Source: Clinical Psychology Review
Preprint
Date: January 27, 2007
URL: http://www.sciencedirect.com/science/journal/02727358
Personality and chronic fatigue syndrome: Methodological and conceptual issues
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Stefan M. van Geelen(a), Gerben Sinnema(a), Hubert J.M. Hermans(b), Wietse
Kuis(c,*)
a Department of Psychology, Wilhelmina Children's Hospital, University Medical
Center Utrecht, The Netherlands
b Faculty of Clinical Psychology and Personality, Radboud University Nijmegen,
The Netherlands
c Department of Immunology, Wilhelmina Children's Hospital, University Medical
Center Utrecht, The Netherlands
* Corresponding author. Division of Pediatrics, Wilhelmina Children's Hospital,
University Medical Center Utrecht, P.O. Box 85090, KB.03.023.2,
3508 AB, Utrecht, The Netherlands.
E-mail address: [log in to unmask] (W. Kuis).
Received 9 December 2005; received in revised form 29 November 2006; accepted
19 January 2007
Abstract
Among clinical psychologists, consulting physicians, scientific researchers
and society in general an image has emerged of patients with chronic fatigue
syndrome (CFS) as perfectionist, conscientious, hardworking, somewhat
neurotic and introverted individuals with high personal standards, a great
desire to be socially accepted and with a history of continuously pushing
themselves past their limits. The aim of this article is to (a) give a
concise review of the main recent studies on personality and CFS, (b) address
the major methodological problems in the study of personality in CFS and (c)
discuss some of the conceptual assumptions that seem to limit the research on
personality and CFS. The results of the reviewed studies range from no
evidence of major differences between the personalities of patients with CFS
and controls, to evidence of severe psychopathology and personality disorder
in patients with CFS. Although personality seems to play a role in CFS, it is
difficult to draw general conclusions on the relation between personality and
CFS. It is argued that this is partially due to the diversity and
heterogeneity in study methods, patient populations, control groups and CFS
case definitions. Personality should be regarded as an important factor to be
studied in CFS. However, additional studies are needed, not focusing
exclusively on personality disorder, or personality considered on a general
trait level. In recent developments in personality research, the continually
evolving life narrative that makes sense of, and gives direction to, an
individual's life is also regarded as an important aspect of personality. New
insights into personality and CFS might be gained by systematically studying
the self-narratives of patients with the syndrome.
Keywords: Chronic fatigue syndrome; Personality; Clinical psychology;
Narrative; Medicine
1. Introduction
This article's main concern is the study of personality in the chronic
fatigue syndrome (CFS). CFS is a syndrome of unknown origin. It is mainly
characterized by a severely disabling fatigue and it is commonly associated
with symptoms such as myalgias, headache, sleep disturbance, swollen lymph
nodes and cognitive impairment. In recent years CFS has become a growing
concern, not only for patients suffering from the illness and for their
families, but also for medical science, clinical psychology and society in
general.
Some of these concerns already become apparent in defining what CFS is. In
many cases, it is difficult to distinguish between idiopathic chronic
fatigue, CFS and other unexplained medical conditions such as fibromyalgia,
tension headache and irritable bowel syndrome, as these seem to be very
similar and substantially overlapping (Aaron & Buchwald, 2001; Wessely,
Nimnuan, & Sharpe, 1999). As no causes for CFS are found and definite markers
for the illness are absent, the diagnostic process is usually extended and
patients have to go through a whole battery of laboratory tests, physical
examinations and psychological investigations before they are diagnosed with
CFS. In 1988, the US Centers of Disease Control (CDC) proposed a set of
diagnostic criteria to facilitate scientific research into CFS (Holmes et
al., 1988). However, these criteria were criticized, not only because a large
number of symptoms had to be present for a diagnosis of CFS, which might bias
in favor of psychiatric morbidity (Katon & Russo, 1992), but also because it
excluded such conditions as anxiety and depression, which some propose to be
a result of the syndrome (Ray, 1991; Van Hoof, Cluydts, & De Meirleir, 2003).
Therefore, less restrictive criteria were developed, amongst others in the UK
by Sharpe et al. (1991). Consequently, the CDC criteria were also revised
(Fukuda et al., 1994). At present these criteria are generally accepted and
used for international research purposes. In Table 1 these criteria are
presented.
Estimations on the prevalence of CFS range from 37/100 000 (Lloyd, Hickie,
Boughton, Spencer, & Wakefield, 1990), to 75-267/100 000 (Buchwald et al.,
1995), and even 740/100 000 (Lawrie, Manders, Geddes, & Pelosi, 1997).
However, these numbers are difficult to compare as different populations were
studied and varying CFS case definitions were used. Estimations on the
incidence of CFS are rare but, based on their assumptions with regard to the
prevalence of CFS, Lawrie et al. (1997) estimated the annual incidence of CFS
to be 370/100 000.
Full recovery from CFS is unusual. In a recent review (Cairns & Hotopf, 2005)
of studies on the prognosis of CFS, it was found that the median full
recovery rate was only 5% and the median proportion of patients who had
improved during follow-up was 39.5%. The prognosis for children and
adolescents however, is generally somewhat better (Patel, Smith, Chalder, &
Wessely, 2003). In a recent follow-up study of adolescent patients with CFS
(Gill, Dosen, & Ziegler, 2004) it was found that, at a mean of 4.57 years
after initial examination, 25% of the patients showed near to complete
improvement and 31% showed partial improvement.
Etiological studies into the possible causes of CFS have been abundant.
Active viral infection has frequently been associated with the symptoms of
CFS, but evidence for this hypothesis has not consistently been found. There
appear to be no significant differences between patients with CFS and healthy
controls in the prevalence of human herpes viruses, Epstein-Barr virus,
cytomegalovirus, hepatitis C virus, adenovirus and parvovirus B19, amongst
many others. (Buchwald, Ashley, Pearlman, Kith, & Komaroff, 1996; Koelle et
al., 2003; Wallace, Natelson, Gause, & Hay, 1999).
Immune dysfunction is another possible etiological factor that has been
widely studied. Chronic lymphocyte overactivation with cytokine abnormalities
in patients with CFS, associations between T cell markers and CFS, and
associations between low natural killer cells and CFS have all been reported
(Patarca-Montero, Antoni, Fletcher, & Klimas, 2001; Straus, Fritz, Dale,
Gould, & Strober, 1993). However, in a recent systematic review of the
immunology of CFS, the authors noted that studies supporting almost any
conclusion regarding the presence, or absence of immunological abnormalities
in CFS could now be found, and concluded that no consistent pattern could be
identified (Lyall, Peakman, & Wessely, 2003).
The same holds true of studies on the role of the neuroendocrine system in
CFS. Disturbed neuroendocrineimmune system interactions, low circulating
cortisol, high nocturnal melatonin, abnormalities in the relationship between
cortisol and central neurotransmitter function, a disturbance of
neurotransmitters in HPA axis function, and alterations in adrenal function
in CFS have all been suggested and some evidence for these claims has been
found (Cleare, Blair, Chambers, & Wessely, 2001; Demitrack et al., 1991;
Kavelaars, Kuis, Knook, Sinnema, & Heijnen, 2000; Knook, Kavelaars, Sinnema,
Kuis, & Heijnen, 2000; Segal, Hindmarsh, & Viner, 2005). Again however, in an
extensive review on the neuroendocrinology of CFS, it was concluded that no
consistent evidence of abnormalities could be found and that it was unclear
whether neuroendocrine changes (if any) are primary or secondary to
behavioral changes in sleep or exercise (Parker, Wessely, & Cleare, 2001).
Along other lines of research, the psychiatric status of patients with CFS
has received much attention. Several studies have reported a high prevalence
of current psychiatric disorders in CFS, predominantly depression,
somatization disorder and hypochondria (Ciccone, Busichio, Vickroy, &
Natelson, 2003; Schweitzer, Robertson, Kelly, & Whiting, 1994). However,
while some studies concluded that psychiatric illness in many cases predated
the development of CFS (Katon, Buchwald, Simon, Russo, & Mease, 1991; Lane,
Manu, & Matthews, 1991), other studies concluded that psychiatric disorder
was concurrent with the onset of CFS and therefore more likely to be a
consequence of, rather than a risk factor to CFS (Axe & Satz, 2000; Hickie,
Lloyd, Wakefield, & Parker, 1990). In that case, CFS is not seen as a
manifestation of an underlying psychiatric disorder and more somatic causes
are presumed (Komaroff & Buchwald, 1998).
Neuropsychological deficits and impaired cognitive functioning in patients
with CFS have also received widespread attention, and have frequently been
implied to be an important explanatory factor for some of the symptoms of
CFS. People with CFS often complain of difficulties with memory and
concentration. Several studies have described an impaired cognitive
performance of patients with CFS on neuropsychological tests measuring speed
of information processing, memory, motor speed and executive functioning
(Busichio, Tiersky, Deluca, & Natelson, 2004; Cluydts & Michiels, 2001).
Problems with neuropsychological functioning were found to be unrelated to
depression, fatigue or anxiety (Short, McCabe, & Tooley, 2002) and have
instead been related to low levels of physical activity (Vercoulen et al.,
1998), a more extensive use of frontal and parietal brain regions (Lange et
al., 2005) and even genetic traits (Mahurin et al., 2004). In contrast with
this, many other studies have found no difference in cognitive performance
between patients with CFS and controls, and no evidence of any
neuropsychological deficits in CFS (Fry & Martin, 1996; Schmaling,
DiClementi, Cullum, & Jones, 1994). However, although in many studies
objectively no cognitive differences between patients with CFS and controls
are found, patients with CFS consistently report cognitive complaints and
underestimate their actual performance on neuropsychological tests. This
difference between the subjective perception of cognitive impairment and the
absence of any objective evidence has led some researchers to speculate that,
in contrast to laboratory cognitive tests, in CFS everyday cognitive tasks
may require excessive processing resources leaving patients with CFS
diminished spare attentional capacity (Wearden & Appleby, 1996), and other
researchers to suggest that patients with CFS set impossibly high standards
of personal performance (Metzger & Denney, 2002).
Other risk factors for the development of CFS that have been implied (and for
which some evidence has been found) are birth order (Brimacombe, Helmer, &
Natelson, 2002), family reinforcement of illness behavior (Brace,
Scott-Smith, McCauley, & Sherry, 2000), maternal overprotection in relation
to the formation of belief systems about activity avoidance (Fisher &
Chalder, 2003) and a family history of physical and mental illness (Endicott,
1999). However, as with all of the etiological studies that have been
discussed so far, the contrary conclusions can also be found. In a large
birth cohort study into childhood predictors of CFS in adulthood, in which
more than 11 000 people were followed up until the age of 30, no associations
between maternal or child psychological distress, parental illness or birth
order, and an increased risk of lifetime CFS were identified (Viner & Hotopf,
2004).
There have also been many studies into possibly effective treatment
strategies for CFS. However, presently there is no established, universally
beneficial intervention for the management and treatment of CFS (Whiting et
al., 2001). With regard to medical and pharmacological treatment, amongst
others, intramuscular dialyzable leukocyte extract (Lloyd et al., 1993),
intravenous immunoglobulin (Vollmer-Conna et al., 1997), hydrocortisone
(McKenzie et al., 1998) and antidepressants (Vercoulen et al., 1996; Natelson
et al., 1998) were investigated in placebo-controlled studies, without
proving their effectiveness. Recently, the effects of galantamine
hydrobromide (Blacker et al., 2004), polynutrient supplements (Brouwers, Van
der Werf, Bleijenberg, Van der Zee, & Van der Meer, 2002), homeopathic
treatment (Weatherley-Jones et al., 2004) and corticosteroids (Kakumanu,
Mende, Lehman, Hughes, & Craig, 2003) have been studied in randomized
controlled trials, but were also found to be ineffective. At the moment, only
cognitive behavior therapy (Price & Couper, 2000; Prins et al., 2001; Sharpe,
1998) and graded exercise therapy (Wallman, Morton, Goodman, Grove, &
Guilfoyle, 2004; Edmonds, McGuire, & Price, 2004) have shown some
effectiveness, for a proportion of patients, in randomized controlled trials.
So, CFS seems surrounded by controversy. Patients are confronted with a
highly ambiguous illness that severely incapacitates them. In addition to
this they suffer from the consequences of the unclear medical status of the
disease. Due to the uncertainties surrounding the etiology of CFS, its
symptomatology and the overall objective 'realness' of the syndrome, they are
likely to encounter disbelief concerning their medical condition (Friedberg &
Jason, 2001). At present it is being discussed whether the impact of labeling
patients with a diagnosis of CFS is enabling, or rather disabling (Huibers &
Wessely, 2006). In the absence of a clear biological marker for the illness,
which would permit a definite diagnosis instead of a descriptive one, based
almost solely on the exclusion of other disease entities, patients are often
faced with skepticism by their families, employers, insurance companies,
psychologists and physicians. In a recent study on illness experience in CFS
it was found that lack of illness recognition ranked high as a source of
dissatisfaction for patients and was thought to aggravate psychiatric
morbidity (Lehman, Lehman, Hemphill, Mandel, & Cooper, 2002). In contrast
with this, physicians participating in a study on their perspectives on
patients with CFS (Asbring & Narvanen, 2003) expressed the view that patients
seem to exaggerate the severity of their problems, and that there appears to
be a discrepancy between their reported health and the way they look and
behave.
Although it has been widely recognized that a positive and co-operative
caregiver-patient relationship is of the utmost importance in the successful
treatment of CFS (Sharpe, Chalder, Palmer, & Wessely, 1997), uncertainty and
conflicts about the causal attribution of the syndrome, in many cases, put
this relationship under pressure. Steven et al. (2000) showed that one-third
of a group of more than two-thousand general practitioners did not believe
that CFS was a distinct syndrome and thought the most likely cause was
depression. This finding was confirmed by another study in which it became
clear that while most of the doctors participating in the study believed CFS
to have a psychological cause, all of the patients attributed their illness
to a physical cause (Deale & Wessely, 2001). This disagreement over the
perceived origins of CFS was thought to largely account for the fact that
two-thirds of the patients in this study were dissatisfied with the quality
of the medical care they had received.
This same dispute about the etiology of the syndrome, in combination with
concerns about its nosological status, seems to have characterized and
dichotomized medical and psychological thought on CFS. In spite of the great
advances medical science has made in the explanation and treatment of
diseases with an evident organic cause, the causes for CFS remain unclear and
our understanding of the illness progresses only slowly. This "prototypical
mind/ body problem" (Johnson, DeLuca, & Natelson, 1999, p. 258) seems to
confront medicine with the limitations of the traditional paradigm, through
which it has made such progress in the understanding and treatment of
'classical' diseases. As is now widely acknowledged the debates on chronic
fatigue and immune dysfunction syndrome, neurasthenia, postviral fatigue
syndrome, myalgic encephalomyelitis, chronic mononucleosis and chronic
Epstein-Barr virus infection, as CFS was formerly known, were, and not
uncommonly still are, characterized by a mind/body dualism that seems
inherent to a biomedical model of thought, oriented towards monocausal
explanation (Lewis, 1996; Taerk & Gnam, 1994; Ware, 1994). On the one hand,
there are those who believe that CFS is initiated by a still unknown physical
cause such as a chronic or relapsing viral infection, immunological
deficiencies or abnormalities in the neuroendocrinological system. The
absence of a clear and objective organic cause, on the other hand, leads
others to relegate CFS to the realm of the mental and 'subjective' illnesses.
In that case CFS is mostly thought of as a psychiatric disorder (e.g. a
masked expression of depression, or a form of somatization), or a cognitive
phenomenon.
However, a more logical explanation of the variety of findings and opinions
on CFS would be that the illness is multifactorial. Social, mental and
somatic causes, and psychological and physical effects are not easily
discernible, but instead appear to be interrelated. In recent years, a more
biopsychosocial approach in the scientific research into CFS has become the
standard (Main, Richards, & Fortune, 2000). In line with this approach (and
in addition to the already mentioned studies) researchers have now also begun
to study the iatrogenic factors in CFS (Deale & Wessely, 2001), associations
in symptoms between patients with CFS and their parents (Van de Putte et al.,
2006), the illness beliefs and attributions of patients with CFS (Deale,
Chalder, & Wessely, 1998; Van Houdenhove, Neerinckx, Onghena, Lysens, &
Vertommen, 2000), the psychological adjustment of patients with CFS (Van
Middendorp, Geenen, Kuis, Heijnen, & Sinnema, 2001), the health-related
quality of life of patients with CFS (Hardt et al., 2001), the locus of
health control in patients with CFS (Van de Putte et al., 2005), the
relationship between ethnicity and CFS (Luthra & Wessely, 2004), the coping
strategies of patients with CFS (Ax, Gregg, & Jones, 2001), the influence of
family members in CFS (Gray et al., 2001), the cultural and historical
context of CFS (Abbey & Garfinkel, 1991; Ware, 1994; Ware & Kleinman, 1992;
Wessely 1990; Wessely, 1996) and the personalities of individuals who have
developed CFS (reviewed in this article).
So, within the biopsychosocial model of CFS one of the aspects studied, that
might have a perpetuating and even a predisposing role in the syndrome, is
the personality of people suffering from CFS. Among clinical psychologists,
consulting physicians, scientific researchers and in society in general, a
typical image has emerged of patients with CFS as perfectionist,
conscientious, hardworking, somewhat neurotic and introverted individuals
with high personal standards, a great desire to be socially accepted and with
a history of continuously pushing themselves past their limits. (Lewis,
Cooper, & Bennett, 1994; Surawy, Hackmann, Hawton, & Sharpe, 1995). In
addition to this, they are characterized as being particularly averse to any
psychological or psychiatric explanation of the syndrome and extremely
persistent in fixed beliefs concerning their illness, thereby reducing the
chance of successful treatment (Sharpe, 1998). However, this image of people
suffering from CFS was never really scrutinized, with most of the research
activity concerning the individual with CFS focusing on psychopathology and
possible psychiatric disorder.
The aim of this article is to (a) give a concise review of the main recent
studies on personality and CFS, (b) address the major methodological problems
in the study of personality in CFS and (c) discuss some of the conceptual
assumptions that seem to limit the research on personality and CFS.
2. Selection of studies
The PubMed and PsychINFO databases from 1988 (when the original Centers for
Disease Control criteria for CFS were first established) to November 2006
were searched using the keywords CFS and personality, CFS and psychology, CFS
and individual, CFS and identity. On PubMed this generated 623 hits and on
PsychINFO an additional 333 hits. All 956 abstracts were read. In addition
the reference lists of the retrieved articles were examined.
The intention in the selection of studies was to include all original
articles describing primary research on personality and CFS. Review articles,
articles describing studies without mentioning which CFS case definition
criteria were used, or without an appropriate control group, and articles
focusing exclusively on psychiatric morbidity, were all excluded. Using these
criteria led to the inclusion of a final 16 studies.1 This review might not
have captured all relevant studies. However, the discussed articles are the
most important ones and can be seen as representative of the current state of
affairs in the field. In Table 2 a concise overview of the main recent
studies on the role of personality in CFS is given.
3. Results
Studying these results, it soon becomes obvious that the findings regarding
the association of personality and CFS are not definitive. Although some
studies seem to confirm, for a proportion of patients, some of the aspects of
the aforementioned stereotype of people suffering from CFS, other studies
found no such evidence. Some findings however, seem to be more consistent
than others.
3.1. Neuroticism
All in all, there seems to be most empirical evidence for an increased level
of neuroticism in patients with CFS. Taillefer, Kirmayer, Robbins and Lasry
(2003) found significantly higher neuroticism scores in patients with CFS
compared to the general population. Chubb et al. (1999) found increased
scores in their CFS subjects with concurrent depression. Masuda, Munemoto,
Yamanaka, Takei, and Tei (2002) found elevated neuroticism scores in their
noninfectious CFS group, although not in their postinfectious CFS group.
Fiedler et al. (2000), Blakely et al. (1991), Buckley et al. (1999) and
Johnson, DeLuca and Natelson (1996) also found significant differences in
neuroticism scores between patients with CFS and healthy controls and Rangel,
Garralda, Levin, and Roberts (2000) found the related items of
conscientiousness, worthlessness and emotional lability to be significantly
more common in patients than in controls. However, most subjects in their
study were recovered and their mothers, instead of the patients themselves,
had been used as informants. Several other important limitations in the
interpretation of these findings regarding neuroticism should also be
mentioned. One study found elevated scores of neuroticism only in comparison
to non-study recruited norm values for a general population (Taillefer et
al., 2003). In addition, generally no differences in neuroticism between
patients with CFS and other patients suffering from a chronic disease were
found (Johnson et al., 1996; Taillefer et al., 2003; Wood & Wessely, 1999).
Other studies used the MMPI to detect neuroticism (Blakely et al., 1991;
Schmaling & Jones, 1996) which, due to its sensitivity to physical symptoms,
has been found to perform poorly in CFS and to overestimate psychopathology
in chronically ill populations (Johnson, De Luca, & Natelson, 1996) and
finally, many of the findings of high neuroticism were later accounted for by
co-morbid depression (Chubb et al., 1999; Fiedler et al., 2000; Johnson et
al., 1996; Taillefer et al., 2003).
3.2. Personality disorder
Furthermore, there also seems to be evidence for the prevalence of
personality disorder in a proportion of patients with CFS. In the first study
on personality and CFS, Millon et al. (1989) found elevated base rate means,
above those of a non-clinical population, on the histrionic, schizoid and
avoidant scales of the MCMI, measuring DSM axis II personality disorders.
Henderson and Tannock (2004) also found quite a high level of personality
disorder (39%), predominantly obsessive-compulsive personality disorders, in
their sample of patients with CFS. Similar rates and findings were reported
by Ciccone et al. (2003). In the study by Johnson et al. (1996), 37% of the
subjects with CFS met the criteria for at least one personality disorder,
predominantly histrionic and borderline personality disorders. So, there
certainly seems to be a somewhat higher rate of personality disorder within
the CFS population than in non-clinical populations, in which it is
estimated to be between 10-19% (Moran, Coffey, Carlin, & Patton, 2006;
Zimmerman & Corryell, 1990). However, personality disorder rates were similar
in patients with CFS and those with other medical conditions (Johnson et al.,
1996). Also, it should be noted that personality disorder was not found in
the majority of patients. Furthermore, again there are some important
confounding aspects and the generalizability of the findings in the
abovementioned studies can be questioned. For example, some studies did not
have a control group (Ciccone et al., 2003; Millon et al., 1989). Moreover,
the MCMI that Millon et al. used includes many items that tap somatic
concerns, thereby increasing the likelihood of a diagnosis of personality
disorder in chronically ill patients. Co-morbid depression accounted for
most personality pathology in one study (Johnson et al., 1996) and although
this was not the case in the study by Henderson and Tannock, they only
included patients attending a teaching hospital, who are likely to have a
more severe form of CFS.
3.3. Perfectionism, social desirability and extroversion/introversion
Although perfectionism, social desirability and introversion have commonly
been referred to as some of the most characteristic features of the
personalities of patients with CFS, the scientific evidence on this subject
is far less clear-cut. White and Schweitzer (2000) found higher
perfectionism scores in individuals with CFS than in their control group and
Christodoulou et al. (1999) found the only difference between their CFS and
MS groups to be an elevated persistence score, which they related to
perfectionism. However, in contrast to these findings Wood and Wessely
(1999), and Blenkiron, Edwards and Lynch (1999) did not find higher
perfectionism scores in patients than in controls.
There were three studies that specifically studied social desirability among
patients with CFS (Buckley et al., 1999; Chubb et al., 1999; Wood & Wessely,
1999), but these studies revealed no differences between patients and control
groups. With regard to extroversion and introversion, Masuda et al. (2002)
found the members of their postinfectious CFS group to score higher on
extroversion than controls, although the members of their noninfectious CFS
group were found to be more introspective. And finally, while Buckley et al.
found that patients with CFS scored significantly lower than their healthy
controls on extroversion, Chubb et al. found the scores on extroversion of
their CFS group not to be different from those of their healthy control
group.
3.4. Personality: predisposing, initiating or perpetuating?
So, the results vary from the uncovering of "evidence of severe personality
pathology and affective distress" (Millon et al., 1989, p. 131), to the
finding of "little evidence that any particular personality trait
discriminates CFS patients [...] from other patients suffering a physically
disabling condition" (Wood & Wessely, 1999, p. 395). However, even when
evidence of abnormalities in the personality profiles of patients with CFS is
found, there remains a considerable lack of clarity regarding the precise
role of personality in the syndrome, and this is reflected in the conclusions
these studies draw. For example, while Van Houdenhove, Neerinckx, Onghena,
Lysens, and Vertommen (2001) conclude that "high 'action-proneness' and an
associated 'overactive' lifestyle may be one of the factors playing a
predisposing, initiating as well as a perpetuating role in CFS" (p. 575),
Christodoulou et al. (1999) found no evidence to suggest that patients with
CFS had any particular personality traits that would have predisposed them to
develop their illness. Rangel et al. (2000) conclude that personality
difficulty might either be a contributory factor to CFS, or result from the
prolonged disease, and Buckley et al. (1999) and Blenkiron et al. (1999)
conclude that the personality of subjects with CFS might have changed as a
result of their disease.
Although the impression of many psychologists, physicians and researchers,
that the personality of patients is a factor in CFS, seems to be justified by
clinical experience and is supported somewhat by the available research,
decisive conclusions on this subject are difficult to draw on the basis of
the relevant scientific studies. Even though these studies have scrutinized
the aforementioned image of the 'typical' individual with CFS, no definitive
conclusions for the patients as a group can be drawn, and a general and
uniform answer to the question of the role of personality in CFS is hard to
formulate. A provisional conclusion might be that it is "difficult to
disentangle personality factors that may have contributed to the development
of the condition from emotional reactions that are consequences of the
debilitating symptoms and the mixed responses of others to the illness"
(Lewis, 1996, p. 237).
However, part of the reason for this opaqueness, seems to be due to a certain
heterogeneity of the reviewed studies with regard to study methods, patient
populations, control groups and CFS case definitions. Therefore, before
discussing what seem to be some shared conceptual assumptions of these
studies, in the next section some of the major methodological issues
concerning the study of personality in CFS will be addressed.
4. Methodological issues regarding the study of personality in CFS
4.1. Study methods
An obvious reason for the discrepancies in the conclusions of the studies
discussed might be the use of different methods to measure personality. This
diversity seems almost inevitable when we consider the variety and divergence
in health care settings and traditions of personality research. However, even
when using the same instruments there often was no uniformity in the
findings. In three studies, all using the Multidimensional Perfectionism
Scale (MPS) for example, a remarkable lack of consensus in the results
emerges. While White and Schweitzer (2000) demonstrated higher perfectionism
scores in individuals with CFS than in persons in their healthy control
group, Wood and Wessely (1999) using the same MPS, found no differences in
measures of perfectionism between the patients with CFS and the patients with
rheumatoid arthritis in their control group. This difference might be
explained by the fact that these studies used different control groups.
However, Blenkiron et al. (1999) also used a healthy control group and in
contrast with White and Schweitzer, they found the values for perfectionism
on the MPS to be lower in their CFS sample than in their healthy control
group. This example brings us to another issue in the possible explanation of
the lack of uniformity in the major findings of the studies.
4.2. Control groups
Another possible reason for a lack of consistency in the major findings could
be that not all studies used comparable control groups. Whereas many studies
used healthy individuals as (part of) their control group (Blakely et al.,
1991; Blenkiron et al., 1999; Buckley et al., 1999; Christodoulou et al.,
1999; Chubb et al., 1999; Fiedler et al., 2000; Johnson et al., 1996; Masuda
et al., 2002; Rangel et al., 2000; Schmaling & Jones, 1996; White &
Schweitzer, 2000), others used patients with fibromyalgia/chronic pain
(Blakely et al., 1991; Van Houdenhove et al., 2001), depressed patients
(Buckley et al., 1999; Chubb et al., 1999; Johnson et al., 1996), patients
with multiple sclerosis (Christodoulou et al., 1999; Johnson et al., 1996;
Taillefer et al., 2003), or patients with rheumatoid arthritis (Wood &
Wessely, 1999). As a consequence, the results of the studies can only be
interpreted relative to the specific control groups that were used. Certain
differences between patients with CFS and controls that might be obvious with
one control group, might become less significant, or even get completely lost
with another.
4.3. Patient populations and CFS case definitions
So, the results of a specific study can only be interpreted in the light of
the control group that was used. However, this is of course rather common in
medical and psychological research. Be that as it may, in the case of CFS the
same applies to the patient groups that were included, which is far less
usual. While most studies used adult patients with CFS, one study used
adolescent patients with CFS of whom most were recovered (Rangel et al.,
2000) and another study exclusively included combat exposed Gulf War veterans
with CFS (Fiedler et al., 2000). Nevertheless, this would seem to leave all
the studies using 'ordinary' adult individuals with CFS to be comparable.
However, as different CFS case definitions were used, this is not the case.
Some studies used the original CDC criteria of 1988 (Holmes et al., 1988),
others the revised CDC criteria of 1992 (Schluenderberg et al., 1992), others
the revised CDC criteria of 1994 (Fukuda et al., 1994), others the UK
operational criteria of 1991 (Sharpe et al., 1991) and one New Zealand's
McKenzie criteria of 1988 (McKenzie, 1988). To add to the confusion and
making the different findings even more difficult to compare, some studies
distinguished between noninfectious and postinfectious CFS patients (Masuda
et al., 2002), some studies distinguished between patients with CFS and
co-morbid psychiatric disorder/depression and patients with CFS without
co-morbid psychiatric disorder/depression (Chubb et al., 1999; Fiedler et
al., 2000), and one study only included non-depressed patients with CFS
(Buckley et al., 1999). This brings us to the next important problem, the
influence of depression on the study of CFS and personality.
4.4. CFS and depression
Several studies on the psychiatric status of patients with CFS were discussed
in the Introduction. However, as was mentioned there, depression is not an
exclusionary criterion for the diagnosis of CFS and therefore inevitably
plays an important role in the personality studies on CFS. As was noted by
Buchwald (1996) and Wessely, Chalder, Hirsch, Wallace, and Wright (1996),
amongst others, there is a considerable overlap between the criteria used for
several psychiatric DSM-diagnoses (most notably depression) and CFS. As a
consequence patients with symptoms required for a diagnosis of CFS, at the
same time have symptoms fitting into a diagnosis of depression.
When distinguishing between patients with or without depression, some found
that depression had a great impact on the major findings of their study. In
the study by Fiedler et al. (2000), the CFS with psychiatric co-morbidity
group scored significantly higher than the CFS without psychiatric
co-morbidity group on the neuroticism subscales of anxiety, hostility,
self-consciousness, impulsivity and vulnerability. Chubb et al. (1999) found
that the scores of patients with CFS were not different from those of healthy
controls, except for those subjects with CFS who were concurrently depressed,
where the scores resembled the scores of their depressed control
group.Johnson et al. (1996) also found that most of the personality disorders
in their CFS group were accounted for by the CFS group with concurrent
depressive disorder. However, in contrast with these findings, Henderson and
Tannock (2004) concluded that they were unable to account for the presence of
personality disorder in their assessment of patients with CFS, by co-morbid
depression. An additional problem is that the Beck Depression Inventory
(BDI), which three of the studies used (Blakely et al., 1991; Johnson et al.,
1996; Wood & Wessely, 1999), was found to perform poorly as a screener for
depression in subjects with CFS (Farmer et al., 1996).
All in all, the role of depression in CFS is extremely difficult to determine
as there are at least three plausible relationships. It could be that
depression is a predisposing, causative factor in CFS. On the other hand, it
might be that "CFS is no more than depression masquerading as a physical
illness" (Ray, 1991, p. 2), but it is also possible that depression is a
reaction to the illness and to the lack of clarity that surrounds CFS. In
this case it would be likely that depression is caused by the stress of being
diagnosed with a disease of unknown origin, in combination with the absence
of a standard treatment and the possible disbelief encountered in the health
care setting. As it seems to be the case with many of the findings of
abnormalities in CFS, the role of depression in the pathogenesis and
perpetuation of CFS remains unclear. These questions of causality and
nosology however, are somewhat beyond the reach of this article and will
therefore not be discussed further.2 Nevertheless, by raising these questions
we get to a more fundamental level of inquiry. In the next section some
conceptual issues regarding the study of personality in CFS will be
addressed.
5. Conceptual background of personality studies in CFS
As mentioned, the methods used to study personality in CFS are quite diverse.
Nonetheless, in the approach of the reviewed studies, a shared conceptual
model regarding the possible association of personality and CFS, and the
appropriate way to scientifically study it, seems to be reflected.
Firstly, these studies have focused much of their attention on personality
disorder. Psychological malfunctioning, rather than ordinary,
non-pathological and everyday aspects of personality, which are commonly seen
as a primary concern of personality psychology, has been a main interest of
personality research in CFS so far. By such a focus on, and an
overrepresentation of the psychopathological aspects of personality, it is
easy to provide only a one-sided and too stringent image of the personality
of individuals with CFS.
Secondly, on the whole these studies have tended to conceptualize personality
mainly in its most general and decontextualized structures. With the use of
psychological tests like the Tridimensional Personality Questionnaire, the
NEO Five-Factor Inventory and the Eysenk Personality Questionnaire, certain
characteristics of personality, such as extroversion, neuroticism and social
desirability can accurately be studied and compared. However, in this way
personality is approached primarily in its most basic and undifferentiated
structure, and only a limited understanding of personality is provided
(Block, 1995). Although personality traits can provide a kind of
dispositional signature of the person, few links have been made between
traits and actual contextualized behavior (Funder, 2001) and it seems
unlikely that the exclusive knowledge of such a basic structure of relatively
non-conditional and noncontingent dispositional traits, or psychopathological
personality profiles, is enough to wholly explain and account for the
behavioral consequences of CFS, or the complex association between
personality and the syndrome.
Within the humanities and the social sciences, especially personality
psychology, there has been an increasing awareness that persons do not merely
act and experience on the basis of quantifiable, general traits. They
primarily evaluate and motivate their behavior and beliefs in qualitative,
contextualized terms (Richardson, Rogers, & McCaroll, 1998; Taylor, 1989). On
the basis of these terms, persons assess their behavior, interpret
themselves, articulate what they believe to be important, try to make sense
of their past, give meaning to the present, direct their future projects and
provide their life with purpose and unity (McAdams, 1995). Personality is not
a static, independent, self-contained and decontextualized 'given', but is
always dynamically constructed in dialogue with others, and against a
'meaningful' background provided by social practices and culturally shared
moral values (Hermans, Kempen, & Van Loon, 1992; Taylor, 1995). In recent
decades, the idea of the 'narrative' has emerged as a new metaphor not only
within personality psychology (Hermans, 1996; Sarbin, 1986), but also within
clinical psychology (Guignon, 1998; Hermans & Dimaggio, 2004; McLeod, 1997).
>From this approach, persons are understood as the creators of meaning, and
narrative thought is seen as the process by which these meanings are
developed and changed (Bruner, 1991). The narrative is seen not only as a
novel way of conceptualizing human experience and identity, but also as a
useful clinical tool to help individuals understand why they act, and
organize their lives, in certain ways, and to aid them in retelling and
reorganizing their lifestory. In a broader concept of personality, than that
which was used so far in the research on CFS, the lifestory could be seen as
a special kind of psychosocial construction and individuals might be
understood as trying to coauthor a thematically coherent and meaningful
narrative with, and against the background of, their culture and social
world.
Dispositional traits and life narratives can be regarded as two different
levels of personality (McAdams et al., 2004), each with their own methods of
study, frameworks and taxonomies. In CFS, personality traits are usually
studied through the use of standardized questionnaires and (semi) structured
interviews in the search for abnormalities, or deviations from the average.
The benefit and attraction of studying personality in this way is not only
that it is rather time and cost effective, but also that it produces
objective, quantifiable and comparable data and as such seems to be in
accordance with the rigorous methods of the natural sciences. The downside to
this approach is that, to a considerable extent, it decontextualizes human
experience and behavior from its real life setting, and its social and
cultural background. The usefulness and attraction of studying personality on
the level of the life narrative, on the other hand, is that it can remain
much closer to the continually evolving and subjectively experienced reality
of the person. Starting from the assumption of normality, personality on this
level is usually studied through an open dialogue in which the subject
matters are decided, not primarily by the investigator, but in the first
place by the person him - or herself. Just as with personality considered on
a trait level however, the benefits to this approach also entail its main
drawbacks. Besides being rather time-consuming, the obtained data might be
difficult to compare and, because of their specific temporal and spatial
context, be of a contingent and subjective nature. This can lead to the
assumption that personality, considered as a developing lifestory changing
through time, cannot be categorized, quantified or systematically researched
(McAdams, 1995) and that it, because of this, cannot be studied in a proper
methodical way.
Within the scientific debates on CFS, some have tried to draw attention to
the fact that the lifestories of the patients seem to have been neglected.
Van Houdenhove (2002) for example, states that "much of the etiological and
therapeutic controversies about the so called chronic fatigue syndrome
(CFS)[...] may be due to the relative neglect of the patient's story - in
clinical practice as well as in research. More specifically I believe that
insufficient attention is being paid to the mostly significant context in
which the illness began, and the possible connection between the illness and
the patient's life history. [T]he patient's biography should be part of each
diagnostic evaluation and considered an important focus of psychological/
psychiatric research in CFS." (p. 495) At present, there have been few who
have addressed these concerns. Some qualitative studies have described, in
narrative terms, the experience of patients of the impact of CFS as a
disruption and disorganization of their pre-morbid lifestory and identity.
The transformation and rewriting of those stories is depicted as an
inescapable consequence of getting CFS and is usually followed by a
subsequent quest for the restoration and reorganization of a meaningful
autobiographical self-narrative (Bulow & Hyden, 2003; Clark & James, 2003;
Whitehead, 2006). Currently however, the biggest challenge for those wishing
to systematically study the association of personality, considered on the
narrative level, and CFS, will be to do so with methods that are firmly based
in psychological theories about personality and psychotherapy and that have
been specifically designed to analyze and categorize a person's narrative
into its most meaningful temporal constituents. Moreover, such methods should
be psychometrically validated and not only allow a study of the
idiosyncrasies of the single case, but these methods must also have been
developed in such a way that they can be generalized to a population and that
quantitative comparisons between different groups can be made (e.g. Baillio &
Lyddon, 2000; Hermans & Hermans-Jansen, 1995; Van Geel & De Mey, 2003).
6. Conclusion
Every science, whether it be psychology, medicine, physics or sociology, is
based on a set of conceptual assumptions. Usually, when these disciplines are
functioning satisfactory, these presuppositions remain implicit and there is
no need to make them explicit. However, when problems arise that seem
difficult to solve with the normal instruments of these sciences, we have to
focus our attention explicitly on these conceptual assumptions and ask
ourselves whether our understanding of the problem is not somehow obscured by
the commonly accepted model of thought. For psychology and medicine, CFS
poses exactly such a problem.
In this article the first aim was to give a concise review of the current
research on personality and CFS. There seems to be consistent evidence that
patients with CFS often score higher on some personality traits, most notably
neuroticism, than healthy controls. Furthermore, higher levels of DSM axis II
diagnoses, most notably obsessive compulsive, histrionic and borderline
personality disorders, within the CFS population, in comparison to healthy
populations are found. However, there are some important confounding elements
in these findings. When compared to patients with another chronic illness,
the finding of specific personality differences is far less common and
usually annulled. Additionally, the finding of divergence could often be
explained by co-morbid depression/ psychiatric disorder. Another limitation
is that, at times, instruments have been used to study certain aspects of
personality (e.g. the MMPI, the BDI and the MCMI) that have later been found
to perform inadequately for patients with CFS. And lastly, many studies
eventually conclude that the found personality differences are consequences
of the disease, rather than precipating factors and as such play no causal
role in CFS. All in all, under careful scrutiny the previously mentioned
stereotype of patients with CFS does not seem to be justified. Nonetheless,
at present there do seem to be at least three overarching conclusions that
can be drawn with regard to personality and CFS. Firstly, the heterogeneity
of findings within the CFS groups implies that, on the trait or
psychopathological level, there are no unique personality characteristics
that are either a necessary condition for, or an unavoidable consequence of
CFS. Secondly, although personality traits such as neuroticism and
perfectionism are generally considered to be stable, non-conditional and not
effected by life changes (Watson & Walker, 1996; Costa et al., 1986), most
studies seem to agree on the possibility that the pre-morbid personalities of
their subjects might have changed as a result of their condition. Diverse
forms of chronic illness seem to be able to alter personality in similar ways
and increased levels of neuroticism and introversion for example (not to
mention depression), could well be a feature of many different diseases. In
fact, the American Psychiatric Association acknowledges the possibility of
personality change as a result of chronic illness (American Psychiatric
Association, 1994). Thirdly, as a consequence of this, it can be concluded
that cross-sectional designs in the long run will probably not be able to
provide definitive answers to the question of the exact role of personality
in CFS.
In the section on the methodological problems of these personality studies it
was suggested that some of the confusion that remains regarding the
association between personality and CFS might be due to a variety in study
methods, control groups and CFS case definitions. This diversity seems almost
unavoidable. However, with regard to control groups, the substantial overlap
between CFS and some psychiatric diagnoses (e.g. depression), and other
unexplained medical conditions (e.g. fibromyalgia) is truly confusing in
research, and makes patients from these populations difficult to compare. Age
and sex matched healthy individuals, and patients with a somatic illness in
which fatigue is also a main complaint (e.g. rheumatoid arthritis, multiple
sclerosis) seem to be much better suited as control groups. With regard to
study methods, the exclusion of general psychopathology or shared problems on
a dispositional trait level in CFS has of course been essential and valuable
in the personality research on CFS. However, the cross-sectional designs of
the reviewed studies make inferences about causality very difficult. New
insights might be gained by longitudinal designs, studying the predictive
validity of certain personality traits as risk factors for the development of
CFS. Prospective studies in clinical populations of mood disorders and
emotional risk factors in relation to CFS for example, have already been able
to provide some evidence regarding their precipating role (Moss-Morris &
Spence, 2006; White et al., 2001). In addition, it will prove insightful to
follow-up a cohort of patients with a relatively short illness duration (i.e.
a recent diagnosis of CFS) in order to study whether certain personality
characteristics, and levels of depression, changed as a consequence of
prolonged illness duration.
Finally, in the section on the conceptual background of the study on
personality in CFS, it was argued that although the methods used so far were
diverse, the studies seemed to share some basic conceptual assumptions
regarding personality and the way to study it. Up to now, personality
research in CFS has either been in search for personality disorder and
psychological malfunctioning, or has been conducted on a general,
non-relational trait level. Nevertheless, the fact that to a large extent
personality is something that can only exist in, and develop through the
inherent relations and dialogues with family, peers, colleagues, media,
society and culture in general, must be taken in account. In previous issues
of this journal a similar perspective has been brought forward by Dwairy
(2002, 1997) with regard to the understanding of the personality and (mental)
health within collective cultures, but it also seems particularly true in the
study of CFS. Future personality research in CFS should not only take the
abovementioned methodological issues into account and be of a more
longitudinal nature, but should also be directed towards, and become aware of
the dialogically constructed, historically contextualized and indissoluble
relational terms by which persons understand, evaluate and articulate
themselves.
Modern individualized society, to a considerable degree, is focused on
achievement, consumption and success, and is characterized by a plurality of
rapid economical, political, religious, technological and cultural changes.
Against this background, modernity confronts people in a whole new fashion
with a multiplicity of problems and possible ways of life and the need, and
imperative, to find and develop a meaningful identity. New insights into the
possible difficulties and stumbling-blocks in the personality of individuals
with CFS might be gained, if research attention would also concentrate on
systematically and comparatively studying individuals with CFS, as
socioculturally embedded agents who are trying to construct a coherent and
intelligible self-narrative.
Notes
1 Millon et al. (1989), being the first to study the role of personality in
CFS, was included although the study lacked an appropriate control group.
2 See, for example, Abbey and Garfinkel (1990), Moss-Morris and Petrie
(2001), and Swartz (1988) for some of the articles concerned with the
relation between CFS and depression, Wessely et al. (1999) and Aaron and
Buchwald (2001) for a more general discussion concerning the nosological
status of CFS, and Bolton (2001) and Borch-Jacobsen (2001) for a more
philosophical and a historical discussion of nosological problems in the
definition of psychiatric disorders.
The authors are grateful to Elise van de Putte, Coralie Fuchs, Gaston
Franssen, Marc Slors and anonymous reviewers of this journal for their
constructive remarks and suggestions on an earlier draft of this article.
Preparation of this manuscript was supported by a Netherlands Organization
for Scientific Research Grant (400-03-469).
Tables
Table 1. US Centers for Disease Control case definition of CFS, 1994
--------------------------------------------------------------------------------
Diagnostic criteria:
At least 6 months of persistent or recurring fatigue for which no physical
explanation has been found and which
* is of new onset, that is to say it has not been lifelong
* is not the result of ongoing exertion
* is not substantially alleviated by rest
* severely limits functioning
In combination with four or more of the following symptoms, persistent or
regularly recurring over a period of six months and which must not have
predated the fatigue:
* self-reported impairment in memory or concentration
* sore throat
* tender cervical lymph nodes
* muscle pain
* multi-joint pains
* headache
* unrefreshing sleep
* post-exertional malaise lasting 24 h or longer
Exclusionary criteria:
* any medical condition that may explain the presence of chronic fatigue
* a psychotic, major or bipolar depressive disorder (but not an uncomplicated
depression)
* dementia
* anorexia or bulimia nervosa
* alcohol abuse or the use of drugs
* severe obesity
--------------------------------------------------------------------------------
Table 2 Primary research on personality in CFS
----------------------------------------------------------------------------------------------------------------------------------------------------
Study Number of participants Study methods Major findings
----------------------------------------------------------------------------------------------------------------------------------------------------
Henderson and 61 patients with CFS (CDC, 1994 Structured Clinical Interview for 39% of the CFS group, 73% of the
Tannock (2004) (Fukuda et al., 1994)) DSM-III-R Diagnoses (SCID-II) depressed group and 4% of the
40 psychiatric inpatients healthy group were diagnosed with
with depressive disorder personality disorders. Cluster C
45 healthy controls disorders (avoidant, dependent,
obsessive-compulsive, self-defeating
and passive-aggressive) were the most
common in both the CFS and depressed
group. Personality disorder in patient
with CFS could not be accounted for by
co-morbid depression.
Taillefer et al., 45 patients with CFS (CDC, 1988 Illness Worry Scale, Neo Five-Factor There was no difference between the
(2003) (Holmes et al., 1988)) Inventory (NEO-FFI), SCL-90R groups on neuroticism, depressive
40 patients with multiple sclerosis Depression Scale, Symptom symptoms, or on the SIQ. The CFS
Interpretation Questionnaire (SIQ) group did have significantly higher
scores than the MS group on the
Illness Worry Scale. When the CFS
group was divided into more and less
depressed patients, the neuroticism
scores were found to be significantly
higher than the general population in
the more depressed CFS group.
Masuda et al., 16 patients with postinfectious Holmes Social Readjustment Rating The stress, maladjustment, marked
(2002) CFS (CDC, 1992 Scale, Cornell Medical Index (CMI), anxiety, depressive tendency and
(Schluenderberg et al., 1992)) Maudsley Personality Inventory (MPI), hypertense state scores of both CFS
20 patients with noninfectious Yatabe-Guilford test, Self-rating groups were significantly higher than in
CFS (CDC, 1992 Depression Scale (SDS) the control group.
(Sharpe et al., 1992)) No significant differences between
20 healthy controls both CFS groups on these scores
were observed. However members
of the postinfectious CFS group
were diagnosed as social extroverts,
while those in the noninfectious CFS
group were neurotic and introspective.
Van Houdenhove A randomized sample of a 100 Questionnaire for Habitual The patients and their significant others
et al., (2001) patients out of 124 patients with Action-proneness (HAB) scored the questionnaire similar. These
CFS (CDC, 1994 scores were higher than the norm values,
(Fukuda et al., 1994)) suggesting that high "action-proneness"
68 patients with fibromyalgia and an associated "overactive" lifestyle
(FM) may be one of the factors playing a
predisposing, initiating as well as a
perpetuating role in CFS and FM.
White and Schweitzer 44 patients with CFS (CDC, 1994 Multidimensional Perfectionism Scale The study demonstrated higher
(2000) (Fukuda et al., 1994)) (MPS), Rosenberg Self-Esteem Scale perfectionism scores and lower self-
44 healthy controls (RSE), Courtauld Emotional Scale esteem in individuals with CFS, than in
(CECS), Marlowe-Crowne Social individuals in the healthy control group.
Desirability Scale (MCS) The results suggest that individuals with
CFS have a maladaptive perfectionist
personality style.
Rangel et al., 25 adolescent patients with CFS Personality Assessment Schedule (PAS), Subjects with CFS demonstrated
(2000) (Oxford Criteria, 1991 (Sharpe et Kiddie-SADS Psychiatric Interview increased scores for introspection,
al., 1991)) At the time of the study (K-SADS), Children's Global Assessment sensitivity, conscientiousness,
two-thirds (n = 17) had recovered Scale (CGAS), Child Behaviour vulnerability, lability and worthlessness.
and the subject's mothers were used Checklist (CBCL) Personality difficulty may either be a
as informants contributory factor to CFS in children, or
15 healthy controls result from the prolonged disease.
Fiedler et al. 35 veterans with CFS (CDC, 1994 Combat Exposure Scale (CES), Operation Measures of personality and negative
(2000) (Fukuda et al., 1994)) and co- Desert Storm Survey (ODS Survey), coping strategies (as well as self-reported
morbid psychiatric disorder Childhood Traumatic Events Scale, combat and chemical exposures)
23 veterans with CFS and no co- Psychiatric Epidemiology Research significantly differentiated healthy
morbid psychiatric disorder Interview-Life Events Scale (PERI), veterans from those with CFS. On the
45 healthy veterans Neuroticism, Extroversion, Openness neuroticism subscales of anxiety, hostility,
Personality Inventory (NEO-PI), Toronto depression, self-consciousness,
Alexithymia Scale (TAS), Marlowe- impulsivity and vulnerability the CFS/
Crowne Social Desirability Scale psychiatric group scored significantly
higher than the two other groups.
Veterans with CFS reported a poorer
ability to identify and communicate
feelings than did healthy controls.
Chubb et al. 62 patients with CFS (CDC, 1994 Eysenck Personality Questionnaire Patients with CFS and concurrent
(1999) (Fukuda et al., 1994)) and 48 (EPQ), Attributional Style depression scored significantly higher
healthy controls completed the Questionnaire (ASQ) than individuals with CFS without
EPQ. concurrent depression or healthy
50 patients with CFS (CDC, 1994 controls on the neuroticism subscale.
(Fukuda et al., 1994)), 100 healthy On the social desirability subscale subjects
controls and 37 depressed patients with CFS did not differ from the controls.
completed the ASQ. Scores on both questionnaires show no
difference between patients with CFS and
healthy controls except for those subjects
with CFS who are also concurrently
depressed. In these cases the scores
resemble patients with depression.
Buckley et al. 30 non-depressed patients with Revised NEO Five-Factor Higher scores on neuroticism and
(1999) CFS (CDC, 1994 (Fukuda et al., Inventory, Eysenk introversion in patients with CFS than
1994)) Personality Questionnaire in healthy controls. Lower neuroticism in
20 patients with major depressive CFS than MDD patients. Patients with
disorder (MDD) CFS reported increased postmorbid
15 healthy controls neuroticism and introversion,
suggesting that personality may have
changed as a result of the illness.
Christodoulou et al. 38 patients with CFS (CDC,1994 Diagnostic Interview Schedule Personality profiles of CFS and MS
(1999) (Fukuda et al., 1994)) (Q-DIS), Tridimensional subjects were generally similar. Both
40 patients with multiple sclerosis Personality Questionnaire (TPQ) the MS and the CFS groups showed
40 healthy controls elevated levels of Harm Avoidance and
lower levels of Reward Dependence in
comparison to healthy subjects. The
only difference was on the dimension of
persistence, where the CFS group
displayed preserved persistence and
the MS group showed a reduction.
There was no evidence to suggest that
patients with CFS possessed an unusual
level of negativity that would have
predisposed them to develop their illness.
Wood and Wessely 101 patients with CFS (Oxford MacLean's questionnaire on attitudes Alexithymia scores were greater in the
(1999) Criteria, 1991 (Sharpe et al., 1991) towards mental illness, Social Desirability RA patient group and social adjustment
and CDC, 1994 (Fukuda et al., Questionnaire, Defensiveness Scale of was poorer in the CFS group. No
1994)) Adjective Check List, Twenty-Item differences were found between CFS
45 patients with rheumatoid Toronto Alexithymia Scale, and RA patients in measures of
arthritis (RA) Tridimensional Personality Questionnaire, perfectionism, attitudes towards mental
Multidimensional Perfectionism Scale, illness, defensiveness, social desirability,
Beck Depression Inventory (BDI) Social or sensitivity to punishment. There was
Adjustment Scale (SAS) no evidence from this study of major
differences between the personalities of
patients with CFS and patients with RA.
Blenkiron et al., 40 patients with CFS (CDC, 1994 Multidimensional Perfectionism Scale, Women more than men with CFS tend
(1999) (Fukuda et al., 1994)) Chalder Fatigue Questionnaire, Hospital to set lower expectations and standards
31 healthy controls Anxiety and Depression Scale (HAD) for others. The values for perfectionism
found on the MPS were lower in the CFS
sample (reflecting fewer perfectionist
traits) than in the control group. This
may indicate that the CFS respondents in
this survey had already moderated their
perfectionist tendencies and reset their
standards to cope with the
unpredictabilities of the disorder.
Schmaling and Jones 53 patients with CFS Minnesota Multiphasic Personality The aggregate MMPI profile of
(1996) (Approximately CDC, Inventory (MMPI) patients with CFS suggests that they
1988/ 1994 (Holmes et al., 1988; have significant physical complaints
Fukuda et al., 1994)) and difficulties with cognitive
43 healthy controls functioning, are concerned about their
symptoms, and are emotionally
distressed. Their profile is similar to
that of patients with chronic pain.
Johnson et al., 35 patients with CFS (CDC, 1988/ The NEO Neuroticism Scale, Personality The study found progressively higher
(1996) 1992 (Holmes et al., 1988; Sharpe Diagnostic Questionnaire-Revised (PDQ- rates of personality disorders (PD) and
et al., 1992)) R), Beck Depression Inventory neuroticism from healthy controls
20 patients with multiple sclerosis through CFS and MS (who did not
24 depressed patients differ) to the depressed group. The
40 healthy controls most common PD's among subjects with
CFS were histrionic (23%) and
borderline (17%). The CFS group with
concurrent depressive disorder (34% of
the CFS group) was found to account for
most of the personality disorder.
Blakely et al. 58 patients with CFS (McKenzie Minnesota Multiphasic Personality Progressively more elevated scores on
(1991) (New Zealand) criteria, 1988) Inventory, Beck Depression Inventory, most scales from healthy controls
81 patients with chronic pain (CP) General Health Questionnaire (GHQ) through chronic pain to patients with
104 healthy controls Lazarus ways of Coping (WoC) CFS were found. The individuals with
CFS showed more deviant personality
traits reflecting emotionality or
neuroticism, inward hostility, self-
criticism and guilt, although
personality profiles fell into different
groups. The hypothesis is brought
forward that in CFS we are dealing
with a particular subpopulation of
patients with CP, who are particularly
extreme and relatively homogenous in
their endorsement of CFS symptoms.
Millon et al. 24 patients with CFS (CDC, 1988 Millon Clinical Multiaxial Inventory Evidence of severe personality
(1989) (Holmes et al., 1988)) (MCMI-II), Profile of Mood States pathology and affective distress was
No appropriate control group Hamilton Rating Scale of Depression found. Anxiety, somatic disorder and
(HAM-D), Folstein Mini-Mental depression were particularly prominent.
Examination The Wechsler Memory Scale Histrionic (33%), schizoid (29%) and
(WMS) avoidant, narcissistic and aggressive/
sadistic (each 25%) personality scales
were pathologically elevated.
----------------------------------------------------------------------------------------------------------------------------------------------------
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