Fred Friedberg

Symptom patterns in long-duration chronic fatigue syndrome.

OBJECTIVE Our objective was to evaluate symptom patterns in patients with chronic fatigue syndrome (CFS) who were ill for 10 or more years. METHODS This cross-sectional self-report study compared patient groups with long-duration (median = 18 years; n = 258) and short-duration (median = 3 years; n = 28) CFS to a group of healthy significant others (n = 79) on symptomatic, neurocognitive, and psychological variables. Data were gathered from a 574-item postal questionnaire. RESULTS A principal-components analysis of CFS symptom data yielded a three-factor solution: cognitive problems; flu-like symptoms; and neurologic symptoms. Compared with the short-duration CFS group, the long-duration group had significantly higher CFS symptom severity scores (p < 0.04), largely attributable to increased cognitive difficulties. A subgroup comparison of subjects ill for < 3 years versus those ill 4-7 years suggested that denial coping strategies were more likely in those participants with the shorter illness duration. Significant differences between both CFS groups and healthy controls were found in a number of comorbid disorders. Participants with CFS most often endorsed immune/viral abnormalities and persistent stress as important perceived causes of their illness. CONCLUSION Participants with long-duration CFS reported a large number of specific cognitive difficulties that were greater in severity than those reported by participants with short-duration CFS. The pattern of comorbid disorders in the CFS groups was consistent with hypersensitivity and viral reactivation hypotheses.

Non-pharmacologic Interventions for CFS: A Randomized Trial

Non-pharmacological behavioral treatments for CFS have been suggested as promising. These trials have tested protocols composed of behavioral, cognitive and cognitive–behavioral interventions but there have been few efforts to differentially evaluate their outcomes. The primary purpose of the current study was to evaluate the effectiveness of nurse delivered non-pharmacologic interventions. In the present study, 114 participants diagnosed with CFS were randomly assigned to four 6-month interventions. The interventions were: cognitive–behavior therapy, cognitive therapy, anaerobic activity, and a relaxation control group. The study found that these interventions led to increases in several areas of functioning, with more consistent changes occurring among those participants in the cognitive condition. For the 25 variables in this study, significant change occurred for 28%, 20%, 16%, and 12% of the variables for the cognitive, cognitive behavior therapy, anaerobic activity, and relaxation conditions, respectively. However, the majority of participants continued to be diagnosed with CFS following the treatment trial. Implications of these findings are discussed.

Assessment of clinical reasoning: A Script Concordance test designed for pre-clinical medical students

Background: The Script Concordance test (SCT) measures clinical reasoning in the context of uncertainty by comparing the responses of examinees and expert clinicians. It uses the level of agreement with a panel of experts to assign credit for the examinees answers. Aim: This study describes the development and validation of a SCT for pre-clinical medical students. Methods: Faculty from two US medical schools developed SCT items in the domains of anatomy, biochemistry, physiology, and histology. Scoring procedures utilized data from a panel of 30 expert physicians. Validation focused on internal reliability and the ability of the SCT to distinguish between different cohorts. Results: The SCT was administered to an aggregate of 411 second-year and 70 fourth-year students from both schools. Internal consistency for the 75 test items was satisfactory (Cronbachs alpha = 0.73). The SCT successfully differentiated second- from fourth-year students and both student groups from the expert panel in a one-way analysis of variance (F2,508 = 120.4; p < 0.0001). Mean scores for students from the two schools were not significantly different (p = 0.20). Conclusion: This SCT successfully differentiated pre-clinical medical students from fourth-year medical students and both cohorts of medical students from expert clinicians across different institutions and geographic areas. The SCT shows promise as an easy-to-administer measure of “problem-solving” performance in competency evaluation even in the beginning years of medical education.

Chronic fatigue syndrome, fibromyalgia, and related illnesses: a clinical model of assessment and intervention

A clinically informative behavioral literature on chronic fatigue syndrome (CFS) and fibromyalgia (FM) has emerged over the past decade. The purpose of this article is to (a) define these conditions and their less severe counterparts, i.e., unexplained chronic fatigue (UCF) and chronic widespread pain; (b) briefly review the behavioral theory and intervention literature on CFS and FM; and (c) describe a user-friendly clinical model of assessment and intervention for these illnesses. The assessments described will facilitate understanding of the somewhat unusual and puzzling somatic presentations that characterize these patients. Using an individualized cognitive-behavioral approach the mental health clinician can offer significant help to these often stigmatized and medically underserved patients.

Cognitive-behavior therapy in chronic fatigue syndrome: is improvement related to increased physical activity?

This multiple case study of cognitive-behavioral treatment (CBT) for chronic fatigue syndrome (CFS) compared self-report and behavioral outcomes. Eleven relatively high-functioning participants with CFS received 6-32 sessions of outpatient graded-activity oriented CBT. Self-report outcomes included measures of fatigue impact, physical function, depression, anxiety, and global change. Behavioral outcomes included actigraphy and the 6-minute walking test. Global change ratings were very much improved (n=2), much improved (n=2), improved (n=5), and no change (n=2). Of those reporting improvement, clinically significant actigraphy increases (n=3) and decreases (n=4) were found, as well as no significant change (n=2). The nature of clinical improvement in CBT trials for high-functioning CFS patients may be more ambiguous than that postulated by the cognitive-behavioral model.

Memory for fatigue in chronic fatigue syndrome: The relation between weekly recall and momentary ratings

Background: Understanding how patients with chronic fatigue syndrome (CFS) recall their fatigue is important because fatigue is a core clinical dimension of this poorly understood illness. Purpose: This study assessed the associations between momentary fatigue ratings and weekly recall of fatigue in 71 participants with CFS. Method: During the three-week data collection period, fatigue intensity was recorded six times a day in electronic diaries. At the end of each week, participants were asked to recall their fatigue intensity for that week. Statistical analyses were done with t-tests and Pearson’s and intraclass correlations. Results: Average weekly recall of fatigue intensity was significantly higher than average momentary ratings. Furthermore, moderate to high Pearson’s correlations and intraclass correlations (consistency and absolute agreement) between recall and momentary fatigue ratings were found. Conclusion: Individuals with CFS recalled consistently higher levels of fatigue in comparison to real-time momentary ratings, yet the level of agreement between the two measures was moderate to high. These findings may have implications for the conduct of office examinations for CFS.

Lifestyle-oriented non-pharmacological treatments for fibromyalgia: a clinical overview and applications with home-based technologies

Fibromyalgia (FM) is a persistent and disabling widespread pain condition often accompanied by chronic fatigue, cognitive problems, sleep disturbance, depression, anxiety, and headache. To date, the most thoroughly studied non-pharmacological approaches to managing FM are those with a focus on changing patient activities and beliefs that affect the illness. These interventions are intended to facilitate enduring improvement in pain and functional status. Lifestyle-oriented treatments include patient education, aerobic or other physical exercise, and cognitive-behavioral therapy (CBT). These interventions in FM can be delivered in medical or behavioral health care settings by trained professionals, through patient-oriented treatment manuals, or via remote-access technologies. Non-pharmacological treatments, in particular exercise and CBT, have yielded effect sizes and cost–benefit ratios comparable to medications. This paper describes lifestyle-oriented non-pharmacological treatments for FM and highlights selected literature reviews of these interventions. In addition, behavioral and practical issues are addressed that may affect these non-pharmacological treatments, including patient expectations, participant burden, and treatment availability. Recommendations are made to facilitate these interventions and potentially improve outcomes. In particular, the increasing availability of convenient home-based mobile technologies to deliver these non-pharmacological treatments is described.

Chronic Fatigue Self- Management in Primary Care: A Randomized Trial

Objective To assess the efficacy of brief fatigue self-management (FSM) for medically unexplained chronic fatigue (UCF) and chronic fatigue syndrome (CFS) in primary care. Methods A randomized controlled design was used wherein 111 patients with UCF or CFS were randomly assigned to two sessions of FSM, two sessions of symptom monitoring support (attention control; AC), or a usual care control condition (UC). Participants were assessed at baseline and at 3 and 12 months after treatment. The primary outcome, the Fatigue Severity Scale, measured fatigue impact on functioning. Analysis was by intention to treat (multiple imputation) and also by per protocol. Results A group × time interaction across the 15-month trial showed significantly greater reductions in fatigue impact in the FSM group in comparison with the AC group (p < .023) and the UC group (p < .013). Medium effect sizes for reduced fatigue impact in the FSM group were found in comparison with the AC group (d = 0.46) and the UC group (d = 0.40). The per-protocol analysis revealed large effect sizes for the same comparisons. Clinically significant decreases in fatigue impact were found for 53% of participants in the FSM condition, 14% in the AC condition, and 17% in the UC condition. Dropout rates at the 12-month follow-up were high (42%–53%), perhaps attributable to the burden of monthly telephone calls to assess health care use. Conclusion A brief self-management intervention for patients with UCF or CFS seemed to be clinically effective for reducing the impact of fatigue on functioning. Trial Registration clinicaltrials.gov Identifier: NCT00997451.

Classification of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome by Types of Fatigue

Persons with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) often complain of fatigue states (eg, postexertional malaise, brain fog) that are qualitatively different than normal, daily fatigue. Given the heterogeneous nature of ME/CFS, it is likely that individuals with this illness experience these fatigue types differently in terms of severity and frequency. It is also possible that meaningful subgroups of patients exist that exhibit different patterns of the fatigue experience. The purpose of this study was to investigate whether individuals with ME/CFS can be classified in a meaningful way according to the different types of fatigue they experience. One hundred individuals with ME/CFS participated in the study. Individuals that met inclusion criteria were administered the Multiple Fatigue Types Questionnaire (MFTQ), a 5-factor instrument that distinguishes between different types of fatigue. A cluster analysis was used to classify patients into various clusters based on factor subscale scores. Using a 3-factor solution, individuals were classified according to illness severity (low, moderate, severe) across the different fatigue factors. However, a 5-cluster solution enabled participants with moderate to severe fatigue levels to fall into more differentiated clusters and demonstrate distinct fatigue state patterns. These results suggest that fatigue patterns of individuals with ME/CFS are heterogeneous, and that patients may be classified into meaningful subgroups.

Prevalence and predictors of fatigue in middle-aged and older adults: evidence from the health and retirement study.

than 11 out of 15 and a MMSE score of 23 or less out of 30 (correlation coefficient 5 .783). In a study of a two-questions screening test for depression in patients without cognitive impairment (defined as a MMSE score 26), a score of 1 or greater had a sensitivity of 84%, a specificity of 61%, and a NPV of 95% compared with a 15-item Geriatric Depression Scale (GDS-15) score of 5 or greater. To assess functional status, the Older Americans Resources and Services (OARS) questionnaire, with a score ranging from 0 to 28 and taking approximately 5 minutes to administer is the most used in North America. Although the cutoff is not clearly determined, each point under the maximum score indicates a functional disability that must be taken into account for further interventions or advises. The one-leg balance test is a short and simple test during which the patient has just to be able to stand up. The inability to perform this task doubles the risk for an injurious fall during the next 3 years. Concerning malnutrition, there is no validated test that can be routinely used in the ED, and the measurement of body mass index, frequently included in nutritional scores, is difficult to perform in the ED. It is also critical to take advantage of the ED visit to review and improve the medication list to reduce adverse drug events. The Beer’s criteria are a widely accepted list that can help to identify potentially inappropriate medication in older patients and can be used to simplify treatments. In conclusion, older patients admitted to the ED should be screened for risk of adverse outcomes. In patients at high risk of adverse outcomes, the CGA should be administered with brief tools validated in the ED. This two-step intervention has been shown to decrease the rate of functional decline, readmission, and institutionalization. Further research is needed to validate this approach in different populations, such as in Europe or Asia.