مقابله با استرس و شناخت بیماری: سندرم خستگی مزمن

The chronic fatigue syndrome (CFS) is described, and research on coping with this illness reviewed and analysed. CFS is a severely disabling illness of unknown etiology, which has occurred in epidemic forms all over the world. However, the number of sufferers has dramatically increased over previous years. The heterogeneous symptomatology of CFS was reviewed, and diagnostic criteria were discussed. The difficulty in establishing causality was emphasized. An interaction of factors appears most likely to be associated with illness onset and maintenance. As the mediating factor could be sufferers' coping behavior, the existing coping literature was reviewed. There might be an association between coping and physical and psychological well-being. Finally, recommendations are made for longitudinal research on coping and coping effectiveness, and for the development of therapeutic interventions.

THE CHRONIC FATIGUE syndrome (CFS) is a disabling condition of unknown etiology and prognosis. Parallel to an apparent increase in the number of sufferers over the past decade (currently there are half a million diagnosed sufferers in the United States; Friedberg & Jason, 1998), CFS has received increasing attention in the scientific literature. Most studies have been concerned with researching possible causes and treatment of the main symptom, fatigue. The importance of coping with cfs Research into interventions to increase psychological well-being has been rare, as most cognitive-behavioral interventions are aimed at increasing physical functioning. It is argued here that greater attention should be paid to the patient's emotional and psychological state. This could be achieved by focusing on the patient's coping behavior. In accordance with this, the literature on coping with CFS was reviewed. It has been recognized that literature reviews are often influenced by the authors' discipline (Joyce, Rabe-Hesketh, & Wessely, 1998). In this case of CFS, researchers frequently belong to areas of, for example, psychology, psychiatry, and immunology, and so an additional aim was to overcome this problem by reviewing the literature from a multidisciplinary perspective. CFS has been called the “disease of a thousand names” (Bell, 1991). It has been referred to as myalgic encephalomyelitis (ME), postviral fatigue syndrome (PVFS), chronic fatigue immune dysfunction syndrome (CFIDS), and yuppie flu, to name a few. The variety of names stems from the fact that the etiology of CFS is not known. Some people have argued that CFS is an umbrella term and therefore that ME, PVFS, and other conditions are really subclasses of CFS (Jason et al., 1995). The diagnoses of CFS, ME, and PVFS are variously given by physicians, but there is insufficient evidence supporting the existence of such subclasses, and therefore physicians' and researchers' use of CFS to embrace the various symptoms will be adopted here. While names such as ME or PVFS imply specific causes, CFS only points to the most prominent symptom, fatigue. Reports suggest the CFS affects predominantly young (20- to 50-year-old) White women (Fuhrer & Wessely 1995, Fuller & Morrison 1998 and Hilgers, Krueger, Lembke, & Ramon 1991; Kroenke, Wood, Magelsdorff, Meier, & Powell, 1988), many of whom are working in highly demanding jobs before the onset of the illness. This led to the assumption by some physicians that the so-called yuppies, young and successful professionals, and especially women struggling with work and family responsibilities, had finally succumbed to stress (Ho-Yen, 1990). Such suggestions implied that CFS was a product of the stressful Western way of living. However, these assumptions are being challenged now as men, children, and generally people of all ages and who do not report extreme stress prior to the onset of CFS, also appear to be affected (Shepherd, 1992). For instance Bell (1991) suggests that up to 30% of reported cases are children (although there are only few cases under the age of 5). Nevertheless, it appears that overall about 75% of reported cases are adult white females Bell 1991, Showalter 1997 and Wessely and Sharpe 1995. Similar figures are often reflected in study samples. For example, Lewis, Cooper, and Bennett (1994) obtained a sample of 23% males and 77% females, while Ray, Jefferies, and Weir (1995) obtained a female sample of 68%. It must be emphasized that the greater number of females diagnosed with CFS might be related to increased symptom reporting in females and stigma (Lewis & Wessely, 1992). Nevertheless, such figures underline the difficulty associated with recruiting male patients or those from ethnic minorities (an exception is Buchwald et al., 1995). The illness gained widespread recognition only in the last decade when the number of cases increased for no apparent reason. However, some experts argue that it has existed before. For example, Bell (1991) has pointed out that CFS has occurred in epidemic and endemic forms in at least 50 recorded outbreaks all over the world. It is now recognized that previous outbreaks of CFS occurred in the United States (e.g., Gilliam, 1938), New Zealand (e.g., Poore, 1984), Iceland (e.g., Sigurdsson, 1950) and Britain (e.g., Medical Staff of the Royal Free Hospital, 1957). The most severe of these outbreaks appeared to be the epidemic in Iceland in 1950, which presented 1,100 cases in 2 years. Bell (1991) has emphasized the likelihood of an infectious cause for an illness of such epidemic proportions. However, Showalter (1997) argues that outbreaks of hysteria, such as CFS, can have epidemic proportions as they connect with modern social movements. She suggests that infectious diseases are spread by ecological change, human interaction, and so forth, while infectious epidemics of hysteria are spread by stories in the media, whether newspapers or television. So, the epidemic increase in the reports of CFS-related symptoms and its diagnosis remains obscure. CFS is characterized by physical symptoms such as extreme fatigue without exertion, muscle pain, enlarged lymph nodes, chest pain, headaches, noise and light sensitivity, and more. Cognitive symptoms include memory and concentration difficulties or speech problems. In addition, sufferers often experience psychological symptoms such as depression or mood fluctuations Bell 1991, Macintyre 1992 and Wessely 1992. Symptoms differ between sufferers, as well as within people across single days (Wood, 1987). This lack of consistent symptomatology together with any agreed etiology make the diagnosis of CFS difficult. The Centers for Disease Control (CDC; Holmes et al. 1988) proposed in 1988 a set of diagnostic criteria for research into CFS, namely: (1) exclusion of other illnesses (with similar physical symptoms or psychiatric conditions) by evaluation based on history, physical examination, and laboratory findings; (2) new onset of debilitating fatigue that does not resolve with bed rest and with reduced activity level to below 50% of the patient's premorbid activity level; (3) the presence of six symptoms such as fever, sore throat, painful lymph nodes, muscle weakness, and others for at least 6 months; and (4) the presence of at least two physical criteria such as low-grade fever, nonexudative pharyngitis, and tender cervical or axillary lymph nodes. If no physical criteria are present, eight or more symptoms are required for diagnosis. These criteria were initially recommended and widely accepted by researchers as well as physicians. However, they were also criticized for a number of reasons, including the exclusion of all psychiatric conditions, such as depression, and because a large number of symptoms had to be present for a diagnosis of CFS (Price, North, Wessely, & Fraser, 1992). So, the criteria excluded a large number of people with psychiatric disorders, such as depression and anxiety, which have been proposed by some to be secondary to CFS (Bates et al., 1994). Alternative criteria were consequently developed which were less restrictive (in Britain: Sharpe et al., 1991; in Australia: Lloyd, Wakefield, Boughton, & Boyer, 1988). Recently, new criteria have also been defined by the CDC (Fukuda et al., 1994), which require the following: presence of persistent or relapsing fatigue which is new or definite but unexplained, and that lasts 6 or more months, and four out of a range of symptoms such as cognitive impairments, sore throat, muscle pain, or tender lymph nodes, which have been present for at least 6 months but do not predate the fatigue. In addition, the criteria require the exclusion of any medical condition that might lead to chronic fatigue, the exclusion of any past or current major depressive disorder, alcohol or other substance abuse within 2 years before the onset of chronic fatigue, and the exclusion of severe obesity. Thus, the criteria defined by Holmes et al. (1988) and Fukuda et al. (1994) differ in the number of required symptoms, which have been reduced in the new set of criteria, and in the definition of fatigue, which must now have a new or definite onset. The new criteria therefore allow the inclusion of a wider range of conditions which may cause persistent fatigue (Bates et al., 1994). The new CDC criteria are still somewhat more restrictive than the British and Australian criteria, and differ in respect to requirements of fatigue severity, type of fatigue, neuropsychiatric symptoms, and other minor criteria Bates et al. 1994 and Jason et al. 1997. However, all three exclude patients with medical conditions associated with fatigue and major psychiatric disorders (Bates et al., 1994). A problem has emerged in that physicians employ different diagnostic criteria, for example, U.S. doctors generally use the CDC criteria, while British doctors use the Oxford ones. Therefore, patients presenting with a different symptomatology are given the same diagnosis, and this can have an impact not only on treatment, but also on the conclusions drawn from research.