Book Review

Yehuda, S and Mostofsky, DI (eds). Chronic Fatigue Syndrome.

New York: Plenum Press. 1997 HB. 199p. £57.81. USA and Canada: $95.40

This book features papers presented at the Second Faber Center International Conference on CFS held December 12-13, 1995 at Bar-Ilan University, Ramat Gan, Israel. The chapters include a discussion of the problems of diagnosing CFS in elderly patients by Besdine, a description of the development of the 1994 CDC criteria by Fukuda and a literature review by Salit. There is a discussion of original research by Christodoulou et al which focuses on the importance of distinguishing between the various subgroups. Their earlier studies had already documented the differences between patients with and without psychiatric disorders. In this chapter, they also reveal differences between those with an acute and gradual onset. For example, patients with an acute onset were found to have fewer psychiatric disorders and more severe cognitive impairments than those with a gradual onset.

Also original is the theory presented by Chaudhuri et al that CFS is primarily a metabolic problem, possibly related to abnormalities in the ion channels (sodium, potassium and calcium). They cite the similarities between CFS and Syndrome X, as well as some of the relevant research (increased resting energy expenditure and lower body potassium etc.).

In other contributions, Moldofsky discusses the possible role of sleep in CFS and related disorders, Sredni reviews the evidence suggesting immunological imbalance and Kastin et al, who came to CFS through a literature review, suggest that the original trigger might be chronic stress. This hypothesis is based on the assumption that the term CFS excludes epidemic cases.

This interesting and sometimes inspiring book will help many scientists keep up to date with the research. My only criticism is that some of the contributors failed to point out major flaws in the psychiatric literature, leading not only to psychologisation but also to a highly unreliable assessment of psychiatric treatments. However, in contrast to most of the other books on CFS, there is virtually no expression of hostility towards patients.

A final thought. Salit notes that some of the information from the lay media "is at variance with the current body of scientific information" (p. 64). It's a statement which few would argue with but what bothers me is that he needed to point this out. The lay press never rejected stories about miracle cures for cancer and MS, so why expect them to show restraint when it comes to CFS? And if one is going to nit-pick, I should mention that there are probably more factual errors in BMJ articles on fatigue than in the newsletters published by British ME associations!

Most of the mistakes in patient literature probably occur because the term CFS seems to cover more than one condition. However, while some doctors are beginning to acknowledge this (see Fukuda in this book), few have considered the consequences in terms of research and management (notable exceptions include Christodoulou et al, Mawle et al, Lerner et al discussed above). The majority of the medical writers still regard CFS as one entity with many causes. To quote Salit, it may represent "one extreme" on a continuum of fatigue. If only a small group of patients show evidence of immune system abnormalities, this is rejected as an important cause for the illness as a whole. Moreover, when writers discuss the patients' inaccurate beliefs (i.e. in a 'physical' cause), they are assuming that CFS as a whole cannot be attributed to pathology. Every patient is wrong, not just a subgroup. Writers might admit in the discussion section that the condition has a multifactorial aetiology, but if the same pathological abnormality isn't found in the majority of those studied, then it tends to be dismissed.

This view of CFS contrasts with that of the patient groups and researchers like myself. We would probably interpret findings suggesting immune system activation in a minority as further evidence of a subgroup. At the same time, we are happy to accept that other patients may be ill as a result of psychological problems or their lifestyle (cf. Surawy et al). In some cases, it might be more accurate to think in terms of a combination of factors (cf. Buchwald, Komaroff). It goes without saying that this approach does not allow one to generalise about the accuracy of the patients' beliefs. Unless one actually does the relevant tests (cf. Lerner et al), who knows for certain that the patient's attributions are wrong?

The different perspectives mean that the same information might be regarded as inaccurate if one thinks of CFS as one condition, but accurate if one suspects the existence of subgroups. Take the recent literature on CBT and graded activity. Some British researchers have described their CFS patients as clinically depressed and/or highly perfectionist people with the same maladaptive coping strategy ('total rest'). Having found that CBT helped the majority of these individuals, they imply that this treatment will benefit everyone with CFS, regardless of their coping history and psychological state. However, studies which involved slightly 'purer' samples did not find CBT to be particularly useful, so an objective observer might feel that a more cautious approach is warranted. To me, sweeping statements by experienced medical professionals such as "cognitive behavioural treatment has demonstrated excellent results" (p. 52) does not qualify as a piece of accurate information, but I can understand why others might not agree with me.

On the whole, this is one of the better texts on CFS.

Highly recommended.

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