Chronic Fatigue Syndrome and Cognitive Behavioural Therapy - Essay Example

A literature review of Chronic Fatigue Syndrome/ Myalic Encephalomyelites (or encephalopathy) and Cognitive Behavioural Therapy/Psychotherapy A literature review of Chronic Fatigue Syndrome/ Myalic Encephalomyelites (or encephalopathy) and Cognitive Behavioural Therapy/Psychotherapy A literature review of Chronic Fatigue Syndrome/ Myalic Encephalomyelites (or encephalopathy) and Cognitive Behavioural Therapy/Psychotherapy Chronic fatigue syndrome (CFS) is a poorly understood condition and affects 250000 people in the UK and more than 1 million people in the United States by a new estimate just about to be published by the CDC (CFS, NHS; Harder, 2006). Known also as myalgic encephalomyelitis, CFS causes long-term tiredness affecting the daily life (CFS, NHS). The syndrome has been more commonly diagnosed in women (Yamamoto et al, 2003) and the age of occurrence is between 20 years and 40 years (Harder, 2006). Women are three times more likely to be diagnosed with the CFS than men (Prins, 2006). Children of 13-15 are also found to be affected. (CFS, NHS). Cognitive impairments are found in a large proportion of CFS patients: about 75-95 % of them (DeLuca, 2004). The research aims at discovering the effects of CBT specifically targeted at reducing the sustained arousal in CFS patients. The literature review is focusing on the illness, its diagnosis, aetiopathogenesis, the hypotheses involved, the diagnosis, the treatment and the advantages of CBT in CFS. Work-related impairments in CFS included difficulty in learning new matter and remembering how to use it, keeping appointments and maintaining concentration are some of the practical difficulties faced by CFS patients (Attree, 2009). Apart from anxiety, depression and illness intrusiveness, cognitive impairments like retrospective memory deficits and concentration difficulties are found. These problems are believed to be due to reduced or delayed information processing (Attree, 2009). All tasks that are used to compare CFS patients and controls may not always show up the deficits in CFS patients. However timed tasks may show cognitive deficits (DeLuca et al, 2004). Word lists are learnt over a longer time period and fewer items are retrieved in a delayed recall test. Initial learning and subsequent ability to retrieve information is disturbed in CFS patients. Prospective memory for retrieval was studied in women with CFS using a virtual reality environment by Attree and her colleagues (2009). Prospective memory refers to the “remembering to carry out intended actions at an appropriate point in the future.”(Attree, 2009). No cure is available for this illness; management consists of relieving the symptoms exhibited. Mild, moderate and severe varieties have been identified based on symptoms. Mild cases are self-treated and a few days absence from work to rest would be sufficient to allow the patient to continue (CFS, NHS). Moderate cases have a mobility problem and disturbed sleep patterns. The severe cases can perform minimal daily tasks like brushing the teeth but may have to use a wheelchair occasionally. The faculty of concentration suffers (CFS, NHS). Very severe cases remain bed-ridden for most part of the day. Intolerance to noise and bright lights may be a feature. Lasting for years, some patients recover after some time. Younger people have a better prognosis. CFS is defined “as a condition that involves a severe fatigue that usually has a clear starting point, often after a bout of illness, and that doesnt improve after rest; it makes you less able to cope with levels of activity in your work, school or social life that were previously normal for you” (CFS/ME, Bupa). Diagnosis Medical history alone will provide the diagnosis. Intense fatigue of more than six months duration and of unknown cause is the characteristic feature (Fernandez et al, 2009). Osteomuscular, neurovegetative and neuropsychological symptoms are elicited with targeted interrogation (Fernandez et al, 2009). Other accompanying symptoms include asthenia and fatigue which is not relieved after sleep. The difficulty for performance of physical or intellectual activities even after a period of rest when no recovery had taken place would be a suggestive feature. Asthenia also has the same features of inability to perform daily tasks especially towards the evening hours but it is relieved by rest. It has to be differentiated from the weakness of muscular diseases (Fernandez et al, 2009). The inclusion of history of psychiatric disorders, organosphosphorus poisoning, inhalation or ingestion of solvents, multiple chemical hypersensitivity, sick building syndrome and situations which disrupt sleep is essential to be ruled out in order to reach a diagnosis of CFS (Fernandez, 2009). The diagnostic protocol indicates that diagnosis of some of the conditions which resemble CFS automatically rules out CFS: “psychiatric disorders, such as major depression, schizophrenia, eating disorders (anorexia, bulimia), bipolar disorder, alcohol or other substance abuse, in addition to morbid obesity, and active medical diseases, either non-treated or without a completely established resolution” (Fernandez, 2009). Accompanying symptoms include arthralgias, muscle pain, headaches, depression, cognitive dysfunctions, sleep disorders or intolerance to exercise (Fernandez et al, 2009). The peculiarity of CFS is that there is no pathognomonic sign or test. Diagnosis can be made only after ruling out other causes of fatigue ((Fernandez et al, 2009). The difficulty of diagnosis is attributed to the inadequate understanding of the pathogenesis and the inability to making a quantitative and objective assessment. Fatigue may also be the presenting picture in other conditions like “fibromyalgia, irritable bowel syndrome, and temporomandibular joint syndrome”. Research has revealed that these illnesses may also have the same pathophysiology (Godenberg et al, 1990 cited in Fernandez, 2009). Prognosis is best for younger patients and those with psychiatric illnesses. Co-morbidity of CFS patients with fibromyalgia can affect the response to physical and cognitive assessment (Cook et al, 2006). Dysfunctions in the immune mechanism, endocrine and autonomic functions have been reported as originating from the central nervous system (Nijs et al, 2004b; Tanaka et al, 2002). CFS subjects who do not exercise to their full capacity may be doing so due to the impairment in the mechanisms which influence effort sense and avoidance behaviours (Wallman et al, 2004a). In further explorations, Wallman et al considered the relationship among physiological, psychological and cognitive variables; they found that there was a central mechanism which accounted for the sensation of fatigue in CFS patients (2005). Some researchers have attributed the reduced exercise capacity in CFS to central factors (Georgiades et al, 2003). Aetiopathogenesis Pathophysiology, aetiology and pathogenesis of CFS have not been understood yet (Chaudhuri and Behan, 2004). Twin studies have shown that some amount of heritage has been associated with CFS (Cho et al, 2006). Molecular analyses indicate an association between CFS and polymorphisms of genes in the autonomic and endocrine effector systems (Goertzel et al, 2006). Personality traits may have an influence on the CFS especially perfectionism; conscientiousness and internalization could alter the image (Wyller, 2009). The hypotheses that are postulated for the aetiopathogenesis are as follows (RACPWG, 2002). The infectious theory relates the CFS to “Epstein Barr virus, Candida albicans, Borrelia burgdorferi, Enterovirus, Citomegalovirus, Human Herpesvirus, Espumavirus, Retrovirus, Borna virus, Coxsackie B virus, and hepatitis C virus (HCV)” but the pathogenic relationship has not yet been established (Engleberg, 2002). The immunological theory has not been proved yet with scientific evidence even though illnesses have involved the immune system; researches have given contradictory results. The neuroendocrinological theory has been postulated as CFS had increased hormones related to the hypothalamic-pituitary-adrenal axis. A disorder has been found in the autonomous nervous mechanism too. Patients with fibromyalgia have symptoms similar to those of CFS but symptoms appear according to the site of action and the type of neurotransmitters (Rivera, 2004). A different perspective has been indicated by Devanur and colleagues who have taken the stand that the aetiology of chronic fatigue syndrome is multifactorial (2009). The combination of factors could be a viral infection with inadequate rest and excess stress which contribute to the CFS (Devanur, 2009). Wyller et al have indicated a “coherent and integrative model” for CFS (2009). This model of sustained arousal has been an association between the sustained arousal and CFS. The stress theory on which this model is based is CATS (Cognitive activation theory of stress ) Stress is believed to occur when “there is a discrepancy between what is valued and what exists (Wyller, 2009). The process which is fast and automatic allows cognitive evaluation of situations and their outcomes. The present sensory information is compared to stored brain information. The hypothetic mechanism causes sustained arousal and comparison is made in relationship to other researches (Wyller, 2009). Sustained arousal may be experienced as cardiovascular and thermoregulatory homeostasis. In the resting supine position, CFS patients would show a heightened arterial blood pressure and increased body temperature due to sympathetic nervous activity being enhanced in the heart (Wyller et al, 2007). Combining the orthostatic position with exercise, the CFS patients showed a greater cardiovascular out flow and a lesser increase in the arterial blood pressure (Wyller, 2008). CFS patients had a greater sympathetic outflow to skin arterioles and a normal temperature during cooling (Wyller et al, 2007). Exercise The effects of exercise on the chronic fatigue syndrome were explored by Neary and his colleagues in 2008. They focused on the hypothesis that exercise diminished the delivery of oxygen to the brain in CFS subjects (Neary et al, 2008). Exercise intolerance and reduced prefrontal oxygenation were exhibited. The researchers explored the “effects of maximal incremental exercise to the limits of tolerance on quantitative changes in cerebral oxygenation and blood volume in CFS subjects” (Neary et al, 2008). They also compared the cerebral oxygenation in CFS subjects and controls in a situation of maximum incremental exercise. Neary et al concluded that an altered cortical oxygenation response was exhibited by subjects who performed exercise to the limits of tolerance. The diminished oxygenation and blood volume changes may be associated with the regional reductions of cerebral blood flow (Neary et al, 2008). The reduced blood flow may have influenced the neural drive and the CNS functions. Sample size was too small for generalization of findings. Imaging of the brain with NIRS probes on more regions of the brain was not done It would have provided a global reflection of brain oxygenation (Neary et al, 2008). Changes in the cerebral blood flow may have been better detected by the transcranial Doppler which would have provided a direct measure of the flow in the conditions of exercise, rest and recovery. Above all this, there is the possibility of the CFS subjects being unable to perform exercise to the maximum. Research approaches The positivist approach of research is practical in this study (Instance, DeMontfort University). Facts and observable phenomena are focused upon in this kind of scientific study. Primary goals are addressed and predictions can be made followed by explanations for the outcomes. Consistencies in patterns and properties can be identified and generalisation is a possibility. It is mostly a quantitative research as evidence is measurable. Interviews and questionnaires provide useful information on assessments (Fernandez, 2009). Patient diaries also help. Patient self records and functional assessment by the Karnofsky Performance Scale, Medical Outcomes Study Short-Form General Health Survey and Sickness Impact profile help to elicit the patient’s daily routines. Pain assessments are made with the Analogue Visual Scale. Fatigue is assessed by the Multidimensional Fatigue Inventory (Fernandez, 2009). The scale helps the CFS patient to easily identify their problem in a relative manner during the first visit and after six months. The functional capacity scale also helps the patient to keep an eye on his own condition. The maintenance of self records helps the patient to identify severity of symptoms and aggravating factors. Daily functional capacity scale is a useful tool (Fernandez, 2009). The degree of impairment may be quantified by aerobic capacity of patients with the spiro-ergometric tests, expired gases, heart rate and work load quantified. Other semi-quantitative tests are the 6-minute running test, strength of muscles and mobility of peripheral joints (Fernandez, 2009). Three types of tasks may be used for the investigation: event-based, timed and activity based. The tasks that are used are the RM free recall task, Wechsler test of adult reading, Wechsler Abbreviated Scale of Intelligence, Prospective and Retrospective Memory questionnaire and hospital anxiety and depression scale are the tools used to investigate cognitive impairments (Attree, 2009). Prospective memory is tested by the real life and virtual reality tests Statistically significant differences were not seen between the CFS patients and the healthy patients (Attree, 2009). When investigation is being done, participants from a similar background would produce compatible results. CFS patients had a lesser performance in the RM recall test due to slower information processing. Prospective memory may have a retrospective component as future intentions are stored and accessed just like past experiences. Salient environmental cues were found to improve the performance of the CFS patients (Brooks, 2004). This conveyed the impression that with no cues, their daily functions would suffer. CFS patients believed themselves to be forgetful even though their performance on some tasks matched that of controls; they had feelings of insufficiency (Attree, 2009). CFS patients had a habit of setting a higher threshold which may be producing the feelings of insufficiency (Metzger and Denney, 2002 cited in Attree, 2009). Examination of cognitive functions would be difficult as each person had a different level of deficit. CFS patients had difficulty in following instructions in a noisy background. This raises the question as to whether the CFS patients had attentional problems (Attree, 2009). Treatment Different modalities of treatment may be combined for the management of CFS (Fernandez, 2009). Cognitive behaviour therapy with gradual physical exercise appears to be feasible. CBT is combined with other group therapies that increase treatment compliance. CBT instituted early works well for the young (Fernandez et al, 2009). Pharmacological therapies also have been tried. Studies with randomized clinical trials are few and not of reliable standards (Alegre de Miquel, 2005; Vermeulen, 2004; Staud, 2007 all cited in Fernandez, 2009). Ampligen is a recently used drug. It is an anti-viral agent stimulating interferon increase which then decreases the RNasaL (Pae, 2009). Clinical trials have demonstrated moderate improvements. More research has to be done in this direction. The FDA has not approved this experimental drug for general usage yet (Chadler, 2003 in Fernandez, 2009). The Cochrane Collaboration analysed 15 studies with 1043 patients diagnosed with chronic fatigue syndrome of five years duration (Price, 2008). The review found that 40 % who had the CBT felt less fatigued than the control subjects. Only twenty six % of the latter group which had community care or were on a waiting list for care but with no CBT, were less fatigued. The results were similar for the two groups after seven months too during which time, many had dropped out (Price, 2008). The other psychological therapies which were reviewed were relaxation techniques, counseling and education. CBT appeared better off than these other psychological therapies but there was no obvious difference as was seen when compared to usual care. It was concluded that exercise and CBT produced similar effects on patients with CFS (Price, 2008). A follow-up of a trial which indicated that “CBT was more effective than remaining on a waiting list for reducing fatigue and improving physical functioning” was done (Knoop et al, 2008). Adolescents who were included in the initial trial were invited to participate. Of the total of 66, 50 had CBT, 32 in the initial study and 18 in the waiting list received CBT. After the waiting period, 16 refused CBT. The follow-up period of 2.1 years had 61 patients: 47 who had CBT and 16 who had refused the CBT (Knoop et al, 2008). Fatigue severity did not show much difference between the post treatment and follow-up groups of the CBT but physical functioning and school attendance increased by 10% in the CBT group. The CBT group had lesser fatigue and functional impairment and a higher school attendance than the no-CBT group (Knoop et al, 2008). One more interesting finding was that the final outcome was predicted by the fatigue severity of the mother. CBT is proven to be effective in the short term and long term outcomes (Knoop et al, 2008). CBT aimed at modifying the thoughts and behaviour involved in the distressing symptoms (Sharpe, 1997 cited in Fernandez, 2009). The key features of the CBT are “programmed physical exercise, control and coping with disease-associated stress, and cognitive restructuring” (Deale, 1997 cited in Fernandez, 2009). The aim of the gradual physical exercise is to prevent progressive physical deterioration, keeping constant the functional capacity and improving the quality of life (Wallman, 2005b). Ethical issues A written consent would be obtained from the participants who would be informed in detail about the study proposed. They would be given the privilege of participating but they could withdraw at any moment they feel uncomfortable. Strict timings are not adhered to for the study. However the duration taken will be noted. Any discomfort would be given the due consideration and the patient allowed to leave. He may be allowed to continue later. CFS being a disabling condition, it is difficult to get all the patients together as they may be suffering from various accompanying illnesses. Approval for the study will be obtained from the Ethics Approval Council of the university. Implications for further research The hereditary predisposition can be explored for studying the polymorphism of genes involved in the sustained arousal model. CFS with infections produce a long lasting arousal response than in infections alone (Wyller, 2009). In physically or mentally challenged persons, the neurotransmitter activity, perfusion and metabolism in the areas of brain are different in CFS patients and controls. Cognitive behavioural therapy aimed at reducing sustained arousal in CFS patients than in non specific CBT is a proven therapy but the approaches have not been investigated (Wyller, 2009). The functional ability of CFS patients will be improved by the pharmaceutical inhibition of the brain centers which elicit the arousal response. Neary failed to prove without doubt that peripheral changes could also be occurring (2008). Further research is necessary to confirm the Neary findings too where cardiovascular and metabolic changes are to be studied with respect to the cerebral blood flow and oxygenation. Conclusions CFS is a chronic disease which hampers the patient from fulfillment of the social, work and family responsibilities. The problem must be prevented by the adaptation of the education, healthcare and social systems. The present situation is rife with difficulties, shortages and rejections due to lack of care (Fernandez, 2009). No curative care exists. Improving the clinical manifestations and upholding the functional capacity and quality of life by developing a tailored programme is the essential principle behind the treatment Multidisciplinary management is the best approach with the coordination among the specialists as specified. An action protocol is the best technique to approach the therapy of the patients. Patient education and the Healthcare sector need to support each other (Fernandez, 2009). References: Brooks BM, Rose FD, Potter J, et al. (2004). Assessing stroke patients’ prospective memory using virtual reality. Brain Injury 2004; 18:391–401. CFS (Chronic fatigue syndrome). Dated 29/6/2009. Retrieved on 4/12/09. http://www.nhs.uk/me/introduction.aspx NHS, UK CFS/ME, Dated January 2008.Retrieved on 4/12/09. http://hcd2.bupa.co.uk/fact_sheets/html/chronic_fatigue_syndrome2.html British United Provident Assciation (Bupa), UK. Cho HJ, Skowera A, Cleare A, Wessely S (2006). 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