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    1. A report--chronic fatigue syndrome - Guidelines for research
      Sharpe MC, Archard LC, Banatvala JE et al. - J R Soc Med 1991;84:118-21

    2. A review of the evidence for overlap among unexplained clinical conditions
      Aaron LA, Buchwald D – Ann Intern Med 2001;134: 868-81
      Purpose - Unexplained clinical conditions share features, including symptoms (fatigue, pain), disability out of proportion to physical examination findings, inconsistent demonstration of laboratory abnormalities and an association with "stress" and psychosocial factors.
      This literature review examines the nature and extent of the overlap among these unexplained clinical conditions and the limitations of previous research.
      Data sources - English-language articles were identified by a search of the MEDLINE database from 1966 to January 2001 by using individual syndromes and their hallmark symptoms as search terms.
      Study selection - Studies that assessed patients with at least one unexplained clinical condition and that included information on symptoms, overlap with other unexplained clinical conditions or physiologic markers.
      Conditions examined were the chronic fatigue syndrome, fibromyalgia, the irritable bowel syndrome, multiple chemical sensitivity, temporomandibular disorder, tension headache, interstitial cystitis and the postconcussion syndrome.
      Data extraction - Information on authorship, patient and control groups, eligibility criteria, case definitions, study methods and major findings.
      Data synthesis - Many similarities were apparent in case definition and symptoms and the proportion of patients with one unexplained clinical condition meeting criteria for a second unexplained condition was striking.
      Tender points on physical examination and decreased pain threshold and tolerance were the most frequent and consistent objective findings.
      A major shortcoming of all proposed explanatory models is their inability to account for the occurrence of unexplained clinical conditions in many affected patients.
      Conclusions - Overlap between unexplained clinical conditions is substantial.
      Most studies are limited by methodologic problems, such as case definition and the selection and recruitment of case-patients and controls.
      Cfr. :

    3. A search strategy for occupational health intervention studies
      Verbeek J, Salmi J, Pasternack I, Jauhiainen M, Laamanen I, Schaafsma F, Hulshof C, van Dijk F, Cochrane Occupational Health Field, Finnish Institute of Occupational Health, Department of Research and Development of Occupational Health Services, PO Box 93, 70701 Kuopio, Finland : - Occup Environ Med. 2005 Oct;62(10):682-7 - PMID: 16169913
      - As a result of low numbers and diversity in study type, occupational health intervention studies are not easy to locate in electronic literature databases.
      Aim - To develop a search strategy that facilitates finding occupational health intervention studies in Medline, both for researchers and practitioners.
      Methods - A gold standard of articles was created by going through two whole volumes of 19 biomedical journals, both occupational health specialty and non-occupational health journals.
      Criteria for occupational health intervention studies were : evaluating an intervention with an occupational health outcome and a study design with a control group.
      Each journal was searched independently by two of the authors.
      Search terms were developed by asking specialists and counting word frequencies in gold standard articles.
      Results - Out of 11 022 articles published we found 149 occupational health intervention studies.
      The most sensitive single terms were work*[tw] (sensitivity 71%, specificity 88%) and effect*[tw] (sensitivity 75%, specificity 63%).
      The most sensitive string was (effect*[tw] OR control*[tw] OR evaluation*[tw] OR program*[tw]) AND (work*[tw] OR occupation*[tw] OR prevention*[tw] OR protect*[tw]) (sensitivity 89%, specificity 78%).
      The most specific single terms were "occupational health"[tw] (sensitivity 22%, specificity 98%) and effectiveness[tw] (sensitivity 22%, specificity 98%).
      The most specific string was (program[tw] OR "prevention and control"[sh]) AND (occupational[tw] OR worker*[tw]) (sensitivity 47%, specificity 98%).
      Conclusions - No single search terms are available that can locate occupational health intervention studies sufficiently.
      The authors' search strings have acceptable sensitivity and specificity to be used by researchers and practitioners respectively.
      Redefinition and elaboration of keywords in Medline could greatly facilitate the location of occupational health intervention studies.
      Cfr. :

    4. A status report on chronic fatigue syndrome
      Natelson BH, Lange G - Environ Health Perspect 2002;110:673-7
      Medical history has shown that clinical disease entities or syndromes are composed of many subgroups--each with its own cause and pathogenesis.
      Although we cannot be sure, we expect the same outcome for chronic fatigue syndrome (CFS), a medically unexplained condition characterized by disabling fatigue accompanied by infectious, rheumatological and neuropsychiatric symptoms.
      Although the ailment clearly can occur after severe infection, no convincing data exist to support an infectious (or immunologic) process in disease maintenance.
      Instead, data point to several possible pathophysiological processes : a covert encephalopathy, impaired physiological capability to respond to physical and mental stressors and psychological factors related to concerns about effort exacerbating symptoms.
      Each of these is under intense investigation.
      In addition, some data do exist to indicate that environmental agents also can elicit a state of chronic fatigue.
      We expect data to accumulate to support the belief that CFS has multiple causes.
      Cfr. :

    5. A subgroup analysis of cognitive-behavioral treatment studies
      Friedberg F - J Chronic Fatigue Syndr 1999;5:149-59

    6. A systematic review and critical evaluation of the immunology of chronic fatigue syndrome
      Lyall M, Peakman M, Wessely S - J Psychosom Res 2003;55:79-90
      Cfr. :

    7. A systematic review of appraisal tools for clinical practice guidelines - Multiple similarities and one common deficit
      Vlayen J, Aertgeerts B, Hannes K, Sermeus W, Ramaekers D, Belgian Federal Health Care Knowledge Centre, Brussels, Belgium : - Int J Qual Health Care. 2005 Jun;17(3):235-42. Epub 2005 Mar 2 - PMID: 15743883
      Objective - To identify a critical appraisal tool for clinical practice guidelines that could serve as a basis for the development of an appraisal tool for clinical pathways.
      Design - Systematic review of the literature and personal contacts.
      Databases searched were : Medline, Embase and Cinahl.
      Search terms were : practice guidelines, appraisal and evaluation.
      The items of the identified appraisal tools were examined and thematically grouped into 10 guideline dimensions.
      Content analysis and scoring of these domains by the appraisal tools was evaluated.
      Results - Twenty-four different appraisal tools of practice guidelines were identified.
      None scored the evidence base of the clinical content of guidelines.
      Four tools scored all the guideline dimensions.
      The Cluzeau instrument is the only one of these four that has been validated.
      Of the three instruments based on the Cluzeau instrument, the AGREE instrument is the only validated instrument that uses a numerical scale.
      Conclusions - Being a simplified version of the Cluzeau instrument, the AGREE instrument has the most potential to serve as a basis for the development of an appraisal tool for clinical pathways.
      However, important limitations will have to be dealt with when developing such a tool.
      Cfr. :

    8. A systematic review of the content of critical appraisal tools
      Katrak P, Bialocerkowski AE, Massy-Westropp N, Kumar S, Grimmer KA - BMC Med Res Methodol. 2004 Sep 16;4:22 - PMID: 15369598
      - Consumers of research (researchers, administrators, educators and clinicians) frequently use standard critical appraisal tools to evaluate the quality of published research reports.
      However, there is no consensus regarding the most appropriate critical appraisal tool for allied health research.
      We summarized the content, intent, construction and psychometric properties of published, currently available critical appraisal tools to identify common elements and their relevance to allied health research.
      Methods - A systematic review was undertaken of 121 published critical appraisal tools sourced from 108 papers located on electronic databases and the Internet.
      The tools were classified according to the study design for which they were intended.
      Their items were then classified into one of 12 criteria based on their intent.
      Commonly occurring items were identified.
      The empirical basis for construction of the tool, the method by which overall quality of the study was established, the psychometric properties of the critical appraisal tools and whether guidelines were provided for their use were also recorded.
      Results - Eighty-seven percent of critical appraisal tools were specific to a research design, with most tools having been developed for experimental studies.
      There was considerable variability in items contained in the critical appraisal tools.
      Twelve percent of available tools were developed using specified empirical research.
      Forty-nine percent of the critical appraisal tools summarized the quality appraisal into a numeric summary score.
      Few critical appraisal tools had documented evidence of validity of their items or reliability of use.
      Guidelines regarding administration of the tools were provided in 43% of cases.
      Conclusions - There was considerable variability in intent, components, construction and psychometric properties of published critical appraisal tools for research reports.
      There is no "gold standard' critical appraisal tool for any study design, nor is there any widely accepted generic tool that can be applied equally well across study types.
      No tool was specific to allied health research requirements.
      Thus interpretation of critical appraisal of research reports currently needs to be considered in light of the properties and intent of the critical appraisal tool chosen for the task.
      Cfr. :

    9. A taxonomy of medically unexplained symptoms
      Deary IJ - J Psychosom Res 1999;47:51-9

    10. A twin study of chronic fatigue
      Buchwald D, Herrell R, Ashton S et al. - Psychosom Med 2001;63:936-43

    11. ABC of psychological medicine - Functional somatic symptoms and syndromes
      Mayou R, Farmer A – BMJ 2002;325:265-8
      Concern about symptoms is a major reason for patients to seek medical help.
      Many of the somatic symptoms that they present with - such as pain, weakness and fatigue - remain unexplained by identifiable disease even after extensive medical assessment.
      Several general terms have been used to describe this problem - somatisation, somatoform, abnormal illness behaviour, medically unexplained symptoms and functional symptoms.
      We will use the term functional symptoms, which does not assume psychogenesis but only a disturbance in bodily functioning.
      Cfr. :

    12. ABC of psychological medicine - The consultation
      Gask L, Usherwood T - BMJ 2002;324:1567-9

    13. ABC of psychological medicine – Fatigue
      Sharpe M, Wilks D - BMJ 2002;325:480-3
      Fatigue can refer to a subjective symptom of malaise and aversion to activity or to objectively impaired performance.
      It has both physical and mental aspects.
      The symptom of fatigue is a poorly defined feeling and careful inquiry is needed to clarify complaints of "fatigue", "tiredness" or "exhaustion" and to distinguish lack of energy from loss of motivation or sleepiness, which may be pointers to specific diagnoses .../...
      Cfr. :

    14. Abnormal left ventricular myocardial dynamics in eleven patients with chronic fatigue syndrome
      Dworkin HJ, Lawrie C, Bohdiewicz P et al. - Clin Nucl Med 1994; 19: 675-7

    15. Absenteeism among employees treated for depression
      Claxton AJ, Chawla AJ, Kennedy S, Lilly Corporate Center, Eli Lilly and Company, Indianapolis, IN 46285, USA – J Occup Environ Med. 1999 Jul;41(7):605-11 - PMID : 10412102
      Depression-related costs include a relatively large share of indirect costs.
      We describe the impact of antidepressant treatment on absenteeism among workers diagnosed and treated for depression.
      Monthly absenteeism counts from employers were summed in the 6 months before and after the initiation of antidepressant therapy in 630 workers treated for depression with a tricyclic antidepressant or a selective serotonin reuptake inhibitor (fluoxetine, sertraline, paroxetine).
      Monthly mean absenteeism was compared using pairwise t tests.
      Absenteeism increased before antidepressant initiation and decreased after the treatment began for all antidepressant cohorts.
      Absenteeism in the selective serotonin reuptake inhibitor cohorts decreased at similar rates for 4 months but was higher in the paroxetine cohort in months five and six after the treatment initiation.
      Our data suggest that alternative treatments for depression may have differential impact on indirect costs, but further research is warranted.
      Cfr. :

    16. Abuse, personality disorder and chronic fatigue syndrome - Case report and therapeutic implications
      Cuykx V, Van Houdenhove B, Neerinckx E - Gen Hosp Psychiatr 1997

    17. Achieving guidelines for the treatment of depression in primary care - Is physician education enough ?
      Lin EH, Katon WJ, Simon GE, Von Korff M, Bush TM, Rutter CM, Saunders KW, Walker EA, Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, WA 98101-1448, USA - Med Care. 1997 Aug;35(8):831-42 - PMID: 9268255
      - The authors examine whether physician education has enduring effects on treatment of depression.
      Methods - Depressed primary care patients initiating antidepressant treatment from primary care clinics of a staff-model health maintenance organization were studied.
      Quasi-experimental and before-and-after comparisons of physician practices, supplemented with patient surveys, were used to compare the process of care and depression outcomes.
      Intervention consisted of extensive physician education that spanned a 12-month period.
      This included case-by-case consultations, didactics, academic detailing (eg, clearly stating the educational and behavioral objectives to individual physicians) and role-play of optimal treatment.
      Main outcome measures were divided into two groups.
      Quasi-experimental samples included : (1) antidepressant medication selection and (2) adequacy (dosage and duration) of pharmacotherapy.
      Survey samples included : (3) intensity of follow-up; (4) physician delivered educational messages regarding depression treatment; (5) patient satisfaction and (6) depression outcomes.
      Results - No lasting educational effect was observed consistently in any of the outcomes measured.
      Conclusions - There was no enduring improvement in the treatment of depression for primary care patients.
      Depression treatment guidelines were achieved contemporaneously, however, for intervention patients enrolled in a multifaceted program of collaborative care during the training period.
      These results suggest that continuing programs of reorganized service delivery to support the role of a primary care physician (eg, on-site mental health personnel, close monitoring of patient progress and adherence), in addition to physician training, are essential for the success of guideline implementation.
      Cfr. :

    18. Acute sickness behaviour - An immune system-to-brain communication ?
      Vollmer CU - Psychol Med 2001;31:761-7
      Over the past 20 years, psychoneuroimmunological research has produced a large body of evidence that challenges the historically dominant view that the immune system operates in an autonomous manner independent of other physiological systems.
      Today, there is little doubt that the brain and the immune system are intimately linked and capable of reciprocal communication (Ader et al. 1991).
      Despite the acknowledged bi-directional nature of the brain–immune system connection, the predominant focus of study has been on the effects of psychological and behavioural events (e.g. stress) on immune responses and disease processes and the mechanisms underlying such effects (see Kusnekov & Rabin, 1994; Maier et al. 1994; Rozlog et al. 1999).
      However, considerable interest in the possibilities of immune-system-to-brain communication was initiated by a seminal paper considering the biological basis of behaviour in sick animals (Hart, 1988).
      Subsequently, the immunological determinants of the behavioural, cognitive and emotional changes associated with acute illness, as well as with more chronic psychopathological states (e.g. depression) have become the subject of rapidly expanding areas of research (e.g. Kent et al. 1992; Lloyd et al. 1992; Hickie & Lloyd, 1995; Maes et al. 1995a; Rothwell & Hopkins, 1995; Dantzer et al. 1996; Maier & Watkins, 1998; Vollmer-Conna et al. 1998; Maes, 1999).
      The main objective of this editorial is to provide a succinct overview of current knowledge of the normal behavioural correlates of acute infective illness, their adaptive function and underlying mechanisms.
      Elucidation of the processes involved in the appearance, maintenance and inhibition of ‘normal’ sickness behaviour is important if extrapolations from this phenomenon to more chronic psychopathological conditions are to provide more than a new label for poorly understood non-specific symptom clusters.
      Cfr. :;jsessionid=369227417DD8CF82C49F06

    19. Adjuvant occupational therapy for work-related major depression works - Randomized trial including economic evaluation
      A.H. Schene , M.W.J. Koeter, M.J. Kikkert, J.A. Swinkels, P. McCrone, 2006
      Onderzoek naar depressie en werk is tot op heden zeldzaam.
      Eén studie is er verricht naar een behandeling waarin werk en cognitieve gedragstherapie werden gecombineerd.
      In deze studie werd deze gecombineerde behandeling vergeleken met reguliere cognitieve gedragstherapie.
      De gecombineerde behandeling was effectiever waar het gaat om herstel van functioneren dan de reguliere behandeling.
      Cfr. :

    20. Adolescent chronic fatigue syndrome
      Smith MS - Arch Pediatr Adolesc Med 2004;158:207-8
      Cfr. :

    21. AGREE Instrument Training Manual
      AGREE Collaboration, 2003
      Cfr. :

    22. An alternative trial design to overcome validity and recruitment problems in primary care research
      Marcus JH Huibersa,b,c,, Gijs Bleijenbergb, Anna JHM Beurskensa,d, IJmert Kanta, J André Knottnerusc, Daniëlle AWM van der Windte, Ellen Bazelmansb and Constant P van Schayckc -- a Department of Epidemiology and c Department of General Practice, Maastricht University, b Department of Medical Psychology, UMC Nijmegen, d Department of Physiotherapy, Hogeschool Zuyd and e Department of General Practice, Institute for Research in Extramural Medicine, VUmc The Netherlands --Correspondence to : MJH Huibers, Department of Medical, Clinical and Experimental Psychology, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands : - Family Practice Vol. 21, No. 2, 213-218 – Received ; 24 February 2003 – Revised : 2 September 2003 – Accepted : 3 November 2003 - © Oxford University Press 2004
      - Although the randomized controlled trial is widely accepted as the best design to investigate new interventions, conducting a trial in primary care may present researchers with many methodological problems.
      Objective - Our aim was to present an alternative trial design to overcome internal validity and recruitment problems.
      Methods - In a randomized controlled trial, fatigued employees absent from work were selected among the population of an occupational health service in the South of The Netherlands.
      Patients randomly assigned to the experimental condition received cognitive behavioural therapy by a research GP near their home address, whereas patients in the control group received no intervention.
      We describe our considerations for building an alternative design. Research GPs and patients were recruited separately for the study.
      The pre-randomization design was applied.
      Results - Nine research GPs performed all the interventions.
      Seventy-six experimental patients and 75 control patients were selected for study participation.
      Of these, only six patients in the experimental group and seven patients in the control group withdrew from the study at some point during follow-up.
      Conclusion - Results suggest that recruitment and randomization procedures in the alternative design served their purpose well.
      The alternative design proposed here might have several advantages compared with conventional trial procedures.
      However, our design is not widely applicable and there are ethical aspects involved that should be considered.
      Researchers should address their creativity when trying to minimize the problems they may encounter in designing a study.
      Cfr. :

    23. An approach to chronic fatigue syndrome in adults
      Sabin TD - Neurologist 2003;9:28-34
      Background - The neurologist is often asked to evaluate patients with a chief complaint of fatigue.
      Many neurologists do not believe in the pathologically based disease known as chronic fatigue syndrome, yet as a group, neurologists are well suited to guide the diagnostic work up of such patients to pinpoint treatable disorders in the realm of neurology, general medicine, and psychiatry.
      Review summary - Every patient should be carefully evaluated for certain medical, psychiatric and neurologic disease that can cause fatigue as the most prominent symptom.
      This is most pressing because new work in virology, immunology and imaging holds promise but still does not provide any diagnostic test or a mechanism for the production of these symptoms.
      Only a few treatments meet with even modest success in CFS.
      The goal of this paper is to provide the clinical neurologist with a framework for the investigation and management of this challenging group of patients.
      Conclusions - Neurologists are typically also trained in psychiatry and general medicine, and this is a strong position to evaluate the patient with fatigue.
      Because no presently available test can make the diagnosis of CFS, the assessment is vital to seek out more treatable illnesses.
      Cfr. :

    24. An audit of the investigation of patients with suspected chronic fatigue syndrome
      Bethune CA, Wright LJ, Stoker SRG et al. - CPD Bull Immunol Allergy 2003;3:51-3

    25. An empirical delineation of the heterogeneity of chronic unexplained fatigue in women
      Vollmer-Conna U, Aslakson E, White PD, University of New South Wales, School of Psychiatry, 30 Botany Street, Sydney UNSW 2052, Australia : - Pharmacogenomics. 2006 Apr;7(3):355-64 - PMID: 16610946
      Objectives - To test the hypothesis that medically unexplained chronic fatigue and chronic fatigue syndrome (CFS) are heterogeneous conditions and to define the different conditions using both symptom and laboratory data.
      Methods - We studied 159 women from KS, USA.
      A total of 51 of these suffered from fatigue consistent with established criteria for CFS, 55 had chronic fatigue of insufficient symptoms/severity for a CFS diagnosis and 53 were healthy controls matched by age and body mass index (BMI) against those with CFS.
      We used principal components analyses to define factors that best described the variable space and to reduce the number of variables.
      The 38 most explanatory variables were then used in latent class analyses to define discrete subject groups.
      Results - Principal components analyses defined six discrete factors that explained 40% of the variance.
      Latent class analyses provided several interpretable solutions with four, five and six classes.
      The four-class solution was statistically most convincing, but the six-class solution was more interpretable.
      Class 1 defined 41 (26%) subjects with obesity and relative sleep hypnoea.
      Class 2 were 38 (24%) healthy subjects.
      Class 3 captured 24 (15%) obese relatively hypnoeic subjects, but with low heart rate variability and cortisol.
      Class 4 were 23 (14%) sleep-disturbed and myalgic subjects without obesity or significant depression.
      The two remaining classes with 22 (14%) and 11 (7%) subjects consisted of the most symptomatic and depressed, but without obesity or hypnoea.
      Class 5 had normal sleep indices.
      Class 6 was characterized by disturbed sleep, with low sleep heart rate variability, cortisol and sex hormones.
      Conclusion - Chronic medically unexplained fatigue is heterogeneous.
      The putative syndromes were differentiated by obesity, sleep hypnoea, depression, physiological stress response, sleep disturbance, interoception and menopausal status.
      If these syndromes are externally validated and replicated, they may prove useful in determining the causes, pathophysiology and treatments of CFS.
      Cfr. :

    26. An examination of the working case definition of chronic fatigue syndroom
      Komaroff AL, Fagioli LR, Geiger AM et al. - Am J Med. 1996 Jan; 100(1): 56-64

    27. An independent assessment of chiropractic practice guidelines
      Cates JR, Young DN, Guerriero DJ, Jahn WT, Armine JP, Korbett AB, Bowerman DS, Porter RC, Sandman T, King RA, Private practice of chiropractic orthopedics, Oregon, IL 61061, USA - J Manipulative Physiol Ther. 2003 Jun;26(5):282-6 - PMID: 12819623
      Objective - To evaluate the quality of Recommended Clinical Protocols and Guidelines for the Practice of Chiropractic (ICA guidelines) published by the International Chiropractors Association (ICA), August, 2000.
      Methods - The Appraisal Instrument for Clinical Guidelines (Cluzeau instrument) was applied to the ICA guidelines by 10 independent experienced evaluators.
      An independent, global assessment was also made by each evaluator.
      Results - Mean scores (with 95% confidence limit) for each of the instrument's 3 dimensions were Rigor of Development, 27% (5.1); Context and Content, 18.3% (9.4); and Application, 2% (3.9).
      The unanimous global assessment was "not recommended as suitable for utilization in practice."
      Comparison of the ICA guideline scores with the Council on Chiropractic Practice's Clinical Practice Guideline No. 1, Vertebral Subluxation in Chiropractic Practice (CCP guidelines) scores and Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy guidelines) Cluzeau instrument-based scores revealed that the ICA guidelines received slightly higher scores than the CCP guidelines but substantially lower scores than the Mercy guidelines for all dimensions.
      Conclusion - The ICA guidelines were assessed as not suitable for utilization in chiropractic practice.
      Cfr. :

    28. Analysis of aspects of personality and life style in chronic fatigue syndrome
      Neerinckx E, Van Houdenhove B, Bobbaers H et al. - J Chronic Fatigue Syndrome 1996; 3: 99

    29. Analysis of neuropsychological functioning in patients with chronic fatigue syndrome
      Grafman J, Schwartz V, Dale J et al. - J Neurol Neurosurg Psychiatry 1993, 56, 684-9

    30. Antidepressant therapy for unexplained symptoms and symptom syndromes
      O'Malley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K, Department of Medicine, Walter Reed Army Medical Center, Washington, DC, USA - J Fam Pract. 1999 Dec;48(12):980-90 - PMID: 10628579
      - To determine the efficacy of antidepressant therapy for unexplained symptoms or symptom syndromes.
      Search strategies - We identified original studies through searching MEDLINE, EMBASE, PsycLIT, the Federal Research in Progress database and The Cochrane Library.
      We also searched the bibliographies of primary and review articles for additional studies.
      Selection criteria - We excluded trials of patients with neuropathic, oncologic or degenerative joint pain.
      Independent duplicate review of 392 articles identified 94 relevant reports of randomized trials involving 6595 patients across 6 symptom syndromes.
      Independent duplicate assessment was made for inclusion and data abstraction.
      Meta-analysis was performed on extractable placebo-controlled data.
      Main results - Of 94 included trials, most studied either tricyclic antidepressants, antiserotonin antidepressants, selective serotonin reuptake inhibitors (SSRIs) or multiple agents for the treatment of the following syndromes : headache (50), fibromyalgia (18), functional gastrointestinal syndromes (13), idiopathic pain (11), tinnitus (2) and chronic fatigue (2).
      The quality of the studies was fair (mean score = 4.8 on a scale of 0 to 8).
      A majority of the studies (69%) demonstrated benefit for at least one outcome measure.
      Symptom improvement typically did not correlate with depression response in the few studies where it was assessed.
      Meta-analysis of all extractable data showed a substantial benefit from antidepressants : for the dichotomous outcome of improvement, the odds ratio was 3.4 (95% confidence interval [CI], 2.6 - 4.5) and for continuous outcomes, the standardized mean difference was 0.87 (95% CI, 0.59-1.14).
      The absolute percentage difference in improvement between the antidepressant and placebo arms was 32%, yielding a number needed to treat of 3 to improve one person's symptoms.
      Meta-regression indicated no differential effect across the classes of antidepressants; however, onbivariate tally tricyclic studies were associated with a greater likelihood of efficacy than SSRI studies (P = .02).
      Conclusions - Antidepressants can be effective for various physical symptoms and symptom syndromes.
      The relation of outcome to depression and the efficacy of SSRIs needs further study.
      Cfr. :

    31. Antidepressants for depression in medical illness (review)
      Gill D, Hatcher S - Cochrane Database Syst Rev. 2000(4):CD001312
      Cfr. :


    32. Antiviral pathway activation in patients with chronic fatigue syndrome and acute infection
      Gow JW, Simpson K, Behan PO et al. - Clin Infect Dis 2001;33:2080-1
      Gene expression of key enzymes in 2 antiviral pathways (ribonuclease latent [RNase L] and RNA-regulated protein kinase [PKR]) was compared in 22 patients with chronic fatigue syndrome (CFS), 10 patients with acute gastroenteritis and 21 healthy volunteers.
      Pathway activation in the group of patients with infections differed significantly from that of the other 2 groups, in whom there was no evidence of upregulation.
      Therefore, assay of activation is unlikely to provide the basis for a diagnostic test for CFS.
      Cfr. :

    33. Are all evidence-based practices alike ? - Problems in the ranking of evidence
      Upshur RE, Primary Care Research Unit, University of Toronto, Toronto, Ont. : - CMAJ. 2003 Sep 30;169(7):672-3 - PMID: 14517125
      Cfr. :

    34. Are nonspecific practice guidelines potentially harmful ? - A randomized comparison of the effect of nonspecific versus specific guidelines on physician decision making
      Shekelle PG, Kravitz RL, Beart J, Marger M, Wang M, Lee M, Veterans Affairs Health Services Research & Development Service, West Los Angeles Veterans Affairs Medical Center, CA 90073, USA - Health Serv Res. 2000 Mar;34(7):1429-48 - PMID: 10737446
      Objective - To test the ability of two different clinical practice guideline formats to influence physician ordering of electrodiagnostic tests in low back pain.
      Data sources / Study design - Randomized controlled trial of the effect of practice guidelines on self-reported physician test ordering behavior in response to a series of 12 clinical vignettes.
      Data came from a national random sample of 900 U.S. neurologists, physical medicine physicians and general internists.
      Intervention - Two different versions of a practice guideline for the use of electrodiagnostic tests (EDT) were developed by the U.S. Agency for Health Care Policy and Research Low Back Problems Panel.
      The two guidelines were similar in content but varied in the specificity of their recommendations. DATA
      Collection - The proportion of clinical vignettes for which EDTs were ordered for appropriate and inappropriate clinical indications in each of three physician groups were randomly assigned to receive vignettes alone, vignettes plus the nonspecific version of the guideline or vignettes plus the specific version of the guideline.
      Principal findings - The response rate to the survey was 71 percent.
      The proportion of appropriate vignettes for which EDTs were ordered averaged 77 percent for the no guideline group, 71 percent for the nonspecific guideline group and 79 percent for the specific guideline group (p = .002).
      The corresponding values for the number of EDTs ordered for inappropriate vignettes were 32 percent, 32 percent and 26 percent, respectively (p = .08).
      Pairwise comparisons showed that physicians receiving the nonspecific guidelines ordered fewer EDTs for appropriate clinical vignettes than did physicians receiving no guidelines (p = .02).
      Furthermore, compared to physicians receiving nonspecific guidelines, physicians receiving specific guidelines ordered significantly more EDTs for appropriate vignettes (p = .0007) and significantly fewer EDTs for inappropriate vignettes (p = .04).
      Conclusions - The clarity and clinical applicability of a guideline may be important attributes that contribute to the effects of practice guidelines.
      Cfr. :

    35. Assessing attitudes toward new names for chronic fatigue syndrome
      Jason LA, Eisele H, Taylor RR – Eval Health Prof 2001;24:424-35
      Cfr. :

    36. Assessing the quality of research
      Glasziou P, Vandenbroucke J, Chalmers I - BMJ 2004;328:39-41
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    37. Attributes of clinical recommendations that influence change in practice following audit and feedback
      Foy R, MacLennan G, Grimshaw J, Penney G, Campbell M, Grol R, The University of Edinburgh, Department of Obstetrics & Gynaecology, 37 Chalmers Street, UK : - J Clin Epidemiol. 2002 Jul;55(7):717-22 - PMID: 12160920
      The object of this study was to determine which attributes of clinical practice recommendations influence changes in clinical practice following audit and feedback.
      This was an observational study using multilevel modeling to examine the relationship between attributes of clinical practice recommendations and compliance with the recommendations before and after audit and feedback.
      Sixteen hospital gynecology units in Scotland participated in a national audit project.
      Clinical practice recommendations covering selected gynecological topics were developed and data collected to assess baseline (preintervention) compliance.
      Summaries of performance were fed back to consultant gynecologists in each hospital and follow-up (postintervention) data were collected.
      Trained audit assistants used standardized forms to abstract data from case notes.
      Compliance data were available at baseline and follow-up for a total of 42 clinical practice recommendations.
      Altogether, 4,664 case notes contributed to baseline data and 4,382 to follow-up data.
      Thirteen attributes describing clinical practice recommendations were developed, based upon previous work and pretested.
      A panel of seven consultant gynecologists rated the extent to which each of the 42 recommendations possessed each of the 13 attributes.
      The main outcome measures were the association of each attribute with compliance and with changes in clinical practice.
      Recommendations compatible with clinician values and not requiring changes to fixed routines were independently associated with greater compliance at baseline and follow-up.
      However, recommendations incompatible with clinician values were independently associated with greater change in practice following audit and feedback.
      Attributes of recommendations may influence the effectiveness of audit and feedback in secondary care.
      Recommendations seen as incompatible with clinician values are associated with lower compliance but greater behavioral change following audit and feedback.
      Cfr. :

    38. Attributions and self-esteem in depression and chronic fatigue syndromes
      Powell R, Dolan R, Wessely S - J Psychosom Res 1990; 34: 665-73

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    Deel XXI

    1. Autonomic function in panic disorder - Cardiorespiratory and plasma catecholamine responsivity to multiple challenges of the autonomic nervous system
      Presented in part at the 1992 Annual Meeting of the American College of Neuropsychopharmacology, San Juan, Puerto Rico, December 16, 1992 and at the 48th Annual Meeting of the Society for Biological Psychiatry, San Francisco, CA, May 20, 1993
      Murray B. Steinab, Gordon J.C. Asmundsonab – a From the Anxiety Disorders Research Program, Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada – b Department of Pharmacology, University of Manitoba, Winnipeg, Manitoba, Canada - Address reprint requests to : Murray B. Stein, MD, FRCPC, Anxiety & Traumatic Stress Disorders Research Program, Department of Psychiatry, University of California, San Diego Veterans Administration Medical Center, 3350 La Jolla Village Drive, San Diego, California 92161, USA - Biol Psychiatry 1994;Volume 36, Issue 8, Pages 548-558 (15 October 1994)
      We are grateful to Mariette J. Chartier, RN, BSc, for help in conducting the autonomic function studies, to Thomas W. Millar BSc(Eng) for his development of the data acquisition and reduction software, to Ken Dhalla and Dr. Naranjan S. Dhalla for providing the catecholamine assays, to Doug Tataryn, PhD for his assistance with data analysis and to Anjala Bharadwaj for her help in setting up and piloting the autonomic testing procedures. We are also indebted to Meir H. Kryger, MD for the use of his clinical laboratory facilities.
      This investigation was supported in part by grant MA-11344 (to MBS) and a Scholarship Award (to MBS) both from the Medical Research Council of Canada and a Postdoctoral Fellowship Award (to GJGA) from the Manitoba Health Research Council.

      Panic disorder has been widely hypothesized to be associated with dysfunction of the autonomic nervous system.
      In this study, 24 patients with panic disorder and 26 healthy control subjects took part in a broad battery of autonomic function tests, each designed to stress the autonomic nervous system in a particular fashion.
      Testing consisted of postural challenge, isometric exercise, cold pressor and Valsalva maneuver.
      Dependent measures included heart rate, vagal tone, blood pressure, respiratory frequency, end-tidal CO2 levels and plasma norepinephrine and epinephrine levels.
      The testing procedures reliably produced changes in autonomic output in the expected directions, but patients with panic disorder were not found to differ from healthy controls in their cardiorespiratory or plasma catecholaminergic responses.
      This pattern of normal autonomic responsivity in the patients with panic disorder was evident across multiple test conditions with varying autonomic demand characteristics, thereby supporting the integrity of autonomic regulatory systems in this illness.
      These data run counter to a simple notion of autonomic dysfunction in panic disorder.
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    2. Barriers to initiating depression treatment in primary care practice
      Nutting PA, Rost K, Dickinson M, Werner JJ, Dickinson P, Smith JL, Gallovic B, Center for Research Strategies, Suite 1150, 225 E 16th Avenue, Denver, CO 80203, USA : - J Gen Intern Med. 2002 Feb;17(2):103-11 - PMID: 11841525
      Objective and design - This study used qualitative and quantitative methods to examine the reasons primary care physicians and nurses offered for their inability to initiate guideline-concordant acute-phase care for patients with current major depression.
      Participants and setting - Two hundred thirty-nine patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices were randomized to the intervention arm of a trial of the effectiveness of depression treatment.
      Sixty-six (27.6%) patients identified as failing to meet criteria for guideline-concordant treatment 8 weeks following the index visit were the focus of this analysis.
      Methods - The research team interviewed the 12 physicians and 6 nurse care managers to explore the major reasons depressed patients fail to receive guideline-concordant acute-phase care.
      This information was used to develop a checklist of barriers to depression care.
      The 12 physicians then completed the checklist for each of the 64 patients for whom he or she was the primary care provider.
      Physicians chose which barriers they felt applied to each patient and weighted the importance of the barrier by assigning a total of 100 points for each patient.
      Cluster analysis of barrier scores identified naturally occurring groups of patients with common barrier profiles.
      Results - The cluster analysis produced a 5-cluster solution with profiles characterized by patient resistance (19 patients, 30.6%), patient noncompliance with visits (15 patients, 24.2%), physician judgment overruled the guideline (12 patients, 19.3%), patient psychosocial burden (8 patients, 12.9%) and health care system problems (8 patients, 12.9%).
      The physicians assigned 4,707 (75.9%) of the 6,200 weighting points to patient-centered barriers.
      Physician-centered barriers accounted for 927 (15.0%) and system barriers accounted for 566 (9.1%) of weighting points.
      Twenty-eight percent of the patients not initiating guideline-concordant acute-stage care went on to receive additional care and met criteria for remission at 6 months, with no statistical difference across the 5 patient clusters.
      Conclusions - Current interventions fail to address barriers to initiating guideline-concordant acute-stage care faced by more than a quarter of depressed primary care patients.
      Physicians feel that barriers arise most frequently from factors centered with the patients, their psychosocial circumstances and their attitudes and beliefs about depression and its care.
      Physicians less frequently make judgments that overrule the guidelines, but do so when patients have complex illness patterns.
      Further descriptive and experimental studies are needed to confirm and further examine barriers to depression care.
      Because few untreated patients improve without acute-stage care, additional work is also needed to develop new intervention components that address these barriers.
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    3. Behavioral health disability management
      Conti, DJ; Burton, WN – In : 'The Employee Assistance Handbook' – cfr. : - Oher JM, editor - John Wiley & Sons, Inc.; New York : 1999
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    4. Behavioral medicine approaches to somatoform disorders
      Looper KJ, Kirmayer LJ - J Consult Clin Psychol 2002;70:810-27
      This article reviews the research evidence for the efficacy of cognitive-behavioral therapy (CBT) for somatoform disorders.
      Randomized controlled studies support the efficacy of individual CBT for the treatment of hypochondriasis, body dysmorphic disorder (BDD) and undifferentiated somatoform disorders including medically unexplained symptoms, chronic fatigue syndrome and noncardiac chest pain and group CBT for the treatment of BDD and somatization disorder.
      On the basis of this review of the existing research and a theoretical model of the processes involved in somatoform disorders, the authors offer suggestions for future research and effective treatment.
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    5. Beyond somatisation - A review of the understanding and treatment of medically unexplained physical symptoms (MUPS)
      Burton C - Br J Gen Pract 2003;53:231-9
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    6. Bi-directional immune-brain communication - Implications for understanding stress, pain and cognition
      Maier SF - Brain Behav Immun 2003;17:69-85
      The immune system and the central nervous system form a bi-directional communication network.
      The critical roles of pro-inflammatory cytokines in both the periphery and the nervous system are discussed.
      In the periphery, these cytokines initiate the processes that signal the brain that immune activation has occurred and communicate this information over both neural and blood-borne routes.
      The arrival of these signals in the central nervous system induces a neural cascade that includes the de novo induction of pro-inflammatory cytokines.
      The functions of these cytokines in the nervous system are discussed and it is argued that they play a key role in regulating the neural control of immune processes in the periphery.
      In addition, it is argued that these cytokines play a variety of other roles and some implications of the cytokine network for understanding stress, behavior, sensory processing, mood and cognition are described.
      The overall argument is that because brain-mediated host defense involves behavioral, sensory, mood and cognitive alterations, immune activation and immune products such as the cytokines can have a pervasive effect on these functions.
      Finally, these phenomena are placed in an evolutionary perspective.
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    7. Bias and prevalence effects on kappa viewed in terms of sensitivity and specificity
      Hoehler FK, Data Management Center, 210 South Batavia Street, Orange, CA 92868, USA - J Clin Epidemiol. 2000 May;53(5):499-503 - PMID: 10812322
      Paradoxical effects of bias and prevalence on the kappa coefficient are examined using the concepts of sensitivity and specificity.
      Results that appear paradoxical when viewed as a 2 x 2 table of frequencies do not appear paradoxical when viewed as a pair of sensitivity and specificity measures where each observer is treated as a predictor of the other observer.
      An adjusted kappa value can be obtained from these sensitivity/specificity measures but simulation studies indicate that it would result in substantial overestimation of reliability when bias or prevalence effects are observed.
      It is suggested that investigators concentrate on obtaining populations with trait prevalence near 50% rather than searching for statistical indices to rescue or excuse inefficient experiments.
      Cfr. :

    8. Bias, prevalence and kappa
      Byrt T, Bishop J, Carlin JB, Clinical Epidemiology and Biostatistics Unit, Royal Children's Hospital Research Foundation, Parkville, Victoria, Australia - J Clin Epidemiol. 1993 May;46(5):423-9 - PMID: 8501467
      Since the introduction of Cohen's kappa as a chance-adjusted measure of agreement between two observers, several "paradoxes" in its interpretation have been pointed out.
      The difficulties occur because kappa not only measures agreement but is also affected in complex ways by the presence of bias between observers and by the distributions of data across the categories that are used ("prevalence").
      In this paper, new indices that provide independent measures of bias and prevalence, as well as of observed agreement, are defined and a simple formula is derived that expresses kappa in terms of these three indices.
      When comparisons are made between agreement studies it can be misleading to report kappa values alone and it is recommended that researchers also include quantitative indicators of bias and prevalence.
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    9. Biochemical a evidence for a novel low molecular weight 2-5-A-dependent RNase L in chronic fatigue syndrome
      Suhadolnik RJ, Peterson DL, O'Brien et al. - J Interferon and Cytokine Res 1997; 17 July: 377-85

    10. Biological stress markers and misconceptions about them
      Theorell T - Stress Health 2003;:59-60
      Cfr. :

    11. Brain chemistry reflects dual states of pain and anxiety in chronic low back pain
      Grachev ID, Fredrickson BE, Apkarian AV, Department of Anesthesiology, SUNY Upstate Medical University, Syracuse, NY, USA : - J Neural Transm. 2002 Oct;109(10):1309-34 - PMID: 12373563
      The neurobiology of the interaction between pain and anxiety is unknown.
      The present study examined interrelationships between : regional brain chemistry (as identified by in vivo proton magnetic resonance spectroscopy [(1)H-MRS] in dorsolateral prefrontal cortex [DLPFC], orbitofrontal cortex [OFC], cingulate and thalamus), pain (as measured by short form of the McGill Pain Questionnaire [SF-MPQ]) and anxiety (measured by the State-Trait Anxiety Inventory) in chronic low back pain (CLBP) patients and contrasted to the relationship between brain chemistry and anxiety in sex and age-matched normal subjects.
      The results show that brain chemistry depends on a 3-way interaction of brain regions examined, subject groups (normal vs. CLBP) and anxiety levels (high vs. low).
      The concentration of N-Acetyl aspartate (the largest peak in (1)H-MRS) in OFC could distinguish between anxiety levels and between subject groups.
      Chemical-perceptual relationships were analyzed by calculating correlations between regional chemicals and perceptual measures of pain and anxiety.
      To isolate pain from anxiety, these maps were subdivided based on anxiety and, in the CLBP patients along anxiety-more-related vs. anxiety-less-related pain descriptors and along sensory vs. affective pain descriptors.
      There was a precise relationship between perception and brain chemistry.
      The chemical-perceptual network best related to pain in CLBP patients was comprised of the DLPFC and OFC; the chemical-anxiety network was best related to the OFC chemistry in normals and to all four regions studied in CLBP patients; and the cingulate was best related to the affective component of pain.
      We conclude that the chemical-perceptual mapping differentiates between closely related perceptual states of pain and anxiety in chronic pain and provides a brain regional-chemical-perceptual description of the long-term reorganization that occurs with chronic pain.
      Cfr. :

    12. Building an evidence base for occupational health interventions
      Verbeek J, Husman K, van Dijk F, Jauhiainen M, Pasternack I, Vainio H, Kuopio Regional Institute of Occupational Health, Department of Research and Development in Occupational Health, Finland : - Scand J Work Environ Health. 2004 Apr;30(2):164-70 - PMID: 15127785
      This article summarizes arguments for building an evidence base for occupational health.
      Evidence is needed on the most effective ways of eliminating health hazards in the workplace and at work, enhancing healthy behavior or the empowerment of workers and preventing and treating occupational diseases and occupational disability.
      An evidence base for occupational health must include systematic reviews.
      The Cochrane Collaboration has brought together some of the evidence; however, a search for systematic reviews on the top priorities in occupational health research showed that systematic reviews are lacking in many areas.
      Current reviewing methods can be adapted to the special features of occupational health.
      It is concluded that more effort should be invested in the preparation, maintenance and dissemination of systematic reviews in order to create a necessary evidence base for occupational health interventions.
      Occupational health could benefit considerably from greater awareness of the evidence for and against various types of intervention.
      Cfr. :

    13. Building’ a history rather than ‘Taking’ one - A perspective on information sharing during the medical interview
      Haidet P, Paterniti DA - Arch Intern Med 2003;163:1134-40
      Patients and physicians enter the medical encounter with unique perspectives on the illness experience.
      These perspectives influence the way that information is shared during the initial phase of the interview.
      Previous research has demonstrated that patients who are able to fully share their perspective often achieve better outcomes.
      However, studies of patient-physician communication have shown that the patient's perspective is often lost.
      Researchers and educators have responded with calls for practitioners to adopt a "narrative-based medicine" approach to the medical interview.
      In this article, we review the literature on narrative-based medicine with an emphasis on information sharing during the medical interview.
      We suggest a framework of skills and attitudes that can act as a foundation for future work in educating practitioners and researching the medical interview.
      Cfr. :

    14. Can depression treatment in primary care reduce disability ? - A stepped care approach
      Lin EH, VonKorff M, Russo J, Katon W, Simon GE, Unützer J, Bush T, Walker E, Ludman E, Center for Health Studies, Group Health Cooperative of Puget Sound, Center for Health Studies, Met Park II, 1730 Minor Ave, Suite 1600, Seattle, WA 98101-1448, USA : - Arch Fam Med. 2000 Nov-Dec;9(10):1052-8 - PMID: 11115207
      Objective - To assess effects of stepped collaborative care depression intervention on disability. DESIGN: Randomized controlled trial.
      Setting - Four primary care clinics of a large health maintenance organization.
      Patients - Two hundred twenty-eight patients with either 4 or more persistent major depressive symptoms or a score of 1.5 or greater on the Hopkins Symptom Checklist. Depression items were randomized to stepped care intervention or usual care 6 to 8 weeks after initiating antidepressant medication.
      Intervention - Augmented treatment of persistently depressed patients by an on-site psychiatrist collaborating with primary care physicians.
      Treatment included patient education, adjustment of pharmacotherap and proactive monitoring of outcomes.
      Main outcome measures - Baseline, 1-, 3-, and 6-month assessments of the Sheehan Disability Scale and the social function and role limitation subscales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).
      Results - Patients who received the depression intervention experienced less interference in their family, work and social activities than patients receiving usual primary care (Sheehan Disability Scale, z = 2.23; P =.025).
      Patients receiving intervention also reported a trend toward more improvement in SF-36-defined social functioning than patients receiving usual care (z = 1.63, P =.10), but there was no significant difference in role performance (z = 0.07, P =.94).
      Conclusions - Significant disability accompanied depression in this persistently depressed group.
      The stepped care intervention resulted in small to moderate functional improvements for these primary care patients.
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    15. Caring for a relative with chronic fatigue syndrome - Difficulties, cognition and acceptance over time
      Ax S, Gregg VH, Jones D - J R Soc Health 2002;122:35-42
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    16. Case control study of chronic fatigue in pediatric patients
      Carter BD, Edwards JF, Kronenberger WG et al. - Pediatrics 1995;95:179-86

    17. Causal attributions for somatic sensations in patients with chronic fatigue syndrome and their partners
      Butler JA, Chalder T, Wessely S, Department of Psychological Medicine, Maudsley Hospital, London - Psychol Med. 2001 Jan;31(1):97-105 - PMID: 11200964
      Background - Patients with chronic fatigue syndrome (CFS) often make somatic attributions for their illness which has been associated with poor outcome.
      A tendency to make somatic attributions in general may be a vulnerability factor for the development of CFS.
      Methods - This cross-sectional study based on self-report questionnaire data aimed to investigate the type of attributions for symptoms made by patients with CFS and to compare this to attributions made by their partners.
      It was hypothesized that patients with CFS would make more somatic attributions for their own symptoms than control subjects and that partners of patients with CFS would make more somatic attributions for their ill relative's symptoms but would be similar to controls regarding their own symptoms.
      Fifty patients with CFS were compared to 50 controls from a fracture clinic in the same hospital and 46 relatives living with the patients with CFS.
      A modified Symptom Interpretation Questionnaire was used to assess causal attributions.
      Results - CFS patients were more likely to make somatic attributions for their symptoms.
      The relatives of patients with CFS made significantly more somatic attributions for symptoms in their ill relative.
      However, they were like the fracture clinic controls in terms of making predominantly normalizing attributions for their own symptoms.
      Conclusions - The data support modification of existing cognitive behavioural treatments for CFS to investigate whether addressing partners' attributions for patients' symptoms improves recovery in the patient.
      Furthermore, a tendency to make somatic attributions for symptoms may be a vulnerability factor for the development of CFS.
      Cfr. :

    18. CCH Unscheduled Absence Survey 2006
      CCH, Inc. :
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    19. Challenges to conventional thinking about mind and body
      Paul Grossman, Freiburg Institute for Mindfulness Research, Konradstrasse 32, 79100, Freiburg, Germany - E-mail address : - Journal of Psychosomatic Research 55 (2003) 491–492 - D 2003 Elsevier Inc.
      The notion that physical symptoms of sane individuals may sometimes bear little or no relationship to measurable physiological functioning is counterintuitive to most us, whether we are lay people, psychologists, physicians or even psychosomatic experts.
      Such an idea profoundly violates nearly everyone’s ordinary view of reality and challenges our sense of safety in the world : if we cannot trust those filtered cortical transmissions telling us that something is happening to our body, what can we believe ?
      If our bodily perceptions are so error-prone, how do we know when we ought to be truly alarmed by somatic symptoms ?
      If we possess a nervous or fearful disposition, does this mean we are doomed to ‘invent’ or ‘amplify’ physical symptoms and are even more unable than less anxious types to distinguish between genuine physiological alterations and misperceptions ?
      Precisely, these kinds of issues are raised by the research in this issue by Houtveen et al.
      The authors report that the extent of self-rated somatic symptoms during mental stress and CO2 rebreathing was generally unrelated to a variety of cardiovascular, autonomic and ventilatory measures, but it was, on the other hand, strongly and positively associated with trait anxiety and a history of physical complaints.
      These findings correspond to a number of studies that have found no exaggerated physiological reactivity to relevant laboratory stressors among individuals marked by a heightened proclivity to physical complaints and/or chronic anxiety.
      However, it remains unclear why still other investigations of anxiety accompanied by extreme physical symptoms, as in panic disorder, sometimes do find concurrent evidence of atypical physiological levels or reactivity.
      Do these other findings represent real distinctions between normal individuals and patients with distinct types of anxiety disorder, as suggested by differences in laboratory studies of cardiovascular autonomic control between panic patients and normal controls (e.g., Ref. [1]) or by Klein’s suffocation alarm theory of panic disorder [2] in which impaired central regulation of respiration is proposed as a primary cause of the disorder ?
      Or could it merely be that most studies have taken place not in the real world, but in a laboratory environment, often without sufficient time for subjects to adapt themselves to the unfamiliar setting and physiological measurement devices.
      One might reasonably assume that particularly under nonadapted conditions, chronically anxious patients may display greater laboratory physiological responses than nonanxious controls, but that these variations may not necessarily reflect real-life, neurophysiological differences between the groups, as so often suggested in the literature.
      Regarding panic disorder, such laboratory specificity of response is supported by several studies : for example, Stein and Asmundson [3,4] found no autonomic or cardiovascular differences during rest or challenge between panic patients and controls after they employed an extended acclimatization phase.
      An ambulatory study of panic disorder patients and healthy controls also found no differences in cardiac activity between groups under reallife conditions [5].
      Still other research reviewed by Houtveen et al. indicates that even under typical laboratory conditions, highly relevant stressors, such as public speaking, often produce no exaggerated physiological reactions among social phobics, although somatic symptom reporting and anxiety are greatly elevated.
      Furthermore, even when we consider those publications where differences between patient and control groups are reported, there are always large proportions of the patient groups who produce no atypical physiological baseline levels or reactions to stressors, although subjective reports of physical symptoms and anxiety are consistently elevated among these patients.
      When such diverse evidence is considered, incongruence between physiology and experience of anxiety and somatic complaints seems very credible.
      But how can we understand this lack of concordance between physiology and symptomatology ?
      In general, the literature has primarily focused upon the cognitive–behavioral explanation that chronically anxious individuals manifest a tendency toward increased attention to and amplification of bodily symptoms related to consequences of negative, often catastrophic appraisal of somatic sensations.
      However, equally plausible is the possibility that states of anxiety actually alter the central nervous system circuitry so that visceral perceptions are, indeed, more unpleasant or painful.
      Subsequent negative appraisal and aversive responses to bodily sensation may be epiphenomenal to this altered central processing of somatic sensation.
      Increasing support for this second hypothesis has been gathered by imaging and pharmacological studies in recent years, especially by investigations examining relations between pain and anxiety.
      Interactions between serotonergic and endorphinic systems and chemical–perceptual mapping of cortical regions, provide evidence of central links between anxiety and interoceptive experience [6,7].
      Also, emotion-related limbic functioning has been tied to central sensory up-regulation [8] and specific hippocampal networks that exacerbate pain under anxiety-provoking conditions have been identified [9].
      These are just a few examples of the growing body of evidence that indicate that the experience of unpleasant or painful bodily sensations does, in fact, reflect accurate perception during anxious times, despite the lack of heightened peripheral physiological activity.
      Should such an intimate connectedness of emotion and somatic experience continue to be supported by future investigation, we may need to rethink current ideas about mind–body relations.
      At least in terms of interpreting subjective experience of psyche and soma, it may be useful to reexamine pre-Cartesian, even ancient Buddhist views of an inseparable mind/body, in which emotional state (among other things) centrally conditions our every perception.
      For example, the simple wisdom : ‘‘When an ordinary person is contacted by a painful feeling, he feels two feelings — a bodily one and a mental one’’ [10].
      In this light, one may gain courage to attempt to answer the questions posed at the beginning of this commentary : unpleasant somatic symptoms may always tell us something is awry, but only sometimes is peripheral physiological functioning the problem.
      Paying close and impartial attention to our bodies during emotional states may also teach us that we store much of our emotional dysphoria in our bodily sensations, even if these sensations are mainly located at the top of our heads : we ought not to forget that physical symptoms constitute major diagnostic criteria for almost all clinical psychiatric disorders and these symptoms are rarely accompanied by convincing evidence of actual physiological dysfunction.
      Studies like that of Houtveen et al. force us to step out of our perhaps dated scientific paradigms and consider other ways of understanding the embodied mind.
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    20. Changing clinical behaviour by making guidelines specific
      Susan Michie, reader in clinical health psychology1, Marie Johnston, professor of psychology2 - 1 Centre for Outcomes Research and Effectiveness, Department of Psychology, University College London, London WC1E 7HB -- 2 School of Psychology, King's College, University of Aberdeen, Aberdeen, AB24 2UB - Correspondence to : S Michie : – BMJ 2004;328:343-345 (7 February)
      Efforts to get doctors to follow guidelines have overlooked the importance of clear and concise recommendations
      The problems of getting people to act on evidence based guidelines are widely recognised.
      An overview of 41 systematic reviews found that the most promising approach was to use a variety of interventions including audit and feedback, reminders and educational outreach.
      The effective interventions often involved complicated procedures and were always an addition to the provision of guidelines.
      None of the studies used the simplest intervention—that is, changing the wording of the guidelines.
      We examine the importance of precise behavioural recommendations and suggest how some current guidelines could be improved.
      Importance of wording
      The wording of a behavioural instruction affects the likelihood that it will be followed, by influencing comprehension, recall, planning and behaviour.
      For example, work by Philip Ley shows that using specific concrete statements increases the extent to which information is both understood and remembered.
      Individuals who intend to change behaviour are more successful if they have a specific behavioural plan.
      A recognised technique of behaviour modification is to define the target behaviour in specific and concrete terms.
      In a study of attributes of 10 national clinical guidelines, general practitioners followed the guidelines on 67% of occasions if they were concrete and precise but on only 36% of occasions when they were vague and non-specific.
      Implementation of guidelines might therefore be improved by defining the crucial elements precisely.
      Clear specification also makes it possible to assess whether the guideline has been followed.
      Specifying behaviour
      Recommendations in guidelines are rarely specified in precise behavioural terms such as what, who, when, where and how.
      An example is the first clinical guideline to be developed and published by the National Institute for Clinical Excellence, which has been widely circulated throughout the NHS.
      Despite the high quality review of evidence underpinning the guideline, the recommendations are not behaviourally specific.
      The guideline is long, with the recommendations in the short form exceeding 20 pages.
      This may result in recommendations getting lost.
      Furthermore, the style of presentation of the guidelines does not optimise implementation.
      Table 1 gives the main (grade A, based on randomised controlled trials) recommendations with suggestions on how they could be behaviourally specified.
      We have limited the suggestions to what and who, but where, when and how could be similarly added.
      We have used active verbs rather than general exhortations (should) or descriptions (may).
      Translating the recommendations in this way revealed two areas of uncertainty.
      In the first example, it is unclear whether day hospital treatment should be encouraged or merely offered; in the fifth, it is unclear whether depot preparations should be prescribed for everyone with schizophrenia.
      -- Table 1 - Suggested amendments to published guidelines on schizophrenia to improve specification of behaviour --
      Constructing the who component of the recommendation showed that the specification of the health professional is slightly different in each of the five recommendations.
      In practice, the same person may carry out each of the defined functions, but it could be two or more people.
      The person specification clarifies the initial steps of implementing the guideline for trust boards.
      This analysis suggests that these guidelines may have been developed to offer general guidance rather than prescriptive action.
      However, similar patterns are present in the subsequent three evidence based guidelines published by the National Institute for Clinical Excellence.
      Table 2 gives one grade A recommendation from each guideline and illustrative questions that remain unanswered by the guidelines' wording.
      -- Table 2 - Illustrative grade A recommendations from three National Institute for Clinical Excellence guidelines and questions about behavioural specifications --
      Analysing and changing behaviour
      Specifying behaviour precisely serves two functions in implementing guidelines.
      Firstly, as described above, it makes implementation more likely; there is greater clarity about what is required and greater certainty about whether it has been accomplished.
      Secondly, it allows a systematic investigation of the way that the behaviour is linked to what occurs before (antecedents) and what occurs after (consequences).
      Antecedents and consequences can operate as either facilitators of or barriers to, behaviour.
      Changing these is a powerful way of changing behaviour.
      The scientific analysis of the relations between antecedents, behaviour, and consequences (ABC) is known as behavioural analysis or functional analysis and was developed within clinical psychology.
      Examples of manipulating antecedents and consequences and observing the effect on a defined behaviour come from two experimental studies of referral rates of general practitioners.
      The first introduced an antecedent cue to increase referral rates for mammography.
      The cue was a sticker in a schematic breast shape with a bright orange dot placed on the charts of women aged over 50 years.
      Referral rates were higher in this condition than in the control condition.
      The second study evaluated an intervention to reduce the frequency that general practitioners ordered radiography of the lumbar spine and knee.
      Each time the general practitioner ordered an x ray examination, the results were accompanied by an educational sticker that reiterated the guidelines.
      This reduced the frequency of ordering by 20%, in line with the recommendations of the Royal College of Radiologists.
      Ample evidence exists to support the argument that the simplest, most cost effective intervention to increase the implementation of guidelines is rewriting guidelines in behaviourally specific terms.
      Future research could compare the effectiveness of rewritten guidelines with that of the original before assessing more complex interventions.
      Interventions should be developed on the basis of an analysis of the antecedents and consequences controlling implementation behaviours.
      This analysis should be informed by relevant psychological theory.
      Cfr. :

    21. Changing provider behavior - An overview of systematic reviews of interventions
      Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, Grilli R, Harvey E, Oxman A, O'Brien MA, Health Services Research Unit, University of Aberdeen, Foresterhill, United Kingdom. - Med Care. 2001 Aug;39(8 Suppl 2):II2-45 - PMID: 11583120
      Background - Increasing recognition of the failure to translate research findings into practice has led to greater awareness of the importance of using active dissemination and implementation strategies.
      Although there is a growing body of research evidence about the effectiveness of different strategies, this is not easily accessible to policy makers and professionals.
      Objectives - To identify, appraise, and synthesize systematic reviews of professional educational or quality assurance interventions to improve quality of care.
      Research design - An overview was made of systematic reviews of professional behavior change interventions published between 1966 and 1998.
      Results - Forty-one reviews were identified covering a wide range of interventions and behaviors.
      In general, passive approaches are generally ineffective and unlikely to result in behavior change.
      Most other interventions are effective under some circumstances; none are effective under all circumstances.
      Promising approaches include educational outreach (for prescribing) and reminders.
      Multifaceted interventions targeting different barriers to change are more likely to be effective than single interventions.
      Conclusions - Although the current evidence base is incomplete, it provides valuable insights into the likely effectiveness of different interventions.
      Future quality improvement or educational activities should be informed by the findings of systematic reviews of professional behavior change interventions.
      Cfr. :

    22. Changing the behavior of healthcare professionals - The use of theory in promoting the uptake of research findings
      Eccles M, Grimshaw J, Walker A, Johnston M, Pitts N, Centre for Health Services Research, University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne, NE2 4AA, UK : - J Clin Epidemiol. 2005 Feb;58(2):107-12 - PMID: 15680740
      Objective - The uptake of research findings into routine health care is a haphazard and unpredictable process.
      The usefulness of the results of implementation studies is limited, due in part to the lack of an underlying framework of the important dimensions of research studies in this area and the healthcare settings within which they are conducted and may subsequently be used.
      Study design and settings - We explore the role for a theory-based framework and suggest some of the methods that would be needed to operationalize the framework in the context of designing and conducting interventions aimed at improving the use of research findings by individual healthcare professionals or teams.
      Conclusions - This research offers a framework for those who would seek to use the results of such studies in routine healthcare settings.
      Cfr. :
      Also see the comment on this article 'The OFF theory of research utilization' - Oxman AD, Fretheim A, Flottorp S, Norwegian Health Services Research Centre, Informed Choice Research Department, PO Box 7004, St. Olavs Plass, Oslo, Norway : - J Clin Epidemiol. 2005 Feb;58(2):113-6; discussion 117-20 - PMID: 15680741 at :

    23. Characteristics of effective clinical guidelines for general practice
      Jako S Burgers, Richard P T M Grol, Joost O M Zaat, Teun H Spies, Akke K van der Bij, and Henk G A Mokkink, Centre for Quality of Care Research (WOK), University Medical Centre, Nijmegen, PO Box 9101, 6500 HB Nijmegen, Netherlands. - Br J Gen Pract. 2003 January; 53(486): 15–19 - PMCID: PMC1314503
      Background - The use of clinical guidelines in general practice is often limited.
      Research on barriers to guideline adherence usually focuses on attitudinal factors.
      Factors linked to the guideline itself are much less studied.
      Aim - To identify characteristics of effective clinical guidelines for general practice and to explore whether these differ between therapeutic and diagnostic recommendations.
      Design of study - Analysis of performance data from an audit study of 200 general practitioners (GPs) in The Netherlands conducted in 1997.
      Setting - Panel of 12 GPs in The Netherlands who were familiar with guideline methodology.
      Method - A set of 12 attributes, including six potential facilitators and six potential barriers to guideline use, was formulated.
      The panel assessed the presence of these attributes in 96 guideline recommendations formulated by the Dutch College of General Practitioners.
      The attributes of recommendations with high compliance rates (70% to 100%) were compared with those with low compliance rates (0% to 60%).
      Results - Recommendations with high compliance rates were to a lesser extent those requiring new skills (7% compared with 22% in recommendations with low compliance rates), were less often part of a complex decision tree (12% versus 25%), were more compatible with existing norms and values in practice (87% versus 76%) and more often supported with evidence (47% versus 31%).
      For diagnostic recommendations, the ease of applying them and the potential (negative) reactions of patients were more relevant than for therapeutic recommendations.
      Conclusion - To bridge the gap between research and practice, the evidence as well as the applicability should be considered when formulating recommendations.
      If the recommendations are not compatible with existing norms and values, not easy to follow or require new knowledge and skills, appropriate implementation strategies should be designed to ensure change in daily practice.
      Cfr. :

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    1. Childhood abuse and later medical disorders in women – An epidemiological study
      Romans S, Belaise C, Martin J et al. - Psychother Psychosom 2002;71:141-50

    2. Childhood experiences of illness and parenting in adults with chronic fatigue syndrome
      Fisher L, Chalder T - J Psychosom Res 2003;54:439-43
      Objective - There are many similarities between chronic fatigue syndrome (CFS), the somatoform disorders and problems otherwise known as “medically unexplained symptoms”.
      There is some evidence to suggest that a combination of inadequate parenting and early illness experience may predispose the individual to develop medically unexplained symptoms in adult life.
      The aim of this investigation was to compare the contributions of childhood experiences of illness and parenting in adults with CFS with a fracture clinic control group.
      Method - A retrospective case control design was used.
      Thirty patients with a diagnosis of CFS and 30 patients attending a fracture clinic in an inner London teaching hospital completed questionnaires measuring parental care and protection and were interviewed about childhood experiences of illness.
      Results - There were no differences in childhood experience of illness in the two groups.
      However, logistic regression revealed that maternal overprotection and depression were associated with the diagnosis of CFS.
      Conclusion - The findings may represent risk factors for the development of CFS in adult life.
      It is possible that maternal overprotection in particular is related to the formation of belief systems about avoiding activity that operate to adversely influence behaviour in patients with CFS.
      Cfr. :

    3. Childhood predictors of self reported chronic fatigue syndrome/myalgic encephalomyelitis in adults - National birth cohort study
      Viner R, Hotopf M - BMJ 2004;329:941-0
      - To study childhood risk factors for chronic fatigue syndrome in adult life.
      Design - Examination of data from the 1970 British birth cohort.
      Participants - 16 567 babies born 5-11 April 1970, followed up at 5, 10, 16, and 29-30 years.
      Main outcome measures - Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) identified by self report at age 30 years.
      Data from childhood from questionnaires given to parents and teachers.
      Maternal mental health assessed with the malaise inventory.
      Results - 93 (0.8%, 95% confidence interval 0.7 to 1.0) of 11 261 participants reported ever having CFS/ME and 48 (0.4%, 0.3 to 0.6) had the condition currently.
      Higher risk of CFS/ME was associated with having a limiting longstanding condition in childhood (odds ratio 2.3, 1.4 to 3.9), female sex (2.3, 1.4 to 2.6) and high social class in childhood (2.2, 1.4 to 3.5).
      Higher levels of exercise in childhood were associated with lower risk (0.5, 0.2 to 0.9).
      Maternal psychological disorder, psychological problems in childhood, birth weight, birth order, atopy, obesity, school absence, academic ability and parental illness were not associated with risk of CFS/ME.
      Conclusions - We identified no association between maternal or child psychological distress, academic ability, parental illness, atopy or birth order and increasing risk of lifetime CFS/ME.
      Sedentary behaviour increased the risk.
      Cfr. :

    4. Chronic Fatigue - Risk factors symptom persistence in a 2.5-year follow-up study
      Clark M, Katon W Russo J et al. - Am J Med 1995; 98: 187-195

    5. Chronic fatigue - Symptom and syndrome
      Wessely S - Ann Intern Med 2001;134:838-43

    6. Chronic fatigue and anxiety/depression - A twin study
      Roy-Byrne P, Afari N, Ashton S et al. - Br J Psychiatry 2002;180:29-34
      Cfr. :

    7. Chronic fatigue and chronic fatigue syndrome - A co-twin control study of functional status
      Herrell R, Goldberg J, Hartman S et al. - Qual Life Res 2002;11:463-71
      Cfr. :

    8. Chronic fatigue and chronic fatigue syndrome - Shifting boundaries and attributions
      Lloyd AR - Am J Med 1998;105:7S-10S

    9. Chronic fatigue and depression
      Iversen A, Wessely S - Curr Opin Psychiatry 2003;16:17-21
      Purpose of review - Although chronic fatigue is reported by up to one third of patients contacting primary health care physicians, it remains a controversial symptom/syndrome which does not fall comfortably into either psychiatry or other branches of medicine.
      Relevant findings - Prospective studies suggest that the severity of fatigue reported at first consultation predicts severity at follow-up, including an increased risk of future major depressive disorder.
      There is a dual interaction between fatigue and depression, one increasing the risk of the other.
      However, there is not complete symmetry of the disorders; pre-morbid psychiatric history is a better predictor of depression than chronic fatigue syndrome and conversely positive tests for infectious mononucleosis are a better predictor of chronic fatigue syndrome than depression.
      Chronic fatigue appears to show some genetic aetiology but links to immune dysfunction remain tentative and require further research.
      In terms of treatment, cognitive behavioural therapy and graded exercise therapy have proved effective and deliverable both in chronic fatigue syndrome and its related syndromes.
      The benefits are only for some; however, many remain disabled.
      Summary - Fatigue extends its influences and interactions widely.
      It is seen both in its own bespoke syndrome of chronic fatigue syndrome and also within the family of somatoform disorders.
      Depression, fatigue and physical illness appear to be intimately linked, each worsening the experience of the other having profound implications for patients' quality of life.
      Cfr. :

    10. Chronic fatigue and its syndromes
      Wessely S, Hotopf M, Sharpe M - Oxford/New York/Tokyo:Oxford University Press;1998

    11. Chronic fatigue and the chronic fatigue syndrome - Prevalence in a Pacific Northwest Health Care System
      Buchwald D, Umali P, Umali J - Annals of Intern Med 1995; 123: 81-8

    12. Chronic fatigue following infection by Coxiella burnetii (Q fever) - Ten-year follow-up of the 1989 UK outbreak cohort
      Wildman MJ, Smith EG, Groves J et al. - QJM 2002;95:527-38

    13. Chronic fatigue in general practice attenders
      McDonald E, David A. Pelosi A et al. - Psych Med 1993; 23: 987-98

    14. Chronic fatigue in the community - 'A guestion of attribution'
      Chalder T, Power MJ, Wesselly 5 - Psycol Med 1996: Jul; 26 (4): 791-800

    15. Chronic fatigue syndrome
      Reid S, Chalder T, Cleare A, Hotopf M, Wessely S, St Mary's Hospital, London, UK - Clin Evid. 2005 Dec;(14):1366-78 - PMID: 16620458
      Cfr. :

    16. Chronic fatigue syndrome - A case definition
      Holmes GP, Kaplan JE., Gantz NM et al. - Ann Intern Med 1998; 108: 387-9

    17. Chronic fatigue syndrome - A cognitive approach
      Surawy C, Hackmann A, Hawton K et al. - Behav Res Ther 1995;33:535-44

    18. Chronic fatigue syndrome - A practical guide to assessment and management
      Sharpe M, Chalder T, Palmer I et al. - Gen Hosp Psychiatry 1997;19:185-99

    19. Chronic Fatigue Syndrome - A Review
      Niloofar Afari, Ph.D. and Dedra Buchwald, M.D. - Am J Psychiatry 160:221-236, February 2003 - © 2003 American Psychiatric Association
      Objective - Chronic fatigue syndrome is an illness characterized by disabling fatigue of at least 6 months, accompanied by several other symptoms.
      This review summarizes the current state of knowledge about chronic fatigue syndrome.
      Method - The case definition, prevalence, clinical presentation, evaluation and prognosis of chronic fatigue syndrome are discussed.
      Research on the pathophysiology and treatment of chronic fatigue syndrome is reviewed.
      Results - Chronic fatigue syndrome is diagnosed on the basis of symptoms.
      Patients with chronic fatigue syndrome experience significant functional impairment.
      Pathophysiological abnormalities exist across many domains, suggesting that chronic fatigue syndrome is a heterogeneous condition of complex and multifactorial etiology.
      Evidence also is beginning to emerge that chronic fatigue syndrome may be familial.
      Although chronic fatigue syndrome has significant symptom overlap and comorbidity with psychiatric disorders, several lines of research suggest that the illness may be distinct from psychiatric disorders.
      Patients’ perceptions, attributions and coping skills, however, may help perpetuate the illness.
      Treatment for chronic fatigue syndrome is symptom-based and includes pharmacological and behavioral strategies.
      Cognitive behavior therapy and graded exercise can be effective in treating the fatigue and associated symptoms and disability.
      Conclusions - Chronic fatigue syndrome is unlikely to be caused or maintained by a single agent.
      Findings to date suggest that physiological and psychological factors work together to predispose an individual to the illness and to precipitate and perpetuate the illness.
      The assessment and treatment of chronic fatigue syndrome should be multidimensional and tailored to the needs of the individual patient.
      Cfr. :

    20. Chronic fatigue syndrome - A working case definition
      Holmes GP, Kaplan JE, Gantz NM et al. - Ann Intern Med 1988;108:387-9

    21. Chronic Fatigue Syndrome - An Integrative Approach to Evaluation and Treatment
      Demitrack MA, Abbey S - New York/London: Guilford; 1996

    22. Chronic fatigue syndrome - Clinical practice guidelines – 2002
      Royal Australasian College of Physicians Working group - Med J Aust 2002;176:S17-55
      Cfr. :

    23. Chronic fatigue syndrome - From prevalence and perpetuating factors tot cognitive behaviour therapy
      Proefschrift van Ellen Bazelmans - Nijmegen: UMC St Radboud; 2004
      Cfr. :

    24. Chronic fatigue syndrome - Intracellular immune deregulations as a possible etiology for abnormal exercise response
      Nijs J, De Meirleir K, Meeus M et al. - Med Hypotheses 2004;62:759-65
      The exacerbation of symptoms after exercise differentiates Chronic fatigue syndrome (CFS) from several other fatigue-associated disorders.
      Research data point to an abnormal response to exercise in patients with CFS compared to healthy sedentary controls and to an increasing amount of evidence pointing to severe intracellular immune deregulations in CFS patients.
      This manuscript explores the hypothetical interactions between these two separately reported observations.
      First, it is explained that the deregulation of the 2-5A synthetase/RNase L pathway may be related to a channelopathy, capable of initiating both intracellular hypomagnesaemia in skeletal muscles and transient hypoglycemia.
      This might explain muscle weakness and the reduction of maximal oxygen uptake, as typically seen in CFS patients.
      Second, the activation of the protein kinase R enzyme, a characteristic feature in atleast subsets of CFS patients, might account for the observed excessive nitric oxide (NO) production in patients with CFS.
      Elevated NO is known to induce vasidilation, which may limit CFS patients to increase blood flow during exercise and may even cause and enhanced postexercise hypotension.
      Finally, it is explored how several types of infections, frequently identified in CFS patients, fit into these hypothetical pathophysiological interactions.
      Cfr. :

    25. Chronic fatigue syndrome - Probable pathogenesis and possible treatments
      Evengard B, Klimas N – Drugs 2002;62:2433-46
      Chronic fatigue syndrome (CFS) belongs in the medically unexplained illnesses.
      It affects approximately 0.2-0.7% of the population in Western countries.
      It is characterised by unexplained fatigue, lasting 6 months or more, impairment of neurocognitive functions and quality of sleep and of somatic symptoms, such as recurrent sore throat, muscle aches, arthralgias, headache and postexertional malaise.
      No link between infections and CFS has been clearly established but the immune system is activated, there are aberrations in several hypothalamic-pituitary axes and involvement of other parts of the central nervous system.
      No specific treatment has been found.
      Cognitive behavioural therapy is established to be of value to improve quality of life.
      More effective treatment should result, as advances in biomedical as well as psychological research continue.
      Cfr. :

    26. Chronic fatigue syndrome - Successful outcome of an intensive inpatient programme
      Lim A, Lubitz L – J Paediatr Child Health 2002;38:295-9
      Objective - To study the outcome of adolescents with chronic fatigue syndrome (CFS) following an intensive multidisciplinary inpatient programme.
      Methods - A follow-up questionnaire was distributed to all 57 adolescents who had completed the CFS inpatient programme at the Austin and Repatriation Medical Centre.
      Results - Forty-two adolescents (74%) returned follow-up questionnaires.
      Immediately following the programme and up to five years after the programme, the majority of participants had returned to school and were functioning better in terms of physical activity and social interactions as compared with before the programme.
      Before the programme, 94% of adolescents were attending school half-time or less.
      Up to 5 years after the programme, 78% of adolescents were attending school full-time or with occasional absences only.
      Conclusions - A multidisciplinary inpatient programme for CFS was successful in helping to rehabilitate this group of adolescents who were significantly incapacitated prior to entering the inpatient programme.
      Cfr. :

    27. Chronic fatigue syndrome - Summary of report
      Wessely S - J the Royal College of Physicians of London 1996; 30: 497-504

    28. Chronic fatigue syndrome - The patient centred clinical method - A guide for the perplexed
      Murdoch JC - Aust Fam Physician 2003;32:883-7
      Background - Chronic fatigue states are common in general practice and over the past 20 years there has been considerable worldwide consensus developed on the criteria for chronic fatigue syndrome (CFS) also commonly known as myalgic encephalomyelitis (ME).
      Chronic fatigue syndrome is an illness characterised by the new onset of disabling fatigue, accompanied by cognitive, musculoskeletal and sleep symptoms.
      There are no specific diagnostic tests or biological markers and the diagnosis is made by ruling out other causes of fatigue.
      The pathophysiology of CFS is still unclear.
      Objective - This article discusses the application of the patient centred clinical method to the diagnosis and treatment of CFS.
      Discussion - There is no new breakthrough in the diagnosis or management of CFS in spite of much research and controversy.
      There is considerable evidence that the best place to manage CFS is in primary care under the care of the patient's own general practitioner, but it has been suggested that doctors feel unable to deal with the problem.
      The patient centred clinical method offers a constructive guide to management.
      The author considers that the best hope for sufferers is self management guided by a supportive and helpful health professional, preferably the patient's own GP.
      Cfr. :

    29. Chronic fatigue syndrome – A clinically empirical approach to its definition and study
      Reeves WC, Wagner D, Nisenbaum R, Jones JF, Gurbaxani B, Solomon L, Papanicolaou DA, Unger ER, Vernon SD, Heim C - BMC Medicine 2005, 3:8
      Cfr. :

    30. Chronic fatigue syndrome and fibromyalgia - Clinical assessment and treatment - Special Issue : 'Psychological treatment of the patient with chronic disease'
      Friedberg F, Jason LA, Engle D - J Clin Psychol 2001;57:433-55
      Cfr. :

    31. Chronic fatigue syndrome and fibromyalgia resources on the world wide web – A descriptive journey
      Gantz NM, Coldsmith EE - Clin Infect Dis 2001;32:938-48
      Cfr. :

    32. Chronic fatigue syndrome and other fatiguing illnesses in adolescents - A population-based study
      Jones JF, Nisenbaum R, Solomon L et al. - J Adolesc Health 2004;35:34-40
      Purpose - To estimate the prevalence of chronic fatigue syndrome (CFS) and describe characteristics of other fatiguing illnesses in adolescents (aged 12 through 17 years).
      Methods - We conducted a random digit dialing survey of the residents of Wichita, Kansas.
      Adults identified fatigued adolescents in the household and answered questions relating to the child's health.
      Selected adolescents were invited to attend a clinic with a parent/guardian.
      After clinical evaluation they were classified as CFS or another fatigue state as defined in the 1994 CFS definition.
      Annual telephone interviews and clinical evaluations monitored subjects' fatigue status.
      Data were analyzed using the Kruskal-Wallis test, the Mantel-Haenszel test and the exact McNemar test.
      Results - The survey contacted 34,018 households with 90,316 residents.
      Of 8586 adolescents, 138 had fatigue for > or =1 month and most (107 or 78%) had chronic fatigue (> or =6 months) at some point during the 3-year follow-up.
      Twenty-eight had exclusionary diagnoses.
      Thirty-one were considered to have a CFS-like illness and were invited for clinical evaluation.
      Eleven agreed to participate and none met the CFS case definition.
      The baseline weighted prevalence of CFS-like illness was 338 per 100,000.
      Significant differences existed between parental and adolescents' descriptions of illness.
      Conclusions - The prevalence of CFS among adolescents was considerably lower than among adults.
      Evaluation of CFS in adolescents must consider both parent and patient perception of fatigue and other illnesses that might explain the symptom complex.
      Cfr. :

    33. Chronic fatigue syndrome in adolescence
      Smith MS, Carter BD – In :Jason LA et al, editors. 'Handbook of chronic fatigue syndrome' - Hoboken New Jersey: John Wiley & Sons;2003:693-712

    34. Chronic fatigue syndrome in adolescents - A follow-up study
      Gill AC, Dosen A, Ziegler JB - Arch Pediatr Adolesc Med 2004;158:225-9
      Objectives - To compare the frequency of persistent symptoms up to 8 years after illness onset in adolescents diagnosed as having chronic fatigue syndrome, idiopathic chronic fatigue and unexplained fatigue for less than 6 months and to determine if hospital admission is associated with outcome.
      Designs - A cohort study using questionnaire follow-up.
      Setting - A tertiary referral hospital.
      Patients - Consecutive adolescents referred for assessment of persistent fatigue were identified and retrospectively divided into 3 groups according to the diagnostic criteria for chronic fatigue syndrome and idiopathic chronic fatigue.
      Intervention - A questionnaire was designed and administered by telephone at a mean of 4.57 years after the initial examination.
      Main Outcome Measure - The persistence of self-reported symptoms was compared with respect to patient group and admission.
      Results - Outcome data were obtained for 34 (69%) of the 49 eligible subjects.
      Twenty-five percent of the chronic fatigue syndrome group showed near to complete improvement, 31% showed partial improvement and 44% showed no improvement.
      The idiopathic chronic fatigue group had near to complete recovery in 50%, partial in 10% and no improvement in 40%.
      Those with unexplained fatigue for less than 6 months had all recovered.
      There was no difference between the outcome of the subjects admitted to the hospital and those managed as outpatients.
      Conclusions - Adolescents with less than 6 months of fatigue have a good outcome.
      Unexplained fatigue lasting more than 6 months has a similar outcome regardless of the presence of minor criteria for chronic fatigue syndrome.
      Cfr. :

    35. Chronic fatigue syndrome in children - A cross sectional survey
      Patel M, X, Smith DG, Chalder T et al. - Arch Dis Child 2003;88:894-8
      Cfr. :,+Maxine&au

    36. Chronic fatigue syndrome in the community - Prevalence and associations
      Lawrie SM, Pelosi AJ - Br J Psychiatry 1995;166:793-7

    37. Chronic fatigue syndrome is associated with diminished intracellular perforin
      Maher KJ, Klimas NG, Fletcher MA, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL 33176, USA - Clin Exp Immunol. 2005 Dec;142(3):505-11 - PMID: 16297163
      Chronic fatigue syndrome (CFS) is an illness characterized by unexplained and prolonged fatigue that is often accompanied by abnormalities of immune, endocrine and cognitive functions.
      Diminished natural killer cell cytotoxicity (NKCC) is a frequently reported finding.
      However, the molecular basis of this defect of in vitro cytotoxicy has not been described.
      Perforin is a protein found within intracellular granules of NK and cytotoxic T cells and is a key factor in the lytic processes mediated by these cells.
      Quantitative fluorescence flow cytometry was used to the intracellular perforin content in CFS subjects and healthy controls.
      A significant reduction in the NK cell associated perforin levels in samples from CFS patients, compared to healthy controls, was observed.
      There was also an indication of a reduced perforin level within the cytotoxic T cells of CFS subjects, providing the first evidence, to our knowledge, to suggest a T cell associated cytotoxic deficit in CFS.
      Because perforin is important in immune surveillance and homeostasis of the immune system, its deficiency may prove to be an important factor in the pathogenesis of CFS and its analysis may prove useful as a biomarker in the study of CFS.
      Cfr. :

    38. Chronic fatigue syndroom – A stress disorder ?
      Cleare AJ, Wessely SC - Br J Hosp Med. 1996 May 1-14; 55(9): 571-574

    39. Chronic Fatigue Syndroom – Clinical, microbiological and immunological aspects
      Swanink C.M.A. - Proefschrift 1996

    40. Chronic fatigue, abuse-related traumatization and psychiatric disorders in a community-based sample
      Taylor RR, Jason LA - Soc Sci Med 2002;55:247-56
      The relationship between sexual and physical abuse history and negative health effects has been well-documented in medical facility samples.
      Few studies have examined the role of abuse history and its relationship with chronic fatigue and psychiatric disorders in a diverse, randomly selected community-based sample.
      The present study compared rates of different types of abuse events in individuals with chronic fatigue and non-symptomatic controls.
      Relationships between specific types of abuse and psychiatric disorders commonly associated with chronic fatigue were also explored.
      A stratified random sample of 18,675 adults residing in ethnically and socioeconomically diverse neighborhoods in Chicago first completed a telephone screening questionnaire.
      A control group and a group of individuals with chronic fatigue symptomatology were identified and administered a semi-structured psychiatric interview assessing DSM-IV Axis I psychiatric disorders and a sexual and physical abuse history questionnaire.
      Controlling for sociodemographic differences, fatigue outcome was significantly predicted by childhood sexual abuse and the total number of different childhood abuse events.
      Within the chronic fatigue group, diagnosis of posttraumatic stress disorder (PTSD) was significantly predicted by childhood sexual abuse, childhood death threat, the total number of childhood abuse events and lifetime abuse events.
      Sexual abuse during adolescence or adulthood significantly predicted other anxiety disorders among individuals with chronic fatigue.
      These findings suggest that a history of abuse, particularly during childhood, may play a role in the development and perpetuation of a wide range of disorders involving chronic fatigue.
      Among individuals with chronic fatigue, PTSD and other anxiety disorders appear to demonstrate the strongest association with abuse history.
      The implications of these findings are discussed.
      Cfr. :

    41. Chronic pain and fatigue syndromes - Overlapping clinical and neuroendocrine features and potential pathogenic mechanisms
      Clauw DJ, Chrousos GP - Neuroimmunomodulation 1997;4:134-53

    42. Chronic widespread pain as a medico-legal issue
      Duncan A. Gordon FRCPC, FACP, MACR, Professor of Medicine, University of Toronto, Division of Rheumatology, Toronto Western University Health Network, 399 Bathurst Street, Toronto, Ontario, Canada - Received 1999, Accepted 1999, Available online 6 April 2002 - © 1999 Harcourt Publishers Ltd.
      A systematic approach to the determination of disability in persons with chronic widespread pain is based on a careful history, examination for tender points and special investigations to establish a firm diagnosis.
      Further assessment requires determination of subjective and objective measures of impairment.
      The causes of fibromyalgia are multifactorial and understanding them requires an appreciation of the role of physical or psychological trauma and associated medical and psychosocial factors.
      Despite the presence of disability risk factors, most patients with fibromyalgia maintain a good range of normal daily activities and continue working.
      Cfr. :

    43. Clarifying the relationship between unexplained chronic fatigue and psychiatric morbidity - Results from a community survey in Great Britain
      Skapinakis P, Lewis G, Meltzer H - Int Rev Psychiatry 2003;15:57-64
      Cfr. :

    44. Clinical differences exist between patients fulfilling the 1988 and 1994 case definitions of chronic fatigue syndrome
      Brimacombe M, Helmer D, Natelson BH - J Clin Psychol Med Settings 2002;9:309-14
      Despite the existence of 2 different case definitions for chronic fatigue syndrome, little data exist to evaluate how each performs.
      We evaluated the symptom patterns of patients fulfilling either the more demanding 1988 or the less demanding 1994 case definitions of Chronic Fatigue Syndrome over an 11-year period from 1991 to 2001.
      Factor analysis identified 3 factors : muscular–skeletal, viral, and sleep:memory symptom factors accounting for significant variation in the data.
      Further discriminant analysis showed that the first 2 factors and a self-reported measure of decrease in activity alone gave 91% accuracy in the placement of patients into their respective case definitions.
      This analysis did indicate that both case definitions were capturing the same broad group of patients.
      However, the patients in the 1994 group do not endorse infectious-type symptoms as often or to the same degree of severity as those in the 1988 group.
      This may mean that infection as a cause of CFS is more likely in patients fulfilling the earlier, more demanding case definition.
      Cfr. :

    45. Clinical manual of pain management in psychiatry
      Raphael J. Leo - American Psychiatric Publishing, Inc. (1 edition), August 20, 2007 – ISBN-10 : 1585622753 – ISBN-13 : 978-1585622757
      The 'Clinical Manual of Pain Management in Psychiatry' focuses on the role of mental health practitioners in evaluation and assessment, pharmacological management, psychotherapeutic interventions and comprehensive treatment planning for pain.
      It balances theoretical foundations of pain pathophysiology with applied clinical information, all the while viewing the patient from biological, psychological and social perspectives in order to tailor treatment to the whole person.
      This handy portable guide includes numerous tables and illustrations and expands on the author's previous 'Concise Guide to Pain Management for Psychiatrists' (ISBN 10 : 158562103X – ISBN 13 : 9781585621033 - cfr. :
      ) -) to reflect significant advances in the field of pain medicine.
      It features particularly extensive revisions regarding the use of psychiatric and other adjunctive medications in pain management; includes updated coverage of common psychiatric comorbidities such as depression, anxiety and personality disorders; and addresses common pain disorders ranging from headache and back pain to pain related to cancer and HIV.
      The manual includes an extensively revised chapter on pharmacology, fully discusses psychotherapeutic approaches and covers special techniques such as acupuncture and regional neural blockade.
      It also offers updated advice on emerging forensic issues, from disability claims to controlled substance diversion.
      Cfr. :

    46. Cognitive behavior therapy for Chronic Fatigue Syndrome - A randomised controlled trial
      Deale A, Chalder T, Marks I & Wessely S, (1997) - American Journal of Psychiatry, 154, 408-414

    47. Cognitive behavior therapy for chronic fatigue syndrome in adults - Cochrane review
      Couper J, Price J.R - Cochrane Library, Issue 3, 2001
      Cognitive behaviour therapy for adults with chronic fatigue syndrome (Cochrane Review).
      Cognitive behaviour therapy appears to be an effective and acceptable treatment for adult out-patients with chronic fatigue syndrome.
      A systematic review by Price and Couper for the Cochrane Library, Issue 2, 2001, looked at all randomized controlled trials of cognitive-behaviour therapy (CBT) for adults with chronic fatigue syndrome (CFS).
      Although only 3 relevant trials of adequate quality were found, these studies managed to demonstrate that CBT significantly benefits physical functioning in adult out-patients with CFS, when compared to orthodox medical management.
      In addition, these patients found these tools highly acceptable.
      The reviewers conclude that the medical profession should be more aware of the potential of these therapies for improved functioning in their patients and health service managers should increase their availability.
      They also call for further research that conforms to accepted standards of reporting and methodology.
      Cfr. :

    48. Cognitive behavior therapy for functional somatic complaints
      Sharpe M - Psychosom 1997; 38: 356-62

    49. Cognitive behaviour therapy for adolescents with chronic fatigue syndrome - A randomised controlled trial
      Stulemeijer M, de Jong LWAM, Fiselier TWJ et al. - BMJ 2005;14-8
      Cfr. :

    50. Cognitive behaviour therapy for chronic fatigue syndrome - A controlled trial
      Sharpe M, Hawton K, Simkin S et al. - Br J Med 1996; 312: 22-6

    51. Cognitive behaviour therapy for chronic fatigue syndrome - A randomized controlled trial
      Deale A, Chalder T, Marks I et al. - Am J Psychiatry 1997; 154: 408-14

    52. Cognitive behaviour therapy for chronic fatigue syndrome – A multicentre randomised controlled trial
      Prins JB, Bleijenberg G, Bazelmans E et al. - Lancet 2001;357:841-7
      Cfr. :

    53. Cognitive behaviour therapy for chronic fatigue syndrome in adults
      Price JR, Mitchell E, Tidy E, Hunot V, Department of Psychiatry, University of Oxford, Warneford Hospital, Headington, Oxford, UK, OX3 7JX : - Cochrane Database Syst Rev. 2008 Jul 16;(3):CD001027 - PMID: 18646067
      Background - Chronic fatigue syndrome (CFS) is a common, debilitating and serious health problem.
      Cognitive behaviour therapy (CBT) may help to alleviate the symptoms of CFS.
      Objectives - To examine the effectiveness and acceptability of CBT for CFS, alone and in combination with other interventions, compared with usual care and other interventions.
      Search strategy - CCDANCTR-studies and CCDANCTR-references were searched on 28/3/2008.
      We conducted supplementary searches of other bibliographic databases.
      We searched reference lists of retrieved articles and contacted trial authors and experts in the field for information on ongoing/completed trials.
      Selection criteria - Randomised controlled trials involving adults with a primary diagnosis of CFS, assigned to a CBT condition compared with usual care or another intervention, alone or in combination.
      Data collection and analysis - Data on patients, interventions and outcomes were extracted by two review authors independently and risk of bias was assessed for each study.
      The primary outcome was reduction in fatigue severity, based on a continuous measure of symptom reduction, using the standardised mean difference (SMD) or a dichotomous measure of clinical response, using odds ratios (OR), with 95% confidence intervals (CI).
      Main results - Fifteen studies (1043 CFS participants) were included in the review.
      When comparing CBT with usual care (six studies, 373 participants), the difference in fatigue mean scores at post-treatment was highly significant in favour of CBT (SMD -0.39, 95% CI -0.60 to -0.19), with 40% of CBT participants (four studies, 371 participants) showing clinical response in contrast with 26% in usual care (OR 0.47, 95% CI 0.29 to 0.76).
      Findings at follow-up were inconsistent.
      For CBT versus other psychological therapies, comprising relaxation, counselling and education/support (four studies, 313 participants), the difference in fatigue mean scores at post-treatment favoured CBT (SMD -0.43, 95% CI -0.65 to -0.20).
      Findings at follow-up were heterogeneous and inconsistent.
      Only two studies compared CBT against other interventions and one study compared CBT in combination with other interventions against usual care.
      Autors' conclusions - CBT is effective in reducing the symptoms of fatigue at post-treatment compared with usual care and may be more effective in reducing fatigue symptoms compared with other psychological therapies.
      The evidence base at follow-up is limited to a small group of studies with inconsistent findings.
      There is a lack of evidence on the comparative effectiveness of CBT alone or in combination with other treatments and further studies are required to inform the development of effective treatment programmes for people with CFS.
      Cfr. :

    54. Cognitive behaviour therapy for psychiatric problems - A practical guide
      Hawton K, Salkovskis PM, Kirk J et al. - Oxford: Oxford University Press;1994

    55. Cognitive behaviour therapy for the chronic fatigue syndrome – A randomised controlled trial
      Sharpe M, Hawton K, Simkin S et al. - BMJ 1996;312:22-6

    56. Cognitive behavioural therapy for medically unexplained physical symptoms - A randomised controlled trial
      Speckens AE, van Hemert AM, Spinhoven P et al. - BMJ 1995;311:1328-32

    57. Cognitive compromise following exercise in monozygotic twins discordant for chronic fatigue syndrome - Fact or artifact ?
      Claypoole K, Mahurin R, Fischer ME et al. - Appl Neuropsychol 2001;8:31-40
      Cfr. :

    58. Cognitive functioning in chronic fatigue syndrome and depression - A preliminary comparison
      Schmaling K, DiClementi J, Cullum M et al. - Psychosom Med 1994; 56: 383-8

    59. Cognitive functioning in chronic fatigue syndrome and the role of depression, anxiety and fatigue
      Short K, McCabe M, Tooley G - J Psychosom Res 2002;52:475-83
      Objective - This study was designed to investigate the role of depression, anxiety and fatigue in Chronic Fatigue Syndrome (CFS) sufferers' objective and subjective cognitive performance.
      Methods - Twenty-three CFS sufferers and 23 healthy control participants were compared on objective and subjective assessments of cognitive performance.
      Depression, anxiety and fatigue were also evaluated.
      Results - CFS sufferers did not demonstrate any impairment in objective cognitive functioning compared to the control group and objective performance was not related to their higher levels of depression or their level of fatigue.
      Depression scores only accounted for a small amount of the variance in CFS sufferers' lower subjective assessment of their cognitive performance compared to control participants.
      There were no differences between the groups on anxiety scores.
      Conclusion - The results are discussed in terms of the heterogeneity of the CFS population and the complex interaction of symptomatological factors that characterise CFS.
      Cfr. :

    60. Cognitive functioning in patients with chronic fatigue syndrome
      Michiels V, Cluydts R, Fischler B et al. - J Exp Neuropsychol 1996; 18: 666-77

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    Deel XXIII

    1. Cognitive processing in monozygotic twins discordant for chronic fatigue syndrome
      Mahurin RK - Neuropsychology 2004;18:232-9
      Twenty-one pairs of monozygotic twins discordant for chronic fatigue syndrome (CFS) and 21 matched healthy control (HC) subjects were assessed with 5 untimed tests and 5 timed tests from the computer-based NeuroCognitive Assessment Battery (R. K. Mahurin, 1993).
      Random effects regression showed no difference between CFS and healthy twins on any of the cognitive tests.
      Further, the twin groups did not differ from the HC group on any content-dependent measure.
      In contrast, both sets of twins performed worse than the HC group on all speed-dependent tests except Finger Tapping.
      Self-rated fatigue and dysphoric mood were only weakly correlated with cognitive performance.
      These data point toward a shared genetic trait related to information processing that is manifest in the CFS context.
      The findings have implications for differentiating genetic and acquired vulnerability in the symptomatic expression of the disorder.
      Cfr. :

    2. Cognitive-behavior therapy for medically unexplained symptoms – A critical review of the treatment literature
      Nezu AM, Nezu CM, Lombardo ER - Behav Ther 2001;32:537-83
      Research has indicated that substantial numbers of physical or medical symptoms presented by patients remain unexplained medically.
      For example, studies have indicated that less than 25% of physical complaints presented to physicians have known or demonstrable organic or biological causes.
      Cognitive-behavior therapy (CBT) provides for a potentially effective means of impacting on this significant public health problem, both medically and psychologically.
      This paper reviews the extant literature regarding CBT for medically unexplained symptoms, as well as three related disorders-chronic fatigue syndrome, fibromyalgia and noncardiac chest pain.
      Whereas this review provides support for the efficacy of CBT for such problems (e.g., effect sizes for CBT compared to control conditions centered around .40), it also identified a variety of methodological limitations regarding the studies themselves.
      Based on this analysis, recommendations for future research endeavors are provided and the implications of this area for prevention and treatment are offered.
      Cfr. :

    3. Cognitive-behavioral group therapy for irritable bowel syndrome - Effects and long-term follow-up
      Van Dulmen AM, Fennis JF, Bleijenberg G - Psychosom Med 1996;58:508-14

    4. Cognitive-behavioral therapies
      Bleijenberg G, Prins JB, Bazelmans E – Jason LA et al, editors 'Handbook of chronic fatigue syndrome' - Hoboken New Jersey: John Wiley & Sons;2003:713-25
      Cfr. :

    5. Cognitive-behavioral therapy for somatization and symptom syndromes - A critical review of controlled clinical trials
      Kroenke K, Swindle R - Psychother Psychosom 2000;69:205-15
      Cfr. :

    6. Comorbid clinical conditions in chronic fatigue - A co-twin control study
      Aaron LA, Herrell R, Ashton S et al. - J Gen Intern Med 2001;16:24-31
      Cfr. :

    7. Comorbid illness in women with chronic fatigue syndrome - A test of the single syndrome hypothesis
      Ciccone DS, Natelson BH - Psychosom Med 2003;65:268-75
      Objective - Evidence of comorbidity among unexplained illness syndromes raises the possibility that all are variants of a single functional disorder, leading some to suggest that separate case definitions for chronic fatigue syndrome (CFS), fibromyalgia (FM) and multiple chemical sensitivity (MCS) may be unnecessary.
      Our objective was to determine whether discrete diagnostic labels provide useful information about physical functioning, symptom severity and risk of psychiatric illness.
      Methods - The sample consisted of 163 consecutive female referrals with CFS enrolled at a tertiary clinic.
      Each participant was retrospectively assigned to one of four groups : CFS only, CFS/FM, CFS/MCS and CFS/FM/MCS.
      At enrollment, participants gave their history, underwent a physical examination and a standardized psychiatric interview (Diagnostic Interview Schedule) and answered self-report questionnaires.
      Results - Additional unexplained syndromes were prevalent : 37% met criteria for FM and 33% met criteria for MCS.
      With the exception of FM-related pain and disability, there were few differences between the CFS only and CFS with comorbid illness groups.
      Patients with additional illness were more likely to have major depression and a higher risk of psychiatric morbidity compared with patients in the CFS only group (p <.01).
      Rates of lifetime depression increased from 27.4% in the CFS only group to 52.3% in the CFS/FM group, 45.2% in the CFS/MCS group and 69.2% in the CFS/FM/MCS group.
      Conclusions - The prevalence of comorbid illness in the present CFS sample and the failure to find widespread differences in symptom severity can be seen as support for the single syndrome hypothesis.
      On the other hand, the existence of discrete syndromes could not be ruled out because of reliable differences between CFS and CFS/FM.
      Increasing comorbidity was associated with a corresponding increase in risk of major depression.
      Cfr. :

    8. Comparative study of anxiety, depression, somatization, functional disability and illness attribution in adolescents with chronic fatigue or migraine
      Smith MS, Martin-Herz SP, Womack WM et al. - Pediatrics 2003;111:e376-81
      Cfr. :

    9. Comparing self-reported function and work disability in 100 community cases of fibromyalgia syndrome versus controls in London, Ontario - The London Fibromyalgia Epidemiology Study
      White KP, Speechley M, Harth m & Ostbye T, University of Western Ontario, London, Canada - Arthritis and Rheumatism 1999;42(1):76-83
      - To compare function and disability in fibromyalgia syndrome (FMS) cases in the community versus controls and to identify variables predicting poor function and disability.
      We identified 100 FMS cases, 76 pain controls and 135 general controls in a random survey of 3,395 noninstitutionalized adults.
      Results - FMS cases reported worse function (P < 0.00001), more days in bed (P < 0.001) and more healthy years of life lost (P < 0.0001).
      More FMS cases were disabled (P < 0.00001) and receiving pensions (P < 0.00001).
      Risk factors for disability included middle age and previous heavy manual labor.
      Pain, fatigue and weakness were most often claimed to affect the ability to work.
      Variables predicting work disability were the Fibromyalgia Impact Questionnaire (FIQ) score, a prior diagnosis of FMS, nonrestorative sleep and past heavy physical labor.
      Variables influencing the FIQ score were the number of major symptoms, self-reported health satisfaction, tender point count and education level.
      Conclusions - FMS commonly results in loss of function and work disability.
      Cfr. :

    10. Comparing the national economic burden of five chronic conditions
      Druss, BG; Marcus, SC; Olfson, M et al. - Health Aff. 2001;20:233–241
      Using a nationally representative sample of 23,230 U.S. residents, we examine patterns of economic burden across five chronic conditions : mood disorders, diabetes, heart disease, asthma and hypertension.
      Almost half of U.S. health care costs in 1996 were borne by persons with one or more of these five conditions; of that spending amount, only about one-quarter was spent on treating the conditions themselves and the remainder on coexistent illnesses.
      Each condition demonstrated substantial economic burden but also unique characteristics and patterns of service use driving those costs.
      The findings highlight the differing challenges involved in understanding needs and improving care across particular chronic conditions.
      Cfr. :

    11. Comparison of 99mTcHMPAO SPECT scan between chronic fatigue syndrome, major depression and healthy controls - An exploration study of clinical correlates regional cerebral blood flow
      Fischler B, D'Haenen ij, Cluydts R et al. - Neuropsychobiology 1996; 34; 175-83

    12. Comparison of Consensus, Consistency and Measurement Approaches to Estimating Interrater Reliability
      Stemler SE in : 'Practical Assessment, Research & Evaluation 9 (4)' - Yale University PACE Center, 2004
      Cfr. :

    13. Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures - Summary of results from the Medical Outcomes Study
      Ware JE Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A, Health Institute, New England Medical Center, Boston, MA, USA - Med Care. 1995 Apr;33(4 Suppl):AS264-79 - PMID: 7723455
      Physical component summary (PCS) and mental component summary (MCS) measures make it possible to reduce the number of statistical comparisons and thereby the role of chance in testing hypotheses about health outcomes.
      To test their usefulness relative to a profile of eight scores, results were compared across 16 tests involving patients (N = 1,440) participating in the Medical Outcomes Study.
      Comparisons were made between groups known to differ at a point in time or to change over time in terms of age, diagnosis, severity of disease, comorbid conditions, acute symptoms, self-reported changes in health and recovery from clinical depression.
      The relative validity (RV) of each measure was estimated by a comparison of statistical results with those for the best scales in the same tests.
      Differences in RV among scales from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) were consistent with those in previous studies.
      One or both of the summary measures were significant for 14 of 15 differences detected in multivariate analyses of profiles and detected differences missed by the profile in one test.
      Relative validity coefficients ranged from .20 to .94 (median, .79) for PCS in tests involving physical criteria and from .93 to 1.45 (median, 1.02) for MCS in tests involving mental criteria.
      The MCS was superior to the best SF-36 scale in three of four tests involving mental health.
      Results suggest that the two summary measures may be useful in most studies and that their empiric validity, relative to the best SF-36 scale, will depend on the application.
      Surveys offering the option of analyzing both a profile and psychometrically based summary measures have an advantage over those that do not.
      Cfr. :

    14. Complementary and alternative medicine in fibromyalgia and related syndromes
      Holdcraft LC, Assefi N, Buchwald D, Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, University of Washington School of Medicine, Box 359797, 325 Ninth Ave, Seattle, WA 98104-2499, USA : - Best Pract Res Clin Rheumatol. 2003 Aug;17(4):667-83 - PMID: 12849718
      Complementary and alternative medicine (CAM) has gained increasing popularity, particularly among individuals with fibromyalgia syndrome (FMS) for which traditional medicine has generally been ineffective.
      A systematic review of randomized controlled trials (RCTs) and non-RCTs on CAM studies for FMS was conducted to evaluate the empirical evidence for their effectiveness.
      Few RCTs achieved high scores on the CONSORT, a standardized evaluation of the quality of methodology reporting.
      Acupuncture, some herbal and nutritional supplements (magnesium, SAMe) and massage therapy have the best evidence for effectiveness with FMS.
      Other CAM therapies have either been evaluated in only one RCT with positive results (Chlorella, biofeedback, relaxation), in multiple RCTs with mixed results (magnet therapies) or have positive results from studies with methodological flaws (homeopathy, botanical oils, balneotherapy, anthocyanidins, dietary modifications).
      Lastly, other CAM therapies have neither well-designed studies nor positive results and are not currently recommended for FMS treatment (chiropractic care).
      Cfr. :

    15. Computerized, interactive, multimedia cognitive-behavioural program for anxiety and depression in general practice
      Proudfoot J, Goldberg D, Mann A, Everitt B, Marks I, Gray JA, Department of Psychology, Institute of Psychiatry, King's College London - Psychol Med. 2003 Feb;33(2):217-27 - PMID: 12622301
      Background - Cognitive-behavioural therapy (CBT) brings about significant clinical improvement in anxiety and depression, but therapists are in short supply.
      We report the first phase of a randomized controlled trial of an interactive multimedia program of cognitive-behavioural techniques, Beating the Blues (BtB), in the treatment of patients in general practice with anxiety, depression or mixed anxiety/depression.
      Method - One hundred and sixty-seven adults suffering from anxiety and/or depression and not receiving any form of psychological treatment or counselling were randomly allocated to receive, with or without medication, BtB or treatment as usual (TAU).
      Measures were taken on five occasions: prior to treatment, 2 months later and at 1, 3 and 6 months follow-up using the Beck Depression Inventory, Beck Anxiety Inventory and Work and Social Adjustment Scale.
      Results - Patients who received BtB showed significantly greater improvement in depression and anxiety compared to TAU by the end of treatment (2 months) and to 6 months follow-up.
      Symptom reduction was paralleled by improvement in work and social adjustment.
      There were no interactions of BtB with concomitant pharmacotherapy or duration of illness, but evidence, on the Beck Anxiety Inventory only, of interaction with primary care practice.
      Importantly, there was no interaction between the effects of BtB and baseline severity of depression, from which we conclude that the effects of the computer program are independent of starting level of depression.
      Conclusions - These results demonstrate that computerized interactive multimedia cognitive-behavioural techniques under minimal clinical supervision can bring about improvements in depression and anxiety, as well as in work and social adjustment, with and without pharmacotherapy and in patients with pre-treatment illness of durations greater or less than 6 months.
      Thus, our results indicate that wider dissemination of cognitive-behavioural techniques is possible for patients suffering from anxiety and/or depression.
      Also read the comment in 'Methodological aspects of randomized controlled trials of psychotherapy in primary care' at :
      Cfr. :

    16. Connecting cytokines and brain - A review of current issues
      Quan N, Herkenham M - Histol Histopathol 2002;17:273-88

    17. Contribution to the Study of the Psychopathology and Psychobiology of the Chronic Fatigue Syndrome
      Fischler B - Doctoral dissertation : Vrije Universiteit Brussel; 1996

    18. Controlled trials of CQI and academic detailing to implement a clinical practice guideline for depression
      Brown JB, Shye D, McFarland BH, Nichols GA, Mullooly JP, Johnson RE, Kaiser Permanente Center for Health Research, Portland, Oregon, USA : - Jt Comm J Qual Improv. 2000 Jan;26(1):39-54 - PMID: 10677821
      - The release of the Agency for Health Care Policy and Research (AHCPR)'s Guideline for the Detection and Treatment of Depression in Primary Care created an opportunity to evaluate under naturalistic conditions the effectiveness of two clinical practice guideline implementation methods : continuous quality improvement (CQI) and academic detailing.
      A study conducted in 1993-1994 at Kaiser Permanente Northwest Division, a large, not-for-profit prepaid group practice (group-model) HMO, tested the hypotheses that each method would increase the number of members receiving depression treatment and would relieve depressive symptoms.
      Methods - Two trials were conducted simultaneously among adult primary care physicians, physician assistants and nurse practitioners, using the same guideline document, measurement methods and one-year follow-up period.
      The academic detailing trial was randomized at the clinician level.
      CQI was assigned to one of the setting's two geographic areas.
      To account for intraclinician correlation, both trials were evaluated using generalized equations analysis.
      Results - Most of the CQI team's recommendations were not implemented.
      Academic detailing increased treatment rates, but--in a cohort of patients with probable chronic depressive disorder--it failed to improve symptoms and reduced measures of overall functional status.
      Conclusions - New organizational structures may be necessary before CQI teams and academic detailing can substantially change complex processes such as the primary care of depression.
      New research and treatment guidelines are needed to improve the management of persons with chronic or recurring major depressive disorder.
      Cfr. :

    19. Coping and adaptive outcome in chronic fatigue syndrome - Importance of illness cognitions
      Heijmans MJ - J Psychosom Res 1998;45:39-51

    20. Coping and illness cognitions - Chronic fatigue syndrome
      Ax S, Gregg VH, Jones D - Clin Psychol Rev 2001;21:161-82
      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.
      Cfr. :

    21. Correlates of illness worry in chronic fatigue syndrome
      Taillefer SS, Kirmayer LJ, Robbins JM et al. - J Psychosom Res 2003;54:331-7
      Background - Anxiety about illness leading to restriction of activity and physical deconditioning has been hypothesized to contribute to the chronicity of fatigue.
      Pathological symptom attributions, personality traits and depression have all been hypothesized to contribute to illness worry.
      Methods - We compared 45 chronic fatigue syndrome (CFS) and 40 multiple sclerosis (MS) outpatients using a battery of psychometric instruments comprising the 12-item Illness Worry scale, the Symptom Interpretation Questionnaire (SIQ), the NEO Five-Factor Inventory (NEO-FFI) and a modified version of the SCL-90R Depression scale.
      Results - There was no difference between the two diagnostic groups on neuroticism, depressive symptoms, as well as the three scales of the SIQ.
      On the illness worry index, the CFS group had significantly higher scores than the MS group.
      This difference was due to items tapping vulnerability to illness and the perception that others are not taking their illness seriously.
      Somatic attributional style, neuroticism, depressive symptoms and age were all significant predictors of illness worry in both CFS and MS patients.
      Conclusions - Somatic attributions, neuroticism and depression all contribute to illness worry in chronic illness.
      However, these factors do not account for the higher levels of illness worry in CFS as opposed to MS, which may be due to other specific cognitive and social interactional processes.
      Cfr. :

    22. Corticotropin-releasing hormone (CRH) in psychiatry - From stress to psychopathology
      Claes SJ - Ann Med 2004;36:50-61
      Corticotropin-releasing hormone (CRH) plays a central role in the adaptation of the organism to stress.
      It serves as the main regulating hormone of the hypothalamic pituitary adrenal (HPA) axis, which is activated within seconds after exposure to acute stress.
      Furthermore, it acts as a neurotransmitter in numerous other brain regions.
      Globally, CRH leads to a number of metabolic, neuroendocrine and autonomic adaptations, which are vitally important for an adequate reaction to acute stress, but can lead to pathological somatic and psychological effects in chronic stress situations.
      The adequate functioning of CRH is a delicate equilibrium, which can be permanently disturbed by early experiences of physical or sexual abuse, leading to psychopathology in adulthood.
      This review discusses the physiological functions of CRH as the stress response hormone.
      Subsequently, the emerging data on the disruptive effects of early trauma on the CRH system are summarized.
      The third part is devoted to CRH and HPA axis abnormalities in major depression and other psychiatric disorders.
      This rapidly accumulating evidence will change our understanding of psychopathology and might challenge the established classification of psychiatric disorders.
      Cfr. :

    23. Cortisol response to a cognitive stress challenge in posttraumatic stress disorder (PTSD) related to childhood abuse
      Bremner JD, Vythilingam M, Vermetten E et al. - Psychoneuroendocrinology 2003;28:733-50
      Cfr. :

    24. Cost of Lost Productive Work Time Among US Workers With Depression
      Walter F. Stewart, PhD, MPH; Judith A. Ricci, ScD, MS; Elsbeth Chee, ScD; Steven R. Hahn, MD; David Morganstein, MS, AdvancePCS Center for Work and Health, Hunt Valley, Md (Drs Stewart, Ricci, and Chee); Outcomes Research Institute, Geisinger Health Systems, Danville, Pa (Dr Stewart); Albert Einstein College of Medicine, Bronx, NY (Dr Hahn); WESTAT, Rockville, Md (Mr Morganstein) – JAMA. 2003;289:3135-3144
      Context - Evidence consistently indicates that depression has adversely affected work productivity.
      Estimates of the cost impact in lost labor time in the US workforce, however, are scarce and dated.
      Objective - To estimate the impact of depression on labor costs (ie, work absence and reduced performance while at work) in the US workforce.
      Design, setting and participants - All employed individuals who participated in the American Productivity Audit (conducted August 1, 2001-July 31, 2002) between May 20 and July 11, 2002, were eligible for the Depressive Disorders Study.
      Those who responded affirmatively to 2 depression-screening questions (n = 692), as well as a 1:4 stratified random sample of those responding in the negative (n = 435), were recruited for and completed a supplemental interview using the Primary Care Evaluation of Mental Disorders Mood Module for depression, the Somatic Symptom Inventory and a medical and treatment history for depression.
      Excess lost productive time (LPT) costs from depression were derived as the difference in LPT among individuals with depression minus the expected LPT in the absence of depression projected to the US workforce.
      Main outcome measure - Estimated LPT and associated labor costs (work absence and reduced performance while at work) due to depression.
      Results - Workers with depression reported significantly more total health-related LPT than those without depression (mean, 5.6 h/wk vs an expected 1.5 h/wk, respectively).
      Eighty-one percent of the LPT costs are explained by reduced performance while at work.
      Major depression accounts for 48% of the LPT among those with depression, again with a majority of the cost explained by reduced performance while at work.
      Self-reported use of antidepressants in the previous 12 months among those with depression was low (<33%) and the mean reported treatment effectiveness was only moderate.
      Extrapolation of these survey results and self-reported annual incomes to the population of US workers suggests that US workers with depression employed in the previous week cost employers an estimated 44 billion dollars per year in LPT, an excess of 31 billion dollars per year compared with peers without depression.
      This estimate does not include labor costs associated with short- and long-term disability.
      Conclusions - A majority of the LPT costs that employers face from employee depression is invisible and explained by reduced performance while at work. Use of treatments for depression appears to be relatively low.
      The combined LPT burden among those with depression and the low level of treatment suggests that there may be cost-effective opportunities for improving depression-related outcomes in the US workforce.
      Cfr. :

    25. Cost-effectiveness of computerised cognitive-behavioural therapy for anxiety and depression in primary care - Randomised controlled trial
      McCrone P, Knapp M, Proudfoot J, Ryden C, Cavanagh K, Shapiro DA, Ilson S, Gray JA, Goldberg D, Mann A, Marks I, Everitt B, Tylee A, Centre for the Economics of Mental Health, Institute of Psychiatry, King's College London, UK - Br J Psychiatry. 2004 Jul;185:55-62 - PMID: 15231556
      - Cognitive-behavioural therapy (CBT) is effective for treating anxiety and depression in primary care, but there is a shortage of therapists.
      Computer-delivered treatment may be a viable alternative.
      Aims - To assess the cost-effectiveness of computer-delivered CBT.
      Methods - A sample of people with depression or anxiety were randomised to usual care (n=128) or computer-delivered CBT (n=146).
      Costs were available for 123 and 138 participants, respectively.
      Costs and depression scores were combined using the net benefit approach.
      Results - Service costs were 40 British pounds (90% CI - 28 British pounds to 148 British pounds) higher over 8 months for computer-delivered CBT.
      Lost-employment costs were 407 British pounds (90% CI 196 British pounds to 586 British pounds) less for this group.
      Valuing a 1-unit improvement on the Beck Depression Inventory at 40 British pounds, there is an 81% chance that computer-delivered CBT is cost-effective and it revealed a highly competitive cost per quality-adjusted life year.
      Conclusions - Computer-delivered CBT has a high probability of being cost-effective, even if a modest value is placed on unit improvements in depression.
      Cfr. :

    26. Cost-effectiveness of practice-initiated quality improvement for depression - Results of a randomized controlled trial
      Schoenbaum M, Unutzer J, Sherbourne C, Duan N, Rubenstein LV, Miranda J et al. - JAMA 2001;286:1325-30
      Cfr. :

    27. Course and outcome of chronic fatigue in children and adolescents
      Krilov LR, Fisher M, Friedman SB et al. - Pediatrics 1998;102:360-6

    28. Current and residual functional disability associated with psychopathology - Findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)
      R. V. Bijl and A. Ravelli, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands – Correspondence : Dr Rob V. Bijl, Netherlands Institute of Mental Health and Addiction, PO Box 725, 3500 AS Utrecht, The Netherlands
      - Few population studies have investigated the functional disabilities that accompany specific psychiatric diagnoses.
      This study assesses the nature and strength of current and residual impairments in various functional domains of life.
      Methods - Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a prospective study in the Dutch general population aged 18 to 64 (N = 7147).
      Psychiatric diagnoses were based on the Composite International Diagnostic Interview; functional disability was assessed on the basis of the Short-Form-36 and the number of disability days.
      Results - Psychopathology was associated with increased disability in social, emotional and physical domains of life.
      Disability levels varied by psychiatric diagnosis, with mood disorders showing the poorest levels of functioning, especially for vitality and social functioning; alcohol-related disorders were associated with few disabilities.
      Co-morbidity strongly aggravated the disability.
      The effect of contextual factors on disability was limited, although somatic ill health, unemployment and adverse youth history increased the likelihood of functional disability.
      The findings indicate that psychopathology can also have residual debilitating effects.
      Conclusions - Mental health care providers should be aware that the extent and the type of disability may vary with the different types of disorders and among different groups within the population.
      Since recovery from functional limitations may not be complete or may take more time than the remission of the psychiatric symptomatology, non-psychiatric follow-up care is needed.
      The high number of lost work days is relevant from an economic perspective.
      There is a need for illness-specific disability assessment instruments.
      Cfr. :;jsessionid=5411F4CF8120CF7CDDD15

    29. Cytokine production and modulation: comparison of patients with chronic fatigue syndrome and normal controls
      Tomoda A, Joudoi T, Rabab el-M, Matsumoto T, Park TH, Miike T - Psychiatry Res 2005, 134(1):101-104
      Cfr. :

    30. Cytokine-induced sickness behavior
      Kelley KW, Bluthe RM, Dantzer R et al. - Brain Behav Immun 2003;17:S112-8
      The behavioral repertoire of humans and animals changes dramatically following infection.
      Sick individuals have little motivation to eat, are listless, complain of fatigue and malaise, loose interest in social activities and have significant changes in sleep patterns.
      They display an inability to experience pleasure, have exaggerated responses to pain and fail to concentrate.
      Proinflammatory cytokines acting in the brain cause sickness behaviors.
      These nearly universal behavioral changes are a manifestation of a central motivational state that is designed to promote recovery.
      Exaggerated symptoms of sickness in cancer patients, such as cachexia, can be life-threatening.
      However, quality of life is often drastically impaired before the cancer becomes totally debilitating.
      Although basic studies in psychoneuroimmunology have defined proinflammatory cytokines as the central mediators of sickness behavior, a much better understanding of how cytokine and neurotransmitter receptors communicate with each other is needed.
      Advances that have been made during the past decade should now be extended to clinical studies in an attempt to alleviate sickness symptoms and improve quality of life for cancer patients.
      Cfr. :

    31. Cytokine-induced sickness behaviour - Mechanisms and implications
      Konsman JP, Parnet P, Dantzer R - Trends Neurosci 2002;25:154-9

    32. Daily hassles reported by chronic fatigue syndrome and fibromyalgia patients in tertiary care - A controlled quantitative and qualitative study
      Van Houdenhove B, Neerinckx E, Onghena P et al. - Psychother Psychosom 2002;71:207-13
      Background - This study aimed at providing insight in the frequency, emotional impact and nature of daily hassles, experienced by patients suffering from chronic fatigue syndrome (CFS) and/or fibromyalgia (FM), compared with patients with a chronic organic disease.
      Methods - One hundred and seventy-seven CFS/FM patients, 26 multiple sclerosis (MS) and 26 rheumatoid arthritis (RA) patients were investigated within 2-6 months after diagnosis.
      All patients completed a self-report questionnaire assessing daily hassles and associated distress, a visual analogue scale assessing fatigue and pain and a depression and anxiety questionnaire.
      Results - CFS/FM patients show a higher frequency of hassles, higher emotional impact and higher fatigue, pain, depression and anxiety levels compared with MS/RA patients.
      Three hassle themes dominate in the CFS/FM group : dissatisfaction with oneself, insecurity and a lack of social recognition.
      In contrast, hassles reported by MS/RA patients show a much larger diversity and are not focused on person-dependent problems.
      Conclusions - Patients recently diagnosed as suffering from CFS and/or FM are highly preoccupied and distressed by daily hassles that have a severe impact on their self-image, as well as their personal, social and professional functioning.
      An optimal therapeutic approach of CFS and FM should take account of this heavy psychosocial burden, which might refer to core themes of these patients' illness experience.
      Cfr. :

    33. Defining and managing chronic fatigue syndrome
      Mulrow C D, Ramirez G, Cornell J E, Allsup K - Defining and Managing Chronic Fatigue Syndrome - Evidence Report/Technology Assessment No. 42 - Prepared by San Antonio Evidence-based Practice Center at The University of Texas Health Science Center at San Antonio under Contract No. 290-97-0012 - AHRQ Publication No. 02-E001. Rockville (MD) : Agency for Healthcare Research and Quality; October 2001
      Objectives - Objectives of this evidence report are to summarize research evidence regarding the case definitions, prevalence, natural history and therapy of chronic fatigue syndrome (CFS).
      Search Strategy - English and non-English citations were identified through July 2000 from four electronic bibliographic databases (MEDLINE, The Cochrane Library, PsycINFO, EMBASE), CFS Internet sites, the Journal of Chronic Fatigue Syndrome, references of pertinent articles, textbooks and experts.
      The electronic search was updated through October 2000 using PubMed; experts identified relevant citations up to January 2001
      Selection Criteria - Published and unpublished studies that were conducted after 1980 and that involved adults with CFS were reviewed.
      Data Collection and Analysis - Two reviewers (physician, psychometrician, research methodologist and/or nurse) independently abstracted data from the selected studies.
      Data were synthesized descriptively, emphasizing the quality and methodologic design of studies.
      Meta-analyses were not done because of marked heterogeneity of study designs.
      Main Results - ° There are four well-recognized case definitions of CFS and the Centers for Disease Control and Prevention (CDC) is spearheading the development of a fifth.
      Definitions, developed primarily by expert knowledge and consensus, have evolved over time.
      A few comparative research studies support the concept of a condition, characterized by prolonged fatigue and impaired ability to function, which is captured by the case definitions.
      The superiority of one case definition over another is not well established.
      The validity of any definition is difficult to establish because there are no clear biologic markers for CFS and no effective treatments specific only to CFS have been identified. -- ° Findings from surveys show that the prevalence of CFS in community populations is probably less than 1% and in primary care populations less than 3%.
      The reliability of these estimates is limited, because surveys used different case definitions and varied assessment and reporting methods and sometimes had poor response rates. -- ° Precise estimates of recovery, improvement and/or relapse from CFS are not possible because there are few natural history studies and those that are available have involved selected referral populations or have used varying case definitions and followup methods. -- ° Thirty-eight controlled trials evaluating multiple treatment interventions show the following mixed results : Immunologic Therapy - Evidence from 11 trials is scant and insufficient to conclude whether immunological therapies, such as immunoglobulin, Ampligen, Acyclovir, interferon and transfer factor, are effective or ineffective. Corticosteroids - Evidence from four trials suggests that there are no consistent benefits from mineralocorticoids (fludrocortisone), but that there are some improvements in fatigue and functional status with glucocorticoids (hydrocortisone).
      However, glucocorticoid therapy may severely suppress adrenal function. Antidepressants - Evidence from five trials show that there is no consistent pattern of benefit from antidepressant therapy, though some participants in these trials experienced improved vigor and less anxiety. Behavioral Therapies - Evidence from nine trials generally show that behavioral interventions that emphasize increased activity levels result in improvements in fatigue, overall well-being, quality of life and functional status. Other - Evidence from trials is scant and insufficient to conclude whether complementary therapies, such as homeopathy, massage therapy and osteopathy are effective or ineffective.
      Evidence from trials is scant and insufficient to conclude whether multiple other therapies, such as nicotinamide adenine dinucleotide (NADH), galanthamine, growth hormone, essential fatty acids and liver extract therapies, are effective or ineffective.
      Findings from one small trial suggest that magnesium therapy may improve energy, overall well-being, pain and distress in patients with CFS and magnesium deficiency.
      Conclusions - Existing case definitions for CFS appear to characterize a group of people with prolonged fatigue and impaired ability to function.
      The validity and superiority of any particular case definition are not well established.
      Surveys suggest that the prevalence of CFS in community populations is less than 1%.
      Precise estimates of rates of recovery, improvement and/or relapse from CFS are not available.
      Although several therapies have been studied, potential benefits as well as harms of most therapies are not well established.
      Behavioral interventions that emphasize increasing activity levels may improve quality of life and function in some people with CFS.
      Cfr. : :

    34. Depression - A neglected major illness
      Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER, Analysis Group, Inc., Cambridge, MA 02138 - J Clin Psychiatry. 1993 Nov;54(11):419-24 - PMID: 8270584
      Background - To illustrate the burden depression imposes on society, we present estimates of the annual costs of depression--$44 billion--as well as the number of individuals it affects per year--almost 11 million.
      Although these estimates point to depression as a major illness, this study examines why it is not generally considered as such by the medical and public health communities or by society at large.
      Method - We develop a framework that compares depression with major illnesses such as coronary heart disease, cancer and AIDS by highlighting salient characteristics of each illness.
      This comparative illness framework considers the costs, prevalence, distribution of sufferers, mortality, recognition and treatability of each disease.
      This comparison underscores many of the similarities and differences among the illnesses examined.
      Results - Because depression often is not properly recognized and begins to affect many people at a relatively early age, it exacts costs over a longer period of time and in a more subtle manner than other major illnesses.
      It also imposes a particularly heavy burden on employers in the form of higher workplace costs.
      Conclusions - We conclude that, because of the potential for successful treatment, increased attempts to reach untreated sufferers of depression appear to be warranted.
      Employers as a group have a particular incentive to invest in the recognition and treatment of this widespread problem, in order to reduce the substantial costs it imposes upon them each year.
      Cfr. :
      Also read the comment on this article : 'The costs of treating depression' at :

    Lees verder : Deel XXIV

    25-11-2009 om 20:19 geschreven door Jules

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    Tags:arbeidsongeschiktbeidsbeoordeling, arbeidsongeschiktheid, bedrijfsarts, begeleiden, behandelen, beoordelen, chronische vermoeidheidssyndroom, fibromyalgie, ME/CVS, psychosomatisch, reïntegratie, verzekeringsarts, werk, werkhervatting, ziekteverzuim
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    Bedrijfsartsen op bres voor arbeidsongeschikten

    Deel XXIV

    1. Depression and the Ability to Work
      Lynn Elinson, Ph.D., Patricia Houck, M.S.H., Steven C. Marcus, Ph.D. and Harold Alan Pincus, M.D. - Psychiatr Serv 55:29-34, January 2004 - © 2004 American Psychiatric Association
      - Depression can have a serious impact on a person's ability to work.
      The purpose of this study was to describe depressed persons who work and depressed persons who do not work and to identify factors related to depressed persons' working.
      Methods - The combined 1994 and 1995 National Health Interview Survey Disability Supplement was used to identify persons aged 18 to 69 with depression.
      Sociodemographic, health, functional and disability characteristics of working depressed persons and nonworking depressed persons were compared with use of a chi square test of significance.
      After adjustment for sociodemographic variables, multiple logistic regression analysis was used to identify factors associated with work among depressed persons.
      Results - Approximately half of the persons who reported major depression were in the labor force.
      Compared with nonworking depressed persons, working depressed persons tended to be younger, to be male, to be better educated, to have a higher income, to live alone or with a nonrelative and to live in an urban or suburban location.
      They less often perceived themselves as unable to work or as disabled and were healthier and less impaired by social, cognitive and physical limitations than their nonworking counterparts.
      After sociodemographic factors were controlled for, health and functional characteristics were strongly associated with depressed persons' working.
      Conclusions - Depressed persons who work and who do not work differed across sociodemographic, health, functional and disability factors.
      Understanding the factors associated with depressed persons' working and not working may help policy makers, employers and clinicians shape health care benefits packages, employee assistance programs, disability programs and treatment programs appropriately.
      In particular, it may be important to focus on individuals with depression and comorbid general health conditions.
      Cfr. :

    2. Depression and work productivity - The comparative costs of treatment versus nontreatment
      Gregory E. Simon (1 2), Catherine Barber (3), Howard G. Birnbaum (4), Richard G. Frank (3), Paul E. Greenberg (4), Robert M. Rose (5), Phillip S. Wang (3) and Ronald C. Kessler (3) -- (1) Center for Health Studies, Group Health Cooperative of Puget Sound, Cambridge, Mass, Etats-Unis -- (2) Department of Psychiatry, University of Washington, Cambridge, Mass, Etats-Unis -- (3) Department of Health Care Policy, Harvard Medical School, Cambridge, Mass, Etats-Unis -- (4) Analysis Group/Economics, Cambridge, Mass, Etats-Unis -- (5) John D. and Catherine T. MacArthur Foundation, Etats-Unis - Journal of occupational and environmental medicine, 2001, vol. 43, no 1 (72 p.) (70 ref.), pp. 2-9 - Lippincott Williams & Wilkins, Hagerstown, MD, ETATS-UNIS  (1995) (Revue) – ISSN : 1076-2752 - © 2008 INIST-CNRS
      This article discusses the impact of depression on work productivity and the potential for improved work performance associated with effective treatment.
      We undertook a review of the literature by means of a computer search using the following key terms : cost of illness, work loss, sickness absence, productivity, performance and disability.
      Published works were considered in four categories : (1) naturalistic cross-sectional studies that found greater self-reported work impairment among depressed workers; (2) naturalistic longitudinal studies that found a synchrony of change between depression and work impairment; (3) uncontrolled treatment studies that found reduced work impairment with successful treatment; and (4) controlled trials that usually, but not always, found greater reduction in work impairment among treated patients.
      Observational data suggest that productivity gains following effective depression treatment could far exceed direct treatment costs.
      Randomized effectiveness trials are needed before we can conclude definitively that depression treatment results in productivity improvements sufficient to offset direct treatment costs.
      Cfr. :

    3. Depression Guideline Panel: Depression in Primary Care - Volume 1 - Detection and Diagnosis
      Clinical Practice Guideline, Number 5. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; Rockville, MD: 1993. (AHCPR Publication No. 93–0550)
      Cfr. :

    4. Depression Guideline Panel: Depression in Primary Care - Volume 2 - Treatment of Major Depression
      Clinical Practice Guideline, Number 5. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; Rockville, MD: 1993. (AHCPR Publication No. 93–0551)
      Cfr. :

    5. Depression in solvent abusers
      Jacobs AM,.Ghodse AH - Soc Sci Med 1987;24:863-6 - PMID: 3616680
      Cfr. :

    6. Depression in the workplace - Effects on short-term disability
      Kessler, RC; Barber, C; Birnbaum, HG, et al. - Health Aff. 1999;18:163–171
      Cfr. :

    7. Depression in the workplace - Epidemiology, economics and effects of treatment
      Russell, JM; Patterson, J; Baker, AM - Disease Manage Health Outcomes. 1998;4:135–142
      Cfr. :

    8. Depression, anxiety and social disability show synchrony of change in primary care patients
      J Ormel, M Von Korff, W Van den Brink, W Katon, E Brilman, and T Oldehinkel, Department of Psychiatry, University of Groningen, The Netherlands - Am J Public Health. 1993 March; 83(3): 385–390 - PMCID: PMC1694652
      - The purposes of this study were to (1) characterize the social disability associated with the common psychiatric illnesses of primary care patients in terms of role dysfunction (self-care, family role, social role, occupational role) and (2) establish whether severity of psychiatric illness and disability level show synchrony of change.
      Methods - A two-stage sample design was employed.
      In the first stage, 1994 consecutive attenders of 25 general practitioners were screened on psychiatric illness by their physicians and with the General Health Questionnaire.
      A stratified random sample (n = 285) with differing probabilities was selected for a second-stage interview.
      Patients with psychiatric symptoms were reinterviewed 1 and 3.5 years later (n = 143).
      Results - (1) Disability level among patients was increased (moderately for depression, mildly for anxiety) and was associated with severity of psychiatric illness - (2) Most disability was found in occupational and social roles - (3) Change in severity of psychiatric illness was concordant with change in level of disability and was largely invariant across diagnosis (depression, anxiety, mixed anxiety/depression).
      At follow-up, disability among improved patients had returned to normal levels.
      Conclusions - Psychiatric illness in primary care patients is associated with mild to moderate disability and severity of psychiatric illness and disability show synchrony of change.
      Cfr. :

    9. Depressive symptoms and health-related quality of life - The Heart and Soul Study
      Ruo, B., Rumsfeld, J. S., Hlatky, M. A. et al (2003) - JAMA, 290, 215
      Context - Little is known regarding the extent to which patient-reported health status, including symptom burden, physical limitation and quality of life, is determined by psychosocial vs physiological factors among patients with chronic disease.
      Objective - To compare the contributions of depressive symptoms and measures of cardiac function to the health status of patients with coronary artery disease.
      Design, setting and participants - Cross-sectional study of 1024 adults with stable coronary artery disease recruited from outpatient clinics in the San Francisco Bay Area between September 2000 and December 2002.
      Main measures - Measurement of depressive symptoms using the Patient Health Questionnaire (PHQ); assessment of cardiac function by measuring left ventricular ejection fraction on echocardiography, exercise capacity on treadmill testing and ischemia on stress echocardiography; and measurement of a range of health status outcomes, including symptom burden, physical limitation and quality of life, using the Seattle Angina Questionnaire.
      Participants were also asked to rate their overall health as excellent, very good, good, fair or poor.
      Results - Of the 1024 participants, 201 (20%) had depressive symptoms (PHQ score 10).
      Participants with depressive symptoms were more likely than those without depressive symptoms to report at least mild symptom burden (60% vs 33%; P<.001), mild physical limitation (73% vs 40%; P<.001), mildly diminished quality of life (67% vs 31%; P<.001) and fair or poor overall health (66% vs 30%; P<.001).
      In multivariate analyses adjusting for measures of cardiac function and other patient characteristics, depressive symptoms were strongly associated with greater symptom burden (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.3-2.7; P = .002), greater physical limitation (OR, 3.1; 95% CI, 2.1-4.6; P<.001), worse quality of life (OR, 3.1; 95% CI, 2.2-4.6; P<.001) and worse overall health (OR, 2.0; 95% CI, 1.3-2.9; P<.001).
      Although decreased exercise capacity was associated with worse health status, left ventricular ejection fraction and ischemia were not.
      Conclusions - Among patients with coronary disease, depressive symptoms are strongly associated with patient-reported health status, including symptom burden, physical limitation, quality of life and overall health.
      Conversely, 2 traditional measures of cardiac function—ejection fraction and ischemia—are not.
      Efforts to improve health status should include assessment and treatment of depressive symptoms.
      Cfr. :

    10. Designing and implementing a primary care intervention trial to improve the quality and outcome of care for major depression
      Rost, K; Nutting, PA; Smith, J et al. - Gen Hosp Psychiatry. 2000;22:66–77
      Cfr. :

    11. Developing case definitions for symptom-based conditions - The problem of specificity
      Hyams KC - Epidemiol Rev 1998;20:148-56

    12. Development and application of a generic methodology to assess the quality of clinical guidelines
      Cluzeau FA, Littlejohns P, Grimshaw J, Feder G, Moran, SE - Int J Quality Health Care 1999;11(1):21-28
      Cfr. :

    13. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines - The AGREE project
      AGREE Collaboration, Writing Group : Cluzeau FA, Burgers JS, Brouwers M, Grol R, Mäkelä M, Littlejohns P, Grimshaw J, Hunt C - Qual Saf Health Care 2003;12:18–23
      Cfr. :

    14. Developmental neurobiology of childhood stress and trauma
      Teicher MH, Andersen SL, Polcari A et al. - Psychiatr Clin North Am 2002;25:397
      Cfr. :

    15. Diabetes - Guidelines from 13 countries
      Diabetes Care 2002;25(11):1933-9
      Cfr. :

    16. Diagnosis of psychiatric disorder in clinical evaluation of chronic fatigue syndrome
      Deale A, Wessely S – J R Soc Med 2000;93:310-2
      Cfr. :

    17. Diagnosis, disease and illness
      Mayou R, Sharpe M - QJM 1995;88:827-31

    18. Diagnostic and statistical manual of mental disorders
      American Psychiatric Association - Am Psychiatric Press Inc: 1994

    19. Dimensional assesment of chronic fatigue syndrome
      Vercoulen J.H.M.M,, Swanink C.M.A., Fennis J.F.M., Galama J,M.D., Meer J.W.M., van der, Bleijenberg G. - Journal of Psychsomatic research, Vol. 38, no. 5, pag. 383-392, 1994
      Cfr. :

    20. Dimensional assessment of chronic fatigue syndrome
      Vercoulen JH, Swanink CM, Fennis JF et al. - J Psychosom Res 1994;38:383-92

    21. Disability and chronic fatigue syndrome - A focus on function (review)
      Ross SD, Estok RP, Frame D, Stone LR, Ludensky V, Levine CB - Arch Intern Med. 2004 May 24;164(10):1098-107
      Cfr. :

    22. Disability management, employee health and fringe benefits and long-term-disability claims for mental disorders - An empirical exploration
      Salkever, DS; Goldman, H; Purushothaman, M et al. - Milbank Q. 2000;78:79–113
      Cfr. :

    23. Dissociation of body-temperature and melanotonin secretion cirdadian rhytms in patients with chronic fatigue syndroom
      Williams C, Pirmohamed J, Minors D et al. - Clin-Physiol 1996 Jul; 16 (4): 327-337

    24. Distinguishing between the validity and utility of psychiatric diagnoses
      Kendell, R. & Jablensky, A. (2003) - American Journal of Psychiatry, 160, 4-12
      Cfr. :

    25. Distinguishing patients with chronic fatigue from those with chronic fatigue syndrome – A diagnostic study in UK primary care
      Darbishire L, Ridsdale L, Seed PT - Br J Gen Pract 2003;53:441-5
      Cfr. :

    26. Disturbed neuroendocrine-immune interactions in chronic fatigue syndrome
      Kavelaars A, Kuis W, Knook L et al. - J Clin Endocrinol Metab 2000;85:692-6

    27. Do early adverse experiences have a pathogenetic role in the development of functional syndromes ?
      Alciati A, Mellado C - J Func Syndromes 2002;2:127-34

    28. Doctor-patient relationship in primary care of chronic fatigue syndrome - Perspectives of the doctor and the patient
      Prins JB, Bleijenberg G, Klein Rouweler E et al. - J Chronic Fatigue Syndr 2000;7:3-15
      Cfr. :

    29. Doctors and social epidemics - The problem of persistent unexplained physical symptoms, including chronic fatigue
      Stanley I, Salmon P, Peters S - Br J Gen Pract 2002;52:355-6
      Cfr. :

    30. Doctors' diagnoses and patients' perceptions lessons from chronic fatigue syndrome
      Sharpe M - Gen Hosp Psychiatry 1998;20:335-8

    31. Does high "action-proneness" make people more vulnerable to chronic fatigue syndrome ? - A controlled psychometric study
      Van Houdenhove B, Neerinckx E, Onghena P et al. - J Psychosom Res 1995, 39, 633-40

    32. Does psychosocial functioning improve independent of depressive symptoms ? - A comparison of nefazodone, psychotherapy and their combination
      Hirschfeld RM, Dunner DL, Keitner G, Klein DN, Koran LM, Kornstein SG et al. - Biol Psychiatr 2002;51:123-33
      Cfr. :

    33. Does the label "fibromyalgia" alter health status, function and health service utilization ? - A prospective, within-group comparison in a community cohort of adults with chronic widespread pain
      White KP, Nielson WR, Harth M, Ostbye T, Speechley M - Arthritis Rheum. 2002;47:260-5
      Cfr. :

    34. Doing things with illness - The micro politics of the CFS clinic
      Banks J, Prior L - Soc Sci Med 2001; 52: 11-23
      Cfr. :

    35. DSM–IV somatoform disorders - Do we need a new classification ?
      Escobar, J. I. & Gara, M. A. (1999) - General Hospital Psychiatry, 21, 154 -156

    36. Early disruption of the mother-infant relationship - Effects on brain plasticity and implications for psychopathology
      Cirulli F, Berry A, Alleva E - Neurosci Biobehav Rev 2003;27:73-82

    37. Economic cost and epidemiological characteristics of patients with fibromyalgia claims
      Robinson RL, Birnbaum HG, Morley MA, Sisitsky T, Greenberg PE, Claxton AJ - J.Rheumatol. 2003;30:1318-25
      Cfr. :

    38. Effect of clinical guidelines on medical practice - A systematic review of rigorous evaluations
      Grimshaw JM, Russell IT, Department of General Practice, University of Aberdeen, Foresterhill Health Centre, UK - Lancet. 1993 Nov 27;342(8883):1317-22 - PMID: 7901634
      Although interest in clinical guidelines has never been greater, uncertainty persists about whether they are effective.
      The debate has been hampered by the lack of a rigorous overview.
      We have identified 59 published evaluations of clinical guidelines that met defined criteria for scientific rigour; 24 investigated guidelines for specific clinical conditions, 27 studied preventive care and 8 looked at guidelines for prescribing or for support services.
      All but 4 of these studies detected significant improvements in the process of care after the introduction of guidelines and all but 2 of the 11 studies that assessed the outcome of care reported significant improvements.
      We conclude that explicit guidelines do improve clinical practice, when introduced in the context of rigorous evaluations.
      However, the size of the improvements in performance varied considerably.
      Cfr. :

    39. Effectieve gehoorbescherming
      Informatie over de multidisciplinaire richtlijn 'Effectieve Gehoorbescherming' - Nieuwsbrief, 1 januari 2006
      Cfr. :

    40. Effective treatments for mental illness are not being used, WHO says
      Brown P - BMJ 2001;323:769 (6 October)
      Cfr. :

    41. Effectiveness and efficiency of guideline dissemination and implementation strategies - Executive summary
      JM Grimshaw,1* RE Thomas,1 G MacLennan,1 C Fraser,1 CR Ramsay,1 L Vale,1,2 P Whitty,3 MP Eccles,4 L Matowe,1† L Shirran,1 M Wensing,5 R Dijkstra5 and C Donaldson6‡ - 1 Health Services Research Unit, University of Aberdeen, UK - 2 Health Economics Research Unit, University of Aberdeen, UK - 3 Department of Epidemiology and Public Health, University of Newcastle upon Tyne, UK - 4 Centre for Health Services Research, University of Newcastle upon Tyne, UK - 5 Centre for Quality of Care Research, University of Nijmegen, The Netherlands - 6 Department of Community Health Sciences, University of Calgary, Canada - * Corresponding author. Current affiliation : Clinical Epidemiology Programme, Ottawa Health Research Institute and Center for Best Practices, Institute of Population Health, University of Ottawa, Canada - † Current affiliation : Department of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, Kuwait - ‡ Current affiliation : Centre for Health Services Research, University of Newcastle upon Tyne, UK - Health Technology Assessment 2004; Vol 8: number 6
      There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances.
      Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits.
      They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour.
      Further research is required to : develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.
      Cfr. :

    42. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care - Hampshire Depression Project randomised controlled trial
      Thompson C, Kinmonth AL, Stevens L, Peveler RC, Stevens A, Ostler KJ, Pickering RM, Baker NG, Henson A, Preece J, Cooper D, Campbell MJ, Department of Mental Health, University of Southampton, Royal South Hants Hospital, Brinton's Terrace, UK - Lancet. 2000 Jan 15;355(9199):185-91 - PMID: 10675118
      - Depression is a major individual and public-health burden throughout the world and is managed mainly in primary care.
      The most effective strategy to reduce this burden has been believed to be education of primary-care practitioners.
      We tested this assumption by assessing the effectiveness of an educational programme based on a clinical-practice guideline in improving the recognition and outcome of primary-care depression.
      Methods - We carried out a randomised controlled trial in a representative sample of 60 primary-care practices (26% of the total) in an English health district.
      Education was delivered to practice teams and quality tested by feedback from participants and expert raters.
      The primary endpoints were recognition of depression, defined by the hospital anxiety and depression (HAD) scale and clinical improvement.
      Analysis was by intention to treat.
      Findings - The education was well received by participants, 80% of whom thought it would change their management of patients with depression.
      21409 patients were screened, of whom 4192 were classified as depressed by the HAD scale.
      The sensitivity of physicians to depressive symptoms was 39% in the intervention group and 36% in the control group after education (odds ratio 1.2 [95% CI 0.88-1.61]).
      The outcome of depressed patients as a whole at 6 weeks or 6 months after the assessment did not significantly improve.
      Interpretation - Although well received, this in-practice programme, which was designed to convey the current consensus on best practice for the care of depression, did not deliver improvements in recognition of or recovery from depression.
      Cfr. :
      Also read the comment on this article :
      'Lessons from the Hampshire Depression Project' - Symons L - Lancet. 2000 May 6;355(9215):1641-2 - PMID: 10821383 at :
      - and the author reply on that 'Lessons from the Hampshire Depression Project' - Henkel V, Althaus D, Hegerl U. - Lancet. 2000 May 6;355(9215):1641; author reply 1642 - PMID: 10821382 at :

    43. Effects of Stress Management Program for Teachers in Japan - A Pilot Study
      Akihito Shimzau, Yusuke Okada, Mitsumi Sakamoto of the Department of Psychology, Hiroshima University Graduate School of Education & Masae Miura of the Department of Clinical Psychology, Hiroshima International University School of Human and Social Environment, Japan – Correspondence : A. Shimazu, Department of Psychology, Hiroshima University Graduate School of Education, 1-1-1 Kagamiyama, Higashi Hiroshima 739-8524, Japan - J Occup Health 2003, vl. 45, Nr. 4, pages 202-208
      The aim of this study was to examine the effects of a stress management program for teachers on their stress responses, social support and coping.
      Participants (n=24) were assigned to either an intervention or a waiting list control group.
      A five-session program, including psychoeducation, group discussion, role-playing and relaxation training, was conducted for the intervention group at two week intervals.
      Eight participants from each of the groups responded to pre- and post-intervention questionnaire surveys.
      The positive intervention effect was significant for social support from co-workers (p=0.035), whereas the negative intervention effect was significant for proactive coping (p=0.033).
      No significant effect was observed for stress responses (vigor, anger, fatigue, anxiety, depression and somatic stress responses) (p>0.05).
      The positive intervention effect was marginally significant for social support from co-workers (p=0.085) and anger (p=0.057) among those who at first had high stress response scores in the pre-intervention survey (n=5 and n=4 for the intervention and waiting list control groups, respectively).
      Furthermore, the positive intervention effect was significant for social support from co-workers (p=0.021) and marginally significant for resignation coping (p=0.070) among those who at first had high job control scores (n=4 and n=5 for the intervention and waiting list control groups, respectively).
      Results showed that the stress management program conducted in this study contributed to increasing social support from co-workers.
      This study suggests that a program that focuses on a particular subgroup (e.g., those with high stress responses or high job control) might be effective in enhancing coping skills, increasing social support and reducing stress responses.
      Cfr. :

    44. Effects of work-related stress reduction on depressive symptoms among Japanese blue-collar workers
      Kawakami N, Araki S, Kawashima M, Masumoto T, Hayashi T - Scand.J Work Environ.Health 1997;23:54-9

    45. Employment barriers among welfare recipients and applicants with chronically ill children
      Smith, LA; Romero, D; Wood, PR; Nutting, PA; Rost, K; Dickinson, M - Am J Public Health. 2002;92:1453–1457

    46. Enhanced glucocorticoid sensitivity in patients with chronic fatigue syndrome
      Gaab J, Rohleder N, Heitz V et al. - Acta Neuropsychiatr 2003;15:184-91
      Cfr. :

    47. Epidemiology of chronic fatigue syndrome - The Centers for Disease Control study
      Gunn Walter J., David B. Connell, Bonnie Randall – In : 'Chronic Fatigue Syndrome' - Wiley, Chichester, Ciba Foundation Symposium 173, pag. 83-101, 1993

    48. Epidemiology of chronic fatigue syndrome and self reported myalgic encephalomyelitis in 5-15 year olds - Cross sectional study
      Chalder T, Goodman R, Wessely S et al. - BMJ 2003;327:654-5

    49. Epstein-Barr virus (EBV) and the chronic fatigue syndrome - Normal virus load in blood and normal immunologic reactivity in the EBV regression assay
      Swanink CM, van der Meer JW, Vercoulen JH et al. - Clin Infect Dis 1995;20:1390-2

    50. Estimating rates of chronic fatigue syndrome from a community-based sample - A pilot study
      Jason LA, Taylor R, Wagner L et al. - Am J Community Psychol 1995;23:557-68

    51. Estimating the prevalence of chronic fatigue syndrome and associated symptoms in the community
      Rumi K., Pnce PhD, MPE, Carol S. North, MD, Simon Wessely, MRCP, MRC Psych Victoria J. Fraser, MD - Public Health Reports, september-oktober 1992, Vol. 107, no. 5, pag. 514-522

    52. European Health Committee (CSDP) Recommendation Rec (2001)13 on developing a methodology for drawing up guidelines on best medical practices and explanatory memorandum
      Strasbourg : Council of Europe Publishing, 2001

    53. Evaluating adolescents with fatigue - Ever get tired of it ?
      Cavanaugh RM, Jr. - Pediatrics Rev 2002;23:337-48
      Cfr. :

    54. Evaluating attributions for an illness based upon the name – Chronic fatigue syndrome, myalgic encephalopathy and Florence Nightingale disease
      Jason L, Taylor RR, Plioplys S et al. - Am J Community Psychol 2002;30:133-48
      Cfr. :

    55. Evaluating neuropsychological impairment in chronic fatigue syndrome
      Vercoulen JH, Bazelmans E, Swanink CM et al. - J Clin Exp Neuropsychol 1998;20:144-56

    56. Evidence-based medicine for occupational health
      Verbeek JH, van Dijk FJ, Malmivaara A, Hulshof CT, Räsänen K, Kankaanpää EE, Mukala K - Scand J Work Environ Health 2002;28(3):197-204

    57. Exaggerated perception of normal physiological responses to stress and hypercapnia in young women with numerous functional somatic symptoms
      Houtveen JH, Rietveld S, de Geus EJ - J Psychosom Res 2003;55:481-90
      Cfr. :

    58. Exercise for treating fibromyalgia syndrome (Cochrane review)
      Busch A, Schachter CL, Peloso PM, Bombardier C - In : The Cochrane Library, Issue 2, 2004 - Chichester, UK : John Wiley & Sons, Ltd.

    59. Exercise responses and psychiatric disorder in chronic fatigue syndrome
      Lane RJM, Burgess AP, Flint J - Br J Med 1995; 311: 544-5

    60. Exercise responsive genes measured in peripheral blood of women with chronic fatigue syndrome and matched control subjects
      Whistler T, Jones JF, Unger ER, Vernon SD - BMC Physiol 5(1):5 - 2005 Mar 24

    61. Exercise therapy for chronic fatigue syndrome (review)
      Edmonds M, McGuire H, Price J - Cochrane Database Syst Rev. 2004(3):CD003200.

    62. Factors of importance for work disability in women with fibromyalgia
      Henriksson C, Liedberg G - J.Rheumatol. 2000;27:1271-6.

    63. Factors of importance for work disability in women with fibromyalgia - An interview study
      Liedberg GM, Henriksson CM - Arthritis Rheum. 2002;47:266-74.

    64. False suffocation alarms, spontaneous panics, and related conditions - An integrative hypothesis
      Klein DF, Department of Psychiatry, Columbia University, New York - Arch Gen Psychiatry. 1993 Apr;50(4):306-17 - PMID: 8466392
      A carbon dioxide hypersensitivity theory of panic has been posited.
      We hypothesize more broadly that a physiologic misinterpretation by a suffocation monitor misfires an evolved suffocation alarm system.
      This produces sudden respiratory distress followed swiftly by a brief hyperventilation, panic and the urge to flee.
      Carbon dioxide hypersensitivity is seen as due to the deranged suffocation alarm monitor.
      If other indicators of potential suffocation provoke panic this theoretical extension is supported.
      We broadly pursue this theory by examining Ondine's curse as the physiologic and pharmacologic converse of panic disorder, splitting panic in terms of symptomatology and challenge studies, reevaluating the role of hyperventilation and reinterpreting the contagiousness of sighing and yawning, as well as mass hysteria.
      Further, the phenomena of panic during relaxation and sleep, late luteal phase dysphoric disorder, pregnancy, childbirth, pulmonary disease, separation anxiety and treatment are used to test and illuminate the suffocation false alarm theory.
      Cfr. :
      Also read the comments on this article :
      - Klein's suffocation theory of panic
      Taylor S, Rachman S - Arch Gen Psychiatry. 1994 Jun;51(6):505-6 - PMID: 8192555
      Cfr. :
      - Panic attacks - Klein's false suffocation alarm, Taylor and Rachman's data and Ley's dyspneic-fear theory
      Ley R - Arch Gen Psychiatry. 1996 Jan;53(1):83-5 - PMID: 8540781
      Cfr. :
      - Nonresponse of adrenocorticotropic hormone in first-ever lactate-induced panic attacks in healthy volunteers
      Kellner M, Wiedemann K - Arch Gen Psychiatry. 1998 Jan;55(1):85-6 - PMID: 9435765
      Cfr. :
      - Response differences of spontaneous panic and fear
      Klein DF - Arch Gen Psychiatry. 2002 Jun;59(6):567-9 - PMID: 12044206
      Cfr. :
      - D-lactate and the false suffocation alarm
      Davies DR, Davies DD - Arch Gen Psychiatry. 2002 Mar;59(3):287-8 - PMID: 11879169
      Cfr. :

    65. Family cognitive behaviour therapy for chronic fatigue syndrome – An uncontrolled study
      Chalder T, Tong J, Deary V - Arch Dis Child 2002;86:95-7
      Cfr. :

    66. Family reinforcement of illness behavior - A comparison of adolescents with chronic fatigue syndrome, juvenile arthritis and healthy controls
      Brace MJ, Scott SM, McCauley E et al. - J Dev Behav Pediatr 2000;21(5): 332-339

    67. Family systems perspective
      Melamed BG – In : Jason LA et al, editors. 'Handbook of chronic fatigue syndrome' - Hoboken New Jersey: John Wiley & Sons;2003:192-201

    68. Faster response on amisulpride 50 mg versus sertraline 50-100 mg in patients with dysthymia or double depression - A randomized, double-blind, parallel group study
      Amore M,.Jori MC - Int Clin Psychopharmacol 2001;16:317-24

    69. Fatigue and psychological distress in the working population - Psychometrics, prevalence and correlates
      Bültmann U, Kant I, Kasl SV, Beurskens AJ, van den Brandt PA, Department of Epidemiology, Maastricht University, P.O. Box 616, Maastricht, The Netherlands : - J Psychosom Res. 2002 Jun;52(6):445-52 - PMID: 12069868
      - The purposes of this study were :
      (1) to explore the relationship between fatigue and psychological distress in the working population,
      (2) to examine associations with demographic and health factors and
      (3) to determine the prevalence of fatigue and psychological distress.
      Methods - Data were taken from 12,095 employees.
      Fatigue was measured with the Checklist Individual Strength and the General Health Questionnaire (GHQ) was used to measure psychological distress.
      Results - Fatigue was fairly well associated with psychological distress.
      A separation between fatigue items and GHQ items was shown.
      No clear, distinct pattern of associations was found for fatigue vs. psychological distress with respect to demographic factors.
      The prevalence was 22% for fatigue and 23% for psychological distress.
      Of the employees reporting fatigue, 43% had fatigue only, whereas 57% had fatigue and psychological distress.
      Conclusions - The results indicate that fatigue and psychological distress are common in the working population.
      Although closely associated, there is some evidence suggesting that fatigue and psychological distress are different conditions, which can be measured independently.
      Cfr. :

    70. Fatigue at work
      Van Dijk F-JH, Swaen G-MH - Occup Environ Med 2003;June:i1-2
      Cfr. :

    71. Fatigue in neurological disorders
      Chaudhuri A, Behan PO - Lancet 2004;363:978-88
      Chronic fatigue is a typical symptom of neurological diseases and is most disabling in multiple sclerosis, postpoliomyelitis, poststroke and in chronic fatigue syndrome.
      Disorders of neuromuscular junction transmission and metabolic diseases cause muscle fatigability, which is characterised by failure to sustain the force of muscle contraction (peripheral fatigue).
      Fatigue is also seen in diseases that affect the central, peripheral and autonomic nervous systems (central fatigue).
      Enhanced perception of effort and limited endurance of sustained physical and mental activities are the main characteristics of central fatigue.
      Metabolic and structural lesions that disrupt the usual process of activation in pathways interconnecting the basal ganglia, thalamus, limbic system and higher cortical centre are implicated in the pathophysiological process of central fatigue.
      A state of pre-existing relative hypocortisolaemia might sensitise the hypothalamic-pituitary-adrenal axis to development of persistent central fatigue after stress.
      The contributions of physiological, cognitive and affective changes underlying fatigue are variable and treatment is largely symptomatic and rehabilitative.
      Cfr. :

    72. Fatigue in primary care - Prevalence, psychiatric comorbidity, illness behavior and outcome
      Cathebras P, Robbins J, Kirmayer l. et al. - J Gen Intern Med 1992; 7: 276-86

    73. Fatigue, burnout and chronic fatigue syndrome among employees on sick leave - Do attributions make the difference ?
      Huibers MJH, Beurskens AJHM, Prins JB et al. - Occup Environ Med 2003;60:i26-31
      Cfr. :

    74. Fibromyalgia - A stress disorder ? - Putting pieces of the biopsychosocial puzzle together
      Van Houdenhove B, Egle UT - Psychother Psychosom 2004;5:267-75

    75. Fibromyalgia – A challenge for modern medicine
      Van Houdenhove B - Clin Rheumatol 2003;22:1-5

    76. Fibromyalgia as a dysfunction of the central pain and stress response (Fibromyalgie als Störung der zentralen Schmerz- und Stressverarbeitung)
      Egle UT, Ecker-Egle ML, Nickel R et al. - Psychother Psychosom Med Psychol 2004;54:137-47

    77. Fibromyalgie-Syndrom und Chronic Fatigue Syndrom – Gemeinsamkeiten und Unterschiede
      Hoffmann A, Linder , Kroger B et al. - Dtsch Med Wochenschr. 1996 Sep 20;121(38): 1165-1168

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    1. Financial, occupational and personal consequences of disability in patients with chronic fatigue syndrome and fibromyalgia compared to other fatiguing conditions
      Assefi NP, Coy T, V, Uslan D et al. - J Rheumatol 2003;30:804-8
      Objective -
      To examine the nature and degree of self-reported disability in patients with chronic fatigue syndrome (CFS) and its associated conditions, fibromyalgia (FM) and subsyndromal fatigue (CF), compared with a chronically fatiguing but unrelated medical condition (MED).
      Methods - Six hundred and thirty patients evaluated at the University of Washington Chronic Fatigue Clinic were sent questionnaires asking them to identify the financial, occupational and personal consequences of their fatiguing illness.
      Thorough medical evaluations had previously applied accepted criteria for defining CFS, FM and CF.
      Results - The FM groups (those with and without CFS) were among the least employed. Likewise, the FM and CFS groups, more frequently than the other groups, endorsed loss of material possessions (such as car), loss of job and loss of support by friends and family, as well as recreational activities as a result of their fatiguing illness.
      There were no reliable differences between groups in use of disability benefits.
      Conclusion - There is substantial illness-related disability among those evaluated at a specialized chronic fatigue clinic.
      Those reporting the most pervasive disability met criteria for FM either alone or in conjunction with CFS.
      Employers and personal relations of patients with chronic fatigue should make a greater effort to accommodate the illness-related limitations of these conditions, especially for those with FM and CFS.
      Cfr. :

    2. Follow-up of patients with fatigue presenting to an infectious diseases clinic
      Sharpe M, Hawton K, Seagroatt V et al. - Br Med J 1995; 302: 347-52

    3. Forming Inferences About Some Intraclass Correlations Coefficients
      McGraw KO, Wong SP

    4. From a lived body to a medicalized body - Diagnostic transformation and chronic fatigue syndrome
      Sachs L - Med Anthropol 2001;19:299-317
      Cfr. :

    5. From best evidence to best practice - Effective implementation of change in patients’ care
      Grol R, Grimshaw J - Lancet 2003;362(11):1225-30.

    6. From Paralysis to fatigue - A History of Psychosomatic Illness in the Modern Era
      Shorter E - New York: Free Press; 1992

    7. Functional disability and depression in the general population - Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)
      Spijker J, Graaf R, Bijl RV, Beekman AT, Ormel J, Nolen WA - Acta Psychiatr Scand 2004;110:208-14

    8. Functional somatic syndromes
      Barsky AJ, Borus JF - Ann Intern Med 1999; 130:910-21

    9. Functional somatic syndromes: one or many ?
      Wessely S, Nimnuan C, Sharpe M - Lancet 1999;354:936-9

    10. Functional status of persons with chronic fatigue syndrome in the Wichita, Kansas, population
      Solomon L, Nisenbaum R, Reyes M et al. - Health and Quality of Life Outcomes 2003;1:48
      Cfr. :

    11. Functional status, neuropsychological functioning and mood in chronic fatigue syndrome (CFS) - Relationship to psychiatric disorder
      Tiersky LA, Matheis RJ, DeLuca J et al. - J Nerv Ment Dis 2003;191:324-31
      Individuals with chronic fatigue syndrome (CFS) face chronic physical debilitation, reduced neuropsychological functioning and changes in emotional well-being that significantly detract from quality of life.
      The role of psychiatric disturbance in reducing quality of life in CFS remains unclear.
      In the current investigation, the role of psychiatric status in reducing health-related quality of life in CFS was examined.
      Four subject groups were compared on measures of functional well-being, mood and neuropsychological status : individuals with CFS and no history of psychiatric illness, individuals who had current symptoms of psychiatric illness that began after their CFS diagnosis, individuals who had current symptoms of psychiatric illness that began before their CFS diagnosis and a healthy sedentary control group.
      Overall, it was found that individuals with CFS suffer from profound physical impairment.
      Concurrent psychiatric illness, however, did not adversely affect physical functional capacity.
      Physical functional capacity was not worse in individuals with a concurrent psychiatric illness.
      As expected, concurrent psychiatric illness was found to reduce emotional well-being.
      Moreover, individuals with a psychiatric illness that predated the onset of CFS suffered the greatest emotional distress.
      Thus, an individual's psychiatric history should be considered when attempting to understand the factors maintaining disability in CFS.
      Cfr. :

    12. Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses
      Hays RD, Wells KB, Sherbourne DC et al. - Arch Gen Psychiatry 1995;52:51-55

    13. Gene expression profile of empirically delineated classes of unexplained chronic fatigue
      Carmel L, Efroni S, White PD, Aslakson E, Vollmer-Conna U, Rajeevan MS, National Center for Biotechnology Information, National Library of Medicine, National Institutes of Health, Bethesda, Maryland, USA - Pharmacogenomics. 2006 Apr;7(3):375-86 - PMID: 16610948
      Objectives - To identify the underlying gene expression profiles of unexplained chronic fatigue subjects classified into five or six class solutions by principal component (PCA) and latent class analyses (LCA).
      Methods - Microarray expression data were available for 15,315 genes and 111 female subjects enrolled from a population-based study on chronic fatigue syndrome.
      Algorithms were developed to assign gene scores and threshold values that signified the contribution of each gene to discriminate the multiclasses in each LCA solution.
      Unsupervised dimensionality reduction was first used to remove noise or otherwise uninformative gene combinations, followed by supervised dimensionality reduction to isolate gene combinations that best separate the classes.
      Results - The authors' gene score and threshold algorithms identified 32 and 26 genes capable of discriminating the five and six multiclass solutions, respectively.
      Pair-wise comparisons suggested that some genes (zinc finger protein 350 [ZNF350], solute carrier family 1, member 6 [SLC1A6], F-box protein 7 [FBX07] and vacuole 14 protein homolog [VAC14]) distinguished most classes of fatigued subjects from healthy subjects, whereas others (patched homolog 2 [PTCH2] and T-cell leukemia/lymphoma [TCL1A]) differentiated specific fatigue classes.
      Conclusion - A computational approach was developed for general use to identify discriminatory genes in any multiclass problem.
      Using this approach, differences in gene expression were found to discriminate some classes of unexplained chronic fatigue, particularly one termed interoception.
      Cfr. :,f1000m,isrctn

    14. General practitioners' beliefs, attitudes and reported actions towards chronic fatigue syndrome
      Steven ID, McGrath B, Qureshi et al. - Aust Fam Physician 2000;29:80-5
      Cfr. :

    15. General practitioners' perceptions of chronic fatigue syndrome and beliefs about its management, compared with irritable bowel syndrome - Qualitative study
      Raine R, Carter S, Sensky T et al. - BMJ 2004;328:1354-57
      Cfr. :

    16. General practitioners' use of guidelines in the consultation and their attitudes to them
      Watkins C, Harvey I, Langley C, Gray S, Faulkner A, University of East Anglia - Br J Gen Pract. 1999 Jan;49(438):11-5 - PMID: 10622009
      Background - There is concern about the apparent lack of uptake of management and referral guideline information by general practitioners (GPs) in their day-to-day consultations with patients.
      Little is understood about the barriers to the uptake of guidelines as perceived by Gps.
      Aims - To explore how GPs gain access to and use guidelines, including computer-based guidelines, in day-to-day consultations with their patients; and to identify the perceived problems and barriers to the use of guidelines in such situations.
      Method - Postal questionnaires enquiring about the practices and attitudes towards the use of guidelines in general practice were completed by 391 of 600 randomly selected GPs in the South and West NHS region.
      Results - GPs found guidelines a useful method of accessing expert information.
      Key factors in their uptake were brevity, an authoritative and unbiased source of evidence and resonance with the GP's usual practices; they also needed to be flexible enough to incorporate individual viewpoints.
      Guidelines were perceived as being valuable to enable safe delegation of care to other health professionals and for sharing decision-making with patients.
      Dissemination of guidelines through the medium of computers was acceptable to the majority of GPs.
      Virtually all (93%) responders reported adapting guidelines to the needs of individual patients.
      Older GPs from non-fundholding practices were least likely to show a positive attitude towards guidelines.
      Conclusion - In principle, there is a very positive attitude towards the use of guidelines in general practice.
      However, those developing guidelines for use by GPs in the consulting room need to be aware of the factors that facilitate their use in practice.
      Educational strategies aimed at increasing the use of guidelines need to take into account the significant proportion who show negative attitudes towards guidelines, whose characteristics have been identified in this study.
      Cfr. :

    17. Generalised anxiety disorder in chronic fatigue syndrome
      Fischer B, Cluydts A, De Gucht V et al. - Acta Psychiatr Scand 1997; 95: 405-13
      Cfr? :

    18. Genetics
      Sullivan PF – In :Jason LA et al, editors. 'Handbook of chronic fatigue syndrome' - Hoboken New Jersey: John Wiley & Sons;2003:89-107
      Cfr. :

    19. Glia - A novel drug discovery target for clinical pain
      Watkins LR, Maier SF, Department of Psychology and the Center for Neuroscience, University of Colorado at Boulder, Boulder, Colorado 80309-0345, USA : - Nat Rev Drug Discov. 2003 Dec;2(12):973-85 - PMID: 14654796
      Cfr. :

    20. Glial activation - A driving force for pathological pain
      Watkins LR, Milligan ED, Maier SF - Trends Neurosci 2001;24:450-5
      Cfr. :

    21. Glial proinflammatory cytokines mediate exaggerated pain states - Implications for clinical pain
      Watkins LR, Milligan ED, Maier SF - Adv Exp Med Biol 2003;521:1-21
      Cfr. :

    22. Glucocorticoids and glucocorticoid receptors - Mediators of fatigue ?
      Cleare AJ - Acta Neuropsychiatr 2003;15:341-53
      Cfr. :

    23. Health status in fibromyalgia - A followup study
      Mengshoel AM,.Haugen M - J.Rheumatol. 2001;28:2085-9
      Cfr. :

    24. Health-related quality of life in patients with chronic fatigue syndrome - An international study
      Hardt J, Buchwald D, Wilks D et al. - J Psychosom Res 2001;51:431-4
      Cfr. :

    25. Healthier Work at Brabantia - A Comprehensive Approach to Wellness at the Worksite
      Maes S, Kittel F, Scholten H, Verhoeven C - Safety Science 1992;15:-6

    26. Hierarchical Linear Models - Applications and Data Analysis Methods
      Bryk, AS; Raudenbush, SW - 1st. Sage Publications; Newbury Park: 1992

    27. High levels of type 2 cytokine-producing cells in chronic fatigue syndrome
      Skowera A, Cleare A, Blair D, Bevis L, Wessely SC, Peakman M - Clin Exp Immunol 2004, 135(2):294-302

    28. High prevalence of somatic symptoms and depression in women with disabling chronic headache
      G. E. Tietjen, J. L. Brandes, K. B. Digre, S. Baggaley, V. Martin, A. Recober, L. O. Geweke, F. Hafeez, S. K. Aurora, N. A. Herial et al., Department of Neurology, The University of Toledo-Health Science Campus, Toledo, OH 43614, USA : – Neurology, January 9, 2007; 68(2): 134 – 140 - PMID: 17210894
      - To better define, in women with headache, the relationship of depression and somatic symptoms to headache, characterized by diagnoses, frequency and disability.
      Methods - At six headache specialty clinics, women with headache were classified using ICHD-II criteria and frequency was recorded.
      A questionnaire addressing demographics, age at onset of headache, headache-related disability, somatic symptom and depression severity was completed.
      Logistic regression was performed to measure the associations of headache frequency and headache-related disability with somatic symptom and depression severity.
      Results - A total of 1,032 women with headache completed the survey, 593 with episodic (96% with migraine) and 439 with chronic headache (87% with migraine).
      Low education and household income was more common in chronic headache sufferers and in persons with severe headache disability.
      Somatic symptom prevalence and severity was greater in persons with chronic headache and with severe headache-related disability.
      Significant correlation was observed between PHQ-9 and PHQ-15 scores (r = 0.62). Chronic headache, severe disability and high somatic symptom severity were associated with major depressive disorder (OR = 25.1, 95% CI: 10.9 to 57.9) and this relationship was stronger in the subgroup with a diagnosis of migraine (OR = 31.8, 95% CI: 12.9 to 78.5).
      Conclusions - High somatic symptom severity is prevalent in women with chronic and severely disabling headaches.
      Synergistic relationship to major depression exists for high somatic symptom severity, chronic headache and disabling headache, suggesting a psychobiological underpinning of these associations.Cfr. :

    29. How can care for depression become more cost-effective ?
      Sturm, R; Wells, KB - J Am Med Assoc. 1995;273:51–58

    30. How many functional somatic syndromes ?
      Nimnuan C, Rabe-Hesketh S, Wessely S et al. - J Psychosom Res 2001;51:549-57
      Cfr. :

    31. How to develop cost-conscious guidelines
      Eccles M, Mason J, Centre for Health Services Research, University of Newcastle, Newcastle upon Tyne, UK - Health Technol Assess. 2001;5(16):1-69 - PMID: 11427188
      Abstract (truncated)
      Background - Clinical guidelines, defined as 'systematically developed statements to assist both practitioner and patient decisions in specific circumstances', have become an increasingly familiar part of clinical care.
      Guidelines are viewed as useful tools for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports.
      Interest in clinical guidelines is international and has its origin in issues faced by most healthcare systems: rising healthcare costs; variations in service delivery with the presumption that at least some of this variation stems from inappropriate care; the intrinsic desire of healthcare professionals to offer and patients to receive, the best care possible.
      Within the UK, there is ongoing interest in the development of guidelines and a fast-developing clinical-effectiveness agenda within which guidelines figure prominently.
      Over the last decade, the methods of developing guidelines have steadily improved, moving from solely consensus methods to methods that take explicit account of relevant evidence.
      However, UK guidelines have tended to focus on issues of effectiveness and have not explicitly considered broader issues, particularly cost.
      This report describes the methods developed to handle benefit, harm and cost concepts in clinical guidelines.
      It reports a series of case studies, each describing the development of a clinical guideline; each case study illustrates different issues in incorporating these different types of evidence.
      Health economics and clinical guidelines - There has been no widely accepted successful way of incorporating economic considerations into guidelines.
      Unlike other areas of guideline development, there is little practical or theoretical experience to direct the incorporation of cost issues within clinical guidelines.
      However, the reasons for considering costs are clearly stated : "Health interventions are not free, people are not infinitely rich and the budgets of [health care] programmes are limited. For every dollar's worth of health care that is consumed, a dollar will be paid. While these payments can be laundered, disguised or hidden, they will not go away" (Eddy DM. A manual for assessing health practices and designing practice policies : the explicit approach. Philadelphia : American College of Physicians; 1992).
      Such opportunity costs are a universal phenomenon.
      In the USA it has been recommended that every set of clinical guidelines should include information on the cost implications of the alternative preventive, diagnostic and management strategies for each clinical situation.
      The stated rationale was that this information would help potential users to evaluate better the potential consequences of different practices.
      However, it was acknowledged that "the reality is that this recommendation poses major methodological and practical challenges" (Institute of Medicine. Guidelines for clinical practice: from development to use. Washington: National Academy Press; 1992).
      Methods of developing clinical guidelines - A guideline development process summarises the technical information about the value of treatments in a manner that makes them accessible and ready for use in clinical practice, alongside information on contextual issues.
      The requirement is that the presentation of costs and benefits of treatments is methodologically sound, robust and accessible.
      This report includes a summary of the current best practice in evidence-based guideline development, including recent methodological advances.
      The manner in which cost and cost-effectiveness concepts have been successfully incorporated into the guideline process is introduced.
      Guideline development case studies - The 'cost-effectiveness' sections of 11 guidelines are reported to illustrate both the range of methods used and the nature of the recommendations reached by the guideline development groups when considering the profile of consequences of treatments including costs.
      These guidelines are broadly grouped as : (1) those using qualitative evidence summary methods; (2) those using quantitative evidence summary methods and addressing relatively narrow clinical questions; (3) those using quantitative evidence summary methods and addressing a broad clinical area; (4) a guideline based upon a decision analysis model.
      Conclusions - The focus of this project was to explore the methods of incorporating cost issues within clinical guidelines.
      However, the process of reviewing evidence in guideline development groups is becoming increasingly sophisticated, not only in considerations of cost but also in review techniques and group process.
      At the outset of the project it was unclear how narrowly or broadly the concept of '
      cost' could be considered.
      Cfr. :

    32. Human capital, physical health and mental health of welfare recipients - Co-occurrence and correlates
      Danziger, SK; Kalil, A; Anderson, NJ - J Soc Issues. 2000;56:635–654

    33. Hypervigilance to pain in fibromyalgia - The mediating role of pain intensity and catastrophic thinking about pain
      Crombez G, Eccleston C, Van den Broeck A, Goubert L, Van Houdenhove B, Department of Experimental-Clinical and Health Psychology, Ghent University, Belgium : - Clin J Pain. 2004 Mar-Apr;20(2):98-102 - PMID: 14770049
      Objective - To investigate the mediating role of pain intensity, catastrophic thinking about pain and negative affectivity in explaining enhanced attention for pain in patients with fibromyalgia.
      Methods - Sixty-four patients with fibromyalgia and 46 patients with chronic low back pain completed self-report instruments of vigilance to pain, negative affectivity and catastrophic thinking about pain.
      These measures, along with diagnostic group and pain intensity, were entered into a partial correlational analysis to investigate which variables mediate the relationship between diagnostic group (fibromyalgia vs. chronic low back pain) and vigilance to pain.
      Results - Fibromyalgia patients reported significantly greater vigilance to pain than patients with chronic low back pain.
      They also reported higher pain intensity, more negative affectivity and more catastrophic thinking about pain than patients with chronic low back pain.
      Vigilance to pain was correlated significantly with pain intensity, negative affectivity and catastrophic thinking about pain.
      Further analyses revealed that pain intensity and catastrophic thinking about pain, but not negative affectivity, mediated the relationship between diagnostic group and vigilance to pain.
      Conclusion - Fibromyalgia patients report a heightened vigilance to pain.
      This vigilance is not a unique characteristic of fibromyalgia but is related to the intensity of pain and catastrophic thinking about pain.
      Cfr. :

    34. Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress
      Tsigos C, Chrousos GP – J Psychosom Res 2002;53:865-71
      Cfr. :

    35. I could not lift my arm holding the fork..." - Living with chronic fatigue syndrome
      Soderlund A, Skoge AM, Malterud K - Scand J Prim Health Care 2000;18:165-9
      Cfr. :

    36. Ideal versus reality - Physicians perspectives on patients with chronic fatigue syndrome (CFS) and fibromyalgia
      Asbring P, Naervaenen AL - Soc Sci Med 2003;57:711-20

    37. Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution
      Reeves WC, Lloyd A, Vernon SD et al. - BMC Health Serv Res 2003;3:25

    38. Identifying illness parameters in fatiguing syndromes using classical projection methods
      Broderick G, Craddock RC, Whistler T, Taylor R, Klimas N, Unger ER, University of Alberta, Institute for Biomolecular Design, Edmonton, Alberta, T6G 2H7, Canada : - Pharmacogenomics. 2006 Apr;7(3):407-19 - PMID: 16610951
      Objectives - To examine the potential of multivariate projection methods in identifying common patterns of change in clinical and gene expression data that capture the illness state of subjects with unexplained fatigue and nonfatigued control participants.
      Methods - Data for 111 female subjects was examined.
      A total of 59 indicators, including multidimensional fatigue inventory (MFI), medical outcome Short Form 36 (SF-36), Centers for Disease Control and Prevention (CDC) symptom inventory and cognitive response described illness.
      Partial least squares (PLS) was used to construct two feature spaces : one describing the symptom space from gene expression in peripheral blood mononuclear cells (PBMC) and one based on 117 clinical variables.
      Multiplicative scatter correction followed by quantile normalization was applied for trend removal and range adjustment of microarray data.
      Microarray quality was assessed using mean Pearson correlation between samples.
      Benjamini-Hochberg multiple testing criteria served to identify significantly expressed probes.
      Results - A single common trend in 59 symptom constructs isolates of nonfatigued subjects from the overall group.
      This segregation is supported by two co-regulation patterns representing 10% of the overall microarray variation.
      Of the 39 principal contributors, the 17 probes annotated related to basic cellular processes involved in cell signaling, ion transport and immune system function.
      The single most influential gene was sestrin 1 (SESN1), supporting recent evidence of oxidative stress involvement in chronic fatigue syndrome (CFS).
      Dominant variables in the clinical feature space described heart rate variability (HRV) during sleep.
      Potassium and free thyroxine (T4) also figure prominently.
      Conclusion - Combining multiple symptom, gene or clinical variables into composite features provides better discrimination of the illness state than even the most influential variable used alone.
      Although the exact mechanism is unclear, results suggest a common link between oxidative stress, immune system dysfunction and potassium imbalance in CFS patients leading to impaired sympatho-vagal balance strongly reflected in abnormal HRV.
      Cfr. :,f1000m,isrctn

    39. Identifying physical activity patterns in chronic fatigue syndrome using actigraphic assessment
      Van der Werf SP, Prins JB, Vercoulen JH et al. - J Psychosom Res 2000;49:373-9

    40. IgM serum antibodies to Epstein-Barr virus are uniquely present in a subset of patients with the chronic fatigue syndrome
      Lerner AM, Beqaj SH, Deeter RG, Fitzgerald JT - In Vivo 2004, 18(2):101-106

    41. Illness experience, depression and anxiety in chronic fatigue syndrome
      Lehman AM, Lehman DR, Hemphill KJ et al. - J Psychosom Res 2002;52:461-5

    42. Illness narrative and chronic fatigue syndrome/myalgic encephalomyelitis - A review
      Hughes JL - Br J Occup Ther 2002;65:9-14
      Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) remains a contentious and stigmatised condition despite its recent medical recognition as an official illness.
      As a chronic condition, both the devastating effect that it has upon the daily occupational functioning of these people and upon their families and the rate of prevalence in the United Kingdom suggest that occupational therapy could make a significant contribution.
      This article seeks to describe and discuss the purposes that illness narratives may serve for those with CFS/ME.
      It is proposed that occupational therapists need to, first, acknowledge the subjective experience of those who are living with CFS/ME through sharing these narratives and, second, facilitate the process by which the voice of people with CFS/ME is heard with regard to the service provision.
      Only then can they claim to offer a truly client-centred service.
      Cfr. :

    43. Immunologic and psychologic therapy for patients with chronic fatigue syndrome - A double-blind, placebo-controlled trial
      Lloyd AR, Hickie I, Brockman A et al. - Am J Med 1993;94:197-203

    44. Immunological abnormalities in patients with chronic fatigue syndrome
      Tirelli U, Marotta G, Improta S et al. - Scand J Immunol 1994;40:601-8

    45. Immunological abnormalities in the chronic fatigue syndroom
      Lloyd AR, Wakefield D, Boughton CR et al. - Med. Journal of Australia 1989: 151: 122-124

    46. Immunological function in chronic fatigue syndrome
      Strober W – In : S. Straus (Ed) 'Chronic Fatigue syndrome' (pp. 207-240) - New York: Marcel Dekker; 1994

    47. Impact of a maximal exercise test on symptoms and activity in chronic fatigue syndrome
      Bazelmans E, Bleijenberg G, Voeten MJM et al. - Chapter 5 in : 'Chronic fatigue syndrome - From prevalence and perpetuating factors tot cognitive behaviour therapy' - Nijmegen: UMC St Radboud; 2004

    48. Impact of disseminating quality improvement programs for depression in managed primary care - A randomized controlled trial
      Wells, KB; Sherbourne, CD; Schoenbaum, M et al. - JAMA. 2000;283:212–220

    49. Impact of improved depression treatment in primary care on daily functioning and disability
      Simon GE, Katon W, Rutter C, VonKorff M, Lin E, Robinson P et al. - Psychol.Med. 1998;28:693-701

    50. Impaired natural immunity, cognitive dysfunction, and physical symptoms in patients with chronic fatigue syndrome - Ppreliminary evidence for a subgroup ?
      Siegel S, Antoni M, Fletcher M, Maher K, Segota M, Klimas N - J Psychosom Res 2006, 60:559-566

    51. Impairment and coping in children and adolescents with chronic fatigue syndrome - A comparative study with other paediatric disorders
      Garralda ME, Rangel L - J Child Psychol Psychiatry Allied Discip 2004;45:543-52

    52. Impairmentof work and leisure in depressed outpatients - A preliminary communication
      De Lisio G, Maremmani I, Perugi G et al. - J Affect Disord 1986;10:79-84

    53. Improving depression outcomes in community primary care practice - A randomized trial of the QuEST intervention
      Rost, K; Nutting, P; Smith, J et al. - J Gen Intern Med. 2001;16:143–149

    54. In search of ‘non-disease’
      Smith R - BMJ 2002;324:883-5

    55. Increased brain serotonin function in men with chronic fatigue syndrome
      Sharpe M, Hawton K, Clement A et al. - Br Med J 1997; 315: 164-5

    56. Increasing coping resources at work - A field experiment to increase social support, improve work team functioning and enhance employee mental health
      Heaney CA, Price RH, Rafferty J - J of Organizational Behavior 1995;16:335-52

    57. Infectious mononucleosis - Psychological symptoms during acute and subacute phases of illness
      Katon W, Russo J, Ashley RL et al. - Gen Hosp Psychiatry 1999;21:21-9

    58. Information demands of occupational health physicians and their attitude towards evidence-based medicine
      Schaafsma F, Hulshof C, van Dijk F, Verbeek J - Scand J Work Environ Health 2004;30(4):327-30.

    59. Information processing efficiency in chronic fatigue syndrome and multiple sclerosis
      DeLuca J, Johnson S, Natelson B - Arch Neurol 1993, 50, 301-4

    60. Inside guidelines - Comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries
      Burgers JS, Bailey JV, Klazinga NS, Van Der Bij AK, Grol R, Feder G; AGREE COLLABORATION, Centre for Quality of Care Research, University Medical Centre Nijmegen, Nijmegen, The Netherlands : - Diabetes Care. 2002 Nov;25(11):1933-9 - PMID: 12401735
      Objective - To compare guidelines on diabetes from different countries in order to examine whether differences in recommendations could be explained by use of different research evidence.
      Research design and methods - We analyzed 15 clinical guidelines on type 2 diabetes from 13 countries using qualitative methods to compare the recommendations and bibliometric methods to measure the extent of overlap in citations used by different guidelines.
      A further qualitative analysis of recommendations and cited evidence for two specific issues in diabetes care explored the apparent discrepancy between recommendations and evidence.
      Results - The recommendations made in the guidelines were in agreement about the general management of type 2 diabetes, with some important differences in treatment details.
      There was little overlap in evidence cited by the guidelines, with 18% (185/1,033) of citations shared with any other guideline and only 10 studies (1%) appearing in six or more guidelines.
      The measurable overlap in evidence between guidelines increases if multiple publications from the same study and the use of reviews are taken into account.
      Research originating from the U.S. predominated (40% of citations); however, nearly all (11/12) guidelines were significantly more likely to cite evidence originating from their own countries.
      Conclusions - Despite the variation in cited evidence and preferential citation of evidence from a guideline's country of origin, we found a high degree of international consensus in recommendations made for the clinical care of type 2 diabetes.
      The influence of professional bodies such as the American Diabetes Association may be an important factor in explaining international consensus.
      Globalization of recommended management of diabetes is not a simple consequence of the globalization of research evidence.
      Cfr. :

    61. International Assessment of the Quality of Clinical Practice Guidelines in Oncology Using the Appraisal of Guidelines and Research and Evaluation Instrument
      Burgers JS, Fervers B, Haugh M, Brouwers M, Browman G, Philip T, Cluzeau FA - J Clin Oncol 2004;22:2000-7.

    62. International Classification of Functioning, Disability and Health
      Worl Health Organisation. Bilthoven, WHO-ICF Collaborating Centre

    63. International Statistical Classification of Diseases and Related Health Problems
      World Health Organization - Tenth Revision, ICD-10. Genève: World Health Organization, 1992, vol. 1, pag. 424, G93.3

    64. Interventions for the treatment and management of chronic fatigue syndrome - A systematic review
      Whiting P, Bagnall AM, Sowden AJ et al. - JAMA 2001;286:1360-8
      Cfr. :

    65. Is acupuncture effective in the treatment of fibromyalgia ? (review)
      Berman BM, Ezzo J, Hadhazy V, Swyers JP - J Fam Pract. 1999 Mar;48(3):213-8

    66. Is disabling fatigue in childhood influenced by genes ?
      Farmer A, Scourfield J, Martin N et al. - Psychol Med 1999;29:279-82

    67. Is it time to review the idea of compliance with guidelines ?
      Baker R - Br J Gen Pract. 2001 Jan;51(462):7 - PMID: 11271891
      Cfr. :
      This article is a comment on 'Blood pressure control in treated hypertensive patients - Clinical performance of general practitioners' - Frijling BD, Spies TH, Lobo CM, Hulscher ME, van Drenth BB, Braspenning JC, Prins A, van der Wouden JC, Grol RP, Centre for Quality of Care Research, University of Nijmegen, P O Box 9101, 6500 HB Nijmegen, The Netherlands : - Br J Gen Pract. 2001 Jan;51(462):9-14 - PMID: 11271892
      Cfr. :

    68. Is neurally mediated hypotension an unrecognised cause of chronic fatigue ?
      Rowe PC, Bou Holaigah I, Kan JS et al. - Lancet, 1995; 345: 623-4

    69. Job burnout
      Maslach C, Schaufeli WB, Leiter MP - Annu Rev Psychol 2001;52:397-422

    70. Job stability and wage progression patterns among early TANF leavers
      Anderson, SG; Julnes, G; Schuldt, R - J Sociol Social Welfare. 2000;27:39–59

    71. Latent class analysis of symptoms associated with chronic fatigue syndrome and fibromyalgia
      Sullivan PF, Smith W, Buchwald D - Psychol Med 2002;32:881-8

    72. Levels of DHEA and DHEAS and responses to CRH stimulation and hydrocortisone treatment in chronic fatigue syndrome
      Cleare AJ, Keane V, Miell JP - Psychoneuroendocrinology 2004;29:724-32

    73. Levels of disability in major depression - Findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)
      Kruijshaar ME, Hoeymans N, Bijl RV, Spijker J, Essink-Bot ML - J Affect Disord. 2003 Oct;77(1):53-64

    74. Life events, difficulties and dilemmas in the onset of chronic fatigue syndrome – A case-control study
      Hatcher S, House A - Psychol Med 2003;33:1185-92
      Background - The role of stress in the onset of chronic fatigue syndrome is unclear.
      Our objectives in this study were first, to determine the relation between the onset of chronic fatigue syndrome and stressful life events and difficulties.
      Secondly, we examined the role of a particular type of problem, dilemmas, in the onset of chronic fatigue syndrome.
      Method - We used a case–control design with 64 consecutive referrals from an Infectious Diseases/Liaison Psychiatry Fatigue clinic and 64 age- and sex-matched controls from a general practice population control group in Leeds.
      We had two main outcome measures; the odds ratios of the risk of developing chronic fatigue syndrome after experiencing a severe life event, severe difficulties or both in the year and 3 months preceding onset; and the proportion of subjects in each group who experienced a dilemma prior to onset.
      Results - Patients with chronic fatigue syndrome were more likely to experience severe events and difficulties in the 3 months (OR=9, 95% CI 3·2 to 25·1) and year (OR=4·3, 95% CI 1·8 to 10·2) prior to onset of their illness than population controls.
      In the 3 months prior to onset 19 of the 64 patients (30%) experienced a dilemma compared to none of the controls.
      Conclusions - Chronic fatigue syndrome is associated with stressful events and difficulties prior to onset.
      Those events and difficulties characterized as being dilemmas seem to be particularly important.
      Cfr. :;jsessionid=B033D22BD7289B556C0A2

    75. Life satisfaction and psychosocial functioning in chronic depression - Effect of acute treatment with antidepressants
      Agosti V, Stewart JW, Quitkin FM - J Affect.Disord. 1991;23:35-41

    76. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States - Results from the National Comorbidity Survey
      Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S et al. - Arch Gen Psychiatr 1994;51:8-19

    77. Listening to CFS - Why we should pay more attention to the story of the patient
      Van Houdenhove B – J Psychosom Res 2002;52:495-9
      Cfr. :

    Lees verder : Deel XXVI

    25-11-2009 om 20:05 geschreven door Jules

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    Tags:arbeidsongeschiktbeidsbeoordeling, arbeidsongeschiktheid, bedrijfsarts, begeleiden, behandelen, beoordelen, chronische vermoeidheidssyndroom, fibromyalgie, ME/CVS, psychosomatisch, reïntegratie, verzekeringsarts, werk, werkhervatting, ziekteverzuim
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    Bedrijfsartsen op bres voor arbeidsongeschikten

    Deel XXVI

    1. Long-term effectiveness of disseminating quality improvement for depression in primary care
      Sherbourne, CD; Wells, KB; Duan, N et al. - Arch Gen Psychiatry. 2001;58:696–703

    2. Long-term outcome of cognitive behavior therapy versus relaxation therapy for chronic fatigue syndrome - A 5-year follow-up study
      Deale A, Husain K, Chalder T et al. - Am J Psychiatry 2001;158:2038-42

    3. Longitudinal study of outcome of chronic fatigue syndrome
      Wilson A, Hickie I, Lloyd A et al. - BMJ 1994;308:756-9

    4. Lyme borreliosis
      Stanek G, Strle F - Lancet 2003;362:1639-47

    5. Lymphocyte subset differences in patients with chronic fatigue syndrome, multiple sclerosis and major depression
      Robertson MJ, Schacterle RS, Mackin GA, Wilson SN, Bloomingdale KL, Ritz J, Komaroff AL, Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA : - Clin Exp Immunol. 2005 Aug;141(2):326-32 - PMID: 15996197
      Chronic fatigue syndrome (CFS) is a heterogeneous disorder of unknown aetiology characterized by debilitating fatigue, along with other symptoms, for at least 6 months.
      Many studies demonstrate probable involvement of the central and autonomic nervous system, as well as a state of generalized immune activation and selective immune dysfunction in patients with CFS.
      The aim of this study was to compare the lymphocyte subsets of patients with chronic fatigue syndrome to those of patients with major depression and multiple sclerosis as well as those of healthy control subjects.
      No differences were found in total numbers of T cells, B cells or natural killer (NK) cells.
      However, differences were found in T, B and NK cell subsets.
      Patients with major depression had significantly fewer resting T (CD3(+)/CD25(-)) cells than the other groups.
      Patients with major depression also had significantly more CD20(+)/CD5(+) B cells, a subset associated with the production of autoantibodies.
      Compared to patients with multiple sclerosis, patients with CFS had greater numbers of CD16(+)/CD3(-) NK cells.
      Further study will be required to determine whether these alterations in lymphocyte subsets are directly involved in the pathophysiology of these disorders, or are secondary effects of the causal agent(s).
      Cfr. :,f1000m,isrctn

    6. Major depression in multiple sclerosis - A population-based perspective
      Patten SB, Beck CA, Williams JV et al. - Neurology 2003;61:1524-7

    7. Management of chronic fatigue syndroom - Case study
      Dyck 0, Allen 5, Barron J et al. - AAOHN J. 1996 Feb; 44(2): 85-92

    8. Management of fibromyalgia syndrome
      Goldenberg DL, Burckhardt C, Crofford L - JAMA 2004;292 (19):2388-2395.

    9. Management of major depression in the workplace - Impact on employee work loss
      Birnbaum, HG; Cremieux, PY; Greenberg, PE et al. - Dis Manage Heath Outcomes. 2000;7:163–171

    10. Markers of viral infection in monozygotic twins discordant for chronic fatigue syndrome
      Koelle D, Barcy S, Huang ML et al. - Clin Infect Dis 2002;35:518-25

    11. Measure, Learn and Improve - Physicians’ Involvement In Quality Improvement
      Audet AMJ, Doty MM, Shamasdin J, Schoenbaum SC - Health Affairs 2005;24(3):843-53.

    12. Measuring Employee Productivity - A Guide to Self-Assessment Tools
      Lynch, W; Reidel, JE - Institute for Health and Productivity Management; Denver, CO: 2001

    13. Measuring the effect of clinical guidelines on patient outcomes
      Marshall DA, Simpson KN, Norton EC, Biddle AK, Youle M, University of North Carolina at Chapel Hill, USA - Int J Technol Assess Health Care. 2000 Autumn;16(4):1013-23 - PMID: 11155825
      Objectives - To identify and examine the methodologic issues related to evaluating the effectiveness of treatment adherence to clinical guidelines.
      The example of antiretroviral therapy guidelines for human immunodeficiency virus (HIV) disease is used to illustrate the points.
      Methods - Regression analysis was applied to observational HIV clinic data for patients with CD4+ cell counts less than 500 per microL and greater than 50 per microL at baseline (n = 704), using Cox proportional hazards time-varying covariates models controlling for baseline risk.
      The results are compared with simpler models (Cox model [without time-varying covariates] and logistic regression).
      In addition, the effect of including a measure of exposure to antiretroviral guidelines in the model is explored.
      Results - This study has three implications for modeling clinical guideline effectiveness.
      To capture events that are time-sensitive, a duration model should be used and covariates that are time-varying should be modeled as time-varying.
      Thirdly, incorporating a threshold measure of exposure to reflect the minimum period of time for guideline adherence required for a measurable effect on patient outcome should be considered.
      Conclusions - The methods proposed in this paper are important to consider if guidelines are to evolve from being a tool for summarizing and transferring the results of research from the literature to clinicians into a practical tool that influences clinical practice patterns.
      However, the methodology tested in this study needs to be validated using additional data on similar patients and using data on patients with other diseases.
      Cfr. :

    14. Medically unexplained physical symptoms
      Mayou, R. A. (1991) - BMJ, 303, 534 -535

    15. Medically unexplained symptoms - Exacerbating factors in the doctor- patient encounter
      Page LA, Wessely S - J R Soc Med 2003;96:223-7

    16. Medically unexplained symptoms and syndromes
      Sharpe M - Clin Med 2002;2:501-4

    17. Methodologic aspects of the study of modern-age diseases - The example of sick-building syndrome
      Thorn A - Int J Occup Environ Health 2002;8:363-70
      In recent decades, variously identified nebulous disorders such as sick-building syndrome, electrical hypersensitivity and chronic fatigue syndrome, characterized by combinations of nonspecific symptoms and absence of demonstrable signs have appeared.
      Their similar nonspecific etiologic attributions have given rise to generic names such as "modern-age disease" and "symptom-based conditions".
      The lack of demonstrable biological correlates as well as the vagueness of the etiologic attributions makes modern-age diseases unusually problematic to study with epidemiologic methods, potentially leading to serious biases.
      Case studies of sick-building syndrome demonstrate that qualitative methods can help to elucidate the dynamic processes involved in syndrome development.
      Cfr. :

    18. Mind-body therapies for the treatment of fibromyalgia - A systematic review
      Hadhazy VA, Ezzo J, Creamer P, Berman BM - J Rheumatol. 2000 Dec;27(12):2911-8.

    19. Motor activity and tonic heart rate in panic disorder
      Clark DB, Taylor CB, Hayward C, King R, Margraf J, Ehlers A, Roth WT, Agras WS, Western Psychiatric Institute and Clinic, University of Pittsburgh, PA 15213 - Psychiatry Res. 1990 Apr;32(1):45-53 - PMID: 2349312
      Motor activity and tonic heart rate were monitored in 62 drug-free panic disorder patients and 40 normal control subjects.
      Mean daily activity, mean waking heart rate controlled for activity and mean sleeping heart rate were determined.
      Panic disorder patients without phobic avoidance showed higher activity than control subjects or patients with limited or extensive avoidance.
      Similarly, an "inverted U", relationship between trait anxiety and activity was observed.
      On the other hand, neither mean waking nor sleeping heart rate showed significant differences between patients and controls, suggesting that the differences previously reported in laboratory studies result from anticipatory anxiety.
      Cfr. :

    20. Multidisciplinary rehabilitation for fibromyalgia and musculoskeletal pain in working age adults (Cochrane review)
      Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B - In : The Cochrane Library, Issue 2, 2004 - Chichester, UK : John Wiley & Sons, Ltd.

    21. Muscle physiology and histopathology in chronic fatigue syndrome
      Edwards R, Gibson H, Clague J et al. - In : A. Kleinman & S. Straus (Eds), 'Chronic Fatigue Syndrome' (pp. 101-131) - Chichester: John Wiley; 1993

    22. Myalgic encephalomyelitis – The dangers of Cartesian fundamentalism
      Fitzpatrick M - Br J Gen Pract 2002;52:432-3

    23. Myalgic encephalomyelitis/chronic fatigue syndrome - Clinical working case definition, diagnostic and treatment protocols
      Carruthers BM, Jain AK, De Meirleir KL et al. - J Chronic Fatigue Syndr 2003;11:7-115

    24. Mycoplasma blood infection in chronic fatigue and fibromyalgia syndromes
      Endresen GK - Rheumatol Int 2003;23:211-5

    25. Natural course and predicting self-reported improvement in patients with chronic fatigue syndrome with a relatively short illness duration
      Van der Werf SP, de Vree B, Alberts M et al. - J Psychosom Res 2002;53:749-53

    26. Natural killer cell function in chronic fatigue syndrome
      Fletcher MA, Maher K, Klimas NG - Clin Applied Immunol Rev 2002, 2:129-139

    27. Neural correlates of the chronic fatigue syndrome – an fMRI study
      De Lange FP, Kalkman JS, Bleijenberg G et al. - Brain 2004;127:1948-57

    28. Neurobehavioral effects of exposure to trichloroethylene through a municipal water supply
      Reif JS, Burch JB, Nuckols JR, Metzger L, Ellington D, Anger WK - Environ Res 2003;93:248-58

    29. Neurobehavioral effects of interferon-alpha in cancer patients - Phenomenology and paroxetine responsiveness of symptom dimensions
      Capuron L, Gumnick JF, Musselman DL et al. - Neuropsychopharmacology 2002;26:643-52

    30. Neurobiology of chronic fatigue syndroom
      Gonzalez MB, Cousins JC, Doraiswamy PM - Prog Neuropsychopharmacol Biol Psychiatry 1996 Jul; 20 (5): 749-759

    31. Neuropsychological deficits in chronic fatigue syndrome - Artifact or reality
      Moss-Morris E, Petrie K Large E et al. - J Neurol Neurosurg Psychiatry 1996; 60: 474-7

    32. Neuropsychological effects of low mercury exposure in dental staff in Erzurum, Turkey
      Aydin N, Karaoglanoglu S, Yigit A, Keles MS, Kirpinar I, Seven N - Int Dent J 2003;53:85-91

    33. Obstructions for quality care experienced by patients with chronic fatigue syndrome (CFS) - A case study
      Ann Marit Gilje(a), Atle Soderlund(a), Kirsti Malterud(b,*) - a Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway - b Research Unit for General Practice, Unifob Health, Kalfarveien 31, N-5018 Bergen, Norway - * Corresponding author. Tel. : +47 55 58 61 33; fax : +47 55 58 61 30; E-mail address : (K. Malterud) - Received 13 September 2007; received in revised form 31 March 2008; accepted 4 April 2008
      Objective - To explore obstructions for quality care from experiences by patients suffering from chronic fatigue syndrome (CFS).
      Methods - Qualitative case study with data drawn from a group meeting, written answers to a questionnaire and a follow-up meeting.
      Purposeful sample of 10 women and 2 men of various ages, recruited from a local patient organization, assumed to have a special awareness for quality care.
      Results - CFS patients said that lack of acknowledgement could be even worse than the symptoms.
      They wanted their doctors to ask questions, listen to them and take them seriously, instead of behaving degrading.
      Many participants felt that the doctors psychologized too much or trivialized the symptoms. Participants described how doctors' lack of knowledge about the condition would lead to long-term uncertainty or maltreatment.
      Even with doctors who were supportive, it would usually take months and sometimes years until a medical conclusion would be reached or other disorders were ruled out. Increased physical activity had been recommend, but most of the informants experienced that this made them worse.
      Conclusion - Current medical scepticism and ignorance regarding CFS shapes the context of medical care and the illness experiences of CFS patients, who may feel they neither get a proper assessment nor management.
      Cfr. :

    34. Occupational health guidelines for the management of low back pain - An international comparison
      Staal JB, Hlobil H, van Tulder MW, Waddell G, Burton AK, Koes BW, van Mechelen W - Occup Environ Med 2003;60:618–26.

    35. Occupational Health guidelines for the management of low back pain at work - Evidence review
      Waddell G, Burton AK - Occup Med 2001;51(2):124-35
      There is increasing demand for evidence-based health care.
      Back pain is one of the most common and difficult occupational health problems, but there has been no readily available evidence base or guidance on management.
      There are well-established clinical guidelines for the management of low back pain, but these provide limited guidance on the occupational aspects.
      Occupational Health Guidelines for the Management of Low Back Pain at Work were launched by the Faculty of Occupational Medicine in March 2000.
      These are the first national occupational health guidelines in the UK and, as far as we are aware, the first truly evidence-linked occupational health guidelines for back pain in the world.
      They were based on an extensive, systematic review of the scientific literature predominantly from occupational settings or concerning occupational outcomes.
      The full evidence review is on the Faculty web site ( -), but an abridged version is presented here to aid its dissemination.
      Cfr. :

    36. Occupational Wages in the United States, 2000 - National Compensation Survey
      Bureau of Labor Statistics - Summary. 2002:01–04

    37. Once-daily fexofenadine HCI improves quality of life and reduces work and activity impairment in patients with seasonal allergic rhinitis
      Meltzer, EO; Casale, TB; Nathan, RA et al. - Ann Allergy Asthma Immunol. 1999;83:311–317

    38. Outcome and prognosis of patients with chronic fatigue versus chronic fatigue syndrome
      Bombardier C, Buchwald D - Arch Intern Med 1995; 155: 2105-10

    39. Outcome and prognosis of patients with chronic fatigue vs chronic fatigue syndrome
      Bombardier CH, Buchwald D - Arch Intern Med 1995;155:2105-10

    40. Outcome of 48 pediatric patients with chronic fatigue - A clinical experience
      Feder HM, Jr., Dworkin PH, Orkin C - Arch Fam Med 1994;3:1049-55

    41. Patient activism and the struggle for diagnosis - Gulf War illnesses and other medically unexplained physical symptoms in the US
      Zavestoski S, Brown P, McCormick S et al. - Soc Sci Med 2004;58:161-75
      Cfr. :

    42. Patient education to encourage graded exercise in chronic fatigue syndrome - 2-Year follow-up of randomised controlled trial
      Powell P, Bentall RP, Nye FJ et al. - Br J Psychiatry 2004;184:142-6
      Cfr. :

    43. Patients' experiences of medication for anxiety and depression - Effects on working life
      Haslam C, Brown S, Atkinson S, Haslam R - Fam.Pract. 2004;21:204-12
      Cfr. :

    44. Patients' perceptions of medical care in chronic fatigue syndrome
      Deale A, Wessely S - Soc Sci Med 2001;52:1859-64
      Cfr. :

    45. Patients' perceptions of medical explanations for somatisation disorders - Qualitative analysis
      Salmon P, Peters S, Stanley I - BMJ 1999;318:372-6
      Cfr. :

    46. Patients' unvoiced agendas in general practice consultations - Qualitative study
      Barry CA, Bradley CP, Britten N et al. - BMJ 2000;320:1246-50
      Cfr. :

    47. Patients' views of the good doctor
      Coulter A - BMJ 2002;325:668-9
      Cfr. :

    48. Personality in adolescents with chronic fatigue syndrome
      Rangel L, Garralda E, Levin M, Roberts H – Eur Child Adolesc Psychiatry 2000;9(1):39-45
      Our aim was to study the presence of personality traits and disorder in adolescents with Chronic Fatigue Syndrome (CFS).
      Personality was then compared to other measures of functioning such as presence of psychiatric disorder and rating on the Child Behavior Checklist 4-18 (CBCL) and in relation to CFS outcome.
      Twenty-five adolescents with CFS followed-up after contacts with tertiary paediatric/psychiatric clinics were compared with 15 matched healthy controls.
      Interviews and questionnaires from parents and youngsters included Personality Assessment Schedule (PAS), Kiddie-SADS Psychiatric Interview, Child Behavior Checklist.
      CFS subjects were significantly more likely than controls to have personality difficulty or disorder.
      Personality features significantly more common amongst them were conscientiousness, vulnerability, worthlessness and emotional lability.
      There was a nonsignificant association between personality disorder and worse CFS outcome.
      Personality difficulty or disorder was significantly associated with psychological symptoms and decreased social competence on the CBCL but it was distinguishable from episodic psychiatric disorder.
      Personality difficulty and disorder are increased in adolescents with a history of CFS.
      Personality disorder may be linked to poor CFS outcome.
      Cfr. :

    49. Phantom lymphadenopathy - An association with chronic fatigue syndrome
      Shee CD - Postgrad Med J 2003;79:59-60
      Cfr. :

    50. Physical fatigability and exercise capacity in the chronic fatigue syndrome - Association with disability, somatisation and psychopathology
      Fischler B, Dendale P, Michiels V et al. - J Psychosom Res 1997; 42: 369-78
      Physical fatigability and avoidance of physically demanding tasks in chronic fatigue syndrome (CFS) were assessed by the achievement or nonachievement of 85% of age-predicted maximal heart rate (target heart rate, THR) during incremental exercise.
      The association with functional status impairment, somatization and psychopathology was examined.
      A statistically significant association was demonstrated between this physical fatigability variable and impairment and a trend was found for an association with somatization.
      No association was demonstrated with psychopathology.
      These results are in accordance with the cognitive-behavioral model of CFS, suggesting a major contribution of avoidance behavior to functional status impairment; however, neither anxiety nor depression seem to be involved in the avoidance behavior.
      Aerobic work capacity was compared between CFS and healthy controls achieving THR.
      Physical deconditioning with early involvement of anaerobic metabolism was demonstrated in this CFS subgroup.
      Half of the CFS patients who did not achieve THR did not reach the anaerobic threshold.
      This finding argues against an association in CFS between avoidance of physically demanding tasks and early anaerobic metabolism during effort.
      Cfr. :

    51. Physicians' diagnoses of psychiatric disorders for people with chronic fatigue syndrome
      Torres-Harding SR, Jason LA et al. - Int J Psychiatry Med 2002;32:109-24
      Objective - To examine rates of psychiatric diagnoses given by patients' primary or regular physicians to persons with chronic fatigue syndrome (CFS), persons with psychiatrically explained fatigue and a control group.
      Physicians' psychiatric diagnosis and participants' self-reported psychiatric diagnoses were compared to lifetime psychiatric diagnoses as measured by a structured psychiatric interview.
      Method - Participants were recruited as part of a community-based epidemiology study of chronic fatigue syndrome.
      Medical records of 23 persons with chronic fatigue syndrome, 25 persons with psychiatrically explained chronic fatigue and 19 persons without chronic fatigue (controls) were examined to determine whether their physician had given a diagnosis of mood, anxiety, somatoform or psychotic disorder.
      Lifetime psychiatric status was measured using the Structured Clinical Interview for the DSM-IV (SCID).
      Participants' self reports of specific psychiatric disorders were assessed as part of a detailed medical questionnaire.
      Results - Physicians' diagnosis of a psychiatric illness when at least one psychiatric disorder was present ranged from 40 percent in the psychiatrically explained group, 50 percent in the control group and 64.3 percent in the CFS group.
      Participants in the psychiatrically explained group were more accurate than physicians in reporting the presence of a psychiatric disorder and in accurately reporting the presence of a mood or anxiety disorder.
      Conclusions - The present investigation found underrecognition of psychiatric illness by physicians, with relatively little misdiagnosis of psychiatric illness.
      Physicians had particular difficulty assessing psychiatric disorder in those patients whose chronic fatigue was fully explained by a psychiatric disorder.
      Results emphasized the importance of using participant self report as a screening for psychiatric disorder.
      Cfr. :

    52. Possible triggers and mode of onset of chronic fatigue syndrome
      De Becker P, McGregor N, De Meirleir K - J Chronic Fatigue Syndr 2002;10:3-18

    53. Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens - Prospective cohort study
      Hickie I, Davenport T, Wakefield D, Vollmer-Conna U, Cameron B, Vernon SD, Reeves WC, Lloyd A, Dubbo Infection Outcomes Study Group - BMJ 333(7568):575- 2006 Sep 16

    54. Post-Lyme syndrome and chronic fatigue syndrome – Neuropsychiatric similarities and differences
      Gaudino EA, Coyle PK, Krupp LB - Arch Neurol 1997;54:1372-6
      Cfr. :

    55. Postinfectious chronic fatigue - A distinct syndroom ?
      Buchwald D, Umali J, Kith P et al. - Infect Dis 1996 Aug;23 (2): 385-387

    56. Postinfectious fatigue - Prospective cohort study in primary care
      Wessely S, Chalder T, Hirsch S, Pawlikowska T, Wallace P, Wright DJ, Department of Psychological Medicine, King's College School of Medicine and Dentistry, London, UK - Lancet. 1995 May 27;345(8961):1333-8 - PMID: 7752755
      The idea that chronic fatigue has an infectious origin has become popular, but the main evidence for such an association has come from retrospective case-control studies, which are subject to ascertainment bias.
      We report a prospective study of the outcome of clinically diagnosed infections in patients presenting to UK general practitioners.
      Questionnaires assessing fatigue and psychiatric morbidity were sent to all patients aged 18-45 years in the study practices.
      The prevalence of chronic fatigue and chronic fatigue syndrome was then ascertained among 1199 people aged 18-45 who presented to the general practitioners with symptomatic infections and in 1167 people who attended the surgeries for other reasons. 84% were followed up at 6 months.
      9.9% of cases and 11.7% of controls reported chronic fatigue (odds ratio 1.0 [95% CI 0.6-1.1]).
      There were no differences in the proportions who met various criteria for chronic fatigue syndrome.
      No effect of infection was noted when we excluded subjects who reported fatigue or psychological morbidity at the baseline screening.
      The strongest independent predictors of postinfectious fatigue were fatigue assessed before presentation with clinical infection (3.0 [1.9-4.7]) and psychological distress before presentation (1.8 [1.2-2.9]) and at presentation with the acute infection (1.8 [1.1-2.8]).
      There was no effect of sex or social class.
      Our study shows no evidence that common infective episodes in primary care are related to the onset of chronic fatigue or chronic fatigue syndrome.
      Cfr. :

    57. Postinfective fatigue
      Lloyd AR – In : Jason LA et al, editors. 'Handbook of chronic fatigue syndrome' - Hoboken New Jersey:John Wiley & Sons;2003:108-123

    58. Postviral fatigue syndrome and psychiatry
      David AS - Br Med Bulletin 1991; 47: 966-88
      The postviral fatigue syndrome overlaps with psychiatry at a number of points.
      First, there is the influence that some psychological states have on physiological processes, such as immunity.
      Second, psychological states have on physiological processes, such as immunity.
      Second, psychological symptoms, particularly depression but also anxiety, are a major feature of the syndrome.
      Third, difficulties in the doctor-patient relationship are common.
      Each of these three areas are discussed in detail.
      Special attention is given to the possible mechanisms underlying the occurrence of psychological symptoms, which are sufficient to make a psychiatric diagnosis in at least two thirds of cases.
      It is concluded that the bulk of the scientific evidence points to psychiatric disturbances being primary but that this does not account for the syndrome in its entirety and other mechanisms probably operate as well.
      Much of the conflict between doctor and patient arises from misconceptions about the nature and cause of psychological disturbances.
      Cfr. :

    59. Precipitating factors for the chronic fatigue syndrome
      Salit IE - J Psychiatr Res 1997;31:59-65
      The etiology of the Chronic Fatigue Syndrome (CFS) is unknown but it is usually considered to be postinfectious or postviral.
      Many infecting agents have been suspected as causative but none has been proven.
      We investigated precipitating factors in 134 CFS patients through the use of a questionnaire, interview, clinical examination and serology for infecting agents; 35 healthy controls completed a similar questionnaire.
      CFS started with an apparently infectious illness in 96 (72%) but a definite infection was only found in seven of these 96 (7%).
      Thirty-eight (28%) had no apparent infectious onset: 15/38 (40%) had noninfectious precipitants (trauma, allergy, surgery).
      There was no apparent precipitating event in 23/38 (61%).
      Immunization was not a significant precipitant.
      Stressful events were very common in the year preceding the onset of CFS (114/134, 85%) but these occurred in only 2/35 (6%) of the controls (p <.0001).
      The onset of CFS may be associated with preceding stressful events and multiple other precipitants.
      An infectious illness is not uniformly present at the onset and no single infectious agent has been found; CFS is most likely multifactorial in origin.
      Cfr. :

    60. Predictions and associations of fatigue syndromes and mood disorders that occur after infectious mononucleosis
      White PD, Thomas JM, Kangro HO et al. - Lancet 2001;358:1946-54
      Cfr. :

    61. Predictors of high quality clinical practice guidelines - Examples in oncology
      Fervers B, Burgers JS, Haugh MC, Brouwers M, Browman G, Cluzeau F, Philip T - Int J Qual Health Care 2005;17(2):123-132.

    62. Predictors of outcome in a fatigued population in primary care following a randomized controlled trial
      Chalder T, Godfrey E, Ridsdale L et al. - Psychol Med 2003;33:283-7
      Background - The objective of this study was to examine factors that predicted outcome in a chronically fatigued group of patients who were randomized to cognitive behaviour therapy or counselling in primary care.
      Methods - Illness perceptions, attributions, fatigue, disability and demographic variables were recorded at assessment and levels of fatigue and disability were measured at 6 months post randomization.
      Logistic regression was used to examine associations.
      Restuls - Factors that predicted a poor outcome (four or more on the fatigue questionnaire) were : poor social adjustment at assessment; the patients self-report that they had never seen the GP for an emotional reason; a physical illness attribution; and, a long perceived future illness duration.
      Conclusions - Patients who are more psychologically minded are more likely to improve with psychological treatments in primary care.
      General practitioners need to assess this before referring to an appropriate therapist.
      Cfr. :

    63. Premorbid "overactive" lifestyle in chronic fatigue syndrome and fibromyalgia - An etiological factor or proof of good citizenship ?
      Van Houdenhove B, Neerinckx E, Onghena P et al. - J Psychosom Res 2001;51:571-6
      Cfr. :

    64. Premorbid psychical hyperactivity and chronic idiopathic musculoskeletal pain
      Van Houdenhove B, Stans L, Dequeker J - Eur J Pain 1992; 13:. 71-6

    65. Prevalence and incidence of Chronic Fatigue Syndrome in Wichita, Kansas
      Reyes M, Nisenbaum R, Hoaglin DC et al. - Arch Intern Med 2003;163:1530

    66. Prevalence of chronic disabling fatigue in children and adolescents
      Farmer A, Fowler T, Scourfield J et al. - Br J Psychiatry 2004;184:477-81
      Cfr. :

    67. Prevalence of fatigue and chronic fatigue syndrome in a primary care practice
      Bates DW, Schmitt W, Buchwald D et al. - Arch Intern Med 1993;153:2759-65

    68. Prevalence of psychiatric disorder in the general population - Results of The Netherlands Mental Health Survey and Incidence Study (NEMESIS)
      Bijl RV, Ravelli A, van Zessen G - Soc Psychiatr Psychiatr Epidemiol 1998;33:587-95

    69. Prevalence of symptoms and symptom-based conditions among Gulf War veterans - Current status of research findings
      Barrett DH, Gray GC, Doebbeling BN et al. - Epidemiol Rev 2002;24:218-27

    70. Prevalentie van het chronische-vermoeidheidsyndroom in 4 huisartspraktijken in de regio Leiden [Prevalence of chronic fatigue syndrome in 4 family practices in Leiden]
      Versluis RG, de Waal MW, Opmeer C et al. - Ned Tijdschr Geneeskd 1997;141:1523-6

    71. Primary care groups - Improving the quality of care through clinical governance
      Campbell S, Roland M, Wilkin D, National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL - BMJ. 2001 Jun 30;322(7302):1580-2 - PMID: 11431301
      Cfr. :

    72. Prolonged psychological stress suppresses cortisol secretion
      Zarkovic M, Stefanova E, Ciric J et al. - Clin Endocrinol 2003;59:811-6
      Objective - Response to acute psychological stress is characterized by activation of the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system.
      However, response to the prolonged psychological stress is less well known.
      Design - This study was designed as a prospective assessment of cortisol secretion during prolonged psychological stress induced by continuous air raids and after elimination of the stress-inducing factor.
      Subjects - The study group consisted of five healthy subjects (34-39 years).
      Measurements - Psychological and endocrine (morning cortisol and 1 microg ACTH test) testing was done 2 months after the war had begun and 18 months after the end of it.
      Psychiatric assessment was done at the same periods, and 30 months after the start of the study.
      Results - After 2.5 years of follow-up, there were no signs of endocrine or psychiatric disorders in any of the subjects.
      After the war, Beck Inventory of Depression and Hamilton Anxiety Rating Scale scores were significantly reduced. Suppression of the HPA axis was present during the war but not after.
      Conclusions - Prolonged psychological stress is associated with a transient suppression of the HPA axis, manifested by low morning cortisol and reduced cortisol response to ACTH.
      The reduction of cortisol response is sufficient to cause false diagnosis of HPA insufficiency.
      Cfr. :

    73. Psychiatric adjustment in adolescents with a history of chronic fatigue syndrome
      Garralda E, Rangel L, Levin M et al. - J Am Acad Child Adolesc Psychiatry 1999;38:1515-21
      Cfr. :

    74. Psychiatric adjustment in chronic fatigue syndrome of childhood and in juvenile idiopathic arthritis
      Rangel L, Garralda ME, Hall A et al. - Psychol Med 2003;33:289-97
      Cfr. :;jsessionid=FF5DFD9C0C06C5BEA1

    75. Psychiatric and somatic disorders and multiple chemical sensitivity (MCS) in 264 'environmental patients'
      Bornschein S, Hausteiner C, Zilker T et al. - Psychol Med 2002;32:1387-94
      Cfr. :

    76. Psychiatric comorbidity in a population of Parkinson's disease patients
      Nuti A, Ceravolo R, Piccinni A et al. - Eur J Neurol 2004;11:315-20
      Cfr. :

    77. Psychiatric disorders among patients with chronic fatigue syndrome in a randomised controlled trial for the effecitiveness of cognitive behaviour therapy
      Prins JB, Bleijenberg G, Klein Rouweler E et al. - In : 'Cognitive behaviour therapy for chronic fatigue syndrome' - Thesis. Nijmegen: University of Nijmegen;2003

    78. Psychiatric morbidity and illness experience of primary care patients with chronic fatigue in Hong Kong
      Lee S, Yu H, Wing Y et al. - Am J Psychiatry 2000;157:380-4

    79. Psychodynamic psychotherapy and clomipramine in the treatment of major depression
      Burnand Y, Andreoli A, Kolatte E, Venturini A, Rosset N - Psychiatr Serv 2002;53:585-90

    80. Psychological correlates of functional status in chronic fatigue syndrome
      Taillefer SS, Kirmayer LJ, Robbins JM et al. - J Psychosom Res 2002;53:1097-106
      Background - The present study was designed to test a cognitive model of impairment in chronic fatigue syndrome (CFS) in which disability is a function of severity of fatigue and depressive symptoms, generalized somatic symptom attributions and generalized illness worry.
      Methods - We compared 45 CFS and 40 multiple sclerosis (MS) outpatients on measures of functional ability, fatigue severity, depressive symptoms, somatic symptom attribution and illness worry.
      Restults - The results confirmed previous findings of lower levels of functional status and greater fatigue among CFS patients compared to a group of patients with MS.
      Fatigue severity was found to be a significant predictor of physical functioning but not of psychosocial functioning in both groups.
      In CFS, when level of fatigue was controlled, making more somatic attributions was associated with worse physical functioning and both illness worry and depressive symptoms were associated with worse psychosocial functioning.
      Conclusions - Our findings support the role of depression and illness cognitions in disability in CFS sufferers.
      Different cognitive factors account for physical and psychosocial disability in CFS and MS.
      The SF-36 may be sensitive to symptom attributions, suggesting caution in its interpretation when used with patients with ill-defined medical conditions.
      Cfr. :

    81. Psychological symptoms, somatic symptoms and psychiatric disorder in chronic fatigue and chronic fatigue syndroom – A prospective study in the primary care setting
      Wessely S, Chalder T, Hirsch 5 et al. - Am J Psychiatry. 1996 Aug; 153(8): 1050-1059

    82. Psychometric properties of the CDC Symptom Inventory for assessment of chronic fatigue syndrome
      Wagner D, Nisenbaum R, Heim C, Jones JF, Unger ER, Reeves WC - Popul Health Metr 2005, 3:8

    83. Psychopathology in the workplace - Recognition and adaptation
      McClanahan TM, Antonucco DO. In Thomas JC. Hersen M (Eds.) - New York: Brunner-Routledge, 2004

    Lees verder : Deel XXVII

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    Bedrijfsartsen op bres voor arbeidsongeschikten

    Deel XXVII

    1. Psychophysiological response patterns in panic disorder
      Hoehn-Saric R, McLeod DR, Zimmerli WD, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205 - Acta Psychiatr Scand. 1991 Jan;83(1):4-11 - PMID: 2011954
      To determine whether panic disorder patients exhibit physiological hyperarousal during rest or during mild, non-panic-inducing stress, 18 patients who experienced frequent panic attacks were compared with nonanxious controls on a battery of physiological assessments.
      During baseline, patients with panic disorder exhibited higher forehead electromyographic activity, higher systolic blood pressure and higher heart rates than non-anxious volunteers.
      During psychological stress, heart rate and systolic blood pressure rose more in patients with panic disorder than in nonanxious controls.
      The skin conductance response, however, was greater and more variable in the nonanxious controls.
      The results suggest that panic disorder patients with frequent panic attacks exhibit heightened cardiovascular arousal and decreased electrodermal flexibility than nonanxious people, even in nonthreatening situations.
      Cfr. :

    2. Psychosocial characteristics and immunological functions in patients with postinfectious chronic fatigue syndrome and noninfectious chronic fatigue syndrome
      Masuda A, Munemoto T, Yamanaka T et al. - J Behav Med 2002;25:477-85
      Differences between patients with postinfectious chronic fatigue syndrome (CFS, n = 16) and noninfectious CFS (n = 20) were clarified.
      The noninfectious CFS group had problems in family and developmental history and had chronic stresses.
      Members of the postinfectious CFS group were social extroverts while those in the noninfectious CFS group was neurotic and introspective.
      Natural killer cell activity was suppressed in both groups.
      These findings suggest that the postinfectious CFS group and the noninfectious CFS group differed in their pathogenesis until the onset of CFS.
      The latter group should be considered as a variant of psychiatric disorder and treated accordingly.
      Cfr. :

    3. Psychosocial disability before, during and after a major depressive episode - A 3-wave population-based study of state, scar and trait effects
      Ormel J, Oldehinkel AJ, Nolen WA, Vollebergh W - Arch Gen Psychiatr 2004 Apr;61(4):387-92

    4. Psychosocial disability during the long-term course of unipolar major depressive disorder
      Judd LL, Akiskal HS, Zeller PJ, Paulus M, Leon AC, Maser JD et al. - Arch Gen Psychiatr 2000;57:375-80

    5. Psychosocial treatments for multiple unexplained physical symptoms - A review of the literature
      Allen L A, Escobar J I, Lehrer P M, Gara M A, Woolfolk R L - Psychosomatic Medicine, 2002. 64(6). 939-950

    6. Psychosomatic medicine - State of the art
      Ursin H, Department of Biological and Medical Psychology, University of Bergen, Norway : - Ann Med. 2000 Jul;32(5):323-8 - PMID: 10949063
      Contemporary psychosomatic medicine must take into consideration developments in psychobiology.
      The difficulty in accepting dualistic concepts is a serious challenge to positions distinguishing between psychological and 'real' causes of disease.
      There is more emphasis on life style factors for disease and on the impact of psychosocial factors on illness rather than on disease.
      The neurophysiological concept of activation or arousal has been important in the development of rational pathophysiological models that describe how sustained arousal may be a pathophysiological factor.
      For illness, sensitization may be an acceptable psychobiological mechanism underlying very frequently occurring and expensive medical conditions that require medical and economical assistance.
      One possible alternative to old dynamic concepts is the development of a cognitive arousal theory of stress.
      Cfr. :

    7. Psychosomatic pain
      S. Tyrer - The British Journal of Psychiatry, January 1, 2006; 188(1): 91 – 93
      Cfr. :

    8. Psychotropic treatment of chronic fatigue syndrome and related disorders
      Coodnick P, Sandoval R - J Clin Psychol 1993; 54: 13-20
      Cfr. :

    9. Quality of brief guidelines produced by professional bodies - A study of the ‘green top’ guidelines by the UK Royal College of Obstetricians and Gynaecologists
      Coomarasamy A, Ola B, Gee H, Khan, KS - J Obst Gynaec 2003;23:479-483.

    10. Quality of Clinical Practical Guidelines
      Burgers JS - Proefschrift Katholieke Universiteit, Nijmegen, 2002.

    11. Quality of Evidence-Based Pediatric Guidelines
      Boluyt N, Lincke CR, Offringa M - Pediatrics 2005;115(5):1378-91

    12. Quality of life of patients with chronic fatigue syndrome
      Guus L. Van Heck, PhD and Jolanda De Vries, PhD, Department of Clinical Health Psychology, Tilburg University, The Netherlands - Address correspondence to : Guus L. Van Heck, PhD or Jolanda De Vries, PhD, Department of Clinical Health Psychology, Tilburg University, P.O. Box 90153, 5000 LE Tilburg, The Netherlands (E-mail : - or -) - The authors wish to thank Tessa Op den Buijs for help with data collection and Karin De Kok for her insightful comments on an earlier version of this article - J of Chronic Fatigue Syndrome, Vol. 10(1) 2002, pp. 17-35 - © 2002 by The Haworth Press, Inc. (Copies of the complete article are available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address : – Website : -).
      The purpose of this study was to compare quality of life between patients with Chronic Fatigue Syndrome (CFS; n = 73) and healthy controls (n = 147), using a broad and generic quality of life assessment instrument, the World Health Organization Quality of Life assessment (WHOQOL-100).
      Participants were assessed on the WHOQOL-100, a self-assessment instrument designed for quantifying 24 facets relating to quality of life.
      These facets are grouped into six larger domains :
      - physical health,
      - psychological health,
      - level of independence,
      - social relationships,
      - environment and
      - spirituality.
      The WHOQOL-100 also includes one facet examining overall quality of life and general health perceptions.
      Analyses revealed that the CFS group reported significantly lower levels of quality of life than the control group on overall quality of life and general health perceptions and on 22 out of the 24 facets of quality of life.
      Compared to earlier studies that used health-status scales or rather limited quality of life measures, this study generated a more complete picture of the problems of patients with CFS.
      The results suggest that the impact of CFS on the patients' lives is very profound.
      CFS has a quality-of-life burden that affects a wide range of factors inherent to quality of life.
      Questions that must be addressed by future research are considered.
      Many patients suffering from a wide range of diseases experience fatigue that is not linked to specific tasks or activities (Bensing, Hulsman & Schreurs, 1996).
      Such chronic fatigue has a dramatic effect on quality of life.
      Persons with chronic fatigue are inclined to undertake less and lack sufficient energy and motivation even for those activities that they conceive of as interesting.
      They loose their mobility and avoid social contacts.
      Furthermore, they often don't take sufficient care of themselves.
      Moreover, they have a wide range of affective and cognitive problems such as pain, sleeping problems, stress, depression, lack of concentration, a deteriorated resoluteness and a weaker reasoning power (Bensing et al., 1996).
      Fatigue is the hallmark of the chronic fatigue syndrome (CFS).
      The key feature of this disabling illness is persisting and disabling fatigue and fatiguability, unexplained by a recognized medical diagnosis (Friedberg & Jason, 1998; Johnson, DeLuca, & Natelson,1999).
      An ever growing body of literature has pointed to a wide range of debilitating symptoms as well as stressful life situations that individuals with CFS have to face.
      These studies not only examine symptoms, health status, physical functioning, functional disability, psychiatric disturbance, but also subjective health, well-being and quality of life; sometimes as isolated phenomena, sometimes in various combinations (Bruce-Jones, White, Thomas & Clare, 1994; Demitrack & Greden, 1991; Friedberg, Dechene, McKenzie & Fontanetta, 2000; Komaroff & Buchwald, 1991; Kruesi, Dale & Straus, 1989; Prasher, Smith & Findley, 1990; Schaefer, 1995; Stewart, 1990; Straus, 1988; Vercoulen et al., 1994; Wilson et al., 1994).
      One of the investigations that measured explicitly health status in CFS patients is a study by Antoni et al. (1994).
      Using multiple regression analyses in examining various predictor variables, it could be demonstrated that depression, physical symptoms, cognitive appraisals and coping behaviors accounted for significant proportions of the variance in severity of illness burden, as indicated by the Sickness Impact Profile (SIP; Bergner, Bobbit, Carter & Gilson,1981), a measure of the impact of illness and disability on daily life.
      All SIP scores correlated positively with maladaptive coping.
      It appeared that the Sleep and Rest, Home Management and Alertness Behavior SIP scales were positively related to the employment of maladaptive coping strategies.
      The Social Interaction, Home Management and Communications SIP scales accounted for the largest proportion of variance in coping strategies.
      In a study by Kroenke, Wood, Mangelsdorff, Meier and Powell (1988) in adult primary-care clinics, the SIP was used in patients with physically unexplained fatigue.
      It was shown that patients had sizeable problems on 10 out of the 12 SIP scales.
      Similar results were found by Vercoulen et al. (1994) and Schweitzer, Kelly, Foran, Terry and Whiting (1995).
      In a study with patients with CFS, a population-based control sample and disease comparison groups with hypertension, congestive heart failure, type II diabetes mellitus, acute myocardial infarction, multiple sclerosis and depression (Komaroff et al., 1996), health status was measured using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; Ware & Sherbourne, 1992).
      This questionnaire consists of eight scales measuring physical functioning, role limitations due to physical limitations, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems and mental health.
      Compared with the general population control group, the CFS group was impaired on all eight scales, especially in role limitations due to physical limitations and vitality.
      With only a few exceptions, the CFS group had more problems in nearly every area compared with the five other disease groups.
      Buchwald, Pearlman, Umali, Schmaling and Katon (1996) found a similar pattern with the SF-36 with marked impairment in patients with CFS for the physical functioning, role functioning, social functioning, general health and body pain subscales.
      Using four scales from the SF-36, assessing physical functioning, social functioning, vitality and psychological adjustment, Heijmans (1998) demonstrated that patients with CFS scored low on the first three measures of adaptive outcome.
      Using a modified version of an Interference scale originally developed for assessing daily interference due to chronic pain, Findley, Kerns, Weinberg and Rosenberg (1998) could demonstrate that somatic and psychological CFS symptoms affect daily life in areas of work, family, social and recreational functioning.
      The studies mentioned above predominantly used instruments like the SIP or the SF-36, which are clearly health status (capabilities) measures.
      As such they assess the impact of disease on persons' functioning.
      A serious problem, when using health status measures, is that lower levels of functioning are equated with lower quality of life.
      However, such outcomes can contrast sharply with findings in quality of life research reflecting high perceived quality of life in spite of low levels of functioning (O'Boyle, 1994; Sprangers & Schwartz, 1999).
      Hunt (1997), discussing the scientific status of quality of life, has pointed at the finding (Lerner, 1973; Pearlman & Uhlmann, 1988) that the same level of health status can co-exist with a wide variety of existential states from despair to tranquillity.
      Quality of life reflecting persons' perception of their own life, is a broader concept than health status, incorporating individual perspectives on life, roles, relationships and experiences.
      It is a multidimensional construct that reflects individuals' overall feeling of well-being and their view of the desirability of the life they are living (Nord, Arnesen, Menzel & Pinto, 2001).
      Recently, Myers and Wilks (1999) examined patients with CFS using, in addition to a health status measure (SF-36), a standardized non-disease-specific survey instrument, the EurQol (Eurogol group, 1990).
      Patients reported a moderate degree of emotional or psychological ill-health, especially with respect to mobility and self-care.
      So, in spite of the fact that the EuroQol has rather limited sensitivity (Brazier, Jones & Kind, 1993), it nevertheless revealed useful information about those aspects of life that are "rooted in existentialism, the values of the individual and the fluid dynamics of human attempts to cope with the exigencies of life" (Hunt, 1997, p. 209).
      Recently, a quality of life instrument has been constructed that reflects a clear definition of the term quality of life and a cross-culturally derived consensus on the components which make up quality of life.
      This assessment instrument, the WHOQOL-100 (Whogol group, 1995) appears to be a valid and internally reliable method for the assessment of quality of life (Power, Bullinger, Harper & the Whogol group, 1999) with good sensitivity to change (O'Carroll, Cossar, Couston & Hayes, 2000).
      Therefore, the present study attempts to contribute to a better understanding of patients with CFS by using the WHOQOL-100 in order to look at quality of life in a more exhaustive way, scrutinizing individuals' physical health, psychological state, level of independence, social relationships, personal beliefs and relationships to salient features of the environment.
      Cfr. :

    13. Race and education differences in disability status and labor force attachment in the Health and Retirement Survey
      Bound, J; Schoenbaum, M; Waidmann, T - J Human Resources. 1995;30:S227–S267

    14. Ramomised, double blind, placebo controlled study of fluoxetine in chronic fatigue syndroom
      Vercoulen JE, Swanink CM, Zitman FG et al. - Lancet. 1996 Mar 30; 347(9005): 858-561

    15. Randomised controlled trial of graded exercise in patients with the chronic fatigue syndrome
      Fulcher AT, White PD - Br Med J, 1997; 314, 1647-52

    16. Randomised controlled trial of patient education to encourage graded exercise in chronic fatigue syndrome
      Powell P, Bentall RP, Nye FJ et al. - BMJ 2001;322:387-90
      Cfr. :

    17. Randomised, double-blind, placebo-controlled study of fluoxetine in chronic fatigue syndrome
      Vercoulen JH, Swanink CM, Zitman FG et al. - Lancet 1996; 347(9005): 858–861

    18. Randomized trial of a depression management program in high utilizers of medical care
      Katzelnick, DJ; Simon, GE; Pearson, SD et al. - Arch Fam Med. 2000;9:345–351
      Background - High utilizers of nonpsychiatric health care services have disproportionally high rates of undiagnosed or undertreated depression.
      Objective - To determine the impact of offering a systematic primary care-based depression treatment program to depressed "high utilizers" not in active treatment.
      Design - Randomized clinical trial.
      Setting - One hundred sixty-three primary care practices in 3 health maintenance organizations located in different geographic regions of the United States.
      Patients - A group of 1465 health maintenance organization members were identified as depressed high utilizers using a 2-stage telephone screening process.
      Eligibility criteria were met by 410 patients and 407 agreed to enroll : 218 in the depression management program (DMP) practices and 189 in the usual care (UC) group.
      Intervention - The DMP included patient education materials, physician education programs, telephone-based treatment coordination and antidepressant pharmacotherapy initiated and managed by patients' primary care physicians.
      Main outcome measures - Depression severity was measured using the Hamilton Depression Rating Scale (Ham-D) and functional status using the Medical Outcomes Study 20-item short form (SF-20) subscales.
      Outpatient visit and hospitalization rates were measured using the health plan's encounter data.
      Results - Based on an intent-to-treat analysis, at least 3 antidepressant prescriptions were filled in the first 6 months by 151 (69.3%) of 218 of DMP patients vs 35 (18.5%) of 189 in UC (P < .001).
      Improvements in Ham-D scores were significantly greater in the intervention group at 6 weeks (P = .04), 3 months (P = .02), 6 months (P < .001) and 12 months (P < .001).
      At 12 months, DMP intervention patients were more improved than UC patients on the mental health, social functioning and general health perceptions scales of the SF-20 (P < .05 for all).
      Conclusion - In depressed high utilizers not already in active treatment, a systematic primary care-based treatment program can substantially increase adequate antidepressant treatment, decrease depression severity and improve general health status compared with usual care.
      Cfr. :

    19. Relationship between stress and pain in work-related upper extremity disorders - The hidden role of chronic multisymptom illnesses
      Clauw DJ, Williams DA - Am J Ind Med 2002;41:370-82
      Cfr. :

    20. Relationship of employee-reported work limitations to work productivity
      Lerner, D; Amick, BC, III; Lee, JC et al. - Med Care. 2003;41:649–659

    21. Reliability and validity of the AGREE instrument used by physical therapists in assessment of clinical practice guidelines
      MacDermid JC, Brooks D, Solway S, Switzer-McIntyre S, Brosseau L, Graham ID - BMC Health Services Research 2005, 5:18 doi:10.1186/1472-6963-5-18.

    22. Report of a workshop on the epidemiology, natural history and pathogenesis of chronic fatigue syndrome in adolescents
      Marshall GS - J Pediatr 1999;134:395-405

    23. Reversible and selective inhibitors of monoamine oxidase A in mental and other disorders
      Priest EG, Gimbrett R, Roberts M - Acta Psychiatr Scand 1995; 386: 40-3

    24. Role of the brain and sensory pathways in gastrointestinal sensory disorders in humans
      Mertz H, Vanderbilt University Medical Center, Nashville 37232-5340, USA : - Gut. 2002 Jul;51 Suppl 1:i29-33 - PMID: 12077061
      Several features of the irritable bowel syndrome (IBS) suggest involvement of the emotional limbic system in the brain.
      Abnormalities which upregulate afferent (sensory) signal intensity anywhere in this system, from the gastrointestinal tract to the brain, could induce hypersensitivity, leading to the pain and discomfort that characterise IBS and other functional disorders.
      Functional gastrointestinal disorders are likely to be heterogeneous given the complexity of the afferent system and a number of different perturbations are possible.
      Intestinal hypersensitivity to pain and discomfort and associated reflex alterations in motility might explain the symptoms of functional bowel diseases.
      Cfr. :

    25. Salivary cortisol response to awakening in chronic fatigue syndrome
      Roberts ADL, Wessely S, Chalder T et al. - Br J Psychiatry 2004;184:136-41
      Cfr. :

    26. Sensitization and subjective health complaints
      Eriksen HR, Ursin H - Scand J Psychol 2002;43:189-96
      Why is it that some of us have more pain, more fatigue, and more gastrointestinal trouble than others ?
      Is it possible that there are brain mechanisms and psychological mechanisms that make some people sensitized to specific complaints ?
      In this concluding paper we review the historical and theoretical background, discuss the evidence and theoretical positions in the contributions and draw some conclusions.
      Traditional psychosomatic models had less predictive value and less therapeutic importance than what was hoped for.
      The main problem with these models was the lack of a pathophysiological explanation for why psychological problems could be related to somatic disease.
      Sustained arousal or "allostatic load" offers more plausible and acceptable mechanisms for pathology and, to some extent, for sensitization and illness.
      The combination of cognitive psychology and neurophysiology offers a model for somatic pathology and, perhaps more important, also for the understanding of subjective complaints and illness.
      Cfr. :

    27. Sensitization, subjective health complaints and sustained arousal
      Ursin H, Eriksen HR - Ann N Y Acad Sci2001;933:119-29
      The purpose of this presentation is to discuss the possibility that sensitization is a psychobiological mechanism underlying not only multiple chemical sensitivity (MCS), but a much more general cluster of illness, referred to as "subjective health complaints".
      Sustained arousal or sustained "stress" responses, may be an important factor for the development of these conditions.
      Patients with subjective complaints without objective changes are sometimes referred to as having "fashionable diagnoses" or "unexplained symptoms".
      They may be given diagnoses like MCS, epidemic fatigue, chronic fatigue syndrome, burnout, stress, a variety of intoxications, environmental illness, radiation, multiple chemical hypersensitivity, food intolerance, functional dyspepsia, irritable bowel, myalgic encephalitis, postviral syndrome, yuppie flu, fibromyalgia or vital exhaustion.
      One issue is whether this is one general condition or separate entities.
      Another issue is whether sensitization may be the psychobiological mechanism for most or all of these conditions.
      Finally, is it likely that sustained arousal may facilitate the development of sensitization in some or many neural circuits ?
      In this review, the main emphasis will be on musculoskeletal pain.
      This is the most frequent and most expensive condition for sickness compensation and disability.
      The comorbidity of other complaints, however, will also be taken into account.
      Cfr. :

    28. Serotonin-mediated increases in the extracellular levels of beta-endorphin in the arcuate nucleus and nucleus accumbens - A microdialysis study
      Zangen A, Nakash R, Yadid G, Department of Life Sciences, Bar-Ilan University, Ramat-Gan, Israel - J Neurochem. 1999 Dec;73(6):2569-74 - PMID: 10582620
      Although the involvement of both endogenous opioid and serotonergic systems in modulation of pain and emotion was suggested, the neurochemical interaction between these systems in the brain has not previously been studied directly.
      Herein, the effects of the local application of serotonin (5-HT) and fluoxetine (a 5-HT reuptake inhibitor) on extracellular levels of beta-endorphin in the arcuate nucleus and nucleus accumbens were assessed in freely moving rats using in vivo microdialysis.
      The mean basal concentrations of beta-endorphin in dialysates obtained from the arcuate nucleus and nucleus accumbens were 259.9 and 143.3 pM, respectively.
      Specific lesion of the serotonergic system by 5,7-dihydroxytryptamine (5,7-DHT) caused a significant decrease in these dialysate beta-endorphin levels.
      When 5-HT (0.25-5 microM) was added to the perfusion solution, the levels of beta-endorphin in the dialysate from the arcuate nucleus increased (186-296% of baseline), in a concentration-dependent manner.
      In the nucleus accumbens, 0.5 and 2 microM 5-HT in the perfusion fluid did not affect the levels of beta-endorphin in the dialysate, whereas 5 and 10 microM 5-HT caused an increase of approximately 190% of baseline.
      When fluoxetine (250 microM) was present in the perfusing solution, the levels of beta-endorphin in the dialysates from the arcuate nucleus and nucleus accumbens increased two- to threefold.
      This effect was not obtained in the 5,7-DHT-lesioned rats.
      Thus, 5-HT, either endogenously or exogenously delivered, appears to facilitate the release of beta-endorphin in the arcuate nucleus and nucleus accumbens.
      This indication of an interaction between serotonergic and endorphinic systems may be relevant for assessing pain and mood disorder circuits and the mode of action of antidepressant drugs.
      Cfr. :

    29. Significant other responses are associated with fatigue and functional status among patients with chronic fatigue syndrome
      Schmaling KB, Smith WR, Buchwald DS - Psychosom Med 2000;62:444-50
      Cfr. :

    30. Similar effectiveness of paroxetine, fluoxetine and sertraline in primary care - A randomized trial
      Kroenke K, West SL, Swindle R, Gilsenan A, Eckert GJ, Dolor R et al. - JAMA 2001;286:2947-55

    31. Sleep anomalies in the chronic fatigue syndrome - A comorbidity study
      Fischler B, Le Ban O, Hoffmann G et al. - Neuropsychobiology 1996; 35:115-22

    32. Social adjustment by self-report in a community sample and in psychiatric outpatiens
      Weisman MM, Prusoff BA, Thompson WD et al. - J Nerv Ment Dis 1978;166:317-326

    33. Social adjustment in dysthymia, double depression and episodic major depression
      Leader JB, Klein DN - J Affect Disord 1996;37:91-101

    34. Social functioning in depression - A review
      Hirschfeld RM, Montgomery SA, Keller MB, Kasper S, Schatzberg AF, Moller HJ et al. . J Clin Psychiatry 2000;61:268-75

    35. Social-vocational adjustment in unipolar mood disorders - Results of the DSM-IV field trail
      Evans S, Cloitre M, Kocsis JH et al. - J Affect Disord 1988;38:73-80

    36. Society mind and body in chronic fatigue syndrome – An anthropological view
      Ware NC – In : A. Kleinman & S. Straus (Eds) 'Chronic Fatigue Syndrome' (pp. 62-82) - Chichester John Wiley: 1993

    37. Somatic hypotheses of war syndromes
      Soetekouw PM, De Vries M, van Bergen L et al. - Eur J Clin Invest 2000;30:630-41

    38. Somatization - A critical review of conceptual and methodological issues
      DeGucht, V. & Fischler, B. (2002) - Psychosomatics, 43, 1 -9

    39. Somatization, illness attribution and the sociocultural psychitry of chronic fatigue syndrome
      Abbey Susan E. - In : 'Chronic Fatigue Syndrome' - Ciba Foundation Symposium 173, John Wiley & Sons, pag. 238-261, 1993

    40. Somatoform and personality disorders - Syndromal comorbidity and overlapping developmental pathways
      Bass, C. & Murphy, M. (1995) - Journal of Psychosomatic Research, 39, 403 -427

    41. Somatoform disorders - A help or hindrance to good patient care ?
      Sharpe M, Mayou R - Br J Psychiatry 2004;184:465-7
      Cfr. :

    42. Somatoform disorders - Severe psychiatric illnesses neglected by psychiatrists
      Bass, C., Peveler, R. & House, A. (2001) - British Journal of Psychiatry, 179, 11-14
      Cfr. :

    43. Somatoform Disorders and DSM-V - Conceptual and Political Issues in the Debate
      V. Starcevic - Psychosomatics, August 1, 2006; 47(4): 277 – 281
      This article furthers the debate on the future of somatoform disorders by critically reviewing the relevant terminology and validity for the separate grouping and classification of these disorders.
      It is suggested that political pressures to change certain terms should be resisted and that such changes should be made only if the alternatives have clear advantages.
      Cfr. :

    44. Somatoform disorders in general practice - Prevalence, functional impairment and comorbidity with anxiety and depressive disorders
      de Waal, M. W. M., Arnold, I. A., Eekhof, J. A. H. et al (2004) - British Journal of Psychiatry, 184, 470-476
      Psychiatric disorders are common in general practice and the general practitioner has a pivotal role in the recognition and subsequent treatment of psychiatric disorders.
      Although psychiatric attention tends to focus on anxiety and depressive disorders, these disorders are not the most prevalent in general practice.
      Fink et al (1999) reported a prevalence of somato-form disorders as high as 30.3%.
      The comorbidity of somatoform disorders with anxiety and depressive disorders is high (Maier & Falkai, 1999) and the burden of illness may be substantial (Kroenke et al, 1997).
      A critical review demonstrated that cognitive–behavioural therapy can be effective in treating patients with somato-form disorders (Kroenke & Swindle, 2000).
      Few comprehensive studies have focused on an accurate quantification of clinically relevant disorders.
      The aim of the present study was to quantify the prevalence of somatoform disorders and comorbidity with anxiety and depressive disorders in primary care using DSM–IV criteria (American Psychiatric Association, 1994), with a particular emphasis on functional impairment.
      Cfr. :

    45. SPECT imaging of the brain – Comparison of findings in patients with chronic fatigue syndrome, AIDS dementia complex and major unipolar depression
      Schwartz R, Komaroff A, Garada B - Am J Roentgenology 1994; 162: 943-51
      Cfr. :

    46. Strength and physiological response to exercise in patients with chronic fatigue syndrome
      Fulcher KY, White PD - J Neurol Neurosurg Psychiatry 2000;69:302-7
      Cfr. :

    47. Stress in the workplace - Unfinished business
      Hotopf M, Wessely S - J Psychosom Res 1997;43:1-6
      Cfr. :

    48. Structured Early Consultation with the Occupational Physician Reduces Sickness Absence Among Office Workers at High Risk for long-term sickness absence - A randomized controlled trial.
      IJ. Kant , N.W.H. Jansen, L.G.P.M. van Amelsvoort, R. van Leusden, A. Berkouwer, 2008
      Onderzoek onder in totaal 299 medewerkers met een hoog risico op uitval.
      De experimentele groep ontving een preventieve begeleiding van de bedrijfsarts.
      Dit had een positief effect : deze groep verzuimde minder en minder lang dan de controle groep.
      Cfr. :

    49. Study of immune alterations in patients with chronic fatigue syndrome with different etiologies
      Racciatti D, Dalessandro M, Delle Donne L, Falasca K, Zingariello P, Paganelli R, Pizzigallo E, Vecchiet J, Sections of Infectious Diseases, Department of Medicine and Sciences of Aging, Centre of Excellence on Aging, University G. D'Annunzio, Chieti, Italy : - Int J Immunopathol Pharmacol. 2004 May-Aug;17(2 Suppl):57-62 - PMID: 15345193
      The Chronic Fatigue Syndrome (CFS) is characterized by symptoms lasting for at least six months and accompanied by disabling fatigue.
      The etiology of CFS is still unclear.
      At the National Center for Study of the Infectious Diseases Department of the Chieti University some immune investigations were performed with the purpose of detecting markers of the disease.
      CD4+, CD8+, NK CD56+ and B CD19+ lymphocytes were studied in 92 male and 47 female patients and in 36 control subjects.
      CFS patients were divided in three groups with a post-infectious onset (PI-CFS), an non post-infectious onset (NPI-CFS) and a non post-infectious onset with associated infections (NPI-CFS + AI).
      Both CD4+ and CD8+ lymphocytes were reduced in the CFS patients.
      However, the CD4+/CD8+ ratio was increased in the CFS patients without difference between males and females.
      CD56+ cells of CFS patients were also reduced.
      In particular, blood CD56+ cells counts were significantly higher in PI-CFS patients than in the NPI-CFS subjects.
      These data confirm our preliminary results suggesting a key-role of a dysfunction of the immune system as a precipitating and-or perpetuating factor of the syndrome.

    50. StudySelf Test on the AGREE Instrument
      MacDermid JC – 2003
      Cfr. :

    51. Subclassifying chronic fatigue syndrome through exercise testing
      VanNess JM, Snell CR, Strayer DR et al. - Med Sci Sports Exerc 2003;35:908-13
      Purpose - The purpose of this study was to examine physiological responses of persons with chronic fatigue syndrome (CFS) to a graded exercise test.
      Methods - Cardiopulmonary exercise tests were performed on 189 patients diagnosed with CFS.
      Based on values for peak oxygen consumption, patients were assigned to one of four impairment categories (none, mild, moderate and severe), using American Medical Association (AMA) guidelines.
      A one-way MANOVA was used to determine differences between impairment categories for the dependent variables of age, body mass index, percentage of predicted [OV0312]O(2), resting and peak heart rates, resting and peak systolic blood pressure, respiratory quotient (RQ) and rating of perceived exertion.
      Results - Significant differences were found between each impairment level for percentage of predicted [OV0312]O(2) and peak heart rate.
      Peak systolic blood pressure values for the "moderate" and "severe" groups differed significantly from each other and both other groups.
      The more impaired groups had lower values.
      The no impairment group had a significantly higher peak RQ than each of the other impairment levels (all P < 0.001).
      Peak [OV0312]O(2) values were less than predicted for all groups.
      Compared with the males, the women achieved actual values for peak [OV0312]O(2) that were closer to their predicted values.
      Conclusion - Despite a common diagnosis, the functional capacity of CFS patients varies greatly.
      Stratifying patients by function allows for a more meaningful interpretation of the responses to exercise and may enable differential diagnosis between subsets of CFS patients.
      Cfr. :

    52. Subclinical depression and performance at work
      Martin, JK; Blum, TC; Beach, SRH et al. - Social Psychiatry Psychiatric Epidemiol. 1996;31:3–9

    53. Subcortical and cortical brain activity during the feeling of self-generated emotions
      Damasio AR, Grabowski TJ, Bechara A et al. - Nat Neurosci 2000;3:1049-56

    54. Subcutaneous sumatriptan compared with usual acute treatments for migraine - Clinical and pharmaco-economic evaluation
      Laloux, P; Vakaet, A; Monseu, G et al. - Acta Neurol Belgica. 1998;98:332–341

    55. Subjective and objective sleepiness in monozygotic twins discordant for chronic fatigue syndrome
      Watson NF, Jacobsen C, Goldberg J et al. - Sleep 2004;27:973-7
      Cfr. :

    56. Subjective health complaints, sensitization and sustained cognitive activation (stress)
      Eriksen HR, Ursin H, Department of Biological and Medical Psychology, University of Bergen, Jonas Lies vei 91, N-5009 Bergen, Norway : - J Psychosom Res. 2004 Apr;56(4):445-8 - PMID: 15094030 - © 2004 Elsevier Inc.
      Introduction - This review argues that "subjective health complaints" is a better and neutral term for "unexplained medical symptoms".
      The most common complaints are musculoskeletal pain, gastrointestinal complaints and "pseudoneurology" (tiredness, sleep problems, fatigue and mood changes).
      These complaints are common in the general population, but for some these complaints reach a level that requires care and assistance.
      Theoretical assumptions - We suggest that these complaints are based on sensations from what in most people are normal physiological processes.
      In some individuals these sensations become intolerable.
      In some cases it may signal somatic disease, in most cases not.
      Cases without somatic disease or with minimal somatic findings, occur under diagnoses like burnout, epidemic fatigue, multiple chemical sensitivity, chronic musculoskeletal pain, chronic low back pain, chronic fatigue syndrome and fibromyalgia.
      These complaints are particularly common in individuals with low coping and high levels of helplessness and hopelessness.
      Conclusion - The psychobiological mechanisms for this is suggested to be sensitization in neural loops maintained by sustained attention and arousal.
      Cfr. :

    57. Subtypes of chronic fatigue syndrome - A review of findings
      Jason LA, Taylor RR, Kennedy CL et al. - J Chronic Fatigue Syndr 2001;8:1-21
      Most studies of Chronic Fatigue Syndrome (CFS) have been based on patients recruited from primary or tertiary care settings.
      Patients from such settings might not be typical of patients in the general population and may not accurately reflect the heterogeneity among individuals diagnosed with this condition.
      The current paper reviews four community-based studies that examined subtypes of individuals with CFS.
      Distinctions between subtype groups based on sociodemographics, illness onset and duration, stressful precipitating events, symptom frequency and comorbidity characteristics are made with respect to outcome measures of fatigue and symptom severity, functional ability and psychiatric comorbidity.
      Cfr. :

    58. Suffering and the social construction of illness – The deligitimisation of illness experience in chronic fatigue syndrome
      Ware NC – Med Anthropology Quarterly 1992; 6: 347-6

    59. Surveillance for chronic fatigue syndrome - Four U.S. Cities - September 1989 through August 1993
      Reyes M, Gary HE, Jr., Dobbins JG et al. - MMWR CDC Surveill Summ 1997;46:1-13

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    Bedrijfsartsen op bres voor arbeidsongeschikten

    Deel XXVIII

    1. Symptom-syndrome distinction and organisational hierarchies in psychiatric classification
      Rena Rosalind et al. - BJP Online, 21 Jun 2004
      Cfr. :

    2. Symptoms research - A fertile field
      Kroenke, K. & Harris, L. (2001) - Annals of Internal Medicine, 134, 801 -802
      Cfr. :

    3. Synchrony of change in depression and disability - What next ?
      Ormel J - Arch Gen Psychiatry 2000;57:381-2

    4. Systematic assessment of the quality of osetoproris guidelines
      Cranney A, Waldegger L, Graham ID, Man-Son-Hing M, Byszewski A, Ooi DS - BMC Musculoskeletal Disorders 2002;3:20,

    5. Systematic review of mental health interventions for patients with common somatic symptoms - Can research evidence from secondary care be extrapolated to primary care ?
      Raine R, Haines A, Sensky T, Hutchings A, Larkin K, Black N - BMJ. 2002 Nov 9;325(7372):1082.

    6. Systematic review of randomized controlled trials of nonpharmacological interventions for fibromyalgia
      Sim J, Adams N.. Clin J Pain. 2002 Sep-Oct;18(5):324-36.

    7. Systematic review of the comorbidity of irritable bowel syndrome with other disorders - What are the causes and implications ?
      Whitehead WE, Palsson O, Jones KR - Gastroenterology 2002;122:1140-56
      Background & aims - Comorbid or extraintestinal symptoms occur frequently with irritable bowel syndrome and account for up to three fourths of excess health care visits.
      This challenges the assumption that irritable bowel is a distinct disorder.
      The aims of this study were to
      (1) assess comorbidity in 3 areas: gastrointestinal disorders, psychiatric disorders and nongastrointestinal somatic disorders and
      (2) evaluate explanatory hypotheses.
      Methods - The scientific literature since 1966 in all languages cited in Medline was systematically reviewed.
      Restuls - Comorbidity with other functional gastrointestinal disorders is high and may be caused by shared pathophysiological mechanisms such as visceral hypersensitivity.
      Psychiatric disorders, especially major depression, anxiety and somatoform disorders, occur in up to 94%.
      The nongastrointestinal nonpsychiatric disorders with the best-documented association are fibromyalgia (median of 49% have IBS), chronic fatigue syndrome (51%), temporomandibular joint disorder (64%) and chronic pelvic pain (50%).
      Conclusions - Multivariate statistical analyses suggest that these are distinct disorders and not manifestations of a common somatization disorder, but their strong comorbidity suggests a common feature important to their expression, which is most likely psychological.
      Some models explain the comorbidity of irritable bowel with other disorders by suggesting that each disorder is the manifestation of varying combinations of interacting physiological and psychological factors.
      An alternative hypothesis is that the irritable bowel diagnosis is applied to a heterogeneous group of patients, some of whom have a predominantly psychological etiology, whereas others have a predominantly biological etiology and that the presence of multiple comorbid disorders is a marker for psychological influences on etiology.
      Cfr. :

    8. Taking time to smell the roses - Accounts of people with chronic fatigue syndrome and their struggle for legitimisation
      Cohn S - Anthropol Med 1999;6:195-215

    9. The accuracy of self-reported disability days
      Revicki, DA; Irwin, D; Reblando, J et al. - Med Care. 1994;32:401–404

    10. The benefits of interventions for work-related stress
      Klink JJLvd, Blonk RWB, Schene AH, Dijk FJHv - Am J Public Health 2001;91:270-6

    11. The burden of musculoskeletal diseases in the general population of Spain - Results from a national survey
      Carmona L, Ballina J, Gabriel R, Laffon A - Ann.Rheum.Dis. 2001;60:1040-5.

    12. The business case for quality mental health services - Why employers should care about the mental health and well-being of their employees
      Ron Z. Goetzel (1), Ronald J. Ozminkowski (2), Lloyd Sederer (3) and Tami L. Mark (1) -- (1) MEDSTAT Group, Inc, Washington, D.C., Etats-Unis -- (2) The MEDSTAT Group, Inc, Ann Arbor, Mich., Etats-Unis -- (3) American Psychiatric Association, Washington, D.C., Etats-Unis - Journal of occupational and environmental medicine, 2002, vol. 44, no4, pp. 320-330 (67 ref.) - Lippincott Williams & Wilkins, Hagerstown, MD, Etats-Uni (1995) (Revue) - ISSN : 1076-2752 - © 2008 INIST-CNRS
      Employers are very concerned about rising mental health care costs.
      They want to know whether their health care spending is improving the health of workers and whether there is a productivity payback from providing good mental health care.
      This article addresses the subject of employee depression and its impact on business.
      The literature suggests that depressed individuals exert a significant cost burden for employers.
      Evidence is mounting that worker depression may have its greatest impact on productivity losses, including increased absenteeism and short-term disability, higher turnover and suboptimal performance at work.
      Although there is no conclusive evidence yet that physical health care costs decrease when depression is effectively treated, there is growing evidence that productivity improvements occur as a consequence of effective treatment, and those improvements may offset the cost of the treatment.
      Cfr. :

    13. The case definition of chronic fatigue syndrome
      Tan EM, Sugiura K, Gupta S, W.M. Keck Autoimmune Disease Center, The Scripps Research Institute, La Jolla, California 92037, USA - J Clin Immunol. 2002 Jan;22(1):8-12 - PMID: 11958593
      The 1994 case definition of chronic fatigue syndrome is widely used not only for diagnosis but also for clinical and laboratory-based observations of this clinical entity.
      The criteria for the 1994 case definition are based primarily on symptoms and not on physical signs or chemical or immunological tests.
      This situation has resulted in conflicting clinical and laboratory observations that in all likelihood is due to different populations of patients being studied in different centers.
      Based on some of the recent publications, there appears to be an emerging picture of this disease entity that we propose could be used to subgroup chronic fatigue syndrome into four different subclasses.
      These subclasses would consist of chronic fatigue with primarily nervous system disorders such as impaired memory or concentration and headache, chronic fatigue with primarily endocrine system disorders such as unrefreshing sleep and postexertional malaise, chronic fatigue with musculoskeletal system disorders such as muscle pain and joint pain and chronic fatigue with immune system/infectious disorders such as sore throat and tender lymph nodes.
      It is suggested that if clinical and laboratory-based studies on chronic fatigue syndrome were conducted on more homogeneous subgroups of patients, the data from one center to the other might not be as conflicting and more insights can be shed on the nature of this clinical condition.
      Cfr. :

    14. The challenge of integrating disparate high-content data - Epidemiologic, clinical and laboratory data collected during an in-hospital study of chronic fatigue syndrome
      Vernon SD, Reeves WC - Pharmacogenomics 2006, 7(3):345-354
      Cfr. :

    15. The chronic fatigue syndrome - A comprehensive approach to its definition and study
      Fukuda K, Straus SE, Hickie I et al. - International chronic fatigue syndrome Study Group. Ann Intern Med 1994;121:953-9

    16. The clinical and scientific basis of Myalgic Encephalomvelitis Cronic fatique syndrome
      Hyde B.M., M.D. - The Nightingale Research Foundation, Ottawa, Ontario, Canada and Ogdensburg, New York USA, 1992

    17. The cognitive activation theory of stress
      Ursin H, Eriksen HR, Department of Biological and Medical Psychology, University of Bergen, Jonas Liesvei 91, N-5009 Bergen, Norway : - Psychoneuroendocrinology. 2004 Jun;29(5):567-92 - PMID: 15041082
      This paper presents a cognitive activation theory of stress (CATS), with a formal system of systematic definitions.
      The term "stress" is used for four aspects of "stress", stress stimuli, stress experience, the non-specific, general stress response and experience of the stress response.
      These four meanings may be measured separately.
      The stress response is a general alarm in a homeostatic system, producing general and unspecific neurophysiological activation from one level of arousal to more arousal.
      The stress response occurs whenever there is something missing, for instance a homeostatic imbalance or a threat to homeostasis and life of the organism.
      Formally, the alarm occurs when there is a discrepancy between what should be and what is-between the value a variable should have (set value (SV)) and the real value (actual value (AV)) of the same variable.
      The stress response, therefore, is an essential and necessary physiological response.
      The unpleasantness of the alarm is no health threat.
      However, if sustained, the response may lead to illness and disease through established pathophysiological processes ("allostatic load").
      The alarm elicits specific behaviors to cope with the situation.
      The level of alarm depends on expectancy of the outcome of stimuli and the specific responses available for coping.
      Psychological defense is defined as a distortion of stimulus expectancies.
      Response outcome expectancies are defined as positive, negative or none, to the available responses.
      This offers formal definitions of coping, hopelessness and helplessness that are easy to operationalize in man and in animals.
      It is an essential element of CATS that only when coping is defined as positive outcome expectancy does the concept predict relations to health and disease.
      Cfr. :

    18. The conundrum of medically unexplained symptoms - Questions to consider
      McFarlane AC, Ellis N, Barton C, Browne D, Van Hooff M, Centre for Military and Veterans Health, University of Adelaide, South Australia - Psychosomatics. 2008 Sep-Oct;49(5):369-77 - PMID: 18794504
      Background - The classification and etiology of medically unexplained symptoms remain a clinical challenge.
      Recent proposals to improve systems of classification include ending the tradition of separating symptoms into medical or psychiatric groups.
      Method - Several research questions are proposed to resolve some of the divergent opinions about the nature of these difficulties.
      Confusion - Unitary models of somatic symptom causation should not be presumed.
      Examination of the causes and nature of somatic distress in those with and without psychiatric disorders requires separate investigation for each and these should not be presumed to be similar.
      Psychophysiological models of somatic symptoms are required that can be studied in research protocols.
      Cfr. :

    19. The costs of treating depression
      Santiago JM, College of Medicine, Department of Psychiatry, University of Arizona, Tucson - J Clin Psychiatry. 1993 Nov;54(11):425-6 - PMID: 8270585
      Cfr. :
      This article is a comment on :
      The economic burden of depression in 1990
      Cfr. :

      Depression - A neglected major illness
      Cfr. :

    20. The diagnosis and management of depression and anxiety in primary care - The need for a different framework
      K S Jacob - Postgrad. Med. J., December 1, 2006; 82(974): 836 – 839
      There has been increased debate related to depression and common mental disorders over the past few decades.
      The high prevalence of depression in primary care and the low recognition and treatment rates have inspired primary care psychiatry.
      Educating general practitioners, preparing practice guidelines and conducting courses to improve their clinical skills have been attempted.
      These efforts have resulted in the expectation that depression would be managed in primary care.
      However, despite piloting, field studies and acceptance by academic general practitioners, the watered-down psychiatric approach, when used in primary care, has few takers in actual practice.
      The culture of primary care psychiatry borrows heavily from academic psychiatry and attempts to adapt it to the reality of primary care.
      The compromise is uneasy, unstable and difficult to apply in general practice.
      Cfr. :

    21. The distinction between mental and physical illness
      Kendell RE - Br J Psychiatry 2001;178:490
      Conditions that now would be regarded as ‘mental illnesses’, such as mania, melancholia and hysteria, have figured in classifications of disease since the time of Hippocrates and for over 2000 years were treated by physicians with much the same range of potions, medicaments and attempts to correct humoral imbalance as they employed for other more obviously medical disorders.
      Although Plato attributed some forms of madness to the Gods and medieval theologians like Thomas Aquinas attributed hallucinations and insanity to demons and other supernatural influences, from the Renaissance to the second half of the 18th century melancholia and other forms of insanity were generally regarded as bodily illnesses, not differing in any fundamental way from other diseases.
      When the mid-18th century belle lettriste Lady Mary Wortley Montagu commented that "madness is as much a corporeal distemper as the gout or asthma", she was simply expressing the "commonplace of high and low, lay and medical opinion alike" (Porter, 1987).
      Cfr. :

    22. The doctor-patient relationship in chronic fatigue syndrome - Survey of patient perspectives
      Van Hoof, Elke - Quality in Primary Care, Volume 17, Number 4, August 2009 , pp. 263-270(8) - Radcliffe Publishing Ltd.
      Cfr. :

    23. The economic burden of depression in 1990
      Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER, Analysis Group, Inc., Cambridge, MA 02138 - J Clin Psychiatry. 1993 Nov;54(11):405-18 - PMID: 8270583
      - We estimate in dollar terms the economic burden of depression in the United States on an annual basis.
      Method - Using a human capital approach, we develop prevalence-based estimates of three major cost-of-illness categories : (1) direct costs of medical, psychiatric and pharmacologic care; (2) mortality costs arising from depression-related suicides; and (3) morbidity costs associated with depression in the workplace.
      With respect to the latter category, we extend traditional cost-of-illness research to include not only the costs arising from excess absenteeism of depressed workers, but also the reductions in their productive capacity while at work during episodes of the illness.
      Results - We estimate that the annual costs of depression in the United States total approximately $43.7 billion.
      Of this total, $12.4 billion-28%-is attributable to direct costs, $7.5 billion-17%-comprises mortality costs and $23.8 billion-55%-is derived from the two morbidity cost categories.
      Conclusion - Depression imposes significant annual costs on society.
      Because there are many important categories of cost that have yet to be estimated, the true burden of this illness may be even greater than is implied by our estimate.
      Future research on the total costs of depression may include attention to the comorbidity costs of this illness with a variety of other diseases, reductions in the quality of life experienced by sufferers and added out-of-pocket costs resulting from the effects of this illness, including those related to household services.
      Finally, it may be useful to estimate the additional costs associated with expanding the definition of depression to include individuals who suffer from only some of the symptoms of this illness.
      Cfr. :

      Also read the comment on this article : 'The costs of treating depression' at : Cfr. :

    24. The economic cost of chronic fatigue and chronic fatigue syndrome in UK primary care
      McCrone P, Darbishire L, Ridsdale L, Seed P, Centre for the Economics of Mental Health, Health Services Research Department, Institute of Psychiatry, King's College, London - Psychol Med. 2003 Feb;33(2):253-61 - PMID: 12622304
      Background - Chronic fatigue and chronic fatigue syndrome are most often encountered in primary care settings.
      Given the disabling nature of chronic fatigue it may have a substantial impact on service use and costs as well as on employment.
      This study estimates this impact.
      Method - Patients presenting to general practitioners with unexplained chronic fatigue were recruited to the study.
      Service use over a 3 month period was measured and lost employment recorded.
      These data were used to estimate economic costs.
      Patients with chronic fatigue syndrome were compared to patients with only chronic fatigue using a multiple regression model with sample differences controlled.
      Results - The mean total cost of services and lost employment across the sample was Pound Sterling1906 for the 3-month period with formal services accounting for 9.3% of this figure.
      Service use was higher for patients with chronic fatigue syndrome compared to those with chronic fatigue alone.
      Total 3-month costs were on average higher for chronic fatigue syndrome (Pound Sterling3515 v. Pound Sterling1176) but when sample differences were taken account of the mean difference was reduced to Pound Sterling1406 (P = 0.086).
      Over 90% of the cost was accounted for by care provided by friends and family members and by lost employment.
      Patients with dependants had significantly higher costs than those with none and costs were also significantly higher for greater levels of functional impairment.
      Conclusion - Chronic fatigue imposes substantial economic costs on society, mainly in the form of informal care and lost employment.
      Treatments need to be developed which recognize these impacts.
      Cfr. :
      Also read the comment on this article :
      Costs, correlates and consequences of fatigue in children and adults
      White PD - Psychol Med. 2003 Feb;33(2):197-201 - PMID: 12622299
      Cfr. :

    25. The Effect of Improving Primary Care Depression Management on Employee Absenteeism and Productivity - A Randomized Trial
      Kathryn Rost, PhD,* Jeffrey L. Smith, BS,† and Miriam Dickinson, PhD* -- *From the Department of Family Medicine, University of Colorado Health Sciences Center, Aurora, Colorado -- †Mental Health QUERI, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas - Med Care. 2004 December; 42(12): 1202–1210
      Objective - To test whether an intervention to improve primary care depression management significantly improves productivity at work and absenteeism over 2 years.
      Setting and Subjects - Twelve community primary care practices recruiting depressed primary care patients identified in a previsit screening.
      Research Design - Practices were stratified by depression treatment patterns before randomization to enhanced or usual care.
      After delivering brief training, enhanced care clinicians provided improved depression management over 24 months.
      The research team evaluated productivity and absenteeism at baseline, 6, 12, 18 and 24 months in 326 patients who reported full-or part-time work at one or more completed waves.
      Results - Employed patients in the enhanced care condition reported 6.1% greater productivity and 22.8% less absenteeism over 2 years.
      Consistent with its impact on depression severity and emotional role functioning, intervention effects were more observable in consistently employed subjects where the intervention improved productivity by 8.2% over 2 years at an estimated annual value of $1982 per depressed full-time equivalent and reduced absenteeism by 28.4% or 12.3 days over 2 years at an estimated annual value of $619 per depressed full-time equivalent.
      Conclusions - This trial, which is the first to our knowledge to demonstrate that improving the quality of care for any chronic disease has positive consequences for productivity and absenteeism, encourages formal cost-benefit research to assess the potential return-on-investment employers of stable workforces can realize from using their purchasing power to encourage better depression treatment for their employees.
      Cfr. :

    26. The effect of screening, sensitization and feedback on notation of depression
      Linn, LS; Yager, J - J Med Educ. 1980;55:942–949

    27. The effects of child care costs on married women's labor force participation
      Connelly, R - Rev Econ Stat. 1992;74:83–90

    28. The effects of chronic medical conditions on work impairment
      Kessler, RC; Mickelson, KD; Barber, C et al. - In : 'Caring and Doing for Others - Social Responsibility in the Domains of the Family, Work and Community' - Rossi AS. , editor - University of Chicago Press; Chicago : 1999

    29. The effects of clonazepam on quality of life and work productivity in panic disorder
      Jacobs, RJ; Davidson, JRT; Gupta, S et al. - Am J Manage Care. 1997;3:1187–1196

    30. The epidemiology of chronic fatigue in San Francisco
      Steele L, Dobbins JG, Fukuda K et al. - Am J Med 1998;105:83S-90S

    31. The existence of a fatigue syndrome after glandular fever
      White PD, Thomas J, Amess J. et al. - Psych Med 1995; 25: 907-16

    32. The HPA axis and the genesis of chronic fatigue syndrome
      Cleare AJ - Trends Endocrinol Metab 2004;15:55-9
      Cfr. :

    33. The ICD–10 Classification of Mental and Behavioural Disorders
      World Health Organization (1992) - Geneva: WHO
      Cfr. :

    34. The impact of a stress management programme on staff well-being and performance at work
      John Rose, Centre for Training in Clinical Psychology, Whitchurch Hospital, Whitchurch and Gwent Community Health (NHS) Trust, Cardiff, Wales, UK - Fiona Jones, Psychology Department, University of Hertfordshire, UK - Ben C. Fletcher, Business School, University of Hertfordshire, UK
      Stress management programmes were implemented for direct care staff in two group homes for people with learning disabilities.
      Staff working in three similar homes were used as controls.
      Assessments were made of anxiety and depression levels and demands, supports and constraints at work.
      Staff in the intervention houses were also observed at work to determine who they were interacting with, the nature and type of the interaction and the amount of time spent on different aspects of the job.
      This information was used to inform and develop an intervention aimed at the groups of staff involved.
      Goals were set with the aim of reducing levels of anxiety and depression in staff and these were subject to review.
      Reassessment in intervention houses showed reductions in anxiety and increased perceived support when compared to controls.
      There were also changes in some observational measures, particularly increased positive interactions and assistance given to clients and formal education programmes.
      These results suggest that intervening to reduce levels of anxiety and depression can have a positive impact on work performance in these settings.
      Cfr. :

    35. The impact of psychiatric disorders on work loss days
      Kessler, RC; Frank, RG - Psychol Med. 1997;27:861–873

    36. The limits of medicine and the social consequences for sufferers of chronic fatigue syndrome
      Pinikahana J, Holloway G, Millen N - Aust J Prim Health 2002;8:70-6
      Chronic fatigue syndrome (CFS) appears to be made up of several clusters of illness categories acting alone or in tandem to cause the decline of health through; fatigue/exhaustion, sensitivity/allergies, pain, general muscle and joint pains, cognitive impairment and gastrointestinal problems.
      This study investigated how patients interpret, evaluate and respond to the complex and varied symptoms of chronic fatigue syndrome.
      Data were collected from persons with CFS using a survey (n=90) and an interview (n=45).
      The researchers investigated how chronic fatigue syndrome is diagnosed by medical practitioners, how the label of CFS is determined and the social consequences for the patient.
      The results confirm the limited ability of the biomedical paradigm to diagnose adequately and treat effectively 'socially constructed' and medically ambiguous illnesses like CFS.
      In the absence of a legitimated regime of medical treatment for CFS, a range of often expensive treatments are employed by CFS sufferers, from formal use of pharmaceutical drugs through to 'alternative' therapies, including herbal, vitamin, homeopathic, esoteric meditative techniques, spiritual healing and general counselling are taken in no particular order.
      Cfr. :

    37. The management of somatoform disorder in childhood
      Taylor S, Garralda E - Curr Opin Psychiatry 2003;16:227-31
      Purpose of review - In this article we aim to review new research into functional somatic symptoms and somatoform disorders in children as it expands the knowledge base on epidemiology, associations and management.
      Recent findings - Somatoform disorders have been found to be present in 12% (lifetime incidence) and 7% (12-month incidence) of adolescents in a German general population.
      Comorbid psychopathology was common.
      Follow-up work shows that most children with conversion disorder and chronic fatigue syndrome attending tertiary referral centres recover from the disorder, but chronic fatigue syndrome can be particularly impairing and outcome appears to be linked to child personality and parental illness beliefs.
      Further support is given to the use of family based cognitive behavioural approaches.
      Cfr. :

    38. The measurement of fatigue - A new instrument
      Schwartz JE, Jandorf L, Krupp LB, Department of Psychiatry and Behavioral Science, SUNY-Stony Brook 11794-8121 - J Psychosom Res. 1993 Oct;37(7):753-62 - PMID: 8229906
      Fatigue is a frequent medical symptom which has not been routinely measured.
      We present a 29-item fatigue assessment instrument, describe its psychometric properties and use it to differentiate normal fatigue from fatigue related medical disorders.
      Differences in fatigue across a variety of medical disorders, the reproducibility of the fatigue instrument and its convergent validity with other fatigue measures are also described.
      Cfr. :

    39. The measurement of fatigue in patientes with multiple sclerosis - A multidimensional comparison with patients with chronic fatigue syndroom and healthy subjects
      Vercoulen JH, Hommes OR, Swanink CM et al. - Arch Neurol. 1996 Jul; 53 (7): 642-649

    40. The neurobiological consequences of early stress and childhood maltreatment
      Teicher MH, Andersen SL, Polcari A et al. - Neurosci Biobehav Rev 2003;27:33-44

    41. The neurobiology and neuroendocrinology of stress - Implications for post-traumatic stress disorder from a basic science perspective
      McEwen BS - Psychiatr Clin North Am 2002;25:469-94

    42. The neurobiology of stress - From serendipity to clinical relevance
      McEwen BS - Brain Res 2000;886(1-2):172-189
      The hormones and other physiological agents that mediate the effects of stress on the body have protective and adaptive effects in the short run and yet can accelerate pathophysiology when they are over-produced or mismanaged.
      Here we consider the protective and damaging effects of these mediators as they relate to the immune system and brain.
      'Stress' is a principle focus, but this term is rather imprecise.
      Therefore, the article begins by noting two new terms, allostasis and allostatic load that are intended to supplement and clarify the meanings of 'stress' and 'homeostasis'.
      For the immune system, acute stress enhances immune function whereas chronic stress suppresses it.
      These effects can be beneficial for some types of immune responses and deleterious for others.
      A key mechanism involves the stress-hormone dependent translocation of immune cells in the blood to tissues and organs where an immune defense is needed.
      For the brain, acute stress enhances the memory of events that are potentially threatening to the organism.
      Chronic stress, on the other hand, causes adaptive plasticity in the brain, in which local neurotransmitters as well as systemic hormones interact to produce structural as well as functional changes, involving the suppression of ongoing neurogenesis in the dentate gyrus and remodelling of dendrites in the Ammon's horn.
      Under extreme conditions only does permanent damage ensue.
      Adrenal steroids tell only part of the story as far as how the brain adapts or shows damage and local tissue modulators - cytokines for the immune response and excitatory amino acid neurotransmitters for the hippocampus.
      Moreover, comparison of the effects of experimenter-applied stressors and psychosocial stressors show that what animals do to each other is often more potent than what experimenters do to them.
      And yet, even then, the brain is resilient and capable of adaptive plasticity.
      Stress-induced structural changes in brain regions such as the hippocampus have clinical ramifications for disorders such as depression, post-traumatic stress disorder and individual differences in the aging process.
      Cfr. :

    43. The neuroendocrinology of chronic fatigue syndrome
      Cleare AJ - Endocr Rev 2003;24:236-52
      Cfr. :

    44. The neuroendocrinology of chronic fatigue syndrome and fibromyalgia
      Parker A-JR, Wessely S, Cleare AJ - Psychol Med 2001;31:1331-45
      - Disturbance of the HPA axis may be important in the pathophysiology of chronic fatigue syndrome (CFS) and fibromyalgia.
      Symptoms may be due to :
      (1) low circulating cortisol;
      (2) disturbance of central neurotransmitters or
      (3) disturbance of the relationship between cortisol and central neurotransmitter function.
      Accumulating evidence of the complex relationship between cortisol and 5-HT function, make some form of hypothesis (3) most likely.
      We review the methodology and results of studies of the HPA and other neuroendocrine axes in CFS.
      Method - Medline, Embase and Psychlit were searched using the Cochrane Collaboration strategy.
      A search was also performed on the King's College CFS database, which includes over 3000 relevant references and a citation analysis was run on the key paper (Demitrack et al. 1991).
      Results - One-third of the studies reporting baseline cortisol found it to be significantly low, usually in one-third of patients.
      Methodological differences may account for some of the varying results.
      More consistent is the finding of reduced HPA function and enhanced 5-HT function on neuroendocrine challenge tests.
      The opioid system and arginine vasopressin (AVP) may also be abnormal, though the growth hormone (GH) axis appears to be intact, in CFS.
      Conclusions - The significance of these changes, remains unclear.
      We have little understanding of how neuroendocrine changes relate to the experience of symptoms and it is unclear whether these changes are primary or secondary to behavioural changes in sleep or exercise.
      Longitudinal studies of populations at risk for CFS will help to resolve these issues.
      Cfr. :

    45. The persistence of fatigue in chronic fatigue syndrome and multiple sclerosis - Development of a model
      Vercoulen JH, Swanink CM, Galama JM et al. - J Psychosom Res 1998;45:507-17

    46. The potential role of hypocortisolism in the pathophysiology of stressrelated bodily disorders
      Heim C, Ehlert U, Hellhammer DH - Psychoneuroendocrinology 2000;25:1-35
      Representing a challenge for current concepts of stress research, a number of studies have now provided convincing evidence that the adrenal gland is hypoactive in some stress-related states.
      The phenomenon of hypocortisolism has mainly been described for patients, who experienced a traumatic event and subsequently developed post-traumatic stress disorder (PTSD).
      However, as presented in this review, hypocortisolism does not merely represent a specific correlate of PTSD, since similar findings have been reported for healthy individuals living under conditions of chronic stress as well as for patients with several bodily disorders.
      These include chronic fatigue syndrome, fibromyalgia, other somatoform disorders, rheumatoid arthritis and asthma and many of these disorders have been related to stress.
      Although hypocortisolism appears to be a frequent and widespread phenomenon, the nature of the underlying mechanisms and the homology of these mechanisms within and across clinical groups remain speculative.
      Potential mechanisms include dysregulations on several levels of the hypothalamic-pituitary adrenal axis.
      In addition, factors such as genetic vulnerability, previous stress experience, coping and personality styles may determine the manifestation of this neuroendocrine abnormality.
      Several authors proposed theoretical concepts on the development or physiological meaning of hypocortisolism.
      Based on the reviewed findings, we propose that a persistent lack of cortisol availability in traumatized or chronically stressed individuals may promote an increased vulnerability for the development of stress-related bodily disorders.
      This pathophysiological model may have important implications for the prevention, diagnosis and treatment of the classical psychosomatic disorders.
      Cfr. :

    47. The prevalence and morbidity of chronic fatigue and chronic fatigue syndrome - A prospective primary care study
      Wessely S, Chalder T, Hirsch S et al. - Am J Public Health 1997;87:1449-55

    48. The prevalence of chronic fatigue syndrome in Iceland - A national comparison by gender drawing on four different criteria
      Lindal E, Stefansson JG, Bergmann S - Nord J Psychiatry 2002;56:273-7

    49. The prognosis after multidisciplinary treatment for patients with postinfectious chronic fatigue syndrome and noninfectious chronic fatigue syndrome
      Masuda A, Nakayama T, Yamanaka T et al. - J Behav Med 2002;25:487-97
      The prognosis after multidisciplinary treatment for patients with postinfectious chronic fatigue syndrome (CFS, n = 9) and noninfectious CFS (n = 9) was clarified.
      After treatment, natural killer (NK) cell activity increased in the postinfectious CFS group but did not recover to within normal range in the noninfectious CFS group.
      In the postinfectious CFS group, physical and mental symptoms improved and 8 patients returned to work.
      In the noninfectious CFS group, symptoms did not improve and only 3 patients returned to work.
      The prognosis of postinfectious CFS group was better than that of noninfectious CFS group.
      Classification of CFS patients into postinfectious and noninfectious groups is useful for choosing the appropriate treatment in order to obtain better prognosis.
      Cfr. :

    50. The psychometric proporties of the SF-36-item Short Form Health Survey - A multidimensional measure of general health status
      Zee K.I., van der, Sanderman R., Heyink J., Haes H., de, 1993

    51. The real measure of productivity
      Burton, WN; Conti, DJ - Business & Health. 1999;17:34–36

    52. The relationship between diabetes and depression - Improving the effectiveness of case management interventions
      Donie JF - Lippincotts Case Manag 2004;9:177-183

    53. The relationship between illness attributions and attributional style in Chronic Fatigue Syndrome
      Creswell C, Chalder T, Sub-Department of Clinical Health Psychology, University College London, UK : - Br J Clin Psychol. 2003 Mar;42(Pt 1):101-4 - PMID: 12675983
      Objective - To examine the relationship between illness attributions and general attributional style in Chronic Fatigue Syndrome (CFS).
      Method - Participants with CFS answered questions on their explanation for their illness and completed the Attributional Style Questionnaire (parallel form).
      Results - Of the participants, 58.3% attributed their illness to predominantly physical factors.
      A significant relationship was found between the presence of a self-serving attributional style and illness attributions.
      Conclusion - Illness attributions were associated with an individual's general attributional style.
      It is suggested that illness attributions may be less important with regards prognosis than, for example, other variables which influence a person's general view of the world.
      Cfr. :

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    Deel XXIX

    1. The relationship between infection and fatigue
      White PD - J Psychosom Res 1997;43:345-50
      Cfr. :

    2. The relevance of psychiatric research on somatization to the concept of chronic fatigue syndrome
      Clark M, Katon W – In : S. Straus (Ed) 'Chronic fatigue syndrome' (pp. 329-49) - New York: Marcel Dekker; 1994

    3. The rise and fall of the chronic fatigue syndroom as definde by Holmes et al.
      Waveren ER van – Ned Hypotheses. 1996 Feb; 46(2): 63-66

    4. The role of fear of physical movement and activity in chronic fatigue syndrome
      Silver A, Haeney M, Vijayadurai P et al. - J Psychosom Res 2002;52(6):485-493
      Objective - To examine beliefs in relation to avoidance of activity in chronic fatigue syndrome (CFS) patients.
      Methods - The first phase consisted of modifying an existing chronic pain measure of kinesiophobia—fear of physical movement and activity—and validating it on the CFS population [Tampa Scale of Kinesiophobia-Fatigue (TSK-F); n=129; test–retest: r=.89, P<.001; α=.68]. Subscales of Illness Beliefs (α=.78) and Beliefs about Activity (α=.70) were identified. The second phase consisted of evaluating whether behavioural persistence was predicted by the TSK-F (n=33). Participants were asked to ride an exercise bike for as long as they felt able.
      Results - Analyses indicated that behavioural persistence did not correlate with maximal heart rate or resting heart rate, level of tiredness, symptom severity, illness identity or emotional distress. However, the TSK-F did correlate highly with distance travelled and added a significant 15% of the variance in distance after adjustments for gender and physical functioning (PF). The TSK-F Beliefs about Activity subscale appears to be the predictive factor, explaining 12% of the variance in excise performance or rather 12% of the avoidance of exercise.
      Conclusion - Beliefs about Activity appear to be an important variable in predicting behaviour and avoidance of exercise.
      As avoidance has been suggested as a key to the maintenance of symptoms, disability and distress in CFS patients, this research has important theoretical, clinical and research implications.
      Cfr. :

    5. The role of health risk factors and disease on worker productivity
      Burton, WN; Conti, DJ; Chen, C et al. - J Occup Environ Med. 1999;41:863–877

    6. The role of physical inactivity in the chronic fatigue syndrome
      White PD - J Psychosom Res 2000;49:283-4
      Cfr. :

    7. The search for legitimacy and the "expertization" of the lay person - The case of chronic fatigue syndrome
      Clarke JN - Soc Work Health Care 2000;30:73-93
      Some "diseases" appear to be recognized first by sufferers.
      At times these diseases may be disclaimed by medical doctors and elusive to scientific categorization and description.
      In these cases sufferers may organize themselves together in support groups and lobby for money to finance the discovery of diagnostic markers that would legitimate and medicalize the constellation of symptoms that they experience.
      Chronic fatigue syndrome is such a disease; and it is characterized by varied and changing symptomatology.
      Its diagnostic markers are in the process of being refined.
      Presently, its diagnosis primarily originates in reports of subjective experience of extreme fatigue.
      Often-times people diagnose themselves after attending a support group and find a doctor through a support group network who believes in the disease.
      Sometimes, people then return to their own family doctors with information and try to teach their doctors about what they believe to be the nature of their disease, its prognosis and treatment.
      Through such paths as described in the paper, patients become "experts" : they may often know more about the illness than doctors and non-suffering others.
      This paper moves beyond the experience of chronic illness to describe the processes through which people seek confirmation and legitimation for the way that they feel and in a sense become the "experts."
      Cfr. :

    8. The self-clues from the brain
      LeDoux J - Ann N Y Acad Sci 2003;1001:295-304
      Can we find a way of thinking about the self that is compatible with modern neuroscience ?
      I think we can.
      First of all, we have to recognize that "the self" is not the same as "the conscious self" since much of who we are as individuals takes place out of conscious awareness.
      Second, we have to accept that some aspects of the self, especially the unconscious aspects, occur in and can be studied in other species, allowing us to relate these aspects of the self to detailed brain mechanisms.
      Finally, it also helps to think of the self in terms of memory.
      Obviously, much of who we are is based on memories learned through personal experience, including both conscious or explicit memories and unconscious or implicit memories.
      This is particularly important since much progress has been made in relating memory to the cells and synapses of the brain.
      By viewing the self as a network of memories the effort to relate the self to the brain can build on this progress.
      Emphasizing memory and experience does not take away from the fact that our genetic history also contributes to who we are.
      In fact, genes and experience or nature and nurture, are, in the end, not different things, but different ways of doing the same thing-wiring the synapses of our brain.
      In many ways, the self is synaptic.
      This synaptic view of the self is not meant as a challenge to other views, such as spiritual, cultural or psychological views.
      It is instead, just a way of understanding how these other aspects of who we are relate, deep down, to the brain.
      Cfr. :

    9. The somatoform conundrum - A question of nosological values
      Martin, R. D. (1999) - General Hospital Psychiatry, 21, 177 -186
      This paper critically reviews the values and perspectives evident in the formulation of the category of Somatoform Disorders in the widely used Diagnostic and Statistical Manual-IV (DSM-IV) [1] of the American Psychiatric Association.
      The conflict of values evident in the DSM Committee’s elimination of causal issues and including only descriptive criteria in the final classification is emphasized.
      In this approach, causation was dismissed and only a description of popular clinical entities was allowed.
      It becomes clear that there was a conflict between causal and descriptive factors in the formation of the current classifications.
      The dubious logic and the inconsistencies that underlie the linking of the various diagnoses under the Somatoform Disorder (SD) rubric is presented.
      A heuristic model of the interaction of psychological and somatic variables is described.
      These variables act in a causal fashion and should be the basis for any nosological system of the SDs.
      There is ample evidence to support the importance of causal factors in the development of SDs and the current descriptive nomenclature does not do justice to the rapidly growing field of Psychosomatic Medicine.
      A new scheme is proposed, using the presence or absence of stress as the connecting link for the diagnoses offered.
      The old nosology enhances the perpetuation of the mind-body dichotomy.
      Stress, representing the way in which the environment impinges on the human being, allows the mind-body dichotomy to be eliminated.
      The preferred synthesis of mind-body interaction as partly the result of experience in the environment becomes the basis for the new nosology.
      Cfr. :

    10. The tenth revision of the international classification of diseases and related health problems (ICD-10)
      World Health Organization - Geneva: WHO;1992
      Cfr. :

    11. The utilisation of health research in policy-making - Concepts, examples and methods of assessment
      Hanney SR, Gonzalez-Block MA, Buxton MJ, Kogan M, Health Economics Research Group, Brunel University, Uxbridge, Middlesex UB8 3PH, UK : - Health Res Policy Syst. 2003 Jan 13;1(1):2 - PMID: 12646071
      The importance of health research utilisation in policy-making, and of understanding the mechanisms involved, is increasingly recognised.
      Recent reports calling for more resources to improve health in developing countries and global pressures for accountability, draw greater attention to research-informed policy-making.
      Key utilisation issues have been described for at least twenty years, but the growing focus on health research systems creates additional dimensions.
      The utilisation of health research in policy-making should contribute to policies that may eventually lead to desired outcomes, including health gains.
      In this article, exploration of these issues is combined with a review of various forms of policy-making.
      When this is linked to analysis of different types of health research, it assists in building a comprehensive account of the diverse meanings of research utilisation.
      Previous studies report methods and conceptual frameworks that have been applied, if with varying degrees of success, to record utilisation in policy-making.
      These studies reveal various examples of research impact within a general picture of underutilisation.
      Factors potentially enhancing utilisation can be identified by exploration of : priority setting; activities of the health research system at the interface between research and policy-making; and the role of the recipients or 'receptors' of health research.
      An interfaces and receptors model provides a framework for analysis.
      Recommendations about possible methods for assessing health research utilisation follow identification of the purposes of such assessments.
      Our conclusion is that research utilisation can be better understood and enhanced, by developing assessment methods informed by conceptual analysis and review of previous studies.
      Cfr. :

    12. The wall between neurology and psychiatry
      Baker MG, Kale R, Menken M - BMJ 2002; 324:1468-9
      For more than 2000 years in the West, neurology and psychiatry were thought to be part of a single, unified branch of medicine, which was often designated neuropsychiatry.
      Charcot, Freud, Jackson, Bleuler, among many others, thought in terms of a unified study of the brain and the mind, irrespective of special clinical and research interests.
      During the 20th century, however, a schism emerged as each of these fields went its separate way.
      Neurologists focused on those brain disorders with cognitive and behavioural abnormalities that also presented with somatic signsstroke, multiple sclerosis, Parkinson's and so forthwhile psychiatrists focused on those disorders of mood and thought associated with no or minor, physical signs found in the neurological examination of the motor and sensory systemsschizophrenia, depression, anxiety disorders, and so on.
      Cfr. :

    13. The Work Limitations Questionnaire
      Lerner, D; Amick, BC, III; Rogers, WH et al. - Med Care. 2000;39:72–85
      Cfr. :

    14. Theories, concepts and terminology
      Sharpe, M., Mayou, R. & Bass, C. (1995) - In 'Treatment of Functional Somatic Symptoms' (eds R. Mayou, C. Bass & M. Sharpe), pp. 3 -16. Oxford: Oxford University Press

    15. There is only one functional somatic syndrome
      Wessely S, White PD - Br J Psychiatry 2004;185:95-6
      Functional somatic symptoms and syndromes are a major health issue.
      They are common, costly, persistent and may be disabling.
      Most of the current literature pertains to specific syndromes defined by medical subspecialties.
      Indeed, each medical subspecialty seems to have at least one somatic syndrome.
      These include : irritable bowel syndrome (gastroenterology); chronic pelvic pain (gynaecology); fibromyalgia (rheumatology); non-cardiac chest pain (cardiology); tension headache (neurology); hyperventilation syndrome (respiratory medicine) and chronic fatigue syndrome (infectious disease).
      In 1999, Wessely and colleagues concluded on the basis of a literature review that there was substantial overlap between these conditions and challenged the acceptance of distinct syndromes as defined in the medical literature (cfr. 'Functional somatic syndromes - One or many?' - Wessely et al, 1999 at : -).
      They proposed the concept of a general functional somatic syndrome.
      But is there any empirical evidence for such a general syndrome ?
      Is it even a useful concept ?
      Five years on, Professor Simon Wessely, King's College London, revisits this debate.
      He is opposed by Dr Peter White from St Bartholomew's Hospital and Queen Mary School of Medicine and Dentistry, London.
      Cfr. :

    16. Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome
      Bell DS, Jordan K, Robinson M - Pediatrics 2001;107: 994-8
      Cfr. :

    17. Time to move beyond the mind-body split
      Bracken P, Thomas P - BMJ 2002;325:1433-34
      Descartes distinguished between the res cogitans and the res extensa.
      The former referred to the soul or mind and was said to be essentially "a thing which thinks".
      The latter was the material stuff of the body.
      It was characterised primarily by the fact of extension : it occupied space and was therefore amenable to measurement.
      In recent years neuroscientists and cognitive psychologists have argued that this ontological separation of mind and body is no longer tenable.
      The former maintain that mental functions can be fully explained by brain science.
      The latter make the case for a distinct psychological realm but one whose operations, like those of computer software, are measurable and open to scientific investigation.
      The res cogitans is illusive no longer.
      We can map it, scan it and explain its functions in biological or computational terms.
      Cfr. :

    18. TNF-alpha and chronic fatigue syndrome
      Moss RB, Mercandetti A, Vojdani A - J Clin Immunol 1999, 19(5):314-316

    19. Toward a model of social course in chronic illness - The example of chronic fatigue syndrome
      Ware NC - Culture 1999;23:303-31
      Retrospective, narrative accounts of illness experience in chronic fatigue syndrome provide the empirical basis for a preliminary conceptual model of social course in chronic illness.
      Qualities of distress interact with culturally specific expectations for social life and personal conduct to trigger microsocial processes of marginalization : role constriction, delegitimation, impoverishment and social isolation.
      Marginalizing processes are opposed by acts of resistance initiated by ill individuals and directed toward integration in social worlds.
      Social distance from the perceived centers of CFS sufferers' interpersonal worlds expands and contracts with the changing predominance of marginalizing and resisting influences over time.
      Social course thus consists of successive, bi-directional movements along a 'continuum of marginality' by persons living lives with chronic illness.
      Cfr. :

    20. Towards evidence-based clinical practice - An international survey of 18 clinical guideline programs
      Burgers JS, Grol R, Klazinga NS, Mäkelä M, Zaat J; AGREE Collaboration, Centre for Quality of Care Research (WOK), University Medical Centre Nijmegen, The Netherlands : - Int J Qual Health Care. 2003 Feb;15(1):31-45 - PMID: 12630799
      Objective - To describe systematically the structures and working methods of guideline programs.
      Design - Descriptive survey using a questionnaire with 32 items based on a framework derived from the literature.
      Answers were tabulated and checked by participants.
      Study participants - Key informants of 18 prominent guideline organizations in the United States, Canada, Australia, New Zealand and nine European countries.
      Main outcome measures - History, aims, methodology, products and deliveries, implementation, evaluation, procedure for updating guidelines and future plans.
      Results - Most guideline programs were established to improve the quality and effectiveness of health care.
      Most use electronic databases to collect evidence and systematic reviews to analyze the evidence.
      Consensus procedures are used when evidence is lacking.
      All guidelines are reviewed before publication.
      Authorization is commonly used to endorse guidelines.
      All guidelines are furnished with tools for application and the Internet is widely used for dissemination.
      Implementation strategies vary among different organizations, with larger organizations leaving this to local organizations.
      Almost all have a quality assurance system for their programs.
      Half of the programs do not have formal update procedures.
      Conclusions - Principles of evidence-based medicine dominate current guideline programs.
      Recent programs are benefiting from the methodology created by long-standing programs.
      Differences are found in the emphasis on dissemination and implementation, probably due to differences in health care systems and political and cultural factors.
      International collaboration should be encouraged to improve guideline methodology and to globalize the collection and analysis of evidence needed for guideline development.
      Cfr. :

    21. Treating depressed primary care patients improves their physical, mental and social functioning
      Coulehan, JL; Schulberg, HC; Block, MR et al. - Arch Intern Med. 1997;157:1113–1120

    22. Treatments for chronic fatigue syndrome and the Internet - A systematic survey of what your patients are reading
      Kisely SR - Aust New Zealand J Psychiatry 2002;36:240-5
      Objective - To evaluate the type, quality and focus of patient information on the treatment of chronic fatigue syndrome on the Internet using simple search techniques.
      Design - The search phrase 'chronic fatigue syndrome' was entered into nine common Internet search engines.
      The 25 most highly ranked pages identified by each of the nine search engines were analysed using a standardized pro forma.
      The following outcome measures were used : balance of content, consistency of content with evidence-based practice, declared authorship with credentials, information sources including the presence of references, the declaration of any potential conflict of interest and the need to clarify information with an appropriate health professional.
      Results - Two hundred and twenty-five websites were reviewed during a 2-week period in September 2000.
      A further 15 sites (6.3%) were inaccessible.
      Agreement between websites and systematic reviews of treatment for chronic fatigue syndrome ranged from 4 to 68%, the greatest agreement being for recommendations for graded exercise and the avoidance of prolonged rest.
      Most sites (64%) had a named author.
      Only a quarter to a third contained a declaration of interest, advised readers to clarify information with an appropriate health professional or avoided inaccurate statements.
      Conclusion - The Internet contains a great deal of information on chronic fatigue syndrome that is neither balanced nor consistent with evidence-based practice.
      Doctors individually and as a profession, should provide guidance on which Internet sites to trust.
      Cfr. :

    23. Treatments of depression and the functional capacity to work
      Mintz J, Mintz LI, Arruda MJ, Hwang SS - Arch Gen Psychiatr 1992;49:761-8
      Treatments of depression and the functional capacity to work
      Mintz J, Mintz LI, Arruda MJ, Hwang SS, Department of Psychiatry and Biobehavioral Sciences, School of Medicine, UCLA - Arch Gen Psychiatry. 1992 Oct;49(10):761-8 - PMID: 1417427

      This study evaluated the effects of antidepressants and psychotherapy on work impairment in depressed patients.
      Original databases from 10 published treatment studies were compiled and analyzed (N = 827).
      Functional work impairment was common at baseline, manifested by unemployment (11%) or on-the-job performance problems (absenteeism, decreased productivity, interpersonal problems, 44%).
      Generally, work outcomes were good when treatment was symptomatically effective, but the trajectories of work restoration and symptom remission were different, with work recovery appearing to take considerably longer.
      Relapse was an important determinant of long-term occupational outcome, particularly for seriously ill patients for whom relapse meant rehospitalization or other profound social disruption.
      Affective impairment was distinguished from functional impairment, with the former characterizing milder depression and the latter characterizing moderate to severe depression.
      Some methodological recommendations are discussed.
      Cfr. :

    24. Twelve month outcome of depression in general practice - Does detection or disclosure make a difference ?
      Dowrick, C; Buchan, I - Br Med J. 1995;311:1274–1276

    25. Unconscious amygdalar fear conditioning in a subset of chronic fatigue syndrome patients
      Gupta A – Med Hypotheses 2002;59:727-5
      Here, a novel hypothesis for chronic fatigue syndrome (CFS) is proposed.
      CFS may be a neurophysiological disorder focussing on the amygdala.
      During a ‘traumatic’ neurological event often involving acute psychological stress combined with a viral infection or other chemical or physiological stressor, a conditioned network or ‘cell assembly’ may be created in the amygdala.
      The unconscious amygdala may become conditioned to be chronically sensitised to negative symptoms arising from the body.
      Negative signals from the viscera or physiological, chemical and dietary stressors, become conditioned stimuli and the conditioned response is a chronic sympathetic outpouring from the amygdala via various brain pathways including the hypothalamus.
      This cell assembly then produces the CFS vicious circle, where an unconscious negative reaction to symptoms causes immune reactivation/dysfunction, chronic sympathetic stimulation, leading to sympathetic dysfunction, mental and physical exhaustion and a host of other distressing symptoms and secondary complications.
      And these are exactly the symptoms that the amygdala and associated limbic structures are trained to monitor and respond to, perpetuating a vicious circle.
      Recovery from CFS may involve projections from the medial prefrontal cortex to the amygdala, to control the amygdala’s expressions.
      I shall firstly discuss predisposing, precipitating and perpetuating factors involved in the possible etiology of chronic fatigue syndrome (CFS), followed by the patient’s experience of the illness.
      Finally, I shall look at a suggested explanation for the symptoms of CFS.
      Cfr. :

    26. Unemployment and health in a community sample
      Kessler, RC; House, JS; Turner, JB - J Health Soc Behav. 1987;28:51–59

    27. Unexplained fatigue syndromes in a multinational primary care sample - Specificity of definition and prevalence and distinctiveness from depression and generalized anxiety
      Skapinakis P, Lewis G, Mavreas V - Am J Psychiatry 2003;160:785-7
      Objective - The authors investigated whether narrow definitions of unexplained fatigue syndromes that require additional minor somatic symptoms are more strongly associated with psychiatric morbidity than wider ones.
      Method - This was a secondary analysis of the World Health Organization Collaborative Project on Psychological Problems in General Health Care.
      A total of 5,438 primary care patients from 14 countries were assessed with the Composite International Diagnostic Interview.
      Results - The prevalence of fatigue syndromes fell from 7.99 to 1.69 as somatic criteria were added.
      Patients with depression or anxiety were more likely to report unexplained fatigue, but this association was stronger for definitions of unexplained fatigue with more somatic criteria.
      Conclusions - Definitions of unexplained fatigue syndromes that require more somatic criteria selected more patients with psychiatric disorders in this culturally diverse sample.
      These findings might have implications for the revision of existing international diagnostic criteria for neurasthenia or chronic fatigue syndrome.
      Cfr. :

    28. Unexplained’ somatic symptoms, functional syndromes and somatization - Do we need a paradigm shift ?
      Sharpe, M. & Carson, A. J. (2001) - Annals of Internal Medicine, 134, 926 -930
      Medically unexplained functional or somatization symptoms are somatic disorders that are not adequately explained by physical disease processes.
      The way in which these disorders have been understood and managed has varied over the history of medicine.
      However, only in the past 100 years has the “mental” explanation predominated.
      A benefit of this trend has been the development of effective treatments in the form of “antidepressant” drugs and cognitive–behavioral therapies; a cost has been limited integration of these treatments into medical practice and lack of acceptability to patients.
      We suggest that there is much to learn from physicians of the pre-Freudian era.
      Their etiologic theories are now supported by new scientific evidence and their clinical practice provided ways of making psychological treatment acceptable to patients.
      We propose a paradigm shift in which unexplained symptoms are remedicalized around the notion of a functional disturbance of the nervous system and treatments currently considered “psychiatric” are integrated into general medical care.
      Cfr. :

    29. Unique genetic and environmental determinants of prolonged fatigue - A twin study
      Hickie I, Kirk K, Martin N - Psychol Med 1999;29:259-68

    30. Update on chronic fatigue syndrome and Epstein-Barr virus
      Katz BZ - Pediatr Ann 2002;31:741-4
      Cfr. :

    31. Use of formal and informal care among people with prolonged fatigue - A review of the literature
      Elliott H - Br J Gen Pract 1999;49:131-4
      Prolonged fatigue is a common symptom in the community and a common complaint in GPs' surgeries.
      The current consensus is that prolonged fatigue is most appropriately managed within primary care but that quality of care is patchy.
      Diagnosis is difficult and there is no conclusive evidence about effective treatment.
      This can lead to confusion and controversy among lay people and health professionals alike.
      Although the value of a positive doctor-patient relationship is emphasized, general practice consultations are frequently experienced as difficult by both parties.
      Moreover, little is known about how people access other sources of care and information about prolonged fatigue, such as alternative medicine, self-help groups, lay others and self care, in conjunction with or as an alternative to care from health professionals.
      This paper reviews the literature on the nature and extent of the problem prolonged fatigue represents for primary care and on the use of formal and informal care for prolonged fatigue.
      Cfr. :

    32. Vagal attenuation in panic disorder - An assessment of parasympathetic nervous system function and subjective reactivity to respiratory manipulations
      Asmundson GJ, Stein MB, Department of Psychiatry, University of Manitoba, Winnipeg, Canada - Psychosom Med. 1994 May-Jun;56(3):187-93 - PMID: 8084962
      We examined the effects of hyperventilation and other manipulations of respiratory pace on parasympathetic nervous system function and subjective reactivity in 15 patients with panic disorder, 15 patients with social phobia and 15 healthy control subjects.
      After a 30-minute rest period subjects completed a 2.5-minute trial of each of hypoventilation, normoventilation and hyperventilation.
      Trials were separated by a 3 minute inter-trial interval. Incidence of panic attacks, symptom severity, vagal tone, heart rate, end-tidal carbon dioxide level and respiratory frequency were measured throughout.
      Resting physiological measures did not differ between groups.
      Each respiratory manipulation resulted in the expected physiological changes (e.g., hyperventilation attenuated vagal tone), however, groups did not exhibit differential physiological reactivity to the manipulations.
      There were no panic attacks reported during either the hypoventilation or normoventilation phases; however, two social phobic subjects (13.3%) and two panic disorder patients (13.3%) reported panic attacks during hyperventilation.
      Although both groups of anxiety patients reported greater severity of hyperventilation-induced symptoms than did control subjects, symptom severity did not correlate significantly with vagal tone or heart rate.
      These results suggest that parasympathetic function is unlikely to be aberrant in PD patients and that diminished parasympathetic activity is not sufficient for the experience of panic attacks.
      Cfr. : -&-
      Also read the comment on this article :
      Inferring vagal tone from heart rate variability
      Jennings JR, McKnight JD - Psychosom Med. 1994 May-Jun;56(3):194-6 - PMID: 8084963
      Cfr. :

    33. Variability in diagnostic criteria for chronic fatigue syndrome may result in substantial differences in patterns of symptoms and disability
      Jason LA, Helgerson J, Torres-Harding SR et al. - Eval Health Prof 2003;26:3-22
      Chronic fatigue syndrome (CFS) is an illness that involves severe, prolonged exhaustion as well as neurologic, immunologic and endocrine system pathology.
      Because the pathogenesis of CFS has yet to be determined, case definitions have relied on clinical observation in classifying signs and symptoms for diagnosis.
      The current investigation examined differences between CFS as defined by Fukuda and colleagues and a set of criteria that has been stipulated for myalgic encephalomyelitis (ME).
      Dependent measures included psychiatric comorbidity, symptom frequency, symptom severity and functional impairment.
      The ME and Fukuda et al. (1994) CFS criteria were compared with a group having chronic fatigue due to psychiatric reasons.
      Significant differences occurred primarily with neurologic, neuropsychiatric, fatigue/weakness and rheumatological symptoms.
      These findings suggest that it might be inappropriate to synthesize results from studies of this illness that use different definitions to select study populations.
      Cfr. :

    34. Victimization in chronic fatigue syndrome and fibromyalgia in tertiary care - A controlled study on prevalence and characteristics
      Van Houdenhove B, Neerinckx E, Lysens R et al. - Psychosomatics 2001;42:21-8
      The authors studied the prevalence and characteristics of different forms of victimization in 95 patients suffering from chronic fatigue syndrome (CFS) or fibromyalgia (FM) compared with a chronic disease group, including rheumatoid arthritis (RA) and multiple sclerosis (MS) patients and a matched healthy control group.
      The authors assessed prevalence rates, nature of victimization (emotional, physical, sexual), life period of occurrence, emotional impact and relationship with the perpetrator by a self-report questionnaire on burdening experiences.
      CFS and FM patients showed significantly higher prevalences of emotional neglect and abuse and of physical abuse, with a considerable subgroup experiencing lifelong victimization.
      The family of origin and the partner were the most frequent perpetrators.
      With the exception of sexual abuse, victimization was more severely experienced by the CFS/FM group.
      No differences were found between healthy control subjects or RA/MS patients and between CFS and FM patients.
      These findings support etiological hypotheses suggesting a pivotal role for chronic stress in CFS and FM and may have important therapeutic implications.
      Cfr. :

    35. Viral antibodies in chronic fatigue syndrome
      Swanink CM, Vercoulen JH, Bazelmans E et al. - Clin Infect Dis 1995;21:708-9
      Cfr. :

    36. Website of the week - Searching for the good doctor
      Ashcroft RE - BMJ 2002;325:719
      Cfr. :

    37. What causes chronic fatigue syndrome ?
      White PD - BMJ 2004;329:928-9
      Cfr. :

    38. What do you think is a non-disease ? - Pros and cons of medicalisation
      Wessely S - BMJ 2002;324:912
      Cfr. :

    39. What should we say to patients with symptoms unexplained by disease ? - The ‘number needed to offend’
      Stone, J., Wojcik, W., Durrance, D. et al (2002) - BMJ, 325, 1449 -1450
      Most doctors make a diagnosis and offer treatment to patients whose symptoms turn out to be unexplained by disease.
      In such cases a diagnostic label is important in signifying to the patient and family that the doctor is taking the problem seriously and accepts the complaints as real.
      Some diagnostic labels, particularly those that sound “psychological” can be perceived by patients as offensive by implying that the patients are “putting on” or “imagining” their symptoms or that they are “mad”.
      Various potentially suitable diagnoses are available to doctors.
      Hysteria” was the traditional term and is still sometimes used.
      Functional nervous disorder” was used in the late 19th century to denote symptoms arising from disordered nervous functioning, but in the 20th century this was superseded by terms that implied psychogenesis, such as psychosomatic.
      In the past 20 years more neutral descriptive terms such as “medically unexplained symptoms” have gained in popularity.
      Despite their importance in the doctor-patient relationship, the implications to patients of these labels have received remarkably little attention.
      We explored the differing connotations and potential offensiveness of 10 different medical labels for the symptom of weakness.
      Cfr. :

    40. When do symptoms become a disease ?
      Aronowitz RA - Ann Intern Med 2001;134:803-8
      When do symptoms become a disease ?
      Are there rules or norms, currently or in the past, that tell us when a particular collection of largely symptom-based criteria has enough specificity, utility or plausibility to justify the appellation disease ?
      The history of numerous symptom-based diagnoses in use today suggests partial answers to these questions.
      The 19th-century shift to understanding ill health as a result of specific diseases, increasingly defined more by signs than symptoms, led to a loss of status for illnesses that possessed little clinical or laboratory specificity.
      Nevertheless, clinicians then and now have used symptom-based diagnoses.
      Some of these diagnoses owe their existence as specific diseases to the norms and practices of an older era much different from our own.
      Others have not only thrived but have resisted plausible redefinition done by using more “objective” criteria.
      Many strategies, such as response-to-treatment arguments, quantitative methods (for example, factor analysis) and consensus conferences, have been used to find or confer specificity in symptom-based diagnoses.
      These strategies are problematic and have generally been used after symptom-based diagnoses have been recognized and defined.
      These historical observations emphasize that although biological and clinical factors have set boundaries for which symptoms might plausibly be linked in a disease concept, social influences have largely determined which symptom clusters have become diseases.
      Cfr. :

    Lees verder : Deel XXX

    25-11-2009 om 19:32 geschreven door Jules

    0 1 2 3 4 5 - Gemiddelde waardering: 0/5 - (0 Stemmen)
    Tags:arbeidsongeschiktbeidsbeoordeling, arbeidsongeschiktheid, bedrijfsarts, begeleiden, behandelen, beoordelen, chronische vermoeidheidssyndroom, fibromyalgie, ME/CVS, psychosomatisch, reïntegratie, verzekeringsarts, werk, werkhervatting, ziekteverzuim
    >> Reageer (0)
    Klik hier om een link te hebben waarmee u dit artikel later terug kunt lezen.Doe een wens... - Make a wish...
    Klik op de afbeelding om de link te volgen

    Doe een wens...

    Een gehuwd paar vierde zijn 40e huwelijksverjaardag in een rustig, romantisch restaurantje.

    Opeens verscheen er een lieve fee aan hun tafel.

    Ze zei : 'Omdat jullie zo'n voorbeeldig gehuwd koppel zijn en omdat jullie liefde al die jaren stand hield mogen jullie élk een wens doen.”

    De vrouw antwoordde : “Oh, ik zou toch zo graag met mijn liefdevolle echtgenoot eens een reis om de wereld maken !

    De fee zwaaide met haar toverstokje en – poef ! - er lagen twee kaartjes voor de Queen Mary II op de tafel.

    De man twijfelde even : “Wel, dit is allemaal heel romantisch, maar een kans als deze krijg ik nooit meer ! Het spijt me liefste, maar ik zou toch liever een vrouwtje hebben dat 30 jaar jonger is dan ik.

    De vrouw én de fee waren diep ontgoocheld, maar beloofd is beloofd...

    Dus zwaaide de fee nogmaals met haar toverstokje en – poef ! - de man was op slag 92 jaar oud !!

    De moraal van dit verhaal :

    Mannen, die ondankbare smeerlappen, zouden beter beseffen dat feetjes vrouwelijk zijn...

    Make a wish

    A married couple in their early 60s was celebrating their 40th wedding anniversary in a quiet, romantic little restaurant…

    Suddenly, a tiny yet beautiful fairy appeared on their table.

    She said, “For being such an exemplary married couple and for being loving to each other for all this time, I will grant you each a wish.”

    The wife answered, “Oh, I want to travel around the world with my darling husband.

    The fairy waved her magic wand and – poof ! - two tickets for the Queen Mary II appeared in her hands.

    The husband thought for a moment : “Well, this is all very romantic, but an opportunity like this will never come again. I'm sorry my love, but my wish is to have a wife 30 years younger than me.”

    The wife, and the fairy, were deeply disappointed, but a wish is a wish.

    So the fairy waved her magic wand and - poof ! - the husband became 92 years old !!

    The moral of this story :

    Men who are ungrateful bastards should remember fairies are female…

    25-11-2009 om 15:03 geschreven door Jules

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    >> Reageer (1)
    Klik hier om een link te hebben waarmee u dit artikel later terug kunt lezen.7 geheimen die mannen verzwijgen
    Klik op de afbeelding om de link te volgen


    7 geheimen
    die mannen verzwijgen

    Jan Willem Wensink
    Dokterdokter, 19-11-2009
     Bronnen : HartenZiel & WebMD

    Elke man heeft geheimen voor zijn vriendin of vrouw.
    Het openbaren van die geheimen acht hij te riskant voor zijn relatie.

    In elke liefdesrelatie komt een fase waarin een man zich realiseert dat de echte waarheden achter bepaalde gevoelens of bezigheden beter niet verteld kunnen worden.
    Mannen praten niet over deze geheimen omdat ze vrezen dat die de relatie schaden of simpelweg omdat ze sommige van hun eigen beweegredenen niet helemaal begrijpen.

    Psychologen zeggen dat de meeste geheimen en leugentjes om bestwil normaal en menselijk zijn.
    In sommige opzichten zijn ze sociaal zelfs noodzakelijk om goed met elkaar te kunnen omgaan.
    Ook vrouwen hebben hun leugentjes om bestwil.
    7 geheimen die mannen nooit vertellen.

    Geheim 1 - Mannen kijken naar alle mooie vrouwen

    Mocht een mooie vrouw zijn pad kruisen, dan volgen zijn ogen haar, zijn primaire hersendelen dwingen hem er domweg toe.
    Het maakt niet uit of jij er naast loopt of niet, hij kijkt.
    Totaal voor ongeveer 43 minuten per dag, blijkt uit onderzoek.
    Ben je op een plaats met veel mensen, dan heeft hij alle leuke vrouwen al gescand en dat iets te lage décolleté had hij ook al gezien.
    Als je er bij bent, zal hij er misschien voor zorgen dat zijn radarblik niet door jou wordt opgemerkt.
    Is het erg ?
    Kijkt hij niet, dan is er iets mis met zijn zichtveld of is zijn testosteronniveau erg laag.

    Geheim 2 - Een man moet soms de deur uit

    Gaat je man altijd sporten omdat hij zo graag wil sporten ?
    Hij zegt van wel.
    Kán hij echt niet een dag per week minder werken of wíl hij het niet ?
    Helaas, het is waar dat mannen graag geregeld het huishouden achter zich willen laten.
    Ze hoeven even geen vrouw, geen kinderen en het gedoe van het huishouden.
    Dat klinkt ernstig, het is het niet.
    Het heeft te maken met een ingebouwde hang naar vrijheid, naar ruimte voor zichzelf, het niet al te sterk verbonden willen zijn aan regels en toestanden.
    Wees gerust, na een tijdje mist hij jou of jullie alweer.
    Dan is het ook weer fijn thuiskomen voor hem.

    Geheim 3 - Hij zweert trouw, maar niet helemaal

    Terwijl vrouwen de wederzijdse liefde met hun partners graag geregeld, bezegeld en gegarandeerd zien in het vastleggen van eeuwige trouw, zit er in vele mannen een heel klein stemmetje dat iets anders zegt.
    Het is een door angst en testosteron gevoed relativerend stemmetje, dat de strakke echtelijke beloftes te benauwend vindt.
    Het gaat er stiekem van uit dat de vrijheid van de jagende man niet zo heel erg aan banden hoeft te worden gelegd.

    Geheim 4 - Geld verdienen geeft hem aanzien

    Hoewel veel mannen het ontkennen, vinden ze het diep in hun hart belangrijk dat zij de kostwinner zijn.
    Het is leuk dat zij ook wat centen verdient, maar hij haalt het grote geld binnen en bepaalt dus ook welke auto er gekocht wordt.
    Niet voor niets wordt in plaats van ‘kostwinner’ ook wel de term ‘kostwinnaar’ gebruikt.
    Wat is de oorsprong van deze mannelijke overtuiging ?
    Sommige deskundigen denken dat het biologisch bepaald is : de man was en is nog altijd de jager en brengt dus de buit binnen in de vorm van geld en eten.
    De vrouw had en heeft de zorg voor het gezin.
    Maar de beroemde evolutionair bioloog Stephen Jay Gould maakte korte metten met die gedachte.
    Volgens hem gaat het eerder om culturele tradities dan om oeroude menselijke instincten.
    Hoe dan ook : als vrouwlief meer verdient, voelt dat bij veel mannen een beetje als een nederlaag.

    Geheim 5 - Hij klaart echt graag jouw klusje

    Het is een klein duwtje in de rug van het man-zijn : de hulpeloze geliefde die haar kerel vraagt iets te repareren of te monteren.
    Ze zal haar hulpeloosheid misschien wat aanzetten om hem zover te krijgen, dat is dan weer haar geheim.
    Hoewel sommige mannen er graag een beetje over mogen mopperen, vinden ze het best prettig om steeds als probleemoplosser te worden ingeschakeld.
    Het is heerlijk voor een man als hij het technische domein helemaal voor zichzelf heeft.
    Hij kan er dan bovendien zijn liefde voor gereedschap op botvieren.
    Na de klus is haar compliment belangrijker voor zijn ziel dan hij zelf zal willen toegeven.

    Geheim 6 - Mannen begrijpen hun vrouw echt niet

    Oei, daar wil ze weer een essentieel punt in de relatie diepgaand bespreken.
    Nou ja, bespreken, emotioneel doorwrochten.
    Net als hij voetbal wil kijken of computeren.
    Hij heeft geleerd voor dit soort discussies niet weg te lopen, haar aan te horen en te doen alsof hij haar begrijpt.
    Het is oppassen geblazen.
    Want hij weet dat als hij haar gevoelens achteloos wegwuift, zij erg boos kan worden.
    Dus knikt hij instemmend.
    Ja, hij ziet haar probleem.
    Hij begrijpt het.
    Zegt hij.
    Maar het is niet waar.
    Hij snapt er eigenlijk geen barst van.
    Dat komt volgens John Gray, schrijver van het boek ‘Mannen komen van Mars, vrouwen van Venus’, door een fundamenteel verschil in benadering van emoties.
    Vrouwen zoeken vooral erkenning voor hun problemen en gevoelens, mannen zoeken voor hun problemen en emoties kant en klare oplossingen.

    Geheim 7 - Ja, mannen zijn pubers

    Hoe komt het dat keurige mannen, liefhebbende vaders met een respectabele baan, ineens thuis kunnen komen met een formidabel zakmes voor in het oerwoud ?
    Waarom draait hij zijn nek om voor een strakke meid in een Porsche ?
    Omdat het symbolen zijn van onbezorgde vrijheid, van de dagen dat verantwoordelijkheden niet aan zijn schouders hingen.
    Van de losbandige tijd in zijn jeugd, toen hij in principe nog pakweg in een rockband kon zitten, naar Ibiza kon gaan om te flirten op het strand of heel veel geld kon gaan verdienen.
    Maar die tijd is voorbij, de keuzes zijn gemaakt.
    Het keurslijf wringt.
    In elke man zit een door simpele hormonen voortgedreven puberjongen die heimelijk weigert groot te worden.
    Gun hem dat zakmes.

    Cfr. :

    25-11-2009 om 00:40 geschreven door Jules

    0 1 2 3 4 5 - Gemiddelde waardering: 3/5 - (7 Stemmen)
    Tags:angst, begrijpen, beloftes, benauwend, boos, décolleté, emoties, erkenning, flirten, geheimen, geld, gevoelens, hulpeloos, keurslijf, liefde, liefdesrelatie, liegen, mopperen, nederlaag, ontkennen, problemen, puber, relatie, testosteron, trouw, verzwijg
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    Klik hier om een link te hebben waarmee u dit artikel later terug kunt lezen.Snel weer aan het werk - Bedrijfsartsen op bres voor arbeidsongeschikten - Deel XXX
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    Snel weer aan het werk

    Bedrijfsartsen op bres voor arbeidsongeschikten

    Deel XXX

    1. When not enough is too much - The role of insufficient glucocorticoid signaling in the pathophysiology of stress-related disorders
      Raison CL, Miller AH - Am J Psychiatry 2003;160:1554-65
      Objective - Previous theories have emphasized the role of excessive glucocorticoid activity in the pathology of chronic stress.
      Nevertheless, insufficient glucocorticoid signaling (resulting from decreased hormone bioavailability or reduced hormone sensitivity) may have equally devastating effects on bodily function.
      Such effects may be related in part to the role of glucocorticoids in restraining activation of the immune system and other components of the stress response, including the sympathetic nervous system (SNS) and corticotropin-releasing hormone (CRH).
      Method - The literature on neuroendocrine function and glucocorticoid-relevant pathologies in stress-related neuropsychiatric disorders, including posttraumatic stress disorder and major depression, was reviewed.
      Results - Although not occurring together, both hypocortisolism and reduced responsiveness to glucocorticoids (as determined by dexamethasone challenge tests) were reliably found.
      Stress-related neuropsychiatric disorders were also associated with immune system activation/inflammation, high SNS tone and CRH hypersecretion, which are all consistent with insufficient glucocorticoid-mediated regulation of stress hyperresponsiveness.
      Finally, antidepressants, a mainstay in the treatment of stress-related disorders, were regularly associated with evidence of enhanced glucocorticoid signaling.
      Conclusions - Neuroendocrine data provide evidence of insufficient glucocorticoid signaling in stress-related neuropsychiatric disorders.
      Impaired feedback regulation of relevant stress responses, especially immune activation/inflammation, may, in turn, contribute to stress-related pathology, including alterations in behavior, insulin sensitivity, bone metabolism and acquired immune responses.
      From an evolutionary perspective, reduced glucocorticoid signaling, whether achieved at the level of the hormone or its receptor, may foster immune readiness and increase arousal.
      Emphasis on insufficient glucocorticoid signaling in stress-related pathology encourages development of therapeutic strategies to enhance glucocorticoid signaling pathways.
      Cfr. :

    2. Why don't physicians follow clinical practice guidelines ? - A framework for improvement
      Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR, Department of Pediatrics, Robert Wood Johnson Clinical Scholars Program, Johns Hopkins School of Medicine, Baltimore, MD, USA : - JAMA. 1999 Oct 20;282(15):1458-65 - PMID: 10535437
      Context - Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior.
      Little is known about the process and factors involved in changing physician practices in response to guidelines.
      Objective - To review barriers to physician adherence to clinical practice guidelines.
      Data sources - We searched the MEDLINE, Educational Resources Information Center (ERIC) and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence.
      Study selection - Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies or national consensus statements.
      One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria.
      Differences were resolved by consensus with a third investigator.
      Data extraction - Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes or behavior.
      This organization was validated by 3 additional investigators.
      Data synthesis - The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14) and absence of external barriers to perform recommendations (n = 34).
      The majority of surveys (70 [58%] of 120) examined only 1 type of barrier.
      Conclusions - Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another.
      Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guideline adherence and a framework for future research.
      Cfr. :
      Cfr. also the comments on this article :
      Reasons physicians do not follow clinical practice guidelines - Montgomery AA, Peters TJ, Fahey T - JAMA. 2000 Apr 5;283(13):1685; author reply 1686 - PMID: 10755486
      Cfr. :
      Reasons physicians do not follow clinical practice guidelines - Veatch RM - JAMA. 2000 Apr 5;283(13):1685; author reply 1686 - PMID: 10755485
      Cfr. :

      Reasons physicians do not follow clinical practice guidelines - Dahlberg K - JAMA. 2000 Apr 5;283(13):1686 - PMID: 10755487
      Cfr. :

    3. Why is neurasthenia important in Asian cultures ?
      Schwartz PY - West J Med 2002;176:257-8

    4. Women's experiences of stigma in relation to chronic fatigue syndrome and fibromyalgia
      Asbring P, Narvanen AL - Qual Health Res 2002;12:148-60
      Chronic fatigue syndrome and fibromyalgia are characterized by being difficult to diagnose and having an elusive etiology and no clear-cut treatment strategy.
      The question of whether these illnesses are stigmatizing was investigated through interviews with 25 women with these illnesses.
      The women experienced stigmatization primarily before receiving a diagnosis and the diffuse symptomatology associated with the illnesses were significant for stigmatization.
      Stigma consisted of questioning the veracity, morality and accuracy of patient symptom descriptions and of psychologizing symptoms.
      Coping with stigma was also explored and found to comprise both withdrawal and approach strategies, depending on the individual's circumstances and goals.
      Cfr. :

    5. Women’s mental health - An evidence based review
      World Health Organisation (WHO) – Geneva : 2000
      In the discussion of the determinants of poor mental health of women, it has become imperative to move from a focus on individual and “
      lifestyle” risk factors to a recognition of the broader, economic, legal and environmental factors that affect women’s lives and constrain their opportunities to control the determinants of their health.
      Social factors can and do change within and between countries in ways that promote or retard gender development and empowerment (UNDP 1997).
      The identification and modification of the social factors that influence women’s mental health holds out the possibility of primary prevention of certain mental disorders by reducing their incidence.
      In this review, a gendered, social model of health is used to investigate critical determinants of women’s mental health with the overall objective of contributing to improved, more effective promotion of women’s mental health that is grounded in research evidence.
      Risk factors for mental disorder as well as for good mental health are addressed and where possible, a clear distinction has been made between the opportunities that exist for individual action and individual behaviour change and those that are dependent on factors outside the control of the individual woman.
      Where poverty, inequality and social disadvantage are entrenched, the health beliefs of individuals may count for nothing in terms of being able to reduce behavioural risk factors.
      As Farmer (1996) has observed : ‘
      Throughout the world, those least likely to comply are those least able to comply.
      It is essential to recognise how the socio-cultural, economic, legal, infrastructural and environmental factors that affect women’s mental health are configured in each country or community setting.
      Only by responding to the complexities and particularities of women’s lives can health promotion strategies hope to increase the opportunities women want and need to control the determinants of their health.
      If programmes to promote women’s mental health focus on the reduction of individual ‘
      lifestyle’ risk factors, they may neglect the very factors that bring that lifestyle into being.
      Moreover, if such programmes fail to meet their objectives, they carry a considerable risk of misattributing that failure to the women towards whom they were directed.
      Such a misattribution precludes an examination of the features of the programmes themselves or of the social circumstances that the programmes did not or could not address.
      A focus on behavioural risk factors that makes the individual responsible for her health may have deleterious effects.
      The acceptance of personal responsibility is not necessarily empowering.
      Indeed, ‘
      it may encourage self blame and despondency and make behavioural change less likely’ (Ziebland et al., 1998).
      Neither self blaming nor victim blaming are compatible with promoting good mental health.
      Both, by concentrating on ‘
      failings’ within the individual may militate against the likelihood of thorough programme evaluation (Pill, Peters & Robling, 1993).
      In addition, victim blaming may increase the very health risks and health behaviours, that health promotion programs are designed to reduce.
      A study of cocaine using pregnant women gives a disturbing insight into the possible consequences of such an approach :
      Most of them were aware of the potential harm to the fetus and ironically used more cocaine to avoid remorse and self loathing. (Chavkin & Kandall, 1990)
      Evaluation of intended and unintended, positive and negative outcomes is thus integral to comprehensive health promotion.
      Although an attempt has been made to draw research evidence from both developed and developing countries, it has to be acknowledged that like many other health and educational activities, most funding and most research comes from richer, developed countries rather than poorer, developing ones.
      To help clarify the meaning women themselves ascribe to mental health and various forms of psychological distress, findings from qualitative research have been employed to augment those from quantitative research.
      Descriptions of life situations, case studies and direct quotes from women themselves have been used to vivify the contexts in which emotional distress, depression, anxiety and other psychological disorders occur.
      It is hoped that such first hand accounts of the experiences of poverty, inequality and violence will assist in developing a more accurate understanding of the structural barriers women face in attempting to exercise control over the determinants of their mental health and in effecting behavioural change.
      Both are needed to better inform the promotion of women’s mental health.
      Moreover, subjective perceptions of health are significantly related to psychological well being and utilisation of the health care system (Ustin & Sartorius, 1995).
      Women’s views and the meanings they attach to their experiences have to be heeded by researchers, health care providers and policy makers.
      Without them, research and the evidence it gathers, service delivery and policy formation, will be hampered in responding to women identified health priorities, problems and needs.
      Moreover, all three will be ignorant of the nature and magnitude of unmet needs and unaware of the factors influencing women’s utilisation of health care.
      Cfr. :

    6. Work and productivity loss in the rizatriptan multiple attack study
      Dasbach, EJ; Carides, GW; Gerth, WC et al. - Cephalalgia. 2000;20:830–834

    7. Workplace performance effects from chronic depression and its treatment
      Berndt ER, Finkelstein SN, Greenberg PE, Howland RH, Keith A, Rush AJ et al. - J Health Econ 1998;17:511-35
      Utilizing data from a clinical trial and an econometric model incorporating the impact of a medical intervention and regression to the mean, we present evidence supporting the hypotheses that for chronically depressed individuals :
      (i) the level of perceived at-work performance is negatively related to the severity of depressive status and
      (ii) a reduction in depressive severity improves the patient's perceived work performance.
      Improvement in work performance is rapid, with about two-thirds of the change occurring already by week 4.
      Those patients having the greatest work improvement are those with both relatively low baseline work performance and the least severity of baseline depression.
      Cfr. :

    Lees ook

    Gespreksprotocol verzekeringsartsen verbeterd
    Robert Crommentuyn - Medisch Contact nr. 11 - 11 maart 2010
    Cfr. :


    25-11-2009 om 00:00 geschreven door Jules

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    Tags:arbeidsongeschiktbeidsbeoordeling, arbeidsongeschiktheid, bedrijfsarts, begeleiden, behandelen, beoordelen, chronische vermoeidheidssyndroom, fibromyalgie, ME/CVS, psychosomatisch, reïntegratie, verzekeringsarts, werk, werkhervatting, ziekteverzuim
    >> Reageer (0)
    Klik hier om een link te hebben waarmee u dit artikel later terug kunt lezen.Fibromyalgie - Genezing is mogelijk - GRATIS !
    Klik op de afbeelding om de link te volgen

    Fibromyalgie - Genezing is mogelijk

    GRATIS ! -

    Georges Pierrard benadrukt – gastenboek dd. 24-11-2009 – dat het boek 'Fibromyalgie - Genezing is mogelijk' van Prof. Dr. Brauer gratis te verkrijgen is.

    Betaal er dus nooit voor !


    * telefonisch : 0041 41 720 2186

    * per e-mail :

    Geef duidelijk aan dat je het boek 'Fibromyalgie - Genezing is mogelijk'
    in het nederlands
    wil en vergeet niet steeds je
    naam en volledig adres
    door te geven !

    24-11-2009 om 20:26 geschreven door Jules

    0 1 2 3 4 5 - Gemiddelde waardering: 4/5 - (7 Stemmen)
    Tags:Bauer, Dr. Bauer, Fibromyalgie - Genezing is mogelijk, fibromyalgie, Prof. Bauer, Prof. Dr. Brauer
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    Klik hier om een link te hebben waarmee u dit artikel later terug kunt lezen.Af en toe een geheim is juist gezond
    Klik op de afbeelding om de link te volgen

    Af en toe een geheim is juist gezond

    De psychologie van wat we niet vertellen

    Andreas Wismeijer & Mirre Bots
    (omslag : Philip Stroomberg )
    Uitgeverij NieuwAmsterdam, oktober 2009
     ISBN : 9789046806371

    Verliefd zijn op je buurvrouw, faalangst hebben, seksueel misbruikt zijn, te veel drinken, verborgen homoseksuele contacten onderhouden, een verrassingsreisje plannen voor je partner.
    Iedereen heeft geheimen : grote of kleine, schokkende of alledaagse.
    Zaken waar anderen aanstoot aan kunnen nemen, houden we verborgen om afkeuring, straf, hoon of, het ergst denkbare, sociale uitsluiting te voorkomen.
    De bescherming die een geheim biedt, heeft echter zijn prijs.
    Zo kunnen geheimen leiden tot piekeren en somberheid.
    Wat weten we eigenlijk over geheimen ?
    Waarom hebben we ze en voor wie ?
    Hoe houd je iets jarenlang geheim ?
    En klopt het dat geheimen altijd slecht voor je zijn ?

    Psycholoog Andreas Wismeijer geeft in dit veelzijdige boek, gebaseerd op jarenlang onderzoek, antwoord op al deze vragen.
    De openhartige interviews, opgetekend door journaliste Mirre Bots, bieden daarnaast een onthullende blik op de mens en zijn geheimen.

    Cfr. :

    Derde van Nederlanders blij met geheim

    de Volskrant, 20-10-2009

    93 procent van de Nederlanders draagt een geheim bij zich.
    Het grootste deel verzwijgt relationele problemen of seksuele gevoelens omdat men bang is voor de reacties van anderen.

    Dat blijkt uit een steekproef die Psychologie Magazine op zijn website heeft gehouden.
    Het maandblad wijdt een groot deel van zijn novembereditie aan het verschijnsel geheimen.
    428 bezoekers vulden anoniem een vragenlijst in.

    De angst voor – negatieve – reacties weerhoudt de meesten (78 procent) ervan hun geheimen te delen.
    Mensen overschatten echter hoe teleurgesteld of afkeurend anderen zullen reageren, zo blijkt uit onderzoek.
    Een wetenschapper van de University of Illinois sprak 300 Amerikanen met een geheim en vroeg ze twee maanden later of ze het hadden onthuld en hoe de respons was geweest.

    Over het algemeen bleek die positiever te zijn geweest dan de proefpersonen hadden verwacht.
    Mensen overdrijven hoe erg anderen hun geheim zullen vinden’, zegt onderzoeker Catrin Finkenauer van de Vrije Universiteit in het blad : ‘Het is net als wanneer je een puistje hebt; jij vindt het een ramp terwijl het anderen misschien niet eens opvalt’.

    Bij een kwart van de ondervraagden in het Amerikaans onderzoek viel de reactie op de bekentenis uit zoals de proefpersonen hadden verwacht of erger.
    Juist de mensen die zichzelf vooraf het meest zorgen maakten over de effecten van hun onthulling, kregen het het zwaarst te verduren.


    Als mensen met een geheim hun mond opendoen, vertrouwen ze dat liever toe aan volslagen onbekenden (44 procent).
    40 procent verklapt het aan de partner, vrienden (39 procent) of familie (31 procent), aldus de peiling in Psychologie Magazine.

    Er is wel een goede reden om te zwijgen.
    Uit Belgisch onderzoek is gebleken dat als mensen iets horen wat ze raakt (niet per se een geheim), ze dat in 66 tot 78 procent van de gevallen doorvertellen.

    Iemand geheimen ontfutselen onder dwang werkt averechts, zeggen deskundigen in het maandblad.
    Ierse neurowetenschappers meldden onlangs dat hoe meer een ondervraagde aan stress lijdt of aan slaapgebrek, hoe slechter zijn geheugen wordt.
    Empathie blijkt de effectiefste verhoormethode.

    Een derde van de ondervraagden in de peiling van Psychologie Magazine ‘koestert’ zijn geheim : het maakt bij hen positieve emoties los.

    Cfr. :

    Af en toe een geheim is juist gezond

    Sara Berkeljon - de Volkskrant, 04-11-2009

    Over seks wordt het meest gelogen, aldus psycholoog Andreas Wismeijer.
    Sommigen zeggen : ik ben totaal transparant. Dat kán helemaal niet. Dan ben je iedereen continu aan het schofferen’.

    Zijn er mensen zonder geheimen ?

    Ik denk het niet.
    Als er al iemand is, dan heeft die persoon een zeer sterke psychopathologie

    Wat betekent dat ?

    Dat ie een psychische ziekte heeft, waardoor hij geen risico-inschattingen kan maken’.

    Iemand zonder geheimen komt nergens in het leven

    Die is gedoemd, trapt zichzelf steeds dieper in de modder.
    Het is niet slim om eerlijk te zeggen wat ik van mijn baas vind.
    Ik zeg ook niet tegen m’n partner dat ik eigenlijk wel eens X of Y wil doen.
    Sommige mensen zeggen : ik ben totaal transparant.
    Dat kán helemaal niet.
    Dan ben je iedereen continu aan het schofferen.
    Als ik vertel dat ik het huiswerk van mijn studenten niet nakijk, word ik misschien wel ontslagen.
    De vraag is : wanneer is een geheim terecht een geheim en wanneer doe je jezelf tekort door iets geheim te houden ?
    Daar moet je achter zien te komen

    Psycholoog Andreas Wismeijer (34) promoveerde begin dit jaar op de relatie tussen geheimen en welzijn.
    Onlangs verscheen zijn populair-wetenschappelijke boek over het onderwerp.
    Wat blijkt : het permanent hebben van geheimen is slecht, soms een geheim hebben is gezond.

    Wismeijer heeft in de loop der jaren – hij begon vijf jaar geleden met zijn onderzoek – ‘duizende’ geheimen gehoord.
    Toen bekend werd dat ik hier onderzoek naar deed, begonnen mensen te bellen en te e-mailen. Soms stonden ze voor de deur om hun geheim op te biechten. Een man die fout geweest was in de oorlog, een vrouw die vond dat ze te grote schaamlippen had, een vrouw die jarenlang verkracht was door haar partner’.

    Dat lijkt me een rare ervaring

    Heel raar en frustrerend.
    Ik kon ze een kopje thee geven, een uur met ze praten – waar ik eigenlijk totaal geen tijd voor had – maar ze kwamen geen klap verder.
    Ik vertelde dit aan Alexander Waringa, een collega-psycholoog hier aan de universiteit.
    Hij zei : we maken een website waarop mensen anoniem hun geheim kwijt kunnen.
    Het was meteen een succes, met nu meer dan 30 duizend bezoekers per maand.
    Maar je kunt het ook een drama noemen.
    Ik betaal het zelf en het kost me handenvol geld.
    Het is niet vol te houden.
    Ik ben niet moeder Theresa

    Is geheimhouding aangeboren gedrag ?

    Het zijn evolutionair bepaalde mechanismen.

    De eerste geheimpjes zijn er rond het vijfde levensjaar en vanaf een jaar of acht gaan kinderen geheimen strategisch inzetten om straf te ontlopen.
    Dat blijven we ons hele leven doen.
    Het hebben van geheimen wordt bovendien aangemoedigd tijdens de opvoeding

    Hoe ?

    Dat begint al bij heel kleine kinderen.
    Als jij vrolijk bent, gaan andere mensen lachen.
    Als jij gaat miepen, worden de mensen boos op je – je moet bepaalde gevoelens dus verborgen houden

    Waarom is een geheim handig ?

    Je voorkomt ermee dat je uitgestoten wordt.
    Vroeger gold : als je uit de groep werd gezet, kon je je niet verdedigen tegen roofdieren, je kon bijna niet jagen en je kon je niet voortplanten.
    Als je wél in de groep bleef, kreeg je nakomelingen.
    En één van de mechanismen waarmee je ervoor kunt zorgen dat je in de groep blijft, is geheimhouding.
    Mensen die goed konden liegen, bedriegen en geheimen konden bewaren – daar zijn wij uiteindelijk de nakomelingen van

    Zijn geheimen nog steeds nodig om te overleven ?

    We hebben salaris, een pinpas, de bakker hoeft mij niet aardig te vinden om mij een brood te verkopen en zelfs voortplanting kun je betaald doen.
    Dus eigenlijk niet.
    Maar we hebben ook nog steeds haar op onze armen

    Hebben dieren ook geheimen ?

    Ik heb twee katten en verdomd : die ene zit vanachter de bank te loeren naar die andere, die net wakker is.
    Ze verstopt zich, zodat ze kan aanvallen !
    Dat is een geheim – ze houdt bewust informatie verborgen

    Wat is het meest voorkomende geheim ?

    Alles wat met seks te maken heeft.
    Dat is altijd zo geweest, sinds de eerste onderzoeken naar dit onderwerp.
    Vreemdgaan, fantasieën, masturberen : hoe vaak, op welke plek, waar je aan denkt – er zijn zoveel variabelen.
    Daarna komen geheimen over relationele problemen, ziektes, persoonlijk falen.
    Seks staat onbetwist op één

    Waarom ?

    Omdat we het allemaal doen.
    Andere veelvoorkomende geheimen gaan over ziekten : over aambeien, bijvoorbeeld.
    Het verschil is : we hebben niet allemaal aambeien, we hebben wel allemaal seks.
    Toch heb ik nog nooit iemand horen zeggen dat hij wat later was omdat hij nog even wilde masturberen.
    Van seks met hun partner zullen veel mensen misschien zeggen : dat gaat je niks aan.
    Maar masturberen wordt echt ontkend, dat is toch een beetje zielig, een beetje vies

    Wanneer is iets een geheim en wanneer een kwestie van privacy ?

    Die scheidslijn is moeilijk te trekken.
    Maar als het om seks gaat, wordt er vaak bewust gelogen : ik heb deze week niet gemasturbeerd, ik ben nooit vreemdgegaan.
    Als ik aan twintig voorbijgangers vraag of ze ooit zijn vreemdgegaan en ze zeggen allemaal ‘Nee’, dan is dat gewoon niet waar.
    Statistisch gezien

    Wat kunnen de negatieve gevolgen zijn van een geheim ?

    Allereerst : piekeren.
    Denk aan Marc-Marie Huijbregts.
    Hij heeft tien jaar lang een pruik gehad.
    Triviaal – maar hij zei : ik kon aan niets anders meer denken, het was een obsessie.
    Dat zie je vaak bij mensen met een groot geheim : ze zijn er continu mee bezig.
    Daarnaast zijn ze somber, achterdochtig, bang hun mond voorbij te praten.
    En ze maken hun geheim veel erger dan het is, ook door gebrek aan feedback.
    Dat meisje dat vindt dat haar schaamlippen te groot zijn, gaat nooit douchen na het sporten en draagt altijd twee onderbroeken over elkaar.
    Daardoor wordt zo’n geheim groter en groter.
    In haar ogen zijn die schaamlippen echt monstrueus

    Wanneer moet je een geheim opbiechten ?

    Als je geen last hebt van je geheim, is het beter het voor jezelf te houden.
    Hoe erg het geheim ook is.
    Stel dat jij iemand hebt vermoord en je weet zéker dat niemand ervan weet.
    Op basis van een rekensom – dus los van morele gronden, daar hebben we het hier niet over – zou je dan moeten zeggen : niet vertellen.
    Kan iemand er wél achter komen, is het een ander verhaal.
    Want : als mensen zélf achter je geheim komen, worden ze heel erg boos.
    Als jij het vertelt, worden ze ook boos – maar minder.
    Je moet elke keer de analyse maken : wat zijn de kosten van het hebben van het geheim ?
    En wat zijn de kosten van het opbiechten ?

    Dus : eerlijk zijn is overgewaardeerd

    De algemene consensus lijkt : nooit liegen, nooit vreemdgaan, altijd eerlijk zijn.
    Maar dat doen we niet, zo simpel is het.
    Moreel gezien is het misschien beter om geheimen op te biechten.
    Maar niet altijd, want je kunt er een ander mee belasten

    Wat is de meest opmerkelijke uitkomst van het onderzoek ?

    Ik had verwacht dat je geheimen zou kunnen indelen van klein naar groot.
    Dat bleek totáál onhaalbaar.
    Is vreemdgaan een groot geheim ?
    Als jij denkt : vervelend, krasje op m’n blazoen – maar niemand weet het en je kunt er prima mee leven, dan is het goed om het geheim te houden.
    Een ander voelt zich misschien een leven lang schuldig, daar valt geen peil op te trekken.
    Een voorbeeld : ik sprak een man die stiekem Spaans leert en zich kapot schaamt.
    Hij komt uit een achterstandsbuurt, heeft geen geld om naar Spanje te gaan, hij doet er niets mee – het is totaal onwerkelijk dat hij die taal wil leren.
    En kennelijk voelt hij dat zelf ook.
    Hij zegt : mensen zullen denken dat ik gek ben

    Ben je anders gaan denken over je eigen geheimen ?

    Ik ben mezelf veel beter gaan begrijpen.
    Ik wist niet dat sociale angst of de angst voor afwijzing, zó belangrijk is.
    Als je uitgelachen of genegeerd wordt, word je boos en verdrietig, je wilt door de grond zakken.
    Als we op dat moment een scan van je hoofd zouden maken, zien we dat bepaalde hersengebieden actief zijn.
    En dat zijn exact dezelfde gebieden die oplichten wanneer ik je fysiek pijn doe

    Wat wil dat zeggen ?

    'Het meest relevante systeem voor onze overleving is het pijnsysteem.
    Als je pijn hebt, laat je alles uit je handen vallen.
    Er is buiten fysieke pijn maar één ding wat dezelfde hersengebieden doet oplichten : afwijzing.
    Afgewezen worden, is dus evolutionair gezien zó levensgevaarlijk, dat het gekoppeld is aan ons pijnsysteem.
    Wij zijn allemaal ieder moment aan het meten hoe we het doen bij anderen

    Ben jij je daar altijd van bewust ?

    Ik signaleer bij mezelf wanneer de oermens in mij actief is.
    Als ik een stukje speculaas eet, bijvoorbeeld.
    Verdomme, wat is dát lekker.
    Voor ik het weet, heb ik vier stukjes gegeten.
    Hoe komt dat ?
    Speculaas heeft een bepaald vetgehalte en je weet maar nooit wanneer je weer te eten krijgt.
    Misschien moet ik het niet zeggen, maar ik heb voor jou al lang een inschatting gemaakt : jong, vrouw, is er iets mogelijk ?

    Dat is het fascinerendst : we leven in 2009, maar ons lijf doet iets heel anders.
    Wat voor grote bek we ook opzetten, hoe we ook pretenderen onafhankelijk van anderen te zijn – het is gewoon niet wáár.
    Iedereen, echt ie-de-reen, loopt met dezelfde kwetsbare gevoelens rond.
    Van al die mensen die ik over hun geheimen heb gesproken, weet ik : dit zijn geen rare mensen.
    Dit zijn wij allemaal


    Geheimen - De psychologie van wat we niet vertellen
    Andreas Wismeijer & Mirre Bots (omslag : Philip Stroomberg ) - Uitgeverij NieuwAmsterdam, oktober 2009 - ISBN : 9789046806371
    Cfr. :

    Cfr. :

    23-11-2009 om 12:34 geschreven door Jules

    0 1 2 3 4 5 - Gemiddelde waardering: 0/5 - (0 Stemmen)
    Tags:afwijzing, angst, fantasieën, geheimen, geheimhouding, gevoelens, kwetsbaar, liegen, negeren, opbiechten, opvoeding, overleven, piekeren, privacy, relaties, seks, slim, somberheid, straf, strategie, transparant, uitsluiting, verborgen, vertrouwen, zwijge
    >> Reageer (1)
    Klik hier om een link te hebben waarmee u dit artikel later terug kunt lezen.FM/CVS en verzekeringen - Info voor thesis
    Klik op de afbeelding om de link te volgen


    FM/CVS en verzekeringen

    - Info voor thesis -

    Studenten die een thesis maken over de verzekeringsproblematiek rond CVS en FM zoeken

    CVS- en fibromyalgiepatiënten die willen getuigen

    over :

    • hun inkomen toen ze nog werkten

    • de grootte van de premies die ze betalen/betaalden voor hun verzekering gewaarborgd inkomen en/of hun hospitalisatie en

    • bij welke verzekeringsmaatschappij die polis liep/loopt

    • hoelang ze premie betaalden

    • het inkomen dat ze nu nog hebben.

    Ook alle andere informatie rond FM/CVS en verzekeringen is welkom !

    Stuur een mailtje aan Nele Vermeulen :

    23-11-2009 om 10:48 geschreven door Jules

    0 1 2 3 4 5 - Gemiddelde waardering: 3/5 - (3 Stemmen)
    Tags:chronisch vermoeidheidssyndroom, CVS, fibromyalgie, FM, gewaarborgd inkomen verzekering, hospitalisatieverzekering, verzekeringen
    >> Reageer (4)
    Klik hier om een link te hebben waarmee u dit artikel later terug kunt lezen.Mogelijke doorbraak MS-behandeling
    Klik op de afbeelding om de link te volgen
    Dr. Paolo Zamboni

    Mogelijke doorbraak

    De Volkskrant, 22-11-2009

    OTTAWA - Een Italiaanse arts heeft een nieuwe behandeling voor mensen met Multiple Sclerose (MS) – cfr. : - ontwikkeld, die hun kwaliteit van leven aanmerkelijk zou verbeteren.
    Volgens Paolo Zamboni is MS mogelijk geen chronische ziekte aan het centrale zenuwstelsel, maar een ziekte aan het vaatstelsel.
    Hij voerde bij 65 patiënten een succesvolle operatie uit aan het vaatstelsel, de zogenoemde ‘Liberation Treatment’.

    Patiënten zouden sindsdien veel minder of geen acute aanvallen meer hebben.
    Ook zouden er veel minder vaak (tijdelijke) lichaamsfuncties uitvallen en zouden patiënten minder moe zijn.
    Zamboni benadrukt echter dat de behandeling mensen niet geneest, maar de behandeling lijkt de beruchte MS-aanvallen een halt toe te roepen, berichtte de Canadese tv-zender CTV zondag op zijn website.
    De resultaten worden 24 november gepubliceerd in het Journal of Vascular Surgery.

    Zamboni stortte zich op MS-onderzoek toen bij zijn toenmalige 37-jarige echtgenote de diagnose MS gesteld werd.
    Zij is inmiddels 51 en klachtenvrij sinds ze drie jaar geleden als een van de eerste patiënten door Zamboni's team behandeld werd.

    Hij kwam er door onderzoek achter dat MS-patiënten een hoger ijzergehalte in hun hersenen hebben met een uniek patroon, wat hij 'Chronic Cerebrospinal Venous Insuffiency' ('CCSVI') noemde (cfr. : -).
    Het ijzer concentreert zich rondom bloedvaten waardoor normaal gesproken bloed uit het hoofd MRI scangepompt wordt.
    Uit verder onderzoek bleek volgens de arts dat bij bijna 100 procent van de onderzochte MS-patiënten een of meerder bloedvaten in het hoofd waren verstopt.
    Volgens Zamboni wordt daardoor de druk in het hoofd zo groot, dat het in de grijze massa komt wat reacties teweeg brengt die mogelijk de symptomen van MS verklaren.
    Bij gezonde mensen kwam hij dit niet tegen.

    Nieuw onderzoek wees onder meer uit, dat hoe meer bloedvaten verstopt waren, hoe progressiever de ziekte leek te zijn.
    Zamboni vermoedt dat de verstopte bloedvaten een aangeboren defect zijn en wil daarom meer MS-patiënten en hun familie gaan onderzoeken.

    Amerikaanse en Canadese MS-organisaties zijn vooralsnog terughoudend over Zamboni's bevindingen.

    Volgens hen is nog steeds onduidelijk wat de oorzaak is van het verlies van myeline (een stof die de zenuwbanen isolererend omhult), wat een kenmerk van MS is.
    Enkele theorieën zijn : een virus, een gebrek aan vitamine D en hormonen.

    MS is de meest voorkomende neurologische aandoening onder jongeren in Nederland.
    Op dit moment hebben zo'n 16.000 mensen in Nederland MS en per jaar komen hier enkele honderden bij.


    23-11-2009 om 10:47 geschreven door Jules

    0 1 2 3 4 5 - Gemiddelde waardering: 4/5 - (4 Stemmen)
    Tags:bloedvaten, centrale zenuwstelsel, Chronic Cerebrospinal Venous Insuffiency (CCSVI), grijze massa, hersenen, hormonen, ijzer, ijzergehalte, Liberation Treatment, moe, MS, Multiple Sclerose (MS), Multiple Sclerose, myeline, vaatstelsel, virus, vitamine D
    >> Reageer (0)
    Klik hier om een link te hebben waarmee u dit artikel later terug kunt lezen.Wees een winterdepressie voor
    Klik op de afbeelding om de link te volgen


    Wees een winterdepressie voor

    Rachel van de Pol, 18-11-2009
     Bronnen: Medisch A-Z,, WebMD

    Heb jij tijdens de donkere dagen last van een winterdepressie ?
    Je kunt al deze narigheid over je heen laten komen.
    Of je kunt er wat tegen doen...

    De winter komt er weer aan.
    Voor sommige mensen is dit de naarste tijd van het jaar.
    Ze zien op tegen de donkere en neerslachtige dagen die gaan komen.
    De moeilijkste maanden zijn doorgaans januari en februari.
    Ben je het zat om je nog een winter moe, lusteloos, neerslachtig en dik te voelen ?
    Wees de winterblues dit jaar dan voor.
    Met deze tips zal de winterblues je niet snel te pakken krijgen.

    Tip 1 - Probeer elke ochtend even in de buitenlucht te komen
    Door de korte dagen en het vaak donkere weer, heb je vaak de neiging om meer binnen te blijven.
    Maar hiermee wordt de blootstelling aan daglicht nog korter.
    Maak er een routine van om voor je werk even naar buiten te gaan.
    Ook al is het bewolkt, dan nog heeft het daglicht effect op je gemoedsstemming.

    Tip 2 - Begin al voor de herfst met lichttherapie
    Voor veel mensen met een winterdepressie biedt lichttherapie uitkomst.
    Samen met een huisarts kun je bepalen of lichttherapie geschikt voor je is.
    De huisarts verwijst je vervolgens naar een instelling die beschikt over de juiste apparatuur.
    Begin al met lichttherapie voordat de winterblues kan toeslaan, bijvoorbeeld voor of tijdens de herfst.
    Voorkomen is beter dan genezen.

    Tip 3 - Eet gevarieerd en gezond, ook al snak je naar calorierijke snacks
    Door de winterblues heb je minder zin om mensen te zien en als alternatief beland je al snel voor de tv met koekjes of chips.
    Hierdoor kun je in de winter flink wat kilo’s aankomen (cfr. 'Waarom je tóch dikker wordt' op : -).
    Dit is niet alleen ongezond, maar het versterkt ook nog eens je winterdepressie.
    Want ongezonde voedingsgewoonten vreten energie en maken je onnodig moe (cfr. 'Voedingsgewoonten die energie wreten' op : -).
    Dus weersta de (sterke) verleiding om op de bank neer te ploffen met een diepvriespizza en kook een lekkere maaltijd voor jezelf of vrienden.

    Tip 4 - Blijf in beweging
    Door een winterdipje heb je nergens zin in, nou ja, slapen misschien.
    De gedachte aan fanatiek bewegen (cfr. 'Ga bewegen en start de kettingreactie' op : -) doet je waarschijnlijk gruwelen.
    Ironisch genoeg is juist het gebrek aan beweging en activiteiten vaak de oorzaak van je lusteloosheid.
    Niets uitvoeren en teveel slapen, beïnvloedt je stemming negatief.
    Studie na studie wijst uit dat beweging de beste natuurlijke remedie is tegen depressieve gevoelens.
    Wat voor beweging dat is, maakt verder niet veel uit. Kies dus een sport die jij leuk vindt.

    Tip 5 - Blijf sociale activiteiten ondernemen
    Door een winterdepressie heb je de neiging om je steeds meer af te sluiten van de buitenwereld.
    Maar door isolatie kun je nog meer in een winterdepressie gezogen worden.
    Blijf daarom betrokken bij je vrienden/familie en je sociale activiteiten.
    Sociale steun is cruciaal als je last heb van stemmingswisselingen.
    Vraag desnoods aan je sociale kring of ze een beetje streng voor je willen zijn.
    Zo mag je bijvoorbeeld alleen activiteiten afzeggen als je een echt goede reden hebt.
    Moeheid of geen zin is geen legitieme reden om niet te gaan.

    Tip 6 - Vind de oorzaak van problemen
    Ga bij jezelf na welke omstandigheden waarschijnlijk een rol spelen bij je depressieve gevoelens.
    Heb je nare herinneringen aan deze periode van het jaar, die het voor jou extra moeilijk maken ?
    Of zie je altijd al op tegen de feestdagen ?
    Bestaan er bepaalde problemen of conflicten, waar je in deze tijd extra last van hebt ?
    Probeer naar oplossingen en andere manieren om hiermee om te gaan, te zoeken, in plaats van er ieder jaar weer tegen aan te lopen.

    Tip 7 - Verwen jezelf
    Door een winterdepressie kun je extra kritisch naar jezelf zijn en weinig eigenwaarde hebben.
    Maar waarom zou je zo streng voor jezelf zijn ?
    Niemand wordt daar gelukkiger van en jij al helemaal niet.
    Probeer daarom jezelf zo nu en dan te verwennen.
    Plan een dag naar de sauna met vriendinnen, laat je masseren door een professional of ga een weekendje weg met je partner.
    Een verandering van omgeving kan je stemming een positieve boost geven.

    Cfr. :

    Cfr. ook :

    1. Winterdepressie (seizoensgebonden depressie)
      Cfr. :

    2. Weg met de winterdepressie
      Cfr. :

    3. Mediterraans eten helpt tegen depressie
      Cfr. :

    4. Loop je depressie van je af
      Cfr. :

    5. Sporten die een vakantiegevoel geven
      Cfr. :

    6. Hoe een winterdepressie ontstaat
      Cfr. :

    23-11-2009 om 01:01 geschreven door Jules

    0 1 2 3 4 5 - Gemiddelde waardering: 4/5 - (2 Stemmen)
    Tags:bewegen, daglicht, depressie, eenzaamheid, eigenwaarde, energie, lichttherapie, lusteloosheid, massage, moe, moeheid, neerslachtig, sauna, slapen, sporten, stemming, stemmingswisselingen, vermoeidheid, voeding, winterblues, winterdepressie, winterdipje
    >> Reageer (1)
    Klik hier om een link te hebben waarmee u dit artikel later terug kunt lezen.Vitamine B12-tekort - Een mogelijke oorzaak van Chronische vermoeidheid ? - Deel I
    Klik op de afbeelding om de link te volgen


    Vitamine B12-tekort
    - Een mogelijke oorzaak van Chronische vermoeidheid ? -

    Deel I

    Vitamine B12

    (Cyano)cobalamine, C63H88CoN14O14P, is evenals alle vitamine uit het vitamine B complex wateroplosbaar.

    Cobalamine zorgt samen met vitamine B6 (pyridoxine) en B11 (foliumzuur) voor de opname van ijzer door het lichaam en het is betrokken bij de vorming van rode bloedcellen.
    Een tekort aan deze vitaminen kan lijden tot bloedarmoede.
    Deze drie vitaminen zorgen ook voor een goede werking van het zenuwstelsel en zijn betrokken bij het aminozuur metabolisme.


    • noodzakelijk voor het in stand houden van het zenuwstelsel

    • verbetert geheugen en concentratie

    • nodig om vetten koolhydraten en eiwitten te kunnen gebruiken

    • geeft meer energie

    • bevordert gezonde groei bij kinderen

    • kan bescherming geven tegen kanker

    • beschermt tegen allergenen en giftige elementen.

    Symptomen bij een tekort

    • pernicieuze anemie

    • menstruatieklachten

    • geestelijke aftakeling

    • trillen.

    Voorzichtig en giftigheid

    Vitamine B12 wordt als niet giftig beschouwd.
    Toch wordt aangeraden maximaal 200 mg per dag te nemen.


    De aanbevolen dagelijkse hoeveelheid van dit vitamine is 0,001 mg (= 1 microgram).
    Doseringen van 5 - 50 microgram zijn voor de meeste mensen voldoende, neem hogere doseringen alleen op advies van je dokter.
    De maximale aanbevolen veilige dosis is 200 mg per dag.

    Natuurlijke bronnen

    • eieren

    • kaas

    • verse plattekaas

    • melk

    • vis

    • vlees.

    Cfr. 'Vitamine B-complex' :

    Hoe verhoog ik mijn weerstand bij vitamine B12-tekort ?


    Sinds enige tijd heb ik een B12-tekort – cfr. 'Vitamin B12 deficiency' op : -, omdat mijn lichaam te weinig van deze vitamine opneemt.
    Daarom krijg ik momenteel vitaminespuiten, maar nog steeds heb ik geen conditie, geen weerstand en bijna geen kracht.
    Wat kan ik doen om weer conditie en weerstand te krijgen ?

    Suzan Tuinier, voedingsdeskundige

    Je krijgt een vitamine B12 injectie omdat er in je maag een stofje ontbreekt.
    Dat stofje heet 'intrinsieke factor' en het zorgt ervoor dat vitamine B12 in de darm kan worden opgenomen.

    Meestal voelen mensen met een vitamine B12 tekort zich snel beter als ze een injectie krijgen.
    De vitamine komt dan namelijk rechtreeks in het bloed terecht.

    Waarom dat bij jou niet het geval is, kan ik helaas niet zeggen.
    Ik raad je aan om je huisarts te vragen om regelmatig het vitamine B12-gehalte in je bloed te laten bepalen (cfr. : -).
    Zo kun je in ieder geval zien of de injecties wel goed werken.

    Een goede weerstand krijg je door te bewegen en wanneer je in de buitenlucht bent.
    In de zon maak je vitamine D aan en die vitamine is belangrijk voor een goede weerstand.
    Alle andere voedingsstoffen die nodig zijn voor een goede weerstand haal je uit een gevarieerde voeding.

    Cfr. :

    Intrinsieke factor

    Intrinsic factor is een glycoproteïne dat door de pariëtale cellen in de maagwand wordt geproduceerd.
    Het wordt gekoppeld aan extrinsic factor (vitamine B12) dat alleen zo kan worden opgenomen ter hoogte van de dunne darm.

    Cfr. :

    Vitamine B12 tekort

    Maag Lever en Darm Stichting

    1. - Beschrijving


    Vitamine B12 deficiëntie.

    Wat is een vitamine B12-tekort ?

    Een vitamine B12 tekort kan veel verschillende oorzaken hebben.
    De behandeling van een vitamine B12 tekort is afhankelijk van de oorzaak.
    Een vitamine B12 tekort komt vrij veel voor bij ouderen boven de zestig jaar, maar het kan ook voorkomen bij jongere mensen.
    Een andere naam voor vitamine B12 is 'cobalamine'.

    Vitamine B12 wordt in het laatste deel van de dunne darm (ileum) opgenomen.
    Vitamine B12 kan alleen opgenomen worden door het lichaam, als het gekoppeld is aan het stofje ‘intrinsic factor’.
    Intrinsic factor is een bestanddeel van maagsap, dat geproduceerd wordt door het maagslijmvlies.
    Als het maagslijmvlies blijvend ernstig beschadigd is, dan kan het (vrijwel) geen maagsap meer produceren.
    Er wordt dan dus ook geen intrinsic factor meer aangemaakt.
    Hierdoor ontstaat op den duur een vitamine B12 tekort, omdat het lichaam geen vitamine B12 meer op kan nemen.

    2. - Oorzaak

    Een vitamine B12 tekort kan veel verschillende oorzaken hebben :

    Pernicieuze anemie

    Dit is een bepaalde vorm van bloedarmoede die ontstaat als gevolg van een auto-immuun ziekte van het maagslijmvlies.
    Door deze auto-immuun ziekte produceert de maag niet of nauwelijks 'intrinsic factror'.
    Dit stofje is echter noodzakelijk voor een goede opname van vitamine B12 in de dunne darm.
    Vanwege een tekort aan intrinsic factor kan vitamine B12 dus niet opgenomen worden.
    Lees ook 'Pernicieuze anemie' op : -.

    Een verminderde inname van vitamine B12

    Dit komt met name voor bij alcoholisten en bij veganisten/vegetariërs (mensen die geen dierlijke producten/vlees eten).

    Operatie laatste deel dunne darm

    Wanneer het laatste deel van de dunne darm (ileum) operatief verwijderd is of niet goed functioneert kan een vitamine B12 tekort ontstaan.
    Vitamine B12 wordt namelijk via de wand van het ileum door het lichaam opgenomen.

    Bacteriële overgroei in de dunne darm

    Hierdoor wordt vitamine B12 minder goed opgenomen door het lichaam.


    Als gevolg van een operatie, waarbij (een groot deel) van de maag verwijderd wordt.
    Het maagslijmvlies produceert dan niet voldoende intrinsic factor, waardoor vitamine B12 niet goed wordt opgenomen.


    In zeldzame gevallen kan een vitamine B12 tekort ontstaan als gevolg van medicijngebruik.

    Verminderde maagzuurproductie

    Bij ouderen kan de productie van maagzuur afnemen.
    Hierdoor kan vitamine B12 minder goed opgenomen worden.
    Ouderen hebben daardoor vaker een vitamine B12 tekort.

    In de volksmond worden de termen 'pernicieuze anemie' en 'vitamine B12 tekort' nogal eens door elkaar gebruikt.
    Officieel spreekt men alleen van pernicieuze anemie als het vitamine B12 tekort veroorzaakt wordt door een auto-immuun ziekte van het maagslijmvlies (auto-immuun gastritis).
    In alle andere gevallen spreekt met van ‘vitamine-B12 tekort’.

    3. - Klachten en symptomen

    Doordat het lichaam beschikt over grote reservehoeveelheden vitamine B12 duurt het een aantal jaren voordat een vitamine B12 tekort ontstaat.
    De eerste klachten die optreden bij pernicieuze anemie, komen overeen met klachten bij de ‘normale’ en meest gangbare vormen van bloedarmoede :

    • bleek zien

    • een slap en moe gevoel

    • licht in het hoofd

    • een gebrek aan eetlust.

    Sommige mensen krijgen last van :

    • een pijnlijke, branderige tong

    • gewichtsverlies

    • diarree.

    Op den duur heeft een vitamine B12 tekort neurologische gevolgen, omdat het zenuwstelsel wordt aangetast.
    Patiënten klagen over tintelingen en een dof gevoel in handen en voeten.
    Dit kan overgaan in een zwaar gevoel en moeilijkheden met lopen.
    Ook kunnen er coördinatieproblemen en psychische stoornissen optreden.

    4. - Diagnose

    Door middel van bloedonderzoek bepaalt de arts het vitamine B12 gehalte.
    Aanvullend bloedonderzoek en/of een kijkonderzoek van de maag (gastroscopie) zijn vaak nodig om de oorzaak van het tekort vast te stellen.

    5. - Behandeling

    De behandeling van een vitamine B12 tekort is afhankelijk van de oorzaak en de ernst van de klachten :

    • Te weinig intrinsic factor
      Als er geen of erg weinig productie van intrinsic factor is, wordt vitamine B12 via injecties in de bloedbaan toegediend.
      Deze injecties moeten vaak levenslang worden gebruikt.
      Het slikken van extra vitamine B12 heeft in dit geval geen zin.
      Vitamine B12 kan alleen door het lichaam opgenomen worden, als het gekoppeld is aan intrinsic factor.

    • Voldoende intrinsic factor
      Als er wel voldoende intrinsic factor wordt aangemaakt door het maagslijmvlies, dan kan extra inname van vitamine B12 voldoende zijn.
      Bij een ernstig tekort geeft de arts eerst een aantal injecties.
      De patiënt kan vervolgens overgaan op voedingssupplementen met extra vitamine B12.

    6. - Tips en adviezen bij Vitamine B12 tekort

    Een vitamine B12 tekort wordt soms veroorzaakt door een ongezonde of eenzijdige voeding.
    Vitamine B12 zit in dierlijke producten zoals vlees, eieren en zuivelproducten.
    Als u vegetariër of veganist bent, dan is het verstandig om vitamine B12 in te nemen via een voedingssupplement, omdat anders een tekort kan ontstaan.
    Uw huisarts of een diëtist kan u adviseren.

    Cfr. :



    Cobalamines, ook wel 'vitamine B12' of 'extrinsieke factor' genoemd, zijn organometaalchemische verbindingen met een enkelvoudig, tweevoudig- of drievoudig positief geladen kobaltion.
    Het zijn de enige bekende natuurlijk voorkomende kobalthoudende verbindingen in de natuur.


    De structuur van cobalamines is gebaseerd op twee karakteristieke componenten :

    • een corrinering, die vergelijkbaar is met de porfyrinering in heem, chlorofyl en cytochroom.
      Het centrale metaalion hierin is kobalt.
      Het kobalt is zeer sterk gebonden aan de corrinering en kan eigenlijk alleen maar door vernietiging van dr ringstructuur daaruit losgemaakt worden.

    • een ribonucleotide (5,6 dimethylbenzimidazolribonucleotide).

    Vier van de zes coördinatieposities van het centrale kobaltatoom worden bezet door de corrinering en een vijfde door een dimethylbenzimidazolgroep.
    De laatste van de 6 coördinatieposities van het centrale kobaltatoom is veel minder sterk aan het kobalt gebonden (op met een R (van "restgroep") aangegeven) en door daar verschillende liganden te binden kunnen verschillende vormen van vitamine B12 ontstaan.

    • een cyanide CN- : Deze vorm van vitamine B12 wordt cyanocobalamine genoemd.
      Het is een reukloze, dieprode, kristalline, hygroscopische substantie.
      Het lost matig in water en slecht in alcohol op en helemaal niet in organische oplosmiddelen als aceton, chloroform en ether.
      Cyanocobalamine komt normaal gesproken niet in de natuur voor, maar wordt gebruikt in vele farmaceutische producten en in voedingssupplementen vanwege de stabiliteit en de lage kosten.
      In het lichaam kan het worden omgezet in de metabolisch actieve vormen van vitamine B12: methylcobalamine en adenosylcobalamine, waarbij cyanide vrijkomt (zij het in minieme hoeveelheden).

    • een hydroxylgroep OH- : hydrocycobalamine

    • een methylgroep -CH3 : methylcobalamine.

    • 5'deoxyadenosine (adenine op ribose) : Ook wel bekend als adenosylcobalamine, 5,6-dimethylbenzimidazolylcobamide-5'-deoxyadenosine, dibencoside, cobamide of coenzyme B12.

    In de lichaamscellen komen cobalamines in de mitochondriën vooral als 5'-desoxyadenosylcobalamine (coenzym B12) voor, in het cytosol daarentegen overwegend als methylcobalamine.
    In voeding komt vitamine B12 meestal voor gebonden aan een eiwit in de methyl of 5'deoxyadenosylvorm.
    Ook de conversie in het lichaam van elke vorm van B12 gebeurt via het methylcobalamine of 5'-deoxyadenosylcobalamine.
    Deze laatste twee vormen zijn actief betrokken in het endogeen metabolisme.
    Methylcobalamine en 5'-deoxyadenosylcobalamine worden beschouwd als de natuurlijke afgeleiden van vitamine B12.

    De covalente C-Co verbinding in bijvoorbeeld methylcobalamine is één van de eerste voorbeelden van koolstof-metaalverbindingen die ontdekt zijn in de natuur.
    Alle vier de verbindingen tussen kobalt en de (stikstofgroepen van de) corrinemoleculen moeten gemaakt worden door bacteriën.
    Als deze verbindingen zijn gelegd, heeft het lichaam slechts een bescheiden capaciteit om vitamine B12 in één van de andere vormen van B12 om te zetten.


    Cobalamine wordt in de maag vrijgemaakt van de omhullende eiwitten uit het voedsel door de werking van maagzuur en enzymen.
    Vervolgens bindt het aan r-factor, een eiwit geproduceerd door de speekselklieren en wordt het naar de twaalfvingerige darm vervoerd.
    Door enzymen uit de alvleesklier wordt de verbinding met het r-factor verbroken en bindt cobalamine met intrinsic factor.
    Dit is een glycoproteïne gemaakt in de pariëtele cellen in de maagwand.
    Het gevormde complex wordt vervolgens opgenomen in het laatste stuk van de dunne darm door specifieke receptoren.
    Circa een procent kan passief worden opgenomen, zonder intrinsic factor of receptoren in de darm.

    Cobalamine is nodig voor de vorming van methionine, een aminozuur dat essentieel is voor de DNA-synthese.
    Een tekort aan cobalamine leidt derhalve tot een probleem bij sneldelende cellen die veel DNA moeten aanmaken.
    Het duidelijkst is dit bij rode bloedcellen, maar ook de bekleding van de darmen, de vagina en tong kan minder goed worden aangemaakt.

    Een tweede functie van cobalamine is het stimuleren van de vorming van myeline.
    Dit eiwit omhult de zenuwuitlopers waardoor de impulsgeleiding van de zenuw wordt versneld.


    Vitamine B12 wordt uitsluitend geproduceerd door micro-organismen.
    Dieren en planten kunnen geen B12 aanmaken.
    Dieren dekken hun behoefte door deze micro-organismen bij zich te dragen, zoals de meeste herkauwers of door andere dieren te eten of door producten te eten waarin zich veel micro-organismen bevinden, zoals (hun eigen) uitwerpselen.
    Ook in de menselijke darm komen micro-organismen voor die in symbiose met de mens B12 produceren.
    Deze micro-organismen bevinden zich echter in een deel van darmen waar de B12 niet meer kan worden opgenomen.
    Daarom zijn mensen afhankelijk van een externe bron van B12 : dierlijke producten of voor veganisten : B12-supplementen.

    B12 wordt grotendeels opgeslagen in de lever, ook bij dieren.
    Lever is daarom een goede bron van B12.
    Toen er nog geen B12-supplementen bestonden werd lever of leverextract gebruikt bij mensen met een B12-tekort.

    Vitamine B12 komt in de natuur voor in microben (oppervlaktewater, humuslaag) en in uitwerpselen.
    Het kan gewonnen worden uit dierlijke producten zoals melk, melkproducten, vlees en vleeswaren, vis en eieren.
    Het wordt toegevoegd aan (een ingrediënt van) Marmite.

    In sommige algen en wieren komt een vitamine B12-gelijkende stof voor, maar die is inactief als vitamine, als voedingsstof voor veganisten, werkt dit dus niet (zoals vroeger gedacht werd).
    De nep-B12 uit wieren en algen kunnen zelfs een negatieve werking hebben doordat ze de opname van echte B12 kunnen blokkeren.
    Ook wordt vaak gedacht dat gist of gistextracten B12 bevatten maar dat is niet het geval.
    Het misverstand is waarschijnlijk ontstaan doordat veel B12-pillen gemaakt zijn van gist waarin kunstmatig B12 is toegevoegd.
    Deze gist bevat uiteraard wel B12. Pure gist bevat van nature echter geen B12.

    Gevolgen van een tekort

    Een tekort aan vitamine B12 kent men vooral bij veganisten.
    Echter, na het stoppen van vitamine B12 inname kan het nog 3 jaar duren voordat een tekort zich kenbaar maakt; het lichaam kan dus enkele jaren op een goede B12-voorraad teren.
    Bij een tekort aan vitamine B12 krijgt men vaak injectiespuiten, met kleine hoeveelheden B12.

    Een tekort aan vitamine B12 ontstaat ook als iemand geen intrinsic factor (een glycoproteïne) maakt.
    Dit is bijvoorbeeld het geval na een operatieve verwijdering van een deel van de maag.
    In zo'n geval zijn B12-injecties nodig om het tekort op te heffen.
    Ook kan het voorkomen dat het lichaam antistoffen tegen deze vitamine maakt, waardoor de opname door het lichaam wordt geremd.

    Door het slikken van hooggedoseerde pillen (tenminste 650 microgram per dag) is het mogelijk om ook zonder intrinsic factor voldoende B12 binnen te krijgen.
    De opname geschiedt in dat geval via diffusie.
    In Nederland zijn injecties echter gebruikelijker.

    Een tekort leidt uiteindelijk tot een vorm van bloedarmoede (pernicieuze anemie) en neurologische gevolgen zoals tintelingen in de vingers (paraestesie), geheugenverlies, coördinatiestoornissen (ataxie) en spierzwakte in de benen.
    De neurologische gevolgen kunnen optreden voordat er bloedarmoede is, evenals het omgekeerde.

    Pernicieuze anemie betekent letterlijk : een verderfelijke (ernstige) vorm van bloedarmoede.
    De ziekte "pernicieuze anemie" staat echter voor iets anders : een stofwisselingsziekte waardoor er geen intrinsieke factor wordt aangemaakt of werkzaam is, met als gevolg een B12 gebrek met als gevolg een bepaald type bloedarmoede.
    Een ander woord voor pernicieuze anemie is de ziekte van Addison-Biermer.
    Een overschot van foliumzuur, vitamine B11 kan een tekort aan vitamine B12 maskeren.

    Deze vorm van bloedarmoede wordt niet altijd ontdekt.
    Vooral ouderen kunnen last krijgen van een vitamine B12 gebrek als hun stofwisseling stoornissen gaat vertonen.
    Door het gebrek aan vitamine B12 wordt de vorming van rode bloedcellen verstoord.
    Hierdoor kan men erg vermoeid raken.
    Tekorten aan vitamine B12 kunnen ontstaan door deficiënte voeding, namelijk te weinig dierlijke producten, maar ook door een verworven defect in de opname van vitamine B12 (pernicieuze anemie).
    Vitamine B12 is ook in grotere hoeveelheden te vinden in het teelvocht(sperma) van de man [bron ?].
    Bij bloedarmoede door gebrek aan vitamine B12 of aan foliumzuur zijn de bloedcellen die men nog heeft meestal te groot; bij ijzergebrek juist meestal te klein.
    De diagnose van vitamine B12 deficiëntie is niet altijd even makkelijk omdat de waarde in het bloed, deze kan men bepalen, niet altijd goed de totale lichaamsvoorraad weergeeft.

    Risicogroepen van een tekort zijn :

    • veganisten (en in mindere mate vegetariërs)

    • personen met een maagaandoening

    • mensen met een aandoening aan de dunne darm

    • oudere mensen.

    Gevolgen van een overschot

    Er zijn geen ongewenste effecten bekend bij personen die langdurig hoge doseringen gebruikten.
    Het lichaam reguleert de opname van vitamine B12 zelf.


    Cobalamine is in 1926 ontdekt, het werd geïsoleerd uit lever.

    Cfr. :

    Vitamine B12
    en de relatie met Chronisch Vermoeidheids Syndroom

    Stichting B12 Tekort

    Voordat de diagnose CVS gesteld wordt, moet een tekort aan vitamine B12 worden uitgesloten.
    Veel (zo niet alle) van de klachten die bij CVS voorkomen, kunnen ook door een tekort aan vitamine B12 worden veroorzaakt.
    Als uit bloedonderzoek (serum B12) blijkt dat er inderdaad sprake is van een vitamine B12 tekort, zal eerst de behandeling met injecties gestart moeten worden.
    Pas als na langere tijd toediening van injecties de klachten blijven bestaan, kan eventueel de diagnose CVS gesteld worden.
    Uiteraard kunnen ook beide naast elkaar bestaan.

    Uit een onderzoek onder 12 patiënten met zowel CVS als fibromyalgie, bleek dat zij allen een verhoogde waarde van homocysteïne hadden in de ruggenmergvloeistof.
    Er was een duidelijke relatie van deze verhoogde homocysteïne waarden met vermoeidheid.
    Ook bleek er een duidelijke relatie van lage waarden vitamine B12 in de ruggenmergvloeistof met vermoeidheid en neurasthenie.
    Een vitamine B12 tekort veroorzaakt een deficiënte remythelisatie van homocysteïne en is daardoor (mede) de oorzaak van het verhoogde homocysteïne niveau.
    Indien door injecties met vitamine B12 de remythelisatie weer op gang komt, verlaagt het gehalte homocysteïne.
    De conclusie is dat verhoogde homocysteïne waarden in het centrale zenuwstelsel patiënten met zowel CVS als fibromyalgie kunnen karakteriseren.

    Uit een onderzoek onder 100 patiënten met CVS bleek dat 30% een verhoogde MMA waarde had.
    MMA (methylmalonzuur) is bij mensen met een tekort aan vitamine B12 vaak verhoogd.
    Dit doet vermoeden dat bij een grote groep CVS-patiënten er een vitamine B12 tekort bestaat, wat zeer waarschijnlijk de oorzaak is van veel, zo niet alle klachten van deze patiënten.

    Ook is uit onderzoek gebleken dat CVS-patiënten zonder tekort aan vitamine B12 baat kunnen hebben bij injecties.
    Lapp en Cheney hebben meer dan 2000 patiënten met CVS behandeld.
    In eerste instantie met relatief kleine hoeveelheden vitamine B12, maar later met 2000 tot 5000 mcg cyanocobalamine elke 2 á 3 dagen.
    Bij 50 tot 80% verbeterde het energieniveau, het uithoudingsvermogen, het welbevinden en vaak al binnen 2 tot 3 weken na aanvang van de behandeling.
    Simpson gaf 1000 mcg cyanocobalamine aan een groep patiënten met CVS, die ook een verhoogd percentage afwijkende rode bloedcellen hadden.
    De rode bloedcellen van veel CVS-patiënten hebben een afwijkende vorm, waardoor het zuurstoftransport door het bloed vermindert.
    De helft van de patiënten die behandeld werden met vitamine B12 injecties voelde zich binnen 24 uur beter en dat ging gelijk op met de afname van de hoeveelheid afwijkende rode bloedcellen.
    Patiënten die geen verbetering bemerkten, hadden ook geen verbetering in de cellen.
    Simpson doet de suggestie dat de toediening van vitamine B12 CVS klachten kan doen afnemen, doordat de erythrocyte afwijkingen verminderen, wat kan leiden tot een verbetering van de zuurstofverzadiging in de weefsels.

    Bij een vermoeden van CVS moet eerst een vitamine B12 tekort worden uitgesloten, alvorens de diagnose gesteld kan worden.


    1. Myalgic encephalomyelitis – Letter
      Simpson LO - J R Soc Med 1991;84:633
      Cfr. :

    2. The rationale for using high-dose cobalamine
      Lapp CW, Cheney PR - The CFIDS Chronicle Physicians' Forum Fall 1993;19-20
      Cfr. :

    3. Increased concentrations of homocysteine in the cerebrospinal fluid in patients with fibromyalgia and chronic fatigue syndrome
      Regland B, Andersson M, Abrahamsson L, Bagby J, Dyrehag LE, Gottfries CG. Scand - J Rheumatol. 1997;26(4):301-7
      Cfr. :

    Cfr. :

    Cfr. ook :

    1. A randomized, double-blind, placebo-controlled study of oral vitamin B12 supplementation in older patients with subnormal or borderline serum vitamin B12 concentrations
      Seal EC, Metz J, Flicker L, Melny J, National Ageing Research Institute, Parkville, Victoria, Australia - J Am Geriatr Soc. 2002 Jan;50(1):146-51 - PMID: 12028259
      Cfr. :

    2. Chronische vermoeidheid syndroom - ATP deficiëntie
      Pillie Willie, 15-03-2008
      Een ATP deficiëntie kan worden veroorzaakt door een mitochondriale disfunctie.
      Mitochondria zijn kleine energiecentrales in onze cellen zij produceren de bio-energetische stof ATP.
      Als de mitochondria niet goed functioneren heeft dat gevolgen voor het gehele lichaam.
      Reeds bij een lichte inspanning kan in de spieren een ATP tekort ontstaan met vermoeidheid en verzuring van de spieren als gevolg.
      Hierdoor ontstaan spierpijnen, krampen en een intolerantie voor extra beweging en in de hersenen de zogenaamde 'Brain Fog' (niet helder kunnen denken).
      Soms kan deze deficiëntie door een eenvoudig vitamine suppletie programma worden verminderd of genezen.
      In dit artikel worden een aantal supplementen besproken die hierbij toegepast kunnen worden.
      Deze stoffen zijn uitzonderlijk veilig.
      Vitamine suppletie veilig en effectief
      De vermoeidheid die een CVS/ME patiënt ervaart kan bij sommige patiënten door een ATP deficiëntie worden veroorzaakt.
      Soms kan deze deficiëntie door een eenvoudig vitamine suppletie programma worden verminderd of genezen.
      In de volgende paragrafen worden een aantal supplementen besproken die hierbij toegepast kunnen worden.
      Deze stoffen zijn uitzonderlijk veilig.
      Er zijn, behalve de reeds eerder genoemde mogelijke allergieën en intoleranties, geen ernstige bijverschijnselen bekend en kunnen daarom zonder supervisie van een arts worden toegepast.
      In de volgende hoofdstukken worden de volgende supplementen behandeld : MSM, Magnesium glycinate, Appelzuur (Malic Acid), Chroom GTF, L-Carnitine, CoQ10 en NADH.
      MSM wordt reeds jaren toegepast bij de behandeling van FMS, de resultaten zijn goed.
      50% van de patiënten heeft baat bij MSM, literatuur over MSM is nog schaars.
      Over de toepassing van magnesium in combinatie met appelzuur is veel materiaal beschikbaar.
      Onderzoek geeft duidelijk aan dat deze combinatie voor een bepaalde subgroep van CVS/ME goede behandelingsresultaten geeft.
      Over carnitine is, in relatie tot de behandeling van CVS/ME en Fibromyalgie, ook veel literatuur beschikbaar.
      De resultaten zijn zeer bemoedigend.
      Over Q10 en chroom bestaan volgens mijn informatie nog geen gepubliceerde resultaten bij de behandeling van CVS/ME, maar wel bij de behandeling van ATP deficiëntie, hartfalen, hypoglycemie, insuline resistentie en andere klachten.
      NADH is door de Amerikaanse overheid (FDA) goedgekeurd voor de behandeling van CVS/ME.
      Er zijn vele dubbelblinde studies beschikbaar.
      Begin met de supplementen die goedkoop zijn en snel resultaat opleveren.
      Is het resultaat nog onvoldoende gebruik dan ook de middelen die duurder zijn of op lange termijn pas werken.
      Hieronder een stappenplan :
      1/ Begin de behandeling met MSM. Het is veilig en goedkoop en geeft binnen een enkele weken resultaat. MSM verbetert het zuurstof transport in het lichaam.
      2/ Voeg daarna Chroom aan de behandeling toe. Chroom is ook erg goedkoop. De resultaten zijn binnen 2 - 4 weken te verwachten. Chroom verbetert in sommige gevallen de verbranding van glucose (koolhydraten).
      3/ In mijn visie zou op dit moment carnitine het best kunnen worden ingezet. Carnitine is duur en moet hoog gedoseerd worden want het wordt slecht opgenomen. Vraag de huisarts of orthomoleculair arts om een recept, dan betaalt de verzekering de kosten. Resultaten : 4 - 6 weken. Carnitine verbetert de verbranding van vetzuren.
      4/ Als de therapeutische dosis voor MSM is bepaald introduceer dan magnesium glycinate en appelzuur als combinatietherapie. Magnesium en appelzuur verbeteren de ATP productie. In sommige onderzoeken wordt gemeld dat de pijnklachten reeds binnen 48 uur sterk verminderen.
      5/ Als de vermoeidheid duidelijk vermindert gebruik dan een goed vitamine B-complex om de ATP productie verder te verbeteren.
      6/ NADH is erg duur. Primair wordt NADH ingezet om vermoeidheid te verminderen. Het is niet op recept te verkrijgen. Resultaat: enkele dagen.
      7/ CoQ10 is duur en de resultaten
      laten lang op zich wachten. Resultaat: 2 - 4 maanden.
      Cfr. :

    3. Cobalamin deficiency in elderly patients - A personal view
      Andrès E, Vogel T, Federici L, Zimmer J, Ciobanu E, Kaltenbach G, Department of Internal Medicine, Diabetes, and Metabolic Diseases, University Hospital of Strasbourg, 67091 Strasbourg, France - Curr Gerontol Geriatr Res. 2008:848267. Epub 2008 May 26 - PMID: 19415147
      Cobalamin (vitamin B12) deficiency is particularly common in the elderly (>65 years of age) but is often unrecognized because its clinical manifestations are subtle; however, they are also potentially serious, particularly from a neuropsychiatric and hematological perspective.
      In the elderly, the main causes of cobalamin deficiency are pernicious anemia and food-cobalamin malabsorption.
      Food-cobalamin malabsorption syndrome is a disorder characterized by the inability to release cobalamin from food or its binding proteins.
      This syndrome is usually caused by atrophic gastritis, related or unrelated to Helicobacter pylori infection and long-term ingestion of antacids and biguanides.
      Management of cobalamin deficiency with cobalamin injections is currently well documented but new routes of cobalamin administration (oral and nasal) are being studied, especially oral cobalamin therapy for food-cobalamin malabsorption.
      Cfr. :

    4. De diagnostiek van vitamine-B12-deficiëntie herzien
      W.J.Wiersinga, Rooij, J.G.M.Huijmans, J.C.Fischer en J.B.L.Hoekstra, Academisch Medisch Centrum/Universiteit van Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam - Afd. Inwendige Geneeskunde: hr.W.J.Wiersinga, assistent-geneeskundige; Rooij en, internisten - Afd. Klinische Chemie: hr.dr.J.C.Fischer, klinisch chemicus - Erasmus MC, afd. Klinische Genetica, Rotterdam. Hr.dr.J.G.M.Huijmans, klinisch chemicus. Correspondentieadres : : - Ned Tijdschr Geneeskd 2005 10 december;149(50)
      - Deficiëntie van vitamine B12 (cobalamine) komt frequent voor met potentieel irreversibele hematologische en neurologische consequenties.
      - De huidige diagnostische tests, zoals de serumbepaling van vitamine B12 en de Schilling-test, zijn ontoereikend, bijvoorbeeld omdat de positief voorspellende waarde van een lage serumspiegel van vitamine B12 voor een werkelijke vitamine-B12-deficiëntie, dat wil zeggen voor een deficiëntie op weefselniveau, laag is.
      - Bij onvoldoende beschikbaarheid van vitamine B12 zal er in het lichaam stapeling optreden van methylmalonzuur en homocysteëne. Nagenoeg alle patiënten met een vitamine-B12-deficiëntie hebben dan ook sterk verhoogde methylmalonzuur- en homocysteënewaarden.
      - De nieuwe laboratoriumbepalingen van methylmalonzuur en homocysteëne in serum hebben een grote gevoeligheid; daarmee kan men de diagnostiek verbeteren en vereenvoudigen en wordt de nogal omslachtige Schilling-test overbodig.
      Recent werd in dit tijdschrift beschreven dat er bij 5-10% van de Nederlandse bevolking een vitamine-B12-tekort bestaat.
      Meestal zal deze deficiëntie niet aan het licht komen, aangezien er op dit moment nog niet stelselmatig op gescreend wordt.
      Een ander probleem is dat, nadat een verlaagde serumvitamine-B12-spiegel vastgesteld is, de diagnostiek naar de onderliggende oorzaak vaak verwaarloosd wordt.
      Lastig hierbij is dat een verlaagde serumvitamine-B12-spiegel niet altijd wil zeggen dat er ook een echte vitamine-B12-deficiëntie bestaat.
      Amerikaans onderzoek wees uit dat 50% van de patiënten met een lage vitamine-B12-spiegel, gedefinieerd als 2 standaarddeviaties beneden het gemiddelde in de niet-afwijkende bevolking, geen deficiëntie op weefselniveau heeft.
      Aan de andere kant sluit een vitamine-B12-uitslag binnen het referentie-interval een functionele deficiëntie niet uit.
      Het is dan ook waarschijnlijk dat er vaak ten onrechte wel of juist geen suppletietherapie wordt ingesteld.
      De plaats van de op dit moment gangbare diagnostische tests, zoals de serumvitamine-B12-bepaling en de Schillingtest, is aan herziening toe.
      Nieuwe bepalingen zijn namelijk beschikbaar gekomen, zoals de methylmalonzuur- en homocysteïnebepalingen, die subklinische en klinische vitamine-B12-deficiëntie met meer zekerheid kunnen aantonen.
      In dit artikel doen wij een suggestie om tot een gestandaardiseerde analyse van vitamine-B12-deficiëntie te komen, die een aanvulling kan zijn bij de recente standaard ‘Anemie’ van het Nederlands Huisartsen Genootschap.
      Cfr. :

    5. Een lage B12 en er gaat geen licht branden... Een internist die geen rekening houdt met eerdere injecties - Het verhaal van N.N.
      B12–tekort - De ziekte van Addison-Biermer (pernicieuze anemie), 22-04-2005
      Ik ben 23 jaar.
      Bij mij is onlangs weer een B12-waarde gevonden van 70.
      Het begon allemaal 4 jaar geleden, ik zag gekleurde vlekken, kon opeens erg angstig worden (ik lag bijvoorbeeld op bed toen ik een deurbel hoorde, vervolgens verstopte ik me onder het dekbed omdat ik bang was dat de mensen die in mijn kamer waren mij iets aan zouden doen, ik was notabene alleen), daarnaast had ik last van tintelingen, het gevoel dat er mieren over mijn armen en benen en later ook hoofd liepen en pijnklachten.
      In deze periode ben ik ook depressief geworden.
      Met deze klachten ben ik naar de studentenarts geweest (ik studeer psychologie) welke een zeer lage B12-waarde vond en een licht verhoogd leverenzym.
      Ik moest terug komen en kreeg te horen dat het waarschijnlijk een labfout was want dit kon niet.
      Nog twee metingen volgden, hetzelfde resultaat wel iets gestegen (inmiddels was ik flink bezig met het slikken van grote hoeveelheden B12, wist ik veel).
      Verder deed de studentenarts niets.
      Toen las ik de site over B12, mijn klachten waren verergerd en ben toen naar de huisarts in mijn ouderlijke woonplaats geweest.
      Deze vond een laag (normale) waarde van 200 en was van mening dat ik injecties moest hebben.
      Met deze informatie heb ik in mijn eigen woonplaats een reguliere huisarts gevonden.
      Ik kreeg 4 wekelijkse injecties en daarna nog een na een maand.
      Ook werd ik doorverwezen naar de internist.
      De meting bij de internist liet een normale waarde zien van 550, verder vertelde hij mij dat ik geen antistoffen had tegen de intrinsic factor.
      Na 6 maanden mocht ik terug komen om te kijken of mijn B12 dan weer laag was.
      Deze bleek nu 235.
      Conclusie van de internist : je waarde is vergeleken met je 'beginwaarde' gestegen en je bloedcellen zijn normaal.
      Dus werd ik naar huis gestuurd zonder verdere bahandeling.
      Ik wist de waarden toen niet, maar de daling lijkt me iets verdacht en er leek op zijn minst een extra meting nodig om te bekijken of de daling zich zou voortzetten.
      Nu ik medisch gezond was verklaard en ik toch veel klachten had, de depressie verergerde (ik had nu ook in de gaten dat dit niet normaal was, ik dacht in het begin dat ik teveel studieboeken had gelezen en me alles teveel aantrok) was het tijd voor een psychologische benadering.
      Ik ben twee jaar lang behandeld via een eerstelijnspsycholoog (erg duur voor een student) en de klachten bleven ik was ook erg moe en sliep veel.
      Omdat ik steeds weer terug viel in mijn klachten heeft zij mij op een gegeven moment doorverwezen naar de deeltijdbehandeling (4 dagen in de week therapie).
      Dit is nu zeven maanden geleden.
      De behandeling is net twee weken afgerond.
      Voordat ik aan de deeltijdbehandeling begon heb ik mijn huisarts om een bloedonderzoek en B12-meting gevraagd, om uit te sluiten of er geen, medische oorzaak voor mijn klachten was.
      Bloedbeeld was goed en geen bloedarmoede.
      Mijn B12 hoefde niet gemeten te worden zei hij, omat ik anders wel bloedarmoede zou hebben.
      De laatste maanden zijn mijn klachten verergerd, weer spiertrekkingen (vingers en tenen die ongecontroleerd bewegen) de gekleurde vlekken (waarschijnlijk vergelijkbaar met aura bij migraine) werden erger, pijnen, het gevoel alsof er elektriciteit door mijn armen en benen loopt, moeheid, veel slapen, irrationele angstgevoelens (ik heb ook hallucinaties gahad waaarvan de psychiater de oorzaak niet kon achterhalen) concentratieproblemen, soms problemen met schrijven (schrijf maar 1 letter op in plaats van het hele woord).
      Een groepsgenoot vertelde mij over haar B12-problemen (bij haar gecombineerd met een traag werkende schildklier).
      Dit op een moment waarop ik er al aan dacht om weer eens naar de huisarts te gaan.
      Ik besefte toen dat mijn B12 helemaal niet gemeten was.
      De uitslag was tot de verbazing van de huisarts dat het dus veel te laag was : 70.
      Hij heeft mij doorgestuurd naar dezelfde internist (die mijn waarden toendertijd normaaal vond).
      Ik heb nu de Schillingtest (cfr. : -) gedaan, krijg een endoscopie en weer bloedonderzoek.
      De huisarts heeft mij intussen drie injecties voorgeschreven (voor 2 maanden) om in de periode voor de uitslag van de internist mijn B12 aan te vullen.
      Toen ik de internist vroeg over de behandeling zei hij luchtig dat er B12-injecties bestaan en die zou ik kunnen gebruiken (het handboek van mijn psychiater gaf aan dat bij deze klachten geadviseerd wordt om gedurende twee jaar twee injecties te doseren en op deze site lees ik over een frequentie van 10 weken lang 1 injectie en daarna onderhoudsinjecties).
      Ik heb net 1 van de drie injecties gehad, nog steeds natuurlijk klachten, maar ik wil van mijn klachten af.
      Welke dosering zou voor mij het geschiktst zijn en is het nuttig om een neuroloog te consulteren (mijn psychiater, die ik inmiddels sinds twee weken niet meer heb vanwege het beëindigen van mijn psychiatrische bahandeling gaf aan dat dit handig zou zijn) ?
      Jij hebt dus gegarandeerd de ziekte van deze site.
      Je had vanaf 4 jaar geleden al blijvend B12-injecties moeten hebben.
      Je zat toen in de beginfase van de ziekte en de pillen deden de waarde nog wel iets verhogen, maar de klachten gingen niet weg.
      Bijna altijd is de ziekte van Addison-Biermer de oorzaak van zo'n tekort.
      Ook op jouw leeftijd.
      Bij een lage B12 moeten bij elke dokter en zeker internist, alle alarmbellen gaan rinkelen.
      Niet dus...
      Jouw klachten, ook de psychische, komen door het B12-tekort.
      De internist heeft het ontzettend slecht gedaan door de waarde 235 goed te vinden omdat deze gestegen was vergeleken met de allereerste meting.
      Hij hield geen rekening met de tussentijdse injecties.
      Bovendien ging de waarde in 6 maanden terug van 550 naar 235 en dat vond deze dokter normaal.
      Niet iedereen heeft bij deze ziekte de antistoffen, dus dat ze niet aangetroffen werden zegt niets.
      Ook de Schillingtest geeft niet altijd een afwijking.
      En is nu helemaal niet nodig, dat de opname niet goed is, is wel zeker.
      Door je medisch gezond verklaren heeft deze internist een enorme verwijtbare fout gemaakt, waardoor jij in de problemen bent gekomen.
      De depressie waar het toen aan geweten werd, was een direct gevolg van je B12-tekort.
      Had dus een lichamelijke oorzaak die door de internist niet werd gezien.
      Zijn licht is niet gaan branden.
      Door deze lange voorgeschiedenis en met je klachten moet je nu eindelijk eens de juiste behandeling hebben.
      De dokters hebben het allemaal verkeerd gedaan en daarom mag je van hen nu alle inspanning verwachten om de schade nu tot een minimum te beperken en zoveel mogelijk verbetering te krijgen.
      Het handboek van de psychiater gaat niet over dit ziektebeeld.
      In het handboek van de internist moet heel iets anders staan.
      Bij neurologische klachten is een begindosering van 10 injecties voorschrift met minimaal interval van 3 dagen.
      Het is beter deze 10 injecties over 10 weken te geven, dan wordt de B12 beter benut.
      Door deze fout van huisarts en internist van 4 jaar geleden zit jij weer in de medische molen.
      Als je vier jaar geleden de juiste behandeling had gekregen, dan zag jouw wereld er nu heel anders uit.
      Jouw gezondheid was stukken beter geweest en de kosten die nu gemaakt worden door de extra onderzoeken waren niet nodig geweest.
      Jij moet nu minimaal 10 weken lang elke week een injectie (1000 microgram hydroxocobalamine in de bilspier) hebben als begindosering en daarna over op de onderhoudsdosering van een injectie per maand.
      De onderhoudsdosering op den duur bepalen aan de hand van de >1000 vuistregel die op de site staat.
      Het heeft geen zin een neuroloog te consulteren.
      Hij kan wel afwijkingen constateren maar kan er verder niets aan doen.
      De enige en juiste behandeling is door de injecties.
      En van die injecties moet je er ruimschoots krijgen, want dat is de manier om de kans op verbetering maximaal te doen zijn.
      Wees niet bang om te veel te krijgen, de B12 is wateroplosbaar en een echt teveel plas je wel weer uit.
      Het ligt op het terrein van de ... internist.
      De huisarts maakte de fout door te denken dat je zonder bloedarmoede geen B12-tekort kunt hebben.
      Hij gebruikt zijn "Standaard anemie (M76)" omgekeerd en dat kan niet.
      Dit feit is al jàaaaaren bekend binnen de medische wereld.
      De internist doet er nu wat luchtig over, maar hij heeft een grote verwijtbare medische misser begaan.
      En die B12-injecties zou je niet KUNNEN gebruiken, maar die MOET je gebruiken.
      Als je met blijvende klachten blijft zitten is hij hier verantwoordelijk voor te stellen.
      Cfr. :

    6. Effect of oral vitamin B-12 with or without folic acid on cognitive function in older people with mild vitamin B-12 deficiency - A randomized, placebo-controlled trial
      Eussen SJ, de Groot LC, Joosten LW, Bloo RJ, Clarke R, Ueland PM, Schneede J, Blom HJ, Hoefnagels WH, van Staveren WA, Division of Human Nutrition, Wageningen University, Wageningen, Netherlands - Am J Clin Nutr. 2006 Aug;84(2):361-70 - PMID: 16895884
      - Vitamin B-12 deficiency is associated with cognitive impairment in older people.
      However, evidence from randomized trials of the effects of vitamin B-12 supplementation on cognitive function is limited and inconclusive.
      Objective - The objective was to investigate whether daily supplementation with high doses of oral vitamin B-12 alone or in combination with folic acid has any beneficial effects on cognitive function in persons aged >/=70 y with mild vitamin B-12 deficiency.
      Design - In a double-blind, placebo-controlled trial, 195 subjects were randomly assigned to receive 1000 microg vitamin B-12, 1000 microg vitamin B-12 + 400 microg folic acid or placebo for 24 wk.
      Vitamin B-12 status was assessed on the basis of methylmalonic acid, total homocysteine (tHcy) and holotranscobalamin (holoTC) concentrations before and after 12 and 24 wk of treatment.
      Cognitive function was assessed before and after 24 wk of treatment with the use of an extensive neuropsychologic test battery that included the domains of attention, construction, sensomotor speed, memory and executive function.
      Results - Vitamin B-12 status did not change significantly after treatment in the placebo group; however, oral vitamin B-12 supplementation corrected mild vitamin B-12 deficiency.
      Vitamin B-12 + folic acid supplementation increased red blood cell folate concentrations and decreased tHcy concentrations by 36%.
      Improvement in memory function was greater in the placebo group than in the group who received vitamin B-12 alone (P = 0.0036).
      Neither supplementation with vitamin B-12 alone nor that in combination with folic acid was accompanied by any improvement in other cognitive domains.
      Conclusion - Oral supplementation with vitamin B-12 alone or in combination with folic acid for 24 wk does not improve cognitive function.
      Cfr. :
      Also read the comment on this article :
      Daily oral vitamin B-12 with or without folic acid for 24 weeks did not improve cognitive function in elderly people
      Lee PE, Rochon PA, University of British Columbia, Vancouver, British Columbia, Canada - Evid Based Med. 2007 Feb;12(1):18 - PMID: 17264266
      Cfr. :

    Lees verder : Deel II

    23-11-2009 om 00:58 geschreven door Jules

    0 1 2 3 4 5 - Gemiddelde waardering: 3/5 - (3 Stemmen)
    Tags:alcohol, ataxie, cobalamine, CVS, cyanocobalamine, extrinsic factor, foliumzuur, geheugen, homocysteïne, hydrocycobalamine, ileum, methylcobalamine, methylmalonzuur, moe, myeline, pernicieuze anemie, vermoeidheid, vis, vitamine B12, vlees, zuivelproduct
    >> Reageer (0)
    Klik hier om een link te hebben waarmee u dit artikel later terug kunt lezen.Vitamine B12-tekort - Een mogelijke oorzaak van Chronische vermoeidheid ? - Deel II
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    Vitamine B12-tekort
    - Een mogelijke oorzaak van Chronische vermoeidheid ? -

    Deel II

    1. Het belang van orale B12
      The Health Connection
      Sinds tientallen jaren injecteren mensen zich met vitamine B12 omdat ze dachten dat dit de beste manier was om het in de bloedbaan op te nemen.
      Nieuw onderzoek heeft aangetoond dat orale B12- supplementen beter zijn dan injecties.
      Mensen die tekorten hebben aan B12 in hun bloed zijn al heel lang aangewezen op de oncomfortabele en pijnlijke toedieningsvorm d.m.v. injecties met deze essentiële B-vitamine.
      Nieuwe onderzoeken tonen dat orale B12 net zo goed, zoniet beter, werkt als injecties, volgens een studie welke gepubliceerd werd in het gezaghebbende blad "Blood".
      Recente gegevens melden dat de orale absorptie net zo goed werkt als injecties en met een toegevoegde waarde van behoud van hoge bloedwaarden over langere tijd.
      De studie toont aan dat de bloedwaarde van mensen die injecties kregen na een maand daalde en zich daar stabiliseerde, terwijl de bloedwaarden van hen die de orale spray gebruikten stegen.
      Om B12 in het lichaam te kunnen opnemen wordt in de maag een stof (een proteïne) uitgescheiden welke essentieel is voor dit opnameproces.
      Dit wordt de 'intrinsieke factor' genoemd.
      Oudere mensen produceren minder van deze intrinsieke factor en zijn hierdoor gevoeliger voor B12 tekorten.
      In de eerder genoemde studie werden hoge doseringen orale B12 even goed opgenomen dan de geïnjecteerde dosering (verstoring van afgifte van intrinsieke factor wordt meestal geassocieerd met een chronisch B12-tekort ook bekend als pernicieuze anemie).
      Iedereen met verhoogde homocysteïne-gehalten, psychiatrische stoornissen, eetstoornissen, slaapstoornissen, alsmede als gevolg van het verouderingsproces, heeft mogelijk een tekort aan B12.
      Het is onderzocht dat het niveau aan B12 elk jaar daalt naarmate je ouder wordt.
      Leeftijdsgerelateerde B12 tekorten worden in verband gebracht met gehoorsvermindering, concentratieproblemen, geheugenvermindering, psychiatrische stoornissen, slaapstoornissen, alsmede hartklachten.
      "U kunt geen of onvoldoende B12 innemen via tabletten als u problemen heeft met de intrinsieke factor"
      De snelle opkomst van obesitas en de vele daaruit voorvloeiende chirurgische ingrepen, zoals maagverkleining en maagbypass, hebben een drastisch gevolg voor de productie van intrinsieke factor en de daardoor ontstane verstoringen.
      Voldoende vitamine B12-toediening "buiten het maagdarmkanaal om" is ook voor deze groep absolute noodzaak.
      Onze voeding en leeftijd en medische ingrepen zijn de belangrijkste boosdoeners bij het ontwikkelen van B12 tekorten.
      Vlees is een uitstekende bron voor onze B12.
      Toch is het niet zo dat een vleesrijk dieet garandeert dat iemand geen tekort heeft.
      Bijvoorbeeld oudere mensen, deze kunnen grote hoeveelheden vlees eten en toch een tekort aan vitamine B12 hebben omdat ze niet genoeg intrinsieke factor meer kunnen produceren als gevolg van veroudering van de maagfunctie en het maagslijmvlies waarin de intrinsieke factor geproduceerd wordt.
      B12 tekorten komen voor bij ruim 30% van de senioren en oudere mensen die regelmatig last hebben van een verstoorde spijsvertering / maag-darmfunctie.
      Het schijnt dat er nog een andere oorzaak is voor tekorten aan vitamine B12 bij ouderen maar dit moeten de onderzoekers nog verklaren.
      In een Nederlandse studie hebben onderzoekers ontdekt dat maar 28% van de mensen die een B12 tekort hebben, problemen hebben met hun intrinsieke factor.
      De overige 72% is, nog steeds, een raadsel.
      Wel weten de medici dat ook foliumzuur een grote rol in dit opnameproces speelt.
      Onderzoekers weten wel dat veel meer mensen tekorten hebben dan tot nu toe werd aangenomen.
      Toen onderzoekers aan het Veterans Hospital in Oklahoma standaard bijgestelde criteria gebruikten bij het testen van B12 tekorten, ontdekten ze dat B12 tekorten twee keer zo vaak voorkwam als bij voorgaande testen.
      "B12 tekort komt zo vaak voor dat het bij de artsen al standaard voorgedrukt staat op de formulieren voor bloedonderzoek"
      Diegenen met slaapproblemen, hebben mogelijk vitamine B12 nodig.
      Studies hebben laten zien dat B12 een vroegere vrijmaking van melatonine veroorzaakt tijdens de nacht, welke zorgt voor de juiste instelling van de natuurlijke slaap-waak-cyclus.
      B12 beïnvloed direct de pijnappelklier voor de prikkeling van een snellere productie van melatonine.
      Aan het eind van de cyclus zorgt B12 ervoor dat de productie van melatonine sneller stopt.
      B12 helpt je sneller in te slapen en kan helpen sneller te ontwaken als het daar tijd voor is.
      B12 activeert je systeem voor de zon 's morgens opkomt en het daglicht helpt je verder wakker te worden.
      Vele serieuze slaap-waak stoornissen zijn succesvol behandeld met orale B12.
      De opmerking dat B12 geïnjecteerd moet worden om effectief te zijn is in verschillende studies steeds weerlegd.
      Een factor waar velen het mee eens zijn is dat B12-supplementatie noodzakelijk is in deze tijden van snelle vergrijzing.
      De keuze is nu aan u : oncomfortabele injecties of een gemakkelijke en smakelijke spray.
      Cfr. :
    2. Het nut van vitamine B12 supplementen
      Diëtiste Tina de Vries – Animalfreedom – Bron : Lyra Alves in het magazine van EVA, zomer 2004
      Cfr. :
    3. How I treat cobalamin (vitamin B12) deficiency
      Carmel R, Department of Medicine, New York Methodist Hospital, Brooklyn, and Weill Medical College, Cornell University, New York, NY 11215, USA : - Blood. 2008 Sep 15;112(6):2214-21. Epub 2008 Jul 7 - PMID: 18606874
      The challenges in medical management of cobalamin deficiency lie in attention to the unique pathophysiology that underlies cobalamin deficiency, more than in the mechanics of therapy.
      The central physiologic principles are that clinically important deficiency is more likely to occur (and progress) when intrinsic factor-driven absorption fails than when diet is poor and that most causes take years to produce clinically obvious deficiency.
      Transient defects have little clinical impact.
      The key management principle is the importance of follow-up, which also requires knowing how the deficiency arose.
      The virtues of these principles are not always fully appreciated.
      Recent developments have made diagnosis and management more difficult by diminishing the ability to determine cobalamin absorption status.
      Clinicians must also grapple with premature medicalization of isolated, mild biochemical changes that added many asymptomatic cases of still undetermined medical relevance to their caseload, often expanded by inflated cobalamin level criteria.
      The potential for misattribution of cobalamin-unrelated presentations to nongermane cobalamin and metabolite abnormalities has grown.
      Pathophysiologically based management requires systematic attention to each of its individual components : correctly diagnosing cobalamin deficiency, reversing it, defining its underlying cause, preventing relapse, managing the underlying disorder and its complications and educating the patient.
      Cfr. :
      Increased concentrations of homocysteine in the cerebrospinal fluid in patients with fibromyalgia and chronic fatigue syndrome
      Regland B, Andersson M, Abrahamsson L, Bagby J, Dyrehag LE, Gottfries CG. Scand - J Rheumatol. 1997;26(4):301-7
      Cfr. :
    4. ME, daar doen we iets aan ! - Multi dimensionele behandeling bij elf patienten met chronische moeheid en het chronisch vermoeidheidssyndroom
      Th.J. Wijlhuizen, M. Hamerslag (e-mail : -) - ME/CVS Documentatiecentrum - Bron : Arts & Bedrijf, 1997/6/7
      Myalgische Encephalitis (afgekort 'ME') of correcter, het chronisch vermoeidheidssyndroom ('CVS' – cfr. : -) .../... staat de laatste jaren volop in de belangstelling.
      Hoewel het syndroom onder andere door de WHO is erkend, stuiten veel patienten in het dagelijks leven en in het contact met allerlei instanties nog op veel onbegrip rond deze aandoening.
      Omdat voor CVS nog geen aantoonbare lichamelijke oorzaak is gevonden wordt patienten dikwijls voorgehouden dat het allemaal tussen de oren zit .../...
      We staan nog maar aan het begin van een lang proces van onderzoek naar de oorzaken en behandeling van CVS .../...
      In dit artikel presenteren we een behandelmethode waarmee we een bijdrage willen leveren aan het onderzoek naar do oorzaken van en mogelijke oplossing voor CVS .../...
      Vitamine-B12-suppletie in de vorm van intramusculaire injecties wordt in Nederland vooral toegepast ter behandeling pernicieuze anaemie.
      Oorzaken hiervan kunnen zijn : hypo-en achloorhydie, intrinsic-factor-deficientie, bacteriele overgroei en parasitaire infecties, ziekten of resectie van het distale ileum en een enkele keer voedingsdeficientie bij veganisten.
      Door een opnametekort ontstaat een te lage bloedspiegel van vitamine B12.
      Uit onderzoeken blijkt dat een tekort aan vitamine B12, ondanks een (laag) normale bloedspiegel, geruime tijd kan bestaan zonder anaemie en neurologische verschijnselen.
      Waarschijnlijk is het beter vitamine B12 op celniveau te meten.
      Twee nieuwe bloedparameters, het plasma homocysteine- en het methylmalonzuurgehalte, geven een beter beeld van de functionele vitamine-B12-status.
      Vitamine B12 is noodzakelijk voor enzymen die deze twee metabolieten omzetten.
      Het heeft er overigens alle schijn van dat hoge spiegels van genoemde metabolieten het risico op hart- en vaatziekten significant verhogen.
      Bij een normale B12-spiegel en verhoging van plasmagehaltes van deze metabolieten, is sprake van een functioneel tekort.
      Een B12-tekort kan dus zelfs bestaan bij een normaal serum-cobalamine, normaal Hb en MCV.
      Meestal zit de B12-spiegel dan in de laag-normale rangen (150-300 mcg/L).
      De neurologische schade die een langere periode van B12-tekort teweeg kan brengen, kan dus optreden zonder de klassieke haematologische afwijkingen die hieraan worden geacht vooraf te gaan.
      Ook kunnen hierbij allerlei neuropsychologische stoornissen zijn.
      Vitamine B12-tekort kan overigens zelfs samen gaan met een normaal resultaat van de Schilling-test.
      Hypothese ten aanzien van de werking van vitamine B12 bij CVS-patienten
      In orthomeleculaire kringen en bij topsporters is het al geruime tijd bekend dat vitamine B12 het herstel van vermoeidheid en overbelasting kan bevorderen.
      Volgens informatie van de fabrikant wordt door artsen in Belgie B12 regelmatig voorgeschreven bij pijn-klachten en vermoeidheid, in hogere doses dan wij gewend zijn. (tot 5000 microgram i.m. per twee dagen).
      In tegenstelling tot sommige andere vitamines zijn er geen schadelijke bijwerkingen van een hoge dosis bekend.
      Vitamine B12 is wel toegepast bij CVS-patienten, in de relatief lage doses die men in Nederland gewoon is (oplaaddoses van drie tot zes maal 1000 microgram en daarna een onderhoudsdosering van 1000 microgram per maand).
      Mogelijk is dit voortgekomen uit het gebruik van zogenaamde lever-injecties uit de tijd dat het mechanisme van pernicieuze anaemie en vermoeidheid nog niet opgehelderd is.
      Voor dit alternatieve gebruik van een regulier geneesmiddel is vooralsnog geen rationeel bewijs.
      Bij 1000 microgram i.m. injecties wordt door CVS-patienten wel vaak een geringe verlichting van de klachten ervaren.
      De mogelijke werkingen van hoge dosis vitamine B12 zijn
      1. Een metabole werking, namelijk het faciliteren van biochemische reacties voor de omzetting van methylmalonzuur en homocysteine in andere, minder schadelijke stoffen.
      2. Een overschot aan vitamine B12, dat snel via de urine wordt uitgescheiden, bindt de schadelijke stof X, die daarmee uit het lichaam wordt verwijderd.
      3. Moleculen die zich hechten op receptoren van zenuwbanen die daardoor (onterechte) sensaties van pijn en vermoeidheid doorgeven, kunnen daarvan worden verdreven door hoge doses B12.
      4. Hoge dosis vitamine B12 beinvloedt een te lage intracellulaire B 12-spiegel gunstiger dan een lage dosis.
      Cfr. :
    5. Myalgic encephalomyelitis – Letter
      Simpson LO - J R Soc Med 1991;84:633
      Cfr. :
    6. Oral cyanocobalamin supplementation in older people with vitamin B12 deficiency - A dose-finding trial
      Simone J. P. M. Eussen, MSc; Lisette C. P. G. M. de Groot, PhD; Robert Clarke, MD; Jörn Schneede, MD; Per M. Ueland, MD; Willibrord H. L. Hoefnagels, MD, PhD; Wija A. van Staveren, PhD - Author affiliations : Division of Human Nutrition, Wageningen University, Wageningen, the Netherlands (Ms Eussen and Drs de Groot and van Staveren); Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, England (Dr Clark); LOCUS of Homocysteine and Related Vitamins, University of Bergen, Bergen, Norway (Drs Schneede and Ueland); and Department of Geriatrics, Hospital St Radboud, Nijmegen, the Netherlands (Dr Hoefnagels) - Arch Intern Med. 2005;165:1167-1172
      Background - Supplementation with high doses of oral cobalamin is as effective as cobalamin administered by intramuscular injection to correct plasma markers of vitamin B12 deficiency, but the effects of lower oral doses of cobalamin on such markers are uncertain.
      Methods - We conducted a randomized, parallel-group, double-blind, dose-finding trial to determine the lowest oral dose of cyanocobalamin required to normalize biochemical markers of vitamin B12 deficiency in older people with mild vitamin B12 deficiency, defined as a serum vitamin B12 level of 100 to 300 pmol/L (135-406 pg/mL) and a methylmalonic acid level of 0.26 µmol/L or greater.
      We assessed the effects of daily oral doses of 2.5, 100, 250, 500 and 1000 µg of cyanocobalamin administered for 16 weeks on biochemical markers of vitamin B12 deficiency in 120 people.
      The main outcome measure was the dose of oral cyanocobalamin that produced 80% to 90% of the estimated maximal reduction in the plasma methylmalonic acid concentration.
      Results - Supplementation with cyanocobalamin in daily oral doses of 2.5, 100, 250, 500 and 1000 µg was associated with mean reductions in plasma methylmalonic acid concentrations of 16%, 16%, 23%, 33% and 33%, respectively.
      Daily doses of 647 to 1032 µg of cyanocobalamin were associated with 80% to 90% of the estimated maximum reduction in the plasma methylmalonic acid concentration.
      Conclusion - The lowest dose of oral cyanocobalamin required to normalize mild vitamin B12 deficiency is more than 200 times greater than the recommended dietary allowance, which is approximately 3 µg daily.
      Cfr. :

    7. Stichting B12 Tekort
      Stichting B12 Tekort is een organisatie die opkomt voor de belangen van mensen met een opnamestoornis van vitamine B12.
      Dit doet zij onder meer door het geven van voorlichting, het bieden van ondersteuning, het organiseren van bijeenkomsten en het bevorderen van lotgenotencontact.
      Op deze website treft u informatie aan die voor u van belang kan zijn, zoals :
      - welke klachten horen bij een tekort aan vitamine B12 ?
      - welke onderzoeken kunnen gedaan worden om de diagnose te stellen ?
      - hoe kan het behandeld worden ?
      - wat kan er in verband met vitamine B12 nog meer belangrijk zijn ?
      Verder kunt u (links naar) wetenschappelijke artikelen vinden over een tekort aan vitamine B12 en alles wat daar mee te maken heeft.
      Dit overzicht wordt voortdurend bijgewerkt.
      Cfr. :

    8. Studies of biomarker responses to intervention with vitamin B-12 - A systematic review of randomized controlled trials
      Hoey L, Strain JJ, McNulty H, Northern Ireland Centre for Food and Health, School of Biomedical Sciences, University of Ulster, Coleraine, Northern Ireland, United Kingdom : - Am J Clin Nutr. 2009 Jun;89(6):1981S-1996S. Epub 2009 Apr 29 - PMID: 19403638
      Background - Mild vitamin B-12 deficiency is common among older adults, but evidence for setting dietary recommendations is limited because most studies have administered vitamin B-12 via nonoral routes or at doses several hundred times higher than current recommendations.
      Furthermore, different biomarkers of vitamin B-12 status have not been systematically reviewed.
      - The aim was to assess the effectiveness of biomarkers of vitamin B-12 status through a systematic review of published randomized controlled trials of oral vitamin B-12 supplementation.
      - Methods included a structured search strategy on Ovid MEDLINE, EMBASE (Ovid) and Cochrane databases; formal inclusion and exclusion criteria; data extraction; validity assessment; and meta-analysis.
      - Eight randomized controlled trials were included and all studies measured serum and plasma total vitamin B-12, 3 studies measured methylmalonic acid and 6 studies measured total homocysteine response.
      All 3 biomarkers were found to be effective measures of altered vitamin B-12 intake in populations with low and borderline baseline vitamin B-12 status (P < 0.00001); however, in the case of total vitamin B-12, substantial heterogeneity that could not be fully explained by subgroup analysis was observed.
      Insufficient data were available to determine the effectiveness of plasma holotranscobalamin, which was measured in only one randomized controlled trial.
      - The available evidence suggests that plasma and serum concentrations of total vitamin B-12, methylmalonic acid and total homocysteine are all effective biomarkers of a change in vitamin B-12 intake; however, because the available data were limited, it was not possible to examine fully the factors that could explain the substantial heterogeneity in total vitamin B-12.
      Future trials should include low-dose vitamin B-12 in adults across the entire age spectrum and measure the holotranscobalamin response to supplementation.
      Cfr. :

    9. The rationale for using high-dose cobalamine
      Lapp CW, Cheney PR - The CFIDS Chronicle Physicians' Forum Fall 1993;19-20
      Cfr. :

    10. Vitamine B12 - Een eenvoudige oplossing
      Is het voor vegetariërs niet moeilijk om voldoende B12 te krijgen ?
      Voeding & Gezondheid, 10/12/98 – Bron : Physicians Committee for Responsible Medicine, U.S.A

      Cfr. :

    11. Vitamine B12 & een B12 tekort
      Een Gezond Diëet, 19-11-2006
      Volgens Deense onderzoekers zou een tekort aan vitamine B12, ook wel cobalamines genaamd, meer voorkomen dan we denken, vooral bij senioren.
      Vandaar hun voorstel om de aanbevolen dagelijkse hoeveelheid (ADH) te verhogen .../...
      Cfr. :

    12. Vitamine B12 en de relatie met CVS/FM
      Fibromyalgie, 17-12-2007

    13. Vitamine B12 en ouderen
      Stichting B12 Tekort
      Cfr. :

    14. Vitamine B12 en veganisme
      Vita Casa plus
      Cfr. :

    15. Vitamine B12 en veganisme – Een literatuurstudie
      Michèl Post - Uitgeverij Den Giraffe, Utrecht 1993 - ISBN: 90-801275-1-5
      Cfr. :

    16. Vitamine B12 of cobalamine
      Voedingscentrum, 08-08-2008
      Cfr. :

    17. Vitamine B12 tekort
      Cfr. :

    18. Vitamine B12-tekort bij ouderen
      R.S.v. 55 + - Bron :
      De Wageningen Universiteit plaatste onlangs een advertentie met de boodschap dat ouderen baat kunnen hebben bij grote hoeveelheden vitamine B12.
      Deze stelling geldt nadrukkelijk alleen voor ouderen met maagaandoeningen die de opname van vitamine B12 beperken of belemmeren.
      Alleen in die gevallen is, in overleg met de arts, extra vitamine B12 nodig.
      Ouderen die extra vitamines willen nemen, kunnen een multivitaminesupplement gebruiken met niet meer dan de Aanbevolen Dagelijkse Hoeveelheid (ADH).
      Bij ouderen kan er sprake zijn van een gestoorde aanmaak of werking van de zogenaamde Intrinsic Factor (IF) in het maagdarmkanaal.
      Door deze aandoening kan het lichaam vrijwel geen (minder dan 1%) vitamine B12 meer opnemen.
      Deze zeldzame aandoening komt bij ongeveer 1 tot 2 op de 1000 personen voor.
      Zij moeten hiervoor worden behandeld door een arts.
      Verminderde opname
      Bij een veel grotere groep ouderen, naar schatting 20-25%, wordt wel voldoende Intrinsic Factor geproduceerd, maar de vitamine B12 minder goed opgenomen uit de voeding.
      Dit is mogelijk een gevolg van maagdarminfecties en/of maagaandoeningen met een verminderde maagzuurproductie.
      Omdat het lichaam eerst de vitamine B12-voorraad in de lever gebruikt, leidt de verminderde opname pas na lange tijd tot een vitamine B12-tekort.
      Vitamine B-12 uit supplementen, ook normale doseringen van eenmaal de Aanbevolen Dagelijkse Hoeveelheid, wordt wel goed opgenomen door het lichaam.
      Klachten bij een tekort
      Alleen de arts kan vaststellen of er sprake is van een vitamine B12-tekort.
      Een chronisch tekort aan vitamine B12 leidt uiteindelijk tot een vorm van bloedarmoede.
      Ook neurologische gevolgen zoals tintelingen in de vingers, geheugenverlies, coördinatiestoornissen en spierzwakte in de benen kunnen het gevolg zijn.
      Soms is er bij deze klachten geen sprake van afwijkingen in het bloedbeeld.
      Vitamine B12 en ouderdomsverschijnselen
      Er zijn aanwijzingen dat lage vitamine B12-gehaltes in het bloed leiden tot depressiviteit, vergeetachtigheid en dementie.
      Toch is hiervoor nog onvoldoende bewijs.
      Ook de beschermende werking van het slikken van extra vitamine B12 tegen dit soort ouderdomsverschijnselen is nog onvoldoende aangetoond.
      Het Voedingscentrum adviseert ouderen daarom niet op eigen houtje hoge doseringen vitamine B12 te gebruiken.
      Er is geen bezwaar tegen het gebruik van een multivitaminesupplement met niet meer dan de Aanbevolen Dagelijkse Hoeveelheid.
      Ga met klachten altijd eerst naar de (huis)arts.
      Cfr. :

    19. Vitamine B12-tekort onderschat
      Arend van Wijngaarden - De Gelderlander, 12-09-2007 (laatst bijgewerkt : 05-10-2009)
      Cfr. :

    23-11-2009 om 00:51 geschreven door Jules

    0 1 2 3 4 5 - Gemiddelde waardering: 1/5 - (2 Stemmen)
    Tags:adenosylcobalamine, ataxie, bloedarmoede, cobalamine, CVS, cyanocobalamine, extrinsic factor, foliumzuur, geheugen, homocysteïne, hydrocycobalamine, ileum, maagsap, methylcobalamine, methylmalonzuur, moe, myeline, pernicieuze anemie, vis, vlees
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