Emma Godfrey

The neural correlates of fatigue: an exploratory imaginal fatigue provocation study in chronic fatigue syndrome

BACKGROUND Fatigue is the central symptom in chronic fatigue syndrome (CFS) and yet very little is known about its neural correlates. The aim of this study was to explore the functional brain response, using functional magnetic resonance imaging (fMRI), to the imaginal experience of fatigue in CFS patients and controls. METHOD We compared the blood oxygen level dependent (BOLD) responses of 12 CFS patients and 11 healthy controls to a novel fatigue provocation procedure designed to mimic real-life situations. A non-fatiguing anxiety-provoking condition was also included to control for the non-specific effects of negative affect. RESULTS During the provocation of fatigue, CFS patients reported feelings of both fatigue and anxiety and, compared to controls, they showed increased activation in the occipito-parietal cortex, posterior cingulate gyrus and parahippocampal gyrus, and decreased activation in dorsolateral and dorsomedial prefrontal cortices. The reverse pattern of findings was observed during the anxiety-provoking scenarios. CONCLUSIONS The results may suggest that, in CFS patients, the provocation of fatigue is associated with exaggerated emotional responses that patients may have difficulty suppressing. These findings are discussed in relation to the cognitive-behavioural model of CFS.

Probing the working memory system in chronic fatigue syndrome: a functional magnetic resonance imaging study using the n-back task.

Objective: Up to 90% of patients with chronic fatigue syndrome (CFS) report substantial cognitive difficulties. However, objective evidence supporting these claims is inconsistent. The present functional magnetic resonance imaging study examined the neural correlates of working memory in patients with CFS compared with controls. Methods: Seventeen patients with CFS and 12 healthy control subjects were scanned while performing a parametric version of the n-back task (0-, 1-, 2-, and 3-back). Results: Both groups performed comparably well and activated the verbal working memory network during all task levels. However, during the 1-back condition, patients with CFS showed greater activation than control subjects in medial prefrontal regions, including the anterior cingulate gyrus. Conversely, on the more challenging conditions, patients with CFS demonstrated reduced activation in dorsolateral prefrontal and parietal cortices. Furthermore, on the 2- and 3-back conditions, patients but not control subjects significantly activated a large cluster in the right inferior/medial temporal cortex. Trend analyses of task load demonstrated statistically significant differences in brain activation between the two groups as the demands of the task increased. Conclusions: These results suggest that patients with CFS show both quantitative and qualitative differences in activation of the working memory network compared with healthy control subjects. It remains to be determined whether these findings stay stable after successful treatment. CFS = chronic fatigue syndrome; fMRI = functional magnetic resonance imaging; PASAT = Paced Auditory Serial Addition Test; WM = working memory; SPECT = single photon emission computed tomography; CDC = Centers for Disease Control and Prevention; BOLD = blood oxygen level dependent; BA = Brodmanns area; TR = repetition time; TE = echo time; SSQratio = sum of squares ratio.

A client-generated psychometric instrument: The development of ‘PSYCHLOPS’

PSYCHLOPS (Psychological Outcome Profiles) is a recently developed, client-generated, psychometric instrument that can be used as an outcome measure. Based on a similar instrument developed primarily for use in physical illnesses (MYMOP — ‘Measure Your Medical Outcome Profile’), it seeks the clients perspective on their psychological distress. It asks them to describe and then score the problem that troubles them the most at the start of counselling. We describe the development of PSYCHLOPS, including the involvement of the Plain English Campaign and two national mental health organisations: the mental health charity and support group, Depression Alliance (DA) and Primary Care Mental Health Education (PRIMHE). We review the literature and suggest that PSYCHLOPS, by focusing on the problems of greatest priority to the client, might prove a sensitive measure of improvement after counselling.

Predictors of outcome in a fatigued population in primary care following a randomized controlled trial

BACKGROUND The objective of this study was to examine factors that predicted outcome in a chronically fatigued group of patients who were randomized to cognitive behaviour therapy or counselling in primary care. METHOD Illness perceptions, attributions, fatigue, disability and demographic variables were recorded at assessment and levels of fatigue and disability were measured at 6 months post randomization. Logistic regression was used to examine associations. RESULTS Factors that predicted a poor outcome (four or more on the fatigue questionnaire) were: poor social adjustment at assessment; the patients self-report that they had never seen the GP for an emotional reason; a physical illness attribution; and, a long perceived future illness duration. CONCLUSIONS Patients who are more psychologically minded are more likely to improve with psychological treatments in primary care. General practitioners need to assess this before referring to an appropriate therapist.

Therapeutic writing as an intervention for symptoms of bulimia nervosa: effects and mechanism of change.

OBJECTIVE This study explored the effects on bulimic symptomatology of a writing task intended to reduce emotional avoidance. METHOD Eighty individuals reporting symptoms of bulimia completed, by e-mail, a therapeutic or control writing task. Participants completed questionnaires on bulimic symptoms, mood, and potential moderating and mediating factors, and were followed up after 4 and 8 weeks. Writing content was explored using a word count package and qualitative framework analysis. RESULTS Bulimic symptoms decreased in both groups, although in both groups the number of participants who improved was approximately equal to the number who did not improve. Symptom decreases were associated with increases in perceived mood regulation abilities, and decreases in negative beliefs about emotions. Participants preferred internet delivery to face to face discussion. DISCUSSION For individuals experiencing symptoms of bulimia, the effects of therapeutic writing did not differ significantly from effects of a control writing task.

The experiences of therapists using a new client-centred psychometric instrument, PSYCHLOPS (Psychological Outcome Profiles)

PSYCHLOPS (‘Psychological Outcome Profiles’) is a newly developed client-generated psychometric instrument which can be used as an outcome measure. Uniquely, it asks clients to state their own problems, in their own words. As part of its validation, we used it alongside an existing measure, CORE-OM (‘Clinical Outcomes Routine Evaluation – Outcome Measure’). Based on a qualitative methodology, we report here on the first-hand experiences of four therapists using both instruments. The key themes that emerged from therapists’ responses were feasibility, validity and usefulness. Both questionnaires were perceived as complementing each other, the qualitative information from PSYCHLOPS balancing the quantitative information from CORE-OM and that both could contribute to the therapist-client interaction. The key features of PSYCHLOPS are likely to prove attractive to therapists and should increase acceptance and uptake of outcome measures.

The development and initial psychometric evaluation of a measure assessing adherence to prescribed exercise: The Exercise Adherence Rating Scale (EARS)

OBJECTIVES There is no gold standard for measuring adherence to prescribed home exercise. Self-report diaries are commonly used however lack of standardisation, inaccurate recall and self-presentation bias limit their validity. A valid and reliable tool to assess exercise adherence behaviour is required. Consequently, this article reports the development and psychometric evaluation of the Exercise Adherence Rating Scale (EARS). DESIGN Development of a questionnaire. SETTING Secondary care in physiotherapy departments of three hospitals. PARTICIPANTS A focus group consisting of 8 patients with chronic low back pain (CLBP) and 2 physiotherapists was conducted to generate qualitative data. Following on from this, a convenience sample of 224 people with CLBP completed the initial 16-item EARS for purposes of subsequent validity and reliability analyses. METHODS Construct validity was explored using exploratory factor analysis and item response theory. Test-retest reliability was assessed 3 weeks later in a sub-sample of patients. RESULTS An item pool consisting of 6 items was found suitable for factor analysis. Examination of the scale structure of these 6 items revealed a one factor solution explaining a total of 71% of the variance in adherence to exercise. The six items formed a unidimensional scale that showed good measurement properties, including acceptable internal consistency and high test-retest reliability. CONCLUSIONS The EARS enables the measurement of adherence to prescribed home exercise. This may facilitate the evaluation of interventions promoting self-management for both the prevention and treatment of chronic conditions.

A life of living death: the experiences of people living with chronic low back pain in rural Nigeria.

Abstract Purpose: This study explored the experiences of people living with non-specific chronic low back pain (CLBP) in a rural Nigerian community. Method: Qualitative in-depth semi-structured face-to-face interviews were conducted with purposively sampled participants until data saturation. Questions explored back pain beliefs, coping/management strategies and daily activities. Thematic analysis of transcripts was performed using the Framework approach. Results: Themes showed that back pain beliefs were related to manual labour/deprivation, infection/degeneration, spiritual/cultural beliefs and rural–urban divide. These beliefs impacted on gender roles resulting in adaptive or maladaptive coping. Adaptive coping was facilitated by positive beliefs, such as not regarding CLBP as an illness, whereas viewing CLBP as illness stimulated maladaptive coping strategies. Spirituality was associated with both adaptive and maladaptive coping. Maladaptive coping strategies led to dissatisfaction with health care in this community. Conclusions: CLBP-related disability in rural Nigeria is strongly influenced by beliefs that facilitate coping strategies that either enhance or inhibit recovery. Interventions should therefore target maladaptive beliefs while emphasizing behavioural modification. Implications for Rehabilitation Non-specific chronic low back pain (CLBP) is highly prevalent and responsible for much pain and disability in rural Nigeria. No qualitative study has investigated the experiences of people living with CLBP in rural Nigeria or any other rural African context. Qualitative study of peoples’ experiences of living with CLBP in rural Nigeria has the potential of exposing complex socio-cultural and psychological factors associated with CLBP which has potential implications for designing effective interventions. The results of this study may inform the development of complex interventions for reducing the disability associated with CLBP in rural Nigeria and other rural African contexts.

Benefits of dramatherapy for Autism Spectrum Disorder: a qualitative analysis of feedback from parents and teachers of clients attending Roundabout dramatherapy sessions in schools

Objective. To investigate parent/carer and teacher feedback on dramatherapy provided by Roundabout dramatherapists for children and young people with Autism Spectrum Disorder (ASD) in schools. Design. A qualitative study of written feedback from parents/carers collected after treatment had finished. Methods. Forty-two comments on dramatherapy were analysed using Interpretative Phenomenological Analysis (IPA). Results. Five themes emerged from the data and were reported using verbatim quotes under the following headings: Feelings: a safe place to explore; Peers: being included and making friends; Social skills: role play provides a short cut to learning about and practising social skills; Structure: predictability lessens anxiety; and Families: supporting the whole system. There were no negative comments about the dramatherapy treatment recorded on the feedback forms. Conclusion. The findings revealed overwhelming support from parents/carers and teachers for the use of dramatherapy for children and young people with ASD. These results are encouraging and indicate that further study of dramatherapy treatment is warranted in order to build the evidence base for such interventions in this client group.

Visually induced dizziness in children and validation of the Pediatric Visually Induced Dizziness Questionnaire

Aims To develop and validate the Pediatric Visually Induced Dizziness Questionnaire (PVID) and quantify the presence and severity of visually induced dizziness (ViD), i.e., symptoms induced by visual motion stimuli including crowds and scrolling computer screens in children. Methods 169 healthy (female n = 89; recruited from mainstream schools, London, UK) and 114 children with a primary migraine, concussion, or vestibular disorder diagnosis (female n = 62), aged 6–17 years, were included. Children with primary migraine were recruited from mainstream schools while children with concussion or vestibular disorder were recruited from tertiary balance centers in London, UK, and Pittsburgh, PA, USA. Children completed the PVID, which assesses the frequency of dizziness and unsteadiness experienced in specific environmental situations, and Strength and Difficulties Questionnaire (SDQ), a brief behavioral screening instrument. Results The PVID showed high internal consistency (11 items; α = 0.90). A significant between-group difference was noted with higher (i.e., worse) PVID scores for patients vs. healthy participants (U = 2,436.5, z = −10.719, p < 0.001); a significant difference was noted between individual patient groups [χ2(2) = 11.014, p = 0.004] but post hoc analysis showed no significant pairwise comparisons. The optimal cut-off score for discriminating between individuals with and without abnormal ViD levels was 0.45 out of 3 (sensitivity 83%, specificity 75%). Self-rated emotional (U = 2,730.0, z = −6.169) and hyperactivity (U = 3,445.0, z = −4.506) SDQ subscale as well as informant (U = 188.5, z = −3.916) and self-rated (U = 3,178.5, z = −5.083) total scores were significantly worse for patients compared to healthy participants (p < 0.001). Conclusion ViD is common in children with a primary concussion, migraine, or vestibular diagnosis. The PVID is a valid measure for identifying the presence of ViD in children and should be used to identify and quantify these symptoms, which require specific management incorporating exposure to optokinetic stimuli.