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Background: To examine the role of psychological distress, negative life events, social support and lack of fitness (using breathlessness on exertion as a proxy) in the development of new onset fatigue in a primary care population., Method: Adults between the ages of 18 and 45 years who were registered with five general practices in South East England were asked to complete a fatigue questionnaire and the 12-item General Health Questionnaire. Between 1 and 12 months later, subjects who visited the general practitioner (GP) with a suspected viral infection were recruited to the study and asked to complete measures of fatigue, psychological distress, life events, social support and allergies (stage 2). The next person to present to the GP with a complaint other than a viral illness was recruited as a control. Factors assessed at stage 2 that were associated with the development of fatigue were examined with stepwise logistic regression., Results: Acute fatigue was not associated with a viral illness. Negative life events and breathlessness on exertion (interpreted as lack of fitness) were associated with incident cases of fatigue. However, when controlling for concurrent psychological distress, the independent association of negative life events disappeared., Conclusions: Psychological distress was strongly associated with new onset fatigue and hence emphasizes the significance of psychological distress as a concomitant complaint in fatigue. Further, the salient association between breathlessness and fatigue may indicate the need to recommend exercise as a therapeutic strategy to improve physical fitness in the primary care setting.

Objective: The Chalder Fatigue Scale (CFQ) is a widely used instrument to assess fatigue in both clinical and nonclinical settings. Psychometric properties of the scale and discriminative abilities were examined., Methods: A total of 361 patients with CFS and 1615 individuals in the community were assessed with the CFQ. Principal component analysis (PCA) was used to explore the structure of the scale. Receiver-operating characteristic curve (ROC) was used to investigate the discriminative properties., Results: Two components, physical and mental fatigue, were identified in the CFS patient group and in the general population samples. Area under the curve for ROC was .91. The fatigue scale effectively discriminates, at high scores, between CFS patients and the general population., Conclusion: Physical and mental fatigue are clearly separable components of fatigue. The CFQ can discriminate reliably between clinical and nonclinical conditions., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Objective: To compare cognitive-behavioral therapy (CBT) and standard medical care (SMC) as treatments for psychogenic nonepileptic seizures (PNES)., Methods: Our randomized controlled trial (RCT) compared CBT with SMC in an outpatient neuropsychiatric setting. Sixty-six PNES patients were randomized to either CBT (plus SMC) or SMC alone, scheduled to occur over 4 months. PNES diagnosis was established by video-EEG telemetry for most patients. Exclusion criteria included comorbid history of epilepsy, <2 PNES/month, and IQ <70. The primary outcome was seizure frequency at end of treatment and at 6-month follow-up. Secondary outcomes included 3 months of seizure freedom at 6-month follow-up, measures of psychosocial functioning, health service use, and employment., Results: In an intention-to-treat analysis, seizure reduction following CBT was superior at treatment end (group x time interaction p < 0.0001; large to medium effect sizes). At follow-up, the CBT group tended to be more likely to have experienced 3 months of seizure freedom (odds ratio 3.125, p = 0.086). Both groups improved in some health service use measures and on the Work and Social Adjustment Scale. Mood and employment status showed no change., Conclusions: Our findings suggest that cognitive-behavioral therapy is more effective than standard medical care alone in reducing seizure frequency in PNES patients., Classification of Evidence: This study provides Class III evidence that CBT in addition to SMC, as compared to SMC alone, significantly reduces seizure frequency in patients with PNES (change in median monthly seizure frequency: baseline to 6 months follow-up, CBT group, 12 to 1.5; SMC alone group, 8 to 5).

Objectives: To determine whether (i) motivational enhancement therapy (MET) + cognitive behaviour therapy (CBT) compared with usual care, (ii) MET compared with usual care, (iii) or MET + CBT compared with MET was more effective in improving glycaemic control when delivered by general nurses with additional training in these techniques., Design: A three-arm parallel randomised controlled trial as the gold standard design to test the effectiveness of psychological treatments., Setting: The recruiting centres were diabetes clinics in seven acute trusts in south-east London and Greater Manchester., Participants: Adults (18-65 years) with a confirmed diagnosis of type 1 diabetes for a minimum duration of 2 years and a current glycated (or glycosylated) haemoglobin (HbA1c) value between 8.2% and 15.0%., Interventions: The control arm consisted of usual diabetes care which varied between the hospitals, but constituted at least three monthly appointments to diabetes clinic. The two treatments arms consisted of usual care with MET and usual care with MET + CBT., Main Outcome Measures: The primary outcome was HbA1c at 12 months from randomisation. Secondary outcome measures were 1-year costs measured by the Client Service Receipt Inventory at baseline, 6 months and 12 months; quality of life-years [quality-adjusted life-years (QALYs)] measured by the SF-36 (Short Form-36 Health Survey Questionnaire) and EQ-5D (European Quality of Life-5 Dimensions) at baseline and 12 months., Results: One thousand six hundred and fifty-nine people with type 1 diabetes were screened and 344 were randomised to MET + CBT (n = 106), MET (n = 117) and to usual care (n = 121). The 12-month follow-up rate for HbA1c was 88% (n = 305). The adjusted mean 12-month HbA1c was 0.45% lower in those treated with MET + CBT [95% confidence interval (CI) 0.16% to 0.79%, p = 0.008] than for usual care; 0.16% lower in those treated with MET (95% CI 0.20% to 0.51%, p = 0.38) than for usual care; and 0.30% lower with MET + CBT than with MET (95% CI -0.07% to 0.66%, p = 0.11). The higher the HbA1c, and the younger the participant at baseline, the greater was the reduction in HbA1c. The interventions had no effect on secondary outcomes such as depression and quality of life. The economic evaluation was inconclusive. Both interventions were associated with increased health care costs than for usual care alone. There was no significant difference in social costs. Cost effectiveness ratios, up to one year, varied considerably according to whether QALY estimates were based on EQ-5D or SF-36 and whether imputed or complete data were used in the analyses., Conclusions: A combination of MET and CBT may be useful for patients with persistent sub-optimal diabetic control. MET alone appears less effective than usual care. Economic evaluation was inconclusive., Trial Registration: Current Controlled Trials ISRCTN77044517.

Objective: To examine predictors of treatment outcome in IBS-patients who participated in a randomized controlled trial in primary care, where 149 irritable bowel syndrome (IBS) patients were randomized to mebeverine hydrochloride (n=77) or mebeverine+cognitive behavior therapy (CBT) (n=72). CBT offered additional benefit over mebeverine alone., Methods: Regression analyses were used to identify predictors of work and social adjustment 12 months after treatment ended. The intervention groups were analyzed separately in order to look at the separate effects in each group., Results: Lower levels of psychological distress (anxiety and depression) at baseline predicted a good outcome in the mebeverine group [beta=0.388 (95% CI: 0.065-0.936), P=.025] but not in the mebeverine+CBT group. In the adjusted model for the mebeverine+CBT group less adaptive IBS related behavioral coping predicted a good outcome [beta=0.285 (95% CI: 0.002-0.210), P=.045]., Conclusion: Different factors are associated with outcome depending on the treatment received. At assessment clinicians should assess patients coping styles and may want to consider recommending CBT to those patients with IBS in primary care who are engaging in unhelpful coping behavior., (Copyright 2010 Elsevier Inc. All rights reserved.)

Objective: To test the hypothesis that people with chronic fatigue syndrome (CFS) would differ significantly from a healthy control group on measures of general personality and perfectionism, specifically on measures of neuroticism and unhealthy perfectionism., Method: A total of 27 female CFS outpatients and 30 female healthy controls completed questionnaires, including the NEO Personality Inventory-Revised, the Multi-dimensional Perfectionism Scale and measures of anxiety and depression., Results: The CFS group was significantly more fatigued, anxious and depressed than healthy controls. They scored significantly higher on neuroticism and unhealthy perfectionism. Healthy and unhealthy perfectionism were positively correlated in the CFS group, but not in the control group., Conclusion: The present study confirms the link between neuroticism and fatigue and finds a link between unhealthy perfectionism and fatigue. A 'healthy trait', such as healthy perfectionism, when coupled with evaluative concerns is not necessarily healthy in a fatigued population. Researchers and clinicians should note the context in which apparently benign traits are expressed, and how they interact with other traits.

Objective: Beliefs about the unacceptability of experiencing or expressing negative emotions have been noted in individuals with a range of problems, including chronic fatigue syndrome (CFS), irritable bowel syndrome, somatization disorder, depression, eating disorders, social phobia, posttraumatic stress disorder, and borderline personality disorder. These beliefs are likely to have implications for emotion regulation and processing, and are addressed explicitly or implicitly within many therapies including cognitive behavior therapy (CBT), mindfulness-based cognitive therapy (MBCT), and Acceptance and Commitment Therapy (ACT). This article describes the development, validation, and internal reliability of the Beliefs about Emotions Scale (BES), a self-report questionnaire to assess such beliefs., Methods: The new scale was completed by people with CFS (n=121) and healthy controls (n=73). Twenty-two individuals with CFS completed the scale before and after CBT., Results: People with CFS had significantly higher scores on this new questionnaire than healthy controls. Principal components analysis identified one factor, and the scale had high internal consistency (0.91). Scores on the BES were most highly correlated with a measure of negative perfectionism (r=0.59) and also showed significant correlations with measures of dysfunctional attitudes, self-sacrifice, depression, anxiety, and fatigue. When completed before and after CBT for CFS, the questionnaire was sufficiently sensitive to detect a significant reduction in endorsement of unhelpful beliefs about emotions., Conclusion: The new Beliefs about Emotions Scale showed good internal reliability, validity and sensitivity to change., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: There is evidence that patients with chronic fatigue syndrome (CFS) have mild hypocortisolism. The clinical significance of this is unclear. We aimed to determine whether hypocortisolism exerted any effect on the response of CFS to cognitive behavioural therapy (CBT)., Method: We measured 24-h urinary free cortisol (UFC) in 84 patients with Centers for Disease Control and Prevention (CDC)-defined CFS (of whom 64 were free from psychotropic medication) who then received CBT in a specialist, tertiary out-patient clinic as part of their usual clinical care. We also measured salivary cortisol output from 0800 to 2000 h in a subsample of 56 psychotropic medication-free patients., Results: Overall, 39% of patients responded to CBT after 6 months of treatment. Lower 24-h UFC output was associated with a poorer response to CBT but only in psychotropic medication-free patients. A flattened diurnal profile of salivary cortisol was also associated with a poor response to CBT., Conclusions: Low cortisol is of clinical relevance in CFS, as it is associated with a poorer response to CBT. Hypocortisolism could be one of several maintaining factors that interact in the persistence of CFS.

Objectives: Recent trials have produced optimistic results for family-focussed cognitive behavioural therapy (CBT) for chronic fatigue syndrome (CFS) in young people. This study sought to examine the under-researched question of the views and experiences of patients and families who take part., Design: Semi-structured interviews and qualitative analysis were chosen in order to address clients' perspectives in depth., Methods: Sixteen young people and sixteen parents who participated in a trial of CBT versus psycho-education (PE) for CFS were interviewed. Key themes were discerned using inductive thematic analysis., Results: Most families had low expectations of a cure but hope for improvement. Generally speaking, participants found both CBT and PE acceptable and helpful. Behavioural aspects of CBT (e.g. goal-setting, graded activity) were found helpful. The opportunity to gain support, recognition and validation was important. Cognitive elements of therapy were sometimes deemed inappropriate and some felt emotional aspects of CFS were not adequately addressed. Participants were ambivalent towards the extent of family involvement. Negative experiences related to the therapy setting and feeling inappropriately labeled. Most participants felt therapy was a stepping-stone towards normal life, although many felt recovery was incomplete. Very few differences were found between themes from CBT and PE participants. A notable exception was that every young person who experienced CBT described therapy as helpful, whereas the participants who strongly opposed the therapy approach had all experienced PE., Conclusions: The detailed insights regarding families' therapy experiences suggest areas of improvement for service delivery and topics for further investigation.

Background: People with diabetic foot ulcers report poor quality of life. However, prospective studies that chart quality of life from the onset of diabetic foot ulcers are lacking. We describe change in quality of life in a cohort of people with diabetes and their first foot ulcer during 18 months and its association with adverse outcomes., Methods: In this prospective cohort study of adults with their first diabetic foot ulcer, the main outcome was change in Medical Outcomes Study 36-Item Short Form Health Survey scores between baseline and 18-month follow-up. We recorded baseline demographics, diabetes characteristics, depression, and diabetic foot outcomes and mortality at 18 months., Results: In 253 people with diabetes and their first ulcer, there were 40 deaths (15.8%), 36 amputations (15.5%), 99 recurrences (43.2%), and 52 nonhealing ulcers (21.9%). The 36-Item Short Form Health Survey response rate of survivors at 18 months was 78% (n = 157). There was a 5- to 6-point deterioration in mental component summary scores in people who did not heal (adjusted mean difference, -6.54; 95% confidence interval, -12.64 to -0.44) or had recurrent ulcers (adjusted mean difference, -5.30; 95% confidence interval, -9.87 to -0.73) and a nonsignificant reduction in those amputated (adjusted mean difference, -5.00; 95% confidence interval, -11.15 to 1.14)., Conclusions: Quality of life deteriorates in people with diabetes whose first foot ulcer recurs or does not heal within 18 months.

Background: Multiple Sclerosis (MS) is an incurable, chronic, potentially progressive and unpredictable disease of the central nervous system. The disease produces a range of unpleasant and debilitating symptoms, which can have a profound impact including disrupting activities of daily living, employment, income, relationships, social and leisure activities, and life goals. Adjusting to the illness is therefore particularly challenging. This trial tests the effectiveness of a Cognitive Behavioural intervention compared to Supportive Listening to assist adjustment in the early stages of MS., Methods/design: This is a two arm randomized multi-centre parallel group controlled trial. 122 consenting participants who meet eligibility criteria will be randomly allocated to receive either Cognitive Behavioral Therapy or Supportive Listening. Eight one hour sessions of therapy (delivered over a period of 10 weeks) will be delivered by general nurses trained in both treatments. Self-report questionnaire data will be collected at baseline (0 weeks), mid-therapy (week 5 of therapy), post-therapy (15 weeks) and at six months (26 weeks) and twelve months (52 weeks) follow-up. Primary outcomes are distress and MS-related social and role impairment at twelve month follow-up. Analysis will also consider predictors and mechanisms of change during therapy. In-depth interviews to examine participants' experiences of the interventions will be conducted with a purposively sampled sub-set of the trial participants. An economic analysis will also take place., Discussion: This trial is distinctive in its aims in that it aids adjustment to MS in a broad sense. It is not a treatment specifically for depression. Use of nurses as therapists makes the interventions potentially viable in terms of being rolled out in the NHS. The trial benefits from incorporating patient input in the development and evaluation stages. The trial will provide important information about the efficacy, cost-effectiveness and acceptability of the interventions as well as mechanisms of psychosocial adjustment., Trial Registration: Current Controlled Trials ISRCTN91377356.

Objective: This cross-sectional study aimed to measure the discrepancy between actual and perceived IQ in a sample of adolescents with CFS compared to healthy controls. We hypothesized that adolescents with CFS and their parent would have higher expectations of the adolescent's intellectual ability than healthy adolescents and their parent., Methods: The sample was 28 CFS patients and 29 healthy controls aged 11-19 years and the parent of each participant. IQ was assessed using the AH4 group test of general intelligence and a self-rating scale which measured perceived IQ., Results: Parents' perceptions of their children's IQ were significantly higher for individuals with CFS than healthy controls., Conclusions: High expectations may need to be addressed within the context of treatment.

Background: There is evidence that patients with chronic fatigue syndrome (CFS) have mild hypocortisolism. One theory about the aetiology of this hypocortisolism is that it occurs late in the course of CFS via factors such as inactivity, sleep disturbance, chronic stress and deconditioning. We aimed to determine whether therapy aimed at reversing these factors--cognitive behavioural therapy for CFS--could increase cortisol output in CFS., Methods: We measured diurnal salivary cortisol output between 0800 and 2000 h before and after 15 sessions (or 6 months) of CBT in 41 patients with CDC-defined CFS attending a specialist, tertiary outpatient clinic., Results: There was a significant clinical response to CBT, and a significant rise in salivary cortisol output after CBT., Limitations: We were unable to control for the passage of time using a non-treated CFS group., Conclusions: Hypocortisolism in CFS is potentially reversible by CBT. Given previous suggestions that lowered cortisol may be a maintaining factor in CFS, CBT offers a potential way to address this.

Multiple Sclerosis (MS) is a chronic neurological disease which poses significant psychological adjustment challenges. The purpose of this systematic review was to identify factors that are related to adjustment in people with MS and may be modifiable through psychological intervention. It aimed to gain an overview of the strength of evidence for relationships between psychological factors and adjustment and identify limitations to existing studies and directions for future research. Seventy two studies met inclusion criteria and were included in the review and a narrative synthesis was conducted. A wide range of psychological factors have been studied in relation to adjustment outcomes. The strongest and most consistent finding was that perceived stress and certain emotion-focussed coping strategies are related to worse adjustment in MS. Uncertainty was fairly robustly associated with worse adjustment. There was also more tentative evidence available for relationships between adjustment outcomes and a range of other factors including social support and interactions with others, cognitive errors and biases, illness and symptom cognitions, control perceptions, positive psychology factors, and health behaviours. Implications for therapeutic interventions are discussed and a preliminary model of adjustment to MS is outlined. In light of the shortcomings of extant studies, suggestions for future research are offered.

Background: Although psychological issues can interfere with diabetes care, the effectiveness of psychological treatments in improving diabetes outcomes is uncertain., Objective: To determine whether motivational enhancement therapy with or without cognitive behavior therapy improves glycemic control in type 1 diabetes compared with usual care., Design: Randomized, controlled trial., Setting: 8 diabetes centers in London and Manchester, United Kingdom., Patients: 344 adults with type 1 diabetes for longer than 2 years, with hemoglobin A(1c) levels of 8.2% to 15%, and without complications or severe comorbid disease., Intervention: Nurse-delivered motivational enhancement therapy (4 sessions over 2 months), motivational enhancement therapy plus cognitive behavior therapy (12 sessions over 6 months), or usual care., Measurements: 12-month change in hemoglobin A(1c) levels (primary outcome), hypoglycemic events, depression, quality of life, fear of hypoglycemia, diabetes self-care activities, and body mass index (secondary outcomes)., Results: In an analysis including all randomly assigned patients, the 12-month change in hemoglobin A(1c) levels compared with usual care was -0.46% (95% CI, -0.81% to -0.11%) in the motivational enhancement therapy plus cognitive behavior therapy group and -0.19% (CI, -0.53% to 0.16%) in the motivational enhancement therapy group alone. There was no evidence of treatment effects on secondary outcomes., Limitations: Of 1659 screened patients, only 507 were eligible and 344 participated. Data on the primary outcome were unavailable for 11.3% of the participants. Study design did not permit distinction of the additive effect of cognitive behavior therapy plus motivational enhancement therapy from the effect of greater intensity and duration of the combined intervention compared with the motivational enhancement therapy alone., Conclusion: Nurse-delivered motivational enhancement therapy and cognitive behavior therapy is feasible for adults with poorly controlled type 1 diabetes. Combined therapy results in modest 12-month improvement in hemoglobin A(1c) levels compared with usual care, but motivational enhancement therapy alone does not.

Introduction: Chronic fatigue syndrome (CFS) affects between 0.006% and 3% of the population depending on the criteria of definition used, with women being at higher risk than men., Methods and Outcomes: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for chronic fatigue syndrome? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2007 (BMJ Clinical evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA)., Results: We found 45 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions., Conclusions: In this systematic review we present information relating to the effectiveness and safety of the following interventions: antidepressants, cognitive behavioural therapy (CBT), corticosteroids, dietary supplements, evening primrose oil, galantamine, graded exercise therapy, homeopathy, immunotherapy, intramuscular magnesium, oral nicotinamide adenine dinucleotide, and prolonged rest.

Background: Fatigue is the central symptom in chronic fatigue syndrome (CFS) and yet very little is known about its neural correlates. The aim of this study was to explore the functional brain response, using functional magnetic resonance imaging (fMRI), to the imaginal experience of fatigue in CFS patients and controls., Method: We compared the blood oxygen level dependent (BOLD) responses of 12 CFS patients and 11 healthy controls to a novel fatigue provocation procedure designed to mimic real-life situations. A non-fatiguing anxiety-provoking condition was also included to control for the non-specific effects of negative affect., Results: During the provocation of fatigue, CFS patients reported feelings of both fatigue and anxiety and, compared to controls, they showed increased activation in the occipito-parietal cortex, posterior cingulate gyrus and parahippocampal gyrus, and decreased activation in dorsolateral and dorsomedial prefrontal cortices. The reverse pattern of findings was observed during the anxiety-provoking scenarios., Conclusions: The results may suggest that, in CFS patients, the provocation of fatigue is associated with exaggerated emotional responses that patients may have difficulty suppressing. These findings are discussed in relation to the cognitive-behavioural model of CFS.

Objectives: Irritable bowel syndrome is often treated in primary-care settings, and it has a relatively large economic impact. Cognitive behaviour therapy (CBT) in addition to mebeverine has been shown to be effective in the short term, compared with treatment with mebeverine alone. This study assesses the impact that CBT in addition to mebeverine has on resource use, and its cost-effectiveness., Methods: Participants were recruited from general practices: those with ongoing symptoms were randomly allocated either to remain just on mebeverine or to receive CBT in addition to mebeverine. Service use and lost employment were measured at baseline and at the 3-month, 6-month and 12-month follow-ups. The net-benefit approach was used for combining the data on therapy costs and symptoms., Results: The mean additional cost of CBT was pound 308. No significant impact of CBT on the use of other services or on lost employment was noted. The cost per clinically important reduction in symptoms was pound 220 by the end of treatment, pound 171 at the 3-month follow-up, pound 1027 at the 6-month follow-up and pound 3080 at the 12-month follow-up, for CBT in addition to mebeverine compared with mebeverine alone., Conclusions: CBT in addition to mebeverine seems to have reasonable cost-effectiveness in the short-term treatment of irritable bowel syndrome, but not beyond 3 months.

Background: The purpose of this study was to assess the efficacy of cognitive behavior therapy (CBT) as a treatment for multiple sclerosis (MS) fatigue., Methods: A randomized controlled design was used where 72 patients with MS fatigue were randomly assigned to eight weekly sessions of CBT or relaxation training (RT). RT was designed to control for therapist time and attention. Participants were assessed before and after treatment, and at 3 and 6 months posttreatment. The primary outcome was the Fatigue Scale. Secondary outcomes included measures of stress, mood, and fatigue-related impairment., Results: Analysis was by intention-to-treat. A group by time interaction showed that the CBT group reported significantly greater reductions in fatigue across the 8 months compared with the RT group (p < .02). Calculated effect sizes for fatigue from baseline to the end of treatment were 3.03 [95% confidence interval, 2.22-3.68] for the CBT group and 1.83 [95% confidence interval, 1.26-2.34] for the RT group. Results also indicted that both groups showed clinically significant decreases in fatigue defined as fatigue levels equivalent or less than those reported by a non-fatigued healthy comparison group. There were no significant interactions between group and any of the secondary outcome variables, with both groups showing improvements over time on all measures., Interpretation: Both CBT and RT appear to be clinically effective treatments for fatigue in MS patients, although the effects for CBT are greater than those for RT. Even 6 months after treatment, both treatment groups reported levels of fatigue equivalent to those of the healthy comparison group.

Aims/hypothesis: The aim of this study was to determine which clinic-based measures of diabetes and foot status at baseline were associated with adverse outcomes 18 months later in people with diabetes presenting with their first foot ulcer., Subjects and Methods: This was a prospective population-based cohort study of adults with type 1 and type 2 diabetes mellitus presenting with their first foot ulcer (excluding those with severe ischaemia, ankle brachial pressure index <0.5). The main explanatory variables were age, sex, smoking status, ulcer site (dorsal or plantar), size and severity of ulcer, severity of neuropathy, ischaemia, glycosylated haemoglobin, presence of micro- and macrovascular complications, and depression. The main outcomes recorded were death, amputation and recurrence of ulceration, and the time taken for each outcome to occur., Results: Two hundred fifty-three people were recruited. There were 40 deaths (15.8%), 36 amputations (15.5%), and 99 recurrences (43.2%) at 18 months. Our main findings were that being older [hazard ratio (HR) 1.07, 95% CI 1.04-1.11], having lower glycosylated haemoglobin (HR 0.73, 95% CI 0.56-0.96), moderate ischaemia (HR 2.74, 95% CI 1.46-5.14), and depression (HR 2.51, 95% CI 1.33-4.73) were associated with mortality. Ulcer severity was the only explanatory factor significantly associated with amputation (HR 3.18, 95% CI 1.53-6.59). Microvascular complications were the only explanatory factor associated with recurrent ulceration (HR 3.34, 95% CI 1.17-9.56)., Conclusions/interpretation: Commonly used primary and secondary care clinic-based measures could provide the basis for a risk assessment tool for adverse outcomes following first presentation of diabetic foot ulcers.

Service in the Persian Gulf in 1991 is associated with increased reporting of symptoms and distress in a proportion of those who served there. Yet despite clear evidence of an increase in symptom burden and a decrease in well being, exhaustive clinical and laboratory based scientific research has failed to document many reproducible biomedical abnormalities in this group. Likewise, there has been no evidence of an increase in disease related mortality. Formal psychiatric disorders are twice as common in Gulf War veterans, as might be expected in the aftermath of any conflict, but this too is insufficient to explain the ill-health observed. Many service personnel who returned unwell believe that they have Gulf War Syndrome, and that their ill-health is due to exposures that they encountered in theatre. Research on multiple exposures to date has not generated a plausible aetiological mechanism for veterans' ill-health. Even if medical research has failed to provide a satisfactory explanation, it remains the case that many of those affected continue to be unwell and disabled some 15 years after returning from combat. For this reason, it is time that more attention is given to developing effective interventions to relieve their ill-health and distress. In this review we discuss the importance of the wider social context, individual illness beliefs and attributions and go on to outline a model of continuing ill-health in Gulf veterans. The review concludes with some suggestions for future research priorities, in particular the need for further qualitative studies to further our understanding of the illness, in order that better treatments may be developed.

The article is a narrative review of the theoretical standing and empirical evidence for the cognitive behavioural model of medically unexplained symptoms (MUS) in general and for chronic fatigue syndrome (CFS) and irritable bowel syndrome (IBS) in particular. A literature search of Medline and Psychinfo from 1966 to the present day was conducted using MUS and related terms as search terms. All relevant articles were reviewed. The search was then limited in stages, by cognitive behavioural therapy (CBT), condition, treatment and type of trial. Evidence was found for genetic, neurological, psychophysiological, immunological, personality, attentional, attributional, affective, behavioural, social and inter-personal factors in the onset and maintenance of MUS. The evidence for the contribution of individual factors, and their autopoietic interaction in MUS (as hypothesised by the cognitive behavioural model) is examined. The evidence from the treatment trials of cognitive behavioural therapy for MUS, CFS and IBS is reviewed as an experimental test of the cognitive behavioural models. We conclude that a broadly conceptualized cognitive behavioural model of MUS suggests a novel and plausible mechanism of symptom generation and has heuristic value. We offer suggestions for further research.

Background: It has been shown that nonpharmacologic interventions are effective management techniques for cancer-related fatigue (CRF) in cancer survivors. However, few studies have investigated their effectiveness in patients who are receiving chemotherapy. In this study, the authors tested the effectiveness of a brief behaviorally oriented intervention in reducing CRF and improving physical function and associated distress in individuals who were receiving chemotherapy., Methods: For this randomized controlled trial, 60 patients with cancer were recruited and received either usual care or the intervention. The intervention was delivered on an individual basis on 3 occasions over a period from 9 weeks to 12 weeks, and the objective of the intervention was to alter fatigue-related thoughts and behavior. Primary outcomes were assessed as follows: CRF using the Visual Analogue Scale-Global Fatigue; physical functioning using the European Organization for Research and Treatment of Cancer Quality-of-Life Core 30 Questionnaire, and CRF-associated distress using the Fatigue Outcome Measure. Assessments were made on 4 occasions: at baseline (T0), at the end of chemotherapy (T1), 1 month after chemotherapy (T2), and 9 months after recruitment (T3). Normally distributed data were analyzed using t tests and random-slope/random-intercept mixed models., Results: The intervention demonstrated a trend toward improved CRF, although this effect was reduced once confounders had been controlled statistically. There was a significant improvement in physical functioning (coefficient, 10.0; 95% confidence interval, 2.5-17.5; P = .009), and this effect remained once the confounding effects of mood disturbance and comorbid disorders were controlled statistically. No decrease in fatigue-related distress was detected., Conclusions: The behaviorally oriented intervention brought about significant improvements in physical functioning, indicated a trend toward improved CRF, but detected no effect for fatigue-related distress., ((c) 2007 American Cancer Society.)

Objectives: To develop a brief measure of the therapy process and use it to examine which therapeutic ingredients were associated with outcome in a sample of patients from a randomized controlled trial (RCT) of cognitive behaviour therapy (CBT) versus counselling for patients with chronic fatigue in primary care. It was hypothesized that the two therapies would be clearly distinguishable and that in terms of process variables, the therapeutic alliance would be important in predicting outcome., Design: The data for this study were collected alongside a RCT in primary care and included audiotaped therapy sessions. These tapes were assessed by two independent raters using a newly devised measure in order to evaluate therapy process and its relationship with outcome., Methods: Tapes from 71 patients participating in the RCT were assessed to form the basis of the process analysis. Outcome was self-reported fatigue symptoms at 6 months follow-up. Data reduction was achieved via a principal component analysis (PCA). Factors were entered into a multiple regression analysis to produce a final model of predictors of outcome., Results: The process measure showed that although the treatments could be distinguished, there was some overlap between them. The key predictor of a good fatigue outcome was emotional processing, including the expression, acknowledgement and acceptance of emotional distress., Conclusion: A new process measure was developed successfully which now warrants further testing. It was able to assess treatment adherence and unpack, and distinguish the common factor which predicted outcome across therapy modalities. The findings lend preliminary support to the view that the specific techniques associated with particular 'brand names' of therapy are not necessarily the 'active ingredients' that help patient's change within the primary care setting. Emotional processing predicted outcome for patients with chronic fatigue and therefore future research might explore this in more depth, in order to understand better how it can be facilitated.

Objective: The objective of this study was to assess the prevalence of chronic fatigue (CF) and its association with somatization syndrome [Somatization Syndrome Index (SSI) 4/6: >/=4 somatoform symptoms in men, 6 in women] in the general population., Methods: A representative sample of the German population (N=2412) completed a fatigue questionnaire and a screening instrument for current somatoform symptoms (Screening for Somatoform Symptoms 7)., Results: The prevalence rate of CF was 6.1% (n=147). Females were affected significantly more often as compared with males (7% vs. 5.1%). The mean number of somatoform symptoms was higher in CF cases than in control subjects without CF (11 vs. 2; P<.001). Seventy-two percent of the subjects with CF fulfilled the SSI4/6 criterion for somatization syndrome. Quality of life (EUROHIS-QOL and 8-item Short-Form Health Survey) and well-being (5-item WHO Well-Being Index) were markedly decreased in CF and SSI4/6. The results of regression analyses suggest that fatigue and somatization severity had a similar impact on quality of life., Conclusions: The results suggest that CF is relevant in the general population. Its substantial overlap with somatization syndrome supports the hypothesis that the two syndromes are only partially different manifestations of the same underlying processes.

Outcomes for cognitive-behaviour therapy (CBT) in randomised controlled trials (RCTs) have rarely been compared to those in routine clinical practice. Taking the case of CBT for chronic fatigue syndrome (CFS), we evaluated the results of a successful RCT against those of the same treatment given in the same setting as part of routine practice. Fatigue and social adjustment scores were compared for patients who received CBT for CFS as part of a RCT (N=30) and patients who received CBT as part of everyday clinical practice (N=384). The results in the RCT were superior to those in routine clinical practice. Between pre-treatment and 6-month follow-up, the RCT showed a larger reduction in fatigue and greater improvement in social adjustment than those in routine treatment. The changes in fatigue scores were similar for both groups during treatment but were greater in the RCT between post-treatment and follow-up. Potential reasons for the superior results of the RCT include patient selection, therapist factors and the use of a manualised treatment protocol. Practitioners need to pay particular attention to relapse prevention and ensuring adequate follow-up in addition to encouraging patients to continue with cognitive-behavioural strategies once treatment has ended.

Objective: The aim was to evaluate over 18 months whether depression was associated with mortality in people with their first foot ulcer., Research Design and Methods: A prospective cohort design was used. Adults with their first diabetic foot ulcer were recruited from foot clinics in southeast London, U.K. At baseline, the Schedules for Clinical Assessment in Neuropsychiatry 2.1 was used to define those who met DSM (Diagnostic and Statistical Manual of Mental Disorders)-IV criteria for minor and major depressive disorders. Potential covariates were age, sex, marital status, socioeconomic status, smoking, antidepressant use, A1C, macro- and microvascular complications, and University of Texas classification-based severity and size of ulcer. The main outcome was mortality 18 months later, and A1C was the secondary outcome. The proportion who had an amputation, had recurrence, and whose ulcer had healed was recorded., Results: A total of 253 people with their first diabetic foot ulcer were recruited. The prevalence of minor and major depressive disorder was 8.1% (n = 21) and 24.1% (n = 61), respectively. There were 40 (15.8%) deaths, 36 (15.5%) amputations, and 99 (43.2%) recurrences. In the adjusted Cox regression analysis, minor and major depressive disorders were associated with an approximately threefold hazard risk for mortality compared with no depression (3.23 [95% CI 1.39-7.51] and 2.73 [1.38-5.40], respectively). There was no association between minor and major depression compared with no depression and A1C (P = 0.86 and P = 0.43, respectively)., Conclusions: One-third of people with their first diabetic foot ulcer suffer from clinical depression, and this is associated with increased mortality.

Background: Chronic fatigue syndrome (CFS, also called myalgic encephalomyelitis /encephalopathy or ME) is a debilitating condition with no known cause or cure. Improvement may occur with medical care and additional therapies of pacing, cognitive behavioural therapy and graded exercise therapy. The latter two therapies have been found to be efficacious in small trials, but patient organisations surveys have reported adverse effects. Although pacing has been advocated by patient organisations, it lacks empirical support. Specialist medical care is commonly provided but its efficacy when given alone is not established. This trial compares the efficacy of the additional therapies when added to specialist medical care against specialist medical care alone., Methods: 600 patients, who meet operationalised diagnostic criteria for CFS, will be recruited from secondary care into a randomised trial of four treatments, stratified by current co morbid depressive episode and different CFS/ME criteria. The four treatments are standardised specialist medical care either given alone, or with adaptive pacing therapy or cognitive behaviour therapy or graded exercise therapy. Supplementary therapies will involve fourteen sessions over 23 weeks and a booster session at 36 weeks. Outcome will be assessed at 12, 24, and 52 weeks after randomisation. Two primary outcomes of self-rated fatigue and physical function will assess differential effects of each treatment on these measures. Secondary outcomes include adverse events and reactions, subjective measures of symptoms, mood, sleep and function and objective measures of physical activity, fitness, cost-effectiveness and cost-utility. The primary analysis will be based on intention to treat and will use logistic regression models to compare treatments. Secondary outcomes will be analysed by repeated measures analysis of variance with a linear mixed model. All analyses will allow for stratification factors. Mediators and moderators will be explored using multiple linear and logistic regression techniques with interactive terms, with the sample split into two to allow validation of the initial models. Economic analyses will incorporate sensitivity measures., Discussion: The results of the trial will provide information about the benefits and adverse effects of these treatments, their cost-effectiveness and cost-utility, the process of clinical improvement and the predictors of efficacy.

Objective: The objective of this study was to describe the incidence, prevalence, risk factors, and prognosis of fatigue, chronic fatigue, and chronic fatigue syndrome in 11- to 15-year-olds., Methods: A random general population sample (n = 842) of British adolescents and their parents were assessed at baseline and 4 to 6 months later. The main outcomes were fatigue, chronic fatigue, and chronic fatigue syndrome, operationally defined., Results: The incidence over 4 to 6 months was 30.3% for fatigue, 1.1% for chronic fatigue, and 0.5% for chronic fatigue syndrome. The point prevalence was 34.1% and 38.1% for fatigue, 0.4% and 1.1% for chronic fatigue, and 0.1% and 0.5% for chronic fatigue syndrome at time 1 and time 2, respectively. Of participants who were fatigued at time 1, 53% remained fatigued at time 2. The 3 cases of chronic fatigue and 1 case of chronic fatigue syndrome at time 1 had recovered by time 2. Higher risk for development of chronic fatigue at time 2 was associated with time 1 anxiety or depression, conduct disorder, and maternal distress; in multivariate analysis, baseline anxiety or depression remained a significant predictor of chronic fatigue. Increased risk for development of fatigue at time 2 was associated with time 1 anxiety or depression, conduct disorder, and older age; in multivariate analyses, these factors and female gender all were significant predictors of fatigue., Conclusions: The incidence rates for chronic fatigue and chronic fatigue syndrome in this adolescent sample were relatively high, but the prognosis for these conditions was good. This prospective study provides evidence for an association between emotional/behavioral problems and subsequent onset of fatigue/chronic fatigue.

Objective: The Chalder Fatigue Questionnaire (CFQ) is an instrument used to measure physical and mental fatigue. We translated and adapted the questionnaire and tested its reliability and validity in a Brazilian primary care setting., Method: A pilot study with 204 consecutive primary care attenders in Sao Paulo, Brazil, verified the internal consistency and factor structure of the questionnaire. After some modifications through a rigorous translation, back-translation, and cross-cultural adaptation procedure, a validation study was conducted with 304 attenders, who also completed the fatigue section of the Revised Clinical Interview Schedule (CIS-R)., Results: The internal consistency of the Brazilian CFQ slightly improved from the pilot to the validation study: Cronbach's alpha from .86 to .88. The two-factor structure (physical and mental fatigue) also improved. According to the receiver operating curve analysis with the fatigue section of the CIS-R as the standard criterion, 3/4 was chosen as the cutoff for Brazilian primary care (sensitivity 69.1% and specificity 79.4%)., Conclusion: The Brazilian CFQ had good reliability and validity. The cutoff was determined as 3/4 and the factor structure of the English CFQ was closely reproduced.

The aim of this review is to outline the various psychological models of medically unexplained somatic symptoms in children and the interventions derived from these. The interventions that have been evaluated in randomised controlled trials are reviewed, and the implications of the findings for the models are described.

Background: Hemodialysis is a palliative treatment for patients with established renal failure (ERF), and volume overload is a common problem for hemodialysis patients with low urinary output. Volume overload is thought to be mostly attributable to interdialytic fluid intake by the patient and is associated with an increased symptom burden and the development of serious medical complications. Repeated episodes of volume overload may adversely affect staff-patient relationships and the perception of care in this patient population. The aim of this case series study was to evaluate the effect and experience of a psychological intervention on interdialytic weight gain in a small group of patients., Methods: Five patients were treated. The intervention involved using techniques derived from both cognitive behavior therapy and motivational interviewing. The main outcome measures were interdialytic weight gain and patient perception of the intervention., Results: Three of the five patients reduced both mean interdialytic weight gain and the frequency with which they gained in excess of 3% of their dry weight during the intervention phase. The intervention was found to be acceptable to patients., Significance of Results: The intervention was effective in helping three of the five patients to reduce both the frequency and the severity of volume overload, and two of these patients maintained this for at least 6 months post intervention. The intervention used actively engaged the patients and appeared to be experienced positively. The methods used to mobilize patient resources and optimize staff-patient relationships as vehicles of change are discussed. Both may have implications for treatment concordance and the perception of care delivered.

Objective: Up to 90% of patients with chronic fatigue syndrome (CFS) report substantial cognitive difficulties. However, objective evidence supporting these claims is inconsistent. The present functional magnetic resonance imaging study examined the neural correlates of working memory in patients with CFS compared with controls., Methods: Seventeen patients with CFS and 12 healthy control subjects were scanned while performing a parametric version of the n-back task (0-, 1-, 2-, and 3-back)., Results: Both groups performed comparably well and activated the verbal working memory network during all task levels. However, during the 1-back condition, patients with CFS showed greater activation than control subjects in medial prefrontal regions, including the anterior cingulate gyrus. Conversely, on the more challenging conditions, patients with CFS demonstrated reduced activation in dorsolateral prefrontal and parietal cortices. Furthermore, on the 2- and 3-back conditions, patients but not control subjects significantly activated a large cluster in the right inferior/medial temporal cortex. Trend analyses of task load demonstrated statistically significant differences in brain activation between the two groups as the demands of the task increased., Conclusions: These results suggest that patients with CFS show both quantitative and qualitative differences in activation of the working memory network compared with healthy control subjects. It remains to be determined whether these findings stay stable after successful treatment.

Objectives: To determine whether cognitive behavioural therapy (CBT) in addition to antispasmodic treatment offers a cost-effective benefit to primary care patients with irritable bowel syndrome (IBS) and to identify predictors of outcome., Design: This was a randomised controlled trial in primary care of the addition of CBT to standard general practice management of IBS, using the antispasmodic agent mebeverine hydrochloride. The study set out to compare the addition of a standardised package of IBS-specific CBT to treatment with mebeverine hydrochloride., Setting: Ten general practices, serving a population of around 45,000 patients, located principally in south London, with some patients resident in north London., Participants: Patients identified as having IBS by their GPs, aged between 17 and 54 (mean 34) years and predominantly white; 82% were female and half had had IBS for more than 5 years., Interventions: Practice nurses delivered CBT in a randomised trial of the addition of CBT to mebeverine in patients who had IBS of moderate or greater severity after 2 weeks of GP care and 4 weeks of mebeverine. The Symptom Severity Scale (SSS) was used to identify patients with moderate or severe IBS. Patients who continued to report moderate or severe IBS after 4 weeks of mebeverine at a dose of 270 mg three times a day were randomised to receive six sessions of CBT in addition to mebeverine (72 patients) or mebeverine alone (77 patients). These patients were followed at 3, 6 and 12 months after treatment. As part of the baseline evaluation, blood tests for antiendomysial and antigliadin antibodies were carried out on 141 patients to determine the prevalence of coeliac disease in this population., Main Outcome Measures: The principal outcome measure was the SSS. Others included the Hospital Anxiety and Depression Scale, psychopathology, the Work and Social Adjustment Scale (WASA, disability), a modified version of the Illness Perception Questionnaire (illness perceptions), the Beliefs about Medicine Questionnaire (attitudes to medication), the Reported Adherence to Medication Scale (adherence to prescribed medication), the Client Service Receipt Inventory (economic analysis), the Cognitive Scale for Functional Bowel Disorders (illness cognitions) and the Behaviour Scale for IBS (IBS coping behaviour)., Results: The addition of CBT produced a significant benefit compared with the mebeverine-only group at 3 months after treatment on all outcome measures, except for the adherence to medication scales. The difference between the groups was 107.8 points on the SSS, 24.5 points on question 4 of the SSS and 6.3 points on the WASA, representing therapeutic gains of approximately 20%, 28% and 40%, respectively. However, there was also evidence that these improvements began to wane, so that at 6 and 12 months follow-up significant therapeutic benefit of the addition of CBT could only be detected on question 4 of the SSS and on the WASA. The behaviour scale for IBS detected significant, positive changes in coping behaviours at up to 6 months after treatment. Three factors predicting a poor outcome were identified: male gender, believing that IBS had serious consequences and belief in an external aetiology, all of which were associated with greater than average disability at follow-up. The addition of CBT to mebeverine did not reduce overall treatment or social costs. The nested study on testing for coeliac disease provides cautious support for the inclusion of antiendomysial and antigliadin antibody testing in the investigation of patients thought to have IBS., Conclusions: Specially trained practice nurses can provide effective CBT to primary care patients with a clinical diagnosis of IBS, which although effective does not reduce service or social costs. Using a variety of measures the beneficial therapeutic effects of the addition of CBT to antispasmodic therapy persist for up to 6 months. Future research might include studies of the long-term follow-up of IBS patients treated with CBT, cost-benefit analyses comparing CBT with other therapeutic approaches to IBS, and evaluating means of training both non-specialist health professionals and GPs to deliver CBT.

Background: Chronic fatigue syndrome (CFS) is being increasingly recognized in children and adolescents. Yet comparatively little attention has been given in the literature to management., Methods: Description of the main features of the disorder, precipitating and maintaining factors and diagnostic assessment. Outline of different views on the nature and treatment of CFS in childhood. Description of a rehabilitation program based on cognitive behavior therapy and graded activity., Results: Using adult research criteria, CFS can be diagnosed in children and adolescents. In its severe form it is often triggered by infectious illness episodes. It is commonly associated with mood disorders in the child and with mental distress and high levels of emotional involvement in parents. A number of patient support groups hold the view that CFS is a medical disorder, contest a psychiatric contribution and advocate 'pacing' as an approach to rehabilitation which includes avoiding activities. To date there is no empirical evidence for the efficacy of this approach. Research in adults, open and clinical reports in children support the use of graded activity and family cognitive behavior therapy. The main aim is to enable children, with the help of their family, to carry out their own rehabilitation with some support and guidance from a health professional. Engaging the child and family in treatment and forming a therapeutic alliance is a continual process and a crucial aspect of management, as many families view the condition as a medical disorder and are initially ambivalent towards this approach., Conclusions: There is controversy about the nature and management of CFS in childhood but a rehabilitation program based on family cognitive behavior therapy can be implemented and seems to hold most promise in the management of children with CFS. Family engagement is a crucial aspect of management.

Objective: To assess the efficacy of cognitive behaviour therapy delivered in primary care for treating irritable bowel syndrome., Design: Randomised controlled trial., Setting: 10 general practices in London., Participants: 149 patients with moderate or severe irritable bowel syndrome resistant to the antispasmodic mebeverine., Interventions: Cognitive behaviour therapy delivered by trained primary care nurses plus 270 mg mebeverine taken thrice daily compared with mebeverine treatment alone., Main Outcome Measures: Primary measures were patients' scores on the irritable bowel syndrome symptom severity scale. Secondary measures were scores on the work and social adjustment scale and the hospital anxiety and depression scale., Results: Of 334 referred patients, 72 were randomised to mebeverine plus cognitive behaviour therapy and 77 to mebeverine alone. Cognitive behaviour therapy had considerable initial benefit on symptom severity compared with mebeverine alone, with a mean reduction in score of 68 points (95% confidence interval 103 to 33), with the benefit persisting at three months and six months after therapy (mean reductions 71 points (109 to 32) and 11 points (20 to 3)) but not later. Cognitive behaviour therapy also showed significant benefit on the work and social adjustment scale that was still present 12 months after therapy (mean reduction 2.8 points (5.2 to 0.4)), but had an inconsistent effect on the hospital anxiety and depression scale., Conclusion: Cognitive behaviour therapy delivered by primary care nurses offered additional benefit over mebeverine alone up to six months, although the effect had waned by 12 months. Such therapy may be useful for certain patients with irritable bowel syndrome in primary care.

Objective: The relationship between eating disorders (ED) and irritable bowel syndrome (IBS) is poorly understood. We wanted to determine the prevalence of IBS in a large sample of eating disordered individuals, examine the timing of onset of these disorders and assess whether there are any predictors of IBS symptoms in ED sufferers., Methods: Participants with a current or past ED were recruited from a volunteer register. Two hundred thirty-four respondents completed a questionnaire on IBS devised for the study. ED symptoms were assessed using the Eating Disorders Examination-Questionnaire (EDE-Q)., Results: Sixty-four percent currently met the widely used Manning criteria for IBS. The majority of participants (87%) had developed their ED before the onset of IBS, with a mean of 10 years between the onset of ED and IBS. All EDE subscales were associated with current IBS symptoms, whereas ED duration was not., Conclusion: Preliminary findings suggest that EDs may increase the risk of developing IBS.

Objective: The aim of this study was to describe the advice that patients with acute infectious mononucleosis recall having been given by their general practitioner (GP; family or primary care doctor)., Methods: Individuals with a recent diagnosis of infectious mononucleosis were recruited for a randomised controlled trial assessing the effectiveness of a brief educational intervention on recovery. All participants were asked at their initial assessment what advice that they had been given by their GP. They were not given any prompts and were free to give several responses. Responses were grouped into various themes., Results: Seventy-one patients took part. Of these, 11 (15%) recalled being given no specific advice. Of the remaining 60 participants, 70% recalled being given advice to rest, or to "take it easy", usually without any qualification; 10% recalled being given dietary advice, and 17% advice on simple symptom management., Conclusion: The majority of individuals with recent onset infectious mononucleosis recall being given advice to rest by their GPs. This finding is discussed in relation to evidence suggesting that rest may be unhelpful.

Background: The aim of this study was to design a self-report measure of behavioural responses during the acute phase of an illness, in order to assess the importance of these behaviours in the development of ongoing medically unexplained syndromes., Method: An initial pool of items derived from theoretical models and clinical observation, was piloted on a group of 312 university students to assess the factor structure of the scale and the best fit items. The scale was further validated in a second study of 758 patients who were experiencing Campylobacter gastroenteritis. At 3 months post-infection, patients were sent a second questionnaire assessing symptoms of irritable bowel syndrome (IBS)., Results: Principal components analysis of the items in the student sample yielded a four-factor solution, labelled all-or-nothing behaviour, limiting behaviour, emotional support seeking and practical support seeking. The factor structure was confirmed in the Campylobacter sample, and internal reliability was good. All-or-nothing behaviour was associated with IBS at 3 months post-infection. In contrast, limiting behaviour and practical support seeking at the time of infection appeared to be protective., Conclusion: The results suggest that this is a valid and reliable measure that can predict the development of a medically unexplained syndrome after acute infection. Overdoing things at the time of infection and then needing to rest for prolonged periods (all-or-nothing behaviour), appears to be a particular risk factor for the development of IBS. Targeted interventions at the time of infection may improve coping and prevent symptoms from becoming chronic.

Aims: To review studies evaluating the treatment of chronic fatigue and chronic fatigue syndrome, to describe predictors of response to treatment and to discuss the role of the occupational health physician., Methods: A literature search was carried out using Medline and PsychInfo., Results: Studies evaluating cognitive behaviour therapy, graded exercise therapy, pharmacological interventions (e.g. antidepressants and corticosteroids), immunological interventions and nutritional supplements were reviewed. The most promising results have been found with cognitive behaviour therapy and graded exercise therapy, and some predictors of outcome have been identified. Most of the other interventions were evaluated in just one or two studies and therefore evidence is insufficient to draw firm conclusions., Conclusions: By applying the models of fatigue that form the bases for cognitive behaviour therapy and graded exercise therapy, occupational health physicians may play an important role in helping the patients with chronic fatigue syndrome to reduce their symptoms, improve their functioning and return to work.

Objectives: Glandular fever is associated with an approximate fivefold increase in fatigue at 6 months. Reduced levels of fitness and illness beliefs may be important predictors of fatigue following glandular fever. We therefore developed a brief psycho-educational intervention aimed at improving recovery from infectious mononucleosis, and piloted a randomised controlled trial to evaluate the intervention., Methods: We performed a randomised-controlled trial in primary health care in Southeast London and Kent. Sixty-nine patients aged between 16 and 45 years who were diagnosed, serologically and clinically, with acute infectious mononucleosis between December 1999 and December 2000 were randomised. The control group received a standardised fact-sheet about infectious mononucleosis, which gave no advice on rehabilitation. Patients who were randomised to the intervention received an individual treatment session, two follow-up telephone calls, and an information booklet. Fatigue score 6 months after the onset of infectious mononucleosis was the main outcome measure., Results: Sixty-nine out of 139 patients referred were recruited and randomised. Eighty-seven percent of those recruited completed the Fatigue Questionnaire at 6 months. The intervention was acceptable to all who received it. There were fewer fatigue cases in the intervention group than the control group at 6 months follow-up (odds ratio 0.31, 95% confidence interval 0.09-0.91)., Conclusions: A brief intervention at the diagnosis of infectious mononucleosis is acceptable, and may help prevent the development of chronic fatigue. Definitive randomised controlled trials are required to test the intervention.

Background: There is accumulating evidence of hypothalamic-pituitary-adrenal (HPA) axis disturbances in chronic fatigue syndrome (CFS). The salivary cortisol response to awakening has been described recently as a non-invasive test of the capacity of the HPA axis to respond to stress. The results of this test correlate closely with those of more invasive dynamic tests reported in the literature; furthermore, it can be undertaken in a naturalistic setting., Aims: To assess the HPA axis using the salivary cortisol response to awakening in CFS., Method: We measured salivary cortisol upon awakening and 10, 20, 30 and 60 min afterwards in 56 patients with CFS and 35 healthy volunteers., Results: Patients had a lower cortisol response to awakening, measured by the area under the curve., Conclusions: This naturalistic test of the HPA axis response to stress showed impaired HPA axis function in CFS.

Depersonalisation (DP) and derealisation (DR) are subjective experiences of unreality in, respectively, one's sense of self and the outside world. These experiences occur on a continuum from transient episodes that are frequently reported in healthy individuals under certain situational conditions to a chronic psychiatric disorder that causes considerable distress (depersonalisation disorder, DPD). Despite the relatively high rates of reporting these symptoms, little research has been conducted into psychological treatments for this disorder. We suggest that there is compelling evidence to link DPD with the anxiety disorders, particularly panic. This paper proposes that it is the catastrophic appraisal of the normally transient symptoms of DP/DR that results in the development of a chronic disorder. We suggest that if DP/DR symptoms are misinterpreted as indicative of severe mental illness or brain dysfunction, a vicious cycle of increasing anxiety and consequently increased DP/DR symptoms will result. Moreover, cognitive and behavioural responses to symptoms such as specific avoidances, 'safety behaviours' and cognitive biases serve to maintain the disorder by increasing awareness of the symptoms, heightening the perceived threat and preventing disconfirmation of the catastrophic misinterpretations. A coherent model facilitates the development of potentially effective cognitive and behavioural interventions.

Objective: To investigate the strength of chronic fatigue syndrome (CFS) patients' negative illness perceptions by comparing illness perceptions and self-reported disability in patients with CFS and rheumatoid arthritis (RA)., Methods: Seventy-four RA patients and 49 CFS patients completed the Illness Perception Questionnaire-Revised and the 36-item Short-Form Health Survey., Results: When compared to the RA group, the CFS group attributed a wider range of everyday somatic symptoms to their illness, perceived the consequences of their illness to be more profound and were more likely to attribute their illness to a virus or immune system dysfunction. Both groups reported equivalent levels of physical disability but the CFS group reported significantly higher levels of role and social disability., Conclusion: Although the symptoms of CFS are largely medically unexplained, CFS patients have more negative views about their symptoms and the impact that these have had on their lives than do patients with a clearly defined and potentially disabling medical condition. The data support the cognitive behavioural models of CFS that emphasise the importance of patients' illness perceptions in perpetuating this disorder.

Background: Chronic fatigue syndrome (CFS) in children is a controversial diagnosis with unclear aetiology, ill defined but likely increasing incidence, and debatable clinical management options. However these children experience real and considerable suffering. Appropriate research in this clinical population is sparse and usually occurs in tertiary referral units., Methods: Cross sectional survey of 36 children attending a GP specialist interest clinic in southeast England., Results: Patient sociodemographics and clinical morbidity were largely comparable to the literature from tertiary referral research centres. Some prognostic indicators for adults did not readily transfer to this younger age group, although several children had a positive family psychiatric history. Receiving treatment was associated with increased school attendance, but one third of subjects obtained no qualifications. Return to normal health or significant overall improvement was reported by 29/36 subjects., Conclusions: The outcomes in this setting are favourable and comparable to those seen in a controlled setting; this study supports the concept that the prognosis for CFS in children and adolescents is generally good. However, the impact of the illness is significant and this is perhaps most evident in terms of education. Current methods of reporting educational outcomes in the literature are varied and merit development of standardised tools.