Psychological symptoms, somatic symptoms, and psychiatric disorder in chronic fatigue and chronic fatigue syndrome: a prospective study in the primary care setting

The role of psychiatry in diagnosis and treatment of paediatric chronic fatigue syndrome - a scoping literature review

OBJECTIVES

Paediatric Chronic Fatigue Syndrome (pCFS) is a common condition that significantly disrupts a healthy psychosocial development. Psychiatric symptoms associated with pCFS are conceptualized as either part of its complex etiology, its consequence, or as a comorbidity. However, patients with this condition are rarely seen by psychiatrists. This scoping review aims to explore the role of psychiatry in the diagnosis and treatment of pCFS.

CONTENT

A scoping review of literature was conducted using MEDLINE, EMBASE, Cochrane and PsycINFO. Databases were searched for articles describing psychiatric involvement in the diagnosis or treatment of children and adolescents (age ≤ 18) with pCFS. A grey literature search was also conducted to identify additional guidelines and national recommendations to identify the role of psychiatry in the diagnosis and treatment of pCFS.

SUMMARY

The search provided 436 articles of which 16 met inclusion criteria. Grey literature search identified 12 relevant guidelines. Most studies and guidelines did not include any psychiatric involvement in the care of patients with pCFS. If psychiatry was mentioned, it was used interchangeably with psychological interventions or in the context of treating distinct psychiatric comorbidities and suicidal ideation.

OUTLOOK

The role of psychiatry in diagnosis and treatment of pCFS is poorly defined. Future research is required to understand how psychiatrists can contribute to the care of patients with pCFS.

Recurring Fatigue After Biologic Administration: Patient-Reported Data from the Dutch Biologic Monitor

BACKGROUND

Fatigue is a common problem in immune-mediated inflammatory disease (IMID) patients, significantly impacting their quality of life.

OBJECTIVES

In this study, we describe the pattern and characteristics of fatigue as a patient-reported adverse drug reaction (ADR) of biologics, and compared patient and treatment characteristics with patients reporting other ADRs or no ADRs.

METHODS

In this cohort event monitoring study, the description and characteristics of fatigue reported as a possible ADR in the Dutch Biologic Monitor were assessed and analysed for commonly recurring themes or patterns. Baseline and treatment characteristics of patients with fatigue and patients reporting other ADRs or no ADRs were compared.

RESULTS

Of 1382 participating patients, 108 patients (8%) reported fatigue as an ADR of a biologic. Almost half of these patients (50 patients, 46%) described episodes of fatigue during or shortly after biologic injection, which often recurred following subsequent injections. Patients with fatigue were significantly younger than patients with other ADRs or patients without ADRs (median age for patients with fatigue, 52 years; median age for patients with other ADRs, 56 years; and median age for patients without ADRs, 58 years); significantly more often smoked (25% vs. 16% and 15%); used infliximab (22% vs. 9% and 13%), rituximab (9% vs. 3% and 1%) or vedolizumab (6% vs. 2% and 1%); and significantly more often had Crohn's disease (28% vs. 13% and 13%) and other comorbidities (31% vs. 20% and 15%). Patients with fatigue significantly less frequently used etanercept (12% vs. 29% and 34%) or had rheumatoid arthritis (30% vs. 45% and 43%).

CONCLUSIONS

IMID patients may experience fatigue as a postdosing effect of biologics.

[Asthenia, mental fatigue and cognitive dysfunction]

Conditions associated with asthenia are usually characterized by increased fatigue, impaired activities of daily living and decreased productivity. In clinical practice it is important to distinguish between idiopathic chronic fatigue (primary or functional asthenia) and chronic fatigue syndrome (CFS). Fatigue can also be classified by neuromuscular and/or cognitive and mental fatigue. The article discusses the neuroanatomical basis and focuses on the neurocognitive theory of pathological fatigue. In addition the relationship between mental stress, fatigue and cognitive impairments such as subjective cognitive impairment (SCI) and mild cognitive impairment (MCI) are also discussed. We discuss the rationale that for treatment of asthenic conditions accompanied by cognitive dysfunction it is justified to use combination therapy - fonturacetam and a preparation containing nicotinoyl-GABA and Ginkgo Biloba.

Meta-analysis investigating post-exertional malaise between patients and controls

Post-exertional malaise is either required or included in many previously proposed case definitions of myalgic encephalomyelitis/chronic fatigue syndrome. A meta-analysis of odds ratios (ORs; association between patient status and post-exertional malaise status) and a number of potential moderators (i.e. study-level characteristics) of effect size were conducted. Post-exertional malaise was found to be 10.4 times more likely to be associated with a myalgic encephalomyelitis/chronic fatigue syndrome diagnosis than with control status. Significant moderators of effect size included patient recruitment strategy and control selection. These findings suggest that post-exertional malaise should be considered a cardinal symptom of myalgic encephalomyelitis/chronic fatigue syndrome.

Surrendering to social emptiness: Chronic social exclusion longitudinally predicts resignation in asylum seekers

The current knowledge of the long-term consequences of social exclusion mostly relies on theoretical assumptions. (Williams, 2009, Adv. Exp. Soc. Psychol., 41, 275) hypothesized that chronic ostracism drives individuals into a stage of resignation (depression, alienation, unworthiness, helplessness). We focused on asylum seekers (N = 112) as a social group at risk of experiencing prolonged instances of exclusion. Applying a three-wave longitudinal design with a three-month interval between each wave, we sought to advance the knowledge of the temporal development of chronic social exclusion. Cross-lagged panel analyses showed that social exclusion influenced the development of feelings of resignation in the long term, from baseline to six months and between three and six months. In the same time frame, the perception of social exclusion became stable and chronic. These findings provide empirical evidence that chronic exclusion predicts resignation and shed light on the temporal development of the detrimental impact that pervasive exclusion can have on people belonging to marginalized social groups.

Prevalence and factors associated with fatigue in the Lausanne middle-aged population: a population-based, cross-sectional survey

OBJECTIVE

To assess the prevalence and factors associated with fatigue in the general population.

DESIGN

Population-based, cross-sectional survey performed between May 2014 and April 2017.

SETTING

General population of the city of Lausanne, Switzerland.

PARTICIPANTS

2848 participants (53.2% women, age range 45-86 years).

PRIMARY OUTCOME MEASURE

Prevalence of fatigue the previous week, defined as a score of ≥4 using the Fatigue Severity Scale.

RESULTS

The prevalence of fatigue was 21.9% (95% CI 20.4% to 23.4%) in the total sample. On bivariate analysis, participants with fatigue were younger, had a higher body mass index, a lower handgrip strength and lower ferritin levels. Participants with fatigue were more frequently women, had a lower educational level, presented more frequently with clinical insomnia, diabetes, anaemia, depression and low thyroid stimulating hormone (TSH) values, had a higher consumption of antihistamines, antidepressants and hypnotics, and rated more frequently their health as bad or very bad. Multivariable analysis showed that obesity (OR 1.40 (95% CI 1.03 to 1.91)), insomnia categories (p value for trend <0.001), depression (OR 3.26 (95% CI 2.38 to 4.46)), anaemia (OR 1.70 (95% CI 1.00 to 2.89)) and low self-rated health status (p value for trend <0.001) were positively associated with fatigue, while older age (p value for trend 0.002) was negatively associated with fatigue. Conversely, no association was found for diabetes, TSH levels, antihistamines or hypnotics.

CONCLUSION

In a population-based sample aged 45-86, fatigue was present in one out of five subjects. Regarding clinical factors, sleep disturbances such as insomnia and sleep apnoea should be assessed first, followed by depression. Regarding biological factors, anaemia should be ruled out, while screening for hypothyroidism is not recommended as a first step. Sleep complaints and fatigue in older subjects are not due to ageing and should prompt identification of the underlying cause.

Importance of fatigue and its measurement in chronic liver disease

The mechanisms of fatigue in the group of people with non-alcoholic fatty liver disease and non-alcoholic steatohepatitis are protean. The liver is central in the pathogenesis of fatigue because it uniquely regulates much of the storage, release and production of substrate for energy generation. It is exquisitely sensitive to the feedback controlling the uptake and release of these energy generation substrates. Metabolic contributors to fatigue, beginning with the uptake of substrate from the gut, the passage through the portal system to hepatic storage and release of energy to target organs (muscle and brain) are central to understanding fatigue in patients with chronic liver disease. Inflammation either causing or resulting from chronic liver disease contributes to fatigue, although inflammation has not been demonstrated to be causal. It is this unique combination of factors, the nexus of metabolic abnormality and the inflammatory burden of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis that creates pathways to different types of fatigue. Many use the terms central and peripheral fatigue. Central fatigue is characterized by a lack of self-motivation and can manifest both in physical and mental activities. Peripheral fatigue is classically manifested by neuromuscular dysfunction and muscle weakness. Therefore, the distinction is often seen as a difference between intention (central fatigue) versus ability (peripheral fatigue). New approaches to measuring fatigue include the use of objective measures as well as patient reported outcomes. These measures have improved the precision with which we are able to describe fatigue. The measures of fatigue severity and its impact on usual daily routines in this population have also been improved, and they are more generally accepted as reliable and sensitive. Several approaches to evaluating fatigue and developing endpoints for treatment have relied of biosignatures associated with fatigue. These have been used singly or in combination and include: physical performance measures, cognitive performance measures, mood/behavioral measures, brain imaging and serological measures. Treatment with non-pharmacological agents have been shown to be effective in symptom reduction, whereas pharmacological agents have not been shown effective.

The 'cognitive behavioural model' of chronic fatigue syndrome: Critique of a flawed model

Chronic fatigue syndrome/myalgic encephalomyelitis is a debilitating illness that greatly impacts the lives of sufferers. A cognitive behavioural model attempts to explain illness onset and continuance with a hypothesis that the illness is perpetuated by patients' irrational beliefs and avoidance behaviours. This theory underpins the promotion of cognitive behavioural therapy, a treatment that aims to change beliefs and behaviours. This article reports on a detailed review of the cognitive behavioural model. Our review finds that the model lacks high-quality evidential support, conflicts with accounts given by most patients and fails to account for accumulating biological evidence of pathological and physiological abnormalities found in patients. There is little scientific credibility in the claim that psycho-behavioural therapies are a primary treatment for this illness.

The association between cortisol:C-reactive protein ratio and depressive fatigue is a function of CRP rather than cortisol

PURPOSE

Hormonal and inflammatory factors have been suggested as potentially influencing depressive state and depressive symptoms, but rarely compared for their relative contribution to these states and to specific depressive symptoms. This study examined cortisol:C-reactive protein (CRP) ratio, plus cortisol and CRP separately, as correlates of global depression and fatigue-related depression.

PATIENTS AND METHODS

One hundred and twenty-six community volunteers from rural Australia provided saliva and serum samples, and also completed a depression inventory.

RESULTS

There was a significant correlation between cortisol:CRP ratio and depression-related fatigue, and this resolved to the effects of CRP rather than cortisol. Most of the variance in this association came from patients who were "depressed", and there were no significant gender associations.

CONCLUSION

Inflammation, rather than HPA-axis activity, was associated with depression-related fatigue, supporting a model that places inflammation as a contributor to one of the major symptoms and predictors of depression. Individualization of therapy for depression-related fatigue in chronically stressed or physically ill patients might benefit from future research into cytokine therapy.

Cortisol and Subjective Stress Responses to Acute Psychosocial Stress in Fibromyalgia Patients and Control Participants

OBJECTIVE

Hypothalamic-pituitary-adrenal axis dysfunction may play a role in fibromyalgia (FM) pathogenesis but it remains understudied in this disorder. Furthermore, early childhood adversities (ECA) are common in FM, but whether they moderate stress reactivity is unknown. Hence, we investigated cortisol and subjective responses to acute psychosocial stress in FM and controls, while adjusting for ECA.

METHODS

Twenty-seven female FM patients and 24 age-matched female controls were recruited in a tertiary care center and through advertisements, respectively. The Childhood Trauma Questionnaire was used to measure ECA history. Salivary cortisol levels and subjective stress ratings were measured at multiple time points before and after the Trier Social Stress Test (TSST) was administered.

RESULTS

Significant main effects of group [F(1,43) = 7.04, p = .011, lower in FM] and ECA [F(1,43) = 5.18, p = .028, higher in participants with ECA] were found for cortisol responses. When excluding controls with ECA (n = 5), a significant group-by-time interaction was found [F(6,39) = 2.60, p = .032], driven by a blunted response to the stressor in FM compared with controls (p = .037). For subjective stress responses, a significant main effect of group [F(1,45) = 10.69, p = .002, higher in FM] and a trend toward a group-by-time interaction effect [F(6,45) = 2.05, p = .078, higher in FM 30 minutes before and 30 and 75 minutes after the TSST, and impaired recovery (difference immediately after - 30 minutes after the TSST) in FM] were found.

CONCLUSIONS

Blunted cortisol responsivity to the TSST was observed in FM patients compared with controls without ECA. FM patients had higher subjective stress levels compared with controls, particularly at baseline and during recovery from the TSST. In FM patients, ECA history was not associated with cortisol or subjective stress levels or with responsivity to the TSST. Future research should investigate the mechanisms underlying hypothalamic-pituitary-adrenal axis dysregulation in FM.

Steroids, stress and the gut microbiome-brain axis

It is becoming well established that the gut microbiome has a profound impact on human health and disease. In this review, we explore how steroids can influence the gut microbiota and, in turn, how the gut microbiota can influence hormone levels. Within the context of the gut microbiome-brain axis, we discuss how perturbations in the gut microbiota can alter the stress axis and behaviour. In addition, human studies on the possible role of gut microbiota in depression and anxiety are examined. Finally, we present some of the challenges and important questions that need to be addressed by future research in this exciting new area at the intersection of steroids, stress, gut-brain axis and human health.

The microbiome and disorders of the central nervous system

Alterations of the gut microbiota have been associated with stress-related disorders including depression and anxiety and irritable bowel syndrome (IBS). More recently, researchers have started investigating the implication of perturbation of the microbiota composition in neurodevelopmental disorders including autism spectrum disorders and Attention-Deficit Hypersensitivity Disorder (ADHD). In this review we will discuss how the microbiota is established and its functions in maintaining health. We also summarize both pre and post-natal factors that shape the developing neonatal microbiota and how they may impact on health outcomes with relevance to disorders of the central nervous system. Finally, we discuss potential therapeutic approaches based on the manipulation of the gut bacterial composition.

Patients with mental problems - the most defenseless travellers

BACKGROUND

Severe mental illness occurring abroad is a difficult situation for patients, their families, and for the local medical community. Patients with mental problem are doublely stigmatized due to their mental illness and because they are foreigners in an unfamiliar country. The appropriate treatment is often delayed, while patients are often dealt with in a manner that violates their human rights. Moreover, repatriation - which is vital in this case - is often delayed due to the lack of international protocols for the transportation and treatment of mentally ill travelers.

METHODS

Authors analyzed several factors related to acute mental health problems during travel: the etiology of symptoms, the appropriate treatment possibilities abroad, and medical evacuation and repatriation of the psychotic patient. The article presents a brief review of travel-related mental disorders, the epidemiology of mental health issues faced by travelers, and the significance of pre-travel advice for these patients. The first problem is to recognize (and redress) the particular challenges faced by a psychotic patient in a strange country. The second challenge is to prepare the patients, often in a poor psychiatric state, for medical evacuation by commercial aircraft. Another important question is the best way to take the patient through customs and security control. All of these, as yet unresolved, issues can make the mental patient virtually defenseless.

CONCLUSIONS

Although timely repatriation of a mentally ill patient is vital and urgent, most travel insurance policies exclude treatment and repatriation costs incurred due to acute mental illness. The high cost of treatment and repatriation must be paid by the patient or their family, which could lead to severe financial strain or insolvency. Changing the approaches taken by the local mental health care community, police, airport security, and insurance companies remain a challenge for psychiatrists.

Defense of the PACE trial is based on argumentation fallacies

In defense of the PACE trial, Petrie and Weinman employ a series of misleading or fallacious argumentation techniques, including circularity, blaming the victim, bait and switch, non-sequitur, setting up a straw person, guilt by association, red herring, and the parade of horribles. These are described and explained.

Heterogeneity in chronic fatigue syndrome - empirically defined subgroups from the PACE trial

BACKGROUND

Chronic fatigue syndrome is likely to be a heterogeneous condition. Previous studies have empirically defined subgroups using combinations of clinical and biological variables. We aimed to explore the heterogeneity of chronic fatigue syndrome.

METHOD

We used baseline data from the PACE trial, which included 640 participants with chronic fatigue syndrome. Variable reduction, using a combination of clinical knowledge and principal component analyses, produced a final dataset of 26 variables for 541 patients. Latent class analysis was then used to empirically define subgroups.

RESULTS

The most statistically significant and clinically recognizable model comprised five subgroups. The largest, 'core' subgroup (33% of participants), had relatively low scores across all domains and good self-efficacy. A further three subgroups were defined by: the presence of mood disorders (21%); the presence of features of other functional somatic syndromes (such as fibromyalgia or irritable bowel syndrome) (21%); or by many symptoms - a group which combined features of both of the above (14%). The smallest 'avoidant-inactive' subgroup was characterized by physical inactivity, belief that symptoms were entirely physical in nature, and fear that they indicated harm (11%). Differences in the severity of fatigue and disability provided some discriminative validation of the subgroups.

CONCLUSIONS

In addition to providing further evidence for the heterogeneity of chronic fatigue syndrome, the subgroups identified may aid future research into the important aetiological factors of specific subtypes of chronic fatigue syndrome and the development of more personalized treatment approaches.

The PACE trial missteps on pacing and patient selection

As others have pointed out a variety of complicating factors with the PACE trial (e.g. changing outcome criteria), I will limit my remarks to issues that involve the composition of adaptive pacing therapy and issues involving patient selection. My key points are that the PACE trial investigators were not successful in designing and implementing a valid pacing intervention and patient selection ambiguity further compromised the study's outcomes.

Allostatic Self-efficacy: A Metacognitive Theory of Dyshomeostasis-Induced Fatigue and Depression

This paper outlines a hierarchical Bayesian framework for interoception, homeostatic/allostatic control, and meta-cognition that connects fatigue and depression to the experience of chronic dyshomeostasis. Specifically, viewing interoception as the inversion of a generative model of viscerosensory inputs allows for a formal definition of dyshomeostasis (as chronically enhanced surprise about bodily signals, or, equivalently, low evidence for the brain's model of bodily states) and allostasis (as a change in prior beliefs or predictions which define setpoints for homeostatic reflex arcs). Critically, we propose that the performance of interoceptive-allostatic circuitry is monitored by a metacognitive layer that updates beliefs about the brain's capacity to successfully regulate bodily states (allostatic self-efficacy). In this framework, fatigue and depression can be understood as sequential responses to the interoceptive experience of dyshomeostasis and the ensuing metacognitive diagnosis of low allostatic self-efficacy. While fatigue might represent an early response with adaptive value (cf. sickness behavior), the experience of chronic dyshomeostasis may trigger a generalized belief of low self-efficacy and lack of control (cf. learned helplessness), resulting in depression. This perspective implies alternative pathophysiological mechanisms that are reflected by differential abnormalities in the effective connectivity of circuits for interoception and allostasis. We discuss suitably extended models of effective connectivity that could distinguish these connectivity patterns in individual patients and may help inform differential diagnosis of fatigue and depression in the future.

Chronic Fatigue Syndrome and Chronic Widespread Pain in Adolescence: Population Birth Cohort Study

Although many studies have investigated the overlap between pain phenotypes and chronic fatigue syndrome (CFS) in adults, little is known about the relationship between these conditions in adolescents. The study's aim was therefore to identify whether a relationship exists between chronic widespread pain (CWP) and CFS in adolescents and investigate whether the two share common associations with a set of covariates. A questionnaire was administered to offspring of the Avon Longitudinal Study of Parents and Children (ALSPAC) at age 17, asking about site, duration, and pain intensity, from which participants with CWP were identified. At the same research clinic, a computer-based Revised Clinical Interview Schedule was filled out, from which a classification of CFS was obtained. The relationship between selected covariates and CFS and CWP was investigated using a variety of logistic, ordinal logistic, and multinomial regressions. We identified 3,214 adolescents with complete data for all outcomes and covariates. There were 82 (2.6%) individuals classified as CFS and 145 (4.5%) as CWP. A classification of CFS resulted in an increased likelihood of having CWP (odds ratio = 3.87; 95% confidence interval, 2.05-7.31). Female adolescents were approximately twice as likely to have CFS or CWP, with multinomial regression revealing a greater sex effect for CWP compared with CFS. Those with exclusive CFS were more likely to report higher levels of pain and greater effect of pain compared with those without CFS, although associations attenuated to the null after adjustment for covariates, which did not occur in those with exclusive CWP. Multinomial regression revealed that relative to having neither CFS nor CWP, a 1-unit increase in the depression and anxiety scales increased the risk of having exclusive CFS and, to a greater extent, the risk of having comorbid CFS and CWP, but not exclusive CWP, which was only related to anxiety.

PERSPECTIVE

In this cohort, 14.6% of adolescents with CFS have comorbid CWP. The likely greater proportion of more mild cases observed in this epidemiological study means that prevalence of overlap may be underestimated compared with those attending specialist services. Clinicians should be aware of the overlap between the 2 conditions and carefully consider treatment options offered.

Chronic Fatigue Syndrome in Children and Adolescents: A Review Article

Clinicians have been describing individuals with chronic fatigue states for over 100 years, although chronic fatigue syndrome is often regarded as a modern disease. The aetiology of chronic fatigue syndrome is uncertain. For young individuals with chronic fatigue syndrome there are neither reliable prevalence figures nor scientific evidence concerning the effectiveness of treatments. Information obtained from research into adult individuals with chronic fatigue syndrome may be helpful but is not necessarily directly applicable to children and adolescents. Developmental factors and the influence of other family members on the course of the disorder in young sufferers should be considered. The uncertainties surrounding chronic fatigue syndrome should not deter child and adolescent mental health workers from becoming involved in the assessment and management of individual patients. The mainstay of treatment is rehabilitation with an emphasis on gradually increasing activities. Considerable attention will need to be given to engaging the young people and their families and working effectively with a multidisciplinary team. If mental health workers do not become involved in treating young people with chronic fatigue syndrome there is a risk that psychological factors will not be addressed and that chronic functional impairment will ensue.

Probiotic Lactobacillus casei strain Shirota relieves stress-associated symptoms by modulating the gut-brain interaction in human and animal models

BACKGROUND

This study aimed to examine the effects of Lactobacillus casei strain Shirota (LcS) on gut-brain interactions under stressful conditions.

METHODS

Three double-blind, placebo-controlled trials were conducted to examine the effects of LcS on psychological and physiological stress responses in healthy medical students under academic examination stress. Subjects received LcS-fermented milk or placebo daily for 8 weeks prior to taking a national standardized examination. Subjective anxiety scores, salivary cortisol levels, and the presence of physical symptoms during the intervention were pooled and analyzed. In the animal study, rats were given feed with or without LcS for 2 weeks, then submitted to water avoidance stress (WAS). Plasma corticosterone concentration and the expression of cFos and corticotropin releasing factor (CRF) in the paraventricular nucleus (PVN) were measured immediately after WAS. In an electrophysiological study, gastric vagal afferent nerve activity was monitored after intragastric administration of LcS to urethane-anesthetized rats.

KEY RESULTS

Academic stress-induced increases in salivary cortisol levels and the incidence rate of physical symptoms were significantly suppressed in the LcS group compared with the placebo group. In rats pretreated with LcS, WAS-induced increases in plasma corticosterone were significantly suppressed, and the number of CRF-expressing cells in the PVN was reduced. Intragastric administration of LcS stimulated gastric vagal afferent activity in a dose-dependent manner.

CONCLUSIONS & INFERENCES

These findings suggest that LcS may prevent hypersecretion of cortisol and physical symptoms under stressful conditions, possibly through vagal afferent signaling to the brain and reduced stress reactivity in the PVN.

Structure and Determinants of Illness Representations in Chronic Disease

Although the clinical relevance of illness representations has been demonstrated in several studies, research on the structure and determinants of illness representations is rare. This article examines the illness representations of chronically ill patients, using a structured interview technique and taking chronic fatigue syndrome (CFS) and Addison's disease (AD) as examples. Considerable differences were found between the group of CFS patients (n = 98) and the group of AD patients (n = 63) with regard to their ideas about the identity, time line, control/cure , and consequences of their illness. Despite these differences, the pattern of correlations among these four dimensions of illness representation was found to be similar for the two groups. Moreover, the strength of the correlations points to the coherent nature of illness representations. The relations between the illness representations, personal variables, and disease- related variables were also explored. Regression analyses showed the dimensions of illness representation to be explained rather well by personal and disease-related variables. Disease-related variables were the most important predictors for the dimensions of identity and consequences; personal variables showed strong associations with time line and control/cure.

Mortality of people with chronic fatigue syndrome: a retrospective cohort study in England and Wales from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Clinical Record Interactive Search (CRIS) Register

BACKGROUND

Mortality associated with chronic fatigue syndrome is uncertain. We investigated mortality in individuals diagnosed with chronic fatigue syndrome in secondary and tertiary care using data from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre (SLaM BRC) Clinical Record Interactive Search (CRIS) register.

METHODS

We calculated standardised mortality ratios (SMRs) for all-cause, suicide-specific, and cancer-specific mortality for a 7-year observation period using the number of deaths observed in SLaM records compared with age-specific and sex-specific mortality statistics for England and Wales. Study participants were included if they had had contact with the chronic fatigue service (referral, discharge, or case note entry) and received a diagnosis of chronic fatigue syndrome.

FINDINGS

We identified 2147 cases of chronic fatigue syndrome from CRIS and 17 deaths from Jan 1, 2007, to Dec 31, 2013. 1533 patients were women of whom 11 died, and 614 were men of whom six died. There was no significant difference in age-standardised and sex-standardised mortality ratios (SMRs) for all-cause mortality (SMR 1·14, 95% CI 0·65-1·85; p=0·67) or cancer-specific mortality (1·39, 0·60-2·73; p=0·45) in patients with chronic fatigue syndrome when compared with the general population in England and Wales. This remained the case when deaths from suicide were removed from the analysis. There was a significant increase in suicide-specific mortality (SMR 6·85, 95% CI 2·22-15·98; p=0·002).

INTERPRETATION

We did not note increased all-cause mortality in people with chronic fatigue syndrome, but our findings show a substantial increase in mortality from suicide. This highlights the need for clinicians to be aware of the increased risk of completed suicide and to assess suicidality adequately in patients with chronic fatigue syndrome.

FUNDING

National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London.

The association between metacognitions and the impact of Fibromyalgia in a German sample

OBJECTIVES

Fibromyalgia is a chronic condition of unknown aetiology, characterised by widespread pain, sleep disturbances, and fatigue. In this paper we examined the relationship metacognitions and the impact of Fibromyalgia in a German sample, detailing the translation and validation of a self-report metacognitive instrument.

METHODS

The Metacognitions about Symptoms Control Scale (MaSCS) was translated into German using the back-forward translation process. A total of 348 patients (316 female and 26 male) with Fibromyalgia contributed data to the study to test the structure and psychometric properties of the MaSCS.

RESULTS

Confirmatory factor analyses, informed by modification indices, resulted in a 16-item scale consisting of two factors pertaining to positive and negative metacognitions about symptoms control. Further analyses revealed that both factors had good internal consistency. Correlation analyses established convergent validity, indicating that both factors were significantly associated with: (1) established positive and negative metacognitions scales; and (2) with symptoms severity in Fibromyalgia. Regression analyses revealed that positive metacognitions about symptoms control significantly predicted impairment in physical functioning while negative metacognitions about symptoms control significantly predicted the overall Fibromyalgia impact value, when controlling for stress, anxiety, and depression and a general metacognitions.

CONCLUSION

The findings support the potential relevance of metacognitions, and utility of the German version of MaSCS, in examining the role of metacognitions in Fibromyalgia and other chronic health conditions.

Defining Essential Features of Myalgic Encephalomyelitis and Chronic Fatigue Syndrome

Considerable debate surrounds the search for the defining features of patients with Myalgic Encephalomyelitis (ME) and chronic fatigue syndrome (CFS). Current case definitions were created through clinical consensus. Failure to operationalize these case definitions has led to considerable variability in the identification of patients. In addition, some case definitions (e.g., Fukuda et al., 1994) do not require cardinal symptoms of this illness, where as other case definitions do require core symptoms of this illness (Carruthers et al., 2003, 2011), and these latter case criteria appear to identify a more impaired group of patients. Criterion variance is most likely to occur when operationally explicit criteria do not exist for diagnostic categories (Spitzer, Endicott, & Robins, 1978), or when there are varying criteria for contrasting case definitions, which is an impediment to the research in this field. To deal with this problem, it is possible to differentiate those that meet more loosely defined criteria from those that are more narrowly and defined, thus differentiating CFS from ME. In order to progress the search for biological markers and effective treatments, essential features need to be operationalized and broadly used in order to increase the probability that individuals included in samples have the same underlying illness.

The Population Burden of Chronic Symptoms that Substantially Predate the Diagnosis of a Life-Limiting Illness

Many people in our communities live with symptoms for years or decades, something of relevance to hospice/palliative care clinicians and researchers. The proportion of people in the community at large who have a chronic symptom is likely to approximate the proportion of people referred to hospice/palliative care services with that same chronic symptom that pre-dates their life-limiting illness. Such patients may have different responsiveness to, and expectations from, symptomatic therapies, thus requiring more advanced approaches to symptom control. For researchers evaluating the impact of hospice/palliative care services, failing to account for people with long-term refractory symptoms pre-dating their life-limiting illness may systematically underestimate services' benefits. Observational symptom prevalence studies reported in hospice/palliative care to date have not accounted for people with long-term refractory symptoms, potentially systematically overestimating symptoms attributed to life-limiting illnesses. Cross-sectional community prevalence rates of key chronic refractory symptoms largely unrelated to their life-limiting illness reflect the likely prevalence on referral to hospice/palliative care: fatigue (up to 35%); pain (12%-31%); pain with neuropathic characteristics (9%); constipation (2%-29%); dyspnea (4%-9%); cognitive impairment (>10% of people >65 years old; >30% of people >85 years old); anxiety (4%); and depression (lifetime incidence 2%-15%; one year prevalence 3%). Prospective research is needed to establish (1) the prevalence and severity of chronic symptoms that pre-date the diagnosis of a life-limiting illness in people referred to hospice/palliative care services, comparing this to whole-of-population estimates; and (2) whether this group is disproportionately represented in people with refractory symptoms.

Perceived Experience of Fatigue in Clinical and General Population: Descriptors and Associated Reactivities

The aim of this study is the analysis of different descriptors and reactions related to the experience of fatigue. Two groups were compared: a clinical sample (n = 92, 31 males, mean age = 38.87) and a non-clinical (n = 225, 135 males, mean age = 32.45) sample. The total sample was composed of 317 participants (52% males), ranging in age from 18 to 76 years. Findings show the experience of fatigue was mainly related to somatic terms (76% of the total sample). Specific results were found only for the clinical group: (a) significant relationships between fatigue and anxiety, χ2(1) = 34.71, p < .01; tension, χ2(1) = 16.80, p < .01; and sadness, χ2(1) = 24.59, p < .01; (b) higher intensity of fatigue (F = 84.15, p = .001), and predominance of the cognitive components of fatigue. Results showed that fatigue in subjects with a clinical disorder (versus those without) was associated both, to negative emotional states, and to a higher intensity of fatigue, especially in its cognitive elements. Important clinical implications for its assessment and intervention are discussed.

Gray matter volumes in patients with chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a debilitating and complex disorder characterized by profound fatigue with uncertain pathologic mechanism. Neuroimage may be an important key to unveil the central nervous system (CNS) mechanism in CFS. Although most of the studies found gray matter (GM) volumes reduced in some brain regions in CFS, there are many factors that could affect GM volumes in CFS, including chronic pain, stress, psychiatric disorder, physical activity, and insomnia, which may bias the results. In this paper, through reviewing recent literatures, we discussed these interferential factors, which overlap with the symptoms of CFS.

Metabolism in chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a poorly understood condition that presents as long-term physical and mental fatigue with associated symptoms of pain and sensitivity across a broad range of systems in the body. The poor understanding of the disorder comes from the varying clinical diagnostic definitions as well as the broad array of body systems from which its symptoms present. Studies on metabolism and CFS suggest irregularities in energy metabolism, amino acid metabolism, nucleotide metabolism, nitrogen metabolism, hormone metabolism, and oxidative stress metabolism. The overwhelming body of evidence suggests an oxidative environment with the minimal utilization of mitochondria for efficient energy production. This is coupled with a reduced excretion of amino acids and nitrogen in general. Metabolomics is a developing field that studies metabolism within a living system under varying conditions of stimuli. Through its development, there has been the optimisation of techniques to do large-scale hypothesis-generating untargeted studies as well as hypothesis-testing targeted studies. These techniques are introduced and show an important future direction for research into complex illnesses such as CFS.

Understanding mental and physical fatigue complaints in those with depression and insomnia

Fatigue is a concern for both people with insomnia and with depression, yet it remains poorly understood. Participants (N = 62) included those meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) criteria for insomnia and major depressive disorder (MDD). Multiple regression examined sleep, mood, activity, and cognitive factors as predictors of mental and physical fatigue. Only the cognitive factors (i.e., unhelpful beliefs about sleep and symptom-focused rumination) were predictive of both physical and mental fatigue. Beliefs about not being able to function and needing to avoid activities after a poor night of sleep were related to both types of fatigue. Targeting these beliefs via cognitive therapy and encouraging patients to test maladaptive beliefs about sleep may enhance fatigue response in those with MDD and insomnia.

Fatigue as prognostic risk marker of mental sickness absence in white collar employees

PURPOSE

To investigate fatigue as prognostic risk marker for identifying working employees at risk of long-term sickness absence (SA).

METHODS

At baseline, fatigue was measured in 633 white collar employees with the checklist individual strength (CIS) including scales for fatigue severity, reduced concentration, reduced motivation, and reduced physical activity. SA was medically certified by an occupational physician in the 3rd or 4th SA week with diagnostic codes according to the 10th version of the International Classification of Diseases. Medically certified SA was retrieved at the individual level from an occupational health register after 1-year follow-up. CIS scores were investigated as prognostic risk markers predicting medically certified SA and particularly SA certified as mental SA.

RESULTS

614 employees (N = 378 men and N = 236 women) had complete data and were eligible for analysis; 63 (10 %) had medically certified SA of whom 39 (6 %) had mental SA. Fatigue severity and total CIS scores were associated with medically certified SA in men, but poorly discriminated between men with and without medically certified SA. Fatigue severity, reduced concentration, reduced motivation, and total CIS scores were also associated with mental SA in men. CIS and its reduced concentration scale were valid prognostic risk markers of mental SA. CONCLUSION Fatigue was a prognostic risk marker of mental SA in white collar men. The CIS should be further validated as a screening tool for the risk of mental SA in white collar working populations.

Unstimulated cortisol secretory activity in everyday life and its relationship with fatigue and chronic fatigue syndrome: a systematic review and subset meta-analysis

The hypothalamic-pituitary-adrenal (HPA) axis is a psychoneuroendocrine regulator of the stress response and immune system, and dysfunctions have been associated with outcomes in several physical health conditions. Its end product, cortisol, is relevant to fatigue due to its role in energy metabolism. The systematic review examined the relationship between different markers of unstimulated salivary cortisol activity in everyday life in chronic fatigue syndrome (CFS) and fatigue assessed in other clinical and general populations. Search terms for the review related to salivary cortisol assessments, everyday life contexts, and fatigue. All eligible studies (n=19) were reviewed narratively in terms of associations between fatigue and assessed cortisol markers, including the cortisol awakening response (CAR), circadian profile (CP) output, and diurnal cortisol slope (DCS). Subset meta-analyses were conducted of case-control CFS studies examining group differences in three cortisol outcomes: CAR output; CAR increase; and CP output. Meta-analyses revealed an attenuation of the CAR increase within CFS compared to controls (d=-.34) but no statistically significant differences between groups for other markers. In the narrative review, total cortisol output (CAR or CP) was rarely associated with fatigue in any population; CAR increase and DCS were most relevant. Outcomes reflecting within-day change in cortisol levels (CAR increase; DCS) may be the most relevant to fatigue experience, and future research in this area should report at least one such marker. Results should be considered with caution due to heterogeneity in one meta-analysis and the small number of studies.

Screening for sleep dysfunction after traumatic brain injury

Numerous studies on the high prevalence of sleep disorders in individuals with traumatic brain injury (TBI) have been conducted in the past few decades. These disorders can accentuate other consequences of TBI, negatively impacting mood, exacerbating pain, heightening irritability, and diminishing cognitive abilities and the potential for recovery. Nevertheless, sleep is not routinely assessed in this population. In our review, we examined the selective screening criteria and the scientific evidence regarding screening for post-TBI sleep disorders to identify gaps in our knowledge that are in need of resolution. We retrieved papers written in the English-language literature before June 2012 pertinent to the discussion on sleep after TBI found through a PubMed search. Within our research, we found that sleep dysfunction is highly burdensome after TBI, treatment interventions for some sleep disorders result in favorable outcomes, sensitive and specific tests to detect sleep disorders are available, and the cost-effectiveness and sustainability of screening have been determined from other populations. The evidence we reviewed supports screening for post-TBI sleep dysfunction. This approach could improve the outcomes and reduce the risks for post-TBI adverse health and nonhealth effects (e.g., secondary injuries). A joint sleep and brain injury collaboration focusing on outcomes is needed to improve our knowledge.

Altered functional B cell subset populations in patients with chronic fatigue syndrome compared to healthy controls

Chronic fatigue syndrome (CFS) is a heterogeneous disorder of unknown aetiology characterized by disabling fatigue, headaches, sleep disturbance and several other symptoms. The onset of CFS may follow a viral infection or period of stress. Patients with CFS do not have hypogammaglobulinaemia, predisposition to recurrent bacterial infections or symptoms of autoimmunity. To date, defects in B cell numbers or function have not been shown in the literature. However, treatment with anti-B cell therapy using Rituximab has recently shown benefit to CFS patients. We therefore postulated that patients with CFS had a subtle humoral immune dysfunction, and performed extended B cell immunophenotyping. We undertook a detailed characterization of the proportions of the different B cell subsets in 33 patients with CFS fulfilling the Canadian and Fukada criteria for CFS and compared these with 24 age- and gender-matched healthy controls (HC). CFS patients had greater numbers of naive B cells as a percentage of lymphocytes: 6·3 versus 3·9% in HC (P = 0·034), greater numbers of naive B cells as a percentage of B cells: 65 versus 47% in controls (P = 0·003), greater numbers of transitional B cells: 1·8 versus 0·8% in controls (P = 0·025) and reduced numbers of plasmablasts: 0·5 versus 0·9% in controls (P = 0·013). While the cause of these changes is unclear, we speculate whether they may suggest a subtle tendency to autoimmunity.

The neuropsychiatric and neuropsychological features of chronic fatigue syndrome: revisiting the enigma

The aim of this article is to provide a comprehensive and updated review of the key neuropsychiatric and neuropsychological complaints associated with chronic fatigue syndrome (CFS). Neuropsychiatric and neuropsychological difficulties are common in CFS and are linked primarily to disorders of mood, affect and behaviour. The neuropsychiatric complaint most frequently encountered amongst CFS patients is depression and in particular major depressive disorder (MDD). Despite decades of research, the precise aetiological relationship between CFS and MDD remains poorly understood. This has resulted in the development of a number of interesting and polarised hypotheses regarding the aetiological nature of CFS. Recent scientific advances have however begun to unravel a number of interesting inflammatory and immunological explanations that suggest CFS and MDD are distinct yet interrelated conditions. The possibility that the overlap between CFS and MDD might be explained in terms of shared oxidative and nitrosative (IO&NS) pathways is an area of intense research interest and is reviewed in detail in this article. The overlap between CFS and MDD is further differentiated by variations in HPA axis activity between the two disorders. Important immunological differences between MDD and CFS are also reviewed with particular emphasis on antiviral RNase L pathways in CFS. In addition to the presence of neuropsychiatric complaints, CFS is also associated with neuropsychological symptoms such as impaired attention, memory and reaction time. The key neuropsychological problems reported by CFS patients are also included in the review in an effort to understand the significance of cognitive impairment in CFS.

Phenomena associated with sick leave among primary care patients with Medically Unexplained Physical Symptoms: a systematic review

OBJECTIVE

To explore and synthesize the literature on phenomena associated with sick leave among patients with Medically Unexplained Physical Symptoms (MUPS).

DESIGN

A systematic review of the literature was undertaken in three phases: (1) a search of the following databases: Medline, Embase, Psych Info, Cochrane Collaboration Library, Digital Dissertations, DiVA, SweMed +, NORART, and ISI Web of Science, (2) selection of studies based on pre-specified inclusion criteria was undertaken, extracting study design and results, (3) quality assessment was undertaken independently by two reviewers. Due to heterogeneity in study designs, populations, interventions, and outcome measures, a mixed research synthesis approach was used. Results were assessed in a pragmatic and descriptive way; textual and numerical data were extracted from the included studies, and classified into patient- and doctor-related factors.

RESULTS

Sixteen studies were included. With regard to patients, an association was found between sick leave and psychiatric comorbidity as well as total symptom burden. With regard to doctors, knowledge of the patient, sympathy, and trust appeared to increase the probability of the patient being sick-listed. None of the interventions in the educational programmes aiming to improve doctors' management of MUPS patients succeeded in lowering sick leave.

IMPLICATIONS

Despite MUPS being a leading cause of sickness absence, the review identified only a small number of studies concerning phenomena associated with sick leave. The authors did not identify any studies regarding the impact of the working conditions on sick leave among MUPS patients. This is an important area for further studies.

Alternative diagnoses to chronic fatigue syndrome in referrals to a specialist service: service evaluation survey

Objective

To assess the accuracy of diagnoses made by referrers to a chronic fatigue syndrome (CFS) service.

Design

Retrospective service evaluation surveys of both rejected referral letters and medical case-notes after full clinical assessment.

Setting

A specialist CFS clinic in London, UK.

Participants

In the first survey, we assessed rejected referral letters between March 2007 and September 2008. In the second survey, we ascertained the primary diagnosis made in case-notes of 250 consecutive new patients assessed between April 2007 and November 2008.

Main outcome measures

Reasons for rejection of referrals and primary diagnosis in those assessed.

Results

In the first survey, 154 out of 418 referrals (37%) were rejected. Of these, 77 out of the available 127 referrals (61%) had a likely alternative diagnosis. In the second survey of clinically assessed patients, 107 (43%) had alternative medical/psychiatric diagnoses, while 137 out of 250 (54%) patients received a diagnosis of CFS. The commonest alternative medical diagnoses of those assessed were sleep disorders and the commonest alternative psychiatric diagnosis was depressive illness. Altogether 184 of 377 (49%) patients had alternative diagnoses to CFS.

Conclusions

Half of all the referred patients to a specialist CFS clinic had alternative medical and psychiatric diagnoses. Specialist medical assessment for patients with unexplained, disabling, chronic fatigue needs to incorporate both medical and psychiatric assessments.