Cortisol and hypothalamic-pituitary-gonadal axis hormones in follicular-phase women with fibromyalgia and chronic fatigue syndrome and effect of depressive symptoms on these hormones

Research progress in the treatment of chronic fatigue syndrome through interventions targeting the hypothalamus-pituitary-adrenal axis

Chronic fatigue syndrome (CFS) causes great harm to individuals and society. Elucidating the pathogenesis of CFS and developing safe and effective treatments are urgently needed. This paper reviews the functional changes in the hypothalamus-pituitary-adrenal (HPA) axis in patients with CFS and the associated neuroendocrine mechanisms. Despite some controversy, the current mainstream research evidence indicates that CFS patients have mild hypocortisolism, weakened daily variation in cortisol, a weakened response to the HPA axis, and an increase in negative feedback of the HPA axis. The relationship between dysfunction of the HPA axis and the typical symptoms of CFS are discussed, and the current treatment methods are reviewed.

Epigenetics of inflammation in hypothalamus pituitary gonadal and neuroendocrine disorders

The hormone producing hypothalamus, pituitary and gonadal are arranged in hierarchy to form the hypothalamic-pituitary-gonadal axis (HPG axis). The axis is neuroendocrine in nature and releases hormones in response to the inputs from nervous systems. The axis maintains homeostasis and ensures smooth body functions, particularly those related to growth and reproduction. A deregulated HPG axis, such as observed under inflammation and other conditions, is therefore associated with several disorders such as polycystic ovary syndrome, functional hypothalamic amenorrhea etc. Several factors, both genetic as well as environmental, in addition to aging, obesity etc. affect HPG axis with resulting effects on puberty, sexual maturation and reproductive health. More research is now indicative of a role of epigenetics in mediating these HPG-affecting factors. Hypothalamus-secreted gonadotropin-releasing hormone is important for eventual release of sex hormones and it is subjected to several neuronal and epigenetic regulations. Gene promoter methylation as well as histone methylations and acetylations form the backbone of epigenetic regulation of HPG-axis, as the incoming reports suggest. Epigenetic events also mediate several feedback mechanisms within HPG axis and between HPG axis and the central nervous system. In addition, data is emerging for a role of non-coding RNAs, particularly the miRNAs, in regulation and normal functioning of HPG axis. Thus, the epigenetic interactions need better understanding to understand the functioning and regulation of HPG axis.

Epstein-Barr virus-acquired immunodeficiency in myalgic encephalomyelitis-Is it present in long COVID?

Both myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS) and long COVID (LC) are characterized by similar immunological alterations, persistence of chronic viral infection, autoimmunity, chronic inflammatory state, viral reactivation, hypocortisolism, and microclot formation. They also present with similar symptoms such as asthenia, exercise intolerance, sleep disorders, cognitive dysfunction, and neurological and gastrointestinal complaints. In addition, both pathologies present Epstein-Barr virus (EBV) reactivation, indicating the possibility of this virus being the link between both pathologies. Therefore, we propose that latency and recurrent EBV reactivation could generate an acquired immunodeficiency syndrome in three steps: first, an acquired EBV immunodeficiency develops in individuals with "weak" EBV HLA-II haplotypes, which prevents the control of latency I cells. Second, ectopic lymphoid structures with EBV latency form in different tissues (including the CNS), promoting inflammatory responses and further impairment of cell-mediated immunity. Finally, immune exhaustion occurs due to chronic exposure to viral antigens, with consolidation of the disease. In the case of LC, prior to the first step, there is the possibility of previous SARS-CoV-2 infection in individuals with "weak" HLA-II haplotypes against this virus and/or EBV.

Sex and stress hormone dysregulation as clinical manifestations of hypothalamic function in migraine disorder: A meta-analysis

Migraine is a leading cause of disability in young adults. It occurs more frequently in females, often comorbidly with stress disorders, suggesting an association with hypothalamic sex and stress hormonal function and a likely interaction with autonomic nervous system activation. Thus, this study aimed to meta-analyse current literature pertaining to female and male sex hormones (estrogen, progesterone and testosterone concentration), hypothalamic-pituitary-adrenal axis (HPA axis) cortisol responses and heart rate variability (HRV) in migraineurs and controls aged 13-65 years. A systematic search of MEDLINE, Embase, PsycINFO, PubMed, CINAHL and Web of Science databases on 29/08/2022 identified 29 studies for meta-analysis (encompassing 719 migraineur and 592 control participants) that met inclusion and NHLBI risk of bias criteria. Results demonstrated that estrogen concentrations of female migraineurs were reduced (g = -.60, 95% CI [-.91, -.29], p < .001) in the luteal phase of the menstrual cycle, compared to controls. No differences were found in progesterone levels overall in female migraineurs, nor in testosterone levels in male migraineurs compared to controls. Further, early diurnal cortisol concentrations were elevated (g = .32, 95% CI [.00, .63], p = .036) in female and male migraineurs compared to controls, though no differences were found in HRV of female or male migraineurs compared to controls. These findings of dysregulation of estrogen in females and cortisol dysregulation in female and male migraineurs indicate perturbed hypothalamic function and highlight the association of migraine with stress and the need for further rigorous investigation of hypothalamic neuroendocrine functions in migraineurs of both sexes.

Stress biomarkers in individuals with fibromyalgia syndrome: a systematic review with meta-analysis

ABSTRACT

Evidence suggests an involvement of hypothalamic-pituitary-adrenal (HPA) axis dysregulation in the development and maintenance of fibromyalgia syndrome (FMS). However, studies on the stress response via the HPA-axis in individuals with FMS show conflicting results. To better understand the relationship between FMS and HPA-axis dysregulation, we (1) systematically summarized the current level of evidence on HPA biomarkers in individuals with FMS compared with individuals without and (2) evaluated whether FMS is associated with a specific pattern of HPA dysregulation. The main outcome measures were cortisol, adrenocorticotropic hormone (ACTH), corticotropin-releasing hormone (CRH), epinephrine, and norepinephrine. A systematic search of MEDLINE, EMBASE, and PsychMed yielded 47 studies eligible for meta-analysis, including 1465 individuals with FMS and 1192 FMS-free controls. No main effect of FMS was found on altered levels of blood cortisol, ACTH, CRH, and epinephrine. Compared with controls, salivary and urinary cortisol levels were decreased in individuals with FMS, whereas blood levels of norepinephrine were increased. However, heterogeneity of data was high with significant evidence for publication bias. Overall, the data are compatible with association of FMS with adrenocortical hypofunction in the presence of increased sympathetic tone. However, the data are partially contradictory, so it must be assumed that the data are highly dependent on the respective study designs, patient samples, and analytical methods and do not necessarily demonstrate an abnormal HPA-axis function in FMS.

Influence of Chronic Fatigue Syndrome Codiagnosis on the Relationship between Perceived and Objective Psychoneuro-Immunoendocrine Disorders in Women with Fibromyalgia

Although the predominant symptom in fibromyalgia (FM) is muscle pain, and fatigue in chronic fatigue syndrome (CFS), differential diagnosis is very difficult. This research investigates the psychoneuroimmunoendocrine disorders of FM patients and ascertains whether a previous CFS diagnosis affected them. Through accelerometry objective parameters, physical activity/sedentarism levels in relation to fatigue are studied, as well as whether perceived levels of stress, anxiety, and pain correspond to objective biomarkers, all of these with respect to a reference group (RG) of women without FM. FM patients have a worse psychological state and perceived quality of life than those with RG. These perceived outcomes are consistent with impaired objective levels of a sedentary lifestyle, higher systemic levels of cortisol and noradrenaline, and lower levels of serotonin. However, FM patients with a previous CFS diagnosis had lower systemic levels of IL-8, cortisol, oxytocin, and higher levels of adrenaline and serotonin than FM patients without diagnosed CFS. In conclusion, while perceived health parameters do not detect differences, when objective neuroimmunoendocrine parameters related to stress, inflammation, pain, and fatigue are used, people with CFS could be overdiagnosed with FM. This reinforces the need for objective biomarker assessment of these patients for better diagnostic discrimination between both syndromes.

The Link Between Empty Sella Syndrome, Fibromyalgia, and Chronic Fatigue Syndrome: The Role of Increased Cerebrospinal Fluid Pressure

The etiopathogenesis of fibromyalgia (FM) and chronic fatigue syndrome (CFS) is not yet elucidated. Hypothalamo-pituitary-adrenal (HPA) axis dysfunction is reflected in the hormonal disturbances found in FM and CFS. Some study groups have introduced a novel hypothesis that moderate or intermittent intracranial hypertension may be involved in the etiopathogenesis of FM and CFS. In these conditions, hormonal disturbances may be caused by the mechanical effect of increased cerebrospinal fluid pressure, which hampers blood flow in the pituitary gland. Severe intracranial pressure may compress the pituitary gland, resulting in primary empty sella (ES), potentially leading to pituitary hormone deficiencies. The aim of this narrative review was to explore whether similar hormonal changes and symptoms exist between primary ES and FM or CFS and to link them to cerebrospinal fluid pressure dysregulation. A thorough search of the PubMed and Web of Science databases and the reference lists of the included studies revealed that several clinical characteristics were more prevalent in primary ES, FM or CFS patients than in controls, including increased cerebrospinal fluid pressure, obesity, female sex, headaches and migraine, fatigue, visual disturbances (visual acuity and eye motility abnormalities), vestibulocochlear disturbances (vertigo and neurosensorial hearing loss), and bodily pain (radicular pain and small-fiber neuropathy). Furthermore, challenge tests of the pituitary gland showed similar abnormalities in all three conditions: blunted adrenocorticotropic hormone, cortisol, growth hormone, luteinizing hormone, and thyroid stimulating hormone responses and an increased prolactin response. The findings of this narrative review provide further support for the hypothesis that moderately or intermittently increased cerebrospinal fluid pressure is involved in the pathogenesis of FM and CFS and should stimulate further research into the etiopathogenesis of these conditions.

Neurobiological effects of perceived stress are different between adolescents and middle-aged adults

Stress is an inevitable element of everyday living. Developmental studies suggested that adolescents are more vulnerable and sensitive to the effect of stress due to their developing brains, especially in areas related to stress perception and processing. This voxel-based morphometry study examined the association between various neurobiological markers and the level of perceived stress experienced by adolescents (n = 26) and middle-aged adults (n = 26). Our findings indicated that differences existed in the relationships between perceived stress and the structural volume of the orbitofrontal cortex (OFC) extending to the insula and amygdala. Specifically, the levels of perceived stress and the grey matter volume of the orbitofrontal cortex, the insula, and the amygdala were positively related in adolescents but negatively related for adults. Furthermore, a significant negative correlation between perceived stress and cortisol levels was observed in adults, whereas the relationship between perceived stress and cortisol levels was not significant for adolescents. Perceived stress measurement may be better than cortisol levels in terms of reflecting the emotional states of adolescents. In sum, the relationships between perceived stress and neurobiological markers were different between adolescents and middle-aged adults and thus appeared to be age dependent.

The Comparison of the Biological Rhythms of Patients with Fibromyalgia Syndrome with Biological Rhythms of Healthy Controls

Background

Fibromyalgia syndrome (FMS) is a rheumatic disease characterized by diffuse body pain and decreased muscle function. The aim of the present study was to compare the biological rhythms of patients with fibromyalgia syndrome with the biological rhythms of healthy controls.

Material/Methods

This was a cross-sectional, single blind, and single center case-control study. The patients with fibromyalgia were evaluated using a Fibromyalgia Impact Questionnaire (FIQ), Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN) Scale, Visual Analog Scale (VAS), Pittsburg Sleep Quality Index (PSQI) and Beck Depression Inventory (BDI).

Results

The study included 77 female patients with FMS, and 32 healthy female individuals as the control group. We found that the patients in the FMS group achieved higher scores in VAS, BDI, PSQI, and the BRIAN scale than the patients in the control group (P<0.001). An evaluation of the relationship between FMS evaluation parameters and biological rhythm scores in patients with FMS revealed a significant positive correlation between total BRAIN and VAS, FIQ, BDI, and PSQI scores. When the relationship between FMS evaluation parameters and biological rhythm scores was evaluated in patients with FMS, a significant positive correlation was found between total BRAIN and VAS, FIQ, BDI, and PSQI scores (r=0.555, P<0.001; r=0.461, P<0.001; r=0.630, P<0.001; and r=0.551, P<0.001 respectively).

Conclusions

We consider that an evaluation of the biological rhythm of female patients with FMS, and appropriate treatment when required, would contribute significantly to the treatment and follow-up process of the patients.

Associations Among Trajectories of Sleep Disturbance, Depressive Symptomology and 24-Hour Urinary Cortisol in HIV+ Women Following a Stress Management Intervention

Objective: The burden of sleep disturbance and depressive symptomology is high for persons living with HIV and particularly so for women. While cognitive behavioral stress management (CBSM) is shown to reduce symptoms of depression and 24-hr urinary free cortisol output (CORT) in HIV+ men, less is known about the effects of CBSM on mood and concomitant sleep disturbance in HIV+ women. The study aim is to model longitudinal change in sleep disturbance, depressive symptomology, and CORT for HIV+ women exposed to a 12-week CBSM intervention or control condition. Methods: Self-reported sleep quality and depressive symptomology, along with CORT, was collected from surveys at baseline and approximately every three months thereafter for nine months from 130 HIV+ women (M_age = 38.44, SD = 7.73). The data was used to specify a parallel process latent growth model with CORT as a time-varying covariate. Results: The model showed acceptable fit. There was a linear decline in sleep disturbance (β = -0.32, p < .05) and logarithmic decline in depressive symptomology (β = -0.33, p < .05) for those receiving the intervention. Decline in sleep disturbance predicted lower CORT at nine months. Furthermore, having less depressive symptoms at baseline was associated with lower initial levels of sleep disturbance and greater improvement in sleep quality over time. There was no discernible association between sleep and mood disturbance in the control group. Across groups, there was a consistent association between older age and greater sleep disturbance (r = 0.34, p < .01). Conclusion: Sleep disturbance appears to be a behavioral target for CBSM in HIV+ women although older age, preintervention levels of depressive mood, and time-varying levels of CORT output may limit improvement in sleep quality over time.

Leveraging Prior Knowledge of Endocrine Immune Regulation in the Therapeutically Relevant Phenotyping of Women With Chronic Fatigue Syndrome

PURPOSE

The complex and varied presentation of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) has made it difficult to diagnose, study, and treat. Its symptoms and likely etiology involve multiple components of endocrine and immune regulation, including the hypothalamic-pituitary-adrenal axis, the hypothalamic-pituitary-gonadal axis, and their interactive oversight of immune function. We propose that the persistence of ME/CFS may involve changes in the regulatory interactions across these physiological axes. We also propose that the robustness of this new pathogenic equilibrium may at least in part explain the limited success of conventional single-target therapies.

METHODS

A comprehensive model was constructed of female endocrine-immune signaling consisting of 28 markers linked by 214 documented regulatory interactions. This detailed model was then constrained to adhere to experimental measurements in a subset of 17 candidate immune markers measured in peripheral blood of patients with ME/CFS and healthy control subjects before, during, and after a maximal exercise challenge. A set of 26 competing numerical models satisfied these data to within 5% error.

FINDINGS

Mechanistically informed predictions of endocrine and immune markers that were either unmeasured or exhibited high subject-to-subject variability pointed to possible context-specific overexpression in ME/CFS at rest of corticotropin-releasing hormone, chemokine (C-X-C motif) ligand 8, estrogen, follicle-stimulating hormone (FSH), gonadotropin-releasing hormone 1, interleukin (IL)-23, and luteinizing hormone, and underexpression of adrenocorticotropic hormone, cortisol, interferon-γ, IL-10, IL-17, and IL-1α. Simulations of rintatolimod and rituximab treatment predicted a shift in the repertoire of available endocrine-immune regulatory regimens. Rintatolimod was predicted to make available substantial remission in a significant subset of subjects, in particular those with low levels of IL-1α, IL-17, and cortisol; intermediate levels of progesterone and FSH; and high estrogen levels. Rituximab treatment was predicted to support partial remission in a smaller subset of patients with ME/CFS, specifically those with low norepinephrine, IL-1α, chemokine (C-X-C motif) ligand 8, and cortisol levels; intermediate FSH and gonadotropin-releasing hormone 1 levels; and elevated expression of tumor necrosis factor-α, luteinizing hormone, IL-12, and B-cell activation.

IMPLICATIONS

Applying a rigorous filter of known signaling mechanisms to experimentally measured immune marker expression in ME/CFS has highlighted potential new context-specific markers of illness. These novel endocrine and immune markers may offer useful candidates in delineating new subtypes of ME/CFS and may inform on refinements to the inclusion criteria and instrumentation of new and ongoing trials involving rintatolimod and rituximab treatment protocols.

Evaluating psychosocial contributions to chronic pain outcomes

The biopsychosocial model of pain dominates the scientific community's understanding of chronic pain. Indeed, the biopsychosocial approach describes pain and disability as a multidimensional, dynamic integration among physiological, psychological, and social factors that reciprocally influence one another. In this article, we review two categories of studies that evaluate the contributions of psychosocial factors to the experience of chronic pain. First, we consider general psychosocial variables including distress, trauma, and interpersonal factors. Additionally, we discuss pain-specific psychosocial variables including catastrophizing, expectations, and pain-related coping. Together, we present a diverse array of psychological, social, and contextual factors and highlight the need to consider their roles in the development, maintenance, and treatment of chronic pain conditions.

Cortisol and Subjective Stress Responses to Acute Psychosocial Stress in Fibromyalgia Patients and Control Participants

OBJECTIVE

Hypothalamic-pituitary-adrenal axis dysfunction may play a role in fibromyalgia (FM) pathogenesis but it remains understudied in this disorder. Furthermore, early childhood adversities (ECA) are common in FM, but whether they moderate stress reactivity is unknown. Hence, we investigated cortisol and subjective responses to acute psychosocial stress in FM and controls, while adjusting for ECA.

METHODS

Twenty-seven female FM patients and 24 age-matched female controls were recruited in a tertiary care center and through advertisements, respectively. The Childhood Trauma Questionnaire was used to measure ECA history. Salivary cortisol levels and subjective stress ratings were measured at multiple time points before and after the Trier Social Stress Test (TSST) was administered.

RESULTS

Significant main effects of group [F(1,43) = 7.04, p = .011, lower in FM] and ECA [F(1,43) = 5.18, p = .028, higher in participants with ECA] were found for cortisol responses. When excluding controls with ECA (n = 5), a significant group-by-time interaction was found [F(6,39) = 2.60, p = .032], driven by a blunted response to the stressor in FM compared with controls (p = .037). For subjective stress responses, a significant main effect of group [F(1,45) = 10.69, p = .002, higher in FM] and a trend toward a group-by-time interaction effect [F(6,45) = 2.05, p = .078, higher in FM 30 minutes before and 30 and 75 minutes after the TSST, and impaired recovery (difference immediately after - 30 minutes after the TSST) in FM] were found.

CONCLUSIONS

Blunted cortisol responsivity to the TSST was observed in FM patients compared with controls without ECA. FM patients had higher subjective stress levels compared with controls, particularly at baseline and during recovery from the TSST. In FM patients, ECA history was not associated with cortisol or subjective stress levels or with responsivity to the TSST. Future research should investigate the mechanisms underlying hypothalamic-pituitary-adrenal axis dysregulation in FM.

Association between cortisol levels and pain threshold in systemic sclerosis and major depression

Pain perception and threshold show complex interactions with the inflammatory, psychiatric and neuroendocrine stimuli. This study aims to test whether lower serum cortisol levels are associated with lower pain thresholds and higher degree of depression in systemic sclerosis (SSc) and major depression with atypical features (MD-AF) patients compared to controls. 180 female subjects (SSc = 60, MD-AF = 60, healthy controls = 60) participated in this observational, cross-sectional, parallel group study. Pressure pain threshold (PPT) was assessed in three anatomical sites: nail bed (NB), metacarpophalangeal joint (MCP) and quadriceps muscle (QDR). Depressive symptoms were evaluated using the Beck Depression Inventory (BDI) scale and morning serum cortisol levels were collected. In SSc patients, quality of life was measured through the Health Assessment Questionnaire (HAQ-DI) and the scleroderma-specific visual analogue scales (scleroderma-VAS). Lower PPT scores (NB 4.42 ± 1.6; MCP 4.66 ± 1.4; QDR 4.79 ± 1.5) were observed in SSc patients compared to both MD-AF (NB 7.33 ± 2.2; MCP 6.01 ± 1.9; QDR 6.31 ± 1.6; p < 0.005) and controls (NB 9.57 ± 2; MCP 7.9 ± 2.1 and QDR 8.43 ± 2.1; p < 0.0001), while MD-AF patients had lower PPT scores compared to controls (p < 0.0001). SSc patients had also lower serum cortisol levels compared to MD-AF patients (8.78 vs 13.6 μg/dl; p < 0.05). A direct correlation was observed between serum cortisol and PPT scores both in SSc (r ² for NB 0.29; for MCP 0.25; for QDR 0.27) and in MD-AF (r ² for NB 0.34; for MCP 0.25; for QDR 0.47; p < 0.05), while depressive symptoms negatively correlated with serum cortisol (r ² for NB 0.34; for MCP 0.17; for QDR 0.15) and in MD-AF (r ² for NB 0.19; for MCP 0.31; for QDR 0.30; p < 0.05). Among SSc patients, those with serum cortisol levels below the normal range (n = 16) had higher BDI scores (15, 6-21 vs 9, 2-15; p < 0.005), lower PPTs (NB 4 ± 1.4 vs 4.9 ± 0.9; MCP 4.1 ± 0.8 vs 4.8 ± 0.9; QDR 4.1 ± 1.2 vs 5 ± 0.9; p < 0.005) and higher HAQ-DI (1.25, 0.25-2 vs 0.75, 0-1.25; p < 0.05) and scleroderma-VAS scores (VAS overall severity 7, 5.5-9.5 vs 4.5, 2.5-6; p < 0.05). The effect of cortisol serum levels upon pain mechanism, in chronic inflammatory conditions warrants longitudinal studies to detect treatable variations in pain thresholds, depressive symptoms and to improve quality of life.

Influence of stress systems and physical activity on different dimensions of fatigue in female fibromyalgia patients

OBJECTIVE

Fatigue is a defining characteristic and one of the most debilitating features of fibromyalgia syndrome (FMS). The mechanisms underlying different dimensions of fatigue in FMS remain unclear. The aim of the current study was to test whether stress-related biological processes and physical activity modulate fatigue experience.

METHODS

Using an ambulatory assessment design, 26 female FMS patients reported general, mental, and physical fatigue levels at six time points per day for 14 consecutive days. Salivary cortisol and alpha-amylase were analyzed as markers of neuroendocrine functioning. Participants wore wrist actigraphs for the assessment of physical activity.

RESULTS

Lower increases in cortisol after awakening predicted higher mean daily general and physical fatigue levels. Additionally, mean daily physical activity positively predicted next-day mean general fatigue. Levels of physical fatigue at a specific time point were positively associated with momentary cortisol levels. The increase in cortisol after awakening did not mediate the physical activity - fatigue relationship. There were no associations between alpha-amylase and fatigue.

CONCLUSION

Our findings imply that both changes in hypothalamic-pituitary-adrenal axis activity and physical activity contribute to variance in fatigue in the daily lives of patients with FMS. This study helps to paint a clearer picture of the biological and behavioral underpinnings of fatigue in FMS and highlight the necessity of interdisciplinary treatment approaches targeting biological, behavioral and psychological aspects of FMS.

Hypothalamic-Pituitary-Adrenal Hypofunction in Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS) as a Consequence of Activated Immune-Inflammatory and Oxidative and Nitrosative Pathways

There is evidence that immune-inflammatory and oxidative and nitrosative stress (O&NS) pathways play a role in the pathophysiology of myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS). There is also evidence that these neuroimmune diseases are accompanied by hypothalamic-pituitary-adrenal (HPA) axis hypoactivity as indicated by lowered baseline glucocorticoid levels. This paper aims to review the bidirectional communications between immune-inflammatory and O&NS pathways and HPA axis hypoactivity in ME/CFS, considering two possibilities: (a) Activation of immune-inflammatory pathways is secondary to HPA axis hypofunction via attenuated negative feedback mechanisms, or (b) chronic activated immune-inflammatory and O&NS pathways play a causative role in HPA axis hypoactivity. Electronic databases, i.e., PUBMED, Scopus, and Google Scholar, were used as sources for this narrative review by using keywords CFS, ME, cortisol, ACTH, CRH, HPA axis, glucocorticoid receptor, cytokines, immune, immunity, inflammation, and O&NS. Findings show that activation of immune-inflammatory and O&NS pathways in ME/CFS are probably not secondary to HPA axis hypoactivity and that activation of these pathways may underpin HPA axis hypofunction in ME/CFS. Mechanistic explanations comprise increased levels of tumor necrosis factor-α, T regulatory responses with elevated levels of interleukin-10 and transforming growth factor-β, elevated levels of nitric oxide, and viral/bacterial-mediated mechanisms. HPA axis hypoactivity in ME/CFS is most likely a consequence and not a cause of a wide variety of activated immune-inflammatory and O&NS pathways in that illness.

Assessment of Fatigue in Spondyloarthritis and Its Association with Disease Activity

Objective.

To evaluate fatigue in patients with spondyloarthritis (SpA) and to define its association with disease-related factors and patients’ features.

Methods.

A cross-sectional multicenter study which includes 2251 patients with SpA selected from the national Spondyloarthropathies Registry (the Spanish Society of Rheumatology; REGISPONSER) Spanish cohort. The primary outcome was the assessment of fatigue performed with the first item of the Bath Ankylosing Spondyloarthritis Disease Activity Index followed by the study of its relation with different factors organized into 4 groups: sociodemographics, emotional, disease-related, and disease activity. Univariate logistic regressions, multivariate logistic regression, and multiple linear regressions were performed to relate fatigue with the studied covariates.

Results.

Mean fatigue score in all patients with SpA was 4.3 ± 2.9, with statistically significant differences between different SpA types. In univariate logistic regressions, significant differences were seen for many variables included in the 4 groups. Multivariate logistic regression showed that high fatigue score was related with sex (female), emotional component, the Ankylosing Spondylitis Quality of Life score, stiffness, and high levels of 2 visual analog scale items (vertebral pain in the last week and patient’s global assessment of disease activity). The multivariate linear regression showed that fatigue was mainly explained by disease-related factors and disease activity (54.1%), but sex and emotional status may also be involved in 13.5% of the variance.

Conclusion.

Fatigue is associated with disease-related factors and mostly with SpA activity. However, the emotional component and sex may contribute to the onset of fatigue.

A time to be stressed? Time perspectives and cortisol dynamics among healthy adults

Perceptions of past, present, and future events may be related to stress pathophysiology. We assessed whether Time Perspective (TP) is associated with cortisol dynamics among healthy adults (N=61, Ages=18-35, M=22.9, SD=4.1) exposed to the Trier Social Stress Test (TSST). TP was measured according to two profiles: maladaptive Deviation from Balanced TP (DBTP) and adaptive Deviation from Negative TP (DNTP). Eight salivary cortisol samples were analyzed using area under the curve with respect to ground (AUCg) and to increase (AUCi). Statistic analyses involved partial correlations controlling for depressive symptoms. Results for both sexes showed that higher DBTP scores were associated with lower cortisol AUCg scores, while higher DNTP scores were associated with higher cortisol AUCg scores. These novel findings suggest that maladaptive TP profiles influence hypocortisolism, whereas adaptive TP profiles influence hypercortisolism. Thus, TP profiles may impact conditions characterized by altered cortisol concentrations.

Assessing the prevalence of autoimmune, endocrine, gynecologic, and psychiatric comorbidities in an ethnically diverse cohort of female fibromyalgia patients: does the time from hysterectomy provide a clue?

Background

This retrospective chart review investigated differences in the prevalence of medical comorbidity between women with fibromyalgia (FM) (n=219) and a control group women with chronic pain (CP) without FM (n=116). The specific aims were to compare the prevalence of autoimmune, psychiatric, endocrine, gynecologic pathology, the relationship between timing of gynecologic surgery, and pain onset. We additionally sought to compare the number of comorbidities in an ethnically diverse cohort.

Methods

This was a retrospective chart review of patients seen in FM or CP clinics at an academic medical center in 2009–2010.

Results

Logistic regression modeling found that gynecologic, endocrine, and autoimmune diagnoses were independently associated with a diagnosis of FM. Detailed analyses showed that thyroid disease (P<0.01) and gynecologic surgery (P<0.05) were significantly more common in FM. Women with FM were more likely to have multiple autoimmune, endocrine, gynecologic, or psychiatric pathologies. A relationship was observed between the timing of gynecologic surgery and pain onset in FM, with more surgeries observed in the years just prior to pain onset or in the year after pain onset. A similar pattern was not found in the control group.

Conclusion

This study demonstrates that autoimmune, endocrine, and gynecologic pathologies occur more commonly in women with FM than in those with CP, which is consistent with findings in less ethnically diverse samples. Moreover, a relationship was found between timing of pain onset and gynecologic surgery. A larger prospective study of the relationship between gynecologic surgery and pain onset in FM is warranted.

The common link between functional somatic syndromes may be central sensitisation

OBJECTIVES

Functional somatic syndromes are common and disabling conditions that all include chronic pain, and which may be related to central nervous system sensitisation. Here, we address the concept of central sensitisation as a physiological basis for the functional somatic syndromes.

METHODS

A narrative review of the current literature on central sensitisation and physiological studies in the functional somatic syndromes.

RESULTS

Central sensitisation may be a common neurophysiological process that is able to explain non-painful as well as painful symptoms in these disorders. Furthermore, central sensitisation may represent an endophenotypic vulnerability to the development of these syndromes that potentially explains why they cluster together.

CONCLUSIONS

Further research is needed to verify these findings, including prospective studies and the standardisation of combined methods of investigation in the study of central sensitisation in functional somatic syndromes. In turn, this may lead to new explanatory mechanisms and treatments being evaluated. Our conclusions add to the debate over the nomenclature of these syndromes but importantly also provide an explanation for our patients.

Blunted endocrine and cardiovascular reactivity in young healthy women reporting a history of childhood adversity

BACKGROUND

Chronic or prolonged stress exposure in childhood can alter structural and functional brain development, leading to mental and physical illness and alterations of psychobiological stress systems in adulthood. Recently, attenuation in stress reactivity of the hypothalamic-pituitary-adrenal (HPA) axis and cardiovascular system have been related to the number of adverse childhood experiences (ACEs). We set out to investigate the association of ACE duration and age of ACE occurrence on stress reactivity.

METHODS

104 women in the age range 18-25 years (mean=21.7) free of mental and physical illness underwent psychosocial stress testing with the Montreal Imaging Stress Task (MIST). Free saliva cortisol and heart rate were assessed repeatedly before and after the MIST.

RESULTS

Number of ACEs was associated with attenuated cortisol and heart rate responses to stress in a dose-response relationship. Whereas overall duration of ACEs was significantly associated with an attenuated cortisol response, the specific age of first ACE occurrence did not contribute further to the dampened stress response.

CONCLUSIONS

ACEs are associated with blunted endocrine and cardiovascular stress reactivity in young and healthy women. Adverse life events in childhood, particularly if they occur repeatedly and chronically, show a strong association with alterations in stress reactivity in adulthood, potentially predisposing for later mental or physical disorders.

Higher perceived stress but lower cortisol levels found among young Greek adults living in a stressful social environment in comparison with Swedish young adults

The worldwide financial crisis during recent years has raised concerns of negative public health effects. This is notably evident in southern Europe. In Greece, where the financial austerity has been especially pronounced, the prevalence of mental health problems including depression and suicide has increased, and outbreaks of infectious diseases have risen. The main objective in this study was to investigate whether different indicators of health and stress levels measured by a new biomarker based on cortisol in human hair were different amongst comparable Greek and Swedish young adults, considering that Sweden has been much less affected by the recent economic crises. In this cross-sectional comparative study, young adults from the city of Athens in Greece (n = 124) and from the city of Linkoping in Sweden (n = 112) participated. The data collection comprised answering a questionnaire with different health indicators and hair samples being analyzed for the stress hormone cortisol, a biomarker with the ability to retrospectively measure long-term cortisol exposure. The Greek young adults reported significantly higher perceived stress (p<0.0001), had experienced more serious life events (p = 0.002), had lower hope for the future (p<0.0001), and had significantly more widespread symptoms of depression (p<0.0001) and anxiety (p<0.0001) than the Swedes. But, the Greeks were found to have significantly lower cortisol levels (p<0.0001) than the Swedes, and this difference was still significant in a multivariate regression (p<0.0001), after adjustments for potential intervening variables. A variety of factors related to differences in the physical or socio-cultural environment between the two sites, might possibly explain this finding. However, a potential biological mechanism is that long-term stress exposure could lead to a lowering of the cortisol levels. This study points out a possible hypothesis that the cortisol levels of the Greek young adults might have been suppressed and their HPA-axis down-regulated after living in a stressful environment with economic and social pressure.

Hypothalamic-pituitary-adrenal axis dysfunction in chronic fatigue syndrome

The weight of current evidence supports the presence of the following factors related to hypothalamic-pituitary-adrenal (HPA) axis dysfunction in patients with chronic fatigue syndrome (CFS): mild hypocortisolism; attenuated diurnal variation of cortisol; enhanced negative feedback to the HPA axis; and blunted HPA axis responsiveness. Furthermore, HPA axis changes seem clinically relevant, as they are associated with worse symptoms and/or disability and with poorer outcomes to standard treatments for CFS. Regarding etiology, women with CFS are more likely to have reduced cortisol levels. Studies published in the past 8 years provide further support for a multifactorial model in which several factors interact to moderate HPA axis changes. In particular, low activity levels, depression and early-life stress appear to reduce cortisol levels, whereas the use of psychotropic medication can increase cortisol. Addressing these factors-for example, with cognitive behavioral therapy-can increase cortisol levels and is probably the first-line approach for correcting HPA axis dysfunction at present, as steroid replacement is not recommended. Given what is now a fairly consistent pattern of findings for the type of HPA axis changes found in CFS, we recommend that future work focuses on improving our understanding of the cause and relevance of these observed changes.

Chronic pain therapy and hypothalamic-pituitary-adrenal axis impairment

Opiates and/or nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most effective therapies for chronic pain, but their prolonged time of use can affect health conditions through physical and psychological side effects. They include the very common gastrointestinal effects and changes that can induce osteoporosis, depression, impaired cognition and a generally poor quality of life, which per se can induce and maintain a chronic painful condition. For this reason it is becoming imperative to expand our knowledge of the interaction of these substances with body functions apparently not directly involved in nociception and pain, such as neuroendocrine functions. The purpose of this study was to determine, in male and female patients suffering from chronic pain, the effect of conventional pain therapy (opiates, NSAIDs) on hypothalamic-pituitary-adrenal (HPA) axis function. This was assessed by measuring the blood levels of adrenal-related hormones (adrenocorticotrophin hormone, ACTH; cortisol; dehydroepiandrosterone, DHEA and dehydroepiandrosterone sulfate, DHEAS). The second purpose of the study was to test the hypothesis that these hormones are associated with the psychological profile shown by the chronic pain patients. The results showed significant changes induced by pain therapy on the HPA axis: ACTH, cortisol, DHEA and DHEAS blood levels decreased in all subjects taking opiates or NSAIDs to treat pain. Moreover these changes showed significant correlations with psychological features of the subjects depending on age and sex.

Meta-analysis and meta-regression of hypothalamic-pituitary-adrenal axis activity in functional somatic disorders

Dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis is the most investigated biological risk marker in functional somatic disorders (FSDs), such as chronic fatigue syndrome (CFS), fibromyalgia (FM), and irritable bowel syndrome (IBS). Our aim was to assess whether there is an association between basal hypocortisolism and FSD and to identify potential moderators of this association. Meta-analysis on 85 studies revealed that although basal cortisol levels were generally lower in FSD subjects compared to controls, this association did not reach statistical significance (SMD -0.07, 95% CI -0.17 to 0.04, p=0.241). However, when the three FSD were assessed separately, statistically significant basal hypocortisolism was observed in CFS subjects compared to controls (SMD -0.14, 95% CI -0.28 to 0.00, p=0.047), but not in FM or IBS. When all potential moderators were entered into a meta-regression analysis, only type of FSD and female gender were significant independent predictors of basal hypocortisolism. In conclusion, we did not find evidence to consider all three main FSD as hypocortisolemic disorders, as significant reduction in basal cortisol compared to healthy controls was only found in CFS and in females with FM, but not in IBS.

Fibromyalgia syndrome is associated with hypocortisolism

BACKGROUND

Fibromyalgia syndrome (FMS) is a disease of unknown pathogenesis characterized by chronic musculoskeletal pain. FMS has been also associated with altered endocrinological responses, but findings are inconsistent.

PURPOSE

The aim of the present study was to investigate free salivary cortisol levels in FMS patients compared with healthy controls with a particular focus on the cortisol awakening response (CAR). The saliva samples were collected in a controlled hospital-hotel setting, in which the participants' compliance was high and a number of potential confounders were analyzed.

METHOD

Twenty-nine chronic female FMS patients and 29 age-matched healthy female controls were recruited. Salivary cortisol samples were investigated eight times: in the afternoon when participants arrived at the hospital, after stress provocation (to be reported separately), in the evening, before they went to sleep, upon awakening, 30 and 60 min later, and during the afternoon of the second day. Questionnaires measuring pain levels, sleeping problems, perceived stress, and personality were administered to the participants. Other psychophysiological measurements were used to assess sleep quality and heart rate.

RESULTS

Patients with FMS had significantly lower cortisol levels during the day, most pronounced in the morning (CAR). The potential confounders analyzed did not influence the results. As expected, FMS patients reported more pain, stress, sleeping problems, anxiety, and depression.

CONCLUSION

The results lend support to the hypothesis of a dysfunction in the hypothalamus-pituitary-adrenal axis in FMS patients, with generally lower cortisol values, most pronounced upon awakening (CAR).

Neuroendocrine and immune contributors to fatigue

Central fatigue, a persistent and subjective sense of tiredness, generally correlates poorly with traditional markers of disease. It is frequently associated with psychosocial factors, such as depression, sleep disorder, anxiety, and coping style, which suggest that dysregulation of the body's stress systems may serve as an underlying mechanism in the maintenance of chronic fatigue (CF). This article addresses the endocrine, neural, and immune factors that contribute to fatigue and describes research regarding the role of these factors in chronic fatigue syndrome as a model for addressing the biology of CF. In general, hypoactivity of the hypothalamic-pituitary-adrenal axis, autonomic nervous system alterations characterized by sympathetic overactivity and low vagal tone, as well as immune abnormalities, may contribute to the expression of CF. Noninvasive methods for evaluating endocrine, neural, and immune function are also discussed. Simultaneous evaluation of neuroendocrine and immune systems with noninvasive techniques will help elucidate the underlying interactions of these systems, their role in disease susceptibility, and progression of stress-related disorders.

Salivary cortisol response to acute stress and its relation to psychological factors in women with chronic trapezius myalgia--a pilot study

This study investigated differences in HPA axis function, measured as salivary cortisol concentrations, between 18 women with chronic trapezius myalgia (MYA) and 30 healthy female controls (CON). In addition, the interactions between HPA axis reactions to psychosocial stress and aspects of pain, health and psychological symptoms were analyzed. Salivary cortisol was measured both in daily life, to assess the circadian profile, and in the laboratory during light repetitive work and standardized psychosocial stress (Trier Social Stress Test, TSST). MYA and CON exhibited similar circadian rhythms and comparable salivary cortisol response magnitudes after TSST. In subjects defined as responders to the TSST, the mean peak time point of the cortisol response after TSST differed significantly between MYA and CON. Furthermore, negative psychological states and higher pain intensity were related to a slower HPA axis response to TSST. Low circadian variations in cortisol and smaller cortisol responses to TSST were found among subjects scoring high on anxiety sensitivity. Thus, a relatively favorable sample of female chronic trapezius myalgia patients exhibited normal circadian rhythm and normal salivary cortisol response magnitudes after a psychosocial stress test. In the subgroup of responders, the MYA group showed indications of a slower salivary cortisol response to psychosocial stress. Further studies are needed to elucidate the possibility of altered HPA axis activity in terms of a slower salivary cortisol response.

HPA axis reactivity in chronic pelvic pain: association with depression

OBJECTIVES

Chronic pelvic pain (CPP) is a frequent gynecological complaint. The pathophysiology of CPP is not fully understood. The aim of this study was to determine whether the presence of depressive symptoms is associated with hypothalamic-pituitary-adrenal (HPA) axis dysfunction in CPP.

METHODS

We measured neuroendocrine responses to a standardized social stress test and to a standard adrenocorticotropin (ACTH)(1-24) stimulation test in 18 patients with CPP, stratified based on the presence of high versus low self-reported depressive symptoms, compared with 24 controls.

RESULTS

Women with CPP and low depression exhibited enhanced ACTH responses to psychosocial stress compared with women with CPP and high depression, whereas there were no differences in cortisol responses. In the ACTH(1-24) stimulation test, CPP patients with high depression demonstrated enhanced cortisol responses.

CONCLUSION

These results suggest a relationship between self-reported depression and reactivity of the HPA axis in patients with CPP.

Status of immune mediators in fibromyalgia

Fibromyalgia (FM) is a form of nonarticular rheumatism characterized by long-term (> 3 months) and widespread musculoskeletal pain. However, the biophysiology of FM has remained elusive, and the treatment remains mainly empirical. There are numerous hypotheses about the pathophysiology of chronic widespread pain and FM; one includes a possible role of cytokines. Cytokines play a role in diverse clinical processes and phenomena such as fatigue, fever, sleep, pain, stress, and aching. Cytokines related to acute or repetitive tissue injuries may be responsible for long-term activation of spinal cord glia and dorsal horn neurons, thus resulting in central sensitization. Pain, stiffness, and depression in FM could be associated with some signs of inflammatory response system activation. Illumination of the pathophysiologic secrets of FM will result in more effective treatment regimens. We review the role of immune mediators in the pathophysiology of FM.

Executive functions, self-regulation, and chronic pain: a review

BACKGROUND

Chronic pain conditions are complicated and challenging to live with. Capacity to adjust to such conditions may depend on the ability to self-regulate, that is, the ability to alter thoughts, feelings, and behaviors. Self-regulation appears to rely on executive cognitive functions, and the current review, therefore, sought to draw attention to the impact of self-regulatory capacity and executive functions on chronic pain.

DISCUSSION

Chronic pain conditions present with complex interactions of cognitive, emotional, behavioral, and physiological components for which self-regulatory ability is crucial. The ability to self-regulate varies, and self-regulatory strength appears to be a limited resource that can be fatigued. The many challenges of chronic pain conditions could, therefore, tax self-regulatory strength, leading to self-regulatory deficits.

CONCLUSION

The current review proposes a relationship among pain, self-regulatory capacity, self-regulatory demands, executive functions, and self-regulatory fatigue, suggesting that executive functions and self-regulatory deficits are indeed part of the etiology and maintenance of chronic pain conditions.

Risk factors for fibromyalgia: the role of violence against women

The objectives of the study were to analyse the association between fibromyalgia (FM) and violence against women and to explore the association between FM and sociodemographic factors, social support and psychological distress. A case-control study was conducted in a Spanish hospital. Cases were women diagnosed with FM, with no signs of any other type of inflammatory rheumatic disorder, who were seen at the Rheumatology Department of the hospital. Controls were women not diagnosed with FM who were seen at the Ear, Nose and Throat Department of the same hospital. A self-administered anonymous questionnaire was used to gather data on sociodemographic characteristics, violence, social support and psychological distress. Uni-, bi- and multivariate logistic regression analyses were conducted; 287 cases and 287 controls were recruited. The multivariate analysis showed that the probability of presenting FM increased with age (odds ratios (OR) = 1.06; CI95% = 1.03-1.09); that employed women and housewives were more likely to have the syndrome than unemployed women or students (OR = 4.97; CI95% = 1.45-17.02, and OR = 3.47; CI95% = 0.98-12.22, respectively); that the lower the educational level, the higher the probability of having FM; and that psychological distress was positively associated with the syndrome (OR = 4.62; CI95% = 2.68-7.97). Although abuse was more prevalent in cases than in controls, the differences were not statistically significant. However, frequency of abuse was positively and significantly correlated with FM. Although the aetiology of FM is still uncertain, it seems that certain psychosocial factors may be associated with the syndrome. Therefore, an interdisciplinary approach to the treatment of patients affected with this syndrome should be considered.

Chronic stress in women with localised provoked vulvodynia

BACKGROUND

Localised provoked vulvodynia (former vulvar vestibulitis syndrome) is the most common cause of superficial dyspareunia among young women. In a clinical setting, it is obvious that many women with localised provoked vulvodynia show signs of chronic stress. The objective of this study was to compare chronic stress in a group of women with localised provoked vulvodynia, referred to the vulvar unit at the Division of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden with control women of the same age and educational level, using two independent methods.

METHODS

Forty-three women with localised provoked vulvodynia and 35 healthy control women underwent a gynecological examination, filled in a health questionnaire, and self-collected saliva for analysis of cortisol at awakening and after 15, 30 and 45 min (morning awakening cortisol). Thirty-three patients and 28 controls completed a stress questionnaire.

RESULTS

Morning awakening cortisol was blunted in women with localised provoked vulvodynia (p < 0.05), indicating chronic stress. The stress questionnaire showed more signs of burnout (p < 0.005), and emotional (p < 0.05) and bodily symptoms of stress (p < 0.005) in women with localised provoked vulvodynia compared with control subjects (students t-test).

CONCLUSION

More women with localised provoked vulvodynia showed blunted morning awakening cortisol and reported more symptoms of stress compared with healthy control women of the same age.

Is there an association between fibromyalgia and below-normal levels of urinary cortisol?

Background

Adynamia in fibromyalgia (FM) may be an expression of a functional deficit of the hypothalamic-pituitary-adrenal axis and be associated with below-normal levels of urinary cortisol. Our aim was to demonstrate that urinary cortisol was lower in patients with FM than in healthy subjects.

Findings

We measured urinary cortisol levels for a sample of 47 women aged 29 to 64 years (mean age 53 years), diagnosed with FM 2–3 years previously, and compared the results with those for a control sample of 58 healthy women of a similar age. Samples of 24-hour urine were appropriately collected and levels of urinary cortisol were measured using the fluorescence polarization immunoassay method. The mean cortisol value for the women with FM was 65.40 ± 27.10 μg/L, significantly lower than the mean cortisol level for the control group, at 90.83 ± 38.17 μg/L (p < 0.001).

Conclusion

Our study confirms that women with FM have significantly lower urinary cortisol levels than healthy women.

[Etiology and pathophysiology of fibromyalgia syndrome and chronic widespread pain]

OBJECTIVE

To write a systematic review on the etiology and pathophysiology of the fibromyalgia syndrome (FMS) and of chronic widespread pain (CWP).

METHODS

An interdisciplinary level-3 guideline (i.e. systematic literature search and assessment, logic analysis, formal consensus procedure) for the diagnosis and therapy of FMS was created in cooperation with 10 medical and psychological societies and 2 patient self-help organizations. A literature search was performed covering all available review articles on the etiology and pathophysiology of FMS and CWP using the Cochrane Collaboration Reviews (1993-12/2006), Medline (1980-2006), PsychInfo (1966-12/2006), and Scopus (1980-12/2006). For the assignment of evidence classes the system of the Oxford Centre for Evidence-Based Medicine was applied. Consensus was achieved by a multi-step nominal group procedure.

RESULTS

FMS aggregates in families (evidence level 2c). Physical and psychological stress at the workplace are risk factors for the development of CWP and FMS. Affective disorders are risk factors for the development and maintenance of FMS. Operant learning mechanisms and sensitization are risk factors for the chronification of FMS (evidence levels 2b). Several factors are associated with the pathophysiology of FMS, but the causal relationship is unclear. This includes alterations of central pain pathways, hyporeactivity of the hypothalamus-pituitary-adrenal axis, increased systemic pro-inflammatory and reduced anti-inflammatory cytokine profiles and disturbances in the dopaminergic and serotonergic systems.

CONCLUSIONS

FMS is the common final product of various etiological factors and pathophysiological mechanisms.

Biology and therapy of fibromyalgia. Evidence-based biomarkers for fibromyalgia syndrome

Researchers studying fibromyalgia strive to identify objective, measurable biomarkers that may identify susceptible individuals, may facilitate diagnosis, or that parallel activity of the disease. Candidate objective measures range from sophisticated functional neuroimaging to office-ready measures of the pressure pain threshold. A systematic literature review was completed to assess highly investigated, objective measures used in fibromyalgia studies. To date, only experimental pain testing has been shown to coincide with improvements in clinical status in a longitudinal study. Concerted efforts to systematically evaluate additional objective measures in research trials will be vital for ongoing progress in outcome research and translation into clinical practice.

The associations between basal salivary cortisol and illness symptomatology in chronic fatigue syndrome

Hypocortisolism has been reported in chronic fatigue syndrome (CFS), with the significance of this finding to disease etiology unclear. This study examined cortisol levels and their relationships with symptoms in a group of 108 individuals with CFS. CFS symptoms examined included fatigue, pain, sleep difficulties, neurocognitive functioning, and psychiatric status. Alterations in cortisol levels were examined by calculation of mean daily cortisol, while temporal variation in cortisol function was examined by means of a regression slope. Additionally, deviation from expected cortisol diurnal pattern was determined via clinical judgment. Results indicated that fatigue and pain were associated with salivary cortisol levels. In particular, variance from the expected pattern of cortisol was associated with increased levels of fatigue. The implications of these findings are discussed.

The relationship between clinical parameters and depression level in patients with myofascial pain syndrome

OBJECTIVE

Several studies and reviews have documented the high degree of comorbidity between depression and chronic pain. It was reported that chronic muscle pain is frequently accompanied by symptoms of depression. The purpose of this study was then to investigate the prevalence of major depression in chronic pain patients (CPP) with myofascial pain syndrome (MPS) and to investigate the relationship between some clinical parameters and level of depression, utilizing a healthy control group without MPS.

DESIGN/SETTING/PATIENTS

The study group consisted of 77 MPS patients (65 female, 12 male) and 72 healthy volunteers (60 female, 12 male). The diagnosis of MPS was based on clinical characteristics, examination findings, and ruling out other diagnoses. Major depressive disorder was diagnosed by a psychiatrist utilizing DSM-IV criteria. Levels of depression were obtained from the Beck Depression Inventory (BDI).

RESULTS

There was no significant difference between MPS patients and controls with respect to age and gender (P > 0.05). The mean age of the patients was 31.1 years (SD 9.8) and the mean age of controls was 29.7 years (SD 7.1). Major depression was more frequently found in CPPs with MPS (P < 0.001). BDI scores were higher in the MPS group than in controls (P < 0.001). There was a significant correlation between the severity of pain and depression level in patients with MPS (r = 0.654, P < 0.001).

CONCLUSION

Major depression is found in MPS CPPs at a rate previously noted in the literature in mixed diagnoses CPPs. In addition, the severity of the depression may be related to perceived pain severity.

Alterations in diurnal salivary cortisol rhythm in a population-based sample of cases with chronic fatigue syndrome

OBJECTIVE

To examine diurnal salivary cortisol rhythms and plasma IL-6 concentrations in persons with chronic fatigue syndrome (CFS), persons not fulfilling a diagnosis of CFS (we term them cases with insufficient symptoms or fatigue, ISF) and nonfatigued controls (NF). Previous studies of CFS patients have implicated the hypothalamic-pituitary-adrenal axis and the immune system in the pathophysiology of CFS, although results have been equivocal.

METHODS

Twenty-eight people with CFS, 35 persons with ISF, and 39 NF identified from the general population of Wichita, Kansas, were admitted to a research ward for 2 days. Saliva was collected immediately on awakening (6:30 AM), at 08:00 AM, 12 noon, 4:00 PM, 8:00 PM and at bedtime (10:00 PM) and plasma was obtained at 7:30 AM. Salivary cortisol concentrations were assessed using radioimmunoassay, and plasma IL-6 was measured using sandwich enzyme-linked immunosorbent assay.

RESULTS

People with CFS demonstrated lower salivary cortisol concentrations in the morning and higher salivary cortisol concentrations in the evening compared with both ISF and NF groups indicating a flattening of the diurnal cortisol profile. Mean plasma IL-6 concentrations were highest in CFS compared with the other groups, although these differences were no longer significant after controlling for BMI. Attenuated decline of salivary cortisol concentrations across the day and IL-6 concentration were associated with fatigue symptoms in CFS.

CONCLUSIONS

These results suggest an altered diurnal cortisol rhythm and IL-6 concentrations in CFS cases identified from a population-based sample.

HPA axis reactivity and lymphocyte glucocorticoid sensitivity in fibromyalgia syndrome and chronic pelvic pain

OBJECTIVE

Chronic pelvic pain (CPP) and fibromyalgia syndrome (FMS) have been associated with hypothalamic-pituitary-adrenal (HPA) axis alterations, i.e., mild hypocortisolism and enhanced feedback sensitivity. We tested the hypothesis of reduced cortisol release in response to a psychosocial stressor and pharmacological stimulation. Furthermore, glucocorticoid (GC) sensitivity was evaluated.

METHODS

Plasma total and salivary-free cortisol concentrations were measured in response to a standardized social laboratory stressor, the Trier Social Stress Test, and to adrenocorticotropin (ACTH)(1-24) stimulation. In the Trier Social Stress Test, we additionally measured ACTH. GC sensitivity was measured by dexamethasone inhibition of lipopolysaccharide-induced interleukin-6 and tumor necrosis factor-alpha production in whole blood.

RESULTS

There were no HPA axis alterations in women with CPP (N = 18) in these tests. Patients with FMS (N = 17) showed lower total cortisol release in response to the social stressor and exogenous ACTH, but normal free cortisol and ACTH levels compared with controls (N = 24). GC sensitivity was similar in all groups.

CONCLUSIONS

Our results suggest normal HPA responses to stress and ACTH stimulation in patients with CPP but reduced adrenal reactivity in patients with FMS, namely in total cortisol release. Free cortisol on the other hand was unaltered, possibly reflecting an adaptation to reduced circulating total cortisol.

The hypothalamo-pituitary-adrenal axis in chronic fatigue syndrome and fibromyalgia syndrome

The hypothalamo-pituitary-adrenal (HPA) axis plays a major role in the regulation of responses to stress. Human stress-related disorders such as chronic fatigue syndrome (CFS), fibromyalgia syndrome (FMS), chronic pelvic pain and post-traumatic stress disorder are characterized by alterations in HPA axis activity. However, the role of the HPA axis alterations in these stress-related disorders is not clear. Most studies have shown that the HPA axis is underactive in the stress-related disorders, but contradictory results have also been reported, which may be due to the patients selected for the study, the methods used for the investigation of the HPA axis, the stage of the syndrome when the tests have been done and the interpretation of the results. There is no structural abnormality in the endocrine organs which comprise the HPA axis, thus it seems that hypocortisolemia found in the patients with stress-related disorder is functional. It may be also an adaptive response of the body to chronic stress. In this review, tests used in the assessment of HPA axis function and the HPA axis alterations found in CFS and FMS are discussed in detail.