From threat to challenge-Improving medical students' stress response and communication skills performance through the combination of stress arousal reappraisal and preparatory worked example-based learning when breaking bad news to simulated patients: study protocol for a randomized controlled trial.

BACKGROUND: Breaking bad news (BBN; e.g., delivering a cancer diagnosis) is perceived as one of the most demanding communication tasks in the medical field and associated with high levels of stress. Physicians' increased stress in BBN encounters can negatively impact their communication performance, and in the long term, patient-related health outcomes. Although a growing body of literature acknowledges the stressful nature of BBN, little has been done to address this issue. Therefore, there is a need for appropriate tools to help physicians cope with their stress response, so that they can perform BBN at their best. In the present study, we implement the biopsychosocial model of challenge and threat as theoretical framework. According to this model, the balance between perceived situational demands and perceived coping resources determines whether a stressful performance situation, such as BBN, is experienced as challenge (resources > demands) or threat (resources < demands). Using two interventions, we aim to support medical students in shifting towards challenge-oriented stress responses and improved communication performance: (1) stress arousal reappraisal (SAR), which guides individuals to reinterpret their stress arousal as an adaptive and beneficial response for task performance; (2) worked examples (WE), which demonstrate how to BBN in a step-by-step manner, offering structure and promoting skill acquisition. METHODS: In a randomized controlled trial with a 2 (SAR vs. control) x 2 (WE vs. control) between-subjects design, we will determine the effects of both interventions on stress response and BBN skills performance in N = 200 third-year medical students during a simulated BBN encounter. To identify students' stress responses, we will assess their perceived coping resources and task demands, record their cardiovascular activity, and measure salivary parameters before, during, and after BBN encounters. Three trained raters will independently score students' BBN skills performances. DISCUSSION: Findings will provide unique insights into the psychophysiology of medical students who are tasked with BBN. Parameters can be understood more comprehensively from the challenge and threat perspective and linked to performance outcomes. If proven effective, the evaluated interventions could be incorporated into the curriculum of medical students and facilitate BBN skills acquisition. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05037318), September 8, 2021.

Does childhood trauma impact daily psychobiological stress in somatic symptom disorder? An ambulatory assessment study.

Objectives: Somatic symptom disorder is characterized by excessive thoughts, feelings, and behaviors dedicated to bodily symptoms, which are often medically unexplained. Although 13% of the population are affected by this disorder, its aetiopathogenesis is not fully understood. Research in medically unexplained conditions (e.g., fibromyalgia) points to increased psychosocial stress and alterations in stress-responsive bodily systems as a potential contributing factor. This pattern has often been hypothesized to originate from early life stress, such as childhood trauma. The aim of this study was to examine, for the first time, whether individuals with somatic symptom disorder exhibit elevated levels of self-reported daily stress and alterations in the autonomic nervous system and hypothalamic-pituitary-adrenal axis, both in comparison to healthy controls and individuals with depressive disorders, and whether reports of childhood trauma influence these alterations. Methods: A total of N = 78 individuals were recruited into this study. Of these, n = 27 had a somatic symptom disorder, n = 23 were healthy controls, and n = 28 had a depressive disorder. All individuals underwent a 14-day measurement period at home, with five assessments of self-reported stress, salivary alpha-amylase, and cortisol per day. Childhood trauma was assessed by the Childhood Trauma Questionnaire. Results: Individuals with somatic symptom disorder exhibited higher daily stress levels (p = 0.063) as well as a less pronounced alpha-amylase awakening response (p = 0.050), compared to healthy controls (statistical trends). Moreover, they were characterized by significantly attenuated diurnal cortisol concentrations (p < 0.001). A nearly identical pattern was observed in individuals with depression. In individuals with somatic symptom disorder and depressive disorders, childhood trauma was, by trend, associated with a more pronounced alpha-amylase awakening response (b = -0.27, p = 0.077). Conclusions: This study provides preliminary evidence for elevated daily stress and blunted sympathetic and hypothalamic-pituitary-adrenal axis activity in individuals with somatic symptom disorder and depressive disorders. Further studies will help to uncover the conditions under which these dysregulations develop into medically unexplained vs. depressive symptoms.

The Impact of Coping Styles and Gender on Situational Coping: An Ecological Momentary Assessment Study With the mHealth Application TrackYourStress.

The aim of this study was to investigate the impact of different coping styles on situational coping in everyday life situations and gender differences. An ecological momentary assessment study with the mobile health app TrackYourStress was conducted with 113 participants. The coping styles Positive Thinking, Active Stress Coping, Social Support, Support in Faith, and Alcohol and Cigarette Consumption of the Stress and Coping Inventory were measured at baseline. Situational coping was assessed by the question "How well can you cope with your momentary stress level" over 4 weeks. Multilevel models were conducted to test the effects of the coping styles on situational coping. Additionally, gender differences were evaluated. Positive Thinking (p = 0.03) and Active Stress Coping (p = 0.04) had significant positive impacts on situational coping in the total sample. For women, Social Support had a significant positive effect on situational coping (p = 0.046). For men, Active Stress Coping had a significant positive effect on situational coping (p = 0.001). Women had higher scores on the SCI scale Social Support than men (p = 0.007). These results suggest that different coping styles could be more effective in daily life for women than for men. Taking this into account, interventions tailored to users' coping styles might lead to better coping outcomes than generalized interventions.

Hair cortisol levels in women with medically unexplained symptoms.

Stress has been demonstrated to be involved in the development of medically unexplained symptoms. A key underlying mechanism could be lower levels of cortisol, which can contribute to symptoms such as fatigue or pain. However, the literature is highly equivocal, which may be due to methodological limitations inherent in short-term cortisol assessment. The aim of this case-control study was to investigate, for the first time, whether individuals with different forms of medically unexplained symptoms show altered hair cortisol concentrations, a long-term marker of hypothalamic-pituitary-adrenal functioning. Two groups of women with medically unexplained symptoms were recruited. The first had a functional somatic syndrome, characterised by specific medically unexplained symptoms (i.e., chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome, n = 33). The second had somatic symptom disorder, characterised by excessive thoughts, feelings, and behaviours devoted to various medically unexplained symptoms (n = 23). These groups were contrasted with healthy controls (n = 30), and women with depression (n = 27). Cortisol representing the previous three months was extracted from hair. Chronic stress and childhood trauma were assessed (retrospectively). Women with somatic symptom disorder had lower hair cortisol than healthy controls and women with functional somatic syndromes. No differences in hair cortisol were found between healthy controls, functional somatic syndromes, and depression. Neither childhood trauma nor chronic stress was correlated with hair cortisol. Provided that our findings are replicated, they may suggest that hypocortisolism is found in a specific subgroup of individuals with medically unexplained symptoms, and potentially in those characterised by excessive thoughts, feelings, and behaviours about symptoms.

Factors contributing to stability and instability in alpha-amylase activity in diluted saliva samples over time.

For the measurement of salivary alpha-amylase (sAA) activity, saliva samples first have to be diluted. There is some evidence for instability, that is, a decline of sAA activity in diluted samples. It is not clear which factors during dilution may contribute to this phenomenon and how quickly this decline of sAA activity occurs. Several experiments were conducted to investigate whether and how the material of the container (polystyrene (PS), polypropylene (PP), glass; experiment 1) and the diluent (saline (NaCl) solution, phosphate buffer saline (PBS), ultra-pure water; experiment 2) may affect sAA stability in diluted samples over a broad time window of up to 5 h. To study the velocity of the phenomenon in a fine-grained temporal resolution, sAA activity during the dilution process was studied (experiment 3). The results suggest that the (in)stability of sAA activity in diluted samples is determined by the interaction of material, diluent, and time. The sAA activity was relatively stable if saliva samples were diluted with a NaCl solution or PBS in glass tubes. However, sAA activity in diluted samples decreased in plastic containers (PS, PP), or if ultra-pure water was used as the diluent. There was a clear time effect on this decline. However, the decline appears to require some time to evolve and may not occur immediately during the dilution process. To conclude, the dilution of saliva samples should preferably be conducted with NaCl solution or PBS in glass containers. If glass containers are not available, PS and PP containers can be used if the dilution is processed quickly (within 25 min) and the measurement is initiated immediately upon dilution.

Thyroid Functioning and Fatigue in Women With Functional Somatic Syndromes - Role of Early Life Adversity.

Objective: Fatigue is a core feature of functional somatic syndromes (FSS). Fatigue is also prominent in patients with thyroid diseases, which is unsurprising given the role of the hypothalamic-pituitary-thyroid (HPT) axis in regulating physiological energy demands. Research in healthy women has shown that early life adversity is linked with alterations in the HPT axis. In view of the substantial prevalence of early life adversity in patients with FSS, our aim was to investigate whether HPT functioning is related to (a) fatigue, and (b) early life adversity in these patients. Methods:N = 33 female patients with FSS and n = 30 age-matched controls were recruited. Fasting morning blood samples were taken to determine thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), and thyroxine (fT4). General, physical, and mental fatigue were measured via the multidimensional fatigue inventory (MFI). Early life adversity was measured using the childhood trauma questionnaire (CTQ). Results: Patients with FSS did not differ from controls in any thyroid parameters (all p > 0.672). However, the lower the patients' TSH and the higher their fT4, the greater was their general (ß = -0.32, p = 0.064; ß = 0.35, p = 0.038) and physical (ß = -0.47, p = 0.007; ß = 0.32, p = 0.077) fatigue. In addition, emotional neglect (ß = -0.32, p = 0.057), physical neglect (ß = -0.60, p = 0.001), physical abuse (ß = -0.47, p = 0.015), and sexual abuse (ß = -0.40, p = 0.026) were linked with lower TSH. Conclusion: The lower TSH and the higher fT4, the more fatigue was reported by patients with FSS. In addition, lower TSH was linked with more early life adversity. Larger, prospective studies are warranted to determine whether HPT functioning may be a mediating pathway between early life adversity and fatigue in FSS.

Hair and salivary cortisol in a cohort of women with chronic fatigue syndrome.

Hypocortisolism has been found in CFS patients in blood, urine, and saliva. It is unclear if hypocortisolism can also be demonstrated using long-term cortisol measurements, such as cortisol in hair. In addition, the interaction between the HPA axis and the immune system, both expected to play an important role in CFS, is unclear. The objective of the current study was to compare hair and salivary cortisol concentrations in a cohort of female CFS patients to those in healthy controls, and to test the effect of an interleukin-1 receptor antagonist (anakinra) on the HPA axis. Salivary cortisol concentrations of 107 CFS patients were compared to 59 healthy controls, with CFS patients showing a decreased cortisol awakening response (4.2 nmol/L ±â€¯5.4 vs 6.1 nmol/L ±â€¯6.3, p = 0.036). Total cortisol output during the day did not differ significantly in saliva, but there was a trend to lower hair cortisol in a subset of 46 patients compared to 46 controls (3.8 pg/mg ±â€¯2.1 vs 4.3 pg/mg ±â€¯1.8, p = 0.062). After four weeks of treatment with either daily anakinra (100 mg/day) or placebo, there was a slight decrease of hair cortisol concentrations in the anakinra group compared to an increase in the placebo group (p = 0.022). This study confirms the altered dynamics of the HPA axis in a group of CFS patients, and for the first time shows that this might also be present for long-term cortisol measures.

Preliminary evidence: the stress-reducing effect of listening to water sounds depends on somatic complaints: A randomized trial.

BACKGROUND: Listening to natural sounds is applied in health contexts in order to induce relaxation. However, it remains unclear whether this effect is equally efficacious in all individuals or whether it depends on interindividual differences. Given that individuals differ in how they are impaired by somatic complaints, we investigated whether somatic complaints moderate the stress-reducing effect of listening to water sounds. METHODS: Sixty healthy women (Mage = 25 years) were randomly allocated to 3 different conditions (listening to water sounds, a relaxing piece of music, or no auditory stimulus: n = 20 per condition) for 10 minutes before they were exposed to a standardized psychosocial stress task. Salivary cortisol was assessed before, during, and after the stress task. For binary logistic regression analyses, participants were divided into 2 groups: 1 group with a high salivary cortisol release and 1 group with low cortisol release. The Freiburg Complaints Inventory was used to assess occurrence of somatic complaints. RESULTS: A significant moderating effect of somatic complaints on cortisol secretion was found in the group listening to water sounds (χ(1) = 5.87, P < .015) but not in the other 2 groups, explaining 35.7% of the variance and correctly classifying 78.9% of the cases. CONCLUSION: The stress-reducing effect of listening to water sounds appears to depend on the occurrence of somatic complaints. This effect was not found in the music or silence condition. Individuals with somatic complaints may benefit from other, potentially more powerful forms of stress-reducing interventions, that is, combinations of visual and auditory stimuli. TRIAL REGISTRATION: not applicable (pilot study).

Simultaneous measurement of salivary cortisol and alpha-amylase: Application and recommendations.

Salivary cortisol (sCort) and salivary alpha-amylase (sAA) constitute proxy measures of the two major stress response systems, i.e. the hypothalamic-pituitary-adrenal axis and the autonomic nervous system, respectively. Potentially confounding determinants of sCort and sAA may limit a reliable concurrent measurement of both biomarkers, if not adequately considered. We reviewed the most important determinants of sCort and sAA and provide recommendations for handling these potential confounders. We focused on a selection of confounders, resulting in an in-depth consideration of age, sex steroid-related factors, somatic health, acute medication, smoking, consumption of food and drinks, alcohol consumption, physical activity/fitness, and sleep. Our review further highlights the importance of the consideration of potential confounders for a reliable and valid simultaneous measurement of sCort and sAA. We further provide recommendations about which and how to handle relevant confounders in the study design or data analysis.

Long-term stability of diurnal salivary cortisol and alpha-amylase secretion patterns.

This study aimed to investigate long-term stability and variability of diurnal cortisol and alpha-amylase patterns. Diurnal cortisol and alpha-amylase secretion patterns were assessed on a single workday with three waves of measurement across a total time period of 24months in 189 participants. Separate hierarchical linear models were analyzed, with and without a number of potential predictor variables (age, BMI, smoking, chronic stress, stress reactivity). While low long-term stability was found in diurnal cortisol, the stability of diurnal alpha-amylase was moderate across the time period of 24months. Several predictor variables had a positive impact on diurnal cortisol and alpha-amylase secretion patterns averaged across waves. Our findings underpin the notion that long-term stability is not necessarily warranted in longitudinal studies. It is important to choose an appropriate study design when attempting to disentangle clinically and biologically relevant changes from naturally occurring variations in diurnal cortisol and alpha-amylase.

Patterns of control beliefs in chronic fatigue syndrome: results of a population-based survey.

BACKGROUND: Chronic fatigue syndrome (CFS) represents a unique clinical challenge for patients and health care providers due to unclear etiology and lack of specific treatment. Characteristic patterns of behavior and cognitions might be related to how CFS patients respond to management strategies. METHODS: This study investigates control beliefs in a population-based sample of 113 CFS patients, 264 individuals with insufficient symptoms or fatigue for CFS diagnosis (ISF), and 124 well individuals. RESULTS: Controlling for personality and coping, individuals with low confidence in their problem-solving capacity were almost 8 times more likely to be classified as ISF and 5 times more likely to be classified as CFS compared to being classified as well. However there was a wide distribution within groups and individuals with "low confidence" scores were found in 31.7% of Well individuals. Individuals with low levels of anxiety and who were more outgoing were less likely to be classified as ISF or CFS. CONCLUSIONS: These findings suggest that fostering control beliefs could be an important focus for developing behavioral management strategies in CFS and other chronic conditions.

Influence of stress systems and physical activity on different dimensions of fatigue in female fibromyalgia patients.

OBJECTIVE: Fatigue is a defining characteristic and one of the most debilitating features of fibromyalgia syndrome (FMS). The mechanisms underlying different dimensions of fatigue in FMS remain unclear. The aim of the current study was to test whether stress-related biological processes and physical activity modulate fatigue experience. METHODS: Using an ambulatory assessment design, 26 female FMS patients reported general, mental, and physical fatigue levels at six time points per day for 14 consecutive days. Salivary cortisol and alpha-amylase were analyzed as markers of neuroendocrine functioning. Participants wore wrist actigraphs for the assessment of physical activity. RESULTS: Lower increases in cortisol after awakening predicted higher mean daily general and physical fatigue levels. Additionally, mean daily physical activity positively predicted next-day mean general fatigue. Levels of physical fatigue at a specific time point were positively associated with momentary cortisol levels. The increase in cortisol after awakening did not mediate the physical activity - fatigue relationship. There were no associations between alpha-amylase and fatigue. CONCLUSION: Our findings imply that both changes in hypothalamic-pituitary-adrenal axis activity and physical activity contribute to variance in fatigue in the daily lives of patients with FMS. This study helps to paint a clearer picture of the biological and behavioral underpinnings of fatigue in FMS and highlight the necessity of interdisciplinary treatment approaches targeting biological, behavioral and psychological aspects of FMS.

Classifying Fibromyalgia Syndrome as a Mental Disorder?-An Ambulatory Assessment Study.

PURPOSE: Fibromyalgia syndrome (FMS) is associated with psychological distress. The recent revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) raises the question of whether FMS is classifiable as "somatic symptom disorder" (SSD) and consequently as a mental disorder. To address this, the present ambulatory assessment study focuses on the everyday life occurrence of SSD symptoms in FMS and their predictive value concerning severity indicators of widespread pain. METHOD: Ambulatory data were assessed six times daily on 14 consecutive days via iPod. Twenty-eight women suffering from FMS indicated symptoms associated with SSD (somatic illness beliefs, health anxiety, time/energy devoted to pain, or health concerns) and momentary pain levels. Questionnaires regarding potential covariates (such as somatization, depression, health status) were completed at two additional sessions in the research laboratory. RESULTS: On average, SSD symptoms occurred three to four times daily and were mild to moderate in severity. Furthermore, these symptoms were both concurrently and prospectively associated with momentary pain intensity and subjective impairment by pain. Twenty percent of the variance in pain intensity and 28 % of the variance in subjective impairment were explained by momentary variables (SSD symptoms and intake of pain medication). Eighty-two percent of persons with FMS fulfilled the psychological SSD criterion when considering everyday occurring symptoms with at least mild severity. CONCLUSION: FMS might be diagnosed as a mental disorder according to DSM-5 in many cases. SSD symptoms proved to have predictive value for FMS severity and may thus have clinical relevance for diagnostic, prognostic, and intervention purposes.

The role of week(end)-day and awakening time on cortisol and alpha-amylase awakening responses.

Awakening responses in salivary cortisol (CAR) and alpha-amylase (AAR) constitute proxies of morning activation patterns of the hypothalamic-pituitary-adrenal axis and autonomic nervous system, respectively. Previous studies suggest that the CAR is decreased at weekends and at late awakening. However, it is insufficiently studied (a) whether this also applies to the AAR and (b) whether week(end)-day and awakening time interact with each other. Using an ecological momentary assessment design, 48 healthy young adults (60% women) were investigated over a 7-d period (Study 1), and 27 chronic pain patients diagnosed with fibromyalgia syndrome were examined over a 14-d period (Study 2). For the assessment of the CAR and AAR, participants provided saliva samples each morning (upon awakening, 30 min after awakening). Preprogrammed electronic diary devices were used to track week(end)-day and exact time of saliva sampling (awakening time). In Study 1, CAR was unrelated to weekend, awakening time, or their interaction, whereas only early awakening time was positively associated with AAR. In Study 2, week-days as well as early awakening times on week-days predicted increased CAR. AARs were not predicted by week(end)-day, awakening times, or their interaction. These findings suggest that time-related factors may influence awakening responses, particularly the impact of week(end)-day on the CAR and the impact of awakening times on the AAR. Since week(end)-day and awakening times may negatively affect awakening responses, these potential confounding factors should be assessed and controlled for, particularly in studies assessing both CAR and AAR.

Stress exacerbates pain in the everyday lives of women with fibromyalgia syndrome--The role of cortisol and alpha-amylase.

OBJECTIVE: Although fibromyalgia syndrome (FMS) is a chronic condition, its cardinal symptom pain is known to fluctuate over the day. Stress has often been claimed to exacerbate pain; however, there is barely any evidence on whether or not this is true on a day-to-day basis (and, alternatively, on whether pain leads to increased stress levels). Using an ecologically valid measurement design, we tested whether and how stress and pain are intertwined in participants with FMS. We additionally examined the role of the two major stress-responsive systems, the hypothalamic-pituitary-adrenal axis and the autonomic nervous system, as potential mediators of this relationship. METHODS: An ambulatory assessment study was conducted over the course of 14 days. On each day, 32 females with FMS provided six diary entries on momentary stress and pain levels. Saliva samples were collected at the same time points to determine cortisol and alpha-amylase as indicators of stress-responsive systems. RESULTS: Higher stress at a given measurement time point was associated with higher reported pain levels at the subsequent time point (UC=1.47, p<0.001), but not vice versa (UC<0.01, p=0.179). The stress-pain relationship was neither mediated by momentary cortisol nor by alpha-amylase; however, momentary cortisol was independently associated with momentary pain (UC=0.27, p=0.009). CONCLUSION: Stress seems to be a powerful exacerbating factor for pain as experienced by patients with FMS in their everyday lives. Cortisol may be involved in the diurnal fluctuation of pain levels in patients with FMS. Future studies should identify relevant daily stressors in persons with FMS and scrutinize the mechanisms underlying the cortisol-pain relationship.

The effects of music listening on pain and stress in the daily life of patients with fibromyalgia syndrome.

Music listening is associated with both pain- and stress-reducing effects. However, the effects of music listening in daily life remain understudied, and the psycho-biological mechanisms underlying the health-beneficial effect of music listening remain unknown. We examined the effects of music listening on pain and stress in daily life in a sample of women with fibromyalgia syndrome (FMS; i.e., a condition characterized by chronic pain) and investigated whether a potentially pain-reducing effect of music listening was mediated by biological stress-responsive systems. Thirty women (mean age: 50.7 ± 9.9 years) with FMS were examined using an ecological momentary assessment design. Participants rated their current pain intensity, perceived control over pain, perceived stress level, and music listening behavior five times per day for 14 consecutive days. At each assessment, participants provided a saliva sample for the later analysis of cortisol and alpha-amylase as biomarkers of stress-responsive systems. Hierarchical linear modeling revealed that music listening increased perceived control over pain, especially when the music was positive in valence and when it was listened to for the reason of 'activation' or 'relaxation'. In contrast, no effects on perceived pain intensity were observed. The effects of music listening on perceived control over pain were not mediated by biomarkers of stress-responsive systems. Music listening in daily life improved perceived control over pain in female FMS patients. Clinicians using music therapy should become aware of the potential adjuvant role of music listening in daily life, which has the potential to improve symptom control in chronic pain patients. In order to study the role of underlying biological mechanisms, it might be necessary to use more intensive engagement with music (i.e., collective singing or music-making) rather than mere music listening.

Investigating neural mechanisms of change of cognitive behavioural therapy for chronic fatigue syndrome: a randomized controlled trial.

BACKGROUND: Chronic fatigue syndrome (CFS) is characterized by profound and disabling fatigue with no known somatic explanation. Cognitive behavioral therapy (CBT) has proven to be a successful intervention leading to a reduction in fatigue and disability. Based on previous neuroimaging findings, it has been suggested that central neural mechanisms may underlie CFS symptoms and play a role in the change brought on by CBT. In this randomized controlled trial we aim to further investigate the neural mechanisms that underlie fatigue in CFS and their change by CBT. METHODS/DESIGN: We will conduct a randomized controlled trial in which we collect anatomical and functional magnetic resonance imaging (MRI) measures from female CFS patients before and after CBT (N = 60) or waiting list (N = 30) and compare these with measures from age and education matched healthy controls (N = 30). By including a large treatment group we will also be able to compare patients that benefit from CBT with those that do not. In addition, to further investigate the role of endocrine and immune biomarkers in CFS, we will determine cortisol and cytokine concentrations in blood, hair and/or saliva. DISCUSSION: This project creates an unique opportunity to enhance our understanding of CFS symptoms and its change by CBT in terms of neuroanatomical, neurofunctional, endocrinological and immunological mechanisms and can help to further improve future treatments strategies. TRIAL REGISTRATION: Dutch Trial Register #15852. Registered 9 December 2013 ( http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4311 ).

Functional somatic syndromes: asking about exclusionary medical conditions results in decreased prevalence and overlap rates.

BACKGROUND: The diagnosis of functional somatic syndromes (FSS) requires 1) presence of somatic symptoms, and 2) absence of medical conditions potentially accounting for these symptoms. Due to the limited feasibility of medical examinations, epidemiological research on FSS has neglected to assess the second criterion. Our objective was therefore to evaluate the implications of considering information on exclusionary medical conditions in epidemiological research on FSS. METHODS: A survey among 3'054 students was conducted. We compared prevalence rates and overlap of 17 FSS obtained by: 1) a symptom-based strategy and 2) a symptom-and-exclusion-based strategy including information on exclusionary medical conditions. RESULTS: The symptom-and-exclusion-based strategy led to a marked decrease in prevalence rates compared to the symptom-based strategy. Furthermore, it resulted in fewer individuals who were affected by multiple FSS. CONCLUSIONS: Adding self-reported information on exclusionary medical conditions leads to a significant decrease in the prevalence and overlap of FSS. More rigorous approaches to studying FSS should be adopted.

Norepinephrine and epinephrine responses to physiological and pharmacological stimulation in chronic fatigue syndrome.

Chronic fatigue syndrome (CFS) is characterized by fatigue lasting 6 months or longer. CFS has been associated with a disturbed (re-)activity of the autonomic nervous system. However, the sympathetic adrenomedulla (SAM) remains under-examined in CFS. To investigate SAM reactivity, we implemented a submaximal cycle ergometry (ERGO) and a pharmacological test (Insulin Tolerance Test, ITT) in 21 CFS patients and 20 age-, sex-, and BMI-matched controls. Plasma norepinephrine and epinephrine were collected once before and twice after the tests (+10/+20, and +30 min). Lower baseline levels and attenuated responses of epinephrine to the ERGO were found in CFS patients compared to controls, while the groups did not differ in their responses to the ITT. To conclude, we found evidence of altered sympathetic-neural and SAM reactivity in CFS. Exercise stress revealed a subtle catecholaminergic hyporeactivity in CFS patients. It is conceivable that inadequate catecholaminergic responses to physical exertion might contribute to CFS symptoms.

Mental illness in metropolitan, urban and rural Georgia populations.

BACKGROUND: Mental illness represents an important public health problem. Local-level data concerning mental illness in different populations (e.g., socio-demographics and residence--metropolitan/urban/rural) provides the evidence-base for public health authorities to plan, implement and evaluate control programs. This paper describes prevalence and covariates of psychiatric conditions in Georgia populations in three defined geographic areas. METHODS: Data came from the Georgia population-based random-digit-dialing study investigating unwellness and chronic fatigue syndrome (CFS) in Georgia populations of three defined geographic areas (metropolitan, urban, and rural). Respondents were screened for symptoms of fatigue, sleep, cognition, and pain at household screening interviews, and a randomly selected sample completed detailed individual phone interviews. Based on the detailed phone interviews, we conducted one-day clinical evaluations of 292 detailed interview participants classified as unwell with a probable CFS (i.e. CFS-like; a functional somatic syndrome), 268 classified as other unwell, and 223 well (matched to CFS-like). Clinical evaluation included psychiatric classification by means of the Structured Clinical Interview for DSM (SCID). To derive prevalence estimates we used sample weighting to account for the complexity of the multistage sampling design. We used 2- and 3-way table analyses to examine socio-demographic and urbanicity specific associations and multiple logistic regression to calculate adjusted odds ratios. RESULTS: Anxiety and mood disorders were the most common psychiatric conditions. Nineteen percent of participants suffered a current anxiety disorder, 18% a mood disorder and 10% had two or more conditions. There was a significant linear trend in occurrence of anxiety or mood disorders from well to CFS-like. The most common anxiety disorders were post-traumatic stress disorder (PTSD) (6.6%) and generalized anxiety disorder (GAD) (5.8%). Logistic regression showed that lower education and female sex contributed significantly to risk for both PTSD and GAD. In addition, rural/urban residence and Hispanic ethnicity were associated with PTSD. We defined moderate to severe depression as Major Depressive Disorder or a Zung score>60 and logistic regression found lower education to be significantly associated but sex, age and urbanicity were not. CONCLUSIONS: Overall occurrence of anxiety and mood disorders in Georgia mirrored national findings. However, PTSD and GAD occurred at twice the published national rates (3.6 and 2.7%, respectively). State and local prevalence and associations with education, sex and urbanicity comprise important considerations for developing control programs. The increased prevalence of anxiety and mood disorders in people with a functional somatic syndrome (or CFS-like illness) is important for primary care providers, who should consider additional psychiatric screening or referral of individuals presenting with somatoform symptoms.