Tag: Wessely

Reviewing the reviews: the example of chronic fatigue syndrome

Abstract:

OBJECTIVE: To test the hypothesis that the selection of literature in review articles is unsystematic and is influenced by the authors’ discipline and country of residence.

DATA SOURCES: Reviews in English published between 1980 and March 1996 in MEDLINE, EMBASE (BIDS), PSYCHLIT, and Current Contents were searched.

STUDY SELECTION: Reviews of chronic fatigue syndrome (CFS) were selected. Articles explicitly concerned with a specialty aspect of CFS and unattributed, unreferenced, or insufficiently referenced articles were discarded.

DATA EXTRACTION: Record of data sources in each review was noted as was the departmental specialty of the first author and his or her country of residence. The references cited in each index paper were tabulated by assigning them to 6 specialty categories, by article title, and by assigning them to 8 categories, by country of journal publication.

DATA SYNTHESIS: Of 89 reviews, 3 (3.4%) reported on literature search and described search method. Authors from laboratory-based disciplines preferentially cited laboratory references, while psychiatry-based disciplines preferentially cited psychiatric literature (P = .01). A total of 71.6% of references cited by US authors were from US journals, while 54.9% of references cited by United Kingdom authors were published in United Kingdom journals (P = .001).

CONCLUSION: Citation of the literature is influenced by review authors’ discipline and nationality.

 

Source: Joyce J, Rabe-Hesketh S, Wessely S. Reviewing the reviews: the example of chronic fatigue syndrome. JAMA. 1998 Jul 15;280(3):264-6. http://www.ncbi.nlm.nih.gov/pubmed/9676676

 

Putting the rest cure to rest—again

Go home and rest” is still the advice given to many patients who complain of chronic fatigue. The refrain is echoed in self help books and magazines and adopted by many patients. What are the origins of rest as a treatment, does it work, and what evidence is there on which to base our advice to patients?

Victorian physicians diagnosed them as neurasthenia and routinely prescribed rest. This approach was typified by Silas Weir Mitchell’s “rest cure,” which was so popular as to be described as “the greatest advance of which practical medicine can boast in the last quarter of the century.” Despite such accolades, the popularity of the rest cure was short lived. By the turn of the century the same private clinics that once provided it were changing to more active treatments and to the newer psychotherapies. The years that followed saw the end of the rest cure; Karl Menninger poured scorn on the lack of psychological sophistication shown by its proponents, while Richard Asher drew attention to the “the dangers of going to bed.”

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1112768/

Comment in:

Treating chronic fatigue with exercise. Exercise improves mood and sleep. [BMJ. 1998]

Treating chronic fatigue with exercise. Exercise, and rest, should be tailored to individual needs. [BMJ. 1998]

Treating chronic fatigue with exercise. Results are contradictory for patients meeting different diagnostic criteria. [BMJ. 1998]

 

Source: Sharpe M, Wessely S. Putting the rest cure to rest—again. BMJ. 1998 Mar 14;316(7134):796. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1112768/ (Full article)

 

Salivary cortisol profiles in chronic fatigue syndrome

Abstract:

Salivary cortisol profiles (hourly sampling over a 16-hour period) of 10 patients with chronic fatigue syndrome (CFS) but without concurrent depressive disorder were compared with those of 10 healthy volunteers matched for age, sex and menstrual cycle. The mean saliva cortisol concentration over the 16-hour period was slightly but significantly greater in the patients than the controls (p < 0.05). These findings are at variance with earlier reports that CFS is a hypocortisolaemic state and suggest that in CFS the symptom of fatigue is not caused by hypocortisolaemia.

 

Source: Wood B, Wessely S, Papadopoulos A, Poon L, Checkley S. Salivary cortisol profiles in chronic fatigue syndrome. Neuropsychobiology. 1998;37(1):1-4. http://www.ncbi.nlm.nih.gov/pubmed/9438265

 

The prevalence and morbidity of chronic fatigue and chronic fatigue syndrome: a prospective primary care study

Abstract:

OBJECTIVES: This study examined the prevalence and public health impact of chronic fatigue and chronic  fatigue syndrome in primary care patients in England.

METHODS: There were 2376 subjects, aged 18 through 45 years. Of 214 subjects who fulfilled criteria for chronic fatigue, 185 (86%) were interviewed in the case-control study. Measures included chronic fatigue, psychological morbidity, depression, anxiety, somatic symptoms, symptoms of chronic fatigue syndrome, functional impairment, and psychiatric disorder.

RESULTS: The point prevalence of chronic fatigue was 11.3%, falling to 4.1% if comorbid psychological disorders were excluded. The point prevalence of chronic fatigue syndrome was 2.6%, falling to 0.5% if comorbid psychological disorders were excluded. Rates did not vary by social class. After adjustment for psychological disorder, being female was modestly associated with chronic fatigue. Functional impairment was profound and was associated with psychological disorder.

CONCLUSIONS: Both chronic fatigue and chronic fatigue syndrome are common in primary care patients and represent a considerable public health burden. Selection bias may account for previous suggestions of a link with higher socioeconomic status.

 

Source: Wessely S, Chalder T, Hirsch S, Wallace P, Wright D. The prevalence and morbidity of chronic fatigue and chronic fatigue syndrome: a prospective primary care study. Am J Public Health. 1997 Sep;87(9):1449-55. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380968/ (Full article)

 

Chronic fatigue syndrome. A practical guide to assessment and management

Abstract:

Chronic fatigue and chronic fatigue syndrome (CFS) have become increasingly recognized as a common clinical problem, yet one that physicians often find difficult to manage. In this review we suggest a practical, pragmatic, evidence-based approach to the assessment and initial management of the patient whose presentation suggests this diagnosis. The basic principles are simple and for each aspect of management we point out both potential pitfalls and strategies to overcome them.

The first, and most important task is to develop mutual trust and collaboration. The second is to complete an adequate assessment, the aim of which is either to make a diagnosis of CFS or to identify an alternative cause for the patient’s symptoms. The history is most important and should include a detailed account of the symptoms, the associated disability, the choice of coping strategies, and importantly, the patient’s own understanding of his/her illness. The assessment of possible comorbid psychiatric disorders such as depression or anxiety is mandatory.

When the physician is satisfied that no alternative physical or psychiatric disorder can be found to explain symptoms, we suggest that a firm and positive diagnosis of CFS be made.

The treatment of CFS requires that the patient is given a positive explanation of the cause of his symptoms, emphasizing the distinction among factors that may have predisposed them to develop the illness (lifestyle, work stress, personality), triggered the illness (viral infection, life events) and perpetuated the illness (cerebral dysfunction, sleep disorder, depression, inconsistent activity, and misunderstanding of the illness and fear of making it worse).

Interventions are then aimed to overcoming these illness-perpetuating factors. The role of antidepressants remains uncertain but may be tried on a pragmatic basis. Other medications should be avoided. The only treatment strategies of proven efficacy are cognitive behavioral ones. The most important starting point is to promote a consistent pattern of activity, rest, and sleep, followed by a gradual return to normal activity; ongoing review of any ‘catastrophic’ misinterpretation of symptoms and the problem solving of current life difficulties.

We regard chronic fatigue syndrome as important not only because it represents potentially treatable disability and suffering but also because it provides an example for the positive management of medically unexplained illness in general.

 

Source: Sharpe M, Chalder T, Palmer I, Wessely S. Chronic fatigue syndrome. A practical guide to assessment and management. Gen Hosp Psychiatry. 1997 May;19(3):185-99. http://www.ncbi.nlm.nih.gov/pubmed/9218987

 

The prognosis of chronic fatigue and chronic fatigue syndrome: a systematic review

Abstract:

The prognosis of chronic fatigue syndrome and chronic fatigue has been studied in numerous small case series. We performed a systematic review of all studies to determine the proportion of individuals with the conditions who recovered at follow-up, the risk of developing alternative physical diagnoses, and the risk factors for poor prognosis.

A literature search of all published studies which included a follow-up of patients with chronic fatigue syndrome or chronic fatigue were performed. Of 26 studies identified, four studied fatigue in children, and found that 54-94% of children recovered over the periods of follow-up. Another five studies operationally defined chronic fatigue syndrome in adults and found that < 10% of subjects return to pre-morbid levels of functioning, and the majority remain significantly impaired. The remaining studies used less stringent criteria to define their cohorts. Among patients in primary care with fatigue lasting < 6 months, at least 40% of patients improved.

As the definition becomes more stringent the prognosis appears to worsen. Consistently reported risk factors for poor prognosis are older age, more chronic illness, having a comorbid psychiatric disorder and holding a belief that the illness is due to physical causes.

Comment in:

Chronic fatigue syndrome. [QJM. 1997]

Chronic fatigue syndrome. [QJM. 1997]

 

Source: Joyce J, Hotopf M, Wessely S. The prognosis of chronic fatigue and chronic fatigue syndrome: a systematic review. QJM. 1997 Mar;90(3):223-33. http://qjmed.oxfordjournals.org/content/90/3/223.long (Full article)

 

Cognitive behavior therapy for chronic fatigue syndrome: a randomized controlled trial

Abstract:

OBJECTIVE: Cognitive behavior therapy for chronic fatigue syndrome was compared with relaxation in a randomized controlled trial.

METHODS: Sixty patients with chronic fatigue syndrome were randomly assigned to 13 sessions of either cognitive behavior therapy (graded activity and cognitive restructuring) or relaxation. Outcome was evaluated by using measures of functional impairment, fatigue, mood, and global improvement.

RESULTS: Treatment was completed by 53 patients. Functional impairment and fatigue improved more in the group that received cognitive behavior therapy. At final follow-up, 70% of the completers in the cognitive behavior therapy group achieved good outcomes (substantial improvement in physical functioning) compared with 19% of those in the relaxation group who completed treatment.

CONCLUSIONS: Cognitive behavior therapy was more effective than a relaxation control in the management of patients with chronic fatigue syndrome. Improvements were sustained over 6 months of follow-up.

Comment in: Cognitive behavior therapy for chronic fatigue syndrome. [Am J Psychiatry. 1998]

 

Source: Deale A, Chalder T, Marks I, Wessely S. Cognitive behavior therapy for chronic fatigue syndrome: a randomized controlled trial. Am J Psychiatry. 1997 Mar;154(3):408-14. http://www.ncbi.nlm.nih.gov/pubmed/9054791

 

Changes in growth hormone, insulin, insulinlike growth factors (IGFs), and IGF-binding protein-1 in chronic fatigue syndrome

Abstract:

Chronic fatigue syndrome (CFS) is characterized by severe physical and mental fatigue of central origin. Similar clinical features may occur in disorders of the hypothalamopituitary axis. The aim of the study was to determine whether patients with CFS have abnormalities of the growth hormone/insulinlike growth factor (GH-IGF) axis basally or following hypothalamic stimulation with insulin-induced hypoglycemia.

We compared levels of GH, IGF-I, IGF-II, IGF-binding protein-1 (IGFBP-1), insulin, and C-peptide in nondepressed CFS patients and normal controls. We found attenuated basal levels of IGF-I (214 +/- 17 vs. 263.4 +/- 13.4 micrograms/L, p = .036) and IGF-II (420 +/- 19.8 vs. 536 +/- 24.3 micrograms/L, p = .02) in CFS patients and a reduced GH response to hypoglycemia (peak GH; 41.9 +/- 11.5 vs. 106.0 +/- 25.6 mU/L, p = .017). Insulin levels were higher (7.6 +/- 1.0 vs. 4.3 +/- 0.8 mU/L, p = .02) and IGFBP-1 levels were lower (19.7 +/- 4.6 vs. 43.2 +/- 2.7 mg/L, p = .004) in CFS patients compared with controls.

This study provides preliminary data abnormalities of the GH-IGF axis in CFS. It is not apparent whether these changes are components of a primary pathological process or are acquired secondary to behavioral aspects of CFS such as reduced physical activity.

 

Source: Allain TJ, Bearn JA, Coskeran P, Jones J, Checkley A, Butler J, Wessely S, Miell JP. Changes in growth hormone, insulin, insulinlike growth factors (IGFs), and IGF-binding protein-1 in chronic fatigue syndrome. Biol Psychiatry. 1997 Mar 1;41(5):567-73. http://www.ncbi.nlm.nih.gov/pubmed/9046989

 

Chronic fatigue syndrome: a 20th century illness?

Abstract:

The chronic fatigue syndrome has become the fin de siècle illness, now getting similar attention to that of neurasthenia, which dominated medical thinking at the turn of the century.

Myalgic encephalomyelitis was an early term introduced in the United Kingdom in 1957 for this state, but it had little or no public or professional prominence. Until then “chronic fatigue had become invisible”, with “no name, no known etiology, no case illustrations or clinical accounts in the medical textbook, no ongoing research activity–nothing to relate it to current medical knowledge”.

The reconstruction of chronic fatigue began in the mid-1980s, with the emergence of “chronic Epstein-Barr virus syndrome”, which was later converted to chronic fatigue syndrome. The former term, which first emerged in the mid-1980s, is now regarded as a misnomer and should be abandoned.

In the popular American literature the term “chronic fatigue and immune deficiency syndrome” is preferred by the most active of the patient lobbies, while myalgic encephalomyelitis continues to be the usual label in the United Kingdom.

The relevant research linking chronic fatigue syndrome with somatization is reviewed in this article. Understanding the nature of somatization can still shed some light on the meaning of chronic fatigue at the end of the 20th century.

 

Source: Wessely S. Chronic fatigue syndrome: a 20th century illness? Scand J Work Environ Health. 1997;23 Suppl 3:17-34. http://www.sjweh.fi/show_abstract.php?abstract_id=239 (Full article)

 

Clinical improvement in chronic fatigue syndrome is not associated with lymphocyte subsets of function or activation

Abstract:

The relationship between markers of immune function and chronic fatigue syndrome (CFS) is controversial. To examine the relationship directly, 43 subjects with CFS entering a randomized controlled trial of a nonpharmacological treatment for CFS gave samples for immunological analysis before and after treatment. Percentage levels of total CD3+ T cells, CD4 T cells, CD8 T cells, and activated subsets did not differ between CFS subjects and controls. Naive (CD45RA+ RO-) and memory (CD45RA- RO+) T cells did not differ between subjects and controls.

Natural killer cells (CD16+/CD56+/CD3-) were significantly increased in CFS patients compared to controls, as was the percentage of CD11b+ CD8 cells.

There were no correlations between any immune variable and measures of clinical status, with the exception of a weak correlation between total CD4 T cells and fatigue. There was a positive correlation between memory CD4 and CD8 T cells and depression scores and a negative correlation between naive CD4 T cells and depression.

No immune measures changed during the course of the study, and there was no link between clinical improvement as a result of the treatment program and immune status. Immune measures did not predict response or lack of response to treatment.

In conclusion, we have been unable to replicate previous findings of immune activation in CFS and unable to find any important associations between clinical status, treatment response, and immunological status.

 

Source: Peakman M, Deale A, Field R, Mahalingam M, Wessely S. Clinical improvement in chronic fatigue syndrome is not associated with lymphocyte subsets of function or activation. Clin Immunol Immunopathol. 1997 Jan;82(1):83-91. http://www.ncbi.nlm.nih.gov/pubmed/9000046