Chronic fatigue and its syndromes

Oxford University Press, £25, pp 416

ISBN 0 19 262181 5

Rating:

This is an important book. The preface warns that it may offend those with strong beliefs that chronic fatigue is an exclusively physical syndrome or that it is entirely of psychological origins. Any who are offended will have been exceptionally resistant to the scholarship and the weight and breadth of the evidence as well as to a readable style that has more vigour and humanity than is usual in medical monographs.

The authors fully accept chronic fatigue syndrome as a real illness and one that has been poorly understood and treated by doctors. They consider chronic fatigue as being like any other illness in that its onset and course are influenced by physical, psychological, and social factors. Chapters review these topics as well as the history of chronic fatigue and neurasthenia and the influence of social circumstances.

Several conclusions are apparent. Chronic fatigue (using a working definition that includes the most prominent clinical features) is common in primary and secondary care. The highly selective minority who are seen in specialist clinics and are most prominent in lay accounts are but one of numerous subgroups—subgroups which overlap with other widely recognised syndromes such as fibromyalgia and irritable bowel. Cultures that do not accept the Western separation of mind and body are more successful in accepting and understanding chronic fatigue and “unexplained” physical symptoms.

Aetiology cannot be seen in terms of single physical or psychological causes. It is multifactorial, with physiological, pathological, and psychological variables acting to predispose, to precipitate, and to maintain symptoms. This pattern of interaction of aetiological factors is likely to vary over time: for example, various infections such as influenza and hepatitis are direct causes of acute fatigue, but, months or years later, persistent fatigue seems to be determined by secondary physiological consequences such as deconditioning and psychological variables. Once fatigue is established, patients' frustrations and doctors' bewilderment are often powerful maintaining factors. Inevitably, there are associations with primary and secondary psychiatric disorders such as depression and anxiety. This multicausal view of chronic fatigue syndromes should enable us to replace current therapeutic nihilism, which arises from a lack of understanding or overly simple explanations, by highly practical conclusions about treatment, which are well described in this book.

Discussion of chronic fatigue raises basic issues that apply to many of the unexplained medical symptoms which are common in all medical practice. The chapter on the social history of chronic fatigue in the 20th century has salutary and disturbing lessons about medical and lay understanding of many conspicuous and controversial alleged syndromes (for example, food and environmental allergies, Gulf war syndrome, repetitive strain injury). Both doctors and politicians have been unable or unwilling (in contrast to press and television) to discuss multicausal aetiologies that include major psychological and behavioural variables. This book offers an evidence based “third way.”