Esther12
Senior Member (Voting Rights)
I found that this whole book was on-line while I was searching for something else, and thought I'd post it in case others wanted to be annoyed by some poorly justified assertions that will have made life more difficult for a lot of patients.
https://cdchester.co.uk/wp-content/uploads/2018/05/SUSANA1.pdf
The CFS chapter is only short, and I find these sorts of short summaries are good for helping patients understand the way we're treated by GPs, etc.
I was skimming the whole book, and kept finding annoying stuff in different sections too. I'd like to think that a book like this would not get published today, but actually I get the impression that there are swathes of academia which live in a protective bubble, immune from the growing scepticism outsiders view them with.
https://cdchester.co.uk/wp-content/uploads/2018/05/SUSANA1.pdf
The CFS chapter is only short, and I find these sorts of short summaries are good for helping patients understand the way we're treated by GPs, etc.
I was skimming the whole book, and kept finding annoying stuff in different sections too. I'd like to think that a book like this would not get published today, but actually I get the impression that there are swathes of academia which live in a protective bubble, immune from the growing scepticism outsiders view them with.
Chronic fatigue syndrome
Ruth Cairns and Trudie Chalder
King’s College London
Introduction and definitions
Fatigue is a very common complaint but is typically transient, self-
limiting or explained by other circumstances. Chronic fatigue syn-
drome (CFS) is characterized by persistent or relapsing unexplained
fatigue of new or definite onset lasting for at least six months. It is
not a new condition and corresponds very clearly to an illness called
neurasthenia, commonly seen in Europe around the turn of the
twentieth century (Wessely et al., 1998). The terms ‘myalgic enceph-
alomyelitis’ (ME) and ‘post-viral fatigue syndrome’ have also been
used to describe CFS but are misleading and unsatisfactory: ME
implies the occurrence of a distinct pathological process whereas
post-viral fatigue syndrome wrongly suggests that all cases are
preceded by a viral illness.
Operational criteria developed for research purposes by the US
Centres for Disease Control and Prevention (CDC) (Fukuda
et al., 1994) and from Oxford (Sharpe et al., 1991) are now widely used to
define CFS. The American criteria require at least six months of
persistent fatigue causing substantial functional impairment and
at least four somatic symptoms (from a list of eight) occurring
with the fatigue in a 6-month period. The presence of a medical
disorder that explains the prolonged fatigue excludes a patient
from a diagnosis of CFS, as do a number of psychiatric diagnoses.
Although the British definition is similar it differs by requiring both
physical and mental fatigue but no physical symptoms. By including
a requirement for several physical symptoms, the American defini-
tion reflects the belief that an infective or immune process underlies
the syndrome.
Aetiology
The prevalence of CFS has been reported as 0.1–2.6% in community
and primary care-based studies, depending on the criteria used
(Wessely et al., 1997). Women are at higher risk than men
(Relative risk 1.3–1.7) (Wessely, 1995). In relation to aetiology, phys-
iological and psychological factors are thought to work together to
predispose an individual to CFS and to precipitate and perpetuate
the illness (Afari & Buchwald, 2003). For example, many patients
link the onset of their symptoms to infection and while it is unlikely
that serious viral illness acts as a continuing focus of infection in
CFS, it is known to trigger its onset in some individuals (Cleare &
Wessely, 1996). Other risk factors for developing CFS include previ-
ous psychological illness (Wessely et al., 1998), and severe life events
or difficulties in the months before onset (Hatcher & House, 2003;
see ‘Life events and health’).
A wide range of factors may act to perpetuate chronic fatigue.
Coping responses to acute fatigue are important determinants of
prolonged fatigue: extreme physical activity after an acute illness
may allow insufficient time for recovery whereas prolonged bed
rest may cause physical deconditioning and further exacerbate
symptoms. Illness beliefs and the attribution of symptoms to a phys-
ical cause, with minimization of psychological or personal contribu-
tions, are also important and have been related to increased
symptoms and worse outcomes in CFS (Wilson et al., 1994;
see ‘Illness perceptions’). Similarly, catastrophic beliefs that exer-
cise will be damaging or will worsen symptoms lead to the avoid-
ance of physical and mental activities and greater disability
(Petrie et al ., 1995). Disrupted sleep patterns resulting from exces-
sive daytime rest may contribute to fatigue, muscle pain and poor
concentration.
The response and attitudes of others are also important in deter-
mining the course of fatigue. Overly concerned carers may reinforce
patients’ maladaptive beliefs and coping strategies by inadvertently
encouraging disability. Sceptical or stigmatizing reactions from rela-
tives, health professionals or work colleagues can cause frustration
and leave the patient feeling isolated and unsupported (Deale &
Wessely, 2001; Van Houdenhove et al ., 2002; see ‘Stigma’).
Diagnosis
There are no diagnostic signs or symptoms of CFS. The clinical eval-
uation of chronically fatigued patients is aimed at excluding under-
lying medical or psychiatric causes of fatigue. In individuals with
fatigue of more than six months duration a thorough history, phys-
ical examination, routine laboratory tests (full blood count, ESR,
renal, liver and thyroid function and urinary protein and glucose)
and mental state examination are sufficient to reach a diagnosis of
CFS in most cases. Where abnormalities are revealed on physical or
laboratory investigation, further investigations can be helpful to
help establish alternative diagnosis but should otherwise be limited
to avoid the risk of iatrogenic harm. Specialist referral should be
limited to situations where there is an increased probability of an
alternative diagnosis.
The relationship between CFS and psychiatric illness is more
complex. Fatigue is a common symptom in mental illness and
where an individual’s fatigue is fully explained by a specific
psychiatric disorder, a diagnosis of CFS should not be made.
However, psychiatric co-morbidity (particularly with depressive,
somatoform and anxiety disorders) is also common and when pres-
ent should be diagnosed and treated in addition to the symptoms of
CFS. This does not mean that psychiatric disorders are the cause
of CFS and indeed a substantial minority of patients do not fulfil
criteria for any psychiatric diagnosis (Wessely et al., 1998).
Treatment
The evidence suggests that the most effective treatments for CFS are
cognitive behavioural therapy (CBT) and graded exercise therapy (see
chapters on ‘Cognitive behavioural therapy’ and ‘Exercise interven-
tions’). The CBT model attempts to incorporate the heterogenous
nature of the condition and stresses the role of perpetuating factors
(Wessely et al ., 1991). The treatment for CFS therefore involves
planned activity and rest, graded increases in activity, a sleep routine
and cognitive restructuring of unhelpful beliefs and assumptions.
One systematic review showed that CBT administered in specialist
centres by skilled therapists led to improved physical functioning and
quality of life compared with relaxation therapy or standard medical
care (Price & Couper, 2002). In addition, a multi-centre randomized
controlled trial (RCT) involving less experienced CBT therapists has
reported improvements in fatigue severity and self-reported fatigue
compared with guided support and no treatment (Prins et al., 2001).
Graded aerobic exercise involves a structured exercise programme
that is individually tailored to the patient’s current level of activity
and aims to gradually increase his or her aerobic activity. The exer-
cise is usually walking and patients are advised not to exceed the
prescribed exercise duration or intensity. RCTs evaluating graded
exercise therapy have found that it improves measures of fatigue
and physical functioning compared with flexibility training and
relaxation training or general advice (Reid et al., 2004).
There is insufficient evidence to suggest that antidepressants,
corticosteroids or other pharmacological agents are beneficial in
the treatment of CFS and no reliable evidence that dietary supple-
ments, evening primrose oil or intra-muscular magnesium are
helpful (Reid et al., 2004). Prolonged rest cannot be recommended
as a treatment for CFS and may actually perpetuate or increase
fatigue in people recovering from a viral illness. A review of treat-
ments for CFS reported both limited benefits and substantial
adverse effects with immunoglobulin therapy (Rimes & Chalder,
2005). There is insufficient evidence for the use of interferon as an
effective treatment for CFS.
Prognosis
CFS is not associated with an increased mortality rate and rarely
constitutes a missed medical diagnosis when an attempt has been
made to exclude organic illness prior to making the diagnosis.
A recent systematic review of studies describing the prognosis of
CFS identified 14 studies that used operational criteria to define
cohorts of patients with CFS (Cairns & Hotopf, 2005). Full recovery
from untreated CFS is rare and an improvement in symptoms is a
more commonly reported outcome than full recovery. The median
full recovery rate was 5% (range 0–31%) and the median proportion
of patients who improved during follow-up was 39.5% (range
38–64%). Less fatigue severity at baseline, a sense of control over
symptoms and not attributing illness to a physical cause were all
associated with a good outcome. Psychiatric disorder was associated
with poorer outcomes. The review looked at the course of CFS with-
out systematic intervention but as reported above there is now
increasing evidence for the effectiveness of cognitive behavioural
and graded exercise therapies. Further research is necessary to
explore the prognosis of CFS after such treatment has been given.
REFERENCES
Afari, N. & Buchwald, D.
(2003). Chronic
fatigue syndrome: a review.
The American
Journal of Psychiatry, 160, 221–36.
Cairns, R. & Hotopf, M.
(2005). Review
article: the prognosis of chronic fatigue
syndrome.
Occupational Medicine,55,20–31.
Cleare, A.J. & Wessely, S.C.
(1996). Chronic
fatigue syndrome: a stress disorder?
British Journal of Hospital Medicine,55,571–4.
Deale, A. & Wessely, S.
(2001). Patients’
perceptions of medical care in
chronic fatigue syndrome.
Social Science
and Medicine,52, 1859–64.
Fukuda, K., Straus, S., Hickie, I.
et al. (1994).
The chronic fatigue syndrome: a
comprehensive approach to its
definition and study.
Annals of Internal
Medicine,121, 953–9.
Hatcher, S. & House, A.
(2003). Life events,
difficulties and dilemmas in the onset
of chronic fatigue syndrome: a
case-control study.
Psychological Medicine,33, 1185–92.
Petrie, K., Moss-Morris, R. & Weinman, J.
(1995). Catastophic beliefs and their
implications in chronic fatigue syndrome.
Journal of Psychosomatic Research,39,31–7.
Price, J. R. & Couper, J.
(2002). Cognitive
behaviour therapy for CFS. In:
the
cochrane library, Issue 2
. Oxford: Update
Software.
Prins, J. B., Beijenberg, G., Bazelmans, E.
et al
. (2001). Cognitive behaviour
therapy for chronic fatigue syndrome: a
multicentre randomised trial.
The Lancet,357, 841–5.
Reid, S., Chalder, T., Cleare, A., Hotopf, M. &
Wessely, S.
(2004). Chronic fatigue
syndrome.
Clinical Evidence,11, 1–3.
Rimes, K.A. & Chalder, T.
(2005).
Treatments for chronic fatigue syndrome.
Occupational Medicine,55, 32–9.
Sharpe, M., Arcard, L.C., Banatvala, J. E.
et al
. (1991). A report – chronic fatigue
syndrome: guidelines for research.
Journal of the Royal Society of Medicine,84,118–21.
Van Houdenhove, B., Neerinckx, E.,
Onghena, P.
et al
. (2002).
Psychotherapy and Psychosomatics,71,207–13.
