Peter Van Wambeke

Self-Critical Perfectionism, Stress Generation, and Stress Sensitivity in Patients with Chronic Fatigue Syndrome: Relationship with Severity of Depression

Chronic Fatigue Syndrome (CFS) is a highly disabling disorder that is part of a broader spectrum of chronic pain and fatigue disorders. Although the etiology and pathogenesis of CFS largely remain unclear, there is increasing evidence that CFS shares important pathophysiological disturbances with mood disorders in terms of disturbances in the stress response and the stress system. From a psycho-dynamic perspective, self-critical perfectionism and related personality factors are hypothesized to explain in part impairments of the stress response in both depression and CFS. Yet, although there is ample evidence that high levels of self-critical perfectionism are associated with stress generation and increased stress sensitivity in depression, evidence supporting this hypothesis in CFS is currently lacking. This study therefore set out to investigate the relationship between self-critical perfectionism, the active generation of stress, stress sensitivity, and levels of depression in a sample of 57 patients diagnosed with CFS using an ecological momentary assessment approach. Results showed, congruent with theoretical assumptions, that self-critical perfectionism was associated with the generation of daily hassles, which in turn predicted higher levels of depression. Moreover, multilevel analyses showed that self-critical perfectionism was related to increased stress sensitivity in CFS patients over a 14-day period, and that increased stress sensitivity in turn was related to increased levels of depression. The implications of these findings for future research and particularly for the development of psychodynamic treatment approaches of CFS and related conditions are discussed.

Unraveling the role of perfectionism in chronic fatigue syndrome: Is there a distinction between adaptive and maladaptive perfectionism?

In the current study, we investigated whether the distinction between adaptive (i.e. high personal standards) and maladaptive (i.e. concern over mistakes and doubt about actions) perfectionism that has been found in the literature, is also valid in patients with chronic fatigue syndrome (CFS). We hypothesized that maladaptive, but not adaptive, perfectionism would be significantly and positively related to severity of fatigue and depression in CFS. We examined this hypothesis in a sample of 192 CFS patients using structural equation modelling (SEM). Although the two perfectionism dimensions were related to each other, results supported a model in which only maladaptive perfectionism was positively related to severity of fatigue and depression. Further, we found that depression fully mediated the effect of maladaptive perfectionism on fatigue. The results suggest that adaptive and maladaptive perfectionism are two distinct, albeit related, dimensions in CFS. Findings of this study have important implications for theory and treatment of CFS, particularly for cognitive-behavioral treatment.

Predictors of outcome in a multi-component treatment program for chronic fatigue syndrome

BACKGROUND Little is known about factors predicting treatment outcome in chronic fatigue syndrome (CFS). METHODS Based on Vercoulen et al.s (1998) cognitive-behavioral model of perpetuating factors in CFS, the predictive value of the following patient characteristics were examined in a sample of 178 CFS patients who followed a multi-component treatment program: (1) somatic attributions, (2) psychological attributions, (3) sense of control over symptoms, (4) physical activity, (5) functional impairment, (6) somatic focus, and (7) severity of depression. RESULTS Only pre-treatment severity of depression was associated with negative treatment outcome defined in terms of post-treatment fatigue and improvement in fatigue. LIMITATIONS The study was conducted at a tertiary care centre and did not include a control group or a long-term follow-up. CONCLUSIONS Level of depression may be the most important factor of the cognitive-behavioral model predicting post-treatment fatigue in CFS. Hence, findings suggest that treatment of CFS should include a focus on severity of depression.

The prevalence and impact of early childhood trauma in Chronic Fatigue Syndrome

BACKGROUND Although some studies have found high rates of early childhood trauma in Chronic Fatigue Syndrome (CFS), the role of early trauma in this condition remains controversial. METHODS This study examined the prevalence of early childhood trauma and its impact on daily fatigue and pain levels over a 14-day period in a sample of 90 carefully screened CFS patients using a diary method approach. Data were analyzed using multilevel analysis. RESULTS More than half of the patients (54.4%) had experienced at least one type of early trauma, with the majority of these patients reporting multiple traumas. Prevalence rates were particularly high for emotional trauma (i.e., emotional abuse and/or emotional neglect) (46.7%). Moreover, total trauma scores and emotional abuse significantly predicted higher levels of daily fatigue and pain over the 14-day period, even when controlling for demographic features and depressed mood. CONCLUSIONS This is the first study to demonstrate that early childhood trauma predicts increasing levels of core symptoms of CFS in the daily flow of life. Moreover, findings of this study suggest that emotional trauma may be particularly important in CFS.

Multidisciplinary pain education program (MPEP) for chronic pain patients: preliminary evidence for effectiveness and mechanisms of change

Abstract Objective: There is a need for effective brief interventions in chronic pain patients, and the identification of mechanisms of change. Method: In the present study, we tested the effectiveness of MPEP (Multidisciplinary Pain Education Program), a very brief, four-session cognitive-behaviorally based psycho-educational intervention for chronic pain using a pre-and post-test design. In addition, pre- to post-treatment change scores were calculated to investigate factors associated with change in pain. Participants of the study were 53 patients with chronic non-cancer pain. Primary outcome measures were (1) pain severity, (2) health perception, and (3) severity of depression. Secondary outcome measures included factors that have been implicated in the maintenance of chronic pain and that might be associated with worse treatment outcome: (1) catastrophizing, (2) kinesiophobia, and (3) action-proneness. Results: Findings provided preliminary evidence for the effectiveness of MPEP in that patients showed significant and clinically meaningful improvements in pain symptoms (F = 24.503, p < 0.001, d = 0.59) and action-proneness (F = 178.504, p < 0.001, d = 1.95), and small improvements in health perception (F = 7.116, p < 0.05, d = 0.30). Furthermore, results showed that changes in catastrophizing (β = −0.455, p = 0.001) and severity of depression (β = −0.300, p < 0.05) were independently and significantly associated with changes in pain. However, changes in health perception, kinesiophobia, and action-proneness were not significantly associated with changes in pain (β = 0.203, ns; β = 0.003, ns; and β = 0.154, ns, respectively). Importantly, duration of chronic pain was not related to treatment outcome (β = 0.070, ns). Conclusions: Overall, this study provides preliminary evidence for the effectiveness of MPEP and possible mechanisms through which MPEP is effective. Yet, further research is needed to investigate the efficacy of MPEP.

Fibromyalgia: do not give up the tender point count too easily: comment on the article by Wolfe et al

We read with interest the article by Wolfe et al (1) and the editorial by Wolfe (2), published recently in Arthritis Care & Research, introducing new diagnostic criteria for the fibromyalgia syndrome. These preliminary diagnostic criteria (including a widespread pain index [WPI] 7 and a symptom severity [SS] scale score of 5, or a WPI of 3–6 and an SS scale score of 9) raise important concerns. First, the new criteria are intended to get rid of the tender point examination introduced in 1990 by the American College of Rheumatology (ACR) (3). Abandoning an intrinsic requirement for physical examination in favor of indices and scales carries the risk of discarding the “laying on of hands” and a careful clinical examination altogether. Indeed, the physician who regards the tender point examination as cumbersome may think the same of a thorough rheumatologic and neurologic examination and limit the clinical encounter to a structured interview. Yet, multifocal pain has a broad differential diagnosis, relying on careful history taking and clinical examination. Also, the tenderness to palpitations in specific anatomic locations lends credibility to the fibromyalgia concept. Moreover, the article clearly shows that the tender point count is the most reliable feature to differentiate fibromyalgia and nonfibromyalgia patients. We do not believe that the 11 of 18 tender points requirement is a sacred threshold or that the patient with widespread pain and 8 tender points should be treated any differently from the patient with 15 tender points. However, by discarding the tender point count, this new definition risks throwing out the baby with the bathwater. Second, the new diagnostic criteria, as opposed to the ACR 1990 classification criteria, implicitly state that fibromyalgia should be a diagnosis of exclusion, without detailing what painful disorders should be ruled out or what tests should be performed for that reason. In contrast, the 1990 classification criteria made no exclusions for the presence of concomitant radiographic or laboratory abnormalities and abandoned the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (3). Third, the control group consisted of patients with noninflammatory painful rheumatic disorders. The proportion of control persons with a fibromyalgia diagnosis increased 4-fold (from 2.0% using the 1990 criteria to 9.1% using the new criteria). One can only wonder how the new criteria will perform in patients with other central or chronic pain disorders, or with neuropsychiatric disorders. For example, many chronic pain patients report multifocal pain and associated nonpain symptoms such as fatigue, unrefreshed sleep, mood disturbance, and cognitive difficulties. In other words, the present preliminary criteria need external validation against other patient groups and outside the rheumatology setting. Otherwise, we risk lumping together many patients with so-called functional somatic syndromes or central hypersensitivity states, as well as chronic pain. Abandoning the tender point count may open Pandora’s Box. Fourth, the mean age (54.6 years) of the fibromyalgia study subjects suggests that many had the label for quite some time. Actually, a fair share of subjects ended up in the “prior fibromyalgia” category. Testing diagnostic criteria in a group with shorter durations of symptoms may be more clinically relevant. Fifth, the authors state that the present preliminary criteria are not meant to replace the ACR 1990 classification criteria. Moreover, many patients entering the present study as fibromyalgia patients were labeled as such not based on the ACR classification criteria, but on the personal judgment of the study physician. The coexistence of several sets of criteria (ACR classification criteria, personal opinion, a WPI of 7 and an SS scale score of 5, or a WPI of 3–6 and an SS scale score of 9) will not enlighten the field. If everyone is free to choose his or her preferred set of criteria, a 20-year journey will continue in the fog.

Treatment of Chronic Fatigue Syndrome: Findings, Principles and Strategies

Chronic fatigue syndrome (CFS) is a debilitating condition characterized by serious medically unexplained mental and physical fatigue. The high prevalence and both direct and indirect health costs of CFS patients represent a huge problem for contemporary health care. Moreover, the prognosis of CFS, even when treated, is often poor. In this paper, we first critically review current evidence based treatments of CFS. Second, we discuss the growing insights into the etiopathogenesis of CFS, and the need to translate and integrate these insights into future treatments. In particular, we formulate a pragmatic and empirically testable treatment approach, tailored to the individual needs of patients, which aims at restoring the mental and physical equilibrium of CFS patients by trying to bring about sustained life style changes.

Self‐Critical Perfectionism Predicts Outcome in Multidisciplinary Treatment for Chronic Pain

Self‐critical perfectionistic personality features have been shown to influence the onset and perpetuation of pain symptoms. However, no study to date has investigated whether these personality features are associated with treatment response in chronic pain.

Self-esteem mediates the relationship between maladaptive perfectionism and depression in chronic fatigue syndrome

Patients with chronic fatigue syndrome (CFS) often experience depression which may negatively affect prognosis and treatment outcome. Research has shown that depression in CFS is associated with maladaptive or self-critical perfectionism. However, currently, little is known about factors that may explain this relationship, but studies in nonclinical samples suggest that low self-esteem may be an important mediator of this relationship. The present study therefore examined whether self-esteem mediated the cross-sectional association between maladaptive perfectionism and severity of depression in 192 patients meeting Centres for Disease Control and Prevention criteria for CFS. Patients completed self-report measures of maladaptive perfectionism, self-esteem, depression, and fatigue. Regression analyses and more direct tests of indirect effects (i.e., the Sobel test and bootstrapping) were used to test for mediation. Congruent with expectations, we found that self-esteem fully mediated the relationship between maladaptive perfectionism and depression in CFS. Findings from this study suggest that self-esteem may explain the link between maladaptive perfectionism and depression in CFS, which may have important implications for the treatment and prevention of depression in these patients.

The growing burden of musculoskeletal pain and the urgent need for early prevention and detection at young age

Musculoskeletal pain (MSP) is a highly prevalent, costly and disabling condition that is associated with increased health care utilization. MSP can have varying symptoms and causes, is a rather ill-defined broad condition describing any pain in the musculoskeletal system and believed to arise from the muscles, ligaments, tendons, bones or joints, mostly in the absence of any serious pathology. The pain can be localized or regional (e.g. low back pain), but the pain can also become more generalized [e.g. chronic widespread pain (CWP), including fibromyalgia]. MSP can be acute or chronic. Chronic low back pain is the most predominant cause of chronic MSP. The estimated prevalence of MSP in the general population ranges broadly from 13.5% up to 47% (Cimmino et al., 2011). The prevalence of CWP ranges between 11% and 24% and appears to be increasing in time. The incidence of chronic MSP is about 8% per year. MSP is a frequent cause of disability, more severe in case of CWP compared with localized conditions and is the main reason of disability in older age. Besides its negative impact on activities of daily life, MSP has also a major impact on work capacity. It is the leading medical cause of long-term sickness absence and the second cause of short-term absence after respiratory disorders. The most important risk factors for MSP are female gender and age with an increasing prevalence up to about 65 years of age. Other risk factors are low education levels, work-related factors such as performing manual work, depression, anxiety, sleep disorders and life style factors, e.g. smoking, overweight and low physical activity (Cimmino et al., 2011). Finally, the grade of physical education in adolescence seems predictive for the prevalence of MSP in adulthood. The paper of Oksanen et al. (2014) in this issue of the journal is timely and adds important epidemiological data on MSP. In this survey, among university students, all weekly musculoskeletal pain symptoms increased significantly from 2000 to 2012. The prevalence of neck-shoulder pain was the highest and also increased the most in time, from 25% in 2000 to 29% in 2012. It occurred more than twice as often compared with low back pain (prevalence of 10% in 2000 and 14% in 2012). Temporomandibular joint pain had the lowest prevalence with rates between 4% and 5%. The percentage of students with musculoskeletal pain at multiple sites also increased over time, but was rather low (2.8% had three different pain symptoms, 0.4% had four different pain symptoms). All pain symptoms were more common in the older age group and in women, with neck-shoulder pain two times more prevalent and temporomandibular joint pain three times more prevalent in women than in men. Despite these interesting findings, still some questions remain unanswered and hopefully future research can help us to find some answers. How can we explain the rather high prevalence of shoulder-neck pain in this sample of students compared with the prevalence of low back, taking into account that former research indicates that low back pain seems one of the most predominant causes of MSP? Computer use could indeed be one of the main reasons. Previous studies in high school as well as in university students have shown a clear association between computer use and the prevalence of neck pain. First of all, high hours of computer use is associated with neck pain. Other risk factors are ergonomic and posture problems, e.g. computer screen position not levelled with the eyes, too high keyboard position. On the contrary, a higher percentage of computer use for entertainment seems to reduce the risk of persistent neck pain possibly due to a more dynamic position during gaming and reduction of mental stress. This paper confirms, as discussed by the authors, once again, the higher prevalence of MSP in women than in men and university students form no exception. Although the rate of pain symptoms at multiple sites in this study is rather low compared with other trials, it also increased over time. Besides further following up this trend and searching for underlying mechanisms, it could also be interesting to look within the group of students if there is an evolution from regional