Chronic fatigue syndrome and DSM-IV personality disorders

Abstract

Objective

Personality is an important factor in the research of the chronic fatigue syndrome (CFS). Although some studies report a high rate of personality disorders—around the 40% level—in samples of patients with CFS, the generalizability of these findings can be questioned. The present study evaluates the prevalence of Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) personality disorders in a sample of female CFS patients and in two control groups.

Method

The ADP-IV questionnaire (Assessment of DSM Personality Disorders IV) was used to assess the DSM-IV-TR personality disorders at a dimensional and categorical level in a sample of 50 female CFS patients and in two matched control samples of Flemish civilians (n=50) and psychiatric patients (n=50).

Results

The results indicate a striking lack of statistical significant differences between the CFS sample and the Flemish control group at the level of dimensional Trait scores, number of criteria, and prevalence rates of personality disorder diagnoses. Unsurprisingly, higher scores at these levels were obtained within the psychiatric sample. The prevalence of an Axis II disorder was 12% in the Flemish and CFS samples, whereas the psychiatric sample obtained a prevalence of 54%.

Conclusion

The prominent absence of any significant difference in personality disorder characteristics between the female Flemish general population and the CFS samples seems to suggest only a minor etiological role for personality pathology, as defined by the DSM-IV Axis II, within CFS.

Introduction

Chronic fatigue syndrome (CFS) is a disabling illness that encompasses several health problems with extreme fatigue being the fundamental symptom. Nevertheless, a lack of consensus exists on its etiology since research has been unable to bring forward irrefutable evidence for a biological marker or physical proof. Studies on CFS have proposed several etiological factors, including viral infections, immune dysfunction, dysfunctions in neuroendocrinology, underlying psychiatric disorders, and cognitive impairment. However, there is no consistent evidence for any of these hypotheses [1]. One line of research investigates the psychiatric status of patients with CFS and emphasizes the high prevalence rates of concurrent disorders such as depression [1], somatization disorder, and hypochondriasis [1].

Some researchers explored the relationship between personality characteristics such as personality traits and disorders and CFS. CFS personality characteristic including attribution style [2], [3], [4], [5], [6], alexithymia [7], perfectionism [8], [9], [10], [11], [12], and action-proneness [13], [14] have been studied. According to these findings, CFS subjects have a tendency to minimize psychological contributions to their illness [3] and to view the causes for bad events as external, stable, and global [2]. A depressive attributional style or “learned helplessness” which is related to prolonged exposure to uncontrollable aversive events and comprises the belief that positive outcomes or the avoidance of aversive consequences are unobtainable is found to be a typical feature within the CFS population [3]. Marked externalization, lack of awareness of emotions, difficulty distinguishing emotions from bodily sensations, and difficulty verbalizing emotions are features of the multidimensional construct alexithymia, which is also associated with CFS [7]. Some researchers propose that CFS subjects have a maladaptive perfectionist personality style, which involves severe self-criticism and is associated with dissatisfaction with aspects of oneself, with personal relationships, and with life in general [8]. In one study, the clinical impression that a premorbid hyperactive lifestyle frequently precedes the onset of CFS was examined. CFS subjects were found to be more “action-prone,” i.e., oriented toward direct action and achievement, putting themselves at risk of acute or chronic physical overload and/or sleep deprivation [13]. Recent research by our group compared the Temperament and Character Inventory [15], [16] profiles of CFS patients and healthy controls and found significant higher scores on the dimensions of Harm Avoidance and Persistence [17]. The elevated Harm Avoidance suggests that CFS patients tend to be more cautious, careful, fearful, insecure, or pessimistic even in situations that do not worry other people, whereas the increased score on Persistence indicates that CFS persons tend to be industrious, hardworking, and stable despite frustration and fatigue [17].

A review shows that only a small number of studies focused on the relationships between the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) personality disorders [18], [19], [20], [21], [22], [23], [24], [25] and CFS. In a study by Johnson et al. [26], individuals with CFS were compared with healthy controls, patients with mild multiple sclerosis, and patients with depression. Each sample was scored according to the Personality Disorder Questionnaire (PDQ)-Revised (PDQ-R) [27], [28], [29]. The rates of at least one personality disorder diagnosis according to the PDQ-R varied between 88% in the depressed group, 41% in the multiple sclerosis group, 37% in the CFS group, and 11% in the healthy control group. The personality disorders most represented in the CFS group were histrionic and borderline. The subgroup of CFS patients with a comorbid depression diagnosis accounted for most of the personality pathology observed in CFS. Two more recent studies [30], [31] also found a high level of personality disorder (39%) in CFS patients. The study of Henderson and Tannock [30] used the Structured Clinical Interview-II (SCID-II) to obtain a DSM, Revised Third Edition Axis II diagnosis, whereas Ciccone et al. [31] employed the PDQ-4 self-report questionnaire in order to evaluate DSM-IV personality disorder diagnoses. Both studies concluded a high prevalence of Axis II disorders in CFS, which cannot be explained by comorbid depression [26] or other psychiatric disorders on Axis I of the DSM-IV [31]. The personality disorders most prominent within the CFS groups were Cluster C disorders and, most specifically, the obsessive–compulsive personality disorder. The purpose of the present study is to assess the elevated prevalence—at the 40% level—of DSM-IV Axis II personality disorders in CFS. Indeed, Axis II disorders are known to be associated with negative outcome of Axis I disorder treatment and are deemed a very important factor to consider when investigating CFS [26], [32]. For this purpose, dimensional scores and categorical DSM-IV Axis II diagnoses were obtained with the Assessment of DSM Personality Disorders IV (ADP-IV) questionnaire in three well-matched groups of respectively female CFS patients, psychiatric patients, and a female sample of the general Flemish population.