Childhood predictors of self reported chronic fatigue syndrome/myalgic encephalomyelitis in adults: national birth cohort study
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《英国医生杂志》
1 Department of Paediatrics, Royal Free and University College Medical School, Middlesex Hospital, London W1T 3AA, 2 Department of Psychological Medicine, Institute of Psychiatry, London SE5 8AF
Correspondence to: R Viner R.Viner@ich.ucl.ac.uk
Abstract
Chronic fatigue syndrome (CFS) is a common disabling condition characterised by persistent unexplained fatigue1 that imposes a considerable burden on families and the health services. In the United Kingdom, the term myalgic encephalomyelitis (ME) is often used by patients to describe the symptoms of CFS. We have used the term CFS/ME to refer to self reported CFS or ME. The aetiology of CFS remains unclear. Longitudinal studies in adults have suggested that past psychiatric disorder may have a role.2 Other studies have implicated a range of biological and psychosocial risk factors, including female sex,3 stressful events,4 high academic achievement,5 infections such as mononucleosis6 and viral meningitis,2 higher levels of routine exercise,7 birth order,8 atopy,9 and physical symptoms and diagnoses.10
While factors at the family level are known to be important, it is unclear whether these operate primarily at the environmental or genetic level.11 Small case-control studies have suggested that maternal overprotectiveness and depression12 may be associated with increased risk of disease in adult life, and a recent cross sectional epidemiological study showed an association between maternal psychological distress and parental report of ME/CFS in children.13 Cohort studies of childhood risk factors for adult illness, however, have not been published.
We used longitudinal data from the 1970 British birth cohort study to explore whether childhood risk factors were associated with lifetime risk of developing CFS/ME by the age of 30 years. Prematurity, birth order, obesity, atopy, chronic limiting conditions, high exercise levels, school factors (high academic achievement and absence from school), and psychological factors including poor maternal mental health and childhood behaviour problems have all been proposed as possibly associated with the lifetime risk of CFS/ME.
Methods
Of the 11 261 participants, 93 (0.8%, 95% confidence interval 0.7 to 1.0) reported ever having CFS/ME and 48 (0.4%, 0.3 to 0.6) had the condition currently. Two participants who reported age of onset of illness at 2 years were removed from the analysis as lifetime fatigue is likely to represent a condition other than CFS/ME. Of the 91 remaining participants, reported age at onset of CFS/ME ranged from 14 to 29 years, with a median of 24 years (mean 22.9, SD 4.6 years).
Table 1 shows the associations of demographic, biological, and social factors with lifetime risk of CFS/ME. Odds ratios are shown unadjusted and adjusted for sex, father's social class in childhood, and mother's education. Risk of lifetime CFS/ME was significantly increased by female sex, high socioeconomic status in childhood, and having a longstanding medical condition in childhood that considerably affected home or school life, or both. A parent's report of a child playing sport in his or her spare time significantly decreased the risk of later CFS/ME.
Table 1 Biological, demographic, and social factors and unadjusted and adjusted odds ratios (95% confidence intervals) for lifetime risk of CFS/ME. Figures are percentages of participants, unless stated otherwise
Table 2 shows the association of behavioural and psychological factors in childhood and adulthood with lifetime risk of CFS/ME. There were no significant associations between maternal or child psychological factors and risk of disease. A high score on the malaise inventory at 30 years was strongly associated with increased risk of CFS/ME.
Table 2 Behavioural problems and malaise inventory scores and unadjusted and adjusted odds ratios (95% confidence intervals) for lifetime risk of CFS/ME. Figures are percentages of participants
We then included factors significantly associated with lifetime risk of CFS/ME at the previous stage in a multivariable model (table 3). A limiting longstanding medical condition in childhood, female sex, and high social class in childhood were independently associated with a higher risk of CFS/ME, while higher levels of exercise in childhood were independently associated with lower risk. High malaise scores in adulthood were also significantly associated with higher risk. When we added to this model the childhood factors that were not individually associated with risk of CFS/ME, effect sizes or significance were not substantially altered (except for high score on general health questionnaire at 16 years, which attenuated the significance but did not alter the effect size of limiting medical condition in childhood, probably because of the low number for adolescent general health questionnaire score). When we repeated these analyses using CFS/ME within the previous 12 months as the outcome variable the result was not materially different to that for lifetime CFS/ME (data not shown).
Table 3 Multivariate model of factors predicting lifetime risk of CFS/ME (n=8512)
Discussion
Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;121: 953-9.
Hotopf M, Noah N, Wessely S. Chronic fatigue and minor psychiatric morbidity after viral meningitis: a controlled study. J Neurol Neurosurg Psychiatry 1996;60: 504-9.
Levine PH. Epidemiologic advances in chronic fatigue syndrome. J Psychiatr Res 1997;31: 7-18.
Salit IE. Precipitating factors for the chronic fatigue syndrome. J Psychiatr Res 1997;31: 59-65.
Krilov LR, Fisher M, Friedman SB, Reitman D, Mandel FS. Course and outcome of chronic fatigue in children and adolescents. Pediatrics 1998;102: 360-6.
White PD, Thomas JM, Kangro HO, Bruce-Jones WD, Amess J, Crawford DH, et al. Predictions and associations of fatigue syndromes and mood disorders that occur after infectious mononucleosis. Lancet 2001;358: 1946-54.
MacDonald KL, Osterholm MT, LeDell KH, White KE, Schenck CH, Chao CC, et al. A case-control study to assess possible triggers and cofactors in chronic fatigue syndrome. Am J Med 1996;100: 548-54.
Brimacombe M, Helmer DA, Natelson BH. Birth order and its association with the onset of chronic fatigue syndrome. Hum Biol 2002;74: 615-20.
Endicott NA. Chronic fatigue syndrome in psychiatric patients: lifetime and premorbid personal history of physical health. Psychosom Med 1998;60: 744-51.
Hall GH, Hamilton WT, Round AP. Increased illness experience preceding chronic fatigue syndrome: a case control study. J R Coll Physicians Lond 1998;32: 44-8.
Sullivan PF, Kovalenko P, York TP, Prescott CA, Kendler KS. Fatigue in a community sample of twins. Psychol Med 2003;33: 263-81.
Fisher L, Chalder T. Childhood experiences of illness and parenting in adults with chronic fatigue syndrome. J Psychosom Res 2003;54: 439-43.
Chalder T, Goodman R, Wessely S, Hotopf M, Meltzer H. Epidemiology of chronic fatigue syndrome and self reported myalgic encephalomyelitis in 5-15 year olds: cross sectional study. BMJ 2003;327: 654-5.
Bynner J, Butler N, Ferri E, Shepherd P, Smith K. The design and conduct of the 1999-2000 surveys of the national child development study and the 1970 British birth cohort study. UK data archive. London: Centre for Longitudinal Studies, Institute of Education, London, 2002. (CLS Cohort Studies Working Paper 1.)
Irving B, Bloxsom C. Predicting adolescent delinquent behaviour and criminal conviction by age 30: evidence from the 1970 British birth cohort. London: Police Foundation, 2002.
Goldberg D, Williams P. The users' guide to the general health questionnaire. Windsor: NFER-Nelson, 1988.
Hart JG. LAWSEQ: its relation to other measures of self-esteem and academic ability. Br J Educ Psychol 1982;22: 167-9.
Rodgers B, Pickles A, Power C, Collishaw S, Maughan B. Validity of the malaise inventory in general population samples. Soc Psychiatry Psychiatr Epidemiol 1999;34: 333-41.
Elliot CD. British ability scales technical handbook. Windsor: NFER-Nelson, 1983.
Cole TJ, Freeman JV, Preece MA. Body mass index reference curves for the UK, 1990. Arch Dis Child 1995;73: 25-9.
Wessely S, Chalder T, Hirsch S, Pawlikowska T, Wallace P, Wright DJ. Postinfectious fatigue: prospective cohort study in primary care. Lancet 1995;345: 1333-8.
Euba R, Chalder T, Deale A, Wessely S. A comparison of the characteristics of chronic fatigue syndrome in primary and tertiary care. Br J Psychiatry 1996;168: 121-6.
Garralda E, Rangel L, Levin M, Roberts H, Ukoumunne O. Psychiatric adjustment in adolescents with a history of chronic fatigue syndrome. J Am Acad Child Adolesc Psychiatry 1999;38: 1515-21.(Russell Viner, honorary s)
Correspondence to: R Viner R.Viner@ich.ucl.ac.uk
Abstract
Chronic fatigue syndrome (CFS) is a common disabling condition characterised by persistent unexplained fatigue1 that imposes a considerable burden on families and the health services. In the United Kingdom, the term myalgic encephalomyelitis (ME) is often used by patients to describe the symptoms of CFS. We have used the term CFS/ME to refer to self reported CFS or ME. The aetiology of CFS remains unclear. Longitudinal studies in adults have suggested that past psychiatric disorder may have a role.2 Other studies have implicated a range of biological and psychosocial risk factors, including female sex,3 stressful events,4 high academic achievement,5 infections such as mononucleosis6 and viral meningitis,2 higher levels of routine exercise,7 birth order,8 atopy,9 and physical symptoms and diagnoses.10
While factors at the family level are known to be important, it is unclear whether these operate primarily at the environmental or genetic level.11 Small case-control studies have suggested that maternal overprotectiveness and depression12 may be associated with increased risk of disease in adult life, and a recent cross sectional epidemiological study showed an association between maternal psychological distress and parental report of ME/CFS in children.13 Cohort studies of childhood risk factors for adult illness, however, have not been published.
We used longitudinal data from the 1970 British birth cohort study to explore whether childhood risk factors were associated with lifetime risk of developing CFS/ME by the age of 30 years. Prematurity, birth order, obesity, atopy, chronic limiting conditions, high exercise levels, school factors (high academic achievement and absence from school), and psychological factors including poor maternal mental health and childhood behaviour problems have all been proposed as possibly associated with the lifetime risk of CFS/ME.
Methods
Of the 11 261 participants, 93 (0.8%, 95% confidence interval 0.7 to 1.0) reported ever having CFS/ME and 48 (0.4%, 0.3 to 0.6) had the condition currently. Two participants who reported age of onset of illness at 2 years were removed from the analysis as lifetime fatigue is likely to represent a condition other than CFS/ME. Of the 91 remaining participants, reported age at onset of CFS/ME ranged from 14 to 29 years, with a median of 24 years (mean 22.9, SD 4.6 years).
Table 1 shows the associations of demographic, biological, and social factors with lifetime risk of CFS/ME. Odds ratios are shown unadjusted and adjusted for sex, father's social class in childhood, and mother's education. Risk of lifetime CFS/ME was significantly increased by female sex, high socioeconomic status in childhood, and having a longstanding medical condition in childhood that considerably affected home or school life, or both. A parent's report of a child playing sport in his or her spare time significantly decreased the risk of later CFS/ME.
Table 1 Biological, demographic, and social factors and unadjusted and adjusted odds ratios (95% confidence intervals) for lifetime risk of CFS/ME. Figures are percentages of participants, unless stated otherwise
Table 2 shows the association of behavioural and psychological factors in childhood and adulthood with lifetime risk of CFS/ME. There were no significant associations between maternal or child psychological factors and risk of disease. A high score on the malaise inventory at 30 years was strongly associated with increased risk of CFS/ME.
Table 2 Behavioural problems and malaise inventory scores and unadjusted and adjusted odds ratios (95% confidence intervals) for lifetime risk of CFS/ME. Figures are percentages of participants
We then included factors significantly associated with lifetime risk of CFS/ME at the previous stage in a multivariable model (table 3). A limiting longstanding medical condition in childhood, female sex, and high social class in childhood were independently associated with a higher risk of CFS/ME, while higher levels of exercise in childhood were independently associated with lower risk. High malaise scores in adulthood were also significantly associated with higher risk. When we added to this model the childhood factors that were not individually associated with risk of CFS/ME, effect sizes or significance were not substantially altered (except for high score on general health questionnaire at 16 years, which attenuated the significance but did not alter the effect size of limiting medical condition in childhood, probably because of the low number for adolescent general health questionnaire score). When we repeated these analyses using CFS/ME within the previous 12 months as the outcome variable the result was not materially different to that for lifetime CFS/ME (data not shown).
Table 3 Multivariate model of factors predicting lifetime risk of CFS/ME (n=8512)
Discussion
Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 1994;121: 953-9.
Hotopf M, Noah N, Wessely S. Chronic fatigue and minor psychiatric morbidity after viral meningitis: a controlled study. J Neurol Neurosurg Psychiatry 1996;60: 504-9.
Levine PH. Epidemiologic advances in chronic fatigue syndrome. J Psychiatr Res 1997;31: 7-18.
Salit IE. Precipitating factors for the chronic fatigue syndrome. J Psychiatr Res 1997;31: 59-65.
Krilov LR, Fisher M, Friedman SB, Reitman D, Mandel FS. Course and outcome of chronic fatigue in children and adolescents. Pediatrics 1998;102: 360-6.
White PD, Thomas JM, Kangro HO, Bruce-Jones WD, Amess J, Crawford DH, et al. Predictions and associations of fatigue syndromes and mood disorders that occur after infectious mononucleosis. Lancet 2001;358: 1946-54.
MacDonald KL, Osterholm MT, LeDell KH, White KE, Schenck CH, Chao CC, et al. A case-control study to assess possible triggers and cofactors in chronic fatigue syndrome. Am J Med 1996;100: 548-54.
Brimacombe M, Helmer DA, Natelson BH. Birth order and its association with the onset of chronic fatigue syndrome. Hum Biol 2002;74: 615-20.
Endicott NA. Chronic fatigue syndrome in psychiatric patients: lifetime and premorbid personal history of physical health. Psychosom Med 1998;60: 744-51.
Hall GH, Hamilton WT, Round AP. Increased illness experience preceding chronic fatigue syndrome: a case control study. J R Coll Physicians Lond 1998;32: 44-8.
Sullivan PF, Kovalenko P, York TP, Prescott CA, Kendler KS. Fatigue in a community sample of twins. Psychol Med 2003;33: 263-81.
Fisher L, Chalder T. Childhood experiences of illness and parenting in adults with chronic fatigue syndrome. J Psychosom Res 2003;54: 439-43.
Chalder T, Goodman R, Wessely S, Hotopf M, Meltzer H. Epidemiology of chronic fatigue syndrome and self reported myalgic encephalomyelitis in 5-15 year olds: cross sectional study. BMJ 2003;327: 654-5.
Bynner J, Butler N, Ferri E, Shepherd P, Smith K. The design and conduct of the 1999-2000 surveys of the national child development study and the 1970 British birth cohort study. UK data archive. London: Centre for Longitudinal Studies, Institute of Education, London, 2002. (CLS Cohort Studies Working Paper 1.)
Irving B, Bloxsom C. Predicting adolescent delinquent behaviour and criminal conviction by age 30: evidence from the 1970 British birth cohort. London: Police Foundation, 2002.
Goldberg D, Williams P. The users' guide to the general health questionnaire. Windsor: NFER-Nelson, 1988.
Hart JG. LAWSEQ: its relation to other measures of self-esteem and academic ability. Br J Educ Psychol 1982;22: 167-9.
Rodgers B, Pickles A, Power C, Collishaw S, Maughan B. Validity of the malaise inventory in general population samples. Soc Psychiatry Psychiatr Epidemiol 1999;34: 333-41.
Elliot CD. British ability scales technical handbook. Windsor: NFER-Nelson, 1983.
Cole TJ, Freeman JV, Preece MA. Body mass index reference curves for the UK, 1990. Arch Dis Child 1995;73: 25-9.
Wessely S, Chalder T, Hirsch S, Pawlikowska T, Wallace P, Wright DJ. Postinfectious fatigue: prospective cohort study in primary care. Lancet 1995;345: 1333-8.
Euba R, Chalder T, Deale A, Wessely S. A comparison of the characteristics of chronic fatigue syndrome in primary and tertiary care. Br J Psychiatry 1996;168: 121-6.
Garralda E, Rangel L, Levin M, Roberts H, Ukoumunne O. Psychiatric adjustment in adolescents with a history of chronic fatigue syndrome. J Am Acad Child Adolesc Psychiatry 1999;38: 1515-21.(Russell Viner, honorary s)