Retrospective Analysis of Risk Factors for Periodic Limb Movements in a Large Cohort of Insomnia and Chronic Fatigue Patients.

INTRODUCTION: Although the pathophysiology of periodic limb movements in sleep (PLMS) is not well understood, there is increasing belief that management of PLMS can modulate humans' general health. The aim of this study is to investigate the associations between risk factors including the use of antidepressants, hypnotics, and antihistamines as well as of caffeine, alcohol, and nicotine and the occurrence of PLMS and periodic limb movement disorder (PLMD). METHODS: Patients with either chronic fatigue or insomnia who underwent polysomnography as standardized clinical assessment were included in a retrospective study. Associations were calculated between substance use and sleep variables. RESULTS: Tricyclic antidepressants and serotonin and norepinephrine reuptake inhibitor (SNRI) are significantly associated with higher rates of PLMS. Additionally, SNRI is significantly positive associated with PLMD, as also seen for selective serotonin reuptake inhibitors (SSRI). The most frequently used SSRI escitalopram was significantly positively associated with PLMS and PLMD. A significantly negative association was found between paroxetine and PLMS. Benzodiazepines are negatively associated with PLMS and PLMD. Sedative antidepressants, antihistamines, and substance use are not associated with PLMS nor PLMD in this study. DISCUSSION: This retrospective study adds supportive evidence to the association of drug classes with PLMS and PLMD. These findings may impact on clinical management of patients with a combined anxiety or mood disorder in need for these drug classes on the one hand and a significant sleep architecture disturbance through PLMS, potentially contributing to daytime symptoms, on the other hand.

Improving quality of life in patients with chronic kidney disease: influence of acceptance and personality.

BACKGROUND: A low health-related quality of life (HQL) is associated with the evolution of chronic kidney disease (CKD) and mortality in patients in end-stage of the disease. Therefore research on psychological determinants of HQL is emerging. We investigate whether acceptance of the disease contributes to a better physical and mental health-related quality of life (PHQL and MHQL). We also examine the impact of personality characteristics on acceptance, PHQL and MHQL. METHODS: In this cross-sectional study, patients from an outpatient clinic of nephrology completed self-report questionnaires on quality of life, acceptance and personality characteristics. We performed correlations, regression analyses and a path analysis. RESULTS: Our sample of 99 patients had a mean duration of CKD of 10.81 years and a mean estimated Glomerular Filtration Rate (eGFR) by Modification of Diet in Renal Disease (MDRD)-formula of 34.49 ml/min (SD 21.66). Regression analyses revealed that acceptance had a significant positive contribution to the prediction of PHQL and MHQL. Neuroticism was negatively associated with acceptance and MHQL. Path analysis showed that 37% of the total effect of neuroticism on MHQL was mediated by acceptance. CONCLUSIONS: Acceptance is an important positive variable in accounting for HQL, however, clinicians must be aware that if patients have a high level of neuroticism they are likely to have more difficulties with this coping strategy. These results provide a better understanding of psychological determinants of HQL in CKD, which can initiate another approach of these patients by nephrologists, specific psychological interventions, or other supporting public health services.

Mental quality of life in chronic fatigue is associated with an accommodative coping style and neuroticism: a path analysis.

PURPOSE: An accommodative coping style (e.g. acceptance) is related to a better mental health-related quality of life (MHQL) in patients with chronic fatigue syndrome (CFS). We want to explore whether neuroticism is predictive for this coping style and MHQL. Secondly we want to explore the relation between acceptance and physical health-related quality of life (PHQL) and expect that illness-related variables such as fatigue severity and duration are related to PHQL. METHOD: In this cross-sectional study, 117 patients with chronic fatigue syndrome from an outpatient internal medicine clinic completed self-report questionnaires on quality of life (SF-36), acceptance (ICQ), personality traits (NEO-FFI) and fatigue severity (CIS). RESULTS: Regression analyses showed that neuroticism and acceptance are predictors of MHQL (38% of the variance was explained). The path analysis showed that acceptance mediates between neuroticism and MHQL and that PHQL is related to MHQL. PHQL is related to fatigue severity and duration, but not to neuroticism and acceptance. CONCLUSION: Stimulating an 'accepting accommodative coping style' within the treatment for CFS is important in improving mental quality of life. Our results suggest that neuroticism may be negatively related to acceptance and MHQL. This findings support the idea that a psychological diagnostic workout with special attention to personality traits in relation to their coping style is recommended in order to choose the most appropriate therapeutic approach in this population.

Effects of continuous positive airway pressure on fatigue in two patients with obstructive sleep apnea presenting with chronic fatigue: case report and lessons learned from a failed trial.

INTRODUCTION: Patients referred to tertiary care for multidisciplinary investigation of unexplained chronic fatigue are not seldom diagnosed with obstructive sleep apnoea (OSA). As standard treatment for OSA, continuous positive airway pressure (CPAP) has been shown to decrease daytime sleepiness in OSA patients. However, the effect on fatigue as major complaint in chronic fatigue patients without excessive daytime sleepiness, is not fully understood nor explored. CASE REPORT: A prospective cross-over trial using effective and sham CPAP treatment periods in patients with unexplained chronic fatigue and OSA was interrupted because of poor recruitment and retainment due to complex design issues. We report the effect of CPAP after one month and one to two years follow-up on fatigue as primary outcome and on daytime sleepiness, global sleep quality and global mental and physical health as secondary outcomes in two patients completing the trial. In both patients, comparison of sequential effective and sham CPAP treatments failed to demonstrate consistent short-term effects in outcome measures, in spite of significant differences in apnoea-hypopnea index. However, substantial improvements of fatigue scores were observed at long-term follow-up in both individuals. CONCLUSION: This is the first report of both short- and long-term effects of CPAP treatment on fatigue in patients with OSA and disabling chronic fatigue as primary complaint. A feasible prospective trial remains warranted in order to answer the question of CPAP responsiveness of fatigue in this patient population.

Comparison of subjective sleep and fatigue in breast- and bottle-feeding mothers.

OBJECTIVES: Artificial milk supplementation remains a popular practice in spite of the well documented and indisputable advantages of breast feeding for both mother and child. However, the association between maternal sleep, fatigue and feeding method is understudied and remains unclear. The aim of this study is to investigate whether perceived sleep and fatigue differ between breast- and bottle feeding post partum women. In addition, the relationship between subjective sleep characteristics and fatigue is examined. METHODS: Post partum women (four to 16 weeks) filled out a socio-demographic questionnaire, the Pittsburgh Sleep Quality Index (PSQI) and the Checklist Individual Strength (CIS). FINDINGS: Sixty-one within the past week exclusively breast- and 44 exclusively bottle-feeding mothers were included. The first group showed better subjective sleep quality, but lower habitual sleep efficiency as measured by the PSQI. Global PSQI, as well as subjective fatigue and global CIS, did not differ between the two groups. Significant positive correlations were found between global CIS and the number of night feeds and global PSQI. However, only global PSQI significantly predicted global CIS in relation to the number of night feeds. CONCLUSIONS: Within a general pattern of deteriorated sleep quality, breast-feeding women showed better subjective sleep quality, but lower habitual sleep efficiency, between four and fourteen weeks after childbirth. However, the PSQI component scores compensated for each other, resulting in absence of any difference in global PSQI sleep quality between the two groups. Global PSQI significantly predicted global CIS, resulting in an absence of any difference in post partum fatigue according to feeding method. IMPLICATIONS FOR PRACTICE: Midwives and nurses should, together with the parents, continue to focus on exploring ways to improve maternal sleep quality and to reduce postnatal fatigue.

Factors determining fatigue in the chronic fatigue syndrome: a path analysis.

OBJECTIVES: To explore the interrelationship of different dimensions (fatigue, neuroticism, sleep quality, global mental and physical health) in patients with chronic fatigue syndrome (CFS). METHODS: Patients meeting the Fukuda criteria of CFS filled out two independent fatigue scales (Fatigue Questionnaire, FQ and Checklist Individual Strength, CIS), NEO-Five Factor Inventory (NEO-FFI), Pittsburgh Sleep Quality Index (PSQI) and Medical Outcomes Study 36-item Short Form Health Survey (SF36). Exploratory and confirmatory path analyses were performed. RESULTS: Out of 226 eligible patients, 167 subjects were included (mean age 39.13 years, SD 10.14, 92% female). In a first exploratory path analysis, using FQ for assessment of fatigue, night-time PSQI sleep quality had a direct effect on SF36 physical quality of life (PQoL) and no effect on FQ fatigue. This was confirmed by a subsequent path analysis with CIS fatigue and by confirmatory path analyses in 81 patients. These unexpected results raised the question whether FQ or CIS fatigue sufficiently operationalizes fatigue in CFS patients. CONCLUSIONS: Poor sleep quality seems to directly impact on mental quality of life (MQoL) and PQoL without mediation of fatigue assessed with FQ and CIS. A more cohesive framework needs to be developed with more comprehensive clinical tools for the different dimensions in the construct of CFS.

Sleep in the chronic fatigue syndrome.

Chronic fatigue syndrome (CFS) is a disabling condition characterized by severe fatigue lasting for more than six months and the presence of at least four out of eight minor criteria. Sleep disturbance presenting as unrefreshing or nonrestorative sleep is one of these criteria and is very common in CFS patients. Biologically disturbed sleep is a known cause of fatigue and could play a role in the pathogenesis of CFS. However, the nature of presumed sleep impairment in CFS remains unclear. Whilst complaints of NRS persist over time, there is no demonstrable neurophysiological correlate to substantiate a basic deficit in sleep function in CFS. Polysomnographic findings have not shown to be significantly different between subjects with CFS and normal controls. Discrepancies between subjectively poor and objectively normal sleep suggest a role for psychosocial factors negatively affecting perception of sleep quality. Primary sleep disorders are often detected in patients who otherwise qualify for a CFS diagnosis. These disorders could contribute to the presence of daytime dysfunctioning. There is currently insufficient evidence to indicate that treatment of primary sleep disorders sufficiently improves the fatigue associated with CFS. Therefore, primary sleep disorders may be a comorbid rather than an exclusionary condition with respect to CFS.

Undiagnosed and comorbid disorders in patients with presumed chronic fatigue syndrome.

OBJECTIVE: To assess undiagnosed and comorbid disorders in patients referred to a tertiary care center with a presumed diagnosis of chronic fatigue syndrome (CFS). METHODS: Patients referred for chronic unexplained fatigue entered an integrated diagnostic pathway, including internal medicine assessment, psychodiagnostic screening, physiotherapeutic assessment and polysomnography+multiple sleep latency testing. Final diagnosis resulted from a multidisciplinary team discussion. Fukuda criteria were used for the diagnosis of CFS, DSM-IV-TR criteria for psychiatric disorders, ICSD-2 criteria for sleep disorders. RESULTS: Out of 377 patients referred, 279 (74.0%) were included in the study [84.9% female; mean age 38.8years (SD 10.3)]. A diagnosis of unequivocal CFS was made in 23.3%. In 21.1%, CFS was associated with a sleep disorder and/or psychiatric disorder, not invalidating the diagnosis of CFS. A predominant sleep disorder was found in 9.7%, 19.0% had a psychiatric disorder and 20.8% a combination of both. Only 2.2% was diagnosed with a classical internal disease. In the total sample, a sleep disorder was found in 49.8%, especially obstructive sleep apnea syndrome, followed by psychophysiologic insomnia and periodic limb movement disorder. A psychiatric disorder was diagnosed in 45.2%; mostly mood and anxiety disorder. CONCLUSIONS: A multidisciplinary approach to presumed CFS yields unequivocal CFS in only a minority of patients, and reveals a broad spectrum of exclusionary or comorbid conditions within the domains of sleep medicine and psychiatry. These findings favor a systematic diagnostic approach to CFS, suitable to identify a wide range of diagnostic categories that may be subject to dedicated care.

Validation of the three-factor model of the PSQI in a large sample of chronic fatigue syndrome (CFS) patients.

OBJECTIVE: To evaluate whether a 3-factor model of the Pittsburgh Sleep Quality Index (PSQI) scale would fit the constellation of sleep disturbances in patients with a diagnosis of chronic fatigue syndrome (CFS). METHODS: Consecutive CFS patients filled out the PSQI. Scores from this self-report questionnaire were examined with exploratory and confirmatory factor analysis (CFA). RESULTS: 413 CFS patients were included for analysis in this study. CFA showed that the 7 PSQI component scores clustered into the 3 factors reported by Cole et al. (2006), i.e. Sleep Efficiency, Perceived Sleep Quality and Daily Disturbances. In contrast with the single-factor and all 2-factor models, all factor loadings were significant, and all goodness-of-fit values were acceptable. CONCLUSION: In CFS, the PSQI operates as a 3-factor scoring model as initially seen in healthy and depressed older adults. The separation into 3 discrete factors suggests the limited usefulness of the global PSQI as a single factor for the assessment of subjective sleep quality, as also evidenced by a low Cronbach's alpha (0.64) in this patient sample.