B. Van Houdenhove

The effects of catastrophic thinking about pain on attentional interference by pain: no mediation of negative affectivity in healthy volunteers and in patients with low back pain.

BACKGROUND Previous studies have shown that catastrophic thinking about pain enhances attentional interference in healthy volunteers. OBJECTIVE To investigate whether the attentional effects of pain catastrophizing can be accounted for by the more general predisposition of negative affectivity. METHODS Sixty-seven pain-free students participated in the first experiment, and 33 patients with chronic low back pain participated in the second experiment. In both experiments, participants performed an auditory reaction time task while being exposed to a series of threatening electrocutaneous stimuli. Retardation in reaction times to auditory probes during pain was taken as an index of the attentional interruption by pain. Participants also completed self-report instruments of negative affectivity and pain catastrophizing. RESULTS In both experiments, pain catastrophizing enhanced attentional interference by pain. This effect was most pronounced immediately after the onset of the electrocutaneous stimulus. The effect remained after controlling for the effects of negative affectivity. CONCLUSIONS Catastrophic thinking about pain enhances attentional interruption by pain in normal samples, as well as in clinical samples of patients with chronic back pain. This effect is specific to pain catastrophizing and cannot be explained by the more general disposition of negative affectivity.

A mentalization-based approach to the understanding and treatment of functional somatic disorders

Patients with functional somatic disorders (FSD) represent a sizeable group in our health care system. FSD are associated with high health care use and considerable personal and economic costs. Evidence-based treatments for FSD are only modestly effective in a large subgroup of patients, particularly in the long run, which emphasizes the need to develop more effective treatments rooted in extant knowledge about the nature of FSD. This paper presents a contemporary psychodynamic perspective on the conceptualization and treatment of patients with FSD rooted in attachment and mentalization theory. First, we review animal and human research demonstrating the close relationships among attachment, stress regulation, and immune and pain-regulating systems. We highlight research findings concerning the high interpersonal and metabolic costs associated with the use of insecure secondary attachment strategies (i.e. attachment deactivating and hyperactivating strategies) leading to increased vulnerability for stress. Next, we review evidence for the role of impairments in (embodied) mentalization in patients with FSD both as cause and consequence of functional somatic complaints, leading to the re-emergence of so-called non-mentalizing modes, i.e. modes of subjectivity that antedate the capacity for full mentalizing. Based on these views, a novel brief psychodynamic intervention for patients with functional somatic complaints is presented.

Prevalence and Psychodynamic Interpretation of Premorbid Hyperactivity in Patients with Chronic Pain

The prevalence of premorbid hyperactivity in chronic pain patients and its psychodynamic interpretation are discussed both from the literature and from personal observation. In up to 70% of the cases,

How relevant are exercise capacity measures for evaluating treatment effects in chronic fatigue syndrome? Results from a prospective, multidisciplinary outcome study

Objective: To evaluate the outcome of a multidisciplinary treatment programme for patients with chronic fatigue syndrome, including health-related quality of life (HRQoL) and psychosocial variables, and exercise capacity measures. Design: A six-month prospective outcome study. Setting: University outpatient rehabilitation clinic; group setting. Subjects: One hundred and sixteen women fulfilling chronic fatigue syndrome criteria. Interventions: Cognitive behaviourally and graded exercise-based strategies; emphasis on adaptive lifestyle changes. Measures: Short Form General Health Survey (SF-36); Symptom Checklist (SCL-90); Causal Attribution List (CAL); Self-Efficacy Scale (SE); maximum progressive bicycle ergometer test with respiratory gas analysis; and isokinetic leg strength test, before and after treatment. Results: The total group significantly improved on nearly all reported HRQoL/ psychosocial variables. Changes in exercise capacity measures were rather modest and did not correlate or only weakly correlated with HRQoL/psychosocial variables. Subgroup analyses indicated that less fit patients improved significantly more on exercise capacity measures than their more fit counterparts. Patients who were fitter at baseline scored better on pretreatment HRQoL/psychosocial variables, but both subgroups improved similarly on these variables. Conclusions: Health-related quality of life and psychosocial functioning in patients with chronic fatigue syndrome improves after a six-month cognitive behaviourally and graded exercise-based multidisciplinary treatment programme. Increase in exercise capacity measures is not a necessary condition for reported improvements, except for less fit patients.

Combined dexamethasone/corticotropin-releasing factor test in chronic fatigue syndrome

BACKGROUND Studies of hypothalamic-pituitary-adrenal (HPA) axis function in chronic fatigue syndrome (CFS) point to hypofunction, although there are negative reports. Suggested mechanisms include a reduced hypothalamic or supra-hypothalamic stimulus to the HPA axis and enhanced sensitivity to the negative feedback of glucocorticoids. The aim of the current study was to investigate HPA axis function in CFS with the dexamethasone/corticotropin-releasing factor (Dex/CRF) test, in analogy with research in affective disorders. METHOD Thirty-four well-characterized female CFS patients and 25 healthy control subjects participated in the low-dose Dex/CRF test. Current major depressive episode was an exclusion criterion. History of early-life stress (ELS) was assessed with the Structured Trauma Interview. RESULTS Salivary cortisol responses after 0.5 mg Dex were lower in CFS patients than in controls (before 100 microg CRF, p=0.038; after 100 microg CRF, p=0.015). A secondary analysis revealed an influence of early-life stress and of oestrogen intake. After removal of the 10 participants who were taking an oral oestrogen, patients without a history of ELS showed lower cortisol responses than patients with ELS and controls (before CRF, p=0.005; after CRF, p=0.008). CONCLUSIONS CFS is globally associated with reduced cortisol responses in the combined low-dose Dex/CRF test, but this effect is only clearly present in CFS patients without a history of ELS. This study provides further support for an enhanced glucocorticoid negative feedback and/or a reduced central HPA axis drive in CFS. Furthermore, it demonstrates that ELS is an important variable to consider in CFS research.

Self-critical perfectionism and its relationship to fatigue and pain in the daily flow of life in patients with chronic fatigue syndrome.

BACKGROUND Research suggests that the personality factor of self-critical or maladaptive perfectionism may be implicated in chronic fatigue syndrome (CFS). However, it is not clear whether self-critical perfectionism (SCP) also predicts daily symptoms in CFS. Method In the present study we investigated whether SCP predicted fatigue and pain over a 14-day period in a sample of 90 CFS patients using a diary method approach. After completing the Depressive Experiences Questionnaire (DEQ) as a measure of SCP, patients were asked each day for 14 days to complete Visual Analogue Scales (VAS) of fatigue, pain and severity of depression. Data were analysed using multilevel analysis. RESULTS The results from unconditional models revealed considerable fluctuations in fatigue over the 14 days, suggesting strong temporal variability in fatigue. By contrast, pain was relatively stable over time but showed significant inter-individual differences. Congruent with expectations, fixed-effect models showed that SCP was prospectively associated with higher daily fatigue and pain levels over the 14-day period, even after controlling for levels of depression. CONCLUSIONS This is the first study to show that SCP predicts both fatigue and pain symptoms in CFS in the daily course of life. Hence, therapeutic interventions aimed at targeting SCP should be considered in the treatment of CFS patients with such features.

Depression, attribution style and self-esteem in chronic fatigue syndrome and fibromyalgia patients: is there a link?

The aims of the present study were to compare a single diagnosis (chronic fatigue syndrome, CFS) and a double diagnosis (CFS + fibromyalgia, CFS + FM) group regarding depression, attribution style and self-esteem as well as to examine whether attribution style is a mediator in the relationship between self-esteem and depression. Eighty-five patients (CFS: 47, CFS + FM: 38) completed questionnaires on attribution style, self-esteem and depression. The single and double diagnosis groups tended to differ slightly, but the differences were never statistically significant. In addition, only one condition was met of the four conditions mentioned by Baron and Kenny to establish that mediation exists between two variables. In conclusion, an external attribution style does not protect the CFS or CFS + FM patients with a low self-esteem from depression. The prevalence rate of depression was high in both patient samples, of which clinicians should be aware.

Fibromyalgia: a challenge for modern medicine

The article by Ehrlich [1] rightly points to the hazards of the diagnostic concept of fibromyalgia (FM). However, the author appears to be highly biased by a medicolegal perspective. As a liaison psychiatrist with a main interest in FM, chronic fatigue syndrome (CFS) and other ‘functional somatic syndromes’ [2,3], I disagree on several points with Ehrlich’s comments. In what follows I will try to demonstrate that FM, viewed from a broader clinical perspective, is a kind of ‘ill health’ that constitutes a formidable challenge for modern medicine. My commentary will be organised around six topics: concepts and terminology; diagnostic assessment; labeling; aetiology; pathophysiology; and assessment of disability. I will conclude with some considerations about the task of modern medicine.

What Happens to the Fibromyalgia Concept

Fibromyalgia (FM) has always been a controversial syndrome. In early discussions, researchers were divided into two camps, usually defined as believers and nonbelievers. Believers were those researchers who thought this syndrome was a particular disease entity resulting in a condition of significant disability; non-believers considered this syndrome to be a chimera of an (for one or another reason) interested coalition of patients and medical doctors. During the past years, the confrontations between these groups have regularly been quite heated. However, a new element seems to have entered the discussion. The tenacity of some researchers who developed the concept seems to have weakened. Meanwhile, hypotheses quickly change. This paper aims to describe the recent evolution by means of a review of the most recent literature (1995–1998).

Tender points or tender patients? The value of the psychiatric in-depth interview for assessing and understanding psychopathological aspects of fibromyalgia

SummaryAlthough the aetiology of fibromyalgia is still unexplained, evidence favouring the role of psychopathology is accumulating, at least in a subgroup of patients; however, the exact aetiological significance of psychopathology in this syndrome is difficult to assess. Various assessment strategies have both strengths and weaknesses. Two case reports are presented which illustrate the value of the psychiatric in-depth interview (including psychodynamic-biographical history taking) for assessing and understanding psychological/psychiatric aspects of fibromyalgia.