Ivana Klimes

Cognitive behaviour therapy for the chronic fatigue syndrome: a randomized controlled trial

Abstract Objective: To evaluate the acceptability and efficacy of adding cognitive behaviour therapy to the medical care of patients presenting with the chronic fatigue syndrome. Design: Randomised controlled trial with final assessment at 12 months. Setting: An infectious diseases outpatient clinic. Subjects: 60 consecutively referred patients meeting consensus criteria for the chronic fatigue syndrome. Interventions: Medical care comprised assessment, advice, and follow up in general practice. Patients who received cognitive behaviour therapy were offered 16 individual weekly sessions in addition to their medical care. Main outcome measures: The proportions of patients (a) who achieved normal daily functioning (Karnofsky score 80 or more) and (b) who achieved a clinically significant improvement in functioning (change in Karnofsky score 10 points or more) by 12 months after randomisation. Results: Only two eligible patients refused to participate. All randomised patients completed treatment. An intention to treat analysis showed that 73% (22/30) of recipients of cognitive behaviour therapy achieved a satisfactory outcome as compared with 27% (8/30) of patients who were given only medical care (difference 47 percentage points; 95% confidence interval 24 to 69). Similar differences were observed in subsidiary outcome measures. The improvement in disability among patients given cognitive behaviour therapy continued after completion of therapy. Illness beliefs and coping behaviour previously associated with a poor outcome changed more with cognitive behaviour therapy than with medical care alone. Conclusion: Adding cognitive behaviour therapy to the medical care of patients with the chronic fatigue syndrome is acceptable to patients and leads to a sustained reduction in functional impairment. Key messages Key messages There is no generally accepted form of treatment New findings show that patients referred to hospital for the chronic fatigue syndrome have a better outcome if they are given a course of cognitive behaviour therapy than if they receive only basic medical care Clinical improvement with cognitive behaviour therapy may be slow but often continues after treatment has ended Cognitive behaviour therapy should be considered as an option for patients presenting with the chronic fatigue syndrome

The psychosocial impact of HIV infection in men with haemophilia: controlled investigation and factors associated with psychiatric morbidity.

The aim of the investigation was to establish the prevalence of psychosocial problems in men with haemophilia and HIV infection, and to identify factors associated with psychological morbidity. A cross-sectional controlled study including 37 HIV seropositive and 36 HIV seronegative men with haemophilia under the care of the Oxford Haemophilia Centre were included in the investigation. The outcome measures included current psychological status (PSE, POMS, Beck Hopelessness Scale and Self-Esteem) and psychiatric history; coping and health beliefs (Self-Control Schedule, Hardiness Scale, Health Locus of Control Scale); social functioning (Modified Social Adjustment Scale); and sexual functioning. The results showed that seropositive individuals, whether symptomatic or not, had significantly worse total PSE scores and had higher levels of hopelessness. In addition, symptomatics had worse depression scores (POMS) than seronegatives. However, levels of psychiatric morbidity were generally low, even in the seropositive group. High levels of psychological morbidity were associated with high levels of hopelessness, unfavourable social adjustment, past psychiatric history and symptomatic HIV disease. Seropositives reported greater negative impact on their sex lives, and sexually active seropositives reported a significantly greater prevalence of sexual dysfunction than seronegatives. The majority of seropositives reported regular condom use during intercourse, and also continuing concerns about infecting their sexual partners in spite of it. In summary, it was found that men with haemophilia an HIV infection have higher levels of psychological distress and sexual problems than seronegatives. The skilled staff involved in their treatment are in a good position to identify their difficulties and ensure that good care is provided.

Psychosexual problems in people with HIV infection: Controlled study of gay men and men with haemophilia

HIV infection can be associated with major psychological and social disturbance. Psychosexual problems would be expected to arise in the context of the infection, in view of the contribution that sexual behaviour can make to the acquisition and spread of HIV infection. Here the results of a study of the psychosexual consequences of HIV infection in gay men and men with haemophilia are presented, with the inclusion of data from control groups. Sixteen HIV-positive and 23 HIV-negative gay men, and 20 HIV-positive and 24 HIV-negative men with haemophilia with sexual partners were studied. HIV infection was found to be associated with the greater risk of development of sexual dysfunction in seropositives, in particular in relation to ejaculatory difficulties, both delayed ejaculation in the case of gay men and men with haemophilia, and premature ejaculation in the case of men with haemophilia. Possible aetiological mechanisms are considered, including the possibility of organic disease. The findings are of relevance to those involved in the care of people with HIV infection.

Knowledge and attitudes of health care staff about HIV infection in a health district with low HIV prevalence

The level of awareness of HIV related problems and their implications for health workers were investigated in Oxford, where the problem of HIV infection has not reached the levels of other metropolitan areas. Four hundred nurses and doctors in Oxford were surveyed to ascertain their knowledge about HIV infection, their attitudes to care of HIV patients, and to examine the relationship between knowledge and attitudes. The response rate was 64%. Professional groups differed in their knowledge and attitudes, and staff lacked some basic information about HIV transmission and safety relevant to hospital care. Accurate knowledge about HIV infection and positive attitudes to the care of HIV patients were highly correlated. However, anxiety about HIV infection, which could interfere with the optimum care of patients, affected one quarter of staff surveyed. Implications for staff training are discussed.

Partners of men with HIV infection and haemophilia: Controlled investigation of factors associated with psychological morbidity

The study was concerned with determining the prevalence of psychosocial problems in partners of men with haemophilia and HIV infection, and with identifying factors associated with psychological morbidity. Partners of 17 HIV positive and partners of 19 HIV negative men with haemophilia were assessed in a cross-sectional controlled investigation. Outcome measures included current psychological status and psychiatric history; coping and health beliefs; and social and sexual functioning. Partners of HIV positive men with haemophilia, the majority of whom were asymptomatic, were not found to suffer more psychological difficulties than the partners of HIV negative men with haemophilia. However, partners of haemophiliacs regardless of HIV status suffer from higher levels of psychological distress than comparable women in the community, and those with past psychiatric history and current social difficulties are particularly at risk. The sexual relationships of couples with HIV positive men were more adversely affected than those of HIV negative couples.

The impact of HIV infection on health care staff and other carers

The issues encountered by health workers and informal carers in relation to HIV infection are highlighted. The impact that HIV infection has had on health care staff is described in terms of their emotional responses, knowledge and attitudes toward HIV infection and patients, their occupational risk of HIV transmission, their anxiety about becoming infected at work and use of infection control measures. Stresses, rewards and needs of informal carers are described and the evidence of psychological effects of their care-giving is discussed.

Kognitive Verhaltenstherapie beim Chronic Fatigue Syndrome: Eine randomisierte kontrollierte Studie

The objective of the study was to evaluate the acceptability and efficacy of adding cognitive behaviour therapy to the medical care of patients presenting with the chronic fatigue syndrome. A randomised controlled trial with final assessment at 12 months was carried out in an infectious diseases outpatient clinic. 60 consecutively referred patients meeting consensus criteria for the chronic fatigue syndrome were included in the study. Medical care comprised assessment, advice and follow-up in general practice. Patients who received cognitive behaviour therapy were offered 16 individual weekly sessions in addition to their medical care. Main outcome measures were: the proportions of patients (a) who achieved normal daily functioning (Karnofsky score 80 or more) and (b) who achieved a clinically significant improvement in functioning (change in Karnofsky score 10 points or more) 12 months after randomisation. Only two eligible patients refused to participate. All randomised patients completed treatment. An intention to treat analysis showed that 73% (22/30) of recipients of cognitive behaviour therapy achieved a satisfactory outcome as compared with 27% (8/30) of patients who were given only medical care (difference of 47 percentage points; 95% confidence interval 24 to 69). Similar differences were observed in subsidiary outcome measures. The improvement in disability among patients given cognitive behaviour therapy continued after completion of therapy. Illness beliefs and coping behaviour previously associated with a poor outcome changed more with cognitive behaviour therapy than with medical care alone. We conclude that adding cognitive behaviour therapy to the medical care of patients with the chronic fatigue syndrome is acceptable to patients and leads to a sustained reduction in functional impairment. Schlüsselwörter Chronic Fatigue Syndrome · Kognitive Verhaltenstherapie · Akzeptanz

Psychiatric problems in HIV-infected men with haemophilia

The clinical aspects of haemophilia and its relationship to HIV disease are reviewed, together with discussion of general aspects of the disease progression in men with haemophilia, and transmission to partners and others. The psychiatric consequences are considered, in particular the psychosocial and neuropsychiatric aspects in men with haemophilia and in their partners. The implications of HIV disease in men with haemophilia for the provision of psychiatric care and for further research are discussed.

HIV Infection, the Brain and Behaviour: Major Psychiatric Disorder without Cognitive Impairment before or after the Episode

A 39-year-old man with haemophilia and HIV disease was admitted to an infectious diseases unit with poor memory, impaired thinking, and fears of AIDS and death. HIV infection had been diagnosed 5 years earlier, and he was started on zidovudine (AZT) 8 months before episode, but had to be stopped after 6 months due to lymphopenia. He had no psychiatric or substance misuse history, and had coped well with the diagnosis of HIV. There was a family psychiatric history: maternal grandmother, patients mother (and two of her siblings), and patients sister had been treated for depression. Four weeks before admission he became febrile and had productive cough, and AZT was restarted. Over next 2 weeks he developed night sweats without fever, headache, fatigue, and became forgetful, had difficulty finding words, and complained of recurrent intrusive thoughts about ill health. On examination he was found to have slight pyrexia, but had no other abnormalities (for investigations see Table 1). A provisional diagnosis of CNS disease was made, with the possibility of psychiatric disorder. Mental state assessment found