Category: Overview

Conversation piece

Dr E.G. Dowsett is Honorary Consultant Microbiologist, Basildon and Thurrock Health Authority and is the President of the Myalgic Encephalomyelitis Society.

 

DR P.D. WELSBY: I, and indeed many general physicians, are often asked to see patients whose main complaint is ‘tiredness all the time (TATT)’. From my previous experience also of general practice it seems that there is a wide continuous spectrum of debility ranging from a few days or weeks, but sometimes, distressingly, lasting for years. Such illnesses may or may not follow symptoms of an infection. Does the Myalgic Encephalomyelitis (ME) Society differentiate between post-viral debility, postinfectious (often an undefined infection) fatigue syndrome, chronic fatigue syndrome and ME? If so, how, and should it make any difference to medical management?

DR E.G. DOWSETT: One of the most striking features of ME is that the patient is not tired all the time! Extreme and sudden variability of energy levels both within and between episodes of illness differentiate this syndrome from other diseases associated with fatigue. One can only deplore the current fashion in the United States as well as the United Kingdom to redefine and rename a disability which has been clearly described in the literature for at least 100 years.’ There is nothing to be said in favour of the American acronym CFIDS (chronic fatigue immune deficiency syndrome) with its connotation of a primary immune dysfunction. The term ‘chronic fatigue syndrome’ recently adopted in this country also is nonspecific and non-descriptive because most of the definition is based on a vast number of exclusions (some of which, for example, endocrine disturbance, are actually found in ME). ‘Post-viral fatigue syndrome’, another British name, describes one essential feature (the association of the illness with viral infection) but gives the impression that the infection was antecedent rather than, as we now know, persistent. I prefer to use the more specific term ‘myalgic encephalomyelitis’ as it emphasizes the essential encephalitic component of the illness, the muscle pain, and the close clinical and epidemiological similarity to poliomyelitis.

You can read the rest of this interview here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399326/pdf/postmedj00061-0066.pdf

 

Source: E. G. Dowsett. Conversation piece. Interview by P. D. Welsby.Postgrad Med J. 1992 Jan; 68(795): 63–65. PMCID: PMC2399326 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2399326/

 

Tired all the time

General practitioners often see a syndrome they call “tired all the time.” How often doctors see it depends on how tiredness is defined and where it is measured. Morrell recorded fatigue as the most important reason for consultation in 24 per 2000 registered patients in one year 1; Jerrett recorded fatigue as a presenting or supporting symptom in 150 per 2000 registered patients.2 Yet patients may not necessarily mention fatigue when they consult. A survey of patients waiting in one surgery found that a tenth reported “substantial fatigue” for a month or more 3; 18-34% of respondents in a community survey reported always feeling tired in the past month 4; and when young women patients were asked to record symptoms in diaries 400 episodes of fatigue were recorded for every one reported to the doctor.5 Clinicians may regard this iceberg as a puzzle, and a blessing. But how should they manage the cases that do present?

Little has been published on tiredness in primary care, with only one prospective study from Britain2 and two retrospective ones from American family practice.67 The results suggest that psychosocial causes are paramount in 40-51% of cases and physical causes in 21-39%.267 The remaining cases are of mixed or undetermined cause. Fatigue presents three times more often in women of childbearing age,2 who often have a working day that is long and difficult to organise, with no boundary between home and work.8 The wise doctor steers between the extremes of trivialising and medicalising such “social” fatigue. If the cause is existential rather than medical counselling may help the patient consider various alternatives and make new choices.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1671843/pdf/bmj00157-0008.pdf

 

Source: Ridsdale L. Tired all the time. BMJ. 1991 Dec 14;303(6816):1490-1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1671843/

 

An overview of chronic fatigue syndrome

Abstract:

BACKGROUND: Psychological and immunologic factors both appear to contribute to chronic fatigue syndrome (CFS). By comparing CFS with other disorders in which fatigue is a prominent symptom, the association between fatigue, psychological vulnerability, depression, and immune function may be further defined. Recent data from psychological, neurologic, and immunologic studies that address these issues are reviewed.

METHOD: Articles and abstracts covering CFS and related topics of fatigue, depression, and postinfectious syndromes were identified through MEDLINE and Index Medicus (1980-1990) and by bibliographic review of pertinent review articles.

RESULTS: The 1988 definition of CFS by the Centers for Disease Control encompasses several conditions in which the major characteristic is severe fatigue associated with constitutional symptoms. Several studies have identified immune dysfunction in CFS patients, but the specificity of these findings remains unclear. Most studies have shown that CFS patients, compared with other patients with chronic medical illness, experience more disabling fatigue. Some investigators have found a higher incidence of concurrent and past psychiatric illness in CFS patients compared with other medical patients, thereby suggesting an underlying psychopathology in CFS. However, other studies have not found a higher than expected incidence of past depression in CFS patients and have further shown that many CFS patients have no identifiable psychopathology.

CONCLUSION: CFS appears to be a heterogenous entity. Although there may be a high coincidence of major depression in CFS, a substantial proportion of patients lack any identifiable DSM-III-R psychiatric disorder yet still manifest the syndrome, thereby suggesting it has an autonomous entity. Despite the evolving nature of our current understanding of CFS, a rational diagnostic and therapeutic approach to CFS is possible.

 

Comment in: Pathogenesis of chronic fatigue syndrome. [J Clin Psychiatry. 1992]

 

Source: Krupp LB, Mendelson WB, Friedman R. An overview of chronic fatigue syndrome. J Clin Psychiatry. 1991 Oct;52(10):403-10. http://www.ncbi.nlm.nih.gov/pubmed/1938975

 

Post-viral fatigue syndrome. Epidemiology: lessons from the past

Abstract:

This chapter outlines the recorded epidemiological history of PVFS (including the early epidemics of myalgic encephalomyelitis) and the development of the concept, including the realisation that endemic cases also occur.

Cases of PVFS are still not recorded by the Surveillance Centre for Communicable Diseases, so it is very difficult to detect and monitor any outbreak in the community, since each GP may only have two or three such patients and would, therefore, not be aware of an epidemic in the community as a whole if it occurred.

Epidemiological issues raised by the early epidemics, including the delineation of the syndrome, the question of bias, the role of hysteria and the role of depression; the issue of symptom distribution, and its implications for aetiology; and a multiaxial framework for understanding the association with psychological symptoms are discussed. The value of a future multidisciplinary research programme designed to disentangle direct and predisposing causes of PVFS is emphasised.

 

Source: Jenkins R. Post-viral fatigue syndrome. Epidemiology: lessons from the past. Br Med Bull. 1991 Oct;47(4):952-65. http://www.ncbi.nlm.nih.gov/pubmed/1794093

 

Psychiatric perspectives: an overview

Abstract:

This chapter reviews the evidence concerning the importance of psychological and social factors in the aetiology and pathogenesis of chronic fatigue syndrome. The diagnosis is often offered to doctors by patients; and we consider attribution, stigma, collusion between doctor and patient, and abnormal illness behaviour in this context. We then give a brief description of a model for common mental disorders, and show how chronic fatigue syndrome relates to this model. It emerges that there are special vulnerability factors in these patients’ personalities before the viral illness, but the disorder is seen as being released by the viral illness. By the time the disorder becomes established the original causal nexus is seen as no longer so important, and the disorder can be seen as a form of abnormal illness behaviour maintained by special factors. The implications for treatment are then considered.

 

Source: Woods TO, Goldberg DP. Psychiatric perspectives: an overview. r Med Bull. 1991 Oct;47(4):908-18. http://www.ncbi.nlm.nih.gov/pubmed/1794090

 

Clinical spectrum of postviral fatigue syndrome

Abstract:

Many different neurological and psychiatric syndromes follow viral infections, but their clinical pictures and pathogeneses are poorly understood. The syndromes include acute disseminated encephalomyelitis (post-infectious encephalomyelitis), the Guillain-Barre syndrome (post-infectious neuritis) and Reye’s syndrome.

Recently, attention has been focused on another common postviral neurological syndrome, i.e. the postviral fatigue syndrome (PVFS)–termed myalgic encephalomyelitis (ME) and a host of other designations. PVFS occurs both sporadically and in epidemics, with cases being reported from all over Europe, the United States, Australasia and South Africa.

It is difficult to make the diagnosis and this has meant, in the past, that it is not until an epidemic has occurred that random cases which presented in the preceding years are realised to represent the same condition. With renewed interest in the syndrome and greater attention from physicians, however, diagnosis of sporadic cases is now becoming more common.

 

Source: Behan PO, Bakheit AM. Clinical spectrum of postviral fatigue syndrome. Br Med Bull. 1991 Oct;47(4):793-808. http://www.ncbi.nlm.nih.gov/pubmed/1794085

 

Chronic fatigue syndrome

Three years ago David et al reviewed the available information concerning what was then known as postviral fatigue syndrome, and concluded that little was certain except that the issue was controversial. Since then there have been many welcome changes, including the name, which has shifted to the more appropriate label of chronic fatigue syndrome (CFS), but controversy remains. This editorial attempts a brief summary of the current position, emphasising issues relevant to the neurologist.

You can read the rest of this editorial here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1014466/pdf/jnnpsyc00506-0001.pdf

Comment in:

Chronic fatigue syndrome. [J Neurol Neurosurg Psychiatry. 1992]

 

Source: Wessely S. Chronic fatigue syndrome. J Neurol Neurosurg Psychiatry. 1991 Aug;54(8):669-71. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1014466/

 

Myth of the chronic fatigue syndrome

THE CHRONIC FATIGUE SYNDROME is a symptom complex characterized by fatigue, myalgias, arthralgias, neurologic symptoms-headaches, paresthesias, dizziness-lymph node swelling or tenderness, cognitive dysfunction, sleep disorders, and depression. The symptoms are similar to those seen in inflammatory illnesses and can be induced by the systemic administration of interferon beta. Severe fatigue is a perplexing and constant complaint in many patients with multiple sclerosis. This indicates that the perception of energy level has a sensitive physiologic basis that is dependent on the homeostasis of other body systems.

The chronic fatigue syndrome has gained popularity among the lay public and has stimulated considerable scientific debate about its existence. Many investigators and practitioners have attributed the disorder to chronic depression. Difficulty arises from the diverse symptoms associated with fatigue states; fatigue is a prominent feature of many systemic, neurologic, and psychiatric disorders. Also, fatigue is a subjective complaint without a quantifiable measure. This interweaving of many symptoms and diagnoses with disabling fatigue makes it difficult to compare patient groups. Terms applied to disorders that probably represent chronic fatigue syndrome are chronic infectious mononucleosis, myalgic encephalomyelitis, idiopathic chronic fatigue and myalgia syndrome, epidemic neuromyasthenia, postviral fatigue syndrome, and fibrositis-fibromyalgia.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1002920/pdf/westjmed00095-0070a.pdf

 

Source: Murray RS. Myth of the chronic fatigue syndrome. West J Med. 1991 Jul;155(1):68. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1002920/

 

The chronic fatigue syndrome

Abstract:

The chronic fatigue syndrome (CFS) was formally defined in 1988 to describe disabling fatigue of at least 6 months’ duration of uncertain etiology. Reports of CFS have emerged from the United States, Canada, the United Kingdom, Australia, New Zealand, Israel, Spain, and France. The disease primarily affects individuals between 20 and 50 years of age, and there is a preponderance of females.

Although a triggering infectious illness is reported by most patients with CFS, there is no convincing evidence causally linking any currently recognized infectious agent to CFS. Multiple minor immunologic aberrations are frequent but inconsistent and of uncertain significance. There is no consistent evidence for myopathy or physical deconditioning.

Depression is found in approximately 50% of CFS patients, with depression preceding the physical symptoms in half of the cases. No therapy has been proved effective in controlled clinical trials with prolonged follow-up, although antidepressants have not been formally evaluated.

The long-term prognosis of patients with CFS has not been well studied, but CFS appears to be a disease of prolonged duration with considerable morbidity but no mortality. Further research into the pathogenesis and treatment of CFS is necessary.

 

Source: Shafran SD. The chronic fatigue syndrome. Am J Med. 1991 Jun;90(6):730-9. http://www.ncbi.nlm.nih.gov/pubmed/2042689