Prevalence of DSM-IV personality disorders in patients with chronic fatigue syndrome: a controlled study.

BACKGROUND: It is not yet clear whether chronic fatigue syndrome (CFS) is associated with elevated levels of personality disorders. PURPOSE: This study aims to determine the prevalence of DSM-IV axis II personality disorders among patients with CFS. METHODS: We examined the prevalence of personality disorders in a sample of 92 female CFS patients and in two well-matched control groups, i.e., normal community individuals (N = 92) and psychiatric patients (N = 92). Participants completed the assessment of DSM-IV personality disorders questionnaire (ADP-IV), which yields a categorical and dimensional evaluation of personality disorder features. RESULTS: The prevalence of personality disorders in CFS patients (16.3 %) was significantly lower than in psychiatric patients (58.7 %) and was similar to that in the community sample (16.3 %). Similar results were found for dimensional and pseudodimensional scores, except for the Depressive (DE) and Obsessive-Compulsive Personality Disorder (O-C) subscales. Patients with CFS had significantly higher levels of DE features compared to normal controls and similar dimensional scores on the O-C scale compared to psychiatric controls. CONCLUSIONS: Although the CFS sample was characterized by depressive and obsessive-compulsive personality features, this study provides no evidence for the assumption that these patients generally show a higher prevalence of axis II pathology. Given the conflicting findings in this area, future studies using multiple measures to assess personality disorders in CFS are needed to substantiate these findings.

Unraveling the role of perfectionism in chronic fatigue syndrome: is there a distinction between adaptive and maladaptive perfectionism?

In the current study, we investigated whether the distinction between adaptive (i.e. high personal standards) and maladaptive (i.e. concern over mistakes and doubt about actions) perfectionism that has been found in the literature, is also valid in patients with chronic fatigue syndrome (CFS). We hypothesized that maladaptive, but not adaptive, perfectionism would be significantly and positively related to severity of fatigue and depression in CFS. We examined this hypothesis in a sample of 192 CFS patients using structural equation modelling (SEM). Although the two perfectionism dimensions were related to each other, results supported a model in which only maladaptive perfectionism was positively related to severity of fatigue and depression. Further, we found that depression fully mediated the effect of maladaptive perfectionism on fatigue. The results suggest that adaptive and maladaptive perfectionism are two distinct, albeit related, dimensions in CFS. Findings of this study have important implications for theory and treatment of CFS, particularly for cognitive-behavioral treatment.

Psychiatric aspects of chronic fatigue syndrome and fibromyalgia.

Chronic fatigue syndrome and/or fibromyalgia (CFS/FM) consists of highly overlapping, medically unexplained symptoms, including long-lasting fatigue, effort intolerance, cognitive dysfunction, and widespread pain and tenderness. CFS/FM often seems to be triggered by infections and physical trauma, but depression, sleep disturbances, and personality may also be involved. Moreover, dysregulation of the stress system, the immune system, and central pain mechanisms may determine the pathophysiology of the illness, leading to a loss of capacity to adapt to all kind of stressors. CFS/FM patients can be best helped by a pragmatic and individualized approach aimed at adjusting lifestyle and optimizing self-care, which in the long run may contribute to a restoration of physical and mental adaptability. Future psychiatric research into CFS/FM should focus on the complex interrelationships among pain/fatigue, stress/depression, and personality, as well as on processes of therapeutic change and the advantages of customized treatment.

A comparison of patients with chronic fatigue syndrome in two "ideologically" contrasting clinics.

Aim of the present study was to compare chronic fatigue syndrome (CFS) patients, attending 2 "ideologically" contrasting clinics for CFS, on various patient and illness characteristics. Fifty-nine CFS patients of each clinic, located in Leuven and Brussels (Belgium), participated. Patients did not differ with regard to age, levels of fatigue, psychopathology, and self-efficacy. However, patients from the psychosocially-oriented clinic had a lower level of education, reported more progressive illness onset, and attributed their illness more to psychological causes. Patients in the biologically-oriented clinic reported more pain, and showed higher levels of social functioning, motivation and vitality, as well as fewer limitations related to emotional problems. It is concluded that CFS patients attending the 2 clinics could not be distinguished along dualistic biological/psychosocial lines, but those reporting sudden illness onset and making somatic attributions were more likely to be represented in the biologically-oriented clinic.

Chronic fatigue syndrome: a hormonal origin? A rare case of dysmenorrhea membranacea.

BACKGROUND: Membranous dysmenorrhea is a rare entity involving expulsion of fragments of endometrium retaining the shape of the uterus. The condition is often linked to high progesterone levels. An association with a chronic fatigue syndrome was never described. CASE: A 44-year-old woman with a chronic fatigue syndrome (CFS), presented with membranous dysmenorrhea after taking an oral contraceptive pill containing ethinylestradiol 0.02 mg and desogestrel 0.15 mg for 3 months in a continuous regimen as treatment for dysfunctional bleeding. Oral contraception was discontinued and she resumed normal menstruations. Remarkably, she mentioned complete disappearance of the CFS since expulsion of the tissue and started working again. CONCLUSION: The occurrence of membranous dysmenorrhea with a dissolving chronic fatigue syndrome is very rare and was never described before. This case suggests a hormonal dysfunction as a possible cause of chronic fatigue syndrome. A review of the literature on membranous dysmenorrhea is presented.

Customizing treatment of chronic fatigue syndrome and fibromyalgia: the role of perpetuating factors.

BACKGROUND: Syndromes characterized by chronic, medically unexplained fatigue, effort- and stress-intolerance, and widespread pain are highly prevalent in medicine. RESULTS: In chronic fatigue syndrome (CFS) and fibromyalgia (FM), various perpetuating factors may impair patients' quality of life and functioning and impede recovery. Although cognitive-behavioral and graded-exercise therapy are evidence-based treatments, the effectiveness and acceptability of therapeutic interventions in CFS/FM may largely depend on a customized approach taking the heterogeneity of perpetuating factors into account. CONCLUSION: Further research should clarify the aim and outcome of different treatment strategies in CFS/FM, as well as the underlying mechanisms of change, including those facilitating neurobiological recovery.

Equifinality, multifinality, and the rediscovery of the importance of early experiences: pathways from early adversity to psychiatric and (functional) somatic disorders.

Most current mainstream research, diagnostic assessment, and treatment strategies focus on specific psychiatric disorders--on diagnoses that are based on manifest symptoms within a categorical, atheoretical approach. This disorder-centered approach has been antithetical to psychoanalytic views, which are fundamentally person centered, focusing on the dynamics of individual lives. Growing realization of the high comorbidity among psychiatric disorders has led to the need to include developmental considerations and hierarchical models in the classification and treatment of psychopathology. In addition, this realization has led to a renewed interest in the principles of equifinality and multifinality--that a given end state can be the result of different developmental paths and that similar developmental factors may lead to dissimilar outcomes. In this chapter these developments are illustrated by research on the impact of early adversity, a central domain in psychoanalytic thought. Findings from various strands of research in the neurosciences and genetic research, in particular, suggest that early adversity leads to vulnerability for a wide variety of both psychiatric and (functional) somatic disorders. These findings have contributed to the rediscovery of the importance of early experiences more generally and to the need for a broad developmental perspective. In this context, we also discuss the danger of reductionism associated with the growing influence and popularity of affective neuroscience and genetics as well as the vital role a psychoanalytic perspective might play in countering this reductionism by reestablishing the importance of meaning and meaning making in understanding and treating patients with a history of early adversity. In particular, we focus on the importance of narrative and mental representations in the development of the capacity for mentalization in these patients.

Hyperventilation in patients with chronic fatigue syndrome: the role of coping strategies.

Hyperventilation has been suggested as a concomitant and possible maintaining factor that may contribute to the symptom pattern of chronic fatigue syndrome (CFS). Because patients accepting the illness and trying to live with it seem to have a better prognosis than patients chronically fighting it, we investigated breathing behavior during different coping response sets towards the illness in patients with CFS (N=30, CDC criteria). Patients imagined a relaxation script (baseline), a script describing a coping response of hostile resistance, and a script depicting acceptance of the illness and its (future) consequences. During each imagery trial, end-tidal PCO2 (Handheld Capnograph, Oridion) was measured. After each trial, patients filled out a symptom checklist. Results showed low resting values of PetCO2 overall, while only imagery of hostile resistance triggered a decrease and deficient recovery of PetCO2. Also, more hyperventilation complaints and complaints of other origin were reported during hostile resistance imagery compared with acceptance and relaxation. In conclusion, hostile resistance seems to trigger both physiological and symptom perception processes contributing to the clinical picture of CFS.

Depression research and treatment: are we skating to where the puck is going to be?

This paper critically reviews empirical findings regarding current key assumptions underlying the nature and treatment of depression which heavily rely on the DSM approach. This review shows that empirical evidence provides little support for these assumptions. In response to these findings, an etiologically based, biopsychosocial, dynamic interactionism model of depression is proposed. This model could foster further integration in research on depression and assist in the development of guidelines for the treatment of depression that are better informed by research findings and more congruent with complex clinical realities.

In search of a new balance. Can high "action-proneness" in patients with chronic fatigue syndrome be changed by a multidisciplinary group treatment?

OBJECTIVE: The purpose of this study is to investigate changes in action-proneness (a cognitive and behavioral tendency toward direct action) after a multidisciplinary group intervention, including cognitive behaviour therapy (CBT) and graded exercise therapy (GET). METHODS: Patients with chronic fatigue syndrome (n=62) completed three versions of a Dutch self-report questionnaire evaluating action-proneness retrospectively that is (1) before illness onset, (2) before treatment and (3) after treatment. Significant others (n=62) also gave their opinion about the patients' action-proneness at time points 1 and 2. RESULTS: Premorbid action-proneness levels considerably dropped after illness onset. After treatment, action-proneness levels significantly increased again, although levels remained below premorbid levels. CONCLUSION: High action-proneness retrospectively reported by CFS patients can be adaptively modified by a multidisciplinary group treatment including CBT and GET.

Well-being in patients with chronic fatigue syndrome: the role of acceptance.

OBJECTIVE: Research in chronic pain patients has shown that accepting the chronic nature of their illness is positively related to quality of life. The aim of this study was to investigate whether acceptance is also associated with better well-being in patients suffering from chronic fatigue syndrome (CFS). METHODS: Ninety-seven patients completed a battery of questionnaires measuring fatigue, functional impairment, psychological distress, and acceptance. RESULTS: Results indicated that acceptance has a positive effect upon fatigue and psychological aspects of well-being. More specifically, acceptance was related to more emotional stability and less psychological distress, beyond the effects of demographic variables, and fatigue severity. CONCLUSION: We suggest that promoting acceptance in patients with CFS may often be more beneficial than trying to control largely uncontrollable symptoms.

Self-critical perfectionism predicts lower cortisol response to experimental stress in patients with chronic fatigue syndrome.

OBJECTIVE: Previous studies have suggested that self-critical perfectionism (SCP) may play a role in the development and maintenance of Chronic Fatigue Syndrome (CFS). In this study we investigated whether SCP is related to a hypofunction of the hypothalamic-pituitary-adrenal (HPA) axis, which has been shown to be a key factor in the pathophysiology of CFS. METHOD: We conducted a quasi-experimental study to examine the association between SCP (as measured with the Depressive Experiences Questionnaire) and stress reactivity in a sample of 41 female CFS patients. Participants were exposed to the Trier Social Stress Test (TSST). Both subjective stress and salivary cortisol levels were measured until 90 min after the TSST. We also examined the relationship between stress reactivity and illness characteristics (i.e., duration and severity of symptoms). RESULTS: The results showed that SCP was associated with increased subjective stress reactivity, but with decreased HPA-axis reactivity as indicated by a blunted cortisol response to the TSST. Furthermore, we found an inverse relationship between cortisol reactivity and symptom severity. There was no relationship between cortisol reactivity and illness duration. CONCLUSION: Our findings suggest that SCP is associated with loss of resilience of the neurobiological stress response system in CFS.

Effects of early childhood trauma on hypothalamic-pituitary-adrenal (HPA) axis function in patients with Chronic Fatigue Syndrome.

BACKGROUND: There is a paucity of studies that have investigated the assumption that early childhood trauma is associated with hypothalamic-pituitary-adrenal (HPA) axis dysfunction in Chronic Fatigue Syndrome (CFS). The current study is the first to simultaneously investigate relationships among early childhood trauma, cortisol activity, and cortisol stress reactivity to psychosocial stress in a sample of well-screened CFS patients. We also examined whether self-critical perfectionism (SCP) plays a mediating role in the potential relationship between early trauma and neurobiological stress responses. METHODS: A total of 40 female patients diagnosed with CFS were asked to provide morning saliva cortisol samples (after awakening, 30min later, and 1h later) for seven consecutive days as a measure of cortisol activity. In addition, patients were exposed to the Trier Social Stress Test, a well-validated stress test, to investigate the relationship between early childhood trauma and cortisol stress reactivity. Before the start of the study, patients completed the Childhood Trauma Questionnaire-Short form (CTQ-SF) as a measure of early childhood trauma (i.e. sexual, physical and emotional traumatic experiences). SCP was measured with the Depressive Experiences Questionnaire (DEQ). Data were analyzed by calculating several indices of cortisol secretion (i.e. Cortisol Awakening Response and Area Under the Curve). RESULTS: There was no association between early childhood trauma and cortisol as measured over the 7-day period. However, emotional neglect was significantly negatively related to cortisol reactivity in the TSST. SCP did not significantly mediate this association. CONCLUSION: Findings of this study suggest that emotional neglect is associated with blunted HPA axis reactivity, congruent with the assumption that CFS may reflect loss of adaptability of the neuroendocrine stress response system in at least a subgroup of patients.

Antidepressant-induced analgesia in chronic non-malignant pain: a meta-analysis of 39 placebo-controlled studies.

For 39 controlled studies on the analgesic effect of antidepressants, a meta-analysis was conducted to get an estimation of the effect size, and to obtain a sight on the possible modes of action and the methodology used. The mean size of the analgesic effect was 0.64. It means that the average chronic pain patient who received an antidepressant treatment had less pain than 74% of the chronic pain patients who received a placebo. This quantification, however, is only as good as the studies on which it is based, and it could be differentiated for each of the pain syndromes and antidepressants examined. Real analgesic qualities of antidepressive agents seemed to offer the most plausible and economical explanation for the effect, but the predominant importance of serotonin reuptake blocking was not confirmed. Finally, the meta-analysis appeared to be fruitful for the generation of new hypotheses, for making some recommendations for future research, and for proposing some provisional guidelines for the clinical use of antidepressants in chronic non-malignant pain.

Is there a link between 'pain-proneness' and 'action-proneness'?

The present study was designed to examine the premorbid 'action-proneness' of chronic pain patients without obvious organic etiology. Using a validated psychometric instrument (the HAB questionnaire), 3 clinical groups were compared: 30 patients with chronic 'non-organic' pain, 30 patients with chronic organic pathology and 30 hospitalized psychiatric patients without pain as a primary complaint. The results indicate that the chronic pain patients describe themselves retrospectively as more 'action-prone' than the patients of the two control groups. Using an analysis of covariance to have statistical control on age, occupational level and depression, the results were statistically significant on the 0.05 level. Although this study suggests that a strong tendency towards direct action may be a frequent and relatively specific premorbid feature of chronic pain patients, the pathogenic implications of these findings remain uncertain.

A confirmatory factor analysis of the Pain Catastrophizing Scale: invariant factor structure across clinical and non-clinical populations.

This study examined the factor structure of the Pain Catastrophizing Scale in three different Dutch-speaking samples: 550 pain-free students, 162 chronic low back pain patients, and 100 fibromyalgia patients. Confirmatory factor analyses were used to compare three different models of pain catastrophizing (one factor, two oblique factors, three oblique factors), and to investigate the invariance of the factor structure across the three different samples. The results indicated that a three-factor oblique model with a four-item rumination factor, a three-item magnification factor, and a six-item helplessness factor provided the best fit to the data in the three samples. Furthermore, it was found that this model could be considered as invariant across three samples (pain-free students, chronic low back pain patients, and fibromyalgia patients) and across gender, indicating that the same processes are measured in different subgroups.

Acceptance of pain is an independent predictor of mental well-being in patients with chronic pain: empirical evidence and reappraisal.

This paper reports upon: (1) the value of acceptance of pain in predicting well-being in patients suffering from chronic pain and (2) the construct validity of acceptance by comparing two questionnaires designed to measure acceptance (the Chronic Pain Acceptance Questionnaire, CPAQ, unpublished doctoral dissertation, University of Nevada, Reno, NV, 1992 and the Illness Cognitions Questionnaire, ICQ, J Consult Clin Psychol 69 (2001) 1026). The results of two independent cross-sectional studies are reported. Study 1 included 120 patients seeking help in tertiary care settings. In Study 2, 66 patients were recruited from a self-support group for fibromyalgia patients and from a pain clinic. Both studies revealed that acceptance of pain predicted mental well-being beyond pain severity and pain catastrophizing, but did not account for physical functioning. In both instruments, it was found that acceptance of pain was strongly related to engagement in normal life activities and the recognition that pain may not change. Acceptance in both instruments was strongly related to a cognitive control over pain. Study 2 further revealed that the correlation between the CPAQ and the ICQ is moderate, indicating that both instruments measured different aspects of acceptance. It is concluded that acceptance of chronic pain is best conceived of as the shift away from pain to non-pain aspects of life, and the shift away from a search for a cure with an acknowledgement that pain may not change.

Spinal cord stimulation in Belgium: a nation-wide survey on the incidence, indications and therapeutic efficacy by the health insurer.

The present report describes a nation-wide survey on the incidence, the indications and the efficacy of spinal cord stimulation (SCS), as assessed by the Belgian health authorities. The direct motive for this survey was the rapidly growing expenditures resulting from the increasing use of SCS. Between 1983 and 1992, nearly 700 SCS devices were implanted for a population of less than 10 million inhabitants. The most common indication for SCS was failed back survey (61.4%). Whereas SCS was initially only performed in university teaching hospitals, it is now also widely practised in general hospitals. In 3 studies, the efficacy of SCS was assessed. In a first study, success was defined in terms of resumption of professional activities. After a mean follow-up of more than 1 year, less than 5% of the 147 patients treated with SCS had returned to work. A second study investigated the subjective evaluation of the therapy by the patient. Seventy patients with a mean follow-up of 3.5 years were studied. In 52% of the patients, the effect of SCS was judged as good to very good. Men scored better than women. In addition, the results obtained in the teaching hospitals were significantly better than those obtained in general hospitals. In a third study, the impact of psychiatric screening on patient selection was evaluated. Of the 100 candidates, 36 were withheld from implantation with a SCS device because of psychiatric contra-indications. Patients who had received a positive psychiatric advice showed a significantly better therapeutic outcome than patients for whom the psychiatrist had made reservations.

Combination therapy with hydrocortisone and fludrocortisone does not improve symptoms in chronic fatigue syndrome: a randomized, placebo-controlled, double-blind, crossover study.

PURPOSE: Chronic fatigue syndrome has been associated with decreased function of the hypothalamic-pituitary-adrenal axis. Although neurally mediated hypotension occurs more frequently in patients with chronic fatigue syndrome than in controls, attempts to alleviate symptoms by administration of hydrocortisone or fludrocortisone have not been successful. The purpose of this study was to investigate the effect of combination therapy (5 mg/d of hydrocortisone and 50 microg/d of 9-alfa-fludrocortisone) on fatigue and well-being in chronic fatigue syndrome. METHODS: We performed a 6-month, randomized, placebo-controlled, double-blind, crossover study in 100 patients who fulfilled the 1994 Centers for Disease Control and Prevention criteria for chronic fatigue syndrome. Between-group differences (placebo minus treatment) were calculated on a 10-point visual analog scale. RESULTS: Eighty patients completed the 3 months of placebo and 3 months of active treatment in a double-blind fashion. There were no differences between treatment and placebo in patient-reported fatigue (mean difference, 0.1; 95% confidence interval [CI]: -0.3 to 0.6) or well-being (mean difference, -0.4; 95% CI: -1.0 to 0.1). There were also no between-group differences in fatigue measured with the Abbreviated Fatigue Questionnaire, the Short Form-36 Mental or Physical Factor scores, or in the Hospital Anxiety and Depression Scale. CONCLUSION: Low-dose combination therapy of hydrocortisone and fludrocortisone was not effective in patients with chronic fatigue syndrome.