Personality studies of the chronically ill may do more harm than good.
In their recent article, Nater et al. [1] compare the answers on two personality questionnaires [2,3] that were provided by Chronic Fatigue Syndrome (CFS) patients, controls with disruptive but less serious ‘insufficient fatigue’ (ISF) and healthy controls. Perhaps unsurprisingly, the two groups suffering from health problems agreed to statements such as “I expect other people to do favors for me even though I do not usually do favors for them” at a greater rate than healthy controls. This led to the diagnosis of personality disorders in 29% of CFS patients, 28% of ISF patients and 7% of well controls.
The impact that living with a chronic illness has upon an individual’s life could alter their assessments of themselves in many different ways. For example, Nater et al. report that a quarter of CFS patients are unemployed or on disability benefit; this might be expected to increase the likelihood of patients agreeing to the statement “I see myself as thrifty, but others see me as being cheap”[2], without being an indication of a greater prevalence of obsessive-compulsive personalities. The use of personality questionnaires to diagnose personality disorders amongst the chronically ill may lead to misleading results if such confounding factors cannot be accounted for. Nater et al. note (p316), “studies comparing CFS to other chronic illnesses, such as multiple sclerosis, did not find differences regarding the prevalence of comorbid personality disorders” and this result would seem to be repeated again here.
Coverage of Nater et al.’s work [4,5,6] followed a news release titled ‘Is Chronic Fatigue Syndrome A Personality Disorder?’[7], and promoted the notion that those suffering from CFS are liable to be suffering from severe personality abnormalities related to non-compliance with treatment suggestions. Given the design of the study and the manner of its presentation, such coverage is not surprising. While Nater et al. focus upon the possibility that it is CFS patients’ personalities which lead to a damaging lack of trust and confidence in health care professionals, it could be argued that these are reasonable responses to the negative stereotyping and stigmatization which patients already face [8,9,10], and which papers that casually emphasise the role maladaptive personality features may play in CFS are likely to worsen. Such problems are especially worrying given the concerns raised about the broad criteria the researchers used to define CFS, which appear to lack both sensitivity and specificity. [11,12]
While Nater et al. note many of the limitations of their work, and chose to include a control group suffering with health problems which was absent from their initial presentation of results [13], great care needs to be taken with the design and presentation of such studies in order to ensure meaningful results are gathered, and that they are not used to legitimise the crude profiling and stereotyping of patients. Otherwise, patients agreeing with the statement “Others will use what I tell them against me” [2] might be displaying prescience, not paranoia.
[1] Nater UM, Jones JF, Lin JM, Maloney E, Reeves WC, Heim C: Personality features and personality disorders in chronic fatigue syndrome: a population-based study. Psychotherapy and Psychosomatics. 2010;79(5):312-8
[2] Hyler SE: Personality Diagnostic Questionnaire-4+ (PDQ-4+). New York, New York State Psychiatric Institute, 1994.
[3] American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4, text rev (DSM-IV-TR). Washington, American Psychiatric Association, 2000.
[4]‘Is Chronic Fatigue Syndrome A Personality Disorder?’ rehacare:
http://www.rehacare.com/cipp/md_reh..._Fatigue_Syndrome_A_Personality_Disorder.html Accessed November 21, 2010
[5] ‘Is Chronic Fatigue Syndrome A Personality Disorder?’ Medical News Today:
http://www.medicalnewstoday.com/articles/207006.php Accessed November 21, 2010
[6] ‘Tired and Tested’, Metro. November 9, 2010:27
http://e-edition.metro.co.uk/2010/11/09/ Accessed November 21, 2010
[7]‘Is Chronic Fatigue Syndrome A Personality Disorder?’ Journal of Psychotherapy and Psychosomatics, AlphaGalileo:
http://www.alphagalileo.org/ViewItem.aspx?ItemId=89186&CultureCode=en Accessed November 21, 2010
[8] Drachler Mde L, Leite JC, Hooper L, Hong CS, Pheby D, Nacul L, Lacerda E, Campion P, Killett A, McArthur M, Poland F. The expressed needs of people with chronic fatigue syndrome/myalgic encephalomyelitis: a systematic review. BMC Public Health. 2009 Dec 11;9:458.
[9] Patients with chronic fatigue syndrome are not treated properly BMJ. 2004 June 5; 328(7452): BMJ doi: 10.1136/bmj.328.7452.0-e
http://www.bmj.com/content/328/7452/0.6.full. Accessed November 21, 2010
[10] Newton JL, Jones DEJ. ‘Making sense of fatigue’ Occupational Medicine 2010; 60(5): 326-329
[11] Kindlon T. Criteria used to define chronic fatigue syndrome questioned. Psychosom Med. 2010;72:506-7 [12] Jason LA, Evans M, Brown A, Brown M, Porter N, Hunnell J, Anderson V, Lerch A. (2010). Sensitivity and specificity of the CDC empirical chronic fatigue syndrome case definition. Psychology. 2010;1:9-16.
[13] Nater UM, Jones JF, Lin JM, Maloney E, Reeves WC: Abstract 1747: The Role of Personality in Chronic Fatigue Syndrome: Findings from a Population-Based Study. 2009. American Psychosomatic Society 67th Annual Meeting.