Author: N.A. Endicott, M.D., Department of Research Assessment and Training, New York State Psychiatric Institute, New York, New York.
Objective: This study attempted to determine if patients from a psychiatric practice who met the criteria for Chronic Fatigue Syndrome (CFS) had evidence of different premorbid patterns of brain organization than psychiatric patients who did not meet these critena.
Methods: Patients with CFS (N=46) were matched on age, sex and psychiatric diagnosis with relatively physically healthy patients (N=92) and patients selected without regard to physical health status (N=46). The groups were compared on 20 anomalous brain conditions or phenomena (ABCP).
Differences in the patterns of brain organization were determined by questioning the patients on the life-time occurrence of 20 anomalous brain conditions or phenomena (ABCP). Exarnples of ABCP used in the present study included dyslexia, arithmetic learning disorders, speech disorders, left-right discrimination difficulties, mixed or left handedness, migraine headaches, visual scotomata not associated with headaches and seizures.
Anomalous brain conditions or phenomena (ABCP) are hypothesized to be associated with specific patterns of functional brain organization. Since the phenomenology by which the ABCP are identified deviates from the statistical norm for each of these various types of behavior or phenomena, it is hypothesized that the associated patterns of functional brain organization also differ in significant respects from those associated with behaviors which are phenomenologically more normative. It was further hypothesized that as a consequence, the ABCP may be utilized as markers for the patterns of functional brain organization with which they are associated. Since it is unlikely that the patterns of functional brain organization which are associated with one ABCP will be identical to those associated with another, it follows from the above that differences in the type and number of ABCP reflect different overall patterns of functional organization of the entire brain. That is, the specification of different types, numbers of, and/or patterns of ABCP can be utilized as one method of defining or distinguishing differences in the pattern of functional organization of the brain.
Results: The mean ages for the three groups were 41.3, 42.2, and 42 years (p=n.s.) and the mean years of education were 15.3, 15.6, and 15.5 (p=n.s.). All three groups were 83% female and 89% of the CFS patients had developed a major depression at some time during their lifetime.
Psychiatric patients who subsequently developed CFS reported a significantly greater number of pre-CFS ABCP (5.1 vs. 3.3 and 3.9) (both p < .05), which included those of both childhood (3.0 vs. 2.1 & 2.3) (both p < .05), and adult onset (2.1 vs. 1.2 & 1.6) (both p < .05), than did either control group.
Conclusion: The results suggest that psychiatric patients who develop CFS have a different pre-CFS pattern of brain organization than psychiatric patients who do not develop CFS. A hypothesis relating these findings to the pathogenesis of CFS is presented.
Authors: V. Blomkvist, B. Evengård, G. Lindh, T. Theorell; Institute of Psychosocial Medicine and Dept of Infectious Diseases at Huddinge University Hospital, Karolinska Institutet, Stockholm, Sweden
Objective: The present study aimed at describing the sequence of psychosocial events and infections preceding the onset of CFS. This information was related to the temporal development of crucial symptoms in relation to the onset - namely fatigue, sadness, hostility, pain and feeling of fever.
Methods: A personal interview was performed with 46 patients who filled the international CFS criteria and who had consulted a specialized CFS unit at the clinic of infectious diseases, Huddinge hospital. These patients were matched with regard to age and gender to 46 referents in two different public sector work sites. Twenty-three percent of the study subjects were men. The mean age was 39.5 years, with a standard deviation of 9 years. The distribution of occupational groups did not differ between patients and referents, although there tended to be more administrative occupations among the referents (65% versus 48%) and more occupations dealing with people (care, teaching) among the patients (37% versus 30%). 6.5% and 4.4% of the patients and referents were unemployed, respectively. The focus was on the temporal sequence of events and symptoms. In order to avoid memory artifacts in the comparison between cases and referents, the interviewer identified the time that the patient considered to be the onset of CFS. In the corresponding way, the referents were asked to identify a very difficult period within approximately the same period as the patient that the referent person was matched to. A list of 14 different life events was pursued. The participants were asked to identify for each month whether each one of the listed events had occurred. Furthermore they were asked to rate the importance of the events that they had experienced. In addition, for each one of the cardinal symptoms (fatigue, sadness, hostility, pain and feeling of fever) and for each month, the subjects were asked to rate on a visual analogue scale the intensity. The following questions were asked: Is the temporal sequence of symptoms surrounding the event different in patients and referents? What is the temporal relationship between life events and infections during the period preceding the CFS? Sixty-seven percent of both patients and referents reported at least one clearly negative life event during the year preceding the onset (spouse conflict, conflict with close friend or relative, illness or accident in spouse, death of spouse, death of close relative or friend, crisis in the financial situation, conflict at work).
Results: A statistically significant group difference in fatigue intensity existed during the period four to ten months before the onset of CFS. During the three months preceding the peak of the crisis, there was a dramatic rise in fatigue in both groups. The CFS group reached a much higher level, which leveled off somewhat during the first year of follow-up, but still remained very high in comparison with the referent level. In the latter group, pre-crisis levels were reached four months after the crisis. With regard to sadness, no group difference was observed during the period preceding the crisis. In the patient group the level stayed high throughout the whole first year of follow-up, whereas a slow return started in the referent group - pre-crisis levels were reached after one year. A very similar profile was observed for irritability/hostility. With regard to pain and feeling of fever, the referent group stayed on a low level throughout, whereas in the CFS group, a slightly elevated level was observed during the year preceding onset. After the crisis, the level was markedly higher in the CFS group, with some leveling off towards the end of the follow-up year- but with large differences remaining between cases and referents.
Conclusion: The two groups have been selected in such a way that they have a similar demographic background. The interview was focused on the sequence surrounding a life crisis. The patients in the CFS group differed from the referents with regard to fatigue, pain, and feeling of fever during the months preceding the crisis. With regard to depressive and irritable feeling, no pre-illness differences were observed between the groups. In the referent group, depression and irritability symptoms in relation to the life crisis disappeared within a year. Sixty-seven percent of the CFS patients had a clearly negative life event preceding infection, which preceded CFS onset.
Authors: D. Fairhurst*, M. Waterman*, S. Lynch**
*Cognitive Group, School of Psychology, University of Leeds, Leeds LS2 93T
**Dept. of Psychiatry, School of Medicine, University of Leeds, Leeds.
Objectives: In CFS research, literature has more recently focused on slowed speed of information processing as an explanation for observed deficits in mental performance (12) (9) (11) (7) (2). However, there are also reports of similar deficits in patients with depression, anxiety, schizophrenia and senility (4) (9). It is therefore important to make explicit the nature of such slowing. Additionally, given the high incidence of depression and anxiety in the CFS population (1) it seems important to elucidate their role in tests of speeded performance.
Methods: 62 tertiary-care clinic attendees (11) and a group of matched controls completed measures of speeded performance (lexical decision and word-pair relatedness judgrnents, and decision tasks with graded conceptual load), logical memory and paired-associate subtests from the WMS-R (13), the HAD scale (14) and the Profile for Fatigue Related Symptoms (10).
Results: In support of previous research (3) (6), subjective cognitive fatigue did not correlate with easy paired-associated or logical memory (p > 0.05) but did correlate with performance on hard paired-associates, [p < 0.05 (8) (5)]. Partial correlations, controlling for anxiety and depression, showed a significant positive correlation of subjective cognitive fatigue with reaction time in tests of speeded performance (p <0.05). An independent t-test showed significant differences in lexical decision time between CFS patient and controls, (p < 0.05). MANOVAs revealed significant main effects of group, such that CFS patients were slower than controls on word relatedness.
Conclusions: Perception of fatigue does vary with objective measures of performance speed. This appears to be independent of comorbid anxiety and depression. The CFS group appears to perform more slowly than controls in tests with a higher conceptual-processing load. These results are discussed within the framework of a more specific profile of cognitive slowing in CFS.
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3. Grafman J, Schwartz V, Dale JK, Scheffers M, Houser C, Straus SE. Analysis of neuropsychological funtioning in patients with chronic fatigue syndrome. Journal of Neurology Neurosurgery and Psychiatry 1993;56:684-9.
4. Hartlage S, Alloy LB, Vaquez C, Dykman B. Automatic and effortful processing in depression. Psychological Bulletin 1993,113(2)247-78.
5. Joyce E, Blumenthal S, Wessely S. Memory attention and executive function in chronic fatigue syndrome. Journal of Neurology Neurosurgery and Psychiatry 1996;60(5):495-503.
6. Krupp LB, Sliwinski M, Masur DM, Freidburg F. Cognitive functioning and depression in patients with CFS and MS. Archives of Neurology 1994;51(7):705-10.
7. Marshall PS, Forstot M, Callies A, Peterson PK, Schenck C. Cognitive slowing and working memory difficulties in Chronic Fatigue Syndrome. Psychosomatic Medicine 1997,59:58-66.
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Authors: Richard G. Marlin, Marilyn E. Swinton, Harvey Anchel, and Jarnes C. Gibson
Objective: This study compared cognitive performance, and physiological characteristics of patients diagnosed with either chronic fatigue syndrome, fibromyalgia, or chronic pain syndrome, in an effort to identif~ either differences, or similarities in possible psychopathology, behavioural characteristics, and cognitive functioning.
Methods:Patients meeting the CDC criteria for chronic fatigue syndrome, the American College for Rheumatology criteria for fibromyalgia, or the IASP criteria for chronic pain syndrome, were assessed using all sub-tests of the Wechsler Adult Intelligence Scale-Revised (WAIS-R), and the standard validity and clinical scales for the Minnesota Multiphasic Personality Inventory 2 (MMPI-2). Demographic data including age, gender, duration of symptoms, and duration of vocational disability were also collected. Comparisons were made between the cognitive performance of patients, the apparent presence of psychopathology based upon the MMPI, and other psychological characteristics inferred from the MMPI between groups.
Results: Cognitive performance of patients diagnosed with chronic fatigue syndrome, or fibromyalgia were comparable, and showed no evidence of either global or specific impairments relative to chronic pain patients. None of the 3 groups showed evidence of the presence of marked psychopathology that could not be accounted for based upon their overall illness. Commonalities in psychological and behavioural characteristics inferred from the MMPI were marked and significant, with no consistent differences between the 3 groups.
Conclusion: These data suggest that a psychiatric characterization of any of these syndromes (independent of the clinical features of the syndromes themselves) has very little support, and therefore is not likely to represent a useful conceptualization of these disorders. Cognitive performance for both patients with diagnoses of chronic fatigue syndrome or fibromyalgia did not yield evidence of significant neurocognitive compromise, and was not impaired relative to chronic pain patients. This suggests that understanding these disorders in terms of central nervous system pathology is not likely to be useful, and is consistent with other studies more directly exploring potential pathophysiology in these groups of patients. The marked similarities in what is best characterized as patients' coping styles, and behavioural and cognitive responses to their difficulties, together with increasing evidence for the efficacy of cognitive-behavioural therapy, strongly suggests that the most useful "fmal common pathway" to understand chronic fatigue syndrome and fibromyalgia is at a behavioural and psychological level, rather than in terms of either an underlying pathophysiology or an underlying psychopathology. This is not to suggest that these illnesses have no physiologic basis, or are somehow imaginary, but rather that consistent with other problems of chronic disability, analysis at the level of physical, cognitive, and psychological functioning, and treatment based upon cognitive-behavioural principles is likely to carry the most explanatory power, and greatest clinical utility.
Objective: This presentation details incompatibilities between CFS symptoms and culturally prescribed expectations for work that place CFS sufferers at risk for job loss and disability. Strategies individuals with CFS devise to remain employed are also described.
Methods: Sixty-six persons meeting clinical criteria for CFS participated in in-depth interviews as part of a larger anthropological study. Interviews were audio-taped, transcribed, and subjected to thematic analysis.
Results: Unpredictable symptom flare-ups interfere with the ability to commit to a work schedule. Memory and concentration problems impede job-related learning and communication. Fatigue reduces levels of effort and hence, productivity. Confusion, pain, and lack of stamina complicate commuting to the workplace. Persons with CFS counter these challenges by making work a priority, compensating for deficits, "passing" as healthy, and maximizing job flexibility.
Conclusion: Accommodations that eliminate unnecessary physical demands, allow for flexible schedules, and make < full-time employment economically viable will reduce work-related disability among persons with CFS.