This is a well-written, comprehensive reference text on all aspects of fatigue. It covers the nature and extent of fatigue, the history of chronic fatigue, the main research on CFS as well as the assessment and management of various fatigue states. However, this is not an entirely objective account; the authors' interest in inactivity and deconditioning as a major source of CFS is very clear, and this reviewer was reminded as early as page 55 that the book was written by three male psychiatrists who basically don't believe what their CFS patients say.
The first thing which surprised me was the lack of respect for the experiences of patients. I saw no evidence in the book that the authors have realised, like most of their colleagues, that the F word is totally inappropriate to describe the exhaustion and weakness experienced by people with CFS. I also noted an underlying sense of hostility towards patients and patient groups. Indeed, they continue to perpetuate the myths that sufferers tend to be stupid, weird and wacky and that every patient responds to fatigue in pretty much the same, maladaptive way. Hence, you won't find any references to courageous individuals, coping sensibly with a debilitating illness, and doing the best they can do!
The lack of respect also extends to the discussion about causes. Basically, these psychiatrists seem to have adopted a Thatcherite tendency to blame the patient for much of their own distress. This is illustrated by the obsession with the idea that attributions and excessive inactivity are major determinants of ongoing fatigue. Admittedly, biological variables are acknowledged, but they get just one cross (denoting a possible role) in a grid of perpetuating factors, compared with three crosses (signifying an important role) for attitudes, inactivity, illness beliefs, avoidance behaviour, iatrogenesis, misinformation and occupational issues.
To those unfamiliar with the literature on CFS, the text must appear authoritative and reliable. And while there are undeniably some sections which give a reasonably fair picture of the research (e.g. on immune status, neurasthenia etc.), the discussion on other subjects (the nature of CFS, the views of the patients and the value of CBT) is as one-sided as a party political broadcast.
The approach to the alternative views, i.e. that CFS is a mixed bag of entities (Straus, Demitrack); that some of these are closely linked to ongoing pathology (Bennett et al, McGarry et al, Lerner et al, Schwartz et al,) and that all require individually tailored advice (Jason et al), is largely dismissive, giving readers the impression that it has little going for it. Similarly, there's virtually nothing about the most common coping strategy (pacing), or an indication that it's probably as good as CBT and graded exercise combined.
The authors also fail to distinguish between the findings on chronic fatigue and CFS. This 'trick' not only simplifies an extremely complex subject, but also introduces errors and ends up trivialising and psychologising the latter.
Personally, I found the book desperately depressing because it gives such a distorted picture of CFS, the lives of the majority who suffer from it and the work of the doctors and researchers from other schools of thought. For instance, I recall advice given by the President of the ME Association in 1989 to the effect that patients should try and remain as active as they can. I also know that none of the medical advisors to the British support groups have ever recommended total rest or the avoidance of all activities to treat ME. What doctors have debated since 1989 is not whether patients should exercise or rest but how much activity they should do and when. Basically, the CBT school advised patients to keep to a predetermined plan irrespective of how they felt while ME specialists proposed a more flexible approach, taking into account current energy levels and symptoms such as post-exertional malaise.
The book doesn't acknowledge this. Instead, it promotes the all-or-nothing myth, suggesting that all patients interpret their doctor's advice to rest as meaning they should do nothing else. This is then followed by a discussion on the dangers of bed rest, reinforcing the view that this is a major source of CFS.
I know that's not true, and I believe, so do the authors. As research has shown, the majority of patients with CFS remain ambulant, and although they reduce their activity levels, few suffer from muscle wasting and other common signs of deconditioning. In fact, there isn't a single study supporting the view that the majority of people with CFS take 'excessive rest' and the authors do not provide any references from research on ME or CFS to back up their claim. Studies showing that patients spend less than 17% of daytime resting (Packer et al) or that this population are no more inactive than people with mild MS (Vercoulen et al) are not mentioned. So much for evidence-based medicine!
Elsewhere, the authors argue that all studies to date which have assessed the influence of physical attributions on outcome have shown them to be "indicators of a poor prognosis" (p. 370). Yet, I know of several good studies which show no such relationship (e.g. Lawrie et al, Ray et al). Of course, people have a right to their opinion, but as scientists, shouldn't we expect a more balanced and fair representation of the research?
Finally, as in other writings from this school of thought, there are a number of factual inaccuracies, e.g. that the D in CFIDS stands for deficiency. If nothing else, it serves as an excellent illustration of the lack of attention to detail which I have criticised before. Incidentally, the authors must know that the Peter Nixon's research on hyperventilation has now been totally discredited. However, the description of his work does not mention this (p. 217).
It really saddens me to say this but this textbook is one of the most unbalanced accounts of CFS I have come across in the past 14 years. It will mislead readers, foster an antagonistic attitude towards patients and contribute to the stigmatisation of the latter in the process. Most importantly, this is not a book on the illness ME and will not increase your doctor's understanding of your condition. As the authors say on page 137, "CFS is more... than just fatigue". Unfortunately, the rest of the text failed to communicate just how much more.
For a really up-to-date and balanced review of the research, try Anne Macintyre's revised edition of her book on ME (Thorson 1998).
Copyright EM. Goudsmit 1998.
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