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Index to Abstracts from AACFS Conference October 1998


Abstracts of Papers Presented at
The Bi-Annual Research Conference of the
American Association for
Chronic Fatigue Syndrome (AACFS)

October 10-11, 1998 -- Cambridge, Massachusetts

Poster Session 4: Interdisciplinary Psychiatry

Co-chairs: Mark Demitrack, M.D., and Michael Sharpe, M.D.
October 10, 1998 -- 4:30-5:00 pm

1. Doctor.patient relationship in primary care of CFS: perspectives of the doctor and the patient
J.B. Prins, G. Bleijenberg, E. Klein Rouweler, E. Bazelmans
2. Is Chronic Fatigue Syndrome related to a woman's double role?
E. Bazelmans, G. Bleijenberg, J.W.M. van der Meer, J.H.M.M. Vercoulen
3. Fatigue in disease-free cancer patients in comparison to fatigue in Chronic Fatigue Syndrome patients
P. Servaes, G. Bleijenberg, C. Verhagen, S. van de Werf
4. Characteristics of bedridden CFS patients compared to non-bedridden CFS patients
M. Alberts, G. Bleijenbera, E.H. Klein Rouweler, J.B. Prins, J.W.M. van der Meer
5. Dissatisfaction with one's own performance on a working memory task and neural activation on FMRI in Chronic Fatigue Syndrome and healthy subjects
Christopher Christodoulou, Ph.D.; Gudrun Lange, Ph.D.; John DeLuca, Ph.D.; Wen-Ching Liu, Ph.D.; and Benjamin H. Natelson, M.D.
6. Differences in the experience of fatigue between Chronic Fatigue Syndrome and Multiple Sclerosis
Christopher Christodoulou Ph.D., John DeLuca, Ph.D., Elizabeth A. Gaudino, Ph.D., Gudrun Lange, Ph.D., Lana Tiersky, Ph.D., and Benjamin H. Natelson, M.D.
7. Psychiatric diagnosis and comorbidity and Chronic Fatigue Syndrome
M. Di Giannantonio, M. Nacci, D. Racciatti, A. Barbenio, E. Pizzigallo
8. Short term group therapy for patients with Chronic Fatigue Syndrome
Stina Söderberg and Birgitta Evengård
9. Cognitive brain potentials in Chronic Fatigue Syndrome
Ronald Gordon, Arnold Starr and Henry Michalewski
10. Health-related personality variables in Chronic Fatigue Syndrome and Multiple Sclerosis
Susan K. Johnson, Ph.D., Gudrun Lange, Ph.D., Lana Tiersky, Ph.D., John DeLuca, Ph.D., Benjamin H. Natelson, M.D.
11. Cerebral representation of auditory working memory deficits in patients with Chronic Fatigue Syndrome: an FMRI study
Gudrun Lange. Ph.D., John DeLuca, Ph.D., Joseph A. Maidjian, MD, Wen-Ching Liu, Ph.D., Christopher Christodoulou, Ph.D., Benjamin H. Natelson, MD.
12. I. Cognitive behavioral group rehabilitative therapy for Chronic Fatigue Syndrome patients: a pilot study
Peter V. Madill, MD and Cathy Haynes, RN
13. II. A pre and post group therapy assessment of the high threat perception model of illness susceptibility of Wickram
Peter V. Madill, MD, and Ian Wickramseckera, Ph.D.
14. Negative life events in Chronic Fatigue Syndrome
L.A. Tiersky, J. DeLuca, G. Rappolt, & B. Natelson


Doctor.patient relationship in primary care of CFS: perspectives of the doctor and the patient

Authors:J.B. Prins, G. Bleijenberg, E. Klein Rouweler, E. Bazelmans
Dutch Fatigue Research Group, Dept. of Medical Psychology, University Hospital Nijmegen, the Netherlands

Objective: In a prevalence study among all family doctors in the Netherlands, the estimated prevalence of CFS was 112 patients per 100,000 inhabitants (Bazelmans et al., 1997). Probably this is a minimum estimate. Some family doctors never diagnose CFS, others are reserved in diagnosing CFS for fear of a self-fulfilling prophecy. CFS patients often complain about informational and emotional support from their doctors. The aims of the present study were to investigate whether family doctors use the diagnosis CFS, and whether they feel able to give sufficient information about CFS. Family doctors' attitudes towards CFS patients and factors influencing this attitude were investigated. Opinions of patients, as well as family doctors, about causes of CFS and about the doctor-patient relationship were compared. Finally, changes in the frequency of diagnosis, attitude and opinions over a period of two years with increased public attention for CFS were assessed.

Method: In 1995 seventy-three family doctors completed questionnaires concerning their experience and attitudes towards CFS patients. Twelve family doctors were interviewed more extensively. In 1997 another 48 family doctors answered the same questionnaires. From 211 CFS, patients data concerning causal attributions and doctor-patient relationship were analyzed as well.

Results: In 1995, less than one-half of the family doctors used the diagnosis CFS, compared to 62% two years later. The main reason for not diagnosing CFS was ignorance of the criteria for CFS. Only 10% of the family doctors felt able to give sufficient information about CFS. Nearly all of the family doctors wanted more information about CFS. Concerning their attitude towards CFS patients, half of the family doctors stated that they could sympathize less with the complaints of these patients than with the complaints of other patients. The degree of their empathy was determined by several factors, such as the number of CFS patients in their practice, willingness to attend to possible physical causes, and the number of years working as family doctor. As to the causes for CFS, a large discrepancy between family doctors and CFS patients was found. Patients consider mainly physical attributions for their complaints, whereas family doctors mainly attribute the complaints to psychosocial factors. Patients' opinions about the degree to which doctors did not take their complaints seriously differ for different categories of doctors. Doctors in hospital clinics specialized in CFS nearly always take complaints seriously, family doctors in 80% of the cases and other medical specialists in less than 50% of the cases. Family doctors' opinions about the relationship with CFS patients compared to other patients is less favourable. Family doctors reported that the visits of CFS patients take more time, they regularly experience problems with these patients, and they rate the communication and cooperation as bad.

Conclusion: Family doctors describe their knowledge of CFS as limited. Both family doctors and patients experience problems in their relationship. The empathy and understanding by family doctors is determined by number of patients and years of practising. Based on these results, family doctors are recommended to improve the relationship with CFS patients by expert knowledge of CFS, willingness to diagnose CFS, and attention to patients' causal attributions.

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Is Chronic Fatigue Syndrome related to a woman's double role?

Authors: E. Bazelmans, G. Bleijenberg, J.W.M. van der Meer, J.H.M.M. Vercoulen
Dutch Fatigue Research Group, Depts. of Medical Psychology and Internal Medicine, University Hospital, Nijmegen, the Netherlands

Objective: Chronic fatigue syndrome (CFS) is characterized by a severe disabling fatigue. In the Netherlands, at least one in thousand inhabitants is suffering from CFS, of which 81% are female (Bazelmans et al., 1996). One might wonder why women are more prone to CFS than men. It is often hypothesized that women have a risk of getting overloaded and fulfilling a double role. A lot of women are not only working, but also responsible for the housekeeping. If these women have children as well, there might be even more of a chance of getting overloaded; expressed in extreme fatigue and impairment. To recover, women might be in disadvantage again. Being able to behave according to their own limits is essential for improvement. If necessary, people can quit working. For women, feeling responsible for the housekeeping or having children still living at home, quitting these "jobs" might be extremely difficult, resulting in a worse prognosis for CFS.

Method: To find out whether a double role for women plays a role in CFS, data of a cross-sectional (Vercoulen et al., 1994), as well as a follow-up study (Vercoulen et al., 1996) are examined. Of the initial 298 CFS patients of the first study, 246 (83%) also completed a postal questionnaire at follow-up after 18 months.

Results: For the first hypothesis, data of the cross-sectional study were used. It appeared that 17% of these CFS patients were working women with children still living at home prior to the onset of complaints, 58% were women without this double role, and 25% were men. Because only a small part of the CFS patients were women with a double role, this can not be a sufficient explanation for the dvelopment of CFS. Still, it might be assumed that working women with children are more fatigued and impaired than non-working women, with or without children, or men. However, no differences were found. For the second hypothesis, the same groups were compared on the degree of change of fatigue and impairment between first assessment and follow-up. The results show that at follow-up, the degree of impairment had increased for women with children, with or without a job. This was not the case for women without children, or for men.

Conclusion: It does not seem to be a woman's double role that makes women more prone to CFS. Some indications are found that female CFS patients with children still living at home have a worse prognosis for the level of impairment.

Bazelmans E, Vercoulen JHMM, Swanink CMA, Fennis JFM, Galama JMD, van der Meer JWM, Bleijenberg G. The prevalence of CFS in The Netherlands. J Chronic Fatigue Syndrome 1996;2: 142.
Vercoulen JHMM, Swanink CMA, Galama JMD, Fennis JFM, van der Meer JWM, Bleijenberg G. Dimensional assessment in chronic fatigue svndrome. J Psychosom Res 1994;38:383-392.
Vercoulen JHNIM, Swanink CMA, Galama JMD, Fennis JFM, van der Meer JWM, Bleijenberg G. Prognosis in chronic fatigue syndrome (CFS): a prospective study on the natural course. J Neurol Neurosurg Psychiatry 1996;60:489-494.

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Fatigue in disease-free cancer patients in comparison to fatigue in Chronic Fatigue Syndrome patients

Authors: P. Servaes, G. Bleijenberg, C. Verhagen, S. van de Werf
Dutch Fatigue Research Group, Departments of Medical Psychology and Medical Oncology, University Hospital, Nijmegen, the Netherlands

Objective: Fatigue is a frequently encountered symptom in cancer patients, due to their illness or treatment. Recently several quality-of-life studies in disease-free cancer patients also mention fatigue as a frequent complaint long after treatment. In this study the prevalence of fatigue in a group of cancer patients in remission is described. In addition, an analogue with fatigue in Chronic Fatigue Syndrome (CFS) patients is made and comparisons between cancer patients who are extremely fatigued and those who are not were investigated.

Methods: 85 adult oncology patients from the departments of Medical Oncology, Surgery and Gynecology were included in the study. The patients were all in remission, i.e. disease-free and off treatment for a minimum of 6 months. The sample consisted of 50 men and 35 women with a mean age of 48.5. All patients had surgery, 22% had radiotherapy, 44% had chemotherapy, 9% had immunotherapy and 27% were treated with corticosteroid. The mean duration of treatment was 6 months and the mean time since treatment stopped was 40 months. Participating patients were asked to fill in the Checklist Individual Strength (CIS), which measures fatigue severity, the Beck Depression Inventory, the Spielberger Trait Anxiety Inventory and the Nottingham Health Profile.

Results: The prevalence of severe fatigue (measured with the CIS-fatigue, a subscale of the CIS, using a cut of score of 35) is 19%. This means almost one fifth of this sample of cancer patients in remission experiences extreme fatigue, comparable to fatigue in CFS patients. In comparison to CFS patients, cancer patients in remission are not severely depressed. Contrary to the results of studies with CFS patients they experience little indications of perceived physical, social and emotional health problems. Finally, they do not have elevated anxiety scores, when compared to healthy adults. For further analyses, the sample was divided into two groups: the fatigued group (CIS-fatigue score of 35 or higher) and the not-fatigued group (CIS-fatigue score of 34 or lower). No significant differences between the two groups were found for sex, age, level of education and treatment modalities, although in the fatigued group 40% had radiotherapy while only 17% in the not-fatigued group had radiotherapy. The fatigued group has significant higher scores on depression, anxiety and perceived physical, social and emotional health problems.

Conclusions: Years after treatment, one-fifth of a sample of patients treated for various sorts of cancer experience severe fatigue, comparable to fatigue in CFS patients.

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Characteristics of bedridden CFS patients compared to non-bedridden CFS patients

Authors: M. Alberts, G. Bleijenberg E.H. Klein Rouweler, J.B. Prins, J.W.M. van der Meer
Dutch Fatigue Research Group, Depts. of Medical Psychology and Internal Medicine, University Hospital, Nijmegen, the Netherlands

Objective: Bedridden patients are systematically underrepresented in studies on Chronic Fatigue Syndrome (CFS) since these patients are not capable of visiting the research centres. The objective of this study was to describe patient characteristics, severity of fatigue, psychiatric morbidity, and other fatigue- related factors and to compare these data with a matched non-bedridden group of CFS-patients.

Method: Twenty bedridden CFS-patients, recruited by the Dutch ME-association, agreed to participate. These patients were visited at their homes. During two weeks the patients rated their fatigue through self-observation four times daily on a scale of 0 (no fatigue) to 4 (very severe fatigue). The Daily Observed Fatigue Score (Vercoulen et al, 1996) could vary between 0 and 16. The same was done for pain. An actometer (an apparatus recording the activity level) was worn during the same period. Other measures were functional impairment (SIP), psychological well-being (SCL-90), and depression (BDI). Furthermore, an interview was performed to determine psychiatric morbidity and the Karnofsky score. Comparision data of 33 non-bedridden CFS-patients, matched on gender and duration of complaint, was available.

Results: Bedridden patients were solely women, age 42 ± 9 years, with an average duration of complaints of 12 years (range 4-32 years), and an average duration of being bedridden of 4 years (range 1-8 years). At present, no patients were working, whereas 75% were working before onset of their complaints. Eigthy percent of the patients were dependent on professional homecare, fifteen percent on family support, and one patient (5%) lived without such help. During the two week self-monitoring period, bedridden patients evaluated their fatigue and pain as twofold as intensive as the non-bedridden patients, and they reported significantly more headaches and gastrointestinal complaints. Bedridden patients experienced significantly more functional limitations in household activities, mobility, and walking. No difference was found on scores of depression and psychological wellbeing, although bedridden patients had significantly higher somatization scores. A significant lower level of activity was observed and all bedridden patients were defined as inactive (see paper, van der Werf). Clinical evaluation confirmed the significantly lower functional status (Kamofsky-score) in bedridden patients, and twofold higher prevalence of current psychiatric disorders was observed. Psychiatric disorders were: current depression, social phobia, agoraphobia, conversion, eating disorders, and post traumatic stress disorder.

Conclusion: In comparison to non-bedridden CFS-patients, bedridden patients are more fatigued, experience more impairment in basic activities, and are less active. Bedridden patients appear more focused on physical discomfort and report more physical complaints. They do not differ in self-reported measures of psychological wellbeing, although current psychiatric disorders were present in almost half of the group. Present psychiatric disorders were diagnosed more often in the bedridden group than in the comparison group.

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Dissatisfaction with one's own performance on a working memory task and neural activation on FMRI in Chronic Fatigue Syndrome and healthy subjects

Authors: Christopher Christodoulou Ph.D., Gudrun Lange, Ph.D., John DeLuca, Ph.D., Wen-Ching Liu, Ph.D., and Benjamin H. Natelson, M.D.

Objective: Chronic fatigue syndrome (CFS) patients tend to be quite dissatisfied with their cognitive functioning, particularly their memory and attention. However, neuropsychological studies indicate that their cognitive deficits while significant, tend to be mild. Using BOLD fMRI, this pilot study examined the pattern of neural activation associated with dissatisfaction with one's own performance on a working memory task in CFS subjects and in healthy controls.

Methods: Subjects consisted of 4 healthy, sedentary controls and 5 CFS patients who did not differ in age (M=36, range 23-42) or education (M=15, range 12-20). Only subjects without evidence of major medical diseases, sequelae of head injury, or learning disorders were included. EPI images were acquired using a 1.5 T GE Horizon scanner (TR 2000, TE 60/90). Subjects were scanned once over 5 epochs of 30 seconds each, alternating between binaural presentation of tones (off-period) and an MR modified version of the PASAT (on-period). Fourteen contiguous 5 mm slices oriented along the AC-PC line depicting BOLD contrast were obtained. ROI image analysis was performed using a cross-correlation technique to establish volume of activation in the dorso-lateral frontal cortex (DLF), the superior temporal gyrus (STG), and the angular gyrus (AG) of both hemispheres. A laterality index was established for each ROI to compare the percent difference in activation between the left and right hemispheres. Positive values reflect greater left-sided activation. Immediately following completion of the task, subjects were asked to state the largest number of errors they could have made on the task and still been have happy. Subjects were also asked the number of errors they thought they had made. Based on their responses, subjects were placed into one of two groups: Satisfied (those who felt they met or exceeded their own standards of performance, n=5; 2 of which were CFS) or Dissatisfied (those who felt they did not meet their standards; n=4; 3 were CFS). Two groups were also formed on the basis of the number of errors that subjects actually committed: Low Error (consisting of subjects with 0 or 1 error; n=4; 1 was CFS) and High Error (consisting of subjects with 4 or more errors; n=5; 4 were CFS).

Results: The Dissatisfied group displayed significantly more right-sided activity in DLF than the Satisfied group (See Table). Differences in the other ROI were not significant, although their trends were in the same direction. The Low and High Error groups did not differ on any ROI, nor did they display any trends (DLF p = .938; STG p = .755; AG p = .829).

Regions of Interest (ROI)

Unsatisfied

Satisfied

P

Frontal:

 

 

 

Dorso-lateral Frontal Lobe

4.2 (36.0)

61.7 (29.1)

.032

Posterior:

 

 

 

Superior Temporal Gyrus Only    

-19.6 (77.2)    

-1.9 (60.4)    

.710

Angular Gyrus Only

-46.4 (62.1)

1.1 (19.8)

.146

Conclusions: This pilot study provides evidence that one of the symptoms that is prominent in CFS (i.e., dissatisfaction with one's cognitive functioning) is associated with significantly greater right (vs. left side) activation of the DLF. While these results require replication, associations can be made with previous research. The right hemisphere has been associated with the processing of novel tasks for which a person has yet to develop a standard response. In addition, the right hemisphere has been associated with emotions, especially negative emotions. One hypothesis is that in the present study dissatisfied persons (i.e., those viewing their performance as substandard and/or negative) are delayed in establishing a routinized approach to performing the task. Thus they need to expend increased effort in an attempt to effectively adapt. Dissatisfaction of this kind may therefore be related to the experience of fatigue and/or increased effort.

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Differences in the experience of fatigue between Chronic Fatigue Syndrome and Multiple Sclerosis

Authors:Christopher Christodoulou, Ph.D.; John DeLuca, Ph.D.; Elizabeth A. Gaudino, Ph.D.; Gudrun Lange, Ph.D.; Lana Tiersky, Ph.D.; and Benjamin H. Natelson, M.D.

Objective: This study compared various aspects of fatigue in multiple sclerosis (MS) patients with significant fatigue and a group of chronic fatigue syndrome (CFS) patients. The MS patients provided an appropriate comparison group, since the etiology of their illness involves damage to the central nervous system.

Methods: Subjects consisted of 44 CFS, 56 MS, and 16 healthy controls. Subjects were excluded on the basis of psychiatric (history of bipolar affective disturbance, eating disorder, schizophrenia, alcohol or substance abuse), neurologic (stroke, seizures, dementia, moderate to severe head injury, and/or loss of consciousness for more than five minutes), and medication-related (steroids, benzodiazepenes) criteria. All subjects completed the Multidimensional Fatigue Inventory (MFI), which consists of five subscales: Mental Fatigue, Physical Fatigue, General Fatigue, Reduced Activity, Reduced Motivation. Since not all MS subjects experience significant fatigue, this study only included those 30 subjects scoring > 2 SD above the mean Total Fatigue score of the healthy controls (M = 37.5, SD = 11.6).

Results: Despite the elimination of the less fatigued MS patients, an ANOVA revealed a significant difference between the two illness groups on Total Fatigue Score (F [1, 72] = 9.38, p = .003), with CFS subjects scoring significantly above MS. ANOVAs on the MFI subscales revealed significant differences on General Fatigue (F [1, 72] = 8.49, p = .005) and Mental Fatigue (F [1, 72] = 11.80, p = .001), with CFS subjects higher on both. In order to control for the significant overall differences in Total Fatigue scores and to enable the examination of qualitative differences in fatigue, the five MFI subscale scores for each subject were then examined as a percentage of their Total Fatigue score. ANOVAs on the percent subscales revealed significant differences between CFS and MS subjects on Percent Mental Fatigue (F [1, 72] = 6.77, p = .011) and Percent Physical Fatigue (F [1, 72] = 4.58, p = .036). CFS subjects were significantly higher on Percent Mental Fatigue, while MS subjects were higher on Percent Physical Fatigue.

Conclusions: The present results extend the earlier finding that CFS subjects are particularly elevated in Mental Fatigue as compared to illnesses of a peripheral nature (e.g., peripheral neuromuscular diseases). In the present study CFS patients were elevated in Mental Fatigue in comparison to MS subjects, who are known to have a disorder of the CNS. In addition, because CFS subjects reported a lower percent of Physical Fatigue than MS, it appears that the fatigue in MS is more specifically related to motoric activities than in CFS. Clinicians treating CFS through gradual increases in activity may want to include prescribed target levels for mentally demanding activities (e.g., balancing a checkbook), in addition to more purely motor activities (e.g., exercise such as walking).

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Psychiatric diagnosis and comorbidity and Chronic Fatigue Syndrome

Authors: M. Di Giannantonio¹, M. Nacci¹, D. Racciatti², A. Barberio², E. Pizzigallo².
¹Clinic of Psychiatry and
²Clinic of Infectious Diseases
"G. D'Annunzio" University of Chieti, Italy.

Objective: To assess the usefulness of a neuropsychological evaluation for detecting a comorbidity between Chronic Fatigue Syndrome (CFS) and psychiatric syndromes, and for excluding the presence of major depression in patients with a severe and chronic fatigue.

Methods: Forty patients (30 females and 10 males) complaining of chronic fatigue underwent the diagnostic protocol for CFS in the National Reference Center for CFS Study at the Clinic of Infectious Diseases of "G. D'Annuniio" University in Chieti. All patients underwent a detailed psychiatric investigation and a battery of psychodiagnostic tests: Minnesota Multiphasic Personality Inventory (M.M.P.I.), and Hamilton tests for anxiety and depression. Furthermore, they received the WMS memory subscales, because of the high prevalence of poor concentration and memory disorders in CFS patients.

Results: All forty examined patients showed both current and preexisting psychiatric disorders. Patients with CFS were more likely to have somatization disorder and generalized anxiety disorder. Four patients received diagnosis of a preexisting major depression that excluded CFS. All patients attributed their illness to a physical explanation (i.e., viral infections, neuroendocrine alterations, exposure to toxics) while psychologic attributions were uncommon.

Conclusion: CFS patients show a high prevalence of concurrent psychiatric disorders, which often precede their fatigue syndrome. A psychiatric evaluation of patients with a chief complaint of chronic fatigue should be considered for a better understanding of the potential role of psychologic factors in determining the onset of fatigue and related symptoms.

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Short term group therapy for patients with Chronic Fatigue Syndrome

Authors:Stina Söderberg, Huddinge University Hospital and Birgitta Evengård, Karolinska Institutet at Huddinge University Hospital.

Objective: The purpose with this study was to improve and develop the care of patients with chronic fatigue syndrome (CFS ) through supporting the patient's ability to deal as well with their illness as with their life situation through group therapy.

Method: 14 women with CFS, motivated for participating in short term group therapy, were randomly distributed into two groups: one group received focused group therapy 10 times, 1.5 hour/week while the other group served as a control group and received group therapy 6 months later. The age varied between 28-52 years. Two of the group members were working full-time, five were partially working, and the others had sickness benefits or early retirement pensions. The duration of CFS among the patients varied between 1.5-6 years.

The group therapy may be described as a supportive, focused, short-time therapy. The evaluation of the group therapy was done with a questionnaire. In order to get a conception of the patient's ability to handle problems and stress in life, the Antonovskys Sense of Coherence (SOC) was used. For evaluation of the treatment effects subjective estimations of quality of life and symptoms of fatigue were registered before and after group therapy. For comparison between experimental and control group the paired T-test was used.

Results: The experiences and effects of short-term therapy with patients with chronic fatigue syndrome (CFS) is reported. More than half of the group reported that the therapy had been helpful in order to deal better with their life situation. Most appreciated was the exchange of experiences. The variables of evaluation, quality of life, and symptoms of fatigue, do not show any tendencies of statistical significance after group therapy.

Conclusion: The difficulties with short-term group therapy for CFS-patients is reported. It's important to draw attention to the problems and changes in the life situation and individual behaviour that is caused by CFS. As a alternative to try group therapy lasting at least 1 year, individual tailored short-term therapy is suggested.

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Cognitive brain potentials in Chronic Fatigue Syndrome

Authors: Ronald Gordon, Arnold Starr and Henry Michalewski ,U. of California at Irvine, Irvine, CA.

Objective: Fatigue is a pervasive feature in patients with chronic fatigue syndrome (CFS). Even simple mental or physical tasks require increased effort for these patients. CFS patients and normals were compared in four cognitive tasks during rested and fatigued states. It was hypothesized that patients with fatigue would differ in measures of behavior and measures of electrical brain activity compared to normals.

Methods: Tests included target detection, memory scanning, attention, and self-paced motor activity. Brain potentials were recorded from electrodes distributed over the surface of the scalp along with measures of reaction time (RT). Exp. (1) Auditory target detection: Required subjects to press a button upon detection of a random and infrequently occurring high tone imbedded in a sequence of low tones; Exp (2) Memory Test: Subjects were presented with either 1- or 5-item memory lists consisting of auditory verbal digits (numbers 1 through 9); after a pause, subjects were presented with a probe digit and indicated by button press whether or not the probe was a member of the memory list (in-set) or not (out-of-set); Exp. (3) Attention task: Subjects pressed a RT button to a high tone preceded 2.5 seconds earlier by a low tone. Exp. (4) Motor activity: Subjects made repetitive self-paced button presses at a slow rate (approx. 10 presses/mm).

Results: Reaction time tests indicated that, on average, CFS patients were slower than normals and that slowing was more pronounced during the memory test than target detection. Reaction times for CFS patients were more variable for these tasks compared to normals. For the attention task, reaction times were comparable between groups.

For brain potentials, significant differences were found between normals and CFS patients in some, but not all experimental conditions. Specifically, for target detection, CFS patients had smaller than normal brain potentials associated with response expectancy/preparation before the target appearance. However, no group differences were revealed between post-stimulus brain potentials related to sensory processing of the stimuli. For the Memory Test, significant differences were found in a late, slow brain potential related to memory scanning that was smaller in CFS patients; but, brain responses related to sensory processing were similar for both groups. No group differences in brain potentials were found in the attention task. Finally, some differences in brain potentials were revealed during the motor activity task. Here, CFS patients showed a smaller potential compared to normals when performing the task when feeling fatigued, but not when feeling rested.

Conclusion: Brain potentials recorded from the scalp appear useful in separating CFS patients and normals, but only for certain tasks. Tasks that appear to distinguish the two populations indicate that, in CFS, there is a weakness in accessing brain mechanisms related to motor preparation and execution. Sensory processing, as well as measures of attention and expectancy, are normal for CFS patients. Reaction time analyses indicate that slowness of response is not a general characteristic of CFS (as indicated by the attention task results), but are related to task demands (memory and target detection). Variance in reaction times among CFS patients may indicate that patients have "good" and "bad" days. A significant change in brain potentials associated with self-paced motor activity was apparent when subjects rated themselves as fatigued, opposed to rested. Thus, brain potentials reveal significant differences between CFS patients and healthy normals for tasks that require neural mechanisms responsible for motor preparation and execution.

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Health-related personality variables in Chronic Fatigue Syndrome and Multiple Sclerosis

Authors: Susan K. Johnson, Ph.D.; Gudrun Lange, Ph.D.; Lana Tiersky, Ph.D.; John DeLuca, Ph.D.; Benjamin H. Natelson, M.D.

Objective: This study examined personality variables in chronic fatigue syndrome (CFS, N=22), multiple sclerosis (MS, N=16) as well as in healthy controls (N=l6). CFS and MS share a number of symptoms such as fatigue, depression, and neuropsychological difficulties, yet the etiology of CFS is unresolved whereas etiology in MS is neuropathologic.

Methods: The groups were compared on the following illness-related personality measures: Toronto Alexithymia Scale, Health Locus of Control, Hardiness, Attributional Style Questionnaire, Perceived Stress Scale, Attribution for CFS.

Results: An over all MANOVA was significant, Pillai Trace F (34,62) = 2.2, p=.005, and a test for multi-colinearity showed that the personality variables are independent. Post-hoc tests for specific effects found significant differences for Alexithymia, both MS and CFS were higher than Hea (F(2,51)=5.8, p=0.005). CFS was significantly lower on Health LOC measure for Doctors/other control (F(2,51)=8.6, p=0.001). Both CFS and MS groups show significantly lower global attribution for good events (F(2,51)=3.8, p=0.03) and significantly higher stable attribution for bad events (F(2,51)=3.2, p=0.04) compared to the healthy group. There were no differences in perceived stress levels among the three groups or on the hardiness measure which assessed challenge, control and commitment. When CFS subjects were asked to choose an attribution for their illness, 43% selected the item "my illness is a physical one," 38% chose "my illness is mainly physical," while 19% elected "both physical and psychological factors are involved with my illness." No subjects chose psychological factors as predominant.

Conclusion: CFS and MS groups were higher on alexithymia, characterized as difficulty in describing and differentiating emotions and marked externalization. CFS and MS groups reported a more depressive attributional style than healthies, reflecting beliefs that causes for good events are not diffused into other areas of life while causes for bad events will always be present. These findings could reflect responses to coping with chronic illness. CFS group was significantly lower on Doctors/Others LOC indicating lack of trust in medical professionals. When designating an attribution for CFS, 81% chose physical factors as primary, reflecting organic illness conviction and possible defensiveness regarding psychological views on the illness. Results indicate that CFS and MS are similar to each other while different from the healthy group on certain personality variables that likely reflect the demoralizing effects of coping with a chronic, disabling illness marked by uncertainty. CFS subjects have the additional burden of an illness that lacks medical legitimacy.

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Cerebral representation of auditory working memory deficits in patients with Chronic Fatigue Syndrome: an FMRI study

Authors: Gudrun Lange, Ph.D.; John DeLuca, Ph.D.; Joseph A. Maldjian, MD; Wen-Ching Liu, Ph.D.; Christopher Christodoulou, Ph.D.; Benjamin H. Natelson, MD.

Objective: The purpose of this preliminary study was to examine cerebral patterns of brain activation in response to a complex auditory working memory task (mPASAT) in CFS patients and healthy, sedentary controls using functional magnetic resonance imaging (fMRI). Previous neuropsychological studies have shown that performance on a complex auditory working memory task (PASAT) is impaired (total score > 1 SD below that of normal controls) in many CFS subjects. Findings of structural and functional neuroimaging studies in CFS are suggestive of organic cerebral changes in regions subserving the working memory system.

Methods: Two groups were studied: 4 healthy, sedentary controls, 5 CFS patients. Subjects were matched for age (M=36, range 23-42) and education (M=15, range 12-20). Only subjects without evidence of major medical diseases, sequelae of head injury, or learning disorders were included. EPI images were acquired on a 1.5 T GE Horizon scanner using a standardized acquisition protocol. The number of total errors made on the mPASAT was obtained to validate the subjects' performance in the scanner.

Results: Region of Interest (ROI) image analysis was performed using a cross-correlation technique to establish volume of activation in the dorso-lateral frontal cortex (DLF), the superior temporal gyrus (STG), and the angular gyrus (AG) of both hemispheres. To examine whether absolute activation volumes were different between groups, an activation index was established for each ROI, reflecting the absolute difference between right and left hemisphere activation. Thus, a lower absolute value indicates more bilateral activation, a higher value more unilateral activation. Comparisons using Students T-tests show that CFS patients have increased bilateral activation in the STG relative to controls (p=.02), with a trend in the AG (p=.12). No group differences were observed in DLF (p=.76). CFS subjects made more errors on the mPASAT (M=5.6; SD=3.l) than did healthy controls [M=1.0; SD=2.0), F(1,7)=6.4; p=.039].

Conclusion: Cerebral patterns of activation in response to a complex auditory working memory task are equally lateralized in CFS subjects relative to healthy, sedentary controls. In contrast, posterior activation, specifically in the STG, is more diffuse, less lateralized in CFS subjects than controls. These data suggest that impaired performance of CFS subjects on a complex auditory working memory task may not be due to local changes within the DLF, but that the function of the working memory system may be affected by changes in posterior brain regions.

Acknowledgment: This study was supported by NIH grants M-32247 and MH52810.

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I. Cognitive behavioral group rehabilitative therapy for Chronic Fatigue Syndrome patients: a pilot study

Authors: Peter V. Madill MD and Cathy Haynes, RN.

Objective: The purpose of this pilot study was to assess the feasibility of administering cognitive behavioral therapy to Chronic Fatigue Syndrome patients in a group setting.

Method: Patients for this pilot study were recruited through the first investigator's private practice and a local chronic fatigue syndrome support group. From a larger pool, fourteen patients meeting the 1994 CDC criteria for CFS were chosen to participate in the group therapy experiment. The group met for two hours one afternoon per week. The formal pilot study lasted for twelve weeks, although most of the original group continued to meet on their own on a bi-weekly basis. The time during the group sessions was allotted equally between instruction in a carefully scripted cognitive behavioral therapy, as described by Sharpe and Wessely et al., group sharing and Qi-Gong exercises. The group sharing was encouraged in relationship to the members' experiences with the cognitive and gradual/graded exercise components of the therapy, as well as creating a forum to share their deepest thoughts and feelings about their lives, especially in regard to the deprivations and losses CFS has led to, following the lead of the Stanford University cancer therapy group program. The particular Qi-Gong exercises were chosen from the lexicon of Qi-Gong, the ancient Chinese mind-body therapeutic exercise art. The progress of the participants is being monitored by narrative self-report, the empirically validated CFS fatigue scale of Wessely et al., which is administered at the beginning of trial, and at six months and twelve months of follow-up. Records of medical clinic attendance are also being reviewed at these intervals.

Results: At the time of this abstract writing, the six and twelve month follow-up data are pending. The six month follow up data will be available at the October AACFS conference. The immediate post group fatigue assessment indicates a reduction in fatigue scores averaged for the group was significant (p=.05).

Conclusions: This pilot study supports the feasibility of offering the proven cognitive behavioral/exercise therapies for CFS patients in a group setting. It is felt that adding the group sharing as pioneered by the Stanford University cancer group therapy program and exercises chosen from Qi-Gong enhances the efficacy of the group therapy program. The ability to offer these therapies in a group setting has clear cost-cutting implications.

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II. A pre and post group therapy assessment of the high threat perception model of illness susceptibility of Wickram

Authors: Peter V. Madill MD, and Ian Wickramseckera, Ph.D.

Objectives: The purpose of this pilot study was to assess the potential relevance of the Wickram high-threat perception model of illness susceptibility to a group of CFS patients meeting the CDC criteria for Chronic Fatigue Syndrome, in comparison to a group of age and sex-matched controls.

Method: Patients for this pilot study were recruited through the first investigators private practice and a local chronic fatigue syndrome support group. From a larger pool, fourteen patients meeting the 1994 CDC criteria for CFS were chosen to participate in the pre-and post-group therapy assessment. Wickram's high-threat perception model of illness susceptibility has been receiving support in the behavioral medicine literature, especially in relationship to predicting and understanding core perpetuating factors in defined groups of chronically ill patients. This model involves the administration of a battery of psychometric tests, including a standardized biofeedback psychophysiologic evaluation, which generate the individualized data on the basis of which illness susceptibility risk is predicted by the Wickram high-threat perception model. At the same time a similar group of age and sex-matched controls were administered the same battery of tests that comprise the Wickram profile. The profile was administered before the group therapy experience, and six months following the completion of the group process.

Results: While we are awaiting the six-month follow up data, comparison of the scores on the tests with those of the control group indicate significant differences between the CFS patients and the control group, which will be detailed in the poster presentation. At this time the six-month data will also be available.

Conclusions: The demonstration of clear differences in tests scores between the CFS group and the control group, point to the possible value of the Wickram high-threat perception illness susceptibility model in understanding some aspects of patient's susceptibility to CFS and the pathogenesis of CFS in these patients.

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Negative life events in Chronic Fatigue Syndrome

Authors: L. A. Tierskv, J. DeLuca, G. Rappolt, & B. Natelson.

Objective: The purpose of the present investigation was to determine if individuals with Chronic Fatigue Syndrome (CFS) experience more negative and stressful life events than healthy individuals. Based on the literature which suggests that chronic illness is associated with an increase in negative life experiences, it was hypothesized that CFS subjects would experience more negative life events than healthy controls. Moreover, since it is suggested that psychiatric disturbance can lead to a further reduction in life quality in individuals with chronic illness(es), it was hypothesized that CFS subjects with pre-morbid and/or concurrent psychiatric disorders would experience the most negative life experiences.

Methods: Four groups of individuals were evaluated: 19 subjects with CFS and a psychiatric disorder(s) predating the onset of their CFS, 48 individuals with CFS who developed a psychiatric disorder(s) following the onset of their illness, 56 individuals with CFS and no history of a psychiatric disorder, and 38 healthy controls with no significant medical or psychiatric illnesses. All subjects completed an extensive physical and psychiatric evaluation. All CFS subjects met the 1994 case definition criteria for the illness (Fukuda et al., 1994). A modification of the PERI Life Events scale was administered to all subjects. On this measure CFS subjects endorsed the negative life events experienced at three different time points: anytime before CFS onset, anytime after CFS onset, and in the six months prior to CFS onset. Healthy subjects indicated if they experienced a given event at any point in time. A total lifetime score of negative events was computed for the CFS subjects to facilitate comparison to the healthy controls. All subjects also rated the stressfulness of each event experienced.

Results: All CFS subjects reported significantly more negative life events than healthy controls. Individuals with a psychiatric disorder predating CFS onset, experienced more negative life events following the onset of their illness (i.e., CFS) than the other two CFS groups. There were no significant differences among the three CFS groups in the number of negative life events experienced before CFS onset. Moreover, there were no differences among the three CFS groups in regard to the severity of the events experienced at any time-frame.

Conclusions: Individuals with a chronic illness such as CFS are susceptible to experiencing negative and stressful life events that affect all realms of personal, social and occupational functioning. Moreover, individuals with a psychiatric illness(es) predating the onset of their illness are at increased risk of experiencing negative life events after they become ill with CFS. A pre-illness psychiatric history may make individuals particularly vulnerable to the negative experiences associated with chronic illness.

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Index of Papers -- AACFS Conference October 1998
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