Uplifts and hassles are related to worsening in chronic fatigue syndrome: a prospective study.

BACKGROUND: Limited published data suggests that absence of uplifts (minor pleasant events) is associated with clinical worsening in patients with chronic fatigue syndrome (CFS). The current study aimed to assess the relation of illness worsening to the trajectories of social and non-social uplifts and hassles in a six-month prospective study in CFS. METHODS: Participants were primarily in their 40s, female, white, and ill for over a decade. All participants (N = 128) met criteria for CFS. The interview-based global impression of change rating was used to classify individual outcomes as improved, unchanged, or worsened at six- month follow-up. Uplifts and hassles, both social and non-social, were assessed with the Combined Hassles and Uplifts Scale (CHUS). The CHUS was administered weekly in online diaries over six months. Linear mixed effect models were utilized to examine linear trends for hassles and uplifts. RESULTS: No significant differences were found between the three global outcome groups for age, sex, or illness duration; however, work status was significantly lower for the non-improved groups (p < 0.001). Non-social hassles intensity showed an increasing slope for the worsened group (p = 0.03) and a decreasing slope (p = 0.05) for the improved group. For the worsened group, a downward trend was found for frequency of non-social (p = 0.01) uplifts. CONCLUSION: Individuals with worsening as compared to improving illness in CFS show significantly different six-month trajectories for weekly hassles and a deficit in uplifts. This may have clinical implications for behavioral intervention. Trial registration ClinicalTrials.gov ID: NCT02948556.

Nonimprovement in Chronic Fatigue Syndrome: Relation to Activity Patterns, Uplifts and Hassles, and Autonomic Dysfunction.

OBJECTIVE: To test a model of nonimprovement in chronic fatigue syndrome (CFS) using self-report activity patterns (e.g., "push-crash"), uplifts and hassles, and a biological measure of cardiac autonomic function. Activity pattern impacts on symptoms and objective measures of autonomic and physical activity were also examined. METHODS: This prospective study in CFS collected all data remotely, including 6 months of weekly web diaries that recorded symptom ratings, activity patterns, and hassles and uplifts. In addition, 6 months of weekly heart monitoring and 3 months of daily waking actigraphy data were collected. Improvement or nonimprovement status was assessed using semistructured interviews at the 6-month follow-up. RESULTS: A total of 148 individuals (87.2% female) were enrolled, and 12.2% were lost to follow-up. Participants reporting nonimprovement ( n = 92), as compared with improvement ( n = 38), showed greater autonomic dysfunction (lower heart rate variability, group difference = 5.93 [SE = 2.73] milliseconds; p = .032) and lower mean intensity of behavioral uplifts (group difference = 0.14 [SE = 0.16]; p = .043), but no significant differences in any activity pattern, including push-crash, limiting activity, and healthy pacing. CONCLUSIONS: This study provided evidence for linking patient-reported nonimprovement to a biological variable indexing autonomic dysfunction and a behavioral measure indicating a deficit in psychological uplifts. These findings suggest a possible marker of illness trajectory that could potentially advance the biomedical underpinnings of CFS.Trial Registration:ClinicalTrials.gov ID: NCT02948556.

Trauma-Focused Smoking Cessation for Smokers Exposed to the World Trade Center Disaster: A Randomized Clinical Trial.

INTRODUCTION: The main objective was to evaluate the efficacy of an 8-session, group-based comprehensive smoking cessation and trauma management (CSC-T) treatment among daily smokers (≥5 cigarettes/day) exposed to the World Trade Center (WTC) disaster with elevated WTC-related post-traumatic stress disorder (PTSD) symptoms. METHODS: Participants (N = 90) were randomly assigned to CSC-T (N = 44; 63.6% white; 27.3% female; mean age = 51.32 ± 7.87) or comprehensive smoking cessation (CSC) alone (N = 46; 71.7% white; 28.3% female; mean age = 48.74 ± 10.66), which was comparable in length and time. Assessments included a diagnostic clinical interview and self-report measures of PTSD and respiratory symptoms, and smoking behavior, and biologically confirmed smoking abstinence. Evaluations occurred at a baseline visit, each treatment session, and at 1-, 2-, 4-, 12-, and 26-weeks post-treatment. RESULTS: The two treatments did not differ in regard to PTSD symptom improvement. After quit day (week 6), the two groups had similar 7-day (~15%) and 6-month (~20%) abstinence rates as well as average number of cigarettes smoked, and PTSD and respiratory symptoms. CONCLUSIONS: It is possible that the Cognitive Behavioral Therapy skills specific to quitting smoking, group-based support, and degree of therapist contact, that were available in both treatments may have played a role in equalizing the abstinence rates between the two conditions. Although the current study found no evidence that the CSC-T was superior to the CSC alone treatment, the abstinence rates observed were high relative to previous trials of smokers with diagnosed PTSD. Further development of smoking cessation programs tailored to the needs of smokers with PTSD symptoms continues to be needed. IMPLICATIONS: This study suggests that a CSC program aids in smoking abstinence for smokers with PTSD symptoms and that incorporating trauma management skills, may not add additional benefits for abstinence and PTSD and respiratory symptom relief. Further work is needed to improve smoking cessation efforts for smokers with PTSD symptoms.

Defining recovery in chronic fatigue syndrome: a critical review.

PURPOSE: In chronic fatigue syndrome (CFS), the lack of consensus on how recovery should be defined or interpreted has generated controversy and confusion. The purpose of this paper was to systematically review, compare, and evaluate the definitions of recovery reported in the CFS literature and to make recommendations about the scope of recovery assessments. METHODS: A search was done using the MEDLINE, PubMed, PsycINFO, CINAHL, and Cochrane databases for peer review papers that contained the search terms "chronic fatigue syndrome" and "recovery," "reversal," "remission," and/or "treatment response." RESULTS: From the 22 extracted studies, recovery was operationally defined by reference with one or more of these domains: (1) pre-morbid functioning; (2) both fatigue and function; (3) fatigue (or related symptoms) alone; (4) function alone; and/or (5) brief global assessment. Almost all of the studies measuring recovery in CFS did so differently. The brief global assessment was the most common outcome measure used to define recovery. Estimates of recovery ranged from 0 to 66 % in intervention studies and 2.6 to 62 % in naturalistic studies. CONCLUSIONS: Given that the term "recovery" was often based on limited assessments and less than full restoration of health, other more precise and accurate labels (e.g., clinically significant improvement) may be more appropriate and informative. In keeping with common understandings of the term recovery, we recommend a consistent definition that captures a broad-based return to health with assessments of both fatigue and function as well as the patient's perceptions of his/her recovery status.

Cost-effectiveness of chronic fatigue self-management versus usual care: a pilot randomized controlled trial.

BACKGROUND: Fatigue is a common yet difficult to treat condition in primary care. The objective of this study is to evaluate the cost-effectiveness of a brief cognitive behavioral therapy (CBT) based fatigue self-management (FSM) intervention as compared to usual care among patients with chronic fatigue in primary care. METHODS: An economic evaluation alongside of a parallel randomized controlled study design was used. Computer-generated variable-sized block randomization plan was used to assign patients into treatment groups and data collection staff were blinded to group assignments. Patients aged between 18 and 65 years with at least six months of persistent fatigue and no medical or psychiatric exclusions were enrolled from a large primary care practice in Stony Brook, New York. The FSM group (n = 37) received two sessions of a nurse-delivered, fatigue self-management protocol and a self-help book and the usual care group (n = 36) received regular medical care. The effectiveness measure was the Fatigue Severity Scale and the cost measure was total health care expenditures derived from monthly health services use diaries during follow-up. A societal perspective was adopted and bootstrapped incremental cost-effectiveness ratios (ICERs) and net monetary benefit (NMB) were calculated as measures of cost-effectiveness. RESULTS: The ICER for FSM was -$$2358, indicating that FSM dominates UC and it may generate societal cost savings as compared to usual care. Complete case analysis yielded smaller ICER (-$1199) with greater uncertainties. Net monetary benefit analysis showed that FSM has a probability of 0.833 (95% CI: 0.819, 0.847) to achieve positive NMB and the favorable results were not sensitive to assumptions about informal care or treatment costs. CONCLUSION: This economic evaluation found initial evidence that a two-session brief CBT-based FSM may be cost-effective as compared to usual care over 12 months. The FSM intervention is potentially a promising intervention for chronic fatigue patients in primary care. Additional research is needed to examine the reproducibility and generalizability of these findings. TRIAL REGISTRATION: ClinicalTrials.gov (NCT00997451, March 28, 2009).

Chronic fatigue self-management in primary care: a randomized trial.

OBJECTIVE: To assess the efficacy of brief fatigue self-management (FSM) for medically unexplained chronic fatigue (UCF) and chronic fatigue syndrome (CFS) in primary care. METHODS: A randomized controlled design was used wherein 111 patients with UCF or CFS were randomly assigned to two sessions of FSM, two sessions of symptom monitoring support (attention control; AC), or a usual care control condition (UC). Participants were assessed at baseline and at 3 and 12 months after treatment. The primary outcome, the Fatigue Severity Scale, measured fatigue impact on functioning. Analysis was by intention to treat (multiple imputation) and also by per protocol. RESULTS: A group × time interaction across the 15-month trial showed significantly greater reductions in fatigue impact in the FSM group in comparison with the AC group (p < .023) and the UC group (p < .013). Medium effect sizes for reduced fatigue impact in the FSM group were found in comparison with the AC group (d = 0.46) and the UC group (d = 0.40). The per-protocol analysis revealed large effect sizes for the same comparisons. Clinically significant decreases in fatigue impact were found for 53% of participants in the FSM condition, 14% in the AC condition, and 17% in the UC condition. Dropout rates at the 12-month follow-up were high (42%-53%), perhaps attributable to the burden of monthly telephone calls to assess health care use. CONCLUSION: A brief self-management intervention for patients with UCF or CFS seemed to be clinically effective for reducing the impact of fatigue on functioning. Trial Registration clinicaltrials.gov Identifier: NCT00997451.

Uplifts and hassles are related to worsening in chronic fatigue syndrome A prospective study.

Background: Limited published data suggests that absence of uplifts (minor pleasant events) is associated with clinical worsening in patients with chronic fatigue syndrome (CFS). The current study aimed to assess the relation of illness worsening to the trajectories of social and non-social uplifts and hassles in a six-month prospective study in CFS. Methods: Participants were primarily in their 40s, female, white, and ill for over a decade. All participants (N=128) met criteria for CFS. The interview-based global impression of change rating was used to classify individual outcomes as improved, unchanged, or worsened at six- month follow-up. Uplifts and hassles, both social and non-social, were assessed with the Combined Hassles and Uplifts Scale (CHUS). The CHUS was administered weekly in online diaries over six months. Linear mixed effect models were utilized to examine linear trends for hassles and uplifts. Results: No significant differences were found between the three global outcome groups for age, sex, or illness duration; however, work status was significantly lower for the non-improved groups ( p <.001). Non-social hassles intensity showed an increasing slope for the worsened group ( p =.03) and a decreasing slope ( p =0.05) for the improved group. For the worsened group, a downward trend was found for frequency of non-social ( p =0.01) uplifts. Conclusion: Individuals with worsening as compared to improving illness in CFS show significantly different six-month trajectories for weekly hassles and a deficit in uplifts. This may have clinical implications for behavioral intervention. Trial Registration: ClinicalTrials.gov ID: NCT02948556.

Sex differences in post-exercise fatigue and function in myalgic encephalomyelitis/chronic fatigue syndrome.

To assess biobehavioral sex differences in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) utilizing a low burden exercise protocol, 22 females and 15 males with ME/CFS and 14 healthy controls underwent two six-min walk tests. Fifteen daily assessments were scheduled for fatigue and function ratings and heart monitoring. Six-min walk tests were conducted on days 8 and 9. The ME/CFS group showed high self-report fatigue and impaired physical function, whereas healthy controls did not show fatigue or function abnormalities. In patients, no significant post-exercise changes were found for heart rate variability (HRV); however, heart rate decreased in ME/CFS males from Day 14 to Day 15 (p = 0.046). Female patients showed increased fatigue (p = 0.006) after the initial walk test, but a downward slope (p = 0.008) in fatigue following the second walk test. Male patients showed a decrease in self-report work limitation in the days after exercise (p = 0.046). The healthy control group evidenced a decrease in HRV after the walk tests from Day 9-14 (p = 0.038). This pilot study did not confirm hypotheses that females as compared to males would show slower exercise recovery on autonomic or self-report (e.g. fatigue) measures. A more exertion-sensitive test may be required to document prolonged post-exertional abnormalities in ME/CFS.Trial registration: NCT NCT03331419.

Assessment of clinical reasoning: A Script Concordance test designed for pre-clinical medical students.

BACKGROUND: The Script Concordance test (SCT) measures clinical reasoning in the context of uncertainty by comparing the responses of examinees and expert clinicians. It uses the level of agreement with a panel of experts to assign credit for the examinee's answers. AIM: This study describes the development and validation of a SCT for pre-clinical medical students. METHODS: Faculty from two US medical schools developed SCT items in the domains of anatomy, biochemistry, physiology, and histology. Scoring procedures utilized data from a panel of 30 expert physicians. Validation focused on internal reliability and the ability of the SCT to distinguish between different cohorts. RESULTS: The SCT was administered to an aggregate of 411 second-year and 70 fourth-year students from both schools. Internal consistency for the 75 test items was satisfactory (Cronbach's alpha = 0.73). The SCT successfully differentiated second- from fourth-year students and both student groups from the expert panel in a one-way analysis of variance (F(2,508) = 120.4; p < 0.0001). Mean scores for students from the two schools were not significantly different (p = 0.20). CONCLUSION: This SCT successfully differentiated pre-clinical medical students from fourth-year medical students and both cohorts of medical students from expert clinicians across different institutions and geographic areas. The SCT shows promise as an easy-to-administer measure of "problem-solving" performance in competency evaluation even in the beginning years of medical education.

Classification of myalgic encephalomyelitis/chronic fatigue syndrome by types of fatigue.

Persons with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) often complain of fatigue states (eg, postexertional malaise, brain fog) that are qualitatively different than normal, daily fatigue. Given the heterogeneous nature of ME/CFS, it is likely that individuals with this illness experience these fatigue types differently in terms of severity and frequency. It is also possible that meaningful subgroups of patients exist that exhibit different patterns of the fatigue experience. The purpose of this study was to investigate whether individuals with ME/CFS can be classified in a meaningful way according to the different types of fatigue they experience. One hundred individuals with ME/CFS participated in the study. Individuals that met inclusion criteria were administered the Multiple Fatigue Types Questionnaire (MFTQ), a 5-factor instrument that distinguishes between different types of fatigue. A cluster analysis was used to classify patients into various clusters based on factor subscale scores. Using a 3-factor solution, individuals were classified according to illness severity (low, moderate, severe) across the different fatigue factors. However, a 5-cluster solution enabled participants with moderate to severe fatigue levels to fall into more differentiated clusters and demonstrate distinct fatigue state patterns. These results suggest that fatigue patterns of individuals with ME/CFS are heterogeneous, and that patients may be classified into meaningful subgroups.

Chronic fatigue syndrome, fibromyalgia, and related illnesses: a clinical model of assessment and intervention.

A clinically informative behavioral literature on chronic fatigue syndrome (CFS) and fibromyalgia (FM) has emerged over the past decade. The purpose of this article is to (a) define these conditions and their less severe counterparts, i.e., unexplained chronic fatigue (UCF) and chronic widespread pain; (b) briefly review the behavioral theory and intervention literature on CFS and FM; and (c) describe a user-friendly clinical model of assessment and intervention for these illnesses. The assessments described will facilitate understanding of the somewhat unusual and puzzling somatic presentations that characterize these patients. Using an individualized cognitive-behavioral approach the mental health clinician can offer significant help to these often stigmatized and medically underserved patients.

Longitudinal change in chronic fatigue syndrome: what home-based assessments reveal.

The purpose of this 2-year prospective study was to compare standard self-report and ecologically-based outcome measures in patients with chronic fatigue syndrome (CFS). Standard measures assessed physical function, fatigue impact, psychological variables, and global impression of change ratings. Ecological measures included actigraphy, a structured activity record, and an electronic fatigue/energy diary. Results for this high functioning sample (N = 75) revealed that self-report global improvement was significantly associated with lower momentary fatigue and fatigue impact, and a higher frequency of standing up (at home), but not with actigraphy or psychological variables. However, actigraphy change was significantly correlated with change in self-report physical function. At follow-up, only a small minority (<20%) scored in the healthy adult range for fatigue impact and physical function. The findings suggest that home-based measures of symptom severity and physical functioning may provide evidence of change (or lack of change) that is important for interpreting standard self-report outcomes in CFS.

Unmet needs of patients with systemic lupus erythematosus.

The authors' goal was to assess unmet needs of patients with systemic lupus erythematosus (SLE). Participants (N = 112), who were recruited through the mailing list and support group meetings of a Lupus Alliance of America Affiliate, completed a survey based on prior research. All participants perceived at least 1 unmet need. The most frequently reported unmet needs were in the physical symptoms domain. Older patients were more likely than younger patients to have higher levels of unmet needs related to physical and psychological functioning. African American patients were more likely than white patients to have higher levels of unmet needs related to health services and information. Our findings document the high prevalence and variety of unmet needs among these patients, as well as variations among demographic groups. To address unmet needs of SLE patients, targeted referrals to patient educators, mental health professionals, and support organizations are important adjuncts to medical treatment.

Cognitive-behavior therapy in chronic fatigue syndrome: is improvement related to increased physical activity?

This multiple case study of cognitive-behavioral treatment (CBT) for chronic fatigue syndrome (CFS) compared self-report and behavioral outcomes. Eleven relatively high-functioning participants with CFS received 6-32 sessions of outpatient graded-activity oriented CBT. Self-report outcomes included measures of fatigue impact, physical function, depression, anxiety, and global change. Behavioral outcomes included actigraphy and the 6-minute walking test. Global change ratings were very much improved (n=2), much improved (n=2), improved (n=5), and no change (n=2). Of those reporting improvement, clinically significant actigraphy increases (n=3) and decreases (n=4) were found, as well as no significant change (n=2). The nature of clinical improvement in CBT trials for high-functioning CFS patients may be more ambiguous than that postulated by the cognitive-behavioral model.

Activity Logs as a Measure of Daily Activity Among Patients with Chronic Fatigue Syndrome.

BACKGROUND: Self-report data collected through interviews has been one of the primary ways of assessing symptoms of patients with chronic fatigue syndrome (CFS). An alternative way to collect data involves activity logs, which involves patients writing down the pattern, intensity, and qualitative nature of activity over several days. AIMS: We examined the associations between activity, evaluation of activity and symptoms. METHODS: Activity log data over a two day period of time were used in the present study using a sample of patients with diagnosed CFS. RESULTS: Findings indicated that the percent of time spent feeling fatigued was positively associated with a higher percent of time in pain and doing activities that were fatiguing. However, time spent in meaningful activities was associated with less fatigue. CONCLUSIONS: These findings and others suggest that activity logs can provide investigators and clinicians with valuable sources of data for understanding patterns of behavior and activity among patients with CFS.

Teaching medical students about medically unexplained illnesses: a preliminary study.

BACKGROUND: This study examined how an interactive seminar focusing on two medically unexplained illnesses, chronic fatigue syndrome (CFS) and fibromyalgia, influenced medical student attitudes toward CFS, a more strongly stigmatized illness. METHODS: Forty-five fourth year medical students attended a 90 minute interactive seminar on the management of medically unexplained illnesses that was exemplified with CFS and fibromyalgia. A modified version of the CFS attitudes test was administered immediately before and after the seminar. RESULTS: Pre-seminar assessment revealed neutral to slightly favorable toward CFS. At the end of the seminar, significantly more favorable attitudes were found toward CFS in general (t (42) = 2.77; P < 0.01) and for specific items that focused on (1) supporting more CFS research funding (t (42) = 4.32; P < 0.001; (2) employers providing flexible hours for people with CFS (t (42) = 3.52, P < 0.01); and (3) viewing CFS as not primarily a psychological disorder (t (42) = 2.87, P < 0.01). Thus, a relatively brief exposure to factual information on specific medically unexplained illnesses was associated with more favorable attitudes toward CFS in fourth year medical students. CONCLUSION: This type of instruction may lead to potentially more receptive professional attitudes toward providing care to these underserved patients.

Memory for fatigue in chronic fatigue syndrome: relationships to fatigue variability, catastrophizing, and negative affect.

Fatigue in chronic fatigue syndrome (CFS) is usually assessed with retrospective measures rather than real-time momentary symptom assessments. In this study, the authors hypothesized that in participants with CFS, discrepancies between recalled and momentary fatigue would be related to catastrophizing, anxiety, and depression and to variability of momentary fatigue. They also expected that catastrophizing, anxiety, and depression would be associated with momentary fatigue. The authors asked 53 adults with CFS to carry electronic diaries for 3 weeks and record their experiences of momentary fatigue. The authors assessed participants' fatigue recall with weekly ratings and administered questionnaires for catastrophizing, depression, and anxiety. Recall discrepancy was significantly related to the variability of momentary fatigue. In addition, catastrophizing, depression, and momentary fatigue were all significantly related to recall discrepancy. Catastrophizing, depression, anxiety, and momentary negative affect were all significantly associated with momentary fatigue. The findings suggest that momentary fatigue in patients with CFS is related to modifiable psychological factors.

Alexithymia in chronic fatigue syndrome: associations with momentary, recall, and retrospective measures of somatic complaints and emotions.

OBJECTIVE: The relationship between alexithymia and real-time momentary symptom assessments has not been reported. This cross-sectional study hypothesized that alexithymia would be a predictor of somatic symptoms using three different types of symptom measurement (momentary, recall, and retrospective) in the medically unexplained illness of chronic fatigue syndrome (CFS). In addition, it was hypothesized that negative affect would be a significant mediator of the relationship between alexithymia and somatic symptoms. Finally, the relation of alexithymia to physical illness attribution (a CFS illness predictor) was explored. METHODS: Participants were 111 adults with CFS. Alexithymia was assessed with the Toronto Alexithymia Scale. Momentary ratings of current symptoms and affect were recorded in electronic diaries carried for 3 weeks. Weekly recall of these momentary reports was also recorded. Retrospective measures included 6-month ratings of fatigue and pain, the Fatigue Severity Scale, the Brief Pain Inventory-Short Form, a CFS symptom measure, the Beck Depression Inventory-II, the Beck Anxiety Inventory, and an illness attribution rating. RESULTS: Partial correlations, controlling for age and sex, yielded no significant associations between general or specific forms of alexithymia and momentary ratings of fatigue or pain. On the other hand, a significant association, partially mediated by anxiety scores, was found between a specific form of alexithymia and a retrospective pain measure. Finally, physical illness attribution was not significantly associated with alexithymia. CONCLUSION: Based on assessments of real-time and retrospectively measured symptoms, these data provided only modest support for the alexithymia construct as a predictor of somatic symptoms in people with CFS.