Jason, LA et al. Politics, science, and the emergence of a new disease. The case of chronic fatigue syndrome. American Psychologist, 1997, 52, 9, 973-983.
This article examines the controversy surrounding CFS. The authors note the differences between the narrow and broader criteria currently in use and suggest that the latter may have resulted in more heterogeneous (mixed) groups and subgroups with higher levels of psychiatric illness. They also point out that tests used to assess psychiatric disorders may have produced inaccurate results. For instance, one study compared two different measures: the DIS and SCID. The DIS diagnosed 50% of the patients as having a current psychiatric illness whereas the SCID led to a similar diagnosis in 22%.
The authors believe that the bias of some researchers towards a psychiatric explanation may have filtered down to the media which has portrayed CFS in simplistic and stereotypical ways.
The article goes on to list several differences between CFS and depression (e.g. the former has a higher incidence of severe fatigue, nausea, post-exertional malaise, flu-like symptoms and intolerance to alcohol). They add that the depression that accompanies a long illness should be regarded as demoralisation rather than as a discrete psychiatric condition.
With regard to treatment, the authors note the difficulties in interpreting the data from trials of cognitive-behaviour therapy (CBT). For instance, studies to date have varied in terms of the severity of symptoms, percentage of patients with psychiatric illness etc. They agree with Friedberg and Krupp that CBT is appropriate if activity is avoided due to depressed mood and an unrealistic fear of relapses. However, if this does not apply, they recommend a tailor-made rehabilitation programme to meet the needs of the individual patient, their symptoms and actual activity levels.
Finally, the authors suggest that the current criteria require clarification and that inclusion of different illnesses under the label of CFS makes it difficult to interpret the data (see Medical Update August 1997).
[This important paper, published in an influential journal, challenges the validity of the best-known psycho-social theory of CFS.]
Lapp, C. American Journal of Medicine, 1997, 103, 83-84.
In this letter, Lapp reports a trial involving 31 consecutive CFS patients who were asked to record their symptoms on a simple scale starting three weeks before until 12 days after exercise testing. He used a bicycle ergometer on which the work of peddling increased steadily with time.
The results showed that 74% of patients experienced worsening fatigue and 26% stayed the same. None improved. The average relapse lasted 8.82 days although 22% were still in relapse when the study ended. Aside from fatigue, there were increases in lymph pain, sore throat, depression, abdominal pain, sleep quality, joint and muscle pain. These findings contrast with those from previous studies which found no or little worsening of symptoms following exercise (cf. research by Wessely et al, Sharpe et al).
According to Lapp, patients can do mild to moderate exercise or work without relapse providing they have frequent rest periods. He advises his own patients to follow short periods of activity with rest. This work-rest cycle may be repeated several times daily in order to maintain strength, flexibility, and conditioning.
[Lapp's previous descriptions of patients suggest that he sees many people with PVFS/ME. The presence of significant post-exertional fatigue may be one difference between ME and more common fatigue syndromes such as burn-out and TATT (tired-all-the-time).]
Steinberg, P et al. Journal of Allergy and Clinical Immunology, 1996, 98, 6, 1126-1128.
Delayed type hypersensitivity skin reactions to five antigens were assessed in 30 patients with CFS (CDC criteria '88).
All patients had one positive delayed reaction to at least one antigen. There was a mean of 2.3 positive skin responses per patient.
[This is yet another study suggesting the presence of allergies in many patients with CFS.]
Cannon et al. Journal of Clinical Immunology, 1997, 17, 3, 253-261.
These American researchers found further evidence of chronic, low-level over-activity of the immune system. However, the most interesting aspect of the study was the selection of the patients. As well as meeting the stricter 1988 CDC criteria, they also had post-infectious CFS and experienced post-exertional malaise.
[Another study suggesting that specific subgroups (in this case patients with PVFS/ME?) may have ongoing disease.]
Anderson and Ferrans. Journal of Nervous and Mental Disease, 1997, 185, 6, 359-367.
These researchers report that the quality of life of people with CFS was well below that documented in other medically-ill patient groups. They also observed the fluctuating nature of the symptoms (also described in ME) and found that 50% of their subjects regarded the cognitive symptoms (i.e. poor concentration and memory) as particularly disabling.
[This well-designed study from the States presents a comparatively realistic view of the nature and severity of CFS.]
If you wish to read any of the papers above, please contact your local library.
Copyright EM. Goudsmit 1997.
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