Comparing the dis with the scid: Chronic fatigue syndrome and psychiatric comorbidity

Group Intervention Involving a Client With Chronic Fatigue Syndrome

The following case study outlines results from the assessment and treatment of a 32-year-old African American woman with chronic fatigue syndrome. The case history describes a client who is demoralized as a result of having endured worsening symptomatology for the past 3 years with little help from the health care professionals she has consulted. Following evaluation, the client completed a series of eight empowermentoriented, peer counseling groups. Central issues addressed in treatment included issues surrounding expectations fromhealth care providers, issues of denial versus acceptance, identity integration, and irregular patterns of activity. The case study demonstrates the necessity for an individualized and integrative approach to treatment that addresses both medical and psychological aspects of the illness. Findings indicated that a peer-facilitated group therapy intervention was effective in enabling the client to educate herself and gain some acceptance of her condition, modify negative fatigue-related cognitions, improve self-care, and regulate her activity levels.

Coping and Occupational Participation in Chronic Fatigue Syndrome

Existing studies have shown that individuals with chronic fatigue syndrome demonstrate functional impairment in several domains related to occupational participation. Researchers have not yet explored whether coping styles may be associated with occupational participation in individuals with this condition. The aim of this study was to examine the effects of coping styles on occupational participation among adults with chronic fatigue syndrome. The authors hypothesized that occupational participation would be associated with coping strategies oriented toward information seeking and maintaining activity, and that this relationship would endure despite individual differences in illness severity. The study used a cross-sectional design to describe the associations between coping and occupational participation for 47 individuals diagnosed as having chronic fatigue syndrome. Findings from linear regression analysis revealed that the coping style of maintaining activity was positively associated with occupational participation, whereas illness accommodation was negatively associated. Implications of the findings for continued research and clinical practice in occupational therapy are discussed.

Sub-typing daily fatigue progression in chronic fatigue syndrome

BACKGROUND

Activity logs involve patients writing down their activities and symptoms over 1 or more days. Aims This study sought to classify daily fatigue patterns among patients with chronic fatigue syndrome (CFS) using activity logs.

METHOD

Fatigue intensity was self-reported every 30 min in a sample of 90 patients with CFS over 1 day. A cluster analysis using fatigue intensity, variability and slope was conducted.

RESULTS

Three clusters emerged involving patients with different trajectories. One group evidenced high fatigue intensity, low variability, and fatigue intensity stayed the same over time. A second group had moderate fatigue intensity, high variability, and fatigue intensity decreased over time. A third group had moderate fatigue intensity, high variability, but fatigue intensity increased over time. The three clusters of patients differed on measures of actigraphy, pain and immune functioning.

CONCLUSIONS

Activity logs can provide investigators and clinicians with valuable sources of data for understanding patterns of fatigue and activity among patients with CFS.

Contrasting case definitions for chronic fatigue syndrome, Myalgic Encephalomyelitis/chronic fatigue syndrome and myalgic encephalomyelitis

This article uses data from patients recruited using the 1994 case definition of chronic fatigue syndrome (CFS) to contrast those meeting criteria for the Myalgic Encephalomyelitis/chronic fatigue syndrome (ME/CFS) Canadian case definition with those that did not meet these criteria. The study also contrasts those meeting criteria for Myalgic Encephalomyelitis (ME) based on criteria from Ramsay and other theorists with those that did not meet the ME criteria. The ME/CFS case definition criteria identified a subset of patients with more functional impairments and physical, mental, and cognitive problems than the subset not meeting these criteria. The ME subset had more functional impairments, and more severe physical and cognitive symptoms than the subset not meeting ME criteria. When applied to a population meeting the 1994 CFS case definition, both ME/CFS and ME criteria appear to select a more severe subset of patients.

Factor analysis of the Beck Depression Inventory-II with patients with chronic fatigue syndrome

This study examined the properties of the Beck Depression Inventory-II (BDI-II) in a sample of 111 patients with chronic fatigue syndrome (CFS). Exploratory factor analysis identified two factors. The mean score for the Somatic-Affective factor was significantly higher than the Cognitive factor. Convergent and discriminant validity were assessed for BDI-II total score, the two factor scores, and the BDI for Primary Care (BDI-PC). The BDI-PC and Cognitive factor demonstrated superior validity. Results suggest patients endorse BDI-II somatic items that overlap with CFS symptoms at a high rate. Factor scores should be evaluated separately, or the BDI-PC should be utilized with this population.

Data mining: comparing the empiric CFS to the Canadian ME/CFS case definition

This article contrasts two case definitions for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). We compared the empiric CFS case definition (Reeves et al., 2005) and the Canadian ME/CFS clinical case definition (Carruthers et al., 2003) with a sample of individuals with CFS versus those without. Data mining with decision trees was used to identify the best items to identify patients with CFS. Data mining is a statistical technique that was used to help determine which of the survey questions were most effective for accurately classifying cases. The empiric criteria identified about 79% of patients with CFS and the Canadian criteria identified 87% of patients. Items identified by the Canadian criteria had more construct validity. The implications of these findings are discussed.

The relationship of Fennell phases to symptoms among patients with chronic fatigue syndrome

The Fennell Phase Inventory (FPI) is an instrument designed to measure phases of the illnesses known as Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). The current study explored how the FPI was related to physical and psychological functioning as well as coping style. Based on FPI scores, 111 adults with ME/CFS were placed in one of three groups: crisis, stabilization, or resolution. Results showed that the crisis group demonstrated significantly worse functioning than at least one other group for depression, quality of life, mental functioning, anxiety, and self-efficacy; and utilized less adaptive coping styles. These results indicate that patients with ME/CFS who are in the crisis phase tend to experience more severe psychological and physical symptoms and utilize poorer coping strategies. Those in the resolution phase maintain the most adaptive coping strategies. Implications for these findings are discussed.

A two-year follow-up study of chronic fatigue syndrome comorbid with psychiatric disorders

AIMS

Chronic fatigue syndrome patients often have comorbid psychiatric disorders such as major depressive disorders and anxiety disorders. However, the outcomes of chronic fatigue syndrome and the comorbid psychiatric disorders and the interactions between them are unknown. Therefore, a two-year prospective follow-up study was carried out on chronic fatigue syndrome patients with comorbid psychiatric disorders.

METHODS

A total of 155 patients who met the Japanese case definition of chronic fatigue syndrome were enrolled in this study. Comorbid psychiatric disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders 4th edition criteria. Patients with comorbid psychiatric disorders received psychiatric treatment in addition to medical therapy for chronic fatigue syndrome. Seventy patients participated in a follow-up interview approximately 24 months later.

RESULTS

Of the 70 patients with chronic fatigue syndrome, 33 patients were diagnosed as having comorbid psychiatric disorders including 18 major depressive disorders. Sixteen patients with psychiatric disorders and eight patients with major depressive disorders did not fulfill the criteria of any psychiatric disorders at the follow up. As for chronic fatigue syndrome, nine out of the 70 patients had recovered at the follow up. There is no significant influence of comorbid psychiatric disorders on the outcome of chronic fatigue syndrome.

CONCLUSIONS

Chronic fatigue syndrome patients have a relatively high prevalence of comorbid psychiatric disorders, especially major depressive disorders. The outcomes of chronic fatigue syndrome and psychiatric disorders are independent. Therefore treatment of comorbid psychiatric disorders is necessary in addition to the medical treatment given for chronic fatigue syndrome.

Longitudinal change in chronic fatigue syndrome: what home-based assessments reveal

The purpose of this 2-year prospective study was to compare standard self-report and ecologically-based outcome measures in patients with chronic fatigue syndrome (CFS). Standard measures assessed physical function, fatigue impact, psychological variables, and global impression of change ratings. Ecological measures included actigraphy, a structured activity record, and an electronic fatigue/energy diary. Results for this high functioning sample (N = 75) revealed that self-report global improvement was significantly associated with lower momentary fatigue and fatigue impact, and a higher frequency of standing up (at home), but not with actigraphy or psychological variables. However, actigraphy change was significantly correlated with change in self-report physical function. At follow-up, only a small minority (<20%) scored in the healthy adult range for fatigue impact and physical function. The findings suggest that home-based measures of symptom severity and physical functioning may provide evidence of change (or lack of change) that is important for interpreting standard self-report outcomes in CFS.

The associations between basal salivary cortisol and illness symptomatology in chronic fatigue syndrome

Hypocortisolism has been reported in chronic fatigue syndrome (CFS), with the significance of this finding to disease etiology unclear. This study examined cortisol levels and their relationships with symptoms in a group of 108 individuals with CFS. CFS symptoms examined included fatigue, pain, sleep difficulties, neurocognitive functioning, and psychiatric status. Alterations in cortisol levels were examined by calculation of mean daily cortisol, while temporal variation in cortisol function was examined by means of a regression slope. Additionally, deviation from expected cortisol diurnal pattern was determined via clinical judgment. Results indicated that fatigue and pain were associated with salivary cortisol levels. In particular, variance from the expected pattern of cortisol was associated with increased levels of fatigue. The implications of these findings are discussed.

CHRONIC FATIGUE SYNDROME AMONG NURSES AND HEALTHCARE WORKERS IN A RESEARCH HOSPITAL IN TURKEY

Chronic fatigue syndrome (CFS) among nurses and healthcare workers was evaluated via a questionnaire examining CFS, sociodemographic factors, lifestyle, work capacity and education. The criteria of the Centers for Disease Control were applied. One hundred and eighty-three nurses and 18 healthcare workers (mean age 29.04 ± 5.31 years) participated. More than half of cases (n = 116, 57.7%) complained of fatigue. Thirty-six cases (17.9%) fully matched the criteria of the CDC for CFS. High income level (> 400/month) (p = 0.005) and overworking (> 8 hr/day) (p = 0.017) had a significant effect on CFS [high income (OR: 9.60, CI, 95%: 1.98 – 46.54) and overworking (OR: 7.66, CI, 95%: 1.44 – 40.92), respectively]. CFS was also related to being under 35 years old.

The prevalence of chronic fatigue syndrome in Nigeria

The present study found adult rates of chronic fatigue syndrome (CFS) in Nigeria that were somewhat higher than rates from community-based CFS epidemiologic studies in the USA. The rates of chronic fatigue for both adults and children were also higher than in existing community-based studies. It is possible that the presence of several fatiguing illnesses such as malaria and typhoid, the lack of adequate healthcare resources and poverty in Nigeria, place individuals at greater risk for fatigue and its syndromes. There is a need for more epidemiologic studies on the prevalence and sociodemographic characteristics of CFS in developing countries.

Functioning in individuals with chronic fatigue syndrome: increased impairment with co-occurring multiple chemical sensitivity and fibromyalgia

BACKGROUND

Chronic fatigue syndrome (CFS), multiple chemical sensitivity (MCS), and fibromyalgia (FM) commonly co-occur. Some propose that CFS, MCS, and FM are manifestations of the same illness based on high rates of co-occurrence and overlapping diagnostic criteria. This study seeks to differentiate these diagnoses by comparing individuals with one or more illness on functioning, psychiatric comorbidity, coping style, and in vivo physical measures.

METHODS

Participants included 114 men and women who met criteria for CFS. FM was diagnosed during a physical examination, and MCS was assessed using a questionnaire. Participants were divided into four groups: CFS alone, CFS-MCS, CFS-FM, and CFS-MCS-FM. Self-report measures, a psychiatric interview, and in vivo physical measures were given.

RESULTS

43.9% met criteria for CFS alone, 23.7% met criteria for CFS-MCS, 15.8% met criteria for CFS-FM, and 16.7% met criteria for CFS-MCS-FM. The CFS-MCS-FM group was more disabled than the CFS alone group on measures of physical functioning, general health, and bodily pain. In vivo measures did not differ, but the CFS-MCS-FM group rated exertion higher than the CFS alone group.

CONCLUSION

Individuals with CFS alone were the highest functioning group across several domains, such as disability, depression, and severity of symptoms. Participants with three diagnoses experienced the greatest amount of disability. While substantial co-occurrence of these illnesses was found, this study provides evidence that having more than one illness exacerbates one's disability beyond CFS alone.

The validity of an empirical delineation of heterogeneity in chronic unexplained fatigue

OBJECTIVES

To validate a latent class structure derived empirically from a clinical data set obtained from persons with chronic medically unexplained fatigue.

METHODS

The strategies utilized in this validation study included: recalculating latent class analysis (LCA) results varying random seeds and the number of initial random starting sets; recalculating LCA results by substituting alternate variables to demonstrate a robust solution; determining the statistical significance of between-class differences on disability, fatigue and demographic measures omitted from the data set used for LCA; cross-classifying class membership using established Centers for Disease Control and Prevention (CDC) research criteria for chronic fatigue syndrome (CFS) to compare the relative proportions of subjects designated CFS, chronic fatigue (not CFS) or healthy controls captured by the latent classes.

RESULTS

Recalculation of results and substitution of variables for low-loading variables demonstrated a robust LCA result. Highly significant between-class differences were confirmed between Class 2 (well) and those interpreted as ill/fatigued. Analysis of between-class differences for the fatigue groups revealed significant differences for all disability and fatigue variables, but with equivalent levels of reported activity and reduction in motivation. Cross-classification against established CDC criteria demonstrated that 89% of subjects constituting Class 2 (well) were indeed nonfatigued controls. A general tendency for grouping CFS cases in the multiple symptomatic classes was noted.

CONCLUSION

This study established reasonably good validity for an empirically-derived latent class solution reflecting considerable heterogeneity among subjects with medically unexplained chronic fatigue. This work strengthens the growing understanding of CFS as a heterogeneous entity comprised of several conditions with different underlying pathophysiological mechanisms.

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.

Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution

Background

Chronic fatigue syndrome (CFS) is defined by symptoms and disability, has no confirmatory physical signs or characteristic laboratory abnormalities, and the etiology and pathophysiology remain unknown. Difficulties with accurate case ascertainment contribute to this ignorance.

Methods

Experienced investigators from around the world who are involved in CFS research met for a series of three day workshops in 2000, 2001 and 2002 intended to identify the problems in application of the current CFS case definition. The investigators were divided into focus groups and each group was charged with a topic. The investigators in each focus group relied on their own clinical and scientific knowledge, brainstorming within each group and with all investigators when focus group summaries were presented. Relevant literature was selected and reviewed independent of the workshops. The relevant literature was circulated via list-serves and resolved as being relevant by group consensus. Focus group reports were analyzed and compiled into the recommendations presented here.

Results

Ambiguities in the current CFS research definition that contribute to inconsistent case identification were identified. Recommendations for use of the definition, standardization of classification instruments and study design issues are presented that are intended to improve the precision of case ascertainment. The International CFS Study Group also identified ambiguities associated with exclusionary and comorbid conditions and reviewed the standardized, internationally applicable instruments used to measure symptoms, fatigue intensity and associated disability.

Conclusion

This paper provides an approach to guide systematic, and hopefully reproducible, application of the current case definition, so that case ascertainment would be more uniform across sites. Ultimately, an operational CFS case definition will need to be based on empirical studies designed to delineate the possibly distinct biological pathways that result in chronic fatigue.

Chronic fatigue and sociodemographic characteristics as predictors of psychiatric disorders in a community-based sample

OBJECTIVES

To explore the roles of chronic fatigue and sociodemographic characteristics (eg, parental status, work status, socioeconomic status, sex, age, marital status, and ethnicity) as predictors of psychiatric disorders.

METHODS

A stratified random sample of 18,675 adults residing in diverse neighborhoods in Chicago completed a telephone-screening questionnaire. A control group without chronic fatigue (N = 74) and a group of individuals with chronic fatigue (N = 227) were identified and administered a semi-structured psychiatric interview. Stepwise logistic regression analyses predicting occurrence of current and lifetime psychiatric disorders according to chronic fatigue status and sociodemographics were conducted on this overall sample of 301 participants.

RESULTS

Chronic fatigue, low socioeconomic status, and unemployment were among significant predictors of overall Axis I psychiatric disorders. Chronic fatigue functioned as a predictor for mood and anxiety disorders (including posttraumatic stress disorder), but did not function as a predictor for somatoform disorders, substance abuse/dependence, and eating disorders. Low socioeconomic status and unemployment were significantly associated with current psychiatric disorder, and low socioeconomic status was also significantly associated with mood and anxiety disorders. Women were significantly more likely to experience mood disorder, and minorities (eg, African Americans, Latinos, and individuals of other ethnicity) were significantly more likely to report posttraumatic stress disorder.

CONCLUSIONS

Results support prior findings for increased rates of psychiatric disorder among individuals with chronic fatigue and highlight the roles of low socioeconomic status, unemployment, being a woman, and being classified as a minority in their association with certain psychiatric disorders.

Physicians' diagnoses of psychiatric disorders for people with chronic fatigue syndrome

OBJECTIVE

To examine rates of psychiatric diagnoses given by patients' primary or regular physicians to persons with chronic fatigue syndrome (CFS), persons with psychiatrically explained fatigue, and a control group. Physicians' psychiatric diagnosis and participants' self-reported psychiatric diagnoses were compared to lifetime psychiatric diagnoses as measured by a structured psychiatric interview.

METHOD

Participants were recruited as part of a community-based epidemiology study of chronic fatigue syndrome. Medical records of 23 persons with chronic fatigue syndrome, 25 persons with psychiatrically explained chronic fatigue, and 19 persons without chronic fatigue (controls) were examined to determine whether their physician had given a diagnosis of mood, anxiety, somatoform, or psychotic disorder. Lifetime psychiatric status was measured using the Structured Clinical Interview for the DSM-IV (SCID). Participants' self reports of specific psychiatric disorders were assessed as part of a detailed medical questionnaire.

RESULTS

Physicians' diagnosis of a psychiatric illness when at least one psychiatric disorder was present ranged from 40 percent in the psychiatrically explained group, 50 percent in the control group, and 64.3 percent in the CFS group. Participants in the psychiatrically explained group were more accurate than physicians in reporting the presence of a psychiatric disorder, and in accurately reporting the presence of a mood or anxiety disorder.

CONCLUSIONS

The present investigation found underrecognition of psychiatric illness by physicians, with relatively little misdiagnosis of psychiatric illness. Physicians had particular difficulty assessing psychiatric disorder in those patients whose chronic fatigue was fully explained by a psychiatric disorder. Results emphasized the importance of using participant self report as a screening for psychiatric disorder.

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.

Chronic fatigue syndrome and fibromyalgia: clinical assessment and treatment

Chronic fatigue syndrome (CFS) and fibromyalgia (FM) are closely related illnesses of uncertain etiology. This article reviews the research literature on these biobehavioral conditions, with an emphasis on explanatory models, clinical evaluation of comorbid psychiatric disorders, assessment of stress factors, pharmacologic and alternative therapies, and cognitive-behavioral treatment studies. Furthermore, clinical protocols suitable for professional practice are presented based on an integration of the authors' clinical observations with published data. The article concludes with the recognition that mental health professionals can offer substantial help to these patients.

Chronic fatigue syndrome: reviewing the research findings

This article reviews the current state of research in chronic fatigue syndrome (CFS). The evolving definition, prevalence, and prognosis of this controversial illness are presented. We review studies examining psychiatric, personality, and psychosocial etiology for CFS. The evidence for pathophysiology in CFS is also presented, and studies investigating viral, immune, neuroimaging, neuroendocrine, and central and autonomic nervous system abnormalities in CFS are assessed. Current evidence indicates that CFS is multi-determined and heterogeneous and that subgrouping patients according to factors such as psychiatric state and symptom onset may be fruitful. The current state of treatment for CFS is reviewed, and the challenges for research aimed at resolving this prototypical mind/body problem are discussed.