groups was consistent with hypersensitivity and viral reactivation hypotheses.

Chronic fatigue syndrome among overseas development workers: A qualitative study

BACKGROUND

A relatively high proportion of overseas development workers may develop chronic fatigue syndrome (CFS). A qualitative study was conducted in order to investigate how such people perceived their condition.

METHODS

Twelve people who had developed CFS while working overseas with development organizations, or shortly after visiting development projects, were interviewed about their experiences. Their responses were analyzed using a grounded theory approach.

RESULTS

Most of the participants considered themselves to have been extremely healthy before they developed CFS. The syndrome did not appear to have been caused by depression. The symptoms which were reported covered the range of symptoms typically found in studies of CFS. Respondents described difficulty in receiving, and accepting, a diagnosis. All of the participants attributed the CFS to multiple causes, the principal causes being overwork, stress and infections. Among the consequences of CFS reported to be the most difficult were having to leave the development project prematurely; pain; powerlessness; loss of independence, and the unpredictability of CFS. Factors which had helped respondents cope with these difficulties included religious beliefs; comparisons with people who were worse off than they were; thinking about positive consequences of the condition, and talking with supportive people.

CONCLUSIONS

Some theories have suggested that CFS symptoms arise as a result of depression or other emotional difficulties, which the individual is not able to acknowledge. The results indicated that such theories may not apply to this subgroup of people with CFS. Further research on the etiology of CFS is warranted. Respondents described high levels of work-related stress as common to the experience of development work. It might be beneficial to train development workers in stress management techniques. Development organizations should be encouraged to ensure that their workers take sufficient time to rest, and attempts should be made to reduce work pressures.