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Abstracts from psychosomatics conference

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From Tom Kindlon's twitter:

http://t.co/LefyLSmJ

European Liaison Psychiatry & Psychosomatics June '12 conference abstracts

Here are some of the ones I picked out. I tried to keep the CFS specific ones at the top. Then some general ones, a patch related to the new DSM, and then a few I picked out because of my own interests.


White P
Queen Mary University London
Non-pharmacological management of chronic fatigue syndrome: Efficacy, cost-effectiveness and
economic outcomes in the PACE trial
Objective: To compare the effectiveness, cost-effectiveness, and safety of non-pharmacological
interventions for secondary care patients with chronic fatigue syndrome (CFS).
Methods: 640 patients attending UK secondary care clinics with CFS were recruited into a randomised controlled trial of non-pharmacological treatments. The treatments were adaptive pacing therapy (APT), cognitive behaviour therapy (CBT), or graded exercise therapy (GET), all added to specialist medical care (SMC), and SMC alone. Primary outcomes were the Chalder fatigue questionnaire and the SF36 physical function sub-scale, both being self-rated. Secondary outcomes included adverse events, a global measure of improvement, overall disability, sleep and mood measures, individual symptoms of CFS, and a walking test.
Results: We found that CBT and GET were more effective than APT and SMC. All treatments had similar numbers of adverse events, and there were very few serious adverse reactions. This pattern of results occurred however we defined CFS and whether or not participants also had a depressive episode. Furthermore, CBT was the most cost-effective treatment, while GET was more cost-effective than APT and SMC.
Conclusions: These results support individually delivered CBT and GET as moderately effective, costeffective, and safe treatments for CFS. They imply that testing the limits of the illness is more effective than staying within them.

White P
Queen Mary University London
Psychiatric disorders are neither of the mind or the brain, but of both: Isn't it time the ICD
acknowledged this?
Mental and neurological conditions are classified in different chapters of diagnostic manuals. This dualistic approach is inconsistent with current scientific understanding of disorders of the brain, and fails to acknowledge the frequent co-occurrence of mental and physical symptoms. This presentation will briefly review the evidence that psychiatric conditions have a neurological basis, while neurological conditions typically have psychological aspects. We propose that psychiatric and neurological disease classifications should merge, with benefits for both the conceptualisation and the management of disorders of mind and brain.


Knoop H
Expert centre for chronic fatigue, Radboud University Nijmegen Medical Centre, The Netherlands
Mediators of change in cognitive behaviour therapy for chronic fatigue syndrome
Objective: Cognitive behaviour therapy (CBT) can significantly reduce fatigue in chronic fatigue syndrome (CFS), but little is known about the process of change during CBT. Based on a recently formulated treatment model, we examined how changes in cognitions and behaviour lead to a decrease in fatigue during CBT. The process of change during CBT for CFS was studied in a large sample of CFS patients.
Methods: We included 183 patients who started CBT. All patients met CDC criteria for CFS and were between 18 and 65 years. We measured fatigue and possible process variables before start of treatment, after 6, 12 and 18 weeks and at the end of treatment. Selected process variables were self-efficacy with respect to fatigue, focusing on fatigue, self-reported physical functioning, perceived physical activity and physical activity assessed with actigraphy. A structural equation model was built, explaining changes in fatigue during therapy by changes in the process variables.
Results: The structural equation model indicated that increases in self-efficacy, perceived activity and selfreported physical functioning, as well as decreases in focusing on fatigue were associated with a decrease in fatigue during CBT for CFS. An increase in actual physical activity was not associated with a reduction of fatigue.
Conclusions: Changes in cognitions about fatigue and activity are related to the decrease in fatigue during CBT for CFS. The pattern of change varied considerably between patients, but changes in process variables and fatigue occurred mostly in the same period.
Wiborg J
Radboud University Nijmegen Medical Centre
Therapist effects and the dissemination of cognitive behaviour therapy for chronic fatigue
syndrome in community-based mental health care
Objective: A recent study showed that therapists of a specialised treatment unit were equally effective in delivering manualised cognitive behaviour therapy (CBT) for chronic fatigue syndrome (CFS). We examined the role of the therapist in the dissemination of manualised CBT for CFS outside specialised treatment settings.
Methods: We used the routinely collected outcome data of three community-based mental health care centres (MHCs) which implemented and sustained CBT for CFS. All therapists received the same training in CBT for CFS.
Results: Random effects modelling revealed a significant difference in mean post-treatment fatigue
between therapists. This effect could be explained by the therapists' attitude towards treatment manuals. In particular, the belief that treatment manuals threaten the freedom and flexibility of therapists predicted less effective treatments. Yet, we also found that less favourable attitudes and less effective treatments were augmented within one treatment setting which implemented CBT for CFS in the context of a stepped care approach. This finding may tell us that therapists with less positive attitudes towards treatment manuals tend to work in settings that tolerate or facilitate these attitudes. However, due to the small sample size of MHCs we cannot preclude that our findings may also be a consequence of the specific implementation scenario in which the attitude of the therapist does not play a vital role.
Conclusion: Our findings suggest that the therapy context in which patients receive CBT for CFS might play an important role in the accomplishment of established therapy effects outside specialised treatment settings.

Hotopf M
King's College London, Institute of Psychiatry
Risk factors for chronic fatigue syndrome in 3 birth cohorts. Making sense of contradictory data
The presentation will describe results from analyses on three of the British birth cohorts with self-reported chronic fatigue syndrome/ME as the outcome. These cohorts are large, population based studies which have followed individuals from birth to the present time with varying numbers of assessments. Data from the MRC National Survey of Health and Development (1946 birth cohort); the Child Development Study (1958 birth cohort) and the British Cohort Study (1970 birth cohort), will be presented. The presentation will describe commonalities in the results between these three cohorts (most notably a consistent association between prior psychiatric morbidity and CFS) as well as apparent contradictions (most notably the inconsistent findings we have reported on previous exercise and CFS). The methodological causes of contradictory results in birth cohorts will be explored.


Morriss R
Mental Health Faculty of Medicine & Health Sciences, University of Nottingham, UK
Involving nurses in treatment of MUS, experience of the FINE trial
No abstracts


Morriss R
Mental Health Faculty of Medicine & Health Sciences, University of Nottingham, UK
Targeting frequent attenders in primary care
No abstract



De Gucht V
Clinical and Health Psychology, Leiden University, Leiden, the Netherlands
Illness perceptions and behaviour at baseline predict fatigue, physical symptoms and depression
in Chronic Fatigue Syndrome at one-year follow-up
Objective: To examine the impact of illness perceptions and illness behaviour at baseline (T1) on fatigue, medically unexplained physical symptoms (MUPS) and depression at one-year follow-up (T2) in patients with Chronic Fatigue Syndrome (CFS).
Methods: Members of a CFS patient support group filled out questionnaires at T1 and T2. A total number of 214 patients participated at T1; 144 patients also participated at T2. Illness perceptions were measured with the IPQ-Brief, illness behaviours with the BRIQ, fatigue with the CIS-20, MUPS with the PHQ-15, and depression with the BSI. Hierarchical regression analyses were conducted with age and gender, duration of CFS, illness perceptions and illness behaviour at T1 as predictors.
Results: The regression model explained 41, 21 and 37% of the variance in fatigue, MUPS and depression at T2, respectively. Female gender ( =0.24, p<0.01), perceived personal control over CFS ( =0.20, p<0.05) and all-or-nothing behaviour ( =0.21, p<0.01) at T1 predicted fatigue at T2. Perceived severity of CFS (=0.35, p<0.01) and all-or-nothing behaviour at T1 ( =0.24, p<0.05) predicted MUPS at T2. Depression at T2 was predicted by the perceived emotional consequences of CFS ( =0.44, p<001) and all-or-nothing behaviour ( =0.20, p<0.05) at T1.
Conclusions: All-or-nothing behaviour at baseline significantly predicts fatigue, somatic symptoms and depression one year later. With respect to illness perceptions, there seems to be a differential pattern of associations depending upon the outcome. Future (intervention) studies should explore whether changes in all-or-nothing behaviour and changes in specific illness perceptions lead to changes in physical and psychological symptoms in CFS patients.


Greco M
Goldsmiths College, University of London
Psychosomatic medicine - What role for social scientists?
This position paper addresses the performative dimension of social scientific research in psychosomatic medicine. The 'performative' here refers to the way in which social scientific research actively participates and contributes to the dynamics of interactions between different stakeholders in psychosomatic medicine. The last decade has seen a significant expansion of social scientific research on diagnoses such as ME/CFS, fibromyalgia and IBS, as well as undiagnosed or 'unexplained' symptoms. This body of work has amply documented the psychological and social suffering that stems from experiences of delegitimation associated with diagnoses perceived as problematic and unsatisfying, or indeed with the lack of a diagnosis.
By and large this research has developed in parallel, rather than in dialogue with medical debates. For example there is little explicit recognition of, and even less engagement with, the ways in which problems of diagnostic classification and nomenclature are debated within the medical profession. Instead, social scientists have used alternative terminologies and concepts - such as 'contested' or 'uncertain' illness - to frame their research and analyses. This reflects deliberate and justifiable methodological strategies, and a specific understanding of the division of labour between disciplines.
I will argue that, while this approach has made a positive contribution in enabling forms of recognition and discussion that were previously unavailable, it has also contributed to a polarization of the discursive positions of 'doctor' and 'patient' and to the potential conflict between them. In conclusion, I shall discuss some implications of this analysis for social science research agendas in relation to functional syndromes and symptoms .

Graham C
1 Department of Health Psychology, Institute of Psychiatry King's College London, London, United
Kingdom.
A mixed methods approach to intervention development: characterizing helpful illness schemata in
people with muscle disease
Objective: Muscle diseases (MD) cause an insidious decline in mobility and are currently untreatable.
People with MD experience reduced quality of life (QoL) and mood. Illness perceptions are better
predictors of QoL and mood than the functional impairment caused by muscle symptoms. This suggests that a psychological intervention targeted at illness perceptions could improve QoL and mood even as the disease progresses. Yet, to our knowledge, there have been no reported psychological interventions applied to muscle disease groups. To inform a future intervention, we aimed to describe and compare beneficial and unhelpful illness schemata.
Methods: A cluster analysis of Illness Perception Questionnaire data from 217 people with MD was
performed and clusters associated with better or worse QoL and mood established. Functional impairment was used to control for between-cluster differences in QoL and mood. A qualitative investigation of illness perceptions was then undertaken using cognitive interviewing.
Results: Three clusters emerged, of which two did not differ in functional impairment but reported widely different QoL and mood. The cluster associated with better outcomes held comparatively more realistic perceptions of timeline, better coherence, a smaller range of symptoms and a weaker emotional representation. There was a strong correlation between consequences and emotional representation in the cluster associated with poorer outcomes. The qualitative analysis observed that those in the cluster associated with poorer outcomes tended to compare themselves to others or their past selves, held a negative view of dependence and reported embarrassment at their appearance.
Conclusion: The results suggest that an intervention seeking to promote the illness schema associated with better outcomes should embed this schema within a wider acceptance-based intervention.





Mindfulness training for patients with medically unexplained symptoms in primary care, an RCT
Objective: To assess the effects of mindfulness training on the quality of life of patients with medically unexplained symptoms.
Methods: A randomized controlled study with frequently attending primary care patients. Patients were eligible if they met the criteria of the undifferentiated somatoform disorder. Patients were randomized to mindfulness training or usual care. Follow-up took place at three and 12 months. Primary outcome was the health related quality of life on EQ-5D and SF-36. In-depth interviews were used to further examine the working mechanism of mindfulness training.
Results:125 patients participated. Physical health measures did not differ between the mindfulness and usual care condition at 3 months. At 12 months the results were inconsistent, there were no differences in physical health (SF-36) and health in the past week (EQ-5D visual analogue scale), but the EQ-5D index score was lower in the mindfulness condition than in the usual care condition. However, mental health did improve in the mindfulness condition at 3 months, mostly due to increases in vitality and social functioning, at 12 months the mindfulness and the usual care condition both improved on mental health.
Conclusions: Mindfulness training was feasible for patients with persistent medically unexplained
symptoms. Although physical health did not improve, mental health significantly improved after the
mindfulness training in patients with persistent medically unexplained symptoms.


Fjorback L
Aarhus University Hospital, Research Clinic for Functional Disorders and Psychosomatics
Mindfulness Therapy for Bodily Distress Syndrome - randomized trial, one-year follow-up, active
control
Objective: To conduct a feasibility and efficacy trial of mindfulness therapy in somatization disorder and functional somatic syndromes such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome, defined as bodily distress syndrome (BDS).
Methods: We randomized 119 patients to either mindfulness therapy (mindfulness-based stress reduction and cognitive behavioural therapy for BDS) or to an active control group receiving specialized treatment (short-term psychotherapy and specialist medical care). The primary outcome measure was physical health (SF-36 Physical Component Summary at 15-month follow-up).
Results: The majority of patients were women out of work without an education; 91% reported high patient satisfaction. In the mindfulness group, 88% completed treatment, 92% reported that they were meditating at the end of treatment. Both groups registered significant improvements over time. In the mindfulness therapy group, improvement in physical health was obtained towards the end of treatment and it remained present at 15-month follow-up, whereas the specialized treatment group achieved no change until 15- month follow-up. The change scores averaged half the standard deviation which amounts to a clinically significant change, 29% changed 1 standard deviation. Significant between-group differences were observed at treatment cessation.
Conclusion: Our findings suggest that even a socially marginalized population with chronic bodily distress is willing to participate and engage in a treatment that requires a high level of patient involvement. Clinically important changes in physical health were obtained.



Fjorback L
Aarhus University Hospital, Research Clinic for Functional Disorders and Psychosomatics
Mindfulness Therapy for Bodily Distress Syndrome: Economic evaluation alongside a randomized
trial
Objective: To evaluate economic and social effectiveness of mindfulness therapy compared with
specialized treatment for patients with somatization disorder and functional somatic syndromes such as fibromyalgia and chronic fatigue syndrome, defined as bodily distress syndrome (BDS).
Methods: A total of 119 BDS patients were randomized to mindfulness therapy or specialized treatment and compared with 5950 matched controls. Register data were analysed from 10 years before their inclusion to 15-month follow-up. Main outcome measures are disability pension at the 15-months follow-up and reduction in total health care costs. Unemployment and sickness benefit prior to inclusion was tested as possible risk factors.
Results: At the 15-month follow-up 25% from the mindfulness therapy group received disability pension compared with 45% from the specialized treatment group (p=0.025). Total health care utilization was reduced over time in both groups from the year before inclusion (mean $ 5325, median $ 2971) to the year after inclusion (mean $ 3644, median $ 1593). This overall decline was seen in spite of elevated costs due to assessment and mindfulness therapy or specialized treatment (p=0.0001). BDS patients accumulated significantly more weeks of unemployment and sickness benefit 5 and 10 years before inclusion (p<0.0001) than population controls.
Conclusions: Mindfulness therapy may prevent disability pension and it may have a potential to
significantly reduce societal costs and increase effectiveness of care. Accumulated weeks of
unemployment and sickness benefit are possible risk factors for BDS.


Burton C
University of Edinburgh
EVA – introducing a new model
Conventional approaches to MUS have generally taken three approaches: rule out disease and reassure; embrace uncertainty; or reattribution and reframing. Each of these has major limitations – reassurance can create dependency, uncertainty is particularly difficult for patients with anxiety disorders (and for some doctors) and reattribution and similar approaches run into problems with psychosomatic causality which is often inappropriate and is commonly resisted by patients.
This presentation introduces a new approach which can be adapted to a wide range of physical symptoms – whether “medically explained” or not. It comprises three components: Explanation – in terms of mechanisms rather than causes; Validation – of the individual as a person with a track record of capability and resourcefulness; and Activation – to promote specific behaviours. This triad is built on a foundation of empathy but extends it in specific ways.
The presentation will discuss the evolution of the EVA approach and its relationship to the “ideal
consultation” and factors known to promote the non-specific therapeutic effect (which underpins placebo).
It will briefly describe its use in an intermediate care “Symptoms Clinic” and in routine GP consultations, and will introduce a potential framework for measurement.

Rosmalen J
University Medical Center Groningen, The Netherlands
Methodological problems in case-control studies towards functional somatic syndromes
The field of functional somatic syndromes is largely composed of case-control studies. The objective of this talk is to give an overview of methodological problems that are associated with the use of case control studies in this field of research. The main problem concerns the validity of the diagnostic criteria of functional syndromes, which are based on expert consensus rather than on empirical data.
Using data from a longitudinal population-based study, I will illustrate the problems associated with casecontrols studies towards functional somatic syndromes.
First, only a minority of participants experiencing functional somatic symptoms receive a syndrome label, suggesting that we are studying labeling instead of existence of symptoms. I will present data showing that higher intelligence, number of symptoms, and female gender increase the risk of syndrome labeling in persons with persistent functional somatic symptoms. Second, the diagnostic criteria of the syndromes include different temporal thresholds, suggesting that differences between syndromes might be due to chronicity differences rather than to symptom differences. Third, the selection of controls is equally problematic as the selection of cases, since the symptoms that characterize functional syndromes are prevalent in the population.
Future studies need to be longitudinal population-based studies, in order to unravel the complex etiology of functional somatic syndromes. It is important to add measures of functional somatic symptoms and syndromes to biobanks.

Jørgensen T
Research Centre for Prevention and Health
The way functional somatic syndromes are delimitated needs revision. An example from irritable
bowel syndrome
Objectives: Functional diseases are inconsistently defined in literature, maybe due to different traditions in different medical fields. This will impede any attempt to reach a consensus as regard frequency of the syndromes and identification of consistent risk factors. The aim of this presentation is to evaluate the consistency of various definition of irritable bowel syndrome.
Methods: By means of a questionnaire concerning abdominal symptoms, persons were categorized as having IBS according to five definitions published in the international literature: Two positive Manning criteria; the Rome criteria; a consensus report by Drossman; a definition by Talley; and a definition by Kay.

Rief W
Department of Psychology, University of Marburg
The relevance of placebo effects in clinical trials
There is strong evidence that placebo effects in clinical trials are different from placebo effects in routine clinical care. Experimental data will be presented confirming this assumption, and implications for the planning of clinical trials will be outlined. Methods: Pain thresholds were assessed before and after receiving a novel application form of an analgesic (nasal spray), which in fact was a placebo. After randomization, 144 participants received the information to be a) in the placebo group (0%), b) in the drug group (100%), or c) in a 50% chance group to receive the pain killer. We also manipulated whether the placebo was either passive (no symptoms), or active (mimicking side effects). Results: Placebos inducing side effects stimulate more analgesia, especially in the 50% chance group. Conclusion: Blinded conditions provoke less placebo effects than open conditions in clinical treatments. Differences between side effect in
drug versus placebo treatments significantly influence outcome. Therefore new designs are warranted to analyze unspecific effects of clinical treatments. It will be also outlined how clinical trials should be designed to better reflect what is possible in clinical practice. Future designs should optimize expectation and conditioning effects, instead of trying to eliminate these non-specific treatment effects.

Vase L
Department of Psychology, Aarhus University
Placebo and nocebo effect in chronic pain conditions
Objective: Several studies have shown that placebo analgesia effects can be obtained in healthy
volunteers and in chronic pain conditions such as irritable bowel syndrome. However, it is unknown
whether placebo analgesia effects can be elicited in chronic pain conditions with a known pathophysiology such as a nerve injury.
Method: Patients who had developed neuropathic pain following thoracotomy were exposed to a placebo and nocebo manipulation where they received open and hidden administrations of treatments along with verbal suggestions. Prior to the treatments, patients rated expected pain levels, completed psychological questionnaires on emotional feelings and went through quantitative sensory testing of hypersensitivity.
Results: The placebo and nocebo manipulation influenced the expressions of hypersensitivity and these changes were related to changes in psychological variables, especially low levels of negative affect.
Conclusion: Placebo and nocebo effects can be obtained in chronic pain conditions with a known
pathophysiology. Possible differences and similarities between placebo effects in relation to healthy volunteers and chronic pain patients are discussed and clinical implications are outlined.


Frost Ebstrup J
Research Centre for Prevention and Health, Glostrup
Causal web of determinants for functional somatic syndromes: The role of mental fitness, pain
perception, and the autonomic nervous system.
Due to lack of large scale population based longitudinal studies dealing with functional somatic syndromes (FSS), a large scale (N=10.000) epidemiological population-based study was initiated in Denmark. One of the aims of the study is to identify risk factors to FSS with special focus on psychological factors (e.g. mental health, life events, illness perception), pain perception, and function of the autonomic nervous system.
In planning this population study it was decided to put the various determinants into a theoretical frame, which is important when dealing with many risk factors, which are mutually dependent. This is in line with research done for other chronic diseases (e.g. heart disease). In FSS a special problem is the psychological or mental factors, which sometimes are dealt with as part of the syndrome, sometimes as risk factors for the syndrome and sometime as a consequence of the syndrome. The literature do provide us with indications of mental factors as important risk-factors and predictors of FSS, but the mechanisms of these associations are still unclear.
In order to link multiple determinants for FSS in a causal web focusing on psychosocial factors, the
complex interplay between mind and body have to be further investigated. A working theory of preconditional factors (e.g. genes, intelligence, personality) influencing intermediate factors of affective and behavioural nature which again influence outcome factors (e.g. first bodily markers and later illness) is the core when constructing a simplified mind-body model. The ongoing work with constructing this mind-body model as a theoretical frame for the future bio statistical analyses of the interplay of the "mental fitness" component, pain perception, function of the autonomic nervous system and FSS will be exposed.

Heim C
Institute for Medical Psychology, Charité University Medicine Berlin, Berlin, Germany
Neurobiology of Early Life Adversity: Relevance for Functional Disorders
Childhood trauma is a major risk factor for developing a wide range of psychiatric disorders and certain medical diseases later in life. Our research suggests that childhood trauma in humans is associated with sensitization of the neuroendocrine stress response, glucocorticoid resistance, increased central corticotropin-releasing factor (CRF) and decreased oxytocin activity, immune activation, and reduced hippocampal volume, closely paralleling core features of depression. Neurobiological changes secondary to early life adversity likely reflect risk to develop depression in response to additional stresses. Changes in a connected neural circuitry implicated in emotional, neuroendocrine and autonomic control may contribute to this vulnerability. Similar associations may apply to a spectrum of functional somatic and medical disorders that frequently coincide with depression and are aggravated by stress. This research may ultimately enable optimized clinical care, by directly targeting neurobiological pathways implicated in the link between childhood trauma and adult adverse health outcomes.

M Rosenkrantz
Lab for Affective Neuroscience / Center for Investigating Healthy Minds, University of Wisconsin,
Madsison, USA
The interrelatedness of inflammatory processes and neural response to stress is deeply rooted and highly conserved in evolutionary development. The high degree of conservation suggests that this relationship is adaptive. While these associations are advantageous for most life forms, humans today typically face stressors or threats that do not benefit from prophylactic inflammation. This mismatch is likely one factor that contributes to the rapidly increasing prevalence of chronic inflammatory disease. Likewise, ongoing inflammation may signal continuous threat and lead to chronic activation of stress- and emotion-related neural circuitry, potentially contributing to the overrepresentation of mood and anxiety disorders in populations of individuals with chronic inflammatory diseases. Despite the well-established links between inflammation and psychological factors, little is known about the involvement of emotional neural circuitry in the response to and regulation of peripheral inflammation during inflammatory disease, or about the mechanisms through which this reciprocal modulation is accomplished in humans. Our research uses experimentally-induced inflammation and manipulation of activity in affective neural circuitry to begin to understand how these neural circuits may respond to and participate in the development and regulation of inflammation in the body. The research I will discuss includes neuroimaging experiments in which allergic asthma was used as a model to investigate which neural pathways may be involved in the perception of disease-related cognitive and physiological information and whether the reactivity of these pathways predicts subsequent symptom severity. In addition, I will discuss evidence that behavioral interventions, such as mindfulness-based stress reduction, may be of benefit in buffering the effects of stress on inflammation.


Bodily Distress Syndrome: A new diagnosis for functional disorders in primary care
Aim: Medically unexplained or functional symptoms and disorders are common in primary care. Empirical research has proposed specific criteria for a new unifying diagnosis for functional disorders and syndromes: Bodily Distress Syndrome (BDS). This new concept is expected to be integrated into the upcoming versions of classification systems. The objective of this study is to investigate the concept of BDS in a primary care population, to estimate the prevalence, and to describe the characteristics of patients with BDS.
Method: We recruited a cohort of 4795 patients of 18+ years from the Central Denmark Region from December 2008 until December 2009 as part of a study on reasons for encounter and disease patterns in general practice (Kontakt- og Sygdomsmønster i almen praksis - KOS). A total of 404 general practitioners (GPs) included all patients consecutively for one day (randomly assigned). Besides reason for encounter and diagnoses, the GPs reported a range of issues concerning the content of the contact. Patients in the cohort were assessed with a number of measures in addition to the BDS check list; self evaluated health, mental health, health anxiety, smoking habits, alcohol dependency and social network.
Results: We will present data, based on confirmatory factor analysis, of the symptom patterns of BDS along with data on the prevalence of BDS in a primary care population and the characteristics of patients with BDS.
Conclusion: Results from this study will make precise and moreover clinically relevant contributions to the development of a diagnostic classification which is currently inadequate for primary care patients. This may ultimately help GPs diagnose patients with functional disorders and contribute to improved management.

Nagel A
Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-
Eppendorf & Schön Klinik Hamburg-Eilbek, Germany , Voigt K Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg- Eppendorf & Schön Klinik Hamburg-Eilbek, Germany Diagnostic validity of Complex Somatic Symptom Disorder: Which combination of psychological criteria is best suited for DSM-5?
Objective: The diagnostic category of somatoform disorders is currently under revision for DSM-5 and ICD-11. A variety of psychological characteristics have been suggested as diagnostic criteria. Whether the currently proposed criteria (1. health-related anxiety, 2. concerns about the medical seriousness of symptoms, and 3. excessive time and energy devoted to these concerns; http://www.dsm5.org) are the optimal combination of psychological symptoms to enhance incremental and predictive validity for the diagnosis of Complex Somatic Symptom Disorder" remains unclear. Given that the diagnostic criterion of somatic symptoms will no longer be limited to medically unexplained symptoms, the role of valid psychological symptoms appears to be all the more important.
Methods: In a sample of N = 457 psychosomatic in-patients (59% female, mean age=44.8 yrs) diagnosed with somatoform disorders, anxiety disorders, and depressive disorders (diagnosed by SCID-I) we investigated a wide variety of potential psychological diagnostic criteria by self-report questionnaires as well as somatic symptom severity and health-related quality of life at the time of admission, discharge, and 12 months after admission.
Results: Results regarding the following aspects will be reported: Predictive and incremental validity of the current diagnostic draft vs. the DSM-IV diagnosis


Martin A
University Hospital Erlangen, Psychosomatic Medicine and Psychotherapy
The relevance of psychological features for the classification of somatic syndromes
Objective: It is unclear whether psychological criteria such as health anxiety, catastrophising, symptom focusing or avoidance behavior should be included in the classification of somatic syndromes (e.g., somatoform disorders). If somatic syndromes are defined as psychiatric disorders, the definition of psychological features seems necessary. However, mere symptom counts would be easier to apply for classification. Therefore we investigated the role of psychological features in the definition of somatic syndromes.
Methods: A general population sample of 324 participants was investigated at baseline and one year later. A structured interview asked for all symptoms of somatization disorder, and of associated conditions like fibromyalgia, chronic fatigue and IBS. Additional psychometric scales were used to assess health care use, disability and other variables.
Results: Psychological features are crucial for the definition of samples with somatic symptoms that need medical care, and/or report increased disability. Somatic symptoms alone without pre-existing
psychological features did not lead to health care use or clinically relevant disability. Comparing proposals for the re-definition of somatoform disorders, CSSD (DSM-5 proposal) and other suggestions including psychological features are better in the distinction between highly disabled and low disabled people with somatic symptoms. One-year stability scores underline the validity of the new proposals.
Conclusions: For those somatic syndromes that should be included in DSM-5 or other psychiatric
classification systems, the inclusion of psychological features is warranted. Some of the new proposals still suffer from over-excluding of affected people. A special emphasis will be given to the discussion of the new CSSD proposal.





I find some of the whiplash stuff interesting, particularly in the social context of the current legislative changes that insurance companies are pushing for in the UK:


Kasch H
The Headache Clinic and Danish Pain Research Center, Dept of Neurology, Aarhus University Hospital,
Denmark
The clinical examination for outcome predictors of whiplash
We want to introduce a new grading system for whiplash injuries, including VAS scale for pain and
headache,number-of-nonpainful neurological complaints and grading also of active neck mobility obtained at first visit.The de facto standard in more recent literature rules out WAD grade 0 and WAD grade IV from being whiplash injuries. However, the application of the WAD grading system in the range from I-III has shown limitation as a tool for predicting the transition towards chronicity. It makes sense from a clinical point of view to segregate patients exposed to whiplash injuries into differentrisk strata based on early findings. We did two studies on this.
Firstly, we performed a 1-year observational study of 141 acute whiplash patients (WAD grade I-III) and 40 gender and age matched acute non-sport ankle sprain patients. The two patient groups had similar disability and global pain within first week after injury, however only in the whiplash patient group nonrecovery was encountered. Neurological examination was done at first visit. Semi-structured interviews were performed at all examination points after 1 week, 1 month, 3, 6, and 12 months after injury.
Questionnaires were: The McGill Pain Questionnaire, the Danish version, The Millon Behavioral Health
Inventory, SCL-90R, The Copenhagen Neck Functional Disability Scale. In this study we were interested in the importance of sensitization of the nociceptive system as a mechanism for non-recovery. In a prospective setting, therefore we examined the development of the functioning of the DNIC system in a coldpressor test (diffuse noxious inhibitory control system. We observed the development of remote and regional pain by means of pressure algometry and methodical palpation technique in whiplash and controls. We measured active neck mobility (CROM test, and measured maximal voluntary contraction and duration for neck flexion and neck extension.
Secondly we performed a multi-centre interventional randomized trial of acute whiplash patients
segregated into high and low risk strata based on risk factors derived from the former observational study [6; 9]. Derived risk-factors were: intense neck pain or headache, multiple non-painful symptoms and reduced active neck mobility from early after injury (< 1 week).
These factors were used for an algorithm in order to classify patients in the treatment study into either a low risk group or a high risk group, with following different treatment options obtained by means of randomization (Block randomization, Minimize ®). It was shown in study two when dividing the patients by above risk parameters (neck mobility, VAS headache, VAS neck pain, and number of non-painful complaints, but also based on other study reports applying a gender risk score) that high risk patients had a ten-fold risk of work disability after 1 year (Kasch et al Eur J Neurology 2008). These factors do not reveal the background for chronic disability after whiplash injury, but rather allude to the multi-facetted nature of disability in WAD.
(The rest of the astract can be sent upon request).

Carstensen T
Aarhus University Hospital, The Research Clinic for Functional Disorders and Psychosomatics
Sick leave before acute whiplash trauma predicts course of recovery
Background: Little is known about transfer income before whiplash trauma, and the potential predictive value on recovery after a whiplash trauma has not been explored.
AIMS: To explore if persons exposed to whiplash trauma experience more negative change in healthrelated provisional situation than a matched control group and if transfer benefits received before the accident predict poor recovery one year following collision.
Methods: 719 patients with acute whiplash trauma were recruited from emergency departments or general practitioners after car accidents in Denmark and completed questionnaires on socio-demographic-, collision-, and health characteristics. After 12 months a VAS scale on neck pain intensity was completed.
Matched controls in the general population were sampled and register data on public transfer benefits were obtained for patients and controls from date of accident, 15 months ahead, and 5 years back in time.
Results: Whiplash-exposure increased the odds for negative change in provisional situation one year after the accident (OR (95% CI) = 3.2 (2.3; 4.4). Odds for negative change in future provisional situation increased when receiving sickness benefit before the collision: 1-18 weeks (OR (95% CI) = 2.3 (1.5; 3.6) and >18 weeks of sickness benefit (OR (95% CI) = 5.7 (3.8; 8.7). Moreover, pre-collision >8 weeks of social assistance (OR (95% CI) = 2.5 (1.6; 4.0) and >62 weeks of unemployment benefit (OR (95% CI) = 1.9 (1.3; 3.0) increased negative change in future provisional situation. Furthermore, >18 weeks of sickness benefit pre-collision increased odds for future considerable neck pain (OR (95% CI) = 4.6 (2.3; 9.2).
Conclusions: Being unemployed, sick-listed, or receiving social assistance pre-accident was associated with prolonged recovery. Findings suggest multifactoral vulnerability before the accident to be predisposing for persistent pain triggered by the whiplash trauma.


Andersen T
University Of Southern Denmark
Psychological factors predictive of persistent pain after whiplash injury - A longitudinal study.
Objective: High initial pain and disability are indicators of a poor prognosis after whiplash injury. However, results regarding psychological factors are mainly inconclusive. The fear-avoidance model emphasises the importance of pain catastrophizing and fear-avoidance beliefs in the transition from acute to chronic pain.
Moreover, attachment insecurity and posttraumatic stress disorder (PTSD) symptoms have been
highlighted as risk factors. The aim of the present study was to test the predictive value of the fearavoidance model. In addition, we wanted to test whether attachment insecurity and PTSD symptoms add significantly predictive value to the model in predicting the development of chronic pain after whiplash injury. Methods: Using a longitudinal cohort design, consecutive patients from the emergency ward were all contacted by post within three weeks after their whiplash injury (N=528). Follow up questionnaires were sent three and six months post-injury. Results: Six months post injury, 20.4% had moderate to severe pain.
A high prevalence of PTSD (29.7%) was found in the moderate to severe pain group at all time points. At baseline, the best predictors for level of pain at 6-months follow up were, a prior chronic pain condition, PTSD symptoms, pain catastrophizing, and fear-avoidance beliefs. The association between PTSD symptoms and pain were fully mediated by pain catastrophizing and fear-avoidance beliefs. At three months follow-up, the model explained about 65% of the variance in pain at 6-months follow up.
Conclusions: The results indicate that early prevention of persistent pain could be initiated within the first three months after the whiplash injury for those presenting with high levels of attachment insecurity, pain catastrophizing, fear-avoidance beliefs, and symptoms of PTSD.


Stålnacke B
Department of Community Medicine and Rehabilitation, Umeå University, Sweden
Whiplash injury and concussion - similarities and differences
Whiplash injuries and concussion (mild traumatic brain injuries) are common conditions with high
incidences (100-300 per 100.000 inhabitants per year) that most often affect young persons in working age. Traffic accidents are a common injury mechanism of both whiplash injury and concussion and some persons may also suffer from symptoms from both these injuries at the same time. Although many patients recover within a few months after an accident a significant proportion experiences prolonged similar symptoms after a whiplash injury and concussion with pain, headache, nausea, dizziness, visual impairment, fatigue and impairment of cognitive abilities that may affect both work and leisure activities.
However, there are different pathophysiological mechanisms in whiplash and concussion, since the injuries affect the brain and the neck, respectively. In order to assess the patient, to make the right diagnoses and to give correct information and treatment it is of great importance that clinicians are aware of the symptomatology of these injuries in the acute and late phases. This presentation will address differences and similarities between whiplash and concussion and discuss
rehabilitation aspects.



Some ones on personality/attitude I find a bit interesting, as an indication of the sort of people psychiatry sees as problematic:


Kriegbaum M
University of Copenhagen, Department of Public Health Science
The Joint Effect of Unemployment and Cynical Hostility on All- Cause Mortality
Objective: Unemployment as well as hostility has been associated with mortality and morbidity. Hostility and socioeconomic position, including unemployment are highly associated. It is hypothesized that hostility is a moderator between stressful conditions and health problems, i.e. increased health risk in hostile individuals may stem from higher frequency of conflicts and lower stress -buffering potential. The aim of this study is to analyze the joint effect of labor market exclusion and hostility on all cause mortality.
Methods: This study is based on a Danish survey carried out in the Spring 2000 among a random sample of 40 and 50-year-old men and women, and an oversampled group of previously unemployed. The survey included self-reported measures on employment, education, age and hostility, measured by the eight-item Cynical-Distrust-Scale. The exposure variable was: 1) employed - not hostile (ref); 2) employed - hostile; 3) unemployed- not hostile and 4) unemployed - hostile. Outcome was all-cause mortality. We used Cox's proportional hazard regression model, with age as the underlying time scale and with entry time January 1st 2000. All individuals who reported not working due to illness were excluded.
Results: Compared to what would have been expected from their separate effects of unemployment and hostility, the joint effect was higher than expected among both men and women, men HR= 2.57 (95% CI, 1.50-4.42), women HR=2.23 (95% CI, 1.17-4.24).
Conclusion: The joint effect of unemployment and hostility is a novel finding, indicating that the health damaging consequences of unemployment are accentuated by hostility.

Hoen P
Interdisciplinary Center of Pathology of Emotions, University Medical Center Groningen, the Netherlands
Why does positive attitude make you live longer? Positive affect and survival in the Heart & Soul
Study
Objective: Depression has been acknowledged in the progression of coronary heart disease (CHD), but there is also a growing interest in the role of positive emotions. The aim of this study was to examine whether positive affect is associated with improved survival and decreased cardiovascular morbidity in patients with stable CHD, and to elucidate biological and behavioral factors that might explain this association.
Methods: The Heart and Soul study is a prospective cohort study of 1017 outpatients with stable CHD followed-up for a mean of 7.1±2.5 years. Positive affect was assessed using the PANAS. Cox proportional hazard regression was used to estimate the risk of all-cause mortality and cardiovascular morbidity (heart failure, myocardial infarction, stroke, transient ischemic attack) associated with positive affect, adjusting for disease severity and depression as potential confounders. Potential explanatory factors included biological and behavioral factors.
Results: A total of 369 patients died during follow-up. Each standard deviation increase in PANAS positive affect score was associated with 16% decreased risk of all-cause mortality (HR:0.84;95%CI:0.77- 0.92;p=0.001). Positive affect was not associated with cardiovascular morbidity. After adjustment for disease severity and depression as potential confounders, positive affect remained significantly associated with improved survival (HR:0.87;95%CI:0.77-0.97;p=0.017). Biological factors did not explain this assocation. Further adjustment for potential behavioral mechanisms, including physical activity, explained away this association (HR:0.93;95%CI:0.82-1.05;p=0.251).
Conclusions: In this sample of outpatients with CHD, positive affect was associated with improved survival.
This association was not explained by biological markers but largely by physical activity.
 

Dolphin

Senior Member
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17,567
Thanks for posting the different abstracts, Esther12.

This abstract is pretty rubbish in terms of giving info from the PACE trial on cost-effectiveness and economic outcomes. He added very little not in the Lancet (Feb/March 2011) paper.
White P
Queen Mary University London
Non-pharmacological management of chronic fatigue syndrome: Efficacy, cost-effectiveness and
economic outcomes in the PACE trial

Objective: To compare the effectiveness, cost-effectiveness, and safety of non-pharmacological
interventions for secondary care patients with chronic fatigue syndrome (CFS).

Methods: 640 patients attending UK secondary care clinics with CFS were recruited into a randomised controlled trial of non-pharmacological treatments. The treatments were adaptive pacing therapy (APT), cognitive behaviour therapy (CBT), or graded exercise therapy (GET), all added to specialist medical care (SMC), and SMC alone. Primary outcomes were the Chalder fatigue questionnaire and the SF36 physical function sub-scale, both being self-rated. Secondary outcomes included adverse events, a global measure of improvement, overall disability, sleep and mood measures, individual symptoms of CFS, and a walking test.

Results: We found that CBT and GET were more effective than APT and SMC. All treatments had similar numbers of adverse events, and there were very few serious adverse reactions. This pattern of results occurred however we defined CFS and whether or not participants also had a depressive episode. Furthermore, CBT was the most cost-effective treatment, while GET was more cost-effective than APT and SMC.

Conclusions: These results support individually delivered CBT and GET as moderately effective, costeffective, and safe treatments for CFS. They imply that testing the limits of the illness is more effective than staying within them.
 

user9876

Senior Member
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4,556
Thanks for posting the different abstracts, Esther12.

This abstract is pretty rubbish in terms of giving info from the PACE trial on cost-effectiveness and economic outcomes.

Do they publish papers or just abstracts. I would have thought the way they monitise that gains from the different treatments would be really interesting since this should reflect reductions in cost associated with illness along with gains through employment etc.It should also look at the dangers of treatments and additional costs due to relapses. It would be nice if they also talked about how uncertainty of the outcomes lead ot uncertainty in the decision making.


Ok I would be very surprised if they had done anything more than say CBT and GET allow 1/3 of people to get back to "normal" and cost this much. I doubt if they even amortise the cost of endless expensive trials into their costs. But to do the job properly they need to do more.
 

user9876

Senior Member
Messages
4,556
This abstract amused me. Basically they are trying to disassociate the idea of fatigue from the ability to do physical stuff. Its interesting since they report that people give better survey results after CBT but the actigraphy results show no increase in activity.

I particularly like the statement "the structural equation model indicated that increases in self-efficacy, perceived activity and selfreported physical functioning, as well as decreases in focusing on fatigue were associated with a decrease in fatigue" what they forget is that their measure of fatigue is based on perceived and reported fatigue hence you would expect it to be highly correlated with how people perceive fatigue.

There overall theme is to look at the process by which CBT may work. I'm alarmed that they do this by getting people to fill in surveys. I don't see how this could ever help them understand mechanism.

Knoop H
Expert centre for chronic fatigue, Radboud University Nijmegen Medical Centre, The Netherlands
Mediators of change in cognitive behaviour therapy for chronic fatigue syndrome
Objective: Cognitive behaviour therapy (CBT) can significantly reduce fatigue in chronic fatigue syndrome (CFS), but little is known about the process of change during CBT. Based on a recently formulated treatment model, we examined how changes in cognitions and behaviour lead to a decrease in fatigue during CBT. The process of change during CBT for CFS was studied in a large sample of CFS patients.
Methods: We included 183 patients who started CBT. All patients met CDC criteria for CFS and were between 18 and 65 years. We measured fatigue and possible process variables before start of treatment, after 6, 12 and 18 weeks and at the end of treatment. Selected process variables were self-efficacy with respect to fatigue, focusing on fatigue, self-reported physical functioning, perceived physical activity and physical activity assessed with actigraphy. A structural equation model was built, explaining changes in fatigue during therapy by changes in the process variables.
Results: The structural equation model indicated that increases in self-efficacy, perceived activity and selfreported physical functioning, as well as decreases in focusing on fatigue were associated with a decrease in fatigue during CBT for CFS. An increase in actual physical activity was not associated with a reduction of fatigue.
Conclusions: Changes in cognitions about fatigue and activity are related to the decrease in fatigue during CBT for CFS. The pattern of change varied considerably between patients, but changes in process variables and fatigue occurred mostly in the same period.
 

Enid

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Psychosomatics - bit if a switch off - haven't they given up yet with their constant appealing to all things "psycho". OK I didn't know the day it was collapsed in A&E ( and frankly between passing out one could't care less). About time these idiots got their own comeuppence -oh yes fatigue secondary like all other ilnesses of course. Quite obvious to find the illness in the first place springs to mind.
 

Dolphin

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17,567
Initially I thought the appended abstract was just the data from Wiborg et al. (2010). However, the number of patients who started CBT is too big (156 for the studies covered by Wiborg et al. (2010) - see Table 1)!

http://forums.phoenixrising.me/inde...-activity-levels-in-3-dutch-cfs-studies.1587/


Knoop H

Expert centre for chronic fatigue, Radboud University Nijmegen Medical Centre, The Netherlands

Mediators of change in cognitive behaviour therapy for chronic fatigue syndrome

Objective: Cognitive behaviour therapy (CBT) can significantly reduce fatigue in chronic fatigue syndrome (CFS), but little is known about the process of change during CBT. Based on a recently formulated treatment model, we examined how changes in cognitions and behaviour lead to a decrease in fatigue during CBT. The process of change during CBT for CFS was studied in a large sample of CFS patients.

Methods: We included 183 patients who started CBT. All patients met CDC criteria for CFS and were between 18 and 65 years. We measured fatigue and possible process variables before start of treatment, after 6, 12 and 18 weeks and at the end of treatment. Selected process variables were self-efficacy with respect to fatigue, focusing on fatigue, self-reported physical functioning, perceived physical activity and physical activity assessed with actigraphy. A structural equation model was built, explaining changes in fatigue during therapy by changes in the process variables.

Results: The structural equation model indicated that increases in self-efficacy, perceived activity and selfreported physical functioning, as well as decreases in focusing on fatigue were associated with a decrease in fatigue during CBT for CFS. An increase in actual physical activity was not associated with a reduction of fatigue.

Conclusions: Changes in cognitions about fatigue and activity are related to the decrease in fatigue during CBT for CFS. The pattern of change varied considerably between patients, but changes in process variables and fatigue occurred mostly in the same period.
 

oceanblue

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Initially I thought the appended abstract was just the data from Wiborg et al. (2010). However, the number of patients who started CBT is too big (156 for the studies covered by Wiborg et al. (2010) - see Table 1)!
http://forums.phoenixrising.me/inde...-activity-levels-in-3-dutch-cfs-studies.1587/
Definitely different (and from the 2012 paper too) as this time they have data collected during treatment, which at least gives them a chance of identifying any causal relationships
. We measured fatigue and possible process variables before start of treatment, after 6, 12 and 18 weeks and at the end of treatment
 

Dolphin

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Definitely different (and from the 2012 paper too) as this time they have data collected during treatment, which at least gives them a chance of identifying any causal relationships
Yes, forgot to say checked this paper also:

Towards an evidence-based treatment model for cognitive behavioral interventions focusing on chronic fatigue syndrome.
Wiborg JF, Knoop H, Frank LE, Bleijenberg G.
J Psychosom Res. 2012 May;72(5):399-404. Epub 2012 Feb 22.
This looks at the data from Knoop et al. (2008), one of the three studies that were looked at together in Wiborg et al. (2010). 64 people who did CBT analysed in Wiborg et al. (2012).
 

oceanblue

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Don't think this one has been posted but is of interest as I think Simon Wessely has claimed CBT is good for diabetes. This study says it isn't:

Petrak F
Clinic of Psychosomatic Medicine and Psychotherapy, LWL-University Clinic Bochum, Ruhr-University
Bochum, Germany

Cognitive behavioural therapy vs. sertraline in patients with depression and poorly controlled diabetes: a multicentre randomised controlled trial

Objective: To compare the efficacy of diabetes-specific cognitive behavioral group therapy (CBT) vs.
sertraline (SER) in patients with poorly controlled diabetes and depression.

Methods: Multicentre randomised controlled trial comparing SER vs. CBT in 251 patients with type1 or type
2 diabetes with HbA1c values >7.5%. After 12 weeks of therapy, only the treatment-responders (50%
reduction in the Hamilton Depression Rating Scale, HAMD) were included in the one-year phase.
Diabetological treatment as usual was given to both groups. CBT-responders received no further
treatment, while SER-responders received a sustained SER regimen. Group differences in HbA1c (primary
outcome) and HAMD (secondary outcome) between 1-year follow-up and baseline were analysed
controlling for baseline values. Subgroup analyses were conducted for type of diabetes.

Results: After 12 weeks 115 (45.8%) patients responded to the treatments (CBT 53, SER 62). In the 1-year
follow-up the HbA1c changed from 9.3±1.6 to 9.2±1.7 after CBT and from 9.2±1.4 to 9.4±1.4 under SER
with no significant treatment difference (p= 0.129). HAMD scores improved significantly after CBT from
18.0±4.6 to 7.8±6.5 and from 18.9±5.1 to 5.5±5.7 under SER (p=0.020). Subgroup analyses revealed
significant differences within the CBT group regarding HbA1c (difference 0.73) favoring type 2 diabetes
(HbA1c reduction: -0.40 vs. +0.32 for type1, p=0.0036).

Conclusions: Both treatments showed considerable and sustained reduction of depression with a small but
significant advantage of sertraline. But, no substantial improvement could be obtained for glycemic control
independently of the type of treatment.
 

Enid

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Wizard of Oz land all of this - yes one tries, yes one (surprising tries) to make Docs around feel better after their interest knowing all along they know nothing but hoping they might. Empathy for them seems to play a big part. (Oh that it were the other way round).

But if this their way of learning "biology" pathology basics at the expense of ill patients we are all back decades where specialist medical findings now point to causes and cures.
 

oceanblue

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This abstract might explain why Simon Wessely and colleagues were so interested in cortisol diurnal rhythmsin CFS. And why they might be looking down the wrong end of the telescope (again):

Diurnal cortisol rhythm: Associated with anxiety and depression, or just an indication of lack of energy?
Harris A, Uni Research, Uni health, Krinkelkroken 1, Bergen, Norway

Dysregulation of hypothalamus pituitary adrenal activity has been associated with chronic low back pain (LBP). The underlying mechanisms are not fully explained, but psychological mechanisms are considered important.

[Method]Psychiatric symptoms measured with three different instruments, and the diurnal rhythm of cortisol was examined in 305 patients, sick-listed 2 to 10 months due to non-specific LBP. Psychiatric disorders were assessed by MINI. The Hospital Anxiety and depression Scale (HADS), and The Hopkins Symptom Checklist-25 (HSCL-25) were used to screen for psychological symptoms. Saliva cortisol was measured on two consecutive days; at awakening, 30 minutes later, at 3pm and 10pm.

[Results] There were no associations between any of the main diagnostic categories from the MINI-interview, or levels of anxiety and/or depression measured with HADS and HSCL-25, and the cortisol awakening response (CAR), cortisol decrease during the day or cortisol levels in the evening.

However, significant associations were found between low CAR [cortisol awakening response] and low cortisol decrease during the day and the somatization scale from HSCL- 25 (dizziness, lack of energy, lack of sexual interest, the feeling that everything requires substantial efforts, difficulties to fall a sleep, and headache).

[Conclusion] The results indicate that cortisol are not directly associated with psychopathology, such as anxiety and depression, but are associated with one dimension of the psychopathology; namely the lack of energy. This should be explored further to assess whether cortisol is just a measure of awakening or if it is associated to other symptoms of fatigue.
 
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13,774
Thanks for looking through too OB... there were quite a few abstracts I considered posting, but also worried that I was creating such a massive post.

re CBT for diabetes: surely a 'skilled therapist' could interact with patients in a way that would lead to them taking better care of themselves... but this seems like such an uninteresting point! It amazes me that some see this as having any particular biopsychosocial significance.

Surely a 'skilled therapist' (sensible person) could help almost any group of people behave more sensible manner compared to another group in an RCT. This could be used to argue that all those with the most power and influence should have their cognitions and behaviour medicalised, so as to improve social outcomes, but instead we seem to be focusing much more upon medicalising those with the least power and influence. Perhaps this is more about imposing will than clarifying cognitive distortions or pursuing truth.

[edit] That HPA paper does look interesting too OB. I don't know how I missed that one.

Thanks for all the comments people. It will be interesting to see some new actigraphy data - I wonder if they've started focusing more upon trying to improve these?
 

Dolphin

Senior Member
Messages
17,567
However, significant associations were found between low CAR [cortisol awakening response] and low cortisol decrease during the day and the somatization scale from HSCL- 25 (dizziness, lack of energy, lack of sexual interest, the feeling that everything requires substantial efforts, difficulties to fall a sleep, and headache).

[Conclusion] The results indicate that cortisol are not directly associated with psychopathology, such as anxiety and depression, but are associated with one dimension of the psychopathology; namely the lack of energy. This should be explored further to assess whether cortisol is just a measure of awakening or if it is associated to other symptoms of fatigue.
Thanks oceanblue, interesting.

The list of items which makes up the somatization scale from HSCL- 25 (above) is an example of why the name put on a set of questions may be misleading/far from ideal.
 

Dolphin

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Messages
17,567
re CBT for diabetes: surely a 'skilled therapist' could interact with patients in a way that would lead to them taking better care of themselves... but this seems like such an uninteresting point! It amazes me that some see this as having any particular biopsychosocial significance.

Surely a 'skilled therapist' (sensible person) could help almost any group of people behave more sensible manner compared to another group in an RCT. This could be used to argue that all those with the most power and influence should have their cognitions and behaviour medicalised, so as to improve social outcomes, but instead we seem to be focusing much more upon medicalising those with the least power and influence. Perhaps this is more about imposing will than clarifying cognitive distortions or pursuing truth.
Interesting points, Esther12.

Yes, I wouldn't find it that amazing if some sort of therapy could improve outcomes in diabetes, particularly type 2 diabetes. A lot of people with type 2 diabetes won't have the best lifestyles, in terms of diet and exercise, which partly or solely resulted in the diabetes. It's not hard to imagine that not all of them will then all live "perfect diabetic lifestyles". I have a (distant) relative who seems to live a "pretty bad diabetic lifestyle" (e.g. he eats quite a lot of (sugared) sweets (=candy)), and it seems a least partly in his case because he's widower who suffers from depression or at least still grieves for his dead wife and hasn't adjusted to new scenario.

I think diabetes is different from ME/CFS where, for the latter, it's far from clear that graded activity/exercise, a significant element of many/most CBT programs, is the best management strategy.
 

Snow Leopard

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The most (only) interesting presentation to me is the one from Hotopf. Of course we know that CFS in these studies was merely self-reported and the measurements used were not originally intended for the purposes used in the studies.

Contradictory is exactly the word to explain the longitudinal data:

http://www.ncbi.nlm.nih.gov/pubmed/15469945 (2004)
Higher risk of CFS/ME was associated with having a limiting longstanding condition in childhood (odds ratio 2.3, 1.4 to 3.9), female sex (2.3, 1.4 to 2.6), and high social class in childhood (2.2, 1.4 to 3.5). Higher levels of exercise in childhood were associated with lower risk (0.5, 0.2 to 0.9). Maternal psychological disorder, psychological problems in childhood, birth weight, birth order, atopy, obesity, school absence, academic ability, and parental illness were not associated with risk of CFS/ME.

2/3 based on non-specific measures is not at all 'consistent'.


The problem with these studies (a) they are questionnaire based and the questions don't exactly measure what we want to measure. (b) any associations made tend to have extremely poor specificity and sensitivity (so poor that these terms aren't even discussed), leading to questions of whether these are in fact key contributing factors or not.

As for "Why does positive attitude make you live longer? Positive affect and survival in the Heart & Soul", the results can be spun in the opposite way, since physical activity was associated with survival, since physical activity is a strong predictor of physical health, then perhaps it is better health that predicts positive affect and in parallel, greater physical activity was associated with improved survival rates?
 
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13,774
Interesting points, Esther12.

Yes, I wouldn't find it that amazing if some sort of therapy could improve outcomes in diabetes, particularly type 2 diabetes. A lot of people with type 2 diabetes won't have the best lifestyles, in terms of diet and exercise, which partly or solely resulted in the diabetes. It's not hard to imagine that not all of them will then all live "perfect diabetic lifestyles". I have a (distant) relative who seems to live a "pretty bad diabetic lifestyle" (e.g. he eats quite a lot of (sugared) sweets (=candy)), and it seems a least partly in his case because he's widower who suffers from depression or at least still grieves for his dead wife and hasn't adjusted to new scenario.

I think diabetes is different from ME/CFS where, for the latter, it's far from clear that graded activity/exercise, a significant element of many/most CBT programs, is the best management strategy.

I find it hard not to sound like an adolescent leftist when talking briefly about the potential for power to corrupt... but it's always relevant!

It seems to me that one of the main reasons that some diabetics do not follow medical advice is that they feel doctors have a tendency to exaggerate their certainty about matters and try to take unreasonable amounts of control over the lives of others (this is only based upon one person I've known, and three or four interviews with fat American comedians... mixed in with my own beliefs about medical practice). I reckon that the most effective way to encourage people to follow medical advice would be to ensure that when incorrect advice is given, those responsible share some of the burden and cost of following it. As you say, the key problem with CFS is that we have so little understanding of the condition of how to best respond to it.

The best way to improve respect for the medical profession and their guidelines is to cut down on quackery. I've become way more sceptical of all medical advice since I started looking more closely at CFS stuff, and saw how the results from PACE were spun.
 

Simon

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Monmouth, UK
Mediators of change in cognitive behaviour therapy for chronic fatigue syndrome (see abstract below)

This is perhaps more revealing than I realised. It appears to provide very little evidence for cognitive behavioural mediators of improvements in fatiuge, despite being fairly well set up to find any that existed.

How to establish 'true' mediators
Mediators are things that explain the mechanism of action of a treatment, specifically things that directly cause the treatment effect. A cross-sectional study can never do that, but here they looked at baseline, treatment outcome and also at three time points along the way. If they could show that, say, focusing on fatigue (a goal of CBT) reduced first, then perceived fatigue reduced later, that would be evidence of a causal relationship where reducing fatigue-focusing meditated the effect of CBT on fatiuge.

Otherwise you just end up with a correlation eg' focusing on fatigue' reduces and so does fatigue: well, if fatigue severity declined you would expect fatigue focusing to decline too, just as pain focusing reduces as pain fades away.

No evidence of 'true' mediators
The study found a correlation between potential mediators and the reduced fatigue but they didn't find evidence that the mediators changed before fatiuge ie no evidence of a causal relationship:
  • Changes in cognitions about fatigue and activity are related to the decrease in fatigue during CBT for CFS.
  • The pattern of change varied considerably between patients,
  • but changes in process variables and fatigue occurred mostly in the same period
So sometimes fatigue reduced first then fatigue focusing reduced. Sometimes they happened at the same time (ie within the same 6-week measurement interval) and other times fatigue focusing reduced first. In other words, no clear pattern at all.

Given that the PACE Trial too are struggling to find any mediators of CBT and GET, it does look like investigators are not able to find evidence to back up the model of change they have proposed for these therapies.

Knoop H
Expert centre for chronic fatigue, Radboud University Nijmegen Medical Centre, The Netherlands

Mediators of change in cognitive behaviour therapy for chronic fatigue syndrome

Objective: Cognitive behaviour therapy (CBT) can significantly reduce fatigue in chronic fatigue syndrome (CFS), but little is known about the process of change during CBT. Based on a recently formulated treatment model, we examined how changes in cognitions and behaviour lead to a decrease in fatigue during CBT. The process of change during CBT for CFS was studied in a large sample of CFS patients.

Methods: We included 183 patients who started CBT. All patients met CDC criteria for CFS and were between 18 and 65 years. We measured fatigue and possible process variables before start of treatment, after 6, 12 and 18 weeks and at the end of treatment. Selected process variables were self-efficacy with respect to fatigue, focusing on fatigue, self-reported physical functioning, perceived physical activity and physical activity assessed with actigraphy. A structural equation model was built, explaining changes in fatigue during therapy by changes in the process variables.

Results: The structural equation model indicated that increases in self-efficacy, perceived activity and selfreported physical functioning, as well as decreases in focusing on fatigue were associated with a decrease in fatigue during CBT for CFS. An increase in actual physical activity was not associated with a reduction of fatigue.

Conclusions: Changes in cognitions about fatigue and activity are related to the decrease in fatigue during CBT for CFS. The pattern of change varied considerably between patients, but changes in process variables and fatigue occurred mostly in the same period.
 
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13,774
Changes in cognitions about fatigue and activity are related to the decrease in fatigue during CBT for CFS.

Isn't another important point that: We don't have a good measure for fatigue. Isn't it slightly absurd for them to say that cognitions about fatigue and activity are related to a decrease in fatigue (which is measured via a questionnaire which will reflect patient's cognitions about fatigue and activity).

Especially as they also say:

An increase in actual physical activity was not associated with a reduction of fatigue.

If it is 'fatigue' which is restricting people's activity levels, then a reduction in fatigue really should be association with an increase in activity.