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Chronic Fatigue and its Syndromes
  1. ANDREW LEVER

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    Chronic Fatigue and its Syndromes. By simon wessely, matthew hotopf, and michael sharpe. (Pp 428, £29.50). Published by Oxford University Press, Oxford, 1998. ISBN 0-19-263046-6.

    My first sensation is that such a book is long overdue. There is a paucity of books written by clinicians on this subject compared with the many gloom and doom tracts written by sufferers who have apparently been ill with CFS/PVS/ME for 20 years and which depress the hell out of the patients that I see. Why this lack? Undoubtedly because relatively few doctors want to put their heads above the parapet and profess to a great expertise or desire to see patients with it. It is a condition for which there is no objective test, no objective monitoring of progress, whose symptoms are so vague that they repeatedly defy classification and can only be catalogued. Among those patients with a genuine postinfectious fatigue (who mainly get better relatively quickly) there is a large body of those with hospital records measured by the kilogram who arrive with sheaves of self compiled additional notes and occupy huge periods in the clinic to little effect other than frustration for both doctor and patient. Why they do this is a different story.

    So what about the book? Firstly I must say it comes armour plated against criticism with a pack of glowing references from ennobled and famous physicians on the back. Presumably the authors chose these referees whose major feature in common is distinction in fields other than chronic fatigue syndrome. So, for whatever reason they were chosen the result is also to make this a poisoned chalice to review if one has the temerity to disagree with such a company.

    Chronic fatigue and its Syndromes is written by three psychiatrists. That in itself is a little odd as although psychiatric illness is quite common in the chronic fatigue syndrome group, most patients with chronic fatigue syndrome are very reluctant to be seen on first presentation by psychiatrists. One usually has to reassure them that one is not dismissing their symptoms as psychiatric if one does suggest such a referral. What proportion of patients I wonder go to psychiatrists as their first hospital referral? I would guess very few.

    The book is very comprehensive. As a source of references on the subject of fatigue it is encyclopaedic. It begins with a nice history of the syndrome. Of a 428 page book only 44 pages cover assessment of the patient and a very telling paltry 14 are devoted to treatment. What is all the rest? The answer is that the authors have attempted to deal with every fatigue associated subject including: aetiology of chronic fatigue syndrome (summary - not known) and in a move which Sir Humphrey Appleby might have described as “courageous“ they have ventured way outside their own areas of expertise into subjects such as viruses and immunity. The result is a collection of comprehensively referenced and uncritically selected facts from the literature, many of which are very useful, such as the collected data on enteroviruses and chronic fatigue syndrome but much of which is of uncertain value—for example, “divorced and separated women have higher titres of EBV-VCA antibodies” quoted out of context but not unrepresentatively. To glean interesting and important information from this book requires a fair degree of skill in distinguishing timber from forest.

    When in their own field of psychiatry there is, unsurprisingly, a much more confident and informative air to the book. It is disappointing and somewhat introspective that they did not think that subjects such as neurobiology, microbiology, and immunology might justify equally expert contributors.

    Is it an easy read? There is no easy way to write on a subject such as this, bedevilled by lack of objective facts and the writers have chosen a discursive, debating style which when not tightly controlled can slip towards verbosity. This, however, is not a standard medical text book and it would be unfair to make direct comparisons..

    Is this a useful book? As a source of references, yes. As a guide to clinicians I am less convinced. The two commonest questions patients ask are hardly mentioned: “How long does the illness last?” and “What are my chances of recovery” Cognitive behavioural therapy is concisely and usefully summarised. There is a single page on complementary treatment, which again is often an area of considerable interest to patients notwithstanding the lack of controlled evidence for or against it.

    On that note it is perhaps appropriate to quote one very intelligent patient with chronic fatigue syndrome I saw who became ill during his PhD. “I’ve done a lot of reading and internet searching about the causes and possible cures of this, before I came to see you” he said “It seems to me that most people have an illness a bit like that which you commonly see after glandular fever and nobody seems to think it odd that after glandular fever you can feel unwell for quite a long time” he continued “If most people get better from this” (and many do) and if you try all sorts of other treatments like homoeopathy, acupuncture, meditation then the one you were doing when you got better will be the one you think cured you”. He had of course discovered the maxim of entertaining the patient while nature gets them better. One could do worse perhaps than keep patients with chronic fatigue syndrome occupied, if not necessarily always entertained for quite a while, by recommending this book for them to read. They might end up with a greater understanding of fatigue and they would certainly realise how little really is known and how the search for an instant cure (which drives many of them) is currently futile.

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