Brief Description
Ms X has been off work for approximately 10 years with supposed ME/Chronic Fatigue Syndrome.  The brief is initially to advise whether Ms X has CFS or has a psychiatric illness and also to devise a treatment programme which will ultimately allow a structured return to work.

History
A detailed history will not be included in this report as both Dr Y and Dr Z give very detailed histories in their reports and my discussions with Ms X reflected the information given in these reports.

In large part our discussion was around the diagnosis and treatment of chronic fatigue syndrome/ME (from now on for brevity we will refer to this as CFS). Ms X has been unwell since February 1994 when she developed symptoms which included exhaustion, slurred speech, breathing problems and chest pain.  According to Ms X this was later diagnosed as “a probable encephalitis” by a neurologist at the Radcliffe Infirmary in Oxford, however, there seems to be no notes that confirm this diagnosis. Ms X sees this as a key event and possibly the initial viral infection triggering her CFS.

During our discussions it became evident that Ms X had had a long history of depression which alleged started when she was about 6 years old (I note in Dr Y’s report that Ms X indicated that she was only 2 ½ years old when she recalled this incident) when she was in Africa. At the time her mother took her to the local ‘doctor’ who diagnosed her non-specific illness as depression. When pressed as to how the diagnosis was arrived at Ms X conceded that the doctor was not a “doctor in conventional Western terms”. It appears that Ms X believes that she has suffered from depression since this “diagnosis”.

Ms X has had a number of bouts of depression and has been prescribed anti-depressants on a number of occasions. She has had a number of suicidal thoughts with one attempt to kill herself, however she appears to regret this attempt and seems to have a strategy for controlling her suicidal thoughts. It would appear that her other siblings, two sisters and a brother all have a history of depression, Ms X went on to describe how her mother also has a history of stress related illness and anxiety. 

Ms X recanted a number of incidents were either she or someone in her family had linked an infection with some form of psychological illness.  She linked a number of instances in her life where colds or influenza had triggered bouts of depression and she indicated that she had had repeated infections and “aches and pains” since childhood.  She also described a number of incidents of stress related illness within her family including, how stress had caused psoriasis and heart problems in her mother and how glandular fever and stress had caused problems for her sister.  Ms X seems to have developed a strategy whereby she develops an illness, often a “flu like illness” or some form of cold or minor ailment when she gets under pressure. She indicated one particular instance when her sister had asked her to visit, she made all the arrangements and a couple of days before the visit developed a flu like illness which prevented her from going. This linking of a physical, infective trigger and stress is seen as a key component in patients who later go on to develop CFS.

Ms X detailed a childhood of having been in 8 different schools by the time she was 7 years old, this was due to her father’s profession requiring frequent moves over a number of continents. When asked how she coped with all this change, she said that when she was offered the chance to go to boarding school, she initially liked the idea, as it gave her some stability in her life, however, she later went on to contradict herself by saying she was distressed by constantly having to make friends.  When we investigated Ms X’s ability to make friends she initially said that she had had plenty of friends and had no problems with making friends at school, she claims that there was always one best friend and she gave one particular instance when there was “a gang of four”.

However, when pressed it became apparent that Ms X does have difficulty making friends and this appears to continue up to the present date.  Although she claims she has a good social network, it would appear that her friends are ‘spread all over the world’ and her immediate social circle is limited.  Ms X appeared to be slightly embarrassed by this situation.

It appears throughout her life that she has not been particularly close to her siblings and she only saw her parents on relatively few occasions in her school life. She recounted how her parents often lived in a different country and airlines flights been expensive at the time, she would only see them on holidays and then not on every holiday.  She gave the impression of an extremely lonely child who had difficulties making friends and when I asked her about her relationship with men, she found it difficult to speak about this and glossed over the issue saying she had had a number of relationships in her twenties, however, she was a difficult person to live with, she was “bossy and opinionated, and was much better living on her own”.  Interestingly, she commented that when she was on her own, ‘she did not feel guilty about ruining someone else’s life’.  When asked had she ever been rejected in her life, she indicated that she was always the one who did the rejection and answered ‘no body messes with me’.

In general Ms X’s life appeared to have been a solitary one with relatively few social interactions and this still appears to be the situation. The lack of a social network and the ability to "lay off" stress to friends and family, especially in women, tends to exacerbate stress related issues.  Stress is generally recognised to be a key component in the development of CFS.

I got the impression that although Ms X had had a great deal of academic success in her life, and indeed saw herself as an academic, that there was an underlying feeling of low self esteem that had crept into her life and a general feeling of unfulfillment in her relationships.  One example of this was that she told me on at least two occasions that she had been headhunted several times; something she seemed to be proud of.  However, she failed to take up any of the opportunities. I believe that this may have not  been so much that she had ties in this country to prevent her from taking up these opportunities, the reason given, but that it was self doubt in her own ability.    I got the impression that although outwardly in control and confident Ms X has self-esteem/confidence issues and may indeed have anxiety issues.

CFS or Psychological illness?
I have included by way of appendix current diagnostic criteria for CFS. You will note that there is no single definitive diagnostic criteria and that there are two predominate pieces of work that dominate current thinking.  The Report from the Chronic Fatigue/ME Working Group to the Chief Medical Officer from January 2002 indicates that there are actually 6 currently used definitions in England and Wales all giving roughly the same diagnostic criteria.  The other main one that I have included is the report by the ME/CFS Clinical Working Case Definitions Diagnostic and Treatment Protocol by Carruthers et al from 2003. This is a Canadian report, and the current hot topic of debate amongst the various CFS associations is whether to accept this Canadian report as the basis of an English standard, it looks likely that this will happen.

Although there is no standard diagnostic criteria there are a number of key themes which run throughout the various protocols these include: the existence of an illness with greater than six months duration, were fatigue is the principal symptom and the disease is attributed to an infection, often viral in origin.  Interestingly, certain illnesses such as depressive illness, anxiety disorders, etc are excluded by some criteria yet not by others.  However, it is generally accepted that depression and anxiety are present in 30 to 50% of cases of CFS; there is much debate as to whether these illnesses are co-morbid or causative factors in the development of CFS.  One other statistic worth noting is that the ME Association acknowledges that up to 50% of the 150,000 to 200,000 cases of CFS diagnosed in the UK may be misdiagnoses.

As to whether Ms X has a “genuine” case of CSF, or as Dr Z indicates, a psychological condition. Without doubt she believes she has CFS and ‘acts the role’ of some one with CFS.  In that respect it is largely academic whether Ms X has chronic fatigue syndrome or a psychological illness. It is evident that Ms X has read extensively about CFS and its treatment.  She is acutely aware that she fits many of the diagnostic criteria described above and that she was in the normally age range, 24 to 44 years at the time of onset, she has a long-standing history of depression and anxiety related illnesses and she was a high performing executive, and female.  In short, she knows she fits the profile of someone with CFS.

Ms X’s strategy for dealing with her CFS is largely that endorsed by the various CFS organisations, this falls into three main categories.  The first is a graded exercise programme, Ms X has not embraced graded exercise although she does have a number of walks, and seems to contradict herself in respect of the duration and the frequency of these walks.  What she does embrace whole heartedly is pacing.  Pacing is a concept whereby the patient with CFS has only a limited amount of energy, typically, 30% of their former level and this is the amount quoted by Ms X herself and they gear their life around this idea of having limited energy.  The theory is that energy is like a store, if you want to have an active day tomorrow, you effectively conserve your energy today so that you will have enough for tomorrow.  I am of the same opinion as Dr Z (and roughly 50% of the medical world) that this concept locks people, specifically Ms X, into the illness and this often prolongs the symptoms for many years.

The third major component of treatment is Cognitive Behaviour Therapy.  I would note that Ms X has already had a brief treatment of CBT which she described as only moderately successful.  Although there are many that would dispute it, CBT is generally considered to be the most effective treatment for CFS.  The main criticism that is levelled against CBT in the treatment of CFS is that the therapists often treat the disease as a wholly psychological illness, and fail to recognise that the patient often sees the disease as wholly physical or partly physical and partly psychological.  Failure to acknowledge and validate the patient’s believe that the disease has a physical element dramatically reduces the effectiveness of CBT.  It would appear that Ms X's initial course of CBT did not validate her belief with regard to the physical element of the disease.

Treatment Plan
Whether Ms X has CFS or not is largely academic in that Ms X believes she has CFS and any treatment plan must be geared around this core belief.  Ms X has extensive knowledge about the disease and its treatment and is familiar with the relative merits of the three major treatment strategies.  She believes that pacing and CBT have some merit and the treatment plan must reflect this.  Furthermore, it is crucial that the treatment plan validates her belief that CFS has a physical component.  Ms X was highly receptive to the idea CFS can be treated and not just managed. I believe Ms X will respond well to a course of CBT and I believe to date that she has actually contacted XXX direct and re-affirmed this.  I estimate that Ms X would need 12-15 sessions of CBT to give her an effective treatment. 

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CASE HISTORY TWO

Brief Description
Mr X has to manage a large team of people and becomes very agitated and forgetful.  The referrer wants to know the best way forward in treatment for him.  The report should include a history, present condition, motivational issues regarding work and any treatment recommendations.  The aim of any further treatment should be with regard to a return to work plan.

History
Mr X went absent from work in July 2005 with anxiety and depression which he attributed to work, more specifically, to a "treatment" regime from his line manager Ms Y.  At this point, Mr X had been in his position as a Compliance Assessment Manager for firm Z for approximately 2 years.

Prior to this point, Mr X had had a satisfactory relationship with Ms Y for approximately 18 months.  The problem seems to have arisen when firm Z underwent one of it’s, apparently regular, restructures and Ms Y had her job "de-scoped".  Prior to this restructuring Ms Y had six areas reporting to her, three "people sided" areas based around compliance managers of which Mr X was one and three "task orientated" areas relating to risk managers.

After the restructure Ms Y was left with just three areas namely, the "people orientated" areas.  Mr X claims that Ms Y was fundamentally a task orientated person and that after the restructure her shortcomings as a person orientated manager became evident.  It would appear that the three areas removed from Ms Y were "high-profile" areas, the loss of which, according to Mr X, annoyed Ms Y, this, allegedly, made her difficult to work with, further compounding the situation.

The situation between Ms Y and Mr X deteriorated with Mr X feeling increasingly "insecure, unsupported, devalued and worried".  Mr X felt that Ms Y was deliberately undermining his position and was instrumental in a whispering campaign with other members of the Department which further undermined Mr X's confidence.  Mr X has amassed a number of e-mails claiming to support his case. 

The situation deteriorated to the point where Mr X involved his trade union and "the discrimination people" who raised the issue on his behalf.  The situation came to a head on the 27^th July 2005 when Ms Y who had "been given evidence" coupled with their own observation made an accusation that Mr X lacked concentration at work and was missing meetings.  Mr X claims that he only missed two meetings; a teleconference meeting and one other that he had already informed Ms Y he could not attend.  This pressure, coupled with the anniversary of his mother's death, and external commitments to an ageing aunt and uncle led to Mr X suffering anxiety and depression which in turn led to his being absent from work for approximately 5 months.  At the time of our initial meeting (10th March 2006) Mr X had been back at work for approximate five weeks (returned to work on the 1st February 2006).

Mr X has had two previous episodes when he has had treatment for clinical depression.  The first, approximately 15 years ago, which appeared to be a reactive depression to the death of a close friend.  The treatment for which was Prozac for approximate 12 months by which time the condition had apparently resolved.  The second, triggered by the death of his mother approximately 3 years ago resulted in Mr X being "bad" for approximately 4 to 5 months.  The second incident involved episodes of anxiety and panic attacks.  When interviewing Mr X it was unclear whether this second episode had fully resolved before the resulting anxiety, depression and panic attacks attributed to his relationship with Ms Y began.  Although Mr X believes there was a distinct gap between the second episode and the symptoms triggered by his relationship with Ms Y. Ms Y was apparently aware that Mr X had had depression and anxiety issues regarding the death of his mother.

A further complicating factor in this case is that Mr X developed colitis in 1997 and temporal lobe epilepsy which was diagnosed on the 13th September 1999.  Mr X confirmed that he took his medication as prescribed for these conditions and that both were under control.  His last episodes of fitting were in July 2005 and the second week of August 2005 both attributed to the then ongoing situation with Ms Y.  Although Mr X has had no fits since this time he does have what he described as incidents which feel like "going off line".  During these instances, which last a few seconds, Mr X would give the impression that he was not concentrating on the matter at hand.  These incidences tended to happen when "there's a lot going on in my head or when you are subject to hassle, for example when you’re feeling insecure, no guidance or support".  Clearly, there may have been an increase in the number of these incidents when the problems with Ms Y were reaching a crescendo and may have contributed to her allegations that Mr X lacked concentration at work.

An issue to note is that there are a number of scientific papers linking temporal lobe epilepsy with depression, anxiety and panic attacks.  Put simply, there are two schools of thought the first, that epilepsy and these conditions are linked physiologically and the second, that these conditions arise because epileptics fear disgracing themselves by fitting in public, becoming incontinent etc and they often have a sense of difference .It should also be noted that other scientists, the minority, dispute that epilepsy and these conditions are linked.

Since his return to work Mr X now has a new line manager with whom he seems to have a good working relationship he attributes this in large part to her "person orientated skills".

During the course of the sessions, two other related issues, unrelated to work, arose which may render Mr X sensitive to personal criticism.  Whilst these issues were discussed in some depth I have agreed with Mr X not to put them in this report.

Report

Anxiety and Depression
Two tests were administered to explore if Mr X has anxiety or depression at a clinically significant level.  The first the Hospital Anxiety and Depression Scale (HADS) indicated that Mr X’s results came within the normal range and that he does not experience anxiety or depression at a clinically significant level.  This indicates that Mr X should have the physical and mental energy to undertake his job as per the job descriptions supplied. 

In support of this, the second test completed was the Beck Depression Inventory which tests for psychological and somatic symptoms of depression.  Again, Mr X’s scores fell within the normal range.

A further test, the State-Trait Anger Inventory II (STAX II) was administered to determine whether the anger Mr X experiences is  situationally determined, a state, or is a characteristic of his personality, a trait. As one of his personal characteristics it would appear that Mr X has difficult expressing anger, he came out on the fifth percentile, and that is to say, he rarely expresses anger with 95% of people more openly expressing anger than Mr X.  This would mean that Mr X invests a considerable amount of energy controlling his anger.  This suppressed anger may well express itself as depression, frustration and anxiety. This test also showed that Mr X internalises all these emotions in a highly charged emotional way.  It also indicated that he has a high need for external validation.

Coping strategies
To examine, which coping strategies Mr X uses the Moos Coping Responses Inventory was administered. This explores individual coping strategies both cognitively and behaviourally in different stressful situations. 

The results produced support that Mr X does use cognitive coping strategies such as a logical analysis and that he also perceives himself as a problem solver.  Mr X also employs approach orientated behavioural responses such as seeking support.  In such a situation that existed between himself and Ms Y where he felt unable to seek support this may have led to feelings of powerlessness which due to his difficulty in expressing anger may have been manifested through anxiety.

Mr X’s dominant behavioural coping strategy is avoidant in the form of emotional discharge. In the light of his inability to express anger, this is more likely to be emotionally discharged as anxiety.  There was also a tendency not to see the positives in stressful situations focusing only on the problems.

These methods of coping would render Mr X highly sensitive to criticism from a manager from whom he would expect external validation.  The expression of anger as depression, frustration and anxiety may well have led to impaired performance.

Self-esteem
High self-esteem is linked to the ability to handle criticism from others.  To test Mr X's self-esteem the Battle Culture Free Self Esteem test was administered.  This tests social, general and personal self-esteem.  Overall Mr X score was intermediate however, the individual scores were interesting.

Social self-esteem -- Mr X’s self esteem fell in the high range, although Mr X chose to answer the questions in relation to relationships outside of work.

General self-esteem -- this also came out as high.

Personal self-esteem -- although this came out as intermediate, 76% of individuals would be expected to score as high on this indicator.

Self-esteem has an inverse relationship to anxiety and depression.  High self-esteem allows one to assess criticism from critical others in a more positive way.  These results would be consistent with someone who saw themselves good with relationships and confident in everyday situations yet who may attribute any criticism as a personal failing.

The test also confirms that Mr X has a high need for external validation making him susceptible to external criticism.

Other
During the general course of our conversation it became clear that Mr X is a non-dominant person with a high need to comply.  When he is not allowed to comply this may manifest itself as anxiety and depression.  He has a high need to be recognised by his manager as a loyal and faithful (compliant) employee. When he does not receive this recognition, as in the case with Ms Y, this again may manifest itself as anxiety and depression.

To test for any underlying personality disorders the Personality Assessment Inventory (PIA) was administered. None were evident.

Conclusions
Mr X sees himself as a loyal and faithful employee who for some reason has fallen foul of a manager, Ms Y with whom he had previously had a good relationship.  The result of which is that Ms Y had not only failed to give him the external validation he needed but was actively, in his opinion, instituting a whispering campaign against him.

Although Mr X had had two previous incidents of clinical depression, these appear to be two instances of reactive depression; the literature typically indicates that a "normal" individual may have three such incidences in a lifetime.  He does not have depression at a clinically significant level at the time of testing.

Mr X has a number of factors which may contribute in part or in total to his feelings of anxiety.  His personal characteristics reveal that he is a highly compliant individual with a high need for external validation, when this is not forthcoming this may manifest itself as anxiety.  This position is compound by the fact that Mr X has difficulties expressing his anger.  Instead of expressing anger in the normal way he tends to express it as anxiety and frustration.

His tendencies to internalise blame and see the negatives rather than the positives coupled with a dominant coping strategy of avoidance further makes him sensitive to criticism.

Mr X uses cognitive coping strategies such as a logical analysis and he also sees himself as a problem solver and he does use behavioural responses such as seeking support.  These normally powerful coping strategies would be severely restricted in a situation where he felt he was unable to approach his manager, this would typically lead to a situation where he may consider himself powerless further contributing to feelings of anxiety and frustration.

A further complication is that Mr X has temporal lobe epilepsy and in common with other sufferers may have a degree of anxiety associated with this illness.  Furthermore, his periods of "going offline" due to his illness may have contributed to the suggestion that he was failing to concentrate at work.

Treatment plan
The treatment plan involves a number of factors including:

• More constructive expression of anger
• Development of personal self-esteem
• More constructive expression of emotional discharge
• Overcoming sensitivity to criticism
• Self-assertion training
• Overcoming fear of failure
• Better understanding of his epilepsy
• Understanding the need for external validation
• Help with seeking support
• Emotional regulation of his anxiety

The backbone of the treatment plan will be cognitive behavioural therapy.  This will take eight two hour sessions .Mr X has already indicated that he would be amenable to such a plan.

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