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PHYSIOLOGY
AND BIOCHEMISTRY
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Gaab, J., Engert, V., Heitz, V., Schad, T., Schurmeyer, TH and Ehlert, U. Associations between neuroendocrine responses to the Insulin Tolerance Test and patient characteristics in chronic fatigue syndrome. Journal of Psychosomatic Research, 2004, 56, 419-424.
Subtle dysregulations of the hypothalamic-pituitary-adrenal (HPA) axis have been proposed as an underlying pathophysiological mechanism in CFS. This study attempted to assess the relationship between patient characteristics and HPA axis functioning using a neuroendocrine challenge test.
A test battery designed to assess different dimensions of CFS was given to 18 CFS patients (Oxford and CDC criteria '94) and 17 controls. To evaluate the integrity of the HPA axis, the Insulin Tolerance Test (ITT), a centrally acting neuroendocrine challenge test, was performed on patients and controls. ACTH, salivary free cortisol and total plasma cortisol levels were assessed as a measure of the HPA axis stress response. Correlations of patient characteristics were calculated with integrated responses for all endocrine parameters.
CFS patients had a significantly reduced area under the ACTH response curve (AUC) in the ITT. The AUC was significantly associated with the duration of CFS symptoms (r=-.592, p=.005) and the severity of fatigue symptomatology (r=-.41, p=.045). In addition, duration of CFS was correlated with the severity of fatigue symptoms (r=.38, p=.045). Similar associations were not observed for cortisol parameters.
It has been postulated that neuroendocrine dysregulations observed in CFS are of an acquired nature. The results of a strong association between the integrated ACTH response and the duration of CFS emphasizes the need to consider factors known to be risk factors for the chronicity of CFS symptoms, such as profound inactivity, deconditioning and sleep abnormalities, as possible candidates for secondary causes of neuroendocrine dysregulations in CFS.
Extracts from the discussion:
In comparison to healthy controls matched for age and gender, CFS patients had a clearly reduced integrated ACTH response to the insulin challenge. However, cortisol responses were normal in CFS patients. This concurs with a postulated central origin of HPA axis dysregulations (i.e. a deficient CRH secretion), and a compensatory up-regulation of adrenal sensitivity.
...Given that self-help groups advocate a somatic etiology of CFS, it is possible that differences in the attribution of symptoms experienced partly explains the low number of psychiatric disorders in our sample, since an attribution to a biological cause seems to protect against psychological distress... the reduced ACTH response in the ITT could be explained by a permanent suppression of hypothalamic CRH secretion in CFS, for example, due to permanently enhanced negative feedback. Our finding of a high correlation between the duration of illness and integrated ACTH response in the ITT is consistent with the assumption of a hyporesponsive pituitary due to prolonged insufficient central priming.
It has been postulated that neuroendocrine dysregulations observed in CFS are of an acquired nature, most likely the consequences of traumatic and/or chronic stress. While our finding of a strong association between the integrated ACTH response and the duration of CFS does not refute this assumption, it emphasizes the need to consider other factors known to be risk factors for the chronicity of CFS symptoms, such as ... profound inactivity, deconditioning, and sleep abnormalities.
[Ed. Note: It is unfortunate that despite previous speculation about the role of inactivity on the HPA axis etc, these were not measured. Also, it may have been interesting to check the role of variables which were assessed, e.g. measures of ambulation and sleep (SIP). The normal cortisol levels are noteworthy. It is possible that the stress of the illness may have affected one aspect of the HPA axis (and future studies might include patients with MS as an appropriate comparison group), but that membership of the self-help organization protected against more damaging effects, reflected by cortisol. Whether it is helpful to compare endocrine function in CFS and students undergoing an exam is unclear, as one involves an acute stressor with a possible good outcome, while the other is a severe and chronic one associated with unknown and sometimes poor outcome. Continued speculation about prolonged bed rest is, after so many years and opportunities to investigate it, rather surprising.
If stress is considered to be an influence on the HPA axis, it should be measured, alongside coping strategies.]
Nijs, J., De Meirleir, K., Wolfs, S and Duquet, W. Disability evaluation in chronic fatigue syndrome: associations between exercise capacity and activity limitations/participation restrictions. Clinical Rehabilitation, 2004, 18, 2, 139-148.
In an attempt to examine whether impairments in cardiorespiratory fitness are associated with daily functioning in patients with CFS, this study addresses the correlations between exercise capacity and activity limitations/participation restrictions.
Subjects were 77 patients with CFS (CDC criteria '94). Of these, 64.9% also fulfilled the 1988 criteria. They completed the Chronic Fatigue Syndrome Activities and Participation Questionnaire (CFS-APQ) and performed a maximal exercise stress test on a bicycle ergometer. Heart rate was monitored continuously by use of an electrocardiograph. Metabolic and ventilatory parameters were measured through spirometry.
The researchers found a statistically significant but modest correlation between the score obtained with the CFS-APQ and the body weight-adjusted peak oxygen uptake (rs=-0.32; p=0.005), functional aerobic impairment (rs=0.33; p=0.004), workload/body weight (rs=-0.30; p=0.009), exercise duration (rs=-0.30; p=0.008), and the percentage of target heart rate achieved (rs=-0.33; p=0.004). The correlations between the remaining exercise capacity parameters and the scores obtained with the CFS-APQ all indicated a trend towards association (0.01<p<0.05).
These results indicate that there is no strong association between exercise capacity and activity limitations/participation restrictions in patients with CFS. The observed correlations lack strength to predict activity limitations/participation restriction based on exercise capacity parameters. Disability evaluation in CFS should therefore encompass both exercise capacity testing and measurements at the activity/participation dimension.
Spence, VA., Khan, F., Kennedy, G., Abbot, NC and Belch, JJ. Acetylcholine mediated vasodilatation in the microcirculation of patients with chronic fatigue syndrome. Prostaglandins, Leukotrines and Essential Fatty Acids, 2004, 70, 4, 403-407.
Research into CFS is hindered by the considerable heterogeneity seen across patients but several reports have highlighted disturbances to cholinergic mechanisms in terms of central nervous system activity, neuromuscular function and autoantibodies to muscarinic cholinergic receptors. This paper examines an altogether separate function for acetylcholine (ACh) and that is its role as an important and generalized vasodilator. Most diseases are accompanied by a blunted response to acetylcholine but the opposite is true for CFS. Such sensitivity is normally associated with physical training so the finding in CFS is anomalous and may well be relevant to vascular symptoms that characterise many patients. There are several mechanisms that might lead to ACh endothelial sensitivity in CFS patients and various experiments have been designed to unravel the enigma. These are reported here.
Three studies have identified abnormalities of the ACh endothelium-dependent vasodilator pathway in CFS. Sensitivity to ACh seems to be restricted to people with ME and PVFS and not to those with fibromyalgia (FM), Gulf War Syndrome and those exposed to organophosphates (OPs). The finding of increased sensitivity to ACh seems unusual and robust.
Winkler, AS., Blair, D., Marsden, JT., Peters, TJ., Wessely, S and Cleare, AJ. Autonomic function and serum erythropoietin levels in chronic fatigue syndrome. Journal of Psychosomatic Research, 2004, 56, 2, 179-183.
Given previous findings, we wished to investigate whether there was evidence of autonomic dysfunction in patients with CFS, and whether this could be related to reduced erythropoietin levels and altered red blood cell indices.
We assessed autonomic function and analysed blood parameters (including erythropoietin) in 22 patients with CFS (CDC criteria '94) who were medication-free and without comorbid depression or anxiety. Results were compared to 23 iron-deficiency anaemia patients and 18 healthy individuals.
Autonomic testing in patients with CFS yielded a significantly greater increase in heart rate together with a more pronounced systolic blood pressure fall on standing compared to healthy individuals. Heart rate beat-to-beat variation on deep breathing and responses to the Valsalva manoeuvre were normal. Two of 22 patients with chronic fatigue had mild normochromic normocytic anaemia with normal ferritin, vitamin B12 and folate levels. Serum erythropoietin levels were within reference range.
Some autonomic dysfunction is present in CFS patients; the explanation remains uncertain, but could relate to cardiovascular deconditioning. There were no major haematological, biochemical or immunological abnormalities in these patients.
Henderson, M and Tannock, C. Objective assessment of personality disorder in chronic fatigue syndrome. Journal of Psychosomatic Research, 2004, 56, 2, 251-254.
This study aims to objectively assess the prevalence and nature of personality disorders in depressed and nondepressed CFS patients and compare this to depressed and healthy control groups.
Sixty-one patients attending a tertiary referral clinic with CFS (CDC criteria '94), 40 psychiatric inpatients with depressive disorder and 45 healthy medical students completed the Structured Clinical Interview for DSM-III-R Diagnoses (SCID-II) in addition to providing routine clinical and demographic information.
Thirty-nine percent of the CFS group, 73% of the depressed group and 4% of the healthy group were diagnosed with personality disorders. Cluster C disorders were the most common in both the CFS and depressed group. The depressed CFS patients had more Cluster B personality disorders than nondepressed CFS patients. Overall for CFS patients there was no association between mood state and personality disorder.
Characteristics of the more common obsessive-compulsive personality disorders include perfectionism, excessive conscientiousness, attention to detail and rigidity.
[Ed. note: Some of the patients may have been taken from research into ME, cf. Costa et al 1995. These also had brainstem hypoperfusion. Whether this is causally related or independent of the above findings remains unclear.]
Prins, JB., Bos, E., Huibers, MJH., Servaes, P., van der Werf, SP., van der Meer, JWM and Bleijenberg, G. Social support and the persistence of complaints in chronic fatigue syndrome. Psychotherapy and Psychosomatics, 2004, 73, 174-182.
Several studies suggested that the surroundings of CFS patients are of importance in the persistence of complaints. Contrary to what was expected, participation in support groups has not led to clinical improvement. The purpose of the present study was to describe social support in CFS patients as compared with other fatigued and non-fatigued groups. Further, changes in social support and the influence of social support on the course of CFS over a period of more than 1 year were studied in patients with and without treatment.
Baseline data were assessed in 270 CFS (modified Oxford criteria) patients, 150 disease-free breast cancer patients, 151 fatigued employees on sick-leave and 108 healthy subjects using the Social Support List and Significant Others Scale. CFS patients were followed in cognitive behaviour therapy (CBT), guided support groups and natural course at 8 and 14 months.
CFS patients and fatigued employees reported more negative interactions and insufficiency of supporting interactions than cancer patients and healthy controls. No differences in frequency of supporting interactions were found. Negative interactions decreased significantly after treatment with CBT, but did not change in support groups or natural course.
"Higher levels of functional impairment, less social companionship and less empathy from colleagues and chief at baseline were found to predict higher levels of functional impairment in the support groups". Participation in support groups did not satisfy the need for companionship and empathy. In CFS patients and fatigued employees, social support is worse than in disease-free cancer patients and healthy controls. Lack of social support was identified as a new factor in the model of perpetuating factors of fatigue severity and functional impairment in CFS.
*[Ed. note: The authors suggest that the groups may have spent too long discussing the relief of symptoms, implying this is a bad thing, rather than a result of having a severe illness and inadequate medical care with no other sources of help.]
Roy-Byrne, P., Smith, WR., Goldberg, J., Afari, N and Buchwald, D. Post-traumatic stress disorder among patients with chronic pain and chronic fatigue. Psychological Medicine, 2004, 34, 2, 363-368.
Fibromyalgia (FM) ... often develops following a traumatic event. FM has been associated with post-traumatic stress disorder (PTSD) and major depression disorder (MDD).
Patients seen in a referral clinic (N=571) were evaluated for FM and CFS (CDC '94 criteria). Patients completed questionnaires, and underwent a physical examination and a structured psychiatric evaluation. Critical components of the diagnostic criteria of FM (tender points and diffuse pain) and CFS (persistent debilitating fatigue and four of eight associated symptoms) were examined for their relationship with PTSD.
The prevalence of lifetime PTSD was 20% and lifetime MDD was 42%. Patients who had both tender points and diffuse pain had a higher prevalence of PTSD (OR=3.4) compared with those who had neither of these FM criteria. Stratification by MDD and adjustment for socio-demographic factors and chronic fatigue revealed that the association of PTSD with FM criteria was confined to those with MDD. Patients with MDD who met both components of the FM criteria had a three-fold increase in the prevalence of PTSD; conversely, FM patients without MDD showed no increase in PTSD (OR=1.3). The components of the CFS criteria were not significantly associated with PTSD.
Taylor, RR., Braveman, B and Hammel, J. Developing and evaluating community-based services through participatory action research: two case examples. American Journal of Occupational Therapy, 2004, 58, 1, 73-82.
Occupational therapy has a strong history of embracing concepts of client empowerment. However there is limited literature in the field on how to achieve empowerment, or on how to extend empowerment to the level of the community and social groups and services within it. The participatory action research approach is illustrated using two case examples of participatory action research programs for persons with CFS and individuals with acquired immune deficiency syndrome (AIDS).
Asbring, P and Narvanen, A-L. Patient power and control: a study of women with uncertain illness trajectories. Qualitiative Health Research, 2004, 14, 2, 226-240.
The authors interviewed 12 women diagnosed with CFS (CDC criteria '94) and 13 with FM with the aim of determining the strategies they perceive themselves as using to gain control over their situation during the health care process. The results highlight various strategies that the women report applying to find a way of managing the illness and to influence caregivers. They describe, for example, how they try to gain control over their situation by acquiring knowledge about the illness. The women also describe various power strategies they use in their interaction with the caregivers to take command of their situation, namely exiting, noncompliance, confrontation, persuasion/insistence, making demands, and demonstrative distancing.
The focus is ... on the women's accounts of encounters with health care providers, and their definition of these situations, not on their actual behavior.
Andersen, MM., Permin, H and Albrecht, F. Illness and disability in Danish Chronic Fatigue Syndrome patients at diagnosis and 5-year follow-up. Journal of Psychosomatic Research, 2004, 56, 217-229.
Thirty-three adult patients meeting 1988 and 1994 CDC case criteria answered identical questionnaires at diagnosis and 5 years later, when a retrospective questionnaire was also completed. Measures included lists of symptoms and activities. The average duration of illness at Time 1 was 4 years.
Work disability was very high and increased further, social isolation remained high, emotional adjustment improved. There were increased problems with reading and with allergies. Two measures of improvement were used: The relation between these measures was weak. Length of illness, extent of disability and emotional adjustment* were poorly related to measures of improvement. Average illness scores were unchanged, but most individuals improved in some ways while worsening or remaining the same in others. Only one participant (3%) neared recovery, one other was substantially better but still severely disabled.
CFS patients exhibit severe, long-term functional impairment. Substantial improvement is uncommon, less than 6%. Allergies and aspects of cognition may worsen, emotional adjustment often improves. There is a trend to greater allergies after 5 years.
*[Ed. note: The authors cite Ray et al 1997 as reporting similar findings i.e. that general mental health does not predict improvement.]
Bierl, C., Nisenbaum, R., Hoaglin, DC., Randall, B., Jones, AB., Unger, ER and Reeves WC. Regional distribution of fatiguing illnesses in the United States: a pilot study. Population Health Metrics, 2004, 2 (1):1. Epub 2004 Feb 04.
We conducted a pilot random-digit-dialing survey to estimate the prevalence of fatiguing illnesses in different geographic regions and in urban and rural populations of the United States. This report focuses on 884 of 7,317 respondents 18 to 69 years old. Fatigued (440) and randomly selected non-fatigued (444) respondents completed telephone questionnaires concerning fatigue, other symptoms, and medical history.
We estimated 12,186 per 100,000 persons 18 to 69 years of age suffered from fatigue lasting for at least 6 months (chronic fatigue), and 1,197 per 100,000 described an illness that, though lacking medical evaluation, met criteria for CFS (i.e. CFS-like). Chronic fatigue and CFS-like illness were more common in rural than in urban populations, although the differences were not significant. The prevalence of these fatiguing illnesses did not differ meaningfully among the four regions surveyed, and no significant geographic trends were observed. It was more common in the 40-49 and 50-59 age group than in those aged 18 to 29.
This investigation estimated that nearly 2.2 million American adults suffer from CFS-like illness. The study also suggested the need to focus future investigations of fatigue on populations with lower incomes and less education. There was no evidence for regional differences in the occurrence of fatiguing illnesses.
Gill, AC., Dosen, A and Ziegler, JB. Chronic fatigue syndrome in adolescents: a follow-up study. Archives of Pediatric and Adolescent Medicine, 2004, 158, 3, 225-229.
Consecutive adolescents referred for assessment of persistent fatigue were identified and retrospectively divided into 3 groups according to the diagnostic criteria for CFS and idiopathic chronic fatigue (1994, FM excluded). Those actually admitted to hospital were offered graded activity, daily physiotherapy etc, others were offered education, counselling and advised about exercise.
A questionnaire was designed and administered by telephone at a mean of 4.57 years after the initial examination. Main outcome measure: the persistence of self-reported symptoms was compared with respect to patient group and admission.
Outcome data were obtained for 34 (69%) of the 49 eligible subjects. Twenty-five percent of the CFS group (N=16) showed near to complete improvement, 31% showed partial improvement, and 44% showed no improvement. The idiopathic chronic fatigue group (N=10) had near to complete recovery in 50%, partial in 10%, and no improvement in 40%. Those with unexplained fatigue for less than 6 months (N=8) had all recovered. There was no difference between the outcome of the subjects admitted to the hospital and those managed as outpatients.
Adolescents with less than 6 months of fatigue have a good outcome. Unexplained fatigue lasting more than 6 months has a similar outcome regardless of the presence of minor criteria for CFS. Thus early intervention is important.
With editorial by Smith, MS (p. 207-208), referring to deconditioning and overlooking effective management programmes other than CBT\GET.
[Ed. note: The authors cite a report by Bell et al 2001, showing even better outcomes without graded exercise, 13 years after diagnosis.]
Nisenbaum, R., Reyes, M., Unger, ER and Reeves, WC. Factor analysis of symptoms among subjects with unexplained chronic fatigue - What can we learn about chronic fatigue syndrome? Journal of Psychosomatic Research, 2004, 56, 2, 171-178.
CFS case definitions agree that fatigue must be unexplained, debilitating and present for at least 6 months, but they differ over accompanying symptoms. Our objective was to compare the 1994 CFS case-defining symptoms with those identified by factor analysis.
We surveyed the Wichita population and measured the occurrence of 21 symptoms in 1391 chronically fatigued subjects who did not report fatigue-associated medical or psychiatric conditions. We used factor analyses to identify symptom dimensions of fatigue and cluster analysis to assign subjects to subgroups.
Forty-three subjects had CFS. We confirmed three factors: musculo-skeletal, infection and cognition-mood-sleep, essentially defined by CFS symptoms. Although factor scores were higher among CFS subjects, CFS and non-CFS distributions overlapped substantially. Three clusters also showed overlap between CFS and non-CFS subjects.
CFS symptomatology is a multidimensional phenomenon overlapping with other unexplained fatiguing syndromes and this must be considered in CFS research.
[Ed. Note: The use of broad diagnostic criteria may explain why only three-quarters reported unusual fatigue after exertion, a characteristic of ME and PFVS and acknowledged as typical in CFS by clinical experts. This was, as expected, much less common in patients with chronic fatigue. Stricter criteria for CFS and a more comprehensive assessment of symptoms may give even more precise results. The high percentage with numbness or tingling is noteworthy.]
See also editorial by Shapiro, CM (p. 153-155).
Schacterle, RS and Komaroff, AL. A comparison of pregnancies that occur before and after the onset of chronic fatigue syndrome. Archives of Internal Medicine, 2004, 164, 401-404.
Many women with CFS fear that pregnancy will worsen their condition, increase the risks of maternal complications of pregnancy, or threaten the health of their offspring. Little empirical evidence, however, has been published on this matter.
A detailed questionnaire was administered to 86 women regarding 252 pregnancies that occurred before or after the onset of CFS and the outcomes of these pregnancies were observed. Most fulfilled the CDC criteria '94.
During pregnancy, there was no change in CFS symptoms in 29 (41%), an improvement of symptoms in 21 (30%), and a worsening of symptoms in 20 (29%) of 70 subjects. In all, 20% improved after the pregnancy, 30% were unchanged and 50% worsened.
The rates of many complications were similar in pregnancies occurring before the onset and in those occurring after the onset of CFS. There was a higher frequency of spontaneous abortions in the pregnancies occurring after, vs before, the onset of CFS (22 [30%] of 73 pregnancies after vs 13 [8%] of 171 before; p<.001), but no differences in the rates of other complications. Developmental delays or learning disabilities were reported more often in the offspring of women who became pregnant after, vs before, the onset of CFS (9 [21%] of 43 children vs 11 [8%] of 139 children; p=.01).
Pregnancy therefore did not consistently worsen the symptoms of CFS. Most maternal and infant outcomes were not systematically worse in pregnancies occurring after the onset of CFS. The higher rates of spontaneous abortions and of developmental delays in offspring that we observed could be explained by maternal age or parity differences, and should be investigated by larger, prospective studies with control populations.
Huibers, MJH., Beurskens, AJHM., van Schayck, CP., Bazelmans, E., Metsemakers, JFM., Knottnerus, JA and Bleijenberg, G. Efficacy of cognitive-behavioural therapy by general practitioners for unexplained fatigue among employees. Randomised controlled trial. British Journal of Psychiatry, 2004, 184: 240-246.
Fatigue is a common complaint that may lead to long-term sick leave and work disability. The aim here was to assess the efficacy of CBT by general practitioners (GP) for unexplained, persistent fatigue among employees.
A randomised controlled trial, using a pre-randomisation design in primary care, investigated 151 employees on sick leave with fatigue. Participants in the experimental group were offered five to seven 30 minute sessions of CBT by a GP; those in the control group were offered no treatment. Main outcome measures (fatigue severity, self-reported absenteeism, registered absenteeism and clinical recovery) were assessed at 4 months, 8 months and 12 months.
At baseline, 44% of the patients already met research criteria for CFS. There was no significant difference between the experimental group and the control group on primary or secondary outcomes at any point. CBT by GPs for unexplained, persistent fatigue did not prove to be an effective intervention. Since these doctors were unable to deliver this therapy effectively under ideal circumstances, it is unlikely that doctors in routine practice would be more successful in doing so.
Taylor, RR. Quality of life and symptom severity for individuals with chronic fatigue syndrome: findings from a randomized clinical trial. American Journal of Occupational Therapy, 2004, 58, 1, 35-43.
In the present randomized clinical trial, the effects of an integrative, consumer-driven rehabilitation program on quality of life and symptom severity for individuals with chronic fatigue syndrome were examined.
Forty-seven participants with CFS (CDC criteria '94) were randomly assigned to either an immediate program group (n=23) or a delayed program control group (n=24). Patients spent four months in an "illness management group" covering topics such as goal setting, attending an educational lecture, and discussing relevant topics such as pacing. Also included was cognitive coping skills training, relaxation, meditation, and discussions on relationships and nutrition. This was followed by seven months of one-on-one peer counselling, self-advocacy training, and monitoring of goal attainment. Measures included the CFS Symptom Rating Scale and the Quality of Life Index before the program, after participants completed the group phase, and after participants completed the one-on-one phase. It was hypothesized that the program would lead to improvements in quality of life and an overall reduction in symptom severity.
Linear growth models were estimated comparing program and control conditions over time using random-effects regression analyses. Significant condition by time interactions were observed for the main outcomes of symptom severity and overall quality of life. Effect sizes for these interactions involving symptom severity (Cohen's d=0.71) and overall quality of life (Cohen's d=.66) were moderate.
Findings indicate that consumer driven programs such as this one can have a positive impact on symptom severity and quality of life over time for individuals with CFS.
Weatherley-Jones, E., Nicholl, JP., Thomas, KJ., Parry, GJ., McKendrick, MW., Green, ST., Stanley, PJ and Lynch, SPJ. A randomised, controlled, triple-blind trial of the efficacy of homeopathic treatment for chronic fatigue syndrome. Journal of Psychosomatic Research, 2004, 56, 2, 189-197.
There is no management regime for CFS that has been found to be universally beneficial and no treatment can be considered a "cure". Patients with CFS may use complementary and alternative medicine (CAM). Our aim was to evaluate homeopathic treatment in reducing subjective symptoms of CFS.
Using a triple-blind design (patient and homeopath blind to group assignment and data analyst blind to group until after initial analyses to reduce the possibility of bias due to data analyst), we randomly assigned patients to homeopathic medicine or identical placebo. One hundred and three patients meeting the Oxford criteria* for CFS were recruited from two specialist hospital outpatient departments. Patients had monthly consultations with a professional homeopath for 6 months. Main outcome measures were scores on the subscales of the Multidimensional Fatigue Inventory (MFI) and proportions of each group attaining clinically significant improvements on each subscale. Secondary outcome measures were the Fatigue Impact Scale (FIS) and the Functional Limitations Profile (FLP). Ninety-two patients completed treatment in the trial (47 homeopathic treatment, 45 placebo). Eighty-six patients returned fully or partially completed posttreatment outcome measures (41 homeopathic treatment group who completed treatment, 2 homeopathic treatment group who did not complete treatment, 38 placebo group who completed treatment, and 5 placebo group who did not complete treatment).
Seventeen of 103 patients withdrew from treatment or were lost to follow-up. Patients in the homeopathic medicine group showed significantly more improvement on the MFI general fatigue subscale (one of the primary outcome measures) and the FLP physical subscale but not on other subscales.
Although group differences were not statistically significant on four out of the five MFI subscales (the primary outcome measures), more people in the homeopathic medicine group showed clinically significant improvement. More people in the homeopathic medicine group showed clinical improvement on all primary outcomes (relative risk=2.75, p=.09).
There is weak but equivocal evidence that the effects of homeopathic medicine are superior to placebo. Results also suggest that there may be nonspecific benefits from the homeopathic consultation. Further studies are needed to determine whether these differences hold in larger samples.
*[Ed. Note: Reason given is that this trial began in 1996 when many UK researchers used these criteria. However, it could be argued that best practice requires scientists to use the latest criteria, especially when the earlier versions are known to be flawed. One of the authors wrote a letter to the British Journal of Psychiatry reporting problems with the validity of the criteria in 1991.]
Cox IJ and Puri BK. In vivo MR spectroscopy in diagnosis and research of neuropsychiatric disorders. Prostaglandins, Leukotrines and Essential Fatty Acids, 2004, 70, 4, 357-360.
Magnetic resonance spectroscopy is one of the most important tools for quantitative analysis of chemical composition and structure, and this non-invasive technique is now being applied in vivo to study biochemical processes in those neuropsychiatric disorders that are part of the phospholipid spectrum. Interpretation of a clinical magnetic resonance spectrum can provide information about membrane phospholipid turnover, cellular energetics, neuronal function, selected neurotransmitter activity and intracellular pH. Cerebral proton and phosphorus magnetic resonance spectroscopy findings are summarized in relation to schizophrenia, dyslexia and CFS.
Dittner, AJ., Wessely, SC and Brown, RG. The assessment of fatigue. A practical guide for clinicians and researchers. Journal of Psychosomatic Research, 2004, 56, 2, 157-170.
[Ed. note: Uncritical review of the relevant literature.]
Ball, N., Buchwald, DS., Schmidt, D., Goldberg, J., Ashton, S and Armitage, R. Monozygotic twins discordant for chronic fatigue syndrome. Objective measures of sleep. Journal of Psychosomatic Research, 2004, 56, 2, 207-212.
Our objective was to describe sleep architecture in CFS-discordant twin pairs. We conducted a co-twin control study of 22 pairs of monozygotic twins where one twin met criteria for CFS (1994) and the co-twin was healthy. Twins underwent two nights of polysomnography.
The percentage of Stage 3 and REM sleep was greater among the CFS twins than their healthy co-twins (p<.05 for both), but no other differences in sleep architecture including sleep latency, REM latency, and total sleep time were observed. Compared to their co-twins, CFS twins had higher values for the apnea-hypopnea index and apnea-hypopnea arousal index (p<.05 for both).
These results do not provide strong evidence for a major role for abnormalities in sleep architecture in CFS. Respiration appears impaired in CFS, but these clinical abnormalities cannot alone account for the prominence of sleep complaints in this illness. The co-twin control methodology highlights the importance of selecting well-matched control subjects.
Bulow, PH. Sharing experiences of contested illness by storytelling. Discourse & Society, 2004, 15, 1, 33-53.
Based on audiotaped conversations from a patient school for adults suffering from CFS, this article examines sharing experiences of illness as a mutual activity.
Busichio, K., Tiersky, LA., Deluca, J and Natelson, BH. Neuropsychological deficits in patients with chronic fatigue syndrome. Journal of the International Neuropsychological Society, 2004, 10, 2, 278-285.
For the abstract, see the previous issue of the References (no. 1).
Chaudhuri, A and Behan, PO. Fatigue in neurological disorders. Lancet, 2004, 363, 978-988.
This review deals with various aspects of fatigue in neurological disorders, and includes CFS(ME).
"To imply that fatigue is a medically-unexplained, non-organic symptom in patients who do not have a primary psychiatric diagnosis would be incorrect and inappropriate".
Cleare, AJ. The HPA axis and the genesis of chronic fatigue syndrome. Trends in Endocrinology and Metabolism, 2004, 15, 2, 55-59.
Opinion paper. Many studies of patients with long-standing CFS have found alterations to the HPA axis, including mild hypocortisolism, heightened negative feedback and blunted responses to challenge. However, recent prospective studies of high-risk cohorts suggest that there are no HPA axis changes present during the early stages of the genesis of fatiguing illnesses. Moreover, HPA axis changes can be reversed by modifying behavioural features of the illness, such as inactivity*, deconditioning and sleep disturbance. Nevertheless, raising levels of cortisol pharmacologically can temporarily alleviate symptoms of fatigue.
This article presents the case that there is no specific change to the HPA axis in CFS and that the observed changes are of multi-factorial aetiology, with some factors occurring as a consequence of the illness. Nevertheless, the HPA axis might play a role in exacerbating or perpetuating symptoms late on in the course of the illness.
*[Ed. note: This is supported by research showing increase in cortisol levels following CBT. However, the changes may also reflect a reduction of emotional distress. As findings using objective measures of activity have failed to show an increase in activity levels following CBT, the proposed link between activity and cortisol in CFS remains to be clarified.]
Garralda, ME and Rangel, L. Impairment and coping in children and adolescents with chronic fatigue syndrome: a comparative study with other paediatric disorders. Journal of Child Psychology and Psychiatry, 2004, 45, 3, 543-552.
This study aimed to compare functional impairment, illness attitudes and coping mechanisms in childhood CFS and in other paediatric disorders.
Participants were 28 children and adolescents with CFS (Oxford criteria), 30 with juvenile idiopathic arthritis (JIA) and 27 with emotional disorders (ED). The measures used were interviews with children and parents, with detailed enquiry on impairment, including the Functional Disability Inventory (FDI), Illness Attitudes Scales (IAS), and Kidcope to measure coping styles in relation to common problems, illness and disability.
Children with CFS reported significantly more illness impairment, especially in school attendance, than those with JIA and ED. They had higher 'worry about illness' scores on the IAS. On the Kidcope, they named school issues (work, expectations, attendance) as illness- or disability-related problems more than the other two groups. Fewer CFS participants reported using problem solving as a strategy to cope with illness and disability than with other problems in their lives. More in the CFS than in the JIA group used emotional regulation to cope with illness and disability. Fewer in the CFS than in the ED groups used social withdrawal to cope with illness and self-criticism for disability, but more used resignation to cope with disability.
Severe illness-related impairment, particularly through school non-attendance, and high levels of illness-related school concerns appear specific to CFS. CFS may also have characteristically high levels of generalised illness worry and particular styles of coping with illness and disability.
[Ed. note: There is no information on the type of symptoms experienced, other than fatigue. It is therefore difficult to assess if these findings also relate to patients with ME and PVFS.]
Hartz, AJ., Bentler, S., Noyes, R., Hoehns, J., Logemann, C., Sinift, S., Butani, Y., Wang, W., Brake, K., Ernst, M and Kautzman H. Randomized controlled trial of Siberian ginseng for chronic fatigue. Psychological Medicine, 2004, 34, 1, 51-61.
This randomized controlled trial evaluated the effectiveness of Siberian ginseng for chronic fatigue.
Subjects were recruited from advertisements in Iowa (82%) and mem-bers of CFS support groups (18%). Potential subjects were required to have substantial fatigue > or = 6 months with no identifiable cause. The mean change in a fatigue measure was compared for placebo and Siberian ginseng at 1 and 2 months.
Ninety-six subjects were randomized to treatment groups, and 76 provided information at 2 months of follow-up. Fatigue among subjects assigned to either placebo or Siberian ginseng was substantially reduced during the study, but differences between treatment groups were not statistically significant in the full sample. Fatigue severity and duration had a statistically significant interaction with response to Siberian ginseng at the p<0.05 level. Treatment was effective at 2 months for 45 subjects with less severe fatigue (p=0.04 unadjusted for multiple comparisons) and for 41 subjects with fatigue for > or = 5 years (p=0.09 unadjusted for multiple comparisons).
Overall efficacy was not demonstrated. However, the findings of possible efficacy for patients with moderate fatigue suggests that further research may be of value.
Jason, L.A., Holbert, C., Torres-Harding, S., and Taylor, R.R. Stigma and chronic fatigue syndrome. Results of surveys on a name change. Journal of Disability Policy Studies, 2004, 14, 222-228.
Considerable discussion has occurred over the diagnostic label, CFS. Many patient groups argue that this term trivializes the seriousness of the syndrome. A Name Change Work group was appointed by the CFS Coordinating Committee within the federal government to attempt to change the name. This working group distributed a poll to patients and health care providers to gain information about its recommendation to put forth an umbrella term called Chronic Neuroendocrine Dysfunction Syndrome and subtypes under it. (The latter include ME). In addition, the CFIDS Association, a national self-help advocacy organization, distributed a questionnaire to a group of health care providers concerning the recommendations for a new name. There was much agreement that there should be a new name but less consensus over what it should be.
Khan, F., Kennedy, G., Spence, VA., Newton, DJ and Belch, JJF. Peripheral cholinergic function in humans with chronic fatigue syndrome, Gulf War syndrome and with illness following organophosphate exposure. Clinical Science, 2004, 106, 183-189.
Research comparing 52 patients with CFS(ME), 24 patients with GWS and 25 with fatigue attributed to OP exposure. There were peripheral cholinergic abnormalities (in the vascular endothelium) only in the CFS group, indicating the three have a different aetiology.
For details, see ME and CFS References no. 4, 2003.
Luthra, A and Wessely, S. Unloading the trunk: neurasthenia, CFS and race. Social Science & Medicine, 2004, 58, 11, 2363-2369.
Opinion paper claiming that CFS and neurasthenia are identical and that there has been a simplified view of racial factors in both the medical and lay literature.
[Ed. note: the authors ignore the difference in definition between ME and neurasthenia, and the significant differences in relation to findings of organic disease. The authors appear to have misunderstood the views of Dowsett, who attributed some clusters in the West to poor sanitation, based on evidence. They also overlook the criticisms in the lay press with regard to the role of ethnicity.]
Naschitz, JE., Rosner, I., Rozenbaum, M., Fields, M., Isseroff, H., Babich, JP., Zuckerman, E., Elias, N., Yeshurun, D., Naschitz, S and Sabo, E. Patterns of cardiovascular reactivity in disease diagnosis. Quarterly Journal of Medicine, 2004, 97, 3, 141-151.
Aberrations of cardiovascular reactivity (CVR), an expression of autonomic function, occur in a number of clinical conditions, but lack specificity for a particular disorder. Recently, a CVR pattern particular to CFS was observed.
Aim: To assess whether specific CVR patterns can be described for other clinical conditions.
Methods: Six groups of patients, matched for age and gender, were evaluated with a shortened head-up tilt test: patients with CFS (CDC criteria '94, n=20), non-CFS fatigue (F) (n=15), neurally-mediated syncope (SY) (n=21), familial Mediterranean fever (FMF) (n=17), psoriatic arthritis (PSOR) (n=19) and healthy subjects (H) (n=20). A 10-min supine phase was followed by recording 600 cardiac cycles on tilt (5-10 min). Beat-to-beat heart rate (HR) and pulse transit time (PTT) were measured. Results were analysed using conventional statistics, recurrence plot analysis and fractal analysis.
Results: Multivariate analysis evaluated independent predictors of the CVR in each patient group vs. all other groups. Based on these predictors, equations were determined for a linear discriminant score (DS) for each group. The best sensitivities and specificities of the DS, consistent with disease-related phenotypes of CVR, were noted in the following groups: CFS, 90.0% and 60%; SY, 93.3% and 62.5%; FMF, 90.1% and 75.4%, respectively.
Discussion: Pathological disturbances may alter cardiovascular reactivity. Our data support the existence of disease-related CVR phenotypes, with implications for pathogenesis and differential diagnosis.
Ohashi, K., Bleijenberg, G., Van Der Werf, S., Prins, J., Amaral, LA., Natelson, BH and Yamamoto, Y. Decreased fractal correlation in diurnal physical activity in chronic fatigue syndrome. Methods of Information in Medicine, 2004, 43, 1, 26-29.
Our objectives were to study the temporal correlation of physical activity time series in patients with CFS during normal daily life and to examine if it could identify the altered physical activity in these patients.
Fractal scaling exponents of diurnal and nocturnal physical activity time series in 10 CFS patients and 6 healthy control subjects (CON) were calculated by the detrended fluctuation analysis (DFA) and the wavelet transform modulus maxima (WTMM) method. We hypothesized that, due to their illness- and/or fatigue-induced resting episodes, altered physical activity patterns in CFS patients might be observed at the interruption of activity bursts. Thus, we further developed a new method, the wavelet transform negative modulus maxima (WTNMM) method, which could evaluate the temporal correlation at the interruption of activities. We compared the fractal scaling exponents for CFS and CON by each method.
Both for CFS and CON, we found the fractal time structures in their diurnal physical activity records for at least up to 35 minutes. No group difference was found in nocturnal activities. The WTNMM method revealed that, in diurnal activities, CFS patients had significantly (p<0.01) smaller fractal scaling exponent (0.87 +/- 0.03) compared to controls (1.01 +/- 0.03). Such a difference was identified neither by the DFA nor WTMM method.
CFS patients had more abrupt interruptions of voluntary physical activity during diurnal periods in normal daily life, probed by the decreased correlation in the negative modulus maxima of the wavelet-transformed activity data, possibly due to their exaggerated fatigue.
Papanicolaou, DA., Amsterdam, JD., Levine, S., McCann, SM., Moore, RC., Newbrand, CH., Allen, G., Nisenbaum, R., Pfaff, DW., Tsokos, GC., Vgontzas, AN and Kales A. Neuroendocrine aspects of chronic fatigue syndrome. Neuroimmunomodulation, 2004, 11, 2, 65-74.
A symposium was organized in March 2001 to explore the possibility of an association between neuroendocrine dysfunction and CFS, with special emphasis on the interactions between neuroendocrine dysfunction and other abnormalities noted in the immune and autonomic nervous systems of individuals with CFS. This paper represents the consensus of the panel of experts who participated in this meeting.
[Ed. note: This is an interesting paper, noting the need for improvements in relation to patient selection, the importance of studying subgroups etc.]
Pendergast, DR., Fisher, NM., Meksawan, K., Doubrava, M and Vladutiu GD. The distribution of white blood cell fat oxidation in health and disease. Journal of Inherited Metabolic Disease, 2004, 27, 1, 89-99.
Fat oxidation is important for maintaining health and for supplying energy for exercise. We have proposed that the predisposition for individual rates of fat oxidation is determined genetically but may be modulated by acute exercise or exercise training.
The purpose of this study was to examine cellular fat oxidation in white blood cells (WBC) using [9,10-(3)H]palmitic acid. Sedentary controls free of symptoms (SED-C, n=32), were compared with known carnitine palmitoyltransferase (CPT) II-deficient patients (n=2), patients with fatiguing diseases (CFS, n=6; multiple sclerosis, MS, n =31), obesity (OB, n=5), eating disorders (ED, n=16), sedentary individuals prior to and after exercise (SED-Ex, n=12), exercise-trained sedentary individuals (SED-Tr, n =12), and elite runners (ER, n=5).
Fat oxidation in WBC for all subjects was normally distributed (mean=0.270+/-0.090 nmol/h per 10(9) WBC) and ranged from 0.09 nmol/h per 10(9) WBC in CPT II-deficient patients to 0.59 nmol/h per 10(9) WBC in ER. There were no significant sex or acute exercise effects on WBC fat oxidation. Patients with MS, OB or ED were not different from SED-C; however, in CPT II-deficient patients, fat oxidation was low, while that of CFS patients was high. Exercise training in SED-C resulted in a 16% increase in fat oxidation but in ER it was still 97% higher than in SED-C.
We propose that while WBC fat oxidation is not significantly affected by sex or acute exercise, and only by 15-20% with training, genetic factors play a role in determining both high and low fat oxidation in certain groups of individuals. The genetic predisposition for individual rates of fat oxidation may be easily measured using WBC fat oxidation, as has been shown for CPT II-deficient patients and for elite runners. Ranges of WBC fat oxidation that are abnormally low (<20 nmol/h per 10(9) WBC, normal 20-35) or high (>35 nmol/h per 10(9) WBC) are proposed based on genetic factors evaluated in this study.
Puri, BK. The use of eicosapentaenoic acid in the treatment of chronic fatigue syndrome. Prostaglandins, Leukotrines and Essential Fatty Acids, 2004, 70, 4, 399-401.
There is evidence that there is an association between CFS, a condition of unknown aetiology, and essential fatty acids. This evidence is based on the actions of essential fatty acids, the results of proton neurospectroscopy studies, and essential fatty acid trial data. A series of patients with CFS (CDC '94?) were treated solely with a high-eicosapentaenoic acid-containing essential fatty acid supplement. All showed improvement in their symptomatology within eight to 12 weeks. These results, which are consistent with a recent detailed report of cerebral and clinical changes associated with a high intake of eicosapentaenoic acid, suggest that this n-3 highly unsaturated fatty acid may offer the hope of effective treatment for at least some patients with CFS.
Rief, W and Sharpe, M. Somatoform disorders - new approaches to classification, conceptualization, and treatment. Journal of Psychosomatic Research, 2004, 56, 387-390.
Editorial arguing that somatoform disorders (SD) deserve a new classification, separate from psychiatric disorders. The authors include CFS in the discussion.
[Ed. note: Statements such as those below may be interpreted by some as trivialising CFS. The reliance on generalisations means that important evidence conflicting with the authors' argument is overlooked. The main argument is also inconsistent with the current classification of CFS under G93.3.
"Many patients with somatoform disorders and especially those described as having hypochondriasis manifest a tendency to interpret benign bodily complaints as signs of disease. This is a cognitive phenomenon that can be studied. For example, there is interesting preliminary evidence that patients appear to lack alternative interpretations that normalize the symptoms with anxiety about health as a consequence. ...Normal sensations such as burning feet after a long walk may be perceived as aversive to the point of intolerability. Somatoform disorders can therefore also be understood as a reduced capacity to tolerate aversive somatic sensations".]
Severens, JL., Prins, JB., Van Der Wilt, GJ., Van Der Meer, JW an Bleijenberg G. Cost-effectiveness of cognitive behaviour therapy for patients with chronic fatigue syndrome. Quarterly Journal of Medicine, 2004, 97, 3, 153-161.
CFS patients were randomly assigned to CBT, guided support groups (SG), or the 'natural course' (NC, no protocol-based interventions). Patients were treated for 8 months and followed-up for another 6 months. Costs per patient showing clinically significant improvement, based on the CIS fatigue scale, and costs per quality-adjusted life year, were determined for a time period of 14 months.
Data were available for 171 patients at 8 months and for 128 at 14 months. At 8 and 14 months, the percentages of improved patients were 31% and 27% for CBT, 9% and 11% for SG, and 12% and 20% for NC. Mean QALYs gained at 14 months were, for CBT, SG and NC, respectively, 0.0737, -0.0018 and 0.0458. CBT and SG mean treatment costs were €1490 and €424. Other medical costs for CBT, SG, and NC, respectively, were €324, €623 and €412 for the first period, and €232, €561 and €378 for the second period. Non-medical costs for these periods for CBT, SG and NC were €262, €550, €427 and €226, €439, €287, respectively. Productivity costs were considerable, but not significantly different between groups.
CBT was less costly and more effective than SG. The bootstrap ratios showed considerable uncertainty regarding the results. Future research should focus on productivity costs, and follow patients prospectively over a longer period.
Shin, H-Y, An, N-H., Cha, Y-J., Shin, E-J., Shin, T-Y., Baek, S-H., Kim, C-H., Lyu, Y-S., Lee, E-J and Kim, H-M. Effect of Kuibitang on lipopolysaccharide-induced cytokine production in peripheral blood mononuclear cells of chronic fatigue syndrome patients. Journal of Ethnopharmacology, 2004, 90, (2-3), 253-259.
Kuibitang (KBT) is clinically used to treat patients suffering from CFS in South Korea. However, its effect has not been investigated experimentally. Recent reports have shown that CFS patients display an altered cytokine production.
We examined the effect of KBT on lipopolysaccharide (LPS)-induced various cytokines production in peripheral blood mononuclear cells (PBMC) of CFS patients and healthy controls. KBT (1 mg/ml) significantly inhibited LPS-induced tumor necrosis factor-α, interleukin-10, and transforming growth factor-β1 production in PBMC of CFS patients. However, LPS-induced interferon-γ production was significantly increased by KBT (0.01 mg/ml). These results provide evidence of a novel activity of the KBT that regulate cytokines production related with CFS.
Vermeulen, RCW and Scholte, HR. Exploratory open label, randomized study of acetyl- and propionylcarnitine in chronic fatigue syndrome. Psychosomatic Medicine, 2004, 66, 276-282.
We compared the effects of acetylcarnitine, propionylcarnitine and both compounds on the symptoms of CFS.
In an open, randomized fashion we compared 2 g/d acetyl-L-carnitine, 2 g/d propionyl-L-carnitine, and its combination in 3 groups of 30 patients with CFS (CDC criteria '94) during 24 weeks. Effects were rated by clinical global impression of change. Secondary endpoints were the Multidimensional Fatigue Inventory, McGill Pain Questionnaire, and the Stroop attention concentration test. Scores were assessed 8 weeks before treatment; at randomization; after 8, 16, and 24 weeks of treatment; and 2 weeks later.
Clinical global impression of change after treatment showed considerable improvement in 59% of the patients in the acetylcarnitine group and 63% in the propionylcarnitine group, but less in the acetylcarnitine plus propionylcarnitine group (37%). Acetylcarnitine significantly improved mental fatigue (p=.015) and propionylcarnitine improved general fatigue (p=.004). Attention concentration improved in all groups, whereas pain complaints did not decrease in any group. Two weeks after treatment, worsening of fatigue was experienced by 52%, 50%, and 37% in the acetylcarnitine, propionylcarnitine, and combined group, respectively. In the acetylcarnitine group, but not in the other groups, the changes in plasma carnitine levels correlated with clinical improvement.
Acetylcarnitine and propionylcarnitine showed beneficial effect on fatigue and attention concentration. Less improvement was found by the combined treatment. Acetylcarnitine (which can cross the blood-brain-barrier) had main effect on mental fatigue and propionylcarnitine on general fatigue.
Vermeulen, RCW and Scholte, HR. Chronic fatigue syndrome and sexual dysfunction. Journal of Psychosomatic Research, 2004, 56, 2, 199-201.
The study was undertaken to determine if ambulant female patients with the CFS report problems with their sexual functioning. We studied 35 female CFS patients (CDC criteria '94) and 36 healthy female controls. The severity of CFS was measured with a fatigue questionnaire and the presence and severity of sexual dysfunction with a questionnaire about sexual functioning.
The mean fatigue score was 24.8 in the CFS patients and 11.9 in the controls (p=.000). No increase in sexual dysfunction was found in the CFS group. The control group showed negative correlations between the score of the fatigue questionnaire and the frequency of "sexual fantasies," "(desire for) sexual contact" and "satisfaction with sex life." Such correlations were absent in the CFS group.
The satisfaction with sex life was similar in patients and controls. The results suggest that patients and controls have a different perception of fatigue ('exhausted' in the CFS group, 'feeling tired' in the controls). The results contrast with those of people with depression.
Williams, H and Morris, M. The experience of stigma: living with myalgic encephalomyelitis (ME). Proceedings of the British Psychological Society, 2004, 12, 1, 63.
Short abstract on the effects of the stigma associated with ME.
Woolley, J., Allen, R and Wessely, S. Alcohol use in chronic fatigue syndrome. Journal of Psychosomatic Research, 2004, 56, 2, 203-206. Short report.
Aim: To examine the anecdotal observation that patients with CFS develop alcohol intolerance.
Methods: A consecutive case series of 114 patients fulfilling UK (and CDC '94) criteria for CFS referred to a specialist clinic. Self-reported alcohol use pre- and postdiagnosis, fatigue symptoms and comorbidity measures were collected.
Results: Two-thirds reduced alcohol intake. The most common reasons were increased tiredness after drinking (67%), increased nausea (33%), exacerbated hangovers (23%) and sleep disturbance (24%). One-third of the subjects also stopped drinking because "it seemed sensible." Some had been advised to avoid alcohol, but the majority (66%) did so on the basis of personal experience.
Conclusion: Our data supports the anecdotal belief that CFS patients reduce or cease alcohol intake. This is associated with greater impairment in employment, leisure and social domains of function, and may hint at psycho-pathophysiological processes (neuroendocrine, immunological and cognitive) in common with other conditions that result in alcohol intolerance. The findings also indicate a difference between CFS and depression.
Hobbis, ICA., Turpin, G and Read, NW. Abnormal illness behaviour and locus of control in patients with functional bowel disorders. British Journal of Health Psychology, 2003, 8, 393-408.
Study showing that there was no difference in abnormal illness behaviour (AIB) between patients with Crohn's Disease and functional bowel disorders. AIB is related to psychological distress, irrespective of patient status.
Peckerman, A., Dahl, K., Chemitiganti, R., LaManca, JJ., Ottenweller, JE and Natelson BH. Effects of posttraumatic stress disorder on cardiovascular stress responses in Gulf War veterans with fatiguing illness. Autonomic Neuroscience, 2003, 108, (1-2), 63-72.
Abnormal cardiovascular stress responses have been reported in Gulf War veterans with chronic fatigue. However, many of these veterans also suffer from posttraumatic stress disorder (PTSD), which could potentially explain the reported abnormalities. To test this hypothesis, 55 Gulf veterans (GVs) with CFS or idiopathic chronic fatigue (ICF) were stratified into groups with (N=16) and without (N=39) comorbid PTSD, and were compared to healthy Gulf veterans (N=47) on cardiovascular responses to a series of stressors.
The CFS/ICF with PTSD group had lower blood pressure responses to speech and arithmetic tasks, and more precipitous declines and slower recoveries in blood pressure after standing up than the controls. Similar trends in the CF/ICF group without PTSD were not significant, however. Both CFS/ICF groups had blunted increases in peripheral vascular resistance during mental tasks. However, only the veterans with comorbid PTSD had diminished cardiac output responses to the mental stressors and excessive vasodilatory responses to standing. Symptoms of posttraumatic stress were significant predictors of hypotensive postural responses, but only in veterans reporting a significant exposure to wartime stress.
We conclude that comorbid PTSD contributes to dysregulation of cardiovascular responses to mental and postural stressors in Gulf veterans with medically unexplained fatiguing illness, and may provide a physiological basis for increased somatic complaints in Gulf veterans with symptoms of posttraumatic stress.
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