The Role of Psychotherapy in the Care of Patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.

Myalgic encephalomyelitis/chronic fatigue (ME/CFS) is a post-infectious, chronic disease that can lead to severe impairment and, even, total disability. Although the disease has been known for a long time, and has been coded in the ICD since 1969 (G93.3), medical research has not yet been able to reach a consensus regarding its physiological basis and how best to treat it. Against the background of these shortcomings, psychosomatic disease models have been developed and psychotherapeutic treatments have been derived from them, but their empirical testing has led to sobering results. According to the current state of research, psychotherapy and psychosomatic rehabilitation have no curative effect in the treatment of ME/CFS. Nevertheless, we see numerous patients in practices and outpatient clinics who suffer severely as a result of their illness and whose mental well-being and coping strategies would benefit from psychotherapeutic help. In this article, we outline a psychotherapeutic approach that serves this need, taking into account two basic characteristics of ME/CFS: firstly, the fact that ME/CFS is a physical illness and that curative treatment must therefore be physical; and secondly, the fact that post exertional malaise (PEM) is a cardinal symptom of ME/CFS and thus warrants tailored psychotherapeutic attention.

Smokers show an altered hemodynamic profile to active stress: Evidence of a dysregulated stress response in young adults.

Tobacco smoking has been associated with lower cardiovascular reactivity to psychological stress in middle-aged samples, but its impact on cardiovascular reactivity to stress in young adults remains unclear. The present study examined whether young healthy adults showed differing cardiovascular stress reaction profiles depending on their smoking status. Across two laboratory studies (N = 64 and N = 114), we asked participants to complete cognitive stress-tasks while undergoing continuous hemodynamic monitoring. In both studies, there was not a statistically signification association between systolic blood pressure, diastolic blood pressure, or heart rate reactivity to stress (all ps > .05). However, examination of the underlying hemodynamic profile of the stress response suggested differences between non-smokers and smokers in both studies. In Study 1, non-smokers exhibited the expected myocardial response to the active stress-task; however, smokers exhibited a mixed hemodynamic profile. In Study 2, smokers evidenced a weaker myocardial profile to the active stress-tasks compared to non-smokers. However, the examination of the continuous hemodynamic profile score (HP) did not identify statistical differences. These results highlight that any level of the smoking habit is associated with an altered hemodynamic profile in response to stress in smokers, which may have important implications for long-term cardiovascular health. The findings also suggest that controlling for smoking behavior in reactivity research examining blood pressure and heart rate responses to stress in young adults is not necessary.

Response to Adamson et al. (2020): 'Cognitive behavioural therapy for chronic fatigue and chronic fatigue syndrome: Outcomes from a specialist clinic in the UK'.

In a paper published in the Journal of the Royal Society of Medicine, Adamson et al. (2020) interpret data as showing that cognitive behavioural therapy leads to improvement in patients with chronic fatigue syndrome and chronic fatigue. Their research is undermined by several methodological limitations, including: (a) sampling ambiguity; (b) weak measurement; (c) survivor bias; (d) missing data and (e) lack of a control group. Unacknowledged sample attrition renders statements in the published Abstract misleading with regard to points of fact. That the paper was approved by peer reviewers and editors illustrates how non-rigorous editorial processes contribute to systematic publication bias.

Fatigue Is Associated With Diminished Cardiovascular Response to Anticipatory Stress in Patients With Coronary Artery Disease.

BACKGROUND: Fatigue and psychophysiological reactions to mental stress are known to be problematic in coronary artery disease (CAD) patients. Currently, studies exploring the relationship between fatigue and cardiovascular reactivity to stress are scarce and inconsistent. The current study aimed to investigate the links between cardiovascular response to mental stress and fatigue in CAD patients after acute coronary syndrome (ACS). METHODS: The cross-sectional study investigated 142 CAD patients (85% males, 52 ± 8 years) within 2-3 weeks after recent myocardial infarction or unstable angina pectoris. Fatigue symptoms were measured using Multidimensional Fatigue Inventory 20-items, while cardiovascular reactivity to stress [i.e., systolic (S) and diastolic (D) blood pressure (ΔBP), and heart rate (ΔHR)] was evaluated during Trier Social Stress Test (TSST). In addition, participants completed psychometric measures, including the Hospital Anxiety and Depression scale and the Type D Scale-14. Multivariable linear regression analyses were completed to evaluate associations between fatigue and cardiovascular response to TSST, while controlling for confounders. RESULTS: After controlling for baseline levels of cardiovascular measures, age, gender, education, heart failure severity, arterial hypertension, smoking history, use of nitrates, anxiety and depressive symptoms, Type D Personality, perceived task difficulty, and perceived task efforts, cardiovascular reactivity to anticipatory stress was inversely associated with both global fatigue (ΔHR: ß = -0.238; p = 0.04) and mental fatigue (ΔSBP: ß = -0.244; p = 0.04; ΔHR ß = -0.303; p = 0.01) as well as total fatigue (ΔSBP: ß = -0.331; p = 0.01; ΔHR: ß = -0.324; p = 0.01). CONCLUSION: In CAD patients after ACS, fatigue was linked with diminished cardiovascular function during anticipation of a mental stress challenge, even after inclusion of possible confounders. Further similar studies exploring other psychophysiological stress responses are warranted.

Monitoring treatment harm in myalgic encephalomyelitis/chronic fatigue syndrome: A freedom-of-information study of National Health Service specialist centres in England.

The use of graded exercise therapy and cognitive behavioural therapy for myalgic encephalomyelitis/chronic fatigue syndrome has attracted considerable controversy. This controversy relates not only to the disputed evidence for treatment efficacy but also to widespread reports from patients that graded exercise therapy, in particular, has caused them harm. We surveyed the National Health Service-affiliated myalgic encephalomyelitis/chronic fatigue syndrome specialist clinics in England to assess how harms following treatment are detected and to examine how patients are warned about the potential for harms. We sent 57 clinics standardised information requests under the United Kingdom's Freedom of Information Act. Data were received from 38 clinics. Clinics were highly inconsistent in their approaches to the issue of treatment-related harm. They placed little or no focus on the potential for treatment-related harm in their written information for patients and for staff. Furthermore, no clinic reported any cases of treatment-related harm, despite acknowledging that many patients dropped out of treatment. In light of these findings, we recommend that clinics develop standardised protocols for anticipating, recording, and remedying harms, and that these protocols allow for therapies to be discontinued immediately whenever harm is identified.

Suicidal ideation is associated with elevated inflammation in patients with major depressive disorder.

BACKGROUND: Patients with major depressive disorder (MDD) who attempt or complete suicide have elevated inflammation compared to nonsuicidal patients with MDD. However, greater severity of depression and the medical lethality of suicide attempts could account for such elevated inflammation in suicide attempters and suicide completers. METHODS: To clarify, we measured inflammatory markers in patients with MDD with and without high levels of suicidal ideation and in nondepressed controls (N = 124). Levels of suicidal ideation, depression severity, and recent suicide attempts were assessed by structured clinical interviews. A composite score including the inflammatory markers tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-10 (IL-10), and C-reactive protein (CRP) was used as an inflammatory index. Analysis of covariance models were used to assess group differences with adjustments for age and gender. RESULTS: Patients with MDD and high suicidal ideation had significantly higher inflammatory index scores than both controls, F(1,53) = 18.08, partial η(2) = .25, P < .001, and patients with MDD and lower suicidal ideation F(1,44) = 7.59, partial η(2) = .15, P = .009. In contrast, patients with lower suicidal ideation were not significantly different from controls on the inflammatory index, F(1,63) = .52, partial η(2) = .01, P = .47. Follow-up analyses indicated that differences between patients with MDD and high versus lower suicidal ideation were independent of depression severity and recent suicide attempts. CONCLUSIONS: Suicidal ideation may be uniquely associated with inflammation in depressed patients.

Matching intra-procedural information with coping style reduces psychophysiological arousal in women undergoing colposcopy.

This study assessed the combined effects of coping style and intra-procedural information on indices of distress (physiological measures, observed distress, self-report measures of anxiety and affect) among a group of patients undergoing colposcopy. High and low monitors were exposed to one of three interventions: high information (live video feed of colposcopy); low information (complete audiovisual distraction); and control. Results revealed a 2 (monitoring style) × 3 (information level) × 2 (time) interaction for systolic blood pressure (SBP), F(2, 111) = 3.55, p = .032. Among low monitors, patients in the low-information group exhibited significant SBP reductions during colposcopy, while those in the high-information group exhibited SBP increases. Among high monitors, patients in the high-information and control groups exhibited SBP reductions. Further, significant differences in observed signs of distress were found between groups with high monitors in the low-information group faring best overall, F(2, 111) = 4.41, p = .014. These findings indicate that tailoring information to suit individual coping style may maximize the apparent efficacy of interventions aimed at reducing stress during medical examinations.

Clinical anxiety, cortisol and interleukin-6: evidence for specificity in emotion-biology relationships.

Anxiety confers increased risk for inflammatory diseases, and elevated inflammatory activity in anxious individuals may contribute to this increased risk. One complication, however, is that anxiety could be associated with inflammatory activity either through a specific anxiety pathway or through a more general negative emotionality pathway. To investigate, we measured levels of the stress hormone cortisol, the pro-inflammatory cytokine interleukin-6 (IL-6), and the systemic inflammatory marker C-reactive protein (CRP), as well as depression and neuroticism, in clinically anxious and non-anxious adults. Compared with non-anxious participants, clinically anxious participants exhibited significantly lower levels of morning cortisol and significantly higher levels of IL-6, independent of age, sex, and depressive symptoms. These group differences were robust when controlling for neuroticism. Conversely, the groups had equivalent levels of CRP in all analyses. Results are indicative of anxiety-specific effects on inflammatory activity, and highlight a pathway by which anxiety may increase risk for inflammatory diseases.

Habituation-sensitization of cardiovascular reactivity to repeated stress in smokers and non-smokers: an anthropometrically matched trial.

Previous research has been equivocal as to the impact of smoking status on cardiovascular reactivity to challenge. In addition, little is known about patterns of cardiovascular response habituation-sensitization to repeated challenge, in either smokers or the general population as a whole. The present study sought to clarify whether smokers and non-smokers differ in cardiovascular reactivity to challenge, or in patterns of reactivity to repeated challenge. 28 smokers and 28 anthropometrically matched non-smokers underwent repeated cardiovascular reactivity assessment. Results suggest that smokers had higher diastolic blood pressure (DBP) than non-smokers, and that female non-smokers demonstrated DBP response sensitization. Findings highlight direct associations between smoking and cardiovascular reactivity of potential significance to the etiology of cardiovascular disease.

Social support reduces resting cardiovascular function in women.

Social support is believed to benefit cardiovascular health in part by buffering recipients from life stress. Classically, this has been investigated by exploring the relationship between support and cardiovascular reactivity to laboratory stress. Such research customarily emphasizes stress responses and downplays the relevance of resting cardiovascular levels. However, it is now appreciated that resting cardiovascular function is associated with disease risk independently of reactivity. Moreover, such mechanisms are known to be relevant to female members of the population, despite the fact that much previous research has focused on males. Reactivity research rests on the assumption that stress promotes gradual hypertension over time. As such, it is important to establish the relationship between psychosocial factors and resting blood pressure. In a cross-sectional biopsychosocial screening study, we examined resting cardiovascular levels in 211 healthy non-smoking women, using regression to assess associations with psychometric indices of social support (namely, perceived network size and perceived satisfaction with support) while controlling for a range of potential biometric and psychometric confounds. Overall, social support was found to be associated with reduced resting cardiovascular function independently of, and to a greater extent than, biometric variables, anxiety, and depression. Benchmarking these effects against the differences in cardiovascular function between the present sample and a group of 92 similarly aged males revealed that social support accounted for as much variance as gender, which is widely assumed to be an important biomedical determinant of blood pressure. Such findings corroborate assertions that social support influences disease risk in ways that involve direct psychosomatic mechanisms.