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

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

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.     

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.     

Attributions and self-esteem in depression and chronic fatigue syndromes

There is considerable overlap in symptomatology between chronic fatigue syndrome (CFS) and affective disorder. We report a comparison of depressive phenomenology and attributional style between a group of CFS subjects seen in a specialized medical setting, which included a high proportion with depression diagnosed by Research Diagnostic Criteria (RDC) and depressed controls seen in a specialized psychiatric setting. Significant symptomatic differences between the depressed CFS group and depressed controls were observed for features such as self-esteem and guilt as well as attribution of illness. All the CFS groups tended to attribute their symptoms to external causes whereas the depressed controls experienced inward attribution. This may have resulted from differences in the severity of mood disorder between the samples, but it is also suggested that an outward style of attribution protects the depressed CFS patients from cognitive changes associated with low mood but at the expense of greater vulnerability towards somatic symptoms such as fatigue.     

Generalized anxiety disorder in chronic fatigue syndrome

A structured psychiatric interview, forming part of a global psychopathological approach, revealed higher prevalence rates of current and lifetime psychiatric disorders and a higher degree of psychiatric comorbidity in patients with chronic fatigue syndrome (CFS) than in a medical control group. In contrast to previous studies, a very high prevalence of generalized anxiety disorder (GAD) was found in CFS, characterized by an early onset and a high rate of psychiatric comorbidity. It is postulated that GAD represents a susceptibility factor for the development of CFS. A significantly higher prevalence was also observed for the somatization disorder (SD) in the CFS group. Apart from a higher female-to-male ratio in fibromyalgia, no marked differences were observed in sociodemographic or illness-related features, or in psychiatric morbidity, between CFS patients with and without fibromyalgia. CFS patients with SD have a longer illness duration and a higher rate of psychiatric comorbidity. These findings are consistent with the suggestion of Hickie et al. (1) that chronic fatigued subjects with SD should be distinguished from subjects with 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.     

Undiagnosed and comorbid disorders in patients with presumed chronic fatigue syndrome

Objective

To assess undiagnosed and comorbid disorders in patients referred to a tertiary care center with a presumed diagnosis of chronic fatigue syndrome (CFS).

Methods

Patients referred for chronic unexplained fatigue entered an integrated diagnostic pathway, including internal medicine assessment, psychodiagnostic screening, physiotherapeutic assessment and polysomnography + multiple sleep latency testing. Final diagnosis resulted from a multidisciplinary team discussion. Fukuda criteria were used for the diagnosis of CFS, DSM-IV-TR criteria for psychiatric disorders, ICSD-2 criteria for sleep disorders.

Results

Out of 377 patients referred, 279 (74.0%) were included in the study [84.9% female; mean age 38.8 years (SD 10.3)].A diagnosis of unequivocal CFS was made in 23.3%. In 21.1%, CFS was associated with a sleep disorder and/or psychiatric disorder, not invalidating the diagnosis of CFS. A predominant sleep disorder was found in 9.7%, 19.0% had a psychiatric disorder and 20.8% a combination of both. Only 2.2% was diagnosed with a classical internal disease.In the total sample, a sleep disorder was found in 49.8%, especially obstructive sleep apnea syndrome, followed by psychophysiologic insomnia and periodic limb movement disorder. A psychiatric disorder was diagnosed in 45.2%; mostly mood and anxiety disorder.

Conclusions

A multidisciplinary approach to presumed CFS yields unequivocal CFS in only a minority of patients, and reveals a broad spectrum of exclusionary or comorbid conditions within the domains of sleep medicine and psychiatry. These findings favor a systematic diagnostic approach to CFS, suitable to identify a wide range of diagnostic categories that may be subject to dedicated care.     

Psychiatric illness in diabetes mellitus. Relationship to symptoms and glucose control

The lifetime prevalence of psychiatric illness was determined in 114 patients with diabetes mellitus (types I and II) who were selected randomly from patients undergoing diabetes evaluations at a large medical center. The relationship of psychiatric illness to diabetic control was studied using glycosylated hemoglobin (HbA1) and self-report measures of metabolic symptoms. Seventy-one percent of the patients had a lifetime history of at least one criteria-defined psychiatric illness; affective and anxiety disorders were the most common diagnoses. A significant difference (p = .02) in mean glycosylated hemoglobin levels was observed comparing patients with a recent psychiatric illness (mean = 10.8%) to those never psychiatrically ill (mean = 9.6%). These psychiatrically ill patients also reported more symptoms of poor metabolic control and more distress associated with these symptoms than did patients never psychiatrically ill (p less than .0001 for both). The overall report of diabetes symptoms was unrelated to HbA1 (p = .25) and was influenced primarily by the recent presence of psychiatric disorder (p less than .0001). We conclude that emotional illness is associated with both poorer metabolic control and the increased report of clinical symptoms of diabetes.     

Anxiety and mood disorders in primary care practice

Anxiety and mood disorders are common conditions in primary health care service. Primary care physicians (PCPs) have a privileged role in the early recognition of these conditions. In this study, the prevalence rates of threshold and subthreshold mood and anxiety disorders were surveyed among 1815 primary care attendees in 12 PCPs’ offices in Budapest, using the Diagnostic Interview Schedule (DIS). The 1-year prevalence of DIS/DSM-III-R anxiety and/or mood disorders was 16.8%, and the 1-month prevalence was 12.5%. The occurrence rates of subthreshold anxiety and/or depression were 25.7 and 13.1%, respectively. The impact of threshold anxiety and mood disorders on work performance was considerably higher than the impact of subthreshold symptoms. At the time of the interview, 6.7% of the patients received mood and/or anxiety disorder diagnoses by their PCPs. The measure of agreement between the diagnoses generated by the DIS and the ones given by the PCPs was low. The presence of an acute or chronic physical illness made it more difficult for the PCPs to recognize a psychiatric disorder. Conversely, patients’ psychological complaints significantly improved the recognition of anxiety and/or mood disorders. The use of the Beck Depression Inventory (BDI) brief version would help the patients to reveal their psychological symptoms, and the physicians to recognize an underlying psychiatric disorder.     

Psychiatric morbidity in the chronic fatigue syndrome: are patients with personality disorder more physically impaired?

OBJECTIVE: The long-term consequences of chronic fatigue syndrome (CFS) include substantial impairment in physical functioning and high levels of work disability. In the absence of a medical explanation for this impairment, some have speculated that it may be due to comorbid psychiatric illness or personality disorder. We addressed this possibility by comparing the functional status of three CFS groups: no psychiatric diagnosis, psychiatric illness only, psychiatric illness and personality disorder. A second aim of the study was to determine whether a continuous measure of psychological distress could provide a better account of impairment than psychiatric diagnosis. METHOD: The study sample consisted of 84 consecutive female referrals with CFS. All participants satisfied the case definition and completed an assessment protocol consisting of: physical examination, psychiatric interview and self-report questionnaires. RESULTS: Psychiatric illness, either alone or in combination with a comorbid personality disorder, was not associated with physical impairment or disability in female participants. A regression model of physical functioning found that psychological distress accounted for 6% and symptom severity for 41% of the variance (P=.06 and <.01, respectively). In the case of disability, the corresponding percentages were 2% and 18% (NS and P<.01, respectively). The modest effects of psychological distress could not be attributed to symptom severity. CONCLUSIONS: Although psychiatric illness and personality disorder was prevalent, neither could explain the effects of CFS on physical functioning and disability. As yet, there is no psychological or medical explanation for the behavioral consequences of CFS.     

Psychiatric diagnoses in inner city outpatients with moderate to severe asthma

OBJECTIVE: Psychiatric symptoms may be associated with increased asthma morbidity and mortality. However, no investigations have identified syndromal psychiatric diagnoses in asthma patients using current diagnostic criteria or examined treatment received for mental illness. METHOD: We conducted structured clinical interviews on 32 patients with moderate to severe asthma to identify current and past psychiatric illness. RESULTS: Twenty-five percent of subjects had current major depressive disorder, but only 25 percent of these received antidepressants. Anxiety disorders, including panic disorder (16 percent), and social (13 percent) and specific phobias (28 percent) were also common. All subjects with panic disorder were receiving appropriate therapy. CONCLUSIONS: Asthma patients with moderate to severe asthma treated at community health facilities may have high rates of often untreated mood and anxiety disorders. Interventions aimed at identifying and treating psychiatric disorders in this population are needed.     

Use of general medical services among Medicaid patients with severe and persistent mental illness

OBJECTIVE: The aim of this study was to examine patterns of use of general medical services among persons with a severe and persistent mental illness enrolled in Medicaid from 1996 to 1998. METHODS: A total of 669 persons with a severe and persistent mental illness were identified by using statewide clinical criteria. A three-year database of Medicaid claims was developed to examine service use. The main outcome measures were use of outpatient services for a general medical problem, use of dental and vision services, and use of screening tests for women. Service use was examined by primary psychiatric diagnosis (schizophrenic, affective, paranoid, and anxiety disorders), and analyses controlled for the presence of a chronic medical condition, age, race, and sex. RESULTS: This study found high levels of service use for outpatient services but very low levels for primary and preventive services. Although 78 percent of persons with a schizophrenic disorder had an office-based visit during the three-year period, all persons with an anxiety disorder had such a visit. Sixty-nine percent of persons with a schizophrenic disorder had at least one emergency department visit, whereas 83 percent of those with an anxiety disorder had such a visit. Dental and vision visits and the use of mammograms and pap tests followed the same pattern; persons with a schizophrenic disorder had fewer visits and had less overall use than the other diagnostic groups. The use patterns across the four groups were significantly different in outpatient service use, dental and vision service use, and screening tests for women. Compared with persons with a schizophrenic disorder, those with an anxiety disorder were more likely to have had an office-based visit and to have received vision services, those with a paranoid disorder were more likely to have used dental services or received a mammogram, and those with an affective disorder were more likely to have had a pap test. CONCLUSION: Although this group of Medicaid patients with severe and persistent mental illness had access to providers, they received an unacceptably low level of preventive care. Use of health services for general medical problems differed somewhat by primary psychiatric illness.     

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.     

Psychiatric Symptoms Endorsed by Somatization Disorder Patients in a Psychiatric Clinic

Patients with somatization disorder (SD) endorse high rates of psychiatric symptoms. However, prior studies have not addressed whether these endorsed symptoms reflect underlying psychiatric illness or whether they represent symptom overendorsement mirroring somatic complaints in patients with SD. Thirty-two female outpatients with SD and 101 with other psychiatric disorders completed a checklist of current and lifetime psychiatric symptoms. These findings were analyzed with respect to the diagnoses given by their treating psychiatrists. Patients with SD displayed significantly more current and lifetime psychiatric symptoms than did patients without either SD or cluster B personality disorder. Patients with SD endorsed a large number of psychotic, manic, depressive, and anxiety symptoms; however, they endorsed few alcohol use disorder symptoms. Psychotic and manic symptoms endorsed by patients with SD did not reflect their clinical diagnoses: only two patients with SD carried an additional clinician diagnosis of either schizophrenia or bipolar disorder, despite high rates of endorsed symptoms by the group. Patients with cluster B personality disorders but without SD showed a symptom profile similar to that of patients with SD. Psychiatric outpatients with SD endorse many more psychiatric symptoms than do other psychiatric patients. Patients with SD in the psychiatric treatment setting may mimic other psychiatric illnesses; therefore, SD should be considered in the differential diagnosis for a wide variety of psychiatric illness, including psychotic and mood disorders     

Anxiety and depression in an internal medicine resident continuity clinic: difficult diagnoses.

OBJECTIVE: To determine the prevalence of anxiety and depression in a residents' clinic and if these diagnoses are associated with patients being perceived as difficult, as well as how often these diagnoses are documented in the patients' charts. METHODS: This was a cross-sectional study conducted in a general internal medicine residents' clinic. A total of 135 patients were given the Primary Care Evaluation of Mental Disorders questionnaire (DSM-IIIR version) and their physicians filled out the Difficult Doctor-Patient Relationship Questionnaire after the visit. Charts were reviewed for documentation of a diagnosis of anxiety or depression. RESULTS: Major depression was present in 26 percent, dysthymia 16 percent, major depression in partial remission 9 percent, generalized anxiety disorder 13 percent, and panic disorder 7 percent. Overall, 38 percent had at least one and 21 percent had more than one diagnosis. Of patients with one psychiatric diagnosis, 9 percent were classified as difficult versus 100 percent of patients with four diagnoses. Documentation of depression was noted for 43 percent of patients with major depression but only 9 percent with an anxiety disorder. CONCLUSIONS: Anxiety and depression were very common among the patients in this clinic, and increasing numbers of diagnoses were associated with patients being classified as difficult. Residents diagnosed depressive disorders as often as practicing physicians in other studies, but anxiety less well. The high prevalence of mental disorders has implications for resident education in that they need to be prepared to care for these patients, but residents also may benefit from exposure to sites with more typical prevalences of these illnesses.     

Health status of individuals with serious mental illness

We examined indices of the health of persons with serious mental illness. A sample of 100 adults with schizophrenia and 100 with major mood disorder were recruited from randomly selected outpatients who were receiving community-based psychiatric treatment. Participants were surveyed about health indicators using items from the National Health and Nutrition Examination Study III and the National Health Interview Survey. Their responses were compared with those of matched samples from the general population surveys. A total of 1% of persons with serious mental illness, compared with 10% from the general population sample, met criteria for all 5 of selected health indicators: nonsmoker, exercise that meets recommended standards, good dentition, absence of obesity, and absence of serious medical co-occurring illness. Within the mentally ill group, educational level, but not a diagnosis of schizophrenia versus mood disorder, was independently associated with a composite measure of health behaviors. We conclude that an examination of multiple health indicators may be used to measure overall health status in persons with serious mental illness.     

Illness experience,depression, and anxiety in chronic fatigue syndrome

Objective: Given the high rate of psychiatric comorbidity with chronic fatigue syndrome (CFS), we considered two possible correlates of anxiety and depression: lack of illness legitimization and beliefs about limiting physical activity. Method: A total of 105 people diagnosed with CFS reported on their experiences with medical professionals and their beliefs about recovery and completed the depression and anxiety subscales of the Brief Symptom Inventory. Results: Those who said that their physician did not legitimize their illness (36%) had higher depression and anxiety scores (P's<.05) than their counterparts. Those who believed that limiting their physical exertion was the path to recovery (55%) had lower depression and anxiety scores (P's<.01) than their counterparts. Conclusion: Lack of illness legitimization ranked high as a source of dissatisfaction for CFS patients, and it may aggravate psychiatric morbidity. Many CFS patients believed that staying within what they felt to be their physical limits would improve their condition. This belief, and possibly an accompanying sense of control over their symptoms, may alleviate psychiatric morbidity.     

Mental health training of primary care physicians: an outcome study

It is well documented that primary care physicians encounter many patients in their practices who suffer psychiatric morbidity, especially affective, anxiety and substance abuse disorders. These physicians have been unable to effectively address the needs of these patients, over half of whom receive care exclusively in the primary care sector. Five years after implementing a curriculum to train family practice physicians to assume a comprehensive psychiatric role with patients in their practices, the authors undertook an outcome evaluation. The focus was on psychiatric disorder recognition, diagnosis, documentation, and management, including referral. It was hoped that biopsychosocial and community mental health orientations emphasized during training would be incorporated into the subsequent primary care practices of physicians in the study. In the research design, physician-generated diagnoses were compared with DIS/DSM-III diagnoses; physician interviews and chart audits enabled processes of care delivery to be evaluated. Unexpectedly, physicians were not found to assume an appropriately active or comprehensive mental health role in their practices following the training intervention. Of ninety-four DIS-generated diagnoses in the study population of fifty-one patients, 79 percent were unrecognized. Patients were assumed to function well emotionally, and psychiatric dimensions of patient complaints were not examined in the majority of cases. The physicians did diagnose and treat a number of patients with mental symptoms who were not identified by the DIS. These patients had high, but sub-diagnostic, DIS symptom counts. Most received a diagnosis of adjustment disorder in response to medical illness. Though this finding underscores shortcomings of present psychiatric nosology when applied in the general medical setting, the foremost consideration was the large number of DIS-identified patients with serious psychopathology, needing active assessment and intervention, who were unrecognized, undiagnosed or untreated. Implications of these findings for the psychiatric training of primary care physicians are examined.     

Comorbidity of psychiatric disorders and personality profiles of American World War II prisoners of war

To characterize the effects of trauma sustained more than 40 years ago, prevalence of psychiatric disorders and personality dimensions were examined in a sample of 62 former World War II POWs. The negative effects of their experiences are reflected in their multiple lifetime diagnoses and in their current personality profiles. Fifty percent met DSM-III posttraumatic stress disorder (PTSD) criteria within 1 year of release; 18 (29%) continued to meet the criteria 40 years later at examination (chronic PTSD). A lifetime diagnosis of generalized anxiety disorder was found for over half the entire sample; in 42% of those who never had PTSD, 38% of those with recovery from PTSD, and 94% of those with chronic PTSD. Ten percent of those without a PTSD diagnosis had experienced a depressive disorder, as had 23% of those with recovery from PTSD and 61% of the POWs with chronic PTSD. The combination of depressive and anxiety disorders also was frequent in the total sample (61%). Current MMPIs of three groups with psychiatric diagnosis were compared with those of POWs who had no diagnoses and with a group of Minnesota normal men. Profile elevations for the groups, from highest to lowest, were: POWs with chronic PTSD, POWs with recovery from PTSD, POWs with other psychiatric diagnoses, POWs with no disorders, and Minnesota normal men. Symptoms of anxiety, depression, and somatic concerns combined with the personality styles of suppression and denial characterize the current adjustment of negatively affected POWs.     

Depression and anxiety disorders in pediatric epilepsy

PURPOSE: This study examined affective disorders, anxiety disorders, and suicidality in children with epilepsy and their association with seizure-related, cognitive, linguistic, family history, social competence, and demographic variables. METHODS: A structured psychiatric interview, mood self-report scales, as well as cognitive and language testing were administered to 100 children with complex partial seizures (CPSs), 71 children with childhood absence epilepsy (CAE), and 93 normal children, aged 5 to 16 years. Parents provided behavioral information on each child through a structured psychiatric interview and behavior checklist. RESULTS: Significantly more patients had affective and anxiety disorder diagnoses (33%) as well as suicidal ideation (20%) than did the normal group, but none had made a suicide attempt. Anxiety disorder was the most frequent diagnosis among the patients with a diagnosis of affective or anxiety disorders, and combined affective/anxiety and disruptive disorder diagnoses, in those with suicidal ideation. Only 33% received some form of mental health service. Age, verbal IQ, school problems, and seizure type were related to the presence of a diagnosis of affective or anxiety disorder, and duration of illness, to suicidal ideation. CONCLUSIONS: These findings together with the high rate of unmet mental health underscore the importance of early detection and treatment of anxiety disorders and suicidal ideation children with CPSs and CAE.