The relation of sleep difficulties to fatigue, mood and disability in chronic fatigue syndrome

The relationship of sleep complaints to mood, fatigue, disability, and lifestyle was examined in 69 chronic fatigue syndrome (CFS) patients without psychiatric disorder, 58 CFS patients with psychiatric disorder, 38 psychiatric out-patients with chronic depressive disorders, and 45 healthy controls. The groups were matched for age and gender. There were few differences between the prevalence or nature of sleep complaints of CFS patients with or without current DSM-IIIR depression, anxiety or somatization disorder. CFS patients reported significantly more naps and waking by pain, a similar prevalence of difficulties in maintaining sleep, and significantly less difficulty getting off to sleep compared to depressed patients. Sleep continuity complaints preceded fatigue in only 20% of CFS patients, but there was a strong association between relapse and sleep disturbance. Certain types of sleep disorder were associated with increased disability or fatigue in CFS patients. Disrupted sleep appears to complicate the course of CFS. For the most part, sleep complaints are either attributable to the lifestyle of CFS patients or seem inherent to the underlying condition of CFS. They are generally unrelated to depression or anxiety in CFS.     

Objective assessment of personality disorder in chronic fatigue syndrome

OBJECTIVES: This study aims to objectively assess the prevalence and nature of personality disorders in depressed and nondepressed chronic fatigue syndrome (CFS) patients and compare this to depressed and healthy control groups. METHODS: Sixty-one patients attending a tertiary referral clinic with chronic fatigue syndrome, 40 psychiatric inpatients with depressive disorder and 45 healthy medical students completed the Structured Clinical Interview for DSM-III-R Diagnoses (SCID-II) in addition to providing routine clinical and demographic information. RESULTS: Thirty-nine percent of the CFS group, 73% of the depressed group and 4% of the healthy group were diagnosed with personality disorders. Cluster C disorders were the most common in both the CFS and depressed group. The depressed CFS patients had more Cluster B personality disorders than nondepressed CFS patients. Overall for CFS patients there was no association between mood state and personality disorder. CONCLUSIONS: High levels of personality disorder are found on objective assessment of CFS patients attending a teaching hospital clinic. This cannot be accounted for by comorbid depression.     

Strength and physiological response to exercise in patients with chronic fatigue syndrome

OBJECTIVE: To measure strength, aerobic exercise capacity and efficiency, and functional incapacity in patients with chronic fatigue syndrome (CFS) who do not have a current psychiatric disorder. METHODS: Sixty six patients with CFS without a current psychiatric disorder, 30 healthy but sedentary controls, and 15 patients with a current major depressive disorder were recruited into the study. Exercise capacity and efficiency were assessed by monitoring peak and submaximal oxygen uptake, heart rate, blood lactate, duration of exercise, and perceived exertion during a treadmill walking test. Strength was measured using twitch interpolated voluntary isometric quadriceps contractions. Symptomatic measures included physical and mental fatigue, mood, sleep, somatic amplification, and functional incapacity. RESULTS: Compared with sedentary controls, patients with CFS were physically weaker, had a significantly reduced exercise capacity, and perceived greater effort during exercise, but were equally unfit. Compared with depressed controls, patients with CFS had significantly higher submaximal oxygen uptakes during exercise, were weaker, and perceived greater physical fatigue and incapacity. Multiple regression models suggested that exercise incapacity in CFS was related to quadriceps muscle weakness, increased cardiovascular response to exercise, and body mass index. The best model of the increased exercise capacity found after graded exercise therapy consisted of a reduction in submaximal heart rate response to exercise. CONCLUSIONS: Patients with CFS were weaker than sedentary and depressed controls and as unfit as sedentary controls. Low exercise capacity in patients with CFS was related to quadriceps muscle weakness, low physical fitness, and a high body mass ratio. Improved physical fitness after treatment was associated with increased exercise capacity. These data imply that physical deconditioning helps to maintain physical disability in CFS and that a treatment designed to reverse deconditioning helps to improve physical function.     

Fatigue syndromes: a comparison of chronic "postviral" fatigue with neuromuscular and affective disorders.

Patients (n = 47) presenting to a neurological centre with unexplained chronic "postviral" fatigue (CFS) were studied prospectively. Controls were patients with peripheral fatiguing neuromuscular diseases and inpatients with major depression in a psychiatric hospital. Seventy-two percent of the CFS patients were cases of psychiatric disorder, using criteria that excluded fatigue as a symptom, compared with 36% of the neuromuscular group. There was no difference in subjective complaints of physical fatigue between all groups. Mental fatigue and fatigability was equally common in CFS and affective patients, but only occurred in those neuromuscular patients who were also cases of psychiatric disorder. Overall, the CFS patients more closely resembled the affective than the neuromuscular patients. Attribution of symptoms to physical rather than psychological causes was the principal difference between matched CFS and psychiatric controls. The symptoms of "postviral" fatigue had little ability to discriminate between CFS and affective disorder. The fatigue in CFS appeared central in origin, suggesting it is not primarily a neuromuscular illness. The implications for research and treatment of chronic fatigue are discussed.     

Amplification and attribution styles in somatoform and depressive disorders--a study from Bangalore,India

OBJECTIVE: The present investigation aimed to study attribution styles and somatosensory amplification among patients suffering from somatoform and depressive disorders. METHODS: Two groups of 30 patients with diagnoses of somatoform disorder and depressive disorder, respectively (ICD-10 DCR), and one group of 30 normal controls were recruited. The study patients were assessed using the symptom interpretation questionnaire, somatosensory amplification scale, and scales for assessing alexithymia and illness attitudes. RESULTS: The somatoform and depressive disorder patients had greater recent symptom experience than the normal group. The somatoform disorder group had higher somatic attribution scores, the depressive disorder sample had higher psychological attribution scores, and the normal group had higher normalizing attribution scores than the two other groups. Somatoform disorder patients had higher mean amplification scores than depressed patients, who in turn had higher scores than normals. Correlation analyses showed somatic attribution and certain illness attitudes to be closely associated in all three groups. Recent symptom experience was associated with amplification in the somatoform disorder group alone. Recent symptom experience, a diagnosis of somatoform disorder and lower normalizing attribution scores predicted amplification. DISCUSSION: These findings indicate that somatoform and depressive disorder patients and normals differ from each other in their attribution styles. There is a clustering of attributes among somatoform disorder patients that include greater symptom experience, which is somatically attributed, and is associated with excessive illness worry, concern and preoccupation with bodily symptoms, and a fear of having or developing a disease. On the other hand, depressed patients and normal subjects who do have a somatic attribution style (though, as a group, they have lower somatic attribution scores than the somatoform disorder group), also harbor hypochondriacal beliefs and related attitudes.     

Chronic fatigue syndrome of childhood

OBJECTIVE: To examine clinical specificity in chronic fatigue syndrome (CFS) of childhood, by comparing clinical features in childhood CFS and in emotional disorders (ED). METHOD SAMPLE: 28 children with CFS; 27 with ED. MEASURES: History of disorder; K-SADS psychiatric interviews; self-esteem and physical symptoms questionnaires; premorbid history, behavioural and personality assessments. RESULTS: There were high levels of comorbid emotional disorders in children with CFS, and the two groups were comparable on self-esteem, but CFS children endorsed more fatigue and other somatic symptoms. The two groups were comparable on age at illness onset, but parents of children with CSF reported more biological illness precipitants, more pre-morbid recurrent medical problems and infections. The CFS group had fewer pre-morbid psychological problems and less psychiatric comorbidity than the ED group. CONCLUSION: There is considerable clinical overlap between CFS and ED of childhood, but there are also differences in clinical presentation between these 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.     

Hormonal responses to exercise in chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a debilitating disease characterized by severe, unexplained fatigue and postexertional exacerbation of symptoms. We examined basal endocrine function in a group of CFS patients and a carefully matched group of sedentary controls. The subjects then completed a graded, maximal exercise test on a treadmill, and additional blood samples were drawn 4 min and a day after the end of exercise. There were no differences in basal hormone levels before exercise. Plasma adrenocorticotropin, epinephrine, prolactin and thyrotropin responses 4 min after exercise were lower in the CFS group, but the growth hormone response may have been exaggerated, and the plasma norepinephrine response was similar to that in controls. The next day, there were no differences in hormone levels between the groups, which suggests that long-term changes in endocrine function are unlikely to be a cause of the prolonged fatigue that occurs in CFS patients after a bout of exertion.     

Plasma cytokine expression in adolescent chronic fatigue syndrome

Chronic fatigue syndrome (CFS) is a prevalent and disabling condition among adolescents. The pathophysiology is poorly understood, but low-grade systemic inflammation has been suggested as an important component. This study compared circulating levels of individual cytokines and parameters of cytokine networks in a large set of adolescent CFS patients and healthy controls, and explored associations between cytokines and symptoms in the CFS group.CFS patients (12–18 years old) were recruited nation-wide to a single referral center as part of the NorCAPITAL project (ClinicalTrials ID: NCT01040429). A broad case definition of CFS was applied, requiring three months of unexplained, disabling chronic/relapsing fatigue of new onset, whereas no accompanying symptoms were necessary. Thus, the case definition was broader than the Fukuda-criteria of CFS. Healthy controls having comparable distribution of gender and age were recruited from local schools. Twenty-seven plasma cytokines, including interleukins, chemokines and growth factors were assayed using multiplex technology. The results were subjected to network analyses using the ARACNE algorithm. Symptoms were charted by a questionnaire, and patients were subgrouped according to the Fukuda-criteria.A total of 120 CFS patients and 68 healthy controls were included. CFS patients had higher scores for fatigue (p < 0.001) and inflammatory symptoms (p < 0.001) than healthy controls. All cytokine levels and cytokine network parameters were similar, and none of the differences were statistically different across the two groups, also when adjusting for adherence to the Fukuda criteria of CFS. Within the CFS group, there were no associations between aggregate cytokine network parameters and symptom scores.Adolescent CFS patients are burdened by symptoms that might suggest low-grade systemic inflammation, but plasma levels of individual cytokines as well as cytokine network measures were not different from healthy controls, and there were no associations between symptoms and cytokine expression in the CFS group. Low-grade systemic inflammation does not appear to be a central part of adolescent CFS pathophysiology.     

The relationship between posttraumatic stress disorder, illness cognitions, defence styles, fatigue severity and psychological well-being in chronic fatigue syndrome

This study investigated, firstly, the rate of posttraumatic stress disorder (PTSD) and the level of psychological well-being amongst people with chronic fatigue syndrome (CFS); and secondly, the extent to which illness cognitions, defence styles and PTSD symptom severity related to fatigue severity and psychological well-being. Seventy-eight participants with a diagnosis of CFS completed the Chalder Fatigue Scale, the General Health Questionnaire-28, the Posttraumatic Stress Diagnostic Scale, the Illness Cognition Questionnaire and the Defence Style Questionnaire. Fifty-nine participants were recruited from the general public to form the non-fatigued control group. CFS participants had significantly higher levels of PTSD symptoms, lower levels of psychological well-being and more traumatic life events compared to the non-fatigued controls. Trauma exposure and PTSD severity both predicted CFS status. However, regression analyses demonstrated no significant relationship between PTSD symptoms and fatigue severity or the degree of psychological well-being. ‘Helplessness’ predicted both physical and mental fatigue and psychological well-being, whilst the ‘mature’ defence styles predicted fatigue severity only. The results offer support to previous research showing that the rate of traumatic life events and PTSD are significantly higher amongst the CFS population. The lack of relationship between PTSD symptoms and fatigue severity or psychological well-being indicates that these processes may operate independently of one another, via different appraisal processes. This study focused on fatigue severity, but it may be that the role of pain in CFS is a key element in the previously reported association between PTSD and CFS.     

Examination of Cloninger's basic dimensions of personality in fatiguing illness: chronic fatigue syndrome and multiple sclerosis

Relatively few studies have examined the personality characteristics of patients with chronic fatigue syndrome (CFS). The personality profiles of 38 CFS subjects were compared with 40 healthy controls and 40 subjects with multiple sclerosis (MS), a chronic illness that shares many symptoms with CFS (e.g., fatigue), but has a known neurological substrate. Subjects were examined within Cloninger's biosocial theory of personality, which delineates basic dimensions of temperament. Both illness groups displayed similarly elevated levels of Harm Avoidance, and lower levels of Reward Dependence as compared with healthy controls. The MS group showed a lower level of Persistence than controls and CFS subjects. Implications for the relationship between chronic illness and personality are discussed.     

Psychological correlates of functional status in chronic fatigue syndrome

Background: The present study was designed to test a cognitive model of impairment in chronic fatigue syndrome (CFS) in which disability is a function of severity of fatigue and depressive symptoms, generalized somatic symptom attributions and generalized illness worry. Methods: We compared 45 CFS and 40 multiple sclerosis (MS) outpatients on measures of functional ability, fatigue severity, depressive symptoms, somatic symptom attribution and illness worry. Results: The results confirmed previous findings of lower levels of functional status and greater fatigue among CFS patients compared to a group of patients with MS. Fatigue severity was found to be a significant predictor of physical functioning but not of psychosocial functioning in both groups. In CFS, when level of fatigue was controlled, making more somatic attributions was associated with worse physical functioning, and both illness worry and depressive symptoms were associated with worse psychosocial functioning. Conclusions: Our findings support the role of depression and illness cognitions in disability in CFS sufferers. Different cognitive factors account for physical and psychosocial disability in CFS and MS. The SF-36 may be sensitive to symptom attributions, suggesting caution in its interpretation when used with patients with ill-defined medical conditions.     

Diagnostic and treatment challenges of chronic fatigue syndrome: role of immediate-release methylphenidate

Chronic fatigue syndrome (CFS) is a distinct entity belonging to the group of persistent fatigue that can be challenging to diagnose and to treat. It is characterized by a combination of prolonged fatigue, other nonspecific somatic manifestations and neuropsychological symptoms, including difficulties with concentration, short-term memory and thinking, as well as impaired attention and slowed processing speed. Neurostimulants increasing dopamine and norepinephrine activity, such as bupropion, dextroamphetamine and recently immediate-release methylphenidate have been advocated to improve neurocognitive deficits. The use of immediate-release methylphenidate in CFS has been shown in one small study. Using the positive results of this study and the well-known beneficial effects of the drug on a range of similar cognitive symptoms in attention-deficit/hyperactivity disorder, this perspective addresses CFS and other related disorders and provides a discussion on the potential promising role of methylphenidate in the therapeutic armamentarium of CFS.     

Are fatigue symptoms and chronic fatigue syndrome following Q fever infection related to psychosocial variables?

ObjectiveFatigue is known as one of the most common long-term sequelae of Q fever infections. The study aimed to determine the prevalence of fatigue symptoms, chronic fatigue, and chronic fatigue syndrome (CFS) in a sample of patients who were exposed to Q fever (Coxiella burnetii) infection compared to controls, and to contrast Q fever patients with and without fatigue symptoms related to somatoform symptoms, hypochondriacal worries and beliefs, psychosocial complaints, and social support.MethodsCross-sectional study of 84 Q fever exposed patients from a specific region in Jena (Germany) and 85 matched controls using standardized questionnaires (MFI, SF-12, CDC-SI, SOMS, Whiteley Index, OQ-45 and F-Sozu). Diagnostic interviews were performed to validate questionnaire results in a smaller subsample.ResultsPatients who were exposed to a Q fever infection in the past indicated more fatigue symptoms and chronic fatigue than controls (54.8 vs. 20%, 32.1 vs. 4.7%) but did not show more criteria for a CFS (1 patient in each group). Q fever patients showing fatigue symptoms revealed significantly higher scores in the SOMS, the Whiteley-Index, and higher psychosocial complaints measured with the OQ-45. Their health related Quality of Life was reduced, no differences were found related to perceived social support.ConclusionAlthough in our sample fatigue symptoms were common among Q fever patients, we found no increased prevalence of CFS in contrast to several other studies. The combination of fatigue symptoms with other psychosocial symptoms/problems support the view of a biopsychosocial etiology of fatigue symptoms.     

Effects of one night's sleep deprivation on mood and behavior in panic disorder. Patients with panic disorder compared with depressed patients and normal controls

The effects of one night's sleep deprivation on mood and behavior were evaluated in 12 patients with panic disorder, ten depressed patients, and ten controls. In contrast to the improvement in symptoms of anxiety and depression shown by the majority of depressed patients, the response of patients with panic disorder as a group did not differ from that of normal controls, although a subgroup did experience noticeable worsening in their symptoms of anxiety, with 40% experiencing panic attacks on the day following sleep deprivation. Electroencephalographic recordings with nasopharyngeal electrodes on the day following sleep deprivation were normal, further suggesting that patients with panic disorder do not have seizure activity characteristic of temporal lobe epilepsy.     

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

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

Augmentation therapy with cilostazol for the intractable geriatric major depressive disorder patients with deep white matter hyperintensities on T2-weighted brain MRI

Several studies report that vascular lesions contribute to depression in late life, but whether vascular lesions contribute to depression or indeed result from depression is debatable. To address this question, we segregated mood disorder patients into late- and early-onset mood disorder groups (LOM and EOM, respectively) and compared the areas of high intensity on the subcortical MRI scans of the 2 groups. We found that the LOM group exhibited higher ratings than the EOM group; significant between-group differences were detected in the bilateral frontal areas and in the left parieto-occipital area. Our results suggest that vascular lesions in these areas are crucial for the development of late-onset mood disorders. Furthermore, treatment is often difficult in depressed patients with cerebrovascular lesions. Therefore, a new therapeutic approach that takes into account cerebrovascular factors is necessary. We concomitantly administered cilostazol with conventional antidepressants to patients with intractable geriatric major depressive disorder; of these patients, 2 showed improvements of their depressive symptoms. These findings suggest a potential efficacy of cilostazol as a novel drug for use in augmentation therapy for depressed patients with silent cerebrovascular disorder. Evidence that vascular disease is the underlying link between depression and dementia is strong. Therefore, further studies that include follow-up of such cases are necessary.     

Association between cytokines and psychiatric symptoms in chronic fatigue syndrome and healthy controls

Abstract

Purpose: The reports regarding the status of the immune system in patients with chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) have been inconclusive. We approached this question by comparing a strictly defined group of CFS/ME outpatients to healthy control individuals, and thereafter studied cytokines in subgroups with various psychiatric symptoms.

Materials and methods: Twenty patients diagnosed with CFS/ME according to the Fukuda criteria and 20 age- and sex-matched healthy controls were enrolled in the study. Plasma was analysed by ELISA for levels of the cytokines TNF-α, IL-4, IL-6 and IL-10. Participants also answered questionnaires regarding health in general, and psychiatric symptoms in detail.

Results: Increased plasma levels of TNF-α in CFS/ME patients almost reached significance compared to healthy controls (p?=?.056). When studying the CFS/ME and control groups separately, there was a significant correlation between TNF-α and The Hospital Anxiety and Depression Scale (HADS) depressive symptoms in controls only, not in the CFS/ME group. A correlation between IL-10 and psychoticism was found in both groups, whereas the correlation for somatisation was seen only in the CFS/ME group. When looking at the total population, there was a significant correlation between TNF-α and both the HADS depressive symptoms and the SCL-90-R cluster somatisation. Also, there was a significant association between IL-10 and the SCL-90-R cluster somatisation when analyzing the cohort (patients and controls together).

Conclusions: These findings indicate that immune activity in CFS/ME patients deviates from that of healthy controls, which implies potential pathogenic mechanisms and possible therapeutic approaches to CFS/ME. More comprehensive studies should be carried out on defined CFS/ME subgroups.     

Coping styles in people with chronic fatigue syndrome identified from the general population of Wichita, KS

OBJECTIVE: Studies of primary and tertiary care patients suggest that maladaptive coping styles contribute to the pathogenesis and maintenance of chronic fatigue syndrome (CFS). We assessed coping styles in persons with unexplained fatigue and nonfatigued controls in a population-based study. METHODS: We enrolled 43 subjects meeting the 1994 Research Case Definition of CFS, matching them with 61 subjects with chronic unexplained fatigue who did not meet criteria for CFS [we term them insufficient symptoms or fatigue (ISF)] and 60 non-ill (NI) controls. Coping styles and clinical features of CFS were assessed using standard rating scales. RESULTS: Subjects with CFS and ISF reported significantly more escape-avoiding behavior than NI controls. There were no differences between the CFS and ISF subjects. Among participants with CFS, escape-avoiding behavior was associated with fatigue severity, pain, and disability. CONCLUSIONS: We demonstrate significantly higher reporting of maladaptive coping in a population-based sample of people with CFS and other unexplained fatiguing illnesses defined by reproducible standardized clinical empirical means in comparison to NI controls.     

Personality in adolescents with chronic fatigue syndrome

Our aim was to study the presence of personality traits and disorder in adolescents with Chronic Fatigue Syndrome (CFS). Personality was then compared to other measures of functioning such as presence of psychiatric disorder and rating on the Child Behavior Checklist 4–18 (CBCL) and in relation to CFS outcome. Twenty-five adolescents with CFS followed-up after contacts with tertiary paediatric/psychiatric clinics were compared with 15 matched healthy controls. Interviews and questionnaires from parents and youngsters included Personality Assessment Schedule (PAS), Kiddie-SADS Psychiatric Interview, Child Behavior Checklist. CFS subjects were significantly more likely than controls to have personality difficulty or disorder. Personality features significantly more common amongst them were conscientiousness, vulnerability, worthlessness and emotional lability. There was a nonsignificant association between personality disorder and worse CFS outcome. Personality difficulty or disorder was significantly associated with psychological symptoms and decreased social competence on the CBCL but it was distinguishable from episodic psychiatric disorder. Personality difficulty and disorder are increased in adolescents with a history of CFS. Personality disorder may be linked to poor CFS outcome. Accepted: 23 August 1999