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Cognitions, behaviours and co-morbid psychiatric diagnoses in patients with chronic fatigue syndrome

Dolphin

Senior Member
Messages
17,567
Cognitions, behaviours and co-morbid psychiatric diagnoses in patients with chronic fatigue syndrome.

Psychol Med. 2013 Feb;43(2):375-80. doi: 10.1017/S0033291712000979. Epub 2012 May 9.

Cella M, White PD, Sharpe M, Chalder T.

Source
Institute of Psychiatry, King's College London, UK. matteo.cella@kcl.ac.uk

Abstract*

BACKGROUND:

Specific cognitions and behaviours are hypothesized to be important in maintaining chronic fatigue syndrome (CFS).

Previous research has shown that a substantial proportion of CFS patients have co-morbid anxiety and/or depression.

This study aims to measure the prevalence of specific cognitions and behaviours in patients with CFS and to determine their association with co-morbid anxiety or depression disorders.

METHOD:

A total of 640 patients meeting Oxford criteria for CFS were recruited into a treatment trial (i.e. the PACE trial).

Measures analysed were: the Cognitive Behavioural Response Questionnaire, the Chalder Fatigue Scale and the Work and Social Adjustment Scale.

Anxiety and depression diagnoses were from the Structured Clinical Interview for DSM-IV.
Multivariate analysis of variance was used to explore the associations between cognitive-behavioural factors in patients with and without co-morbid anxiety and/or depression.

RESULTS:

Of the total sample, 54% had a diagnosis of CFS and no depression or anxiety disorder, 14% had CFS and one anxiety disorder, 14% had CFS and depressive disorder and 18% had CFS and both depression and anxiety disorders.

Cognitive and behavioural factors were associated with co-morbid diagnoses; however, some of the mean differences between groups were small.

Beliefs about damage and symptom focussing were more frequent in patients with anxiety disorders while embarrassment and behavioural avoidance were more common in patients with depressive disorder.

CONCLUSIONS:

Cognitions and behaviours hypothesized to perpetuate CFS differed in patients with concomitant depression and anxiety.

Cognitive behavioural treatments should be tailored appropriately.

PMID: 22571806 [PubMed - in process]
* I gave each sentence its own paragraph
 

Dolphin

Senior Member
Messages
17,567
I had filed this in my mental filing cabinet as a PACE Trial paper. However, it only deals with baseline data which makes it less interesting for me.

None of the comments in this message or the next message by me are probably that interesting so feel free not to read.

Overview: this paper is purely based on looking at the illness from the viewpoint of a "CBT therapist" and "GET therapist". Like the Lancet paper on the PACE Trial (White et al., 2011), I don't think it references any findings of biological abnormalities anywhere.

Sample quote:
One of the most consistent findings in CFS is a high level of psychiatric co-morbidity, in particular depression and anxiety (Skapinakis et al. 2003).

The results are all about this questionnaire:

Measures Cognitive Behavioural Response Questionnaire (CBRQ)
The CBRQ (Skerrett & Moss-Morris, 2006) is a selfrated questionnaire designed to measure patients’ cognitive and behavioural responses to illness symptoms. From the questionnaire, five cognitive and two behavioural subscales can be derived. Cognitive subscales include symptom focusing, which assesses the attentional bias towards symptoms and fear avoidance, catastrophizing, damaging beliefs and embarrassment avoidance that assess the appraisal and interpretation of symptoms. The two behavioural subscales include all-or-nothing behaviour, assessing the tendency to alternate periods of intense activity with periods of extensive rest, and avoidance/resting, measuring resting and inactivity behaviour resulting from avoidance behaviour. All items are rated on a five-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree’. The scale has been used to assess beliefs in patients with multiple sclerosis (Skerrett & Moss-Morris, 2006) and in patients with CFS (Knudsen et al. 2011).

Skerrett TN, Moss-Morris R (2006). Fatigue and social impairment in multiple sclerosis : the role of patients’ cognitive and behavioral responses to their symptoms. Journal of Psychosomatic Research 61, 587–593.

Knudsen AK, Henderson M, Harvey SB, Chalder T (2011). Long term sickness absence among patients with chronic fatigue syndrome. British Journal of Psychiatry 199, 430–431.
Unfortunately, I don't have access to the questionnaire. Often those who advocate CBT and GET for ME/CFS portray certain beliefs and behaviours as maladaptive, when patients or sympathetic professionals might disagree with this interpretation.
 

Dolphin

Senior Member
Messages
17,567
<Comments part 2 (I know some people might not read very long messages - I sometimes don't)>

Random observation:
patients with a current diagnosis of obsessive compulsive disorder, post-traumatic stress disorder, any type of phobia and generalized anxiety disorder as the CFS anxiety group (CFS-Anx).
Very often in CFS I see simple phobias (e.g. fear of spiders) not being counted as having a psychiatric disorder. Perhaps it is still the case and the SCID with psychotic screen (SCID i/P; First et al. 2002) does make a distinction.

Table 3 shows the results of the multivariate analysis of variance, with WSAS and CFQ scores entered as covariates. WSAS was found to be a significant contributor to all the cognitive and behavioural subscales of the CBRQ except for all-or-nothing behaviour (F values between 10.9 and 53, all p<0.001).
This is probably good. Possibly more papers should do this or look at it. The CFS-Dep and CFS-Anx&Dep had statistically worse scores on both of these (and the CFS-Anx group had intermediate scores) so without these adjustments, one might wonder whether what is being observed is simply severity.

Here are the main results. I've added in bits in green
The model mean differences and 95% confidence intervals are presented in Table 3. Compared with CFS alone, CFS-Anx patients reported more beliefs about damage -1.14 (-1.70 to -0.51) [F(5, 627)=54.9, p<0.0001.] and symptom focusing -2.23 (-3.29 to -1.16) [F(5, 627)=22.1, p<0.0001]. CFS-Dep patients also reported more symptom focusing -3.16 (-4.22 to -2.10) but unlike CFS-Anx patients reported more avoidance behaviour: embarrassment avoidance -3.08 (-4.26 to -1.90) [F(5, 627)=24.7, p<0.0001] and avoidance resting -1.85 (-2.97 to -0.74) [F(5, 627)=22.1, p<0.0001]. Finally, CFS-Anx&Dep patients reported both more symptom focusing -4.18 (-5.1 to -3.21) and catastrophizing cognitions -2.12 (-2.8 to -1.44) [F(5, 627)=19.9, p<0.0001], higher embarrassment avoidance -3.43 (-4.52 to -2.35) and avoidance resting -1.99 (-3.02 to -0.96) [F(5, 627)=17.3, p<0.0001] compared with CFS alone.

(Aside: Apart from two minor (non-significant) differences for CFS (no psych) vs CFS-Anx (Fear avoidance 0.16 (-0.60 to 0.92) and All or nothing: 0.10 (-0.78 to 0.98)), all the other differences were negative i.e. in the same direction as the statistically significant differences).

Final paragraph:
Our findings have some clinical implications. One potentially important clinical consequence of this finding is that longer or different treatment may be required for some patients to address mood- and anxiety-related cognitions as well as those typical of CFS. Whilst modifications of existing CBT treatments may enhance their effectiveness for specific subgroups of patients, such as those with depression or anxiety and CFS, we currently lack empirical evidence to support this. A second clinical implication relates to classification. A long-lasting debate exists among clinicians and researchers about the possibility and value of subclassifying patients with CFS (Wessely & White, 2004). Such subclassification could potentially contribute to improved treatment protocols (Cella et al. 2011b). The results of this study suggest that subdivision on the basis of co-morbid depression and anxiety may be a useful basis for such subclassification.

Not really sure if the paper justifies this fully. Presuming they are talking about CFS-specific CBT (rather than CBT to treat any anxiety or depressive disorders), White et al. (2011) said there was no difference in responses in those with CFS and depression (also no differences with ME (London) which was virtually all those who didn't have a psych diagnosis). If the CBT model was correct, one might expect a difference; what one might argue then is that the lack of difference suggests these factors are not important. Of course, all we're talking about are the chalder fatigue questionnaire and SF-36 Physical functioning scores when ideally one would like information on more objective measures. But then on the 6 minute walking test, CBT flopped, with no difference with the no therapy group (the no therapy group indeed improved a tiny bit more numerically).
 

Sean

Senior Member
Messages
7,378
What they said:

Cognitions and behaviours hypothesized to perpetuate CFS differed in patients with concomitant depression and anxiety.

What they should have said:

Cognitions and behaviours hypothesized to perpetuate CFS were not common in CFS patients, and hence could not possibly explain perpetuation in the vast majority of patients.
 
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13,774
Thanks. Sounded like a paper that may not have had interesting results, but could be interesting for revealing their spin/assumptions. Your points seemed fair too. I've not read a new CFS paper in ages... I've just got a growing list of one's I'd be interested in!

Sean : lol
 
Messages
15,786
Unfortunately, I don't have access to the questionnaire. Often those who advocate CBT and GET for ME/CFS portray certain beliefs and behaviours as maladaptive, when patients or sympathetic professionals might disagree with this interpretation.
The full name of the CBSQ/CBRQ/CBRSQ is "Cognitive Behavioural Response Questionnaire", "Cognitive and Behavioural Responses Questionnaire", or "Cognitive and Behavioural Responses to Symptoms Questionnaire". A related questionnaire also by Moss-Morris (the BRIQ: Behavioural Responses to Illness Questionnaire) seems like it might have some of the same sections and/or be an earlier version of the CBSQ.

The CBRSQ is listed as being "in development" in 2009 and 2010 or later, so it's a very new questionnaire.

The cognitive subscale purports to measure: Fear avoidance, Damage beliefs, Catastrophising, Symptom focusing, and Embarrassment avoidance. The behavior subscale purports to measure: All-or-nothing, and Avoidance/rest (probably corresponding with the first two sections of the BRIQ). Based on the little that can be seen on the BRIQ, someone answering positively to any behavior (doing less OR pushing themselves to do the same amount) is doing something "unhelpful" - there doesn't seem to be any possibility of a normal response to limitations.

http://bjp.rcpsych.org/content/suppl/2011/08/30/bjp.bp.110.082974.DC1/ds82974.pdf has brief descriptions of the categories and one question example per category.

But basically the questionnaire doesn't seem to be available anywhere outside of the group that created it and is using it. So they came up with some questions, don't tell anyone what the questions are, and try to pretend it means something.
 
Messages
15,786
What they should have said:

Cognitions and behaviours hypothesized to perpetuate CFS were not common in CFS patients, and hence could not possibly explain perpetuation in the vast majority of patients.

Also anxiety and depression were diagnosed using an interview with the DSM-IV as a guide - so no specific questions, just the researcher using their highly subjective skills and opinions. Also, the DSM-IV criterion for depression are pretty stupid if you ignore that there is a physical illness. For example, you can deny feeling depressed, but inability to read, watch TV, or socialize are specifically mentioned as indicating depression, as well as insomnia, hypersomnia, mild or severe cognitive problems, feeling weak, and being totally drained after minimal physical activity. Underlying medical conditions can rule out symptoms being attributed to depression, but only if there's proof of the medical condition.

Major Depression with Atypical Features allows for normal mood responses to positive events.

Regarding anxiety, the symptoms in a panic attack are quite similar to POTS or other OI problems, aside from fear of going insane and impending death (well, after the first one anyhow, when we realize we fall over or sit down and life goes on). But as long as it's unexpected, has a fast onset, is not in response to a "real" threat, and you have to change your behavior to avoid the symptoms, then it's a panic attack. Again, only proven medical conditions can provide for an exception to a Panic Disorder diagnosis. Managing to go out with a companion or taking measures to avoid making a scene in public due to an attack also fit in nicely with the definition.

And they could have easily excluded most ME patients from PACE using the somatoform disorder diagnostic guidelines. Physical symptoms + no proof of cause + impact on life = somatoform disorder.