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Mood and Anxiety Disorders in Chronic Fatigue Syndrome, Fibromyalgia, and Irritable Bowel Syndrome

Dolphin

Senior Member
Messages
17,567
I didn't find it that exciting but as I read it, I thought I'd post it with some comments and data not in the abstract.
Psychosom Med. 2015 May;77(4):449-57. doi: 10.1097/PSY.0000000000000161.
Mood and Anxiety Disorders in Chronic Fatigue Syndrome, Fibromyalgia, and Irritable Bowel Syndrome: Results From the LifeLines Cohort Study.
Janssens KA1, Zijlema WL, Joustra ML, Rosmalen JG.
Author information

Abstract
OBJECTIVE:
Functional somatic syndromes (FSSs) have often been linked to psychopathology. The aim of the current study was to compare prevalence rates of psychiatric disorders among individuals with chronic fatigue syndrome (CFS), fibromyalgia (FM), and irritable bowel syndrome (IBS).

METHODS:
This study was conducted in 94,516 participants (mean [standard deviation] age = 44.6 [12.5] years, 58.7% women) of the general-population cohort LifeLines. FSSs were assessed by self-reports. Mood disorders (i.e., major depressive disorder and dysthymia) and anxiety disorders (i.e., generalized anxiety disorder, social phobia, panic disorder with/without agoraphobia, and agoraphobia) were assessed by means of the Mini International Neuropsychiatric Interview. Risks on psychiatric disorders were compared for individuals with CFS, FM, and IBS by using logistic regression analyses adjusted for age and sex.

RESULTS:
Prevalence rates of CFS, FM, and IBS were 1.3%, 3.0%, and 9.7%, respectively. Individuals with CFS, FM, and IBS had significantly more mood (odds ratios [ORs] = 1.72-5.42) and anxiety disorders (ORs = 1.52-3.96) than did individuals without FSSs, but prevalence rates were low (1.6%-28.6%). Individuals with CFS more often had mood (ORs = 2.00-4.08) and anxiety disorders (ORs = 1.63-2.32) than did individuals with FM and IBS. Major depressive disorder was more common in FM than in IBS (OR = 1.58, 95% confidence interval = 1.24-2.01), whereas these groups did not differ on dysthymia or anxiety disorders.

CONCLUSIONS:
Mood and anxiety disorders are more prevalent in individuals with FSSs, and particularly CFS, than in individuals without FSSs. However, most individuals with FSSs do not have mood or anxiety disorders.

PMID:

25768845

[PubMed - in process]
 

Dolphin

Senior Member
Messages
17,567
There is a 3-circle Venn diagram:

CFS / [Fibromyalgia U IBS] = 713 (0.8% prevalence)
CFS & FMS / {IBS} = 126 (0.1%)
CFS & IBS / FMS = 221 (0.2%)
CFS & IBS & FMS = 106 (0.1%)

Fibromyalgia / {CFS U IBS} = 1705 (1.9% prevalence)
Fibromyalgia & IBS / CFS = 828 (0.9%)

IBS / {CFS U FMS} = 7703 (8.5%)

/ = less than
U = union of
 

Dolphin

Senior Member
Messages
17,567
They used lifetime diagnoses which aren't perfect.

This is what they said on this, for what it's worth.

Patients Showing Complaints in the Past Week(s)

Because lifetime diagnoses of FSSs were assessed, the question remained whether patients were still having the reported syndrome. Analyses were therefore repeated after exclusion of individuals with CFS who did not report fatigue in the past 4 weeks (n= 44), individuals with FM who did not report muscle pain in the past week (n=148), and individuals with IBS who did not report nausea in the past week (n= 5251). Because of the absence of assessment of gastrointestinal symptoms other than nausea, it was not possible to base this selection on bowel complaints. Fatigue was assessed using one item from the short form of the RAND Health Insurance Study Questionnaire (RAND-36) (27), and muscle pain and nausea were assessed by two items from the somatization scale of the Symptom Checklist-90 (28). Results are shown in Table 4. In this sample, participants with CFS did not have more anxiety disorders than did participants with IBS anymore, and participants with FM did not have more MDD than did IBS patients. Results regarding the comparison between individuals with CFS and individuals with FM in mood or anxiety disorders remained essentially the same

Another limitation is that lifetime diagnoses of FSSs were available instead of current diagnoses, which might have given an overestimation of persons who currently have FSSs. However, as mentioned, data of another cohort study in the same geographical area showed that persons who reported to have experienced CFS, FM, or IBS usually report still having the syndrome. Hence, the overestimation of participants who currently have FSSs is likely to be minor. Moreover, most (>95%) participants reporting CFS experienced fatigue, and most (>93%) participants reporting FM experienced musculoskeletal pain in the past week(s).Thirty-nine percent of the participants with IBS reported nausea. Unfortunately, no information about gastrointestinal complaints other than nausea was available for the entire sample. Furthermore, the prevalence rates of FSSs per age category also indicate that diagnoses represent current rather than lifetime diagnoses of FSSs, given the absence of a linear increase during ageing. Nevertheless, as a sensitivity analysis, analyses were repeated after exclusion of patients who did not report the core symptoms in the past week(s). After exclusion of these patients, participants with CFS did not have more anxiety disorders anymore than did participants with IBS, and participants with FM did not have MDD more frequently than did participants with IBS. It should be noted that IBS patients in this subsample might not be representative of average IBS patients because only patients who reported nausea in the past week were included.
 

Dolphin

Senior Member
Messages
17,567
One important issue is that the diagnoses weren't checked.
A prevalence of 1.3% for CFS seems quite high especially when a lot of people in the population who have it don't know they have it.

So I wonder whether the sample includes some people who have chronic fatigue and believe that means they have chronic fatigue syndrome.
 

Dolphin

Senior Member
Messages
17,567
They don't give a break down for all the CFS categories, just only CFS along with 2 FSSs (which may not include CFS) and 3 FSSs, so I'll give the figures for the ones that definitely have CFS.

Only CFS:

Major Depressive Disorder: 10.7% (74)
Core Symptoms Depression: 8.6% (59)
Dysthymia: 6.5% (39)
Generalized Anxiety Disorder: 12.5% (86)
Social Phobia: 3.6% (29)
Panic Disorder with Agoraphobia: 1.9% (13)
Panic Disorder without Agoraphobia: 4.6% (65)
Agoraphobia without panic disorder: 8.9% (61)

Any Mood Disorder: 17.2%
Any Anxiety Disorder: 24.0%

[They don't give combined figures for these two last categories but we have some information from another paper on the same cohort (see here: http://forums.phoenixrising.me/inde...d-irritable-bowel-syndrome.39057/#post-625179) (I'm not sure why the figures don't match exactly):
Mood Disorder: 17%
Anxiety Disorder: 23%
Mood and/or Anxiety Disorder: 26.4%]

========================

3 FSSs (i.e. CFS, FMS & IBS)

Major Depressive Disorder: 19.0% (20)
Core Symptoms Depression: 13.3% (14)
Dysthymia: 8.3% (7)
Generalized Anxiety Disorder: 28.6% (30)
Social Phobia: 4.8% (5)
Panic Disorder with Agoraphobia: 5.7% (6)
Panic Disorder without Agoraphobia: 5.7% (6)
Agoraphobia without panic disorder: 14.3% (15)

Any Mood Disorder: 29.1% (27)
Any Anxiety Disorder: 40.6% (43)
 
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Dolphin

Senior Member
Messages
17,567
All disorders were much more common in women than in men. The sex difference was smallest in CFS (30.9% men) and largest in FM (8.0% was men). Furthermore, 19.0% of participants with IBS were men.
So 69.1% of those with CFS were female and 30.9% male.
 

Dolphin

Senior Member
Messages
17,567
It's good they dealt with this issue:

Because the diagnostic criteria for MDD overlap with FSS, the MDD prevalence in FSS patients might have become artificially high. To control for this overlap, we examined prevalence rates of depression when defining depression as the two core symptoms of MDD (i.e., depressed mood and anhedonia, which are both cognitive) being present. Prevalence rates were indeed lower when taking this approach, particularly in participants with CFS in whom the prevalence rate was now 2.1% lower than when the original diagnostic criteria were used (Table 2).
(Note that Table 2 only gives one set of figures, presumably not the approach when they just used the two core symptoms of MDD).

---
They also say:

An explanation for individuals with CFS reporting the highest levels of psychiatric comorbidity might be that symptoms of psychiatric disorders, especially depressive disorder, overlap with CFS symptoms. Prevalence rates of depressive disorder in participants with CFS were indeed lowerwhentakingthetwocoredepressionsymptomsintoaccount. Therefore, symptom overlap should be taken into account in psychiatric examination of individuals with CFS.
 

Dolphin

Senior Member
Messages
17,567
What can be concluded from the current study is that FSSs, mood, and anxiety disorders only partially overlap, and that most individuals with FSSs do not have mood and anxiety disorders. This finding is in line with previous studies (18,23). Therefore, these syndromes should not be simply considered somatic expressions of anxiety and depression.
This is good

The preceding sentences aren't so good:
Because of the cross-sectional nature of our study, we could not determine whether FSSs lead to mood and anxiety disorders, whether anxiety and mood disorders lead to FSSs, or whether FSSs and mood and anxiety disorders are manifestation of the same underlying pathology. We previously found evidence for all three hypotheses in a longitudinal population-based study of adolescents, with most pronounced evidence for depression and anxiety being risk factors of FSSs (34).
I tend to be sceptical of claims of many claims about risk factors. People with FSSs such as CFS often take a while to be diagnosed. In the intervening period, they may incorrectly be seen as having a mood and/or anxiety disorder and/or may develop one secondary to being ill (esp. when they're not diagnosed and thus often not in a position to reduce their workload or get support from others/the state).
 

SOC

Senior Member
Messages
7,849
One important issue is that the diagnoses weren't checked.
A prevalence of 1.3% for CFS seems quite high especially when a lot of people in the population who have it don't know they have it.

So I wonder whether the sample includes some people who have chronic fatigue and believe that means they have chronic fatigue syndrome.

Since when do research studies on a specific patient group consider self-diagnosis as legitimate diagnosis for inclusion in the patient cohort? o_O Can I get in a research study on MS just by walking in and saying, "Yeah, I think I have MS"? This is especially problematic when even trained physicians have difficulty making an accurate ME/CFS diagnosis based on established criteria.

Oh yeah, this is psychology/psychosomatic theory research where actual scientific methods are not considered necessary. Ya know, stuff like selecting a correct cohort, minimizing confounding factors and accounting for those you can't eliminate, and doing background research on the subject you are claiming to research so you have some idea what you're talking about. :rolleyes: Do these people even know what ME/CFS is?

What utter nonsense.
 

A.B.

Senior Member
Messages
3,780
I tend to be sceptical of claims of many claims about risk factors. People with FSSs such as CFS often take a while to be diagnosed. In the intervening period, they may incorrectly be seen as having a mood and/or anxiety disorder and/or may develop one secondary to being ill (esp. when they're not diagnosed and thus often not in a position to reduce their workload or get support from others/the state).

It's flawed logic to assume that symptoms that appear early are causing the later symptoms. They could be both expression of subtle biological dysfunction. It could also be that some symptoms are just more noticeable than others.

It's a waste of time to even discuss causality when one has no means to test for it. Worst case people end up convincing themselves they understand the cause when they actually don't understand it, leading to inappropriate interventions that are likely to make the situation for the patient even worse.
 

barbc56

Senior Member
Messages
3,657
I tend to be sceptical of claims of many claims about risk factors. People with FSSs such as CFS often take a while to be diagnosed. In the intervening period, they may incorrectly be seen as having a mood and/or anxiety disorder and/or may develop one secondary to being ill (esp. when they're not diagnosed and thus often not in a position to reduce their workload or get support from others/the state).

Thanks @Dolphin

A very important point that is often missed!

Would the term idiopathic be more applicable for me/cfs as well as many other FSS disorders since the latter implies a psychiatric cause. But then the medical community would have to accept that a psychiatric condition can be comorbid but it's not what causes us to be sick!
:bang-head::bang-head::bang-head::bang-head::bang-head::bang-head::bang-head::bang-head::bang-head::bang-head::bang-head::bang-head::bang-head::bang-head::bang-head::bang-head:

Maybe I'm confusing medical terms?

Barb
 

Hip

Senior Member
Messages
17,790
One important issue is that the diagnoses weren't checked.

Could you explain what you mean when you say the diagnoses were not checked? I understand that the diagnoses of depressions and anxieties were determined by the Mini International Neuropsychiatric Interview. What does being checked mean in this context?



Since when do research studies on a specific patient group consider self-diagnosis as legitimate diagnosis for inclusion in the patient cohort?

The diagnoses of depressions and anxieties were determined by the Mini International Neuropsychiatric Interview, which is not self-diagnosis, but a 15 minute interview process.

Don't forget that this is how ME/CFS is diagnosed, by a doctor asking you questions.



Major Depressive Disorder: 10.7% (74)
Dysthymia: 6.5% (39)

If we add these two types of depression together (assuming they were mutually exclusive, so that we can add them), we get a total of 16.2% of ME/CFS patients with depression.

That is low in comparison to the forum poll which was done recently, asking ME/CFS patients whether they had depression; in this poll, 32.5% of ME/CFS patients said they were suffering from depression.

But I guess that forum poll may have included people who had mild depression, and these people may not be included in the selection for Major Depressive Disorder.



Mood and/or Anxiety Disorder: 26.4%

So around 26% of ME/CFS patients anxiety and/or mood disorders.

However I think the total percentage of ME/CFS patients with psychiatric disorders is much higher than this: there are other psychiatric conditions that ME/CFS patients can have that are not included in the anxiety or mood disorders tested for, such as psychosis, depersonalization and derealization, blunted affect, SAD, bipolar, etc.

This study found that 57% of ME/CFS patients have at least one psychiatric comorbidity. So hat study suggests it is more common to have comorbid psychiatric problems in ME/CFS than not to have them. And that 57% does not include the ME/CFS patients who have psychiatric symptoms as part of their ME/CFS (eg: emotional liability, emotional sensitivity, irritability, which are ME/CFS symptoms).



It's flawed logic to assume that symptoms that appear early are causing the later symptoms. They could be both expression of subtle biological dysfunction.

That is very true; however, are the authors assuming it, or are they just suggesting the possibility? Because certainly the possibility is there.

Also, even if certain psychiatric conditions were one day proven to be a risk factor for the development of ME/CFS, that does not automatically imply that it is the psychiatric mental symptoms that are posing the risk; it could instead be some underlying biological dysfunction that causes the psychiatric symptoms which is the actual risk factor and the actual factor playing a causal role in the development of ME/CFS.

For example, if a psychiatric condition were underpinned by brain inflammation, then it may be the brain inflammation rather than the actual psychiatric mental symptoms that is playing a causal role in the development of ME/CFS.
 

Hip

Senior Member
Messages
17,790
@A.B.
Actually, reading it more closely, they found evidence for depression and anxiety being risk factors for functional somatic syndromes like ME/CFS, fire and IBS in longitudinal studies. See Dolphin's quote:
We previously found evidence for all three hypotheses in a longitudinal population-based study of adolescents, with most pronounced evidence for depression and anxiety being risk factors of FSSs (34).

It is not flawed logic to say that anxiety and depression are risk factors for ME/CFS, if they were using longitudinal studies to determine this relationship. Though I agree the causal factor may not be the actual symptoms of depression or anxiety, but may be some underlying biological dysfunction(s) that causes both a propensity to depression or anxiety, as well as a propensity to ME/CFS.

@Dolphin, would you know the title of the paper they are referring to here, the longitudinal study paper?
 

Dolphin

Senior Member
Messages
17,567
Could you explain what you mean when you say the diagnoses were not checked? I understand that the diagnoses of depressions and anxieties were determined by the Mini International Neuropsychiatric Interview. What does being checked mean in this context?

Dolphin said:
One important issue is that the diagnoses weren't checked.
I'm referring to the FSS diagnoses i.e. CFS, FMS and IBS. They just asked them did they ever have them but didn't assess them themselves.
 
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Dolphin

Senior Member
Messages
17,567
So around 26% of ME/CFS patients anxiety and/or mood disorders.

However I think the total percentage of ME/CFS patients with psychiatric disorders is much higher than this: there are other psychiatric conditions that ME/CFS patients can have that are not included in the anxiety or mood disorders tested for, such as psychosis, depersonalization and derealization, blunted affect, SAD, bipolar, etc.

This study found that 57% of ME/CFS patients have at least one psychiatric comorbidity. So hat study suggests it is more common to have comorbid psychiatric problems in ME/CFS than not to have them. And that 57% does not include the ME/CFS patients who have psychiatric symptoms as part of their ME/CFS (eg: emotional liability, emotional sensitivity, irritability, which are ME/CFS symptoms).
That study used the flawed empiric criteria (Reeves et al., 2005). Here's a published letter in reply to that study criticising the criteria used:
http://s3.amazonaws.com/academia.edu.documents/30271514/article-2010kindlon-criteria.pdf?AWSAccessKeyId=AKIAJ56TQJRTWSMTNPEA&Expires=1438611343&Signature=d94rWHQpAjFI5Y4jpE7dqnef9is=&response-content-disposition=inline

If that link doesn't work, try:
https://scholar.google.com/scholar?cluster=16133355348507066158&hl=en&as_sdt=0,5 and click on pdf link with academia.edu
 
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Dolphin

Senior Member
Messages
17,567
@A.B.
Actually, reading it more closely, they found evidence for depression and anxiety being risk factors for functional somatic syndromes like ME/CFS, fire and IBS in longitudinal studies. See Dolphin's quote:
We previously found evidence for all three hypotheses in a longitudinal population-based study of adolescents, with most pronounced evidence for depression and anxiety being risk factors of FSSs (34).

It is not flawed logic to say that anxiety and depression are risk factors for ME/CFS, if they were using longitudinal studies to determine this relationship. Though I agree the causal factor may not be the actual symptoms of depression or anxiety, but may be some underlying biological dysfunction(s) that causes both a propensity to depression or anxiety, as well as a propensity to ME/CFS.

@Dolphin, would you know the title of the paper they are referring to here, the longitudinal study paper?
34. Janssens KAM, Rosmalen JGM, Ormel J, van Oort FVA, Oldehinkel AJ. Anxiety and depression are risk factors rather than consequences of functional somatic symptoms in a general population of adolescents: the TRAILS study. J Child Psychol Psychiatry 2010;51:304–12.

Full paper is available here: https://www.rug.nl/research/portal/files/14547770/02c2.pdf

In this case, FSS refers to functional somatic symptoms rather than functional somatic syndromes:
Functional somatic symptoms FSS were measured by the Somatic Complaints scale of the YSR (Achenbach et al., 2003). This scale contains nine items, which refer to somatic complaints without a known medical cause (aches/pains, headache, nausea, eye problems, skin problems, stomach pain, and vomiting) or without obvious reason (overtiredness and dizziness).
 

Hip

Senior Member
Messages
17,790
I'm referring to the FSS diagnoses i.e. CFS, FMS and IBS. They just asked them did they ever have them but didn't assess them themselves.

OK, understood. Thanks.



That study used the flawed empiric criteria (Reeves et al., 2005). Here's a published letter in reply to that study criticising the criteria used:
http://s3.amazonaws.com/academia.ed...dqnef9is=&response-content-disposition=inline

That's interesting, I was not aware of that.

Your link does not seem to work, but I presume the issue here is that the empirical definition may also select patients with major depression.

Would you know of any other studies that have examined the incidence of the full range of possible psychiatric comorbidities in ME/CFS patients, using more robust ME/CFS selection criteria?



One of the things I have been meaning to do is to set up a poll on this forum asking ME/CFS patients which psychiatric comorbidities they may have. However this poll would be a bit of an undertaking, as there are dozens of psychiatric conditions that would need to be listed in the poll answer options, and the poll would really need to list the symptoms of each psychiatric condition (as it is possible that patients may be unaware that they have a psychiatric condition until they read its symptoms — this happened to me, where I was unaware that I had social anxiety until I happened upon a good description of this condition).

Just for anxiety disorders alone, you have around 7 different types (see this article which lists anxiety disorder types). And there are many forms of depression: major depression, dysthymia, seasonal affective disorder (SAD), atypical depression, bipolar I, bipolar II, premenstrual dysphoric disorder.

Then you would need to include autism-spectrum disorders, schizophrenia-spectrum disorders, and all sorts of other stuff: ADD, ADHD, dyslexia, anorexia nervosa, etc.



34. Janssens KAM, Rosmalen JGM, Ormel J, van Oort FVA, Oldehinkel AJ. Anxiety and depression are risk factors rather than consequences of functional somatic symptoms in a general population of adolescents: the TRAILS study. J Child Psychol Psychiatry 2010;51:304–12.

Full paper is available here: https://www.rug.nl/research/portal/files/14547770/02c2.pdf

Many thanks for that link. I am particularly interested in ME/CFS comorbidities, both physical and mental, that may be playing a role in the development of ME/CFS, as I think these comorbidities should be able to throw some light on the biochemical nature of ME/CFS.

I think it is great they have been able to prove that anxiety and depression are risks factors for somatic symptoms. Often with comorbidities, you don't know whether they are a cause or consequence of the main disease (or neither, and that both disease and comorbidity result from some third factor).

I wish someone would perform a longitudinal study to try to determine whether IBS is a risk factor for ME/CFS. IBS I think is very interesting, because it is probably the most common comorbidity in ME/CFS.

I had IBS-D for 5 years before later developing ME/CFS from a viral infection. Generalized anxiety disorder also appeared alongside my IBS, probably as a consequence of the IBS (although I cannot prove this). So I had both IBS and anxiety for some time before the virus precipitated my ME/CFS.
 
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Dolphin

Senior Member
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17,567