CHRONIC FATIGUE SYNDROME:
A PRACTICAL GUIDE TO ASSESSMENT AND MANAGEMENT
M. Sharpe, M.A., M.R.C.P., M.R.C.Psych., T. Chalder, R.M.N., M.Sc., I. Palmer, B.M., B.Ch., M.R.C.Ps ch., and Simon Wessely, M.A., M.Sc., M.D., F.R.C.P., M.R.C.Psych.
1997
The Management Plan
General Aspects of Management
Before beginning treatment it is essential that physician and patient agree, at least tentatively, on a positive understanding of the illness that is acceptable to both. The precise mechanisms involved in the symptom of CFS are uncertain and controversial. Rather than doctor and patient becoming bogged down in such disputes, we advocate a pragmatic approach that promotes those illness beliefs and models that lead to positive action. Etiological theories for CFS abound but none are established. Some of these theories are clinically unhelpful whatever their scientific merits. Thus, the belief that symptoms are due to a persistent viral infection of muscle may or may not be true [85,86] but more importantly is clinically unhelpful. Such a belief can lead to the patient interpreting myalgia as evidence of worsening disease, and consequently being reluctant to engage in rehabilitation. In general, beliefs implying that activity will have adverse or even ‘catastrophic’ consequences lead to its avoidance [87].
Other beliefs for which there is (at least as good) scientific support have more constructive implications. For example, the idea that many symptoms of CFS are due to the neurophysiological consequences of inactivity (deconditioning) and the delayed onset of postexertional muscle pain [88] offers a positive alternative to the disease explanations Table 4. Possible illness perpetuating factors in case example described above. The belief that symptoms are due to disturbed hypothalamic pituitary function [89,90] does not interfere with rehabilitation and may also provide a rationale for the prescription of antidepressant drugs if relevant. Similarly, the idea that CFS can be triggered by an episode of acute Epstein Barr virus infection [91] does not imply a progressive pathology, and leaves the way open for a discussion of other perpetuating factors. Other positive explanations, all of which might be correct, and none of which are known to be incorrect, are listed in Table 5. The physician’s overall aim is to broaden, rather than confront, patients’ beliefs and behaviors so that they embrace a wider range of possible explanations for continuing ill health, and hence a wider range of treatment options [92-941]. Its essence is to move the discussion from what started the illness to what obstacles stand in the way of recovery. Such a model naturally leads to a discussion of how these obstacles may be overcome.
TABLE 4. POSSIBLE ILLNESS PERPETUATING FACTORS IN CASE EXAMPLE
PERPETUATING FACTORS
BIOLOGICAL
Effect of profound inactivity
Effect of chronic emotional arousal
Neurobiological factors as yet unknown
COGNITIVE AND BEHAVIORAL
Belief in viral infection
Fear of making disease worse
Reduction of activity
SOCIAL
No job
Reinforcement of sick role by mother and doctor
TABLE 5. ILLNESS MODELS
ILLNESS MODELS TO PROMOTE
Glandular fever as trigger
Stress altering immune function
Secondary handicap
Sleep disorder
Hypothalamic dysfunction
ILLNESS MODELS TO AVOID
Persistent virus
Primary muscle disorder
Severe allergy
Progressive immune deficiency
