Personality and perfectionism in chronic fatigue syndrome: a closer look

[Chronic fatigue syndrome against the background of the COVID-19 pandemic]

The more we learn about the new coronavirus infection, the more we understand that we will feel the echoes of the pandemic for many years, and those who have successfully endured the acute phase of COVID-19 may face the consequences of the infection. One of the most frequent manifestations will be the development of chronic fatigue syndrome (CFS) after COVID-19. This article discusses the possible causes of the development of CFS, as well as possible ways of its treatment and prevention.

Occupational Fatigue: Relationship With Personality Traits and Decent Work

Psychology of working theory (PWT) and psychology of working framework (PWF) offered a psychological view of decent work. The present study examined the associations among personality traits, decent work and Occupational Fatigue Exhaustion Recovery Scale (OFER). Two hundred and thirty four participants filled out the Big Five Questionnaire, the Italian version of the Decent Work Scale, and the Italian version of the OFER Scale. Hierarchical regressions showed that decent work explained incremental variance beyond personality traits with respect to OFER both considering total score and its three dimensions (chronic fatigue, acute fatigue, persistent fatigue). The present study underlined the value of decent work in relation to occupational fatigue beyond the contributions of personality, in particular in relation to the dimensions of Adequate compensation and Free time and rest for less occupational fatigue (both as total and as dimensions).

Perfectionism, depression and anxiety in chronic fatigue syndrome: A systematic review

OBJECTIVE

High levels of depression and anxiety are experienced alongside Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). Psychological causal and maintenance factors are not well-understood. Perfectionism is a multifactorial, transdiagnostic risk factor for various physical and mental health conditions. This systematic review assesses the association between perfectionism and depression and/or anxiety in people with CFS/ME.

METHOD

Systematic literature searches used a combination of terms for 'perfectionism', 'depression', 'anxiety' and 'CFS/ME'. Peer-reviewed English-language papers reporting quantitative data regarding the relationship between perfectionism and depression and/or anxiety in adults (aged 18-65 years) with a clinical diagnosis of CFS/ME were included. Screening, selection and assessment of risk of bias was completed independently by two authors. Bivariate and multivariate associations between perfectionism and anxiety and depression were extracted. Data were synthesised narratively.

RESULTS

Seven studies, reported in eight papers, were included. Seven examined the relationship between perfectionism and depression. Moderate-strong significant positive associations were found between depression and maladaptive perfectionism (r = 0.42 to .48, p < .01), and its component factors of concern over mistakes (r = 0.40 to .60, p < .01) and doubts about actions (r = 0.51 to .60, p < .01). Methodological limitations included sample size justification and selection, psychometric measures, and control of potential confounders.

CONCLUSION

Maladaptive perfectionism is consistently associated with depression in patients with CFS/ME. The relationship between perfectionism and anxiety is under-researched. Corroboration is required from longitudinal, cross-cultural studies. Clinical understanding may be increased through examining the interplay between maladaptive perfectionism, depression and anxiety and the physical and cognitive symptoms of CFS/ME.

Mental Fatigue, But Not other Fatigue Characteristics, as a Candidate Feature of Obsessive Compulsive Personality Disorder in Patients with Anxiety and Mood Disorders-An Exploratory Study

BACKGROUND

Obsessive compulsive personality disorder (OCPD) is commonly associated with anxiety and mood disorders (AMDs), in which fatigue and executive dysfunction represent key symptoms. Executive dysfunction has also been demonstrated in subjects with OCPD, and is additionally found to be a cardinal feature of fatigue. This study aimed to investigate the associations between fatigue, executive dysfunction, and OCPD in patients with AMDs.

METHODS

In this cross-sectional study, 85 AMD patients (78% females, mean age 39 ± 11 years) were evaluated for OCPD traits by using the observer-rated Compulsive Personality Assessment Scale. The Multidimensional Fatigue Inventory-20 was used to measure different aspects of fatigue, and the Trail Making Test was employed to assess executive functioning. The Hamilton rating scales were used to evaluate anxiety and depression symptoms.

RESULTS

Controlling for potential confounders, there was a significant link between OCPD and mental fatigue (OR, 1.27; 95% CI, 1.02 to 1.58; p = 0.033). No associations were found between the presence of OCPD and other relevant fatigue characteristics, including general fatigue, physical fatigue, reduced activity, and reduced motivation, as well as executive functions.

CONCLUSIONS

To the best of our knowledge, this study is the first to report associations between OCPD and mental fatigue in patients with AMDs, suggesting mental fatigue as a clinically important symptom when considering particular personality pathologies.

Perfectionism, impostor phenomenon, and mental health in medicine: a literature review

OBJECTIVES

The aims of this review, focused on medical students, residents, and physicians, were a) to determine the levels of perfectionism and prevalence of impostor phenomenon, b) to assess the relationship between perfectionism, impostor phenomenon, and mental health, and c) explore how medical culture may influence these personality characteristics.

METHODS

A narrative literature review was conducted. Search terms were entered into PubMed, PsychINFO, Web of Science, EMBASE, and Google Scholar without date or geographic restrictions. The McMaster Critical Review Forms for Quantitative and Qualitative Studies were used for article appraisal. Final decisions on inclusion and exclusion were reached through discussion. Sixteen articles were included in this review and summarized in a data extraction table.

RESULTS

Medical students had similar perfectionism scores to other student groups but scored lower in maladaptive perfectionism. The overall prevalence of the impostor phenomenon ranged from 22.5% to 46.6%. More females (41% - 52%) experienced clinical levels of impostor phenomenon compared to males (23.7% - 48%). Most studies did not find an association between the impostor phenomenon and academic year of training. Both personality characteristics were associated with negative mental health effects. Medical culture can train for and/or exacerbate these characteristics, affecting professional identity formation. Both characteristics contribute to distress for learners during commonly-used teaching methods in medical education.

CONCLUSIONS

Comprehensive changes in medical education that consider the relationship between medical culture, professional identity formation, impostor phenomenon, and perfectionism are needed. Longitudinal studies will help identify the implications of these findings for professional identity formation and medical education.

Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified

BACKGROUND

Improving Access to Psychological Therapies is a UK Government funded initiative to widen access to psychological treatment for a range of common mental health complaints, such as depression and anxiety. More recently, the service has begun to treat patients with medically unexplained symptoms. This paper reports on a review of treatment protocols and early treatment data for medically unexplained symptoms, specifically the illness myalgic encephalomyelitis/chronic fatigue syndrome.

MAIN TEXT

A series of seven core problems and failings are identified, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment.

CONCLUSIONS

There is a pressing need for independent oversight of this service, specifically evaluation of service performance and methods used to collect and report treatment outcomes. This service offers uniform psycho-behavioural therapy that may not meet the needs of many patients with medically unexplained health complaints. Psychotherapy should not become a default when patients' physical symptoms remain unexplained, and patients should be fully informed of the rationale behind psychotherapy, before agreeing to take part. Patients who reject psychotherapy or do not meet selection criteria should be offered appropriate medical and psychological support.

Perfectionism and beliefs about emotions in adolescents with chronic fatigue syndrome and their parents: a preliminary investigation in a case control study nested within a cohort

Objectives: To investigate perfectionism and beliefs about emotions in adolescents with chronic fatigue syndrome (CFS) and their parents. Design: Case-control comparing adolescents (age 11-18) with CFS (N = 121), asthma (N = 27) and healthy controls (N = 78) with a 3-month follow up for CFS participants. Main outcome measures: Adolescents: Chalder Fatigue Questionnaire, physical functioning, Beliefs about Emotions scale (BES), Child and Adolescent Perfectionism Scale, Frost Multidimensional Perfectionism Scale (FMPS). Parents: BES, FMPS, Self-sacrificing scale, Affective styles questionnaire. Results: Adolescents with CFS did not consistently report higher levels of perfectionism and unhelpful beliefs about emotions than adolescents with asthma or healthy adolescents. Mothers' and adolescents' beliefs about emotions and unhelpful perfectionism were significantly associated (p = .007). Linear regression found that neither adolescent perfectionism nor beliefs about emotions accounted for variance in subsequent fatigue or physical functioning. Conclusion: Parental perfectionism and emotion regulation style may contribute to perfectionism in adolescents with CFS. Parental representations could contribute to fatigue maintenance.

Myalgic encephalomyelitis/chronic fatigue syndrome and the biopsychosocial model: a review of patient harm and distress in the medical encounter

Objective: Despite the growing evidence of physiological and cellular abnormalities in myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS), there has been a strong impetus to tackle the illness utilizing a biopsychosocial model. However, many sufferers of this disabling condition report distress and dissatisfaction following medical encounters. This review seeks to account for this discord.Methods: A narrative review methodology is employed to synthesize the evidence for potential iatrogenesis.Results: We identify seven potential modalities of iatrogenesis or harm reported by patients:difficulties in reaching an acceptable diagnosis;misdiagnosis, including of other medical and psychological conditions;difficulties in accessing the sick role, medical care and social support;high levels of patient dissatisfaction with the quality of medical care;negative responses to controversial therapies (cognitive behavioral therapy and graded exercise therapy);challenges to the patient narrative and experience;psychological harm (individual and collective distress).Conclusion: The biopsychosocial framework currently applied to ME/CFS is too narrow in focus and fails to adequately incorporate the patient narrative. Misdiagnosis, conflict, and harm are observable outcomes where doctors' and patients' perspectives remain incongruent. Biopsychosocial practices should be scrutinized for potential harms. Clinicians should consider adopting alternative patient-centred approaches.Implications for rehabilitationPatients with ME/CFS may report or experience one or more of the modalities of harms and distress identified in this review.It is important health and rehabilitation professionals seek to avoid and minimize harms when treating or assisting ME/CFS patients.There are conflicting models of ME/CFS; we highlight two divergent models, a biopsychosocial model and a biomedical model that is preferred by patients.The 'biopsychosocial framework' applied in clinical practice promotes treatments such as cognitive behavioral therapy and exercise therapy, however, the evidence for their success is contested and many patients reject the notion their illness is perpetuated by dysfunctional beliefs, personality traits, or behaviors.Health professionals may avoid conflict and harm causation in ME/CFS by adopting more concordant 'patient-centred' approaches that give greater prominence to the patient narrative and experience of illness.

A psychosocial intervention for the management of functional dysphonia: complex intervention development and pilot randomised trial

BACKGROUND

Medically unexplained loss or alteration of voice-functional dysphonia-is the commonest presentation to speech and language therapists (SLTs). Besides the impact on personal and work life, functional dysphonia is also associated with increased levels of anxiety and depression and poor general health. Voice therapy delivered by SLTs improves voice but not these associated symptoms. The aims of this research were the systematic development of a complex intervention to improve the treatment of functional dysphonia, and the trialling of this intervention for feasibility and acceptability to SLTs and patients in a randomised pilot study.

METHODS

A theoretical model of medically unexplained symptoms (MUS) was elaborated through literature review and synthesis. This was initially applied as an assessment format in a series of patient interviews. Data from this stage and a small consecutive cohort study were used to design and refine a brief cognitive behavioural therapy (CBT) training intervention for a SLT. This was then implemented in an external pilot patient randomised trial where one SLT delivered standard voice therapy or voice therapy plus CBT to 74 patients. The primary outcomes were of the acceptability of the intervention to patients and the SLT, and the feasibility of changing the SLT's clinical practice through a brief training. This was measured through monitoring treatment flow and through structured analysis of the content of intervention for treatment fidelity and inter-treatment contamination.

RESULTS

As measured by treatment flow, the intervention was as acceptable as standard voice therapy to patients. Analysis of treatment content showed that the SLT was able to conduct a complex CBT formulation and deliver novel treatment strategies for fatigue, sleep, anxiety and depression in the majority of patients. On pre-post measures of voice and quality of life, patients in both treatment arms improved.

CONCLUSION

These interventions were acceptable to patients. Emotional and psychosocial issues presented routinely in the study patient group and CBT techniques were used, deliberately and inadvertently, in both treatment arms. This CBT "contamination" of the voice therapy only arm reflects the chief limitation of the study: one therapist delivered both treatments.

TRIAL REGISTRATION

Registered with the ISRCTN under the title: Training a Speech and Language Therapist in Cognitive Behavioural Therapy to treat Functional Dysphonia - A Randomised Controlled Trial.Trial Identifier: ISRCTN20582523 Registered 19/05/2010; retrospectively registered. http://www.isrctn.com/ISRCTN20582523.

Chronic Fatigue Syndrome: Cognitive, Behavioural and Emotional Processing Vulnerability Factors

BACKGROUND

Cognitive-behavioural models of chronic fatigue syndrome (CFS) suggest that personality factors such as perfectionism and high moral standards may contribute to the development of CFS.

AIMS

To investigate cognitive, behavioural and emotional processing risk factors for CFS.

METHOD

CFS patients (n = 67) at a UK specialist clinic completed questionnaires about psychological characteristics both currently and retrospectively (6 months pre-CFS onset). Responses were compared with those of healthy individuals (n = 73) who rated their current characteristics. Forty-four relatives retrospectively rated the pre-morbid psychological characteristics of the CFS participants.

RESULTS

CFS patients showed similar levels of current perfectionism to controls, though higher pre-morbid perfectionism. CFS patients showed greater self-sacrificial beliefs and more unhelpful beliefs about experiencing and expressing negative emotions, both currently but more markedly prior to onset. In the 6 months pre-illness onset, CFS patients showed more disruption to their primary goal and greater general stress than controls. Ratings of pre-morbid psychological characteristics by relatives were consistent with patients' self-reports. The extent of overinvestment in one goal was significantly associated with fatigue.

CONCLUSIONS

Perfectionism, self-sacrificial tendencies, unhelpful beliefs about emotions, and perceived stress may be present to a greater extent pre-morbidly in CFS patients compared with healthy individuals.

Factors determining fatigue in the chronic fatigue syndrome: a path analysis

OBJECTIVES

To explore the interrelationship of different dimensions (fatigue, neuroticism, sleep quality, global mental and physical health) in patients with chronic fatigue syndrome (CFS).

METHODS

Patients meeting the Fukuda criteria of CFS filled out two independent fatigue scales (Fatigue Questionnaire, FQ and Checklist Individual Strength, CIS), NEO-Five Factor Inventory (NEO-FFI), Pittsburgh Sleep Quality Index (PSQI) and Medical Outcomes Study 36-item Short Form Health Survey (SF36). Exploratory and confirmatory path analyses were performed.

RESULTS

Out of 226 eligible patients, 167 subjects were included (mean age 39.13 years, SD 10.14, 92% female). In a first exploratory path analysis, using FQ for assessment of fatigue, night-time PSQI sleep quality had a direct effect on SF36 physical quality of life (PQoL) and no effect on FQ fatigue. This was confirmed by a subsequent path analysis with CIS fatigue and by confirmatory path analyses in 81 patients. These unexpected results raised the question whether FQ or CIS fatigue sufficiently operationalizes fatigue in CFS patients.

CONCLUSIONS

Poor sleep quality seems to directly impact on mental quality of life (MQoL) and PQoL without mediation of fatigue assessed with FQ and CIS. A more cohesive framework needs to be developed with more comprehensive clinical tools for the different dimensions in the construct of CFS.

Cortisol output in adolescents with chronic fatigue syndrome: pilot study on the comparison with healthy adolescents and change after cognitive behavioural guided self-help treatment

OBJECTIVE

This study examined cortisol in adolescents with chronic fatigue syndrome (CFS) compared to healthy adolescents and changes in cortisol after cognitive behavioural guided self-help treatment. Exploratory analyses investigated the association between cortisol output and psychological variables.

METHODS

Salivary cortisol was measured upon awakening, at 15, 30, 45 and 60 min afterwards and at 12 noon, 4:00 p.m. and 8:00 p.m., in adolescents with CFS and healthy controls (HC). Groups were matched for age, gender, menarche status, menstrual cycle and awakening time. Twenty-four adolescents with CFS provided saliva samples six months after treatment. The main outcome measure was total salivary output over the day, calculated by area under the curve (AUC). The salivary awakening response was also assessed.

RESULTS

Cortisol output over the day was significantly lower in the CFS group (n=46) than in healthy controls (n=33). Within the CFS group, lower daily cortisol output was associated with higher self-reported perfectionist striving and prosocial behaviour. There were no significant group differences in the awakening response (n=47 CFS versus n=34 HC). After treatment, adolescents with CFS (n=21) showed a significant increase in daily cortisol output, up to normal levels.

CONCLUSION

The reduced daily cortisol output in adolescents with CFS is in line with adult findings. Associations between reduced cortisol output and two psychological variables-perfectionism and prosocial behaviour-are consistent with cognitive behavioural models of chronic fatigue syndrome. The mild hypocortisolism is reversible; cortisol output had returned to healthy adolescent levels by six months after cognitive behavioural guided self-help treatment.

Chronic fatigue syndrome and personality: a case-control study using the Alternative Five Factor Model

Neuroticism is the personality dimension most frequently associated with chronic fatigue syndrome (CFS). Most studies have also shown that CFS patients are less extraverted than non-CFS patients, but results have been inconsistent, possibly because the facets of the extraversion dimension have not been separately analyzed. This study has the following aims: to assess the personality profile of adults with CFS using the Alternative Five-Factor Model (AFFM), which considers Activity and Sociability as two separate factors of Extraversion, and to test the discriminant validity of a measure of the AFFM, the Zuckerman-Kuhlman Personality Questionnaire, in differentiating CFS subjects from normal-range matched controls. The CFS sample consisted of 132 consecutive patients referred for persistent fatigue or pain to the Department of Medicine of a university hospital. These were compared with 132 matched normal population controls. Significantly lower levels of Activity and significantly higher levels of Neuroticism-Anxiety best discriminated CFS patients from controls. The results are consistent with existing data on the relationship between Neuroticism and CFS, and clarify the relationship between Extraversion and CFS by providing new data on the relationship of Activity to CFS.

Experiences of daily activity in chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) and their implications for rehabilitation programmes

PURPOSE

Chronic Fatigue Syndrome, also known as Myalgic Encephalomyelitis (CFS/ME), has a significant impact upon daily functioning. Most recommended treatments aim to alter activity patterns based upon assumptions of activity avoidance. However, as there is limited research on the experience of activity and occupational beliefs in people with CFS/ME, this study took a qualitative approach to understand the meaning of activity in people with this disabling condition.

METHOD

This study applied a social constructivist grounded theory methodology. Semi-structured interviews took place with 14 participants attending a Specialist CFS/ME Service in England.

FINDINGS

The emergent themes described a premorbid state of constant action with difficulty stopping an activity once it had commenced. When this pattern was interrupted by illness, participants attempted to maintain their previous level of occupational engagement. Negative associations and emotions were described in response to the concept of doing nothing or limited activity. A recurring cycle was reported of increasing activity levels when symptoms improved, followed by post exertional symptoms.

CONCLUSIONS

Consequently, participants' beliefs about concepts of both activity and inactivity need to be considered within the application of rehabilitation programmes for CFS/ME that aim to modify activity related behaviours.

IMPLICATIONS FOR REHABILITATION

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is commonly treated in the UK using activity modification. In this small qualitative study, patients expressed negative feelings and beliefs towards the concept of doing nothing and therefore sought to push their activity levels when this was available, leading to recurring cycles of symptoms and activity. Rehabilitation programmes need to consider how people with CFS/ME engaged with activity and inactivity before the condition and how this may impact upon engagement with activity-based rehabilitation programmes.

The role of neuroticism, perfectionism and depression in chronic fatigue syndrome. A structural equation modeling approach

OBJECTIVE

Previous studies have reported consistent associations between Neuroticism, maladaptive perfectionism and depression with severity of fatigue in Chronic Fatigue Syndrome (CFS). Depression has been considered a mediator factor between maladaptive perfectionism and fatigue severity, but no studies have explored the role of neuroticism in a comparable theoretical framework. This study aims to examine for the first time, the role of neuroticism, maladaptive perfectionism and depression on the severity of CFS, analyzing several explanation models.

METHODS

A sample of 229 CFS patients were studied comparing four structural equation models, testing the role of mediation effect of depression severity in the association of Neuroticism and/or Maladaptive perfectionism on fatigue severity.

RESULTS

The model considering depression severity as mediator factor between Neuroticism and fatigue severity is the only one of the explored models where all the structural modeling indexes have fitted satisfactorily (Chi square=27.01, p=0.079; RMSE=0.047, CFI=0.994; SRMR=0.033). Neuroticism is associated with CFS by the mediation effect of depression severity. This personality variable constitutes a more consistent factor than maladaptive perfectionism in the conceptualization of CFS severity.

The process of cognitive behaviour therapy for chronic fatigue syndrome: which changes in perpetuating cognitions and behaviour are related to a reduction in fatigue?

OBJECTIVE

Cognitive behaviour therapy (CBT) can significantly reduce fatigue in chronic fatigue syndrome (CFS), but little is known about the process of change taking place during CBT. Based on a recent treatment model (Wiborg et al. J Psych Res 2012), we examined how (changes in) cognitions and behaviour are related to the decrease in fatigue.

METHODS

We included 183 patients meeting the US Centers for Disease Control criteria for CFS, aged 18 to 65 years, starting CBT. We measured fatigue and possible process variables before treatment; after 6, 12 and 18 weeks; and after treatment. Possible process variables were sense of control over fatigue, focusing on symptoms, self-reported physical functioning, perceived physical activity and objective (actigraphic) physical activity. We built multiple regression models, explaining levels of fatigue during therapy by (changes in) proposed process variables.

RESULTS

We observed large individual variation in the patterns of change in fatigue and process variables during CBT for CFS. Increases in the sense of control over fatigue, perceived activity and self-reported physical functioning, and decreases in focusing on symptoms explained 20 to 46% of the variance in fatigue. An increase in objective activity was not a process variable.

CONCLUSION

A change in cognitive factors seems to be related to the decrease in fatigue during CBT for CFS. The pattern of change varies considerably between patients, but changes in process variables and fatigue occur mostly in the same period.

Are there sleep-specific phenotypes in patients with chronic fatigue syndrome? A cross-sectional polysomnography analysis

OBJECTIVES

Despite sleep disturbances being a central complaint in patients with chronic fatigue syndrome (CFS), evidence of objective sleep abnormalities from over 30 studies is inconsistent. The present study aimed to identify whether sleep-specific phenotypes exist in CFS and explore objective characteristics that could differentiate phenotypes, while also being relevant to routine clinical practice.

DESIGN

A cross-sectional, single-site study.

SETTING

A fatigue clinic in the Netherlands.

PARTICIPANTS

A consecutive series of 343 patients meeting the criteria for CFS, according to the Fukuda definition.

MEASURES

Patients underwent a single night of polysomnography (all-night recording of EEG, electromyography, electrooculography, ECG and respiration) that was hand-scored by a researcher blind to diagnosis and patient history.

RESULTS

Of the 343 patients, 104 (30.3%) were identified with a Primary Sleep Disorder explaining their diagnosis. A hierarchical cluster analysis on the remaining 239 patients resulted in four sleep phenotypes being identified at saturation. Of the 239 patients, 89.1% met quantitative criteria for at least one objective sleep problem. A one-way analysis of variance confirmed distinct sleep profiles for each sleep phenotype. Relatively longer sleep onset latencies, longer Rapid Eye Movement (REM) latencies and smaller percentages of both stage 2 and REM characterised the first phenotype. The second phenotype was characterised by more frequent arousals per hour. The third phenotype was characterised by a longer Total Sleep Time, shorter REM Latencies, and a higher percentage of REM and lower percentage of wake time. The final phenotype had the shortest Total Sleep Time and the highest percentage of wake time and wake after sleep onset.

CONCLUSIONS

The results highlight the need to routinely screen for Primary Sleep Disorders in clinical practice and tailor sleep interventions, based on phenotype, to patients presenting with CFS. The results are discussed in terms of matching patients' self-reported sleep to these phenotypes in clinical practice.

The relationship between perfectionism and engagement in preventive health behaviours: the mediating role of self-concealment

If perfectionists avoid engaging in preventive health behaviours, they may be putting their long-term health and well-being at risk. Correlational analyses based on a sample of 370 university students identified maladaptive perfectionism to be associated with decreased levels of engagement in preventive health behaviours, life satisfaction and well-being and increased levels of self-concealment and psychological distress. Adaptive perfectionism was associated with higher levels of engagement in preventive health behaviours. Self-concealment was identified as a partial mediator in the relationship between maladaptive perfectionism and both engagement in preventive health behaviours and psychological distress. Implications of the findings are discussed.

Self-critical perfectionism and its relationship to fatigue and pain in the daily flow of life in patients with chronic fatigue syndrome

BACKGROUND

Research suggests that the personality factor of self-critical or maladaptive perfectionism may be implicated in chronic fatigue syndrome (CFS). However, it is not clear whether self-critical perfectionism (SCP) also predicts daily symptoms in CFS. Method In the present study we investigated whether SCP predicted fatigue and pain over a 14-day period in a sample of 90 CFS patients using a diary method approach. After completing the Depressive Experiences Questionnaire (DEQ) as a measure of SCP, patients were asked each day for 14 days to complete Visual Analogue Scales (VAS) of fatigue, pain and severity of depression. Data were analysed using multilevel analysis.

RESULTS

The results from unconditional models revealed considerable fluctuations in fatigue over the 14 days, suggesting strong temporal variability in fatigue. By contrast, pain was relatively stable over time but showed significant inter-individual differences. Congruent with expectations, fixed-effect models showed that SCP was prospectively associated with higher daily fatigue and pain levels over the 14-day period, even after controlling for levels of depression.

CONCLUSIONS

This is the first study to show that SCP predicts both fatigue and pain symptoms in CFS in the daily course of life. Hence, therapeutic interventions aimed at targeting SCP should be considered in the treatment of CFS patients with such features.

Chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is an illness characterized by disabling fatigue of at least 6 months. The aetiology of the condition has been hotly debated. In this chapter the evidence for CFS as a post viral condition and/or a neurological condition is reviewed. Although there is evidence that CFS is triggered by certain viruses in some patients and that neurobiological changes such as hypocortisolism are associated with the syndrome, neither mechanism is sufficient to explain the extent of the symptoms or disability experienced by patients. It is unlikely that CFS can be understood through one aetiological mechanisms. Rather it is a complex illness which is best explained in terms of a multifactorial cognitive behavioural model. This model proposes that CFS is precipitated by life events and/or viral illness in vulnerable individuals, such as those who are genetically predisposed, prone to distress, high achievement, and over or under activity. A self perpetuating cycle where physiological changes, illness beliefs, reduced and inconsistent activity, sleep disturbance, medical uncertainty and lack of guidance interact to maintain symptoms. Treatments based on this model including cognitive behavioural therapy and graded exercise therapy are effective at significantly reducing fatigue and disability in CFS. This chapter provides a description of these approaches and details of the trials conducted in the area.

Is there a perfectionist in each of us? An experimental study on perfectionism and eating disorder symptoms

Previous studies have shown consistent associations between perfectionism and eating disorder (ED) symptoms. However, to date, only one study (Shafran et al., 2006) used an experimental design to examine in a non-clinical sample the causal relationship between perfectionism and ED symptoms. The current experimental study aimed to build on that study by examining the role of trait perfectionism in the effects of an experimental induction of perfectionism and by adopting a multidimensional approach to perfectionism. University students (N=100; Mage=20.6 years; SD=2.24) were randomly assigned to one of three experimental conditions, that is, a high Personal Standards condition, a condition combining Personal Standards perfectionism and Evaluative Concerns perfectionism, and a non-perfectionist condition. Compared to the non-perfectionist condition, participants in the two perfectionist conditions reported higher levels of state perfectionism during the next 24 h and this effect occurred irrespective of trait perfectionism levels. Further, participants in the perfectionist conditions, compared to those in the non-perfectionist condition, reported significantly higher levels of restraint and binging during the 24 h after manipulation. Together, the results suggest that perfectionism can be induced in people irrespective of their levels of trait perfectionism and that perfectionism represents a causal risk factor for ED pathology.

Personality and fatigue perception in a sample of IBD outpatients in remission: a preliminary study

BACKGROUND AND AIMS

Fatigue is considered as a feature of IBD. Nevertheless, medical variables would partly explain this complex phenomenon. Psychological variables would be especially connected to fatigue for patients in remission. Moreover, personality is known to be linked to the fatigue of patients with CFS. This preliminary study aimed to determine if personality dimensions are linked to the perception of fatigue in IBD.

METHODS

81 IBD outpatients in remission completed the MFI (fatigue); ISI, EES (sleep disturbances); TCI-R (personality); HADS (depression and anxiety). Medical data were collected (ferritin, C-reactive protein, number of flare-ups, number of hospitalizations, duration of the disease and surgical sequelae).

RESULTS

With the exception of surgical sequelae, none of the medical variables was linked to fatigue perception. Anxiety and sleep disturbances were the most continuously connected to fatigue perception. Significant relationships were observed between personality categorization on Persistence, Self-Directness and the level of fatigue.

CONCLUSION

In order to improve vitality in IBD patients in remission, identification and treatment of psychological aspects should become a dimension of disease management. Fatigue should not be considered only as a direct feature of IBD.

Post-inflammatory fatigue in sarcoidosis: personality profiles, psychological symptoms and stress hormones

OBJECTIVES

Chronic fatigue following inflammatory diseases has been well documented. However, little is known about possible risk factors of chronic post-inflammatory fatigue. The aim of this study was to investigate whether chronic post-inflammatory fatigue after clinical remission of the disease sarcoidosis is associated with specific dimensions of personality, psychological symptoms and baseline levels of stress hormones.

METHODS

Thirty-seven non-fatigued and 33 fatigued patients in clinical remission of sarcoidosis were evaluated with the Temperament and Character Inventory-short form (TCI); the Symptom CheckList-90 (SCL), and the Checklist Individual Strength (CIS). Baseline levels of ACTH and cortisol were measured in plasma. Principal component analysis with orthogonal rotation (varimax) was conducted on all personality, psychological and stress hormone data in order to obtain a smaller set of components. Logistic regression was performed to associate these components with chronic post-inflammatory fatigue.

RESULTS

Principal component analyses identified 5 components, of which two components were significantly associated with chronic post-inflammatory fatigue. The first component comprised the personality trait Harm Avoidance and all SCL-subscales except Sleep. The second component consisted of baseline levels ACTH and cortisol, and showed an inverse association with chronic post-inflammatory fatigue. The 3 other components, consisting of respectively SCL-Sleep, TCI-Novelty Seeking-Reward Dependence-Self Transcendence, and TCI-Persistence, were not significantly associated with chronic fatigue.

CONCLUSION

Chronic post-inflammatory fatigue after clinical remission of sarcoidosis is associated with a triad of risk factors: a specific personality profile with profound neurotic characteristics in combination with high levels of psychological distress, and decreased baseline ACTH/cortisol levels.

The role of acceptance in chronic fatigue syndrome

OBJECTIVE

In this paper we consider the role that acceptance plays in fatigue and physical and social functioning. We predicted that lack of acceptance would be positively correlated with fatigue and impairment in functioning; that there would be a significant relationship between perfectionism and acceptance; and cognitive behavioural therapy (CBT) would increase acceptance.

METHODS

Two hundred and fifty nine patients with chronic fatigue syndrome (CFS) completed questionnaires measuring fatigue, physical functioning, work and social adjustment, lack of acceptance, perfectionism and depression. Ninety consecutive attenders received a course of CBT and completed further questionnaires at discharge and 3months post-treatment. Correlations and multiple hierarchical regressions were used to determine relationships between acceptance, perfectionism and clinical outcome variables.

RESULTS

At baseline, lack of acceptance was the key factor associated with impaired physical functioning and work and social adjustment. Lack of acceptance and doubts about actions were associated with fatigue in a multiple regression analysis. At discharge and follow-up patients showed significantly increased acceptance, as well as reduced Concern over Mistakes, less fatigue and impairment of physical functioning, and improved work and social adjustment.

CONCLUSION

This is the first study to our knowledge which shows a change in acceptance after CBT and a relationship between acceptance and perfectionism. Acceptance may be an important factor to consider within treatments for CFS.

Developing a web-based stress management intervention for occupational support workers

BACKGROUND

Occupational support workers in the mental healthcare sector are exposed to considerable occupational stress and have little access to stress management facilities.

AIMS

This article describes the process behind creating a web-based stress management intervention (SMI) for occupational support workers in the mental healthcare sector.

METHOD

Mixed methods were used to inform the content of the web-based SMI, following MRC strategy for designing interventions and PRIMA-EF guidelines for best practice in SMI design. We conducted a literature review to ascertain the content of interventions that had been shown to be successful in reducing stress in mental healthcare populations. In addition, we conducted focus groups in order to assess specific stressors that individuals in the occupational support sector deemed to be important.

RESULTS

The literature review showed that a variety of methods had been successful for reducing occupational stress in the mental healthcare sector including: Relaxation and Cognitive Behavioural Therapy techniques, and skills training in; time management, problem-solving and communication. Individuals in the focus groups identified both personal and organisational stressors to be addressed in the intervention.

CONCLUSIONS

This intervention was developed with reference to a design strategy, using input from the target population.

Self-esteem mediates the relationship between maladaptive perfectionism and depression in chronic fatigue syndrome

Patients with chronic fatigue syndrome (CFS) often experience depression which may negatively affect prognosis and treatment outcome. Research has shown that depression in CFS is associated with maladaptive or self-critical perfectionism. However, currently, little is known about factors that may explain this relationship, but studies in nonclinical samples suggest that low self-esteem may be an important mediator of this relationship. The present study therefore examined whether self-esteem mediated the cross-sectional association between maladaptive perfectionism and severity of depression in 192 patients meeting Centres for Disease Control and Prevention criteria for CFS. Patients completed self-report measures of maladaptive perfectionism, self-esteem, depression, and fatigue. Regression analyses and more direct tests of indirect effects (i.e., the Sobel test and bootstrapping) were used to test for mediation. Congruent with expectations, we found that self-esteem fully mediated the relationship between maladaptive perfectionism and depression in CFS. Findings from this study suggest that self-esteem may explain the link between maladaptive perfectionism and depression in CFS, which may have important implications for the treatment and prevention of depression in these patients.

Unraveling the role of perfectionism in chronic fatigue syndrome: is there a distinction between adaptive and maladaptive perfectionism?

In the current study, we investigated whether the distinction between adaptive (i.e. high personal standards) and maladaptive (i.e. concern over mistakes and doubt about actions) perfectionism that has been found in the literature, is also valid in patients with chronic fatigue syndrome (CFS). We hypothesized that maladaptive, but not adaptive, perfectionism would be significantly and positively related to severity of fatigue and depression in CFS. We examined this hypothesis in a sample of 192 CFS patients using structural equation modelling (SEM). Although the two perfectionism dimensions were related to each other, results supported a model in which only maladaptive perfectionism was positively related to severity of fatigue and depression. Further, we found that depression fully mediated the effect of maladaptive perfectionism on fatigue. The results suggest that adaptive and maladaptive perfectionism are two distinct, albeit related, dimensions in CFS. Findings of this study have important implications for theory and treatment of CFS, particularly for cognitive-behavioral treatment.

Relationship between Fatigue, Perfectionism, and Functional Dysphonia

Objectives. Increased levels of fatigue and perfectionism were noted during evaluation of cognitive behavioral therapy for the treatment of functional dysphonia. The investigators thus aimed to explore levels of general fatigue and perfectionism in patients with functional dysphonia and controls.

Study design. Case-control study.

Setting. Teaching hospital, United Kingdom.

Subjects and Methods. Patients recruited through speech therapy were asked to recruit a friend as a control, of the same sex and within 5 years of their age. An 11-point fatigue questionnaire, previously validated on a normal population, was analyzed using both Likert (0123) and bimodal (0011) systems, with a score greater than 4 on the bimodal system implying substantial fatigue. A 35-point perfectionism questionnaire was also completed and analyzed for “healthy” and “unhealthy” perfectionist traits.

Results. There were 75 cases and 62 controls. The mean fatigue score in patients with functional dysphonia was 17.0 and 14.4 for the controls (Likert, P = .009). Under the bimodal scoring system, the mean fatigue scores in functional dysphonia (5.10) and controls (3.01) were also significantly different ( P = .003). The mean perfectionism scores were 98.9 for patients with functional dysphonia and 91.2 for controls ( P = 0.043).

Conclusions. To the investigators’ knowledge, this is the first substantial report that fatigue and perfectionism scores are significantly elevated in functional dysphonia. Functional dysphonia is shown to be analogous to other medically unexplained physical symptoms that are also marked by generic somatopsychic distress and for which multiple factors are implicated in their onset and maintenance. This has implications for both research and treatment.