Brain, Vol. 123, No. 2, 407-408,
February 2000
© 2000 Oxford University Press
Book reviews |
CHRONIC FATIGUE AND ITS SYNDROMES.
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Department of Medicine and Infectious Diseases, University Hospital of Wales, Cardiff, UK
Since the initial definition of chronic fatigue syndrome in 1988, there has been a huge amount of interest in the subject, especially as fatigue is the second most common complaint in general medical out-patient clinics. The sheer variety of specialists researching into fatigue is remarkable, and includes neurologists, psychiatrists, psychologists, infectious diseases physicians, microbiologists, immunologists, paediatricians, historians and sociologists.
Over the past 10 years, fatigue has risen in prominence from having little said about it at all in the medical literature to being an international talking point. How did this occur? In 1976 a group of doctors interested in the 1955 Royal Free Hospital outbreak of fatigue formed a group interested in epidemic fatigue. Sporadic cases without neurological signs gradually became of more interest and epidemics became very rare. By the 1980s, interest had shifted to sporadic cases with fatigue as the main complaint. Meanwhile, in the United States, papers in 1985 linked `persistent unexplained illness' with `active Epstein–Barr virus infection' (EBV) resulting in widespread media coverage. It was soon discovered that healthy individuals could show EBV early antigen antibodies up to 8 years after recovery from the acute infection in the range previously associated with `chronic EBV'. Between 1984 and 1987 there was a proliferation of patient support groups, research foundations and political lobbying groups, even though `chronic active EBV' suffered its demise in the medical literature.
In 1988 the Centres for Disease Control issued its first definition of Chronic Fatigue Syndrome (CFS), and this definition has undergone several modifications since. At present we still have no objective markers for CFS and most researchers seem to accept the possibility that we may be looking at a range of conditions, or even a final common pathway following on from various instigators. An analogy would be the way that a myocardial infarction can be the end result of numerous risk factors.
To many readers of this book, one of the most interesting aspects will be the extent to which chronic fatigue was studied in previous times and then completely forgotten. In the Revolutionist's Handbook, George Bernard Shaw quotes Hegel as saying `What experience and history teach is this—that people and governments never have learned anything from history or acted on the principles deduced from it'. The history lessons in this book demonstrate how true that has been in medicine. Neurasthenia, a term adopted by George Beard in 1869, was the description of a condition characterized by chronic fatigue of such a severity that victims could not complete the simplest act without feeling immediate and insurmountable lassitude. There was also an inordinate sense of mental fatigue and the combination of quick fatigubility and slow recuperation. However, although neurasthenia was originally claimed to be the disease of brilliant, original, energetic and influential patients, by 1895 there was a popular impression that the sufferer was a work shy labourer or upper class female invalid. In this book, the gradual disillusionment of Freud (who wrote four books on neurasthenia) is noted, and even the disappearance of neurasthenia from Cecil's textbook of medicine is recorded. Neurasthenia merited a whole chapter in 1927 (first edition), but was alluded to in a single sentence in the seventh edition (1947).
The authors of this book will be well known to anyone with an interest in fatigue, and the acknowledgements in the preface demonstrate the breadth of views and expertise consulted in writing this work. This is important, as all three authors are psychiatrists and are therefore potentially exposed to the criticism that they do not understand some issues, for example, immunology or cardiovascular physiology.
The book has 19 chapters, grouped into five sections. Each chapter has a summary at the end, which is very useful. The first section, `The Nature and Extent of Fatigue', has four chapters describing the nature and epidemiology of fatigue, its physical mechanisms (including the fatigue of neurological disorders) and the relationship of fatigue to emotional disorders. The second section examines the history of chronic fatigue from neurasthenia through epidemic neuromyasthenia, post viral fatigue, CFS and fibromyalgia. The third section looks at CFS itself and chronicles in great detail the labyrinthine ways taken by various specialities in search of an answer. Following on from a chapter on definition of CFS are chapters entitled `Muscle and Nerve', `Viruses and Immunity', `Psychiatric Disorder', `Neurobiology', `Psychology', `Children' and `Other chronic fatigue syndromes'. The last chapter in this section examines the sociology of CFS and the influence of the media. This is especially interesting given the great initial enthusiasm and later cynicism of the media about neurasthenia during the last century. The fourth section looks at the assessment of the fatigued patient, the evidence for the efficacy of various treatments, and the practical help that can be offered to patients with CFS.
The approach to this book has been a mixture of very meticulous research and a desire to communicate clearly with health workers of many disciplines. It has a congenial style, illustrated in the first page where the reader is asked to imagine running 5 miles, checking all the references in the book, having `flu and having been awake all night, in order to illustrate the many connotations of the word `fatigue'. Nevertheless, the basic science is scrutinized in great depth—the `Viruses, Immunity and CFS' chapter alone has 248 references and would not be out of place in a virology journal. The sheer number of early studies unearthed by the authors gives an invaluable historical insight into the present controversy surrounding fatigue. For example, of the 160 references in the chapter of neurasthenia, 37 are to articles written before 1900 and 57 refer to articles from between 1900 and 1920. The book progresses easily and benefits from having only three authors, as there is a continuity of style. I am sure it was designed to be read through, but it would be also valuable as a reference work.
What conclusions do the authors reach after such an extensive overview? A central point is that clinical practitioners are not confronted with `fatigue' but with a patient who complains of fatigue. A holistic approach is advocated that considers symptoms, physiology, mood, cognition, behaviour and social circumstances. The authors hope that study of the relationship between the immune response to infection and central neurotransmitter activity will provide the best clues for the future. The authors do not feel that CFS is simply the somatic manifestation of depression, and CFS seems to have more in common with chronic pain disorders than melancholia.
As far as management is concerned, fixed and narrow ideas about the nature of the illness, and a very rigid approach to treatment are said to be incompatible in dealing with a poorly understood condition. A spirit of collaboration with patients is advanced and a stepped care approach is suggested. The authors start with simple education and advice, such as identifying factors (like occupation) that stand in the way of recovery. The next step is pharmacological intervention with agents such as antidepressants that may help pain, sleep, energy or mood in some patients. Behavioural intervention such as regulation of sleep and avoiding cycles of excessive exertion followed by prolonged rest are the next steps. Finally, cognitive behaviour therapy (CBT), which is performed in only a few specialist centres, is suggested. CBT has also been used in fibromyalgia and it is the only specific treatment shown to be of long-term benefit in unselected groups of patients with CFS.
This book should be read by any health professional working with chronically fatigued patients (including neurologists), and it would certainly benefit any doctor who wants to take a broader view of patients who have attended numerous specialists for many years without definable pathology. As an introduction to integrated medicine, as well as a guide to one of the commonest symptoms in out-patient clinics, this book is outstanding. It should also serve as a warning to anyone tempted to describe a new syndrome without objective markers to ponder Hegel's aphorism, and to read some history books before committing themselves to print.
Notes
By Simon Wessely, Matthew Hotopf and Michael Sharpe.1998. Oxford: Oxford University Press. Price £29.50. Pp. 428. ISBN 0-19-263046-6.
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