Trudie Chalder

Development of a fatigue scale

A self-rating scale was developed to measure the severity of fatigue. Two-hundred and seventy-four new registrations on a general practice list completed a 14-item fatigue scale. In addition, 100 consecutive attenders to a general practice completed the fatigue scale and the fatigue item of the revised Clinical Interview Schedule (CIS-R). These were compared by the application of Relative Operating Characteristic (ROC) analysis. Tests of internal consistency and principal components analyses were performed on both sets of data. The scale was found to be both reliable and valid. There was a high degree of internal consistency, and the principal components analysis supported the notion of a two-factor solution (physical and mental fatigue). The validation coefficients for the fatigue scale, using an arbitrary cut off score of 3/4 and the item on the CIS-R were: sensitivity 75.5 and specificity 74.5.

Population based study of fatigue and psychological distress

Abstract Abstract Objectives: To determine the prevalence of fatigue in the general population and the factors associated with fatigue. Design: Postal survey. Setting: Six general practices in southern England. Subjects: 31 651 men and women aged 18-45 years registered with the practices. Main outcome measures: Responses to the 12 item general health questionnaire and a fatigue questionnaire which included self reported measures of duration, severity, and causes of fatigue. Results - 15 283 valid questionnaires were returned, giving a response rate of 48.3%, (64% after adjustment for inaccuracies in the practice registers). 2798 (18.3%) of respondents reported substantial fatigue lasting six months or longer. Fatigue and psychological morbidity were moderately correlated (r=0.62). Women were more likely to complain of fatigue than men, even after adjustment for psychological distress. The commonest cited reasons for fatigue were psychosocial (40% of patients). Of 2798 patients with excessive tiredness, only 38 (1.4%) attributed this to the chronic fatigue syndrome. Conclusion: Fatigue is distributed as a continuous variable in the community and is closely associated with psychological morbidity.

The prevalence and morbidity of chronic fatigue and chronic fatigue syndrome: a prospective primary care study.

OBJECTIVES This study examined the prevalence and public health impact of chronic fatigue and chronic fatigue syndrome in primary care patients in England. METHODS There were 2376 subjects, aged 18 through 45 years. Of 214 subjects who fulfilled criteria for chronic fatigue, 185 (86%) were interviewed in the case-control study. Measures included chronic fatigue, psychological morbidity, depression, anxiety, somatic symptoms, symptoms of chronic fatigue syndrome, functional impairment, and psychiatric disorder. RESULTS The point prevalence of chronic fatigue was 11.3%, falling to 4.1% if comorbid psychological disorders were excluded. The point prevalence of chronic fatigue syndrome was 2.6%, falling to 0.5% if comorbid psychological disorders were excluded. Rates did not vary by social class. After adjustment for psychological disorder, being female was modestly associated with chronic fatigue. Functional impairment was profound and was associated with psychological disorder. CONCLUSIONS Both chronic fatigue and chronic fatigue syndrome are common in primary care patients and represent a considerable public health burden. Selection bias may account for previous suggestions of a link with higher socioeconomic status.

Cognitive-behavioral therapy for psychogenic nonepileptic seizures A pilot RCT

Objective: To compare cognitive-behavioral therapy (CBT) and standard medical care (SMC) as treatments for psychogenic nonepileptic seizures (PNES). Methods: Our randomized controlled trial (RCT) compared CBT with SMC in an outpatient neuropsychiatric setting. Sixty-six PNES patients were randomized to either CBT (plus SMC) or SMC alone, scheduled to occur over 4 months. PNES diagnosis was established by video-EEG telemetry for most patients. Exclusion criteria included comorbid history of epilepsy, <2 PNES/month, and IQ <70. The primary outcome was seizure frequency at end of treatment and at 6-month follow-up. Secondary outcomes included 3 months of seizure freedom at 6-month follow-up, measures of psychosocial functioning, health service use, and employment. Results: In an intention-to-treat analysis, seizure reduction following CBT was superior at treatment end (group × time interaction p < 0.0001; large to medium effect sizes). At follow-up, the CBT group tended to be more likely to have experienced 3 months of seizure freedom (odds ratio 3.125, p = 0.086). Both groups improved in some health service use measures and on the Work and Social Adjustment Scale. Mood and employment status showed no change. Conclusions: Our findings suggest that cognitive-behavioral therapy is more effective than standard medical care alone in reducing seizure frequency in PNES patients. Classification of evidence: This study provides Class III evidence that CBT in addition to SMC, as compared to SMC alone, significantly reduces seizure frequency in patients with PNES (change in median monthly seizure frequency: baseline to 6 months follow-up, CBT group, 12 to 1.5; SMC alone group, 8 to 5).

Cognitive behaviour therapy in chronic fatigue syndrome.

Fifty patients fulfilling operational criteria for the chronic fatigue syndrome (CFS), and who had been ill for a mean of five years, were offered cognitive behaviour therapy in an open trial. Those fulfilling operational criteria for depressive illness were also offered tricyclic antidepressants. The rationale was that a distinction be drawn between factors that precipitate the illness and those that perpetuate it. Among the latter are cognitive factors such as the belief that physical symptoms always imply tissue damage, and behavioural factors such as persistent avoidance of activities associated with an increase in symptoms. Therapy led to substantial improvements in overall disability, fatigue, somatic and psychiatric symptoms. The principal problems encountered were a high refusal rate and difficulties in treating affective disorders. Outcome depended more on the strength of the initial attribution of symptoms to exclusively physical causes, and was not influenced by length of illness. These results suggest that current views on both treatment and prognosis in CFS are unnecessarily pessimistic. It is also suggested that advice currently offered to chronic patients, to avoid physical and mental activity, is counterproductive.

A Randomized Controlled Trial of Cognitive Behavior Therapy for Multiple Sclerosis Fatigue

Background: The purpose of this study was to assess the efficacy of cognitive behavior therapy (CBT) as a treatment for multiple sclerosis (MS) fatigue. Methods: A randomized controlled design was used where 72 patients with MS fatigue were randomly assigned to eight weekly sessions of CBT or relaxation training (RT). RT was designed to control for therapist time and attention. Participants were assessed before and after treatment, and at 3 and 6 months posttreatment. The primary outcome was the Fatigue Scale. Secondary outcomes included measures of stress, mood, and fatigue-related impairment. Results: Analysis was by intention-to-treat. A group by time interaction showed that the CBT group reported significantly greater reductions in fatigue across the 8 months compared with the RT group (p < .02). Calculated effect sizes for fatigue from baseline to the end of treatment were 3.03 [95% confidence interval, 2.22–3.68] for the CBT group and 1.83 [95% confidence interval, 1.26–2.34] for the RT group. Results also indicted that both groups showed clinically significant decreases in fatigue defined as fatigue levels equivalent or less than those reported by a nonfatigued healthy comparison group. There were no significant interactions between group and any of the secondary outcome variables, with both groups showing improvements over time on all measures. Interpretation: Both CBT and RT appear to be clinically effective treatments for fatigue in MS patients, although the effects for CBT are greater than those for RT. Even 6 months after treatment, both treatment groups reported levels of fatigue equivalent to those of the healthy comparison group. MS = multiple sclerosis; CBT = cognitive behavior therapy; RT = relaxation training; RCT = randomized controlled trial; EDSS = expanded disability status scale; HADS = the hospital anxiety and depression scale.

A review of psychological correlates of adjustment in patients with multiple sclerosis

Multiple Sclerosis (MS) is a chronic neurological disease which poses significant psychological adjustment challenges. The purpose of this systematic review was to identify factors that are related to adjustment in people with MS and may be modifiable through psychological intervention. It aimed to gain an overview of the strength of evidence for relationships between psychological factors and adjustment and identify limitations to existing studies and directions for future research. Seventy two studies met inclusion criteria and were included in the review and a narrative synthesis was conducted. A wide range of psychological factors have been studied in relation to adjustment outcomes. The strongest and most consistent finding was that perceived stress and certain emotion-focussed coping strategies are related to worse adjustment in MS. Uncertainty was fairly robustly associated with worse adjustment. There was also more tentative evidence available for relationships between adjustment outcomes and a range of other factors including social support and interactions with others, cognitive errors and biases, illness and symptom cognitions, control perceptions, positive psychology factors, and health behaviours. Implications for therapeutic interventions are discussed and a preliminary model of adjustment to MS is outlined. In light of the shortcomings of extant studies, suggestions for future research are offered.

A Cohort Study of People With Diabetes and Their First Foot Ulcer The role of depression on mortality

OBJECTIVE—The aim was to evaluate over 18 months whether depression was associated with mortality in people with their first foot ulcer. RESEARCH DESIGN AND METHODS—A prospective cohort design was used. Adults with their first diabetic foot ulcer were recruited from foot clinics in southeast London, U.K. At baseline, the Schedules for Clinical Assessment in Neuropsychiatry 2.1 was used to define those who met DSM (Diagnostic and Statistical Manual of Mental Disorders)-IV criteria for minor and major depressive disorders. Potential covariates were age, sex, marital status, socioeconomic status, smoking, antidepressant use, A1C, macro- and microvascular complications, and University of Texas classification–based severity and size of ulcer. The main outcome was mortality 18 months later, and A1C was the secondary outcome. The proportion who had an amputation, had recurrence, and whose ulcer had healed was recorded. RESULTS—A total of 253 people with their first diabetic foot ulcer were recruited. The prevalence of minor and major depressive disorder was 8.1% (n = 21) and 24.1% (n = 61), respectively. There were 40 (15.8%) deaths, 36 (15.5%) amputations, and 99 (43.2%) recurrences. In the adjusted Cox regression analysis, minor and major depressive disorders were associated with an approximately threefold hazard risk for mortality compared with no depression (3.23 [95% CI 1.39–7.51] and 2.73 [1.38–5.40], respectively). There was no association between minor and major depression compared with no depression and A1C (P = 0.86 and P = 0.43, respectively). CONCLUSIONS—One-third of people with their first diabetic foot ulcer suffer from clinical depression, and this is associated with increased mortality.

Postinfectious fatigue: prospective cohort study in primary care

The idea that chronic fatigue has an infectious origin has become popular, but the main evidence for such an association has come from retrospective case-control studies, which are subject to ascertainment bias. We report a prospective study of the outcome of clinically diagnosed infections in patients presenting to UK general practitioners. Questionnaires assessing fatigue and psychiatric morbidity were sent to all patients aged 18-45 years in the study practices. The prevalence of chronic fatigue and chronic fatigue syndrome was then ascertained among 1199 people aged 18-45 who presented to the general practitioners with symptomatic infections and in 1167 people who attended the surgeries for other reasons. 84% were followed up at 6 months. 9.9% of cases and 11.7% of controls reported chronic fatigue (odds ratio 1.0 [95% CI 0.6-1.1]). There were no differences in the proportions who met various criteria for chronic fatigue syndrome. No effect of infection was noted when we excluded subjects who reported fatigue or psychological morbidity at the baseline screening. The strongest independent predictors of postinfectious fatigue were fatigue assessed before presentation with clinical infection (3.0 [1.9-4.7]) and psychological distress before presentation (1.8 [1.2-2.9]) and at presentation with the acute infection (1.8 [1.1-2.8]). There was no effect of sex or social class. Our study shows no evidence that common infective episodes in primary care are related to the onset of chronic fatigue or chronic fatigue syndrome.

Illness beliefs and treatment outcome in chronic fatigue syndrome

Longitudinal studies have shown that physical illness attributions are associated with poor prognosis in chronic fatigue syndrome (CFS). Speculation exists over whether such attributions influence treatment outcome. This study reports the effect of illness beliefs on outcome in a randomized controlled trial of cognitive-behavior therapy versus relaxation. Causal attributions and beliefs about exercise, activity, and rest were recorded before and after treatment in 60 CFS patients recruited to the trial. Physical illness attributions were widespread, did not change with treatment, and were not associated with poor outcome in either the cognitive-behavior therapy group or the control group. Beliefs about avoidance of exercise and activity changed in the cognitive behavior therapy group, but not in the control group. This change was associated with improved outcome. These findings suggest that physical illness attributions are less important in determining outcome (at least in treatment studies) than has been previously thought. In this study, good outcome is associated with change in avoidance behavior, and related beliefs, rather than causal attributions.