Ignace Hanoulle

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

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

Sleep in the chronic fatigue syndrome.

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

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

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

Undiagnosed and comorbid disorders in patients with presumed chronic fatigue syndrome

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

Subjective sleep quality and daytime sleepiness in a large sample of patients with chronic fatigue syndrome (CFS).

Abstract Chronic fatigue syndrome (CFS) is characterised by incapacitating fatigue in combination with a number of minor criteria, including unrefreshing sleep without further specifications, in the absence of psychiatric and internal disease. As little data exist on subjective sleep quality and daytime sleepiness, these parameters were assessed in a large sample of CFS patients. Consecutive patients with a diagnosis of CFS in a tertiary referral centre filled out the Fatigue Questionnaire (FQ), Medical Outcomes Study 36-Item Short Form Health Survey (MOS SF-36), Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI). Inclusion comprised 415 individuals (mean age 40.5 yr, SD 7.9, range 18-64; 86% female). Mean FQ (26.90; SD 4.04), mean Global Physical Health from the MOS SF-36 (29.30; SD 12.25) and Global Mental Health from the MOS SF-36 (49.62; SD 18.31) scores corresponded with literature data for similar CFS samples. High mean ESS (10.51; SD 5.52) and global PSQI (10.17; SD 4.02) were observed. No significant relationship was found between ESS and global PSQI. In contrast, regression analysis demonstrated a significant cubic relation between ESS and ‘PSQI without daytime dysfunction’. A subgroup (n = 69) with an insomnia-like phenotype low ESS (< 5), high PSQI (mean 11.51; SD 3.86) was observed. The assessment of subjective sleep quality and daytime sleepiness in a large sample of CFS patients indicated high mean PSQI and ESS values. ESS and ‘PSQI without daytime dysfunction’ were inversely related at the spectral ends of ESS. A distinct subgroup with clinical features of insomnia was identified.

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

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

PERSONALITY TRAITS IN CHRONIC PAIN PATIENTS ARE ASSOCIATED WITH LOW ACCEPTANCE AND CATASTROPHIZING ABOUT PAIN

Abstract Objective: Pain acceptance is considered important for mental well-being with better functional outcomes for chronic pain patients. The present study explored whether pain-related variables (pain severity, pain interference, pain duration, and pain catastrophizing) and non-pain-related variables (personality traits) influence acceptance and additionally examined the interrelationship between the influencing variables and acceptance. Methods: One hundred patients with chronic pain from a multidisciplinary pain centre completed selfreport questionnaires on acceptance, pain severity, interference of life, pain duration, pain catastrophizing, and personality. Results: Pain severity, pain interference, and pain duration had no significant correlations with acceptance. Pain catastrophizing and most personality traits were significantly and negatively related to acceptance. Regression analyses revealed that of all personality traits, the avoidant personality trait explains most variance of acceptance. Subsequent mediation analysis indicated that catastrophizing about pain mediated the relationship between the avoidant personality trait and acceptance. Conclusion: The findings indicate that acceptance is influenced by catastrophizing and avoidant personality traits. The clinical implication might be that acceptanceoriented treatments may prove less successful in chronic pain patients with more pronounced avoidant personality traits. Extra focus on a reduction of the frequency of pain catastrophizing might be helpful.

Polysomnographic and multiple sleep latency testing data in a large sample of patients with chronic fatigue syndrome and their relationship with subjective scores

ABSTRACT Background: Despite the majority of patients with chronic fatigue syndrome (CFS) complaining about sleep disturbances and/or non-refreshing sleep, abnormalities in objective sleep parameters have not consistently been identified in this population. Purpose: To assess objective parameters of sleep and sleepiness in a large sample of patients with CFS and their relationship with the subjective dimensions of mental and physical health, sleep quality, daytime sleepiness and fatigue. Methods: Objective sleep parameters were derived from polysomnography (PSG) and multiple sleep latency testing (MSLT). Subjective scores for mental and physical health, sleep quality, daytime sleepiness and fatigue were based on validated, self-report questionnaires. Hierarchical multiple regression analysis was performed to predict sleepiness, global quality of sleep and fatigue. Results: PSG in 184 CFS patients indicated decreased total sleep time and sleep efficiency as well as increased sleep latency and waking after sleep onset. Only a few modest but significant correlations (r’s < .30) were found between objective parameters of sleep and sleepiness and subjective scores for health, sleep quality and fatigue. Conclusions: Objective sleep parameters indicated poor sleep in CFS, suggesting an insomnia phenotype, but with only modest associations to subjective scores of mental and physical health, sleep quality, daytime sleepiness and fatigue.

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

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

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

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