Wessely – Page 10 – American ME and CFS Society

The measurement of fatigue and chronic fatigue syndrome

Comment in: Chronic fatigue syndrome and heterogeneity. [J R Soc Med. 1992]

Fatigue remains as elusive a human experience as ever. At the turn of the century fatigue was almost an obsession of doctors, scientists, writers and even politicians. The scientists believed they could measure it, the doctors they could treat it, the writers describe it, and the politicians prevent it (1). Many confidently expected that fatigue could be eliminated from schools, factories, armies, and even society. That it had to be dealt with was not in doubt, since many authorities believed that if not checked, fatigue, the inevitable consequence of modern life in all its forms, would somehow destroy the nation’s health and its future. Perhaps only the writers achieved their objective (2) – certainly, the descriptions of fatigue and exhaustion in the turn of the century literature, and even in the medical journals, are far richer and detailed than the leaden descriptions which we now encounter.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1294719/pdf/jrsocmed00112-0007.pdf

Source: Wessely S. The measurement of fatigue and chronic fatigue syndrome. J R Soc Med. 1992 Apr;85(4):189-90. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1294719/

History of postviral fatigue syndrome

Abstract:

In writing a history of any illness there is always a dilemma whether to attempt the story of the condition ‘itself’, the medical attempts to define its nature, or to glimpse it via our changing reactions. The easiest is a straightforward account of the attempts of scientists to solve a problem–the classic medical detective story. However, this is often more fiction than fact.

Medicine rarely moves smoothly from ignorance to knowledge, but often in a more circular fashion. A historical approach is thus not solely a record of who did what, but also contributes to our understanding of the problems under scrutiny in this issue. Terminology is never easy in this subject, but the following conventions will be used: The terms neurasthenia and ME will be used in their actual context (as authors themselves used them), without defining either. Post-infectious fatigue syndrome (PIFS) will cover similar conditions when related to infective episodes. All will be used in a neutral fashion, to refer to changing realities as understood by doctors and historians.

This chapter attempts both chronological description and social analysis. The justification for this approach is clear in the case of neurasthenia, since ‘as so little was known of its pathological basis physicians’ statements regarding the disease were composed more of social and cultural elements than of scientific knowledge. Although much has changed, a contemporary account still reveals as much about cultural attitudes as the advance of science.

Source: Wessely S. History of postviral fatigue syndrome. Br Med Bull. 1991 Oct;47(4):919-41. http://www.ncbi.nlm.nih.gov/pubmed/1794091

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/

Myalgic encephalomyelitis

Comment in: Myalgic encephalomyelitis. [J R Soc Med. 1991]

Comment on: Myalgic encephalomyelitis: an alternative theory. [J R Soc Med. 1990]

I am pleased that Dr Wilson (August 1990 JRSM, p481) has paid me the compliment of giving my article on the vexed topic of ‘myalgic encephalomyelitis’ (April 1989 JRSM, p 215) serious attention, and echoes our call’ for a ‘new approach’ to the problem, based on an absence of prejudice and a sound clinical and social history. He also notes the parallels between neurasthenia and ‘ME’, although the former was not, as he writes, first described in 18842. However, I only wish I could follow the rest of his arguments so clearly:

Dr Wilson states that I failed to realize that ‘about 100%’ of patients have an allergic diathesis and an allergic family history. I was indeed unaware of this remarkable finding. Unfortunately, I have been unable to trace the two sources cited for this observation, one an American paperback, the other a society newsletter. Similarly, I am afraid that neither I nor any of my colleagues have ever met anyone suffering from ‘Alternate Multiple Personality’. Perhaps this was because I was again unaware of the relevant literature. However, in my defence I would not otherwise have known that the two references quoted, namely Dr Wilson’s paper on allergic disease, multiple personality and dowsing, and his paper on possession and multiple personality, are actually about chronic fatigue syndrome. Similarly, I would not have known that an article in the Christian Parapsychologist called ‘Deliverance and dowsing’ is on the psychopathology of allergy and ME, nor that information on treatment of ME would be published in a series of titles beginning with ‘Current theological perspectives on possession. It is becoming harder to keep up with the relevant literature.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293160/pdf/jrsocmed00126-0074c.pdf

See the article “Myalgic encephalomyelitis: an alternative theory.” in volume 83 on page 481.

See letter “Myalgic encephalomyelitis.” on page 633.

See the reply “The author replies” on page 183a.

Source: Wessely S. Myalgic encephalomyelitis. J R Soc Med. 1991 Mar;84(3):182-3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1293160/

Cognitive behaviour therapy in chronic fatigue syndrome

Abstract:

Fifty patients fulfilling operational criteria for the chronic fatigue syndrome (CFS), and who had been ill for a mean of five years, were offered cognitive behaviour therapy in an open trial. Those fulfilling operational criteria for depressive illness were also offered tricyclic antidepressants. The rationale was that a distinction be drawn between factors that precipitate the illness and those that perpetuate it.

Among the latter are cognitive factors such as the belief that physical symptoms always imply tissue damage, and behavioural factors such as persistent avoidance of activities associated with an increase in symptoms. Therapy led to substantial improvements in overall disability, fatigue, somatic and psychiatric symptoms. The principal problems encountered were a high refusal rate and difficulties in treating affective disorders. Outcome depended more on the strength of the initial attribution of symptoms to exclusively physical causes, and was not influenced by length of illness.

These results suggest that current views on both treatment and prognosis in CFS are unnecessarily pessimistic. It is also suggested that advice currently offered to chronic patients, to avoid physical and mental activity, is counterproductive.

Source: Butler S, Chalder T, Ron M, Wessely S. Cognitive behaviour therapy in chronic fatigue syndrome. J Neurol Neurosurg Psychiatry. 1991 Feb;54(2):153-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1014351/

Old wine in new bottles: neurasthenia and ‘ME’

Abstract:

The history of is discussed in the light of current interest in chronic fatigue, and in particular the illness called myalgic encephalomyelitis (‘ME’). A comparison is made of the symptoms, presumed aetiologies and treatment of both illnesses, as well as their social setting.

It is shown that neurasthenia remained popular as long as it was viewed as a non-psychiatric, neurological illness caused by environmental factors which affected successful people and for which the cure was rest. The decline in neurasthenia was related to the changes which occurred in each of these views. It is argued that similar factors are associated with the current interest in myalgic encephalomyelitis.

It is further argued that neither neurasthenia nor ‘ME’ can be fully understood within a single medical or psychiatric model. Instead both have arisen in the context of contemporary explanations and attitudes involving mental illness. Future understanding, treatment and prevention of these and related illnesses will depend upon both psychosocial and neurobiological explanations of physical and mental fatigability.

Source: Wessely S. Old wine in new bottles: neurasthenia and ‘ME’. Psychol Med. 1990 Feb;20(1):35-53. http://www.ncbi.nlm.nih.gov/pubmed/2181519

Management of post-viral fatigue syndrome

Note: This letter appeared in the February 1990 issue of the British Journal of General Practice. The letter was written in response to an article, “Patient management of post-viral fatigue syndrome,” written by Dr. Ho-Yen, in which he advised that patients rest. You can read the article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371214/

Management of the post-viral fatigue syndrome Sir, We read with interest Dr Ho-Yen’s thoughtful paper on the management of the post-viral fatigue syndrome (January Journal, p.37) and welcome the renewed interest in practical management. Dr HoYen’s article is written in response to our previous paper on the subject, (1) and although there are differences between the two approaches, we must first point out the considerable areas of agreement between us, perhaps no more so than the emphasis on the role of the general practitioner, and of the crucial importance of a healthy doctor-patient relationship.

Many of the apparent differences between our approach and that of Dr HoYen are, as he states, due to sample differences. Our experience is based on patients with chronic illness seen in specialist neurological settings with a mean illness duration of five years.(2 )Dr Ho-Yen is familiar with patients with shorter illness durations, referred for a microbiological opinion. Many of the strategies advocated by Dr Ho-Yen are therefore designed for those in whom spontaneous recovery can still be anticipated. However, what about when such recovery has not occurred? In the two largest samples to date others have noted ‘an alarming tendency to chronicity (1,3) and it has been alleged that ‘most of the cases seen do not improve, give up their work and become permanent invalids’.(4) The current therapeutic approach for these patients is obviously unsatisfactory.

How does such chronicity develop? Dr Ho-Yen criticizes the first stage of the model we proposed to explain such chronicity, and points out that far from initially adopting forced inactivity after a viral infection, many chronic sufferers did the opposite, and tried to exercise away the fatigue. We accept his observation. Dr HoYen’s comments do indeed coincide with our own clinical impressions: many patients report initially adopting such strategies, and find that these are unsatisfactory, leading to a rapid recurrence of symptoms. However, we suggest this is an even more convincing explanation of the remainder of the model we propose Simple operant conditioning suggests that such a powerful experience of failure will lead to persistent avoidance, perhaps when the original need for it is no longer present. We also suggest that early and repeated exposure to uncontrollable, aversive and mysterious symptoms, such as the profound muscle pain that characterizes the syndrome, is another potent cause of the demoralization and helplessness so frequently found (Powell R, Wessely S, manuscript submitted for publication) and may in turn explain the high rates of mood disorder that have been observed in several studies.

We do, however, disagree that the management we advocate is to ‘get out and exercise’. This is a common misconception. Cognitive behavioural therapy is not exercise therapy, and we are not physiotherapists. It is true that in the later stages of treatment patients are encouraged to increase their activity (which must ultimately be the aim of any treatment) but therapy does not involve the simple prescription of set amounts of exercise. Instead, treatment is based on mutually agreed targets, which are themselves jointly chosen as being some activity that the patient wishes to undertake, but has avoided. In practice this may simply be brushing one’s teeth, or sitting out of bed to eat a meal. The behaviour is chosen solely on the basis of avoidance; the physiological and ergonomic consequences of such activity are irrelevant. The aim is to introduce predictability, and the return of self-control and self efficacy, not to restore muscle power. Furthermore, the other important component of our approach to management is an awareness of emotional disorders, and a recognition that these may need treatment in their own right.

We agree that the management we advocate is neither new nor unique. Almost identical management is now the treatment of choice for chronic pain (5) and fibromyalgia. (6) The latter is particularly relevant, since it is increasingly accepted that fibromyalgia may indeed be the same condition as post-viral fatigue.(7) Furthermore, it is difficult to think of a pathological mechanism by which gradual increased activity could be harmful, (8’9) even in the minority of patients with clear cut neuromuscular pathology.

The final decision must be based on evidence. We have already announced preliminary details of a pilot evaluation of cognitive behavioural therapy (Wessely S, et al, abstract presented at the scientific meeting of the Royal College of Psychiatrists, London, 25 September 1989). Our conclusion was that the advice currently offered to these patients may not be accurate, and that the current therapeutic nihilism in this condition may be unduly pessimistic.

In summary, the differences between our approach and that of Dr Ho-Yen may be less marked than at first sight. Given the difference in our samples and clinical experience, one might summarize by saying that whereas Dr Ho-Yen correctly emphasizes the dangers of doing too much, too early in the natural history of the condition, we emphasize the equally damaging consequences of doing too little, too late. The most appropriate strategy depends upon the stage of the illness reached by the patient.

~SIMON WESSELY , ANTHONY DAVID Institute of Psychiatry De Crespigny Park London SE5 8AF

~SUE BUTLER, TRUDIE CHALDER National Hospital for Nervous Diseases Queen Square London WC1N 3BG

References

Wessely S, David A, Butler S, Chalder T. The management of chronic post-viral fatigue syndrome. J R Coll Gen Pract 1989; 39: 26-29.
Wessely S, Powell R. Fatigue syndromes: a comparison of chronic ‘postviral’ fatigue with neuromuscular and affective disorders. J Neurol Neurosurg Psychiatry 1989; 52: 940-948.
Smith D. Myalgic encephalomyelitis. In: 1989 Members’ reference book. London: Sabrecrown Publishing, 1989: 247-250.
Behan P, Behan W. The postviral fatigue syndrome. CRC Crit Rev Neurobiol 1988; 42: 157-158.
Pither C. Treatment of persistent pain. Br Med J 1989; 299: 1239.
Yunus M. Diagnosis, etiology and management of fibromyalgia syndrome: an update. Comp Ther 1988; 14: 8-20.
Goldenberg D. Fibromyalgia and other chronic fatigue syndromes: is there evidence for chronic viral disease? Semin Arthritis Rheum 1988; 18: 111-120.
Vignos P. Physical models of rehabilitation in neuromuscular disease. Muscle Nerve 1981; 6: 323-338.
Milner-Brown S, Miller R. Muscle strengthening through high-resistance weight training in patients with neuromuscular disorders. Arch Phys Med Rehabil 1988; 69; 14-19

Source: Wessely S, David A, Butler S, Chalder T. Management of post-viral fatigue syndrome. Br J Gen Pract. 1990 Feb;40(331):82-3. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371151/pdf/brjgenprac00083-0040.pdf

Attributions and self-esteem in depression and chronic fatigue syndromes

Abstract:

There is considerable overlap in symptomatology between chronic fatigue syndrome (CFS) and affective disorder.

We report a comparison of depressive phenomenology and attributional style between a group of CFS subjects seen in a specialized medical setting, which included a high proportion with depression diagnosed by Research Diagnostic Criteria (RDC), and depressed controls seen in a specialized psychiatric setting.

Significant symptomatic differences between the depressed CFS group and depressed controls were observed for features such as self-esteem and guilt as well as attribution of illness. All the CFS groups tended to attribute their symptoms to external causes whereas the depressed controls experienced inward attribution.

This may have resulted from differences in the severity of mood disorder between the samples, but it is also suggested that an outward style of attribution protects the depressed CFS patients from cognitive changes associated with low mood but at the expense of greater vulnerability towards somatic symptoms such as fatigue.

Source: Powell R, Dolan R, Wessely S. Attributions and self-esteem in depression and chronic fatigue syndromes. J Psychosom Res. 1990;34(6):665-73. http://www.ncbi.nlm.nih.gov/pubmed/2290139

Management of chronic (post-viral) fatigue syndrome

Abstract:

Simple rehabilitative strategies are proposed to help patients with the chronic fatigue syndrome. A model is outlined of an acute illness giving way to a chronic fatigue state in which symptoms are perpetuated by a cycle of inactivity, deterioration in exercise tolerance and further symptoms. This is compounded by the depressive illness that is often part of the syndrome. The result is a self-perpetuating cycle of exercise avoidance. Effective treatment depends upon an understanding of the interaction between physical and psychological factors. Cognitive behavioural therapy is suggested. Cognitive therapy helps the patient understand how genuine symptoms arise from the frequent combination of physical inactivity and depression, rather than continuing infection, while a behavioural approach enables the treatment of avoidance behaviour and a gradual return to normal physical activity.

Source: S Wessely, A David, S Butler, and T Chalder. Management of chronic (post-viral) fatigue syndrome. J R Coll Gen Pract. 1989 Jan; 39(318): 26–29. PMCID: PMC1711569 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1711569/ (Full article)