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The nature of fatigue: comparison of postviral fatigue... (Wessely commentary)

Discussion in 'General ME/CFS News' started by oceanblue, Mar 22, 2012.

  1. oceanblue

    oceanblue Senior Member

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    Editor's choice: Simon Wessely on his 1989 paper. Impact commentaries : A MODERN PERSPECTIVE ON SOME OF THE MOST HIGHLY CITED JNNP PAPERS OF ALL TIME.

    The nature of fatigue: a comparison of chronic postviral fatigue with neuromuscular and affective disorders, Wessely 2012 (free full text)
    J Neurol Neurosurg Psychiatry 2012;83:4-5 doi:10.1136/jnnp-2011-301216

    Not read myself but noticed this on scanning:
  2. Firestormm

    Firestormm Senior Member

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    Thanks Blue. A bit of coffee-table reading :D
  3. Enid

    Enid Senior Member

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    ...."with the expanding knowledge concerning the biological basis of many psychiatric illnesses".......can one ask why they were termed "psychiatric" in the first place and why.

    Sounds like a medical category for "don't know". (Or just your imagination as offered to me once despite collapse).
    Desdinova likes this.
  4. Marco

    Marco Old blackguard

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    What a star!

    I'm in awe (or ennui).

    "There was no instrument available to measure subjective fatigue, so I simply invented one"

    My own trumpet - that I could blow on every occasion.
    Desdinova, Sean, ahimsa and 3 others like this.
  5. Patrick*

    Patrick* Formerly PWCalvin

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    Hmm. What incentive could psychiatrists have to lay claim to physical ailments? None, unless you consider that it would exponentially expand their patient pool, and thus, their relevance and wealth!
    justinreilly, Sean and Enid like this.
  6. Esther12

    Esther12 Senior Member

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    It's not a huge surprise that the Chalder Fatigue Scale was developed as part of a study designed to show the similarities between depression and "postviral" fatigue.

    Maybe that would explain the strange lack of questions on post-exertional problems like "Following a more active day, do you find that you feel worse?"

    A question like "Do you have trouble starting things?" almost seems designed to confuse problems with motivation and physical capability.

    It sometimes seems that the last two decades of psychosocial CFS research has been driven by a belief that the most important thing for patients is to answer those Chalder Fatigue questions more positively, and that explains their disinterest in evidence from actometers, employment, etc that their 'treatments' are not worthwhile.
    Antares in NYC, justinreilly and Sean like this.
  7. Mark

    Mark Acting CEO

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    Yes - the invention of this way of measuring subjective fatigue, the way its make-up influenced by the preconceptions of its author, and its subsequent establishment as a standard for 'CFS' research seems to be absolutely pivotal in locking in the confirmation bias that pervades the field.

    If I read it correctly, one interesting aspect of the recent Ampligen paper was that, while patients improved objectively in a double-blind placebo-controlled drug trial, on treadmill test and on various other objective and subjective measures, to a clinically significant extent, their SF-36 responses didn't improve (I hope I read that right). Then you have the evidence of claimed SF-36 improvements under CBT being contradicted by the objective actimeter readings...and it starts to look very much like the Sf-36 simply measures patients' level of positive thinking about their illness, thereby making 'treatments' like CBT look good without delivering any real objective improvement. The whole thing seems to be a circular, self-perpetuating exercise in confirmation bias.
  8. Firestormm

    Firestormm Senior Member

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    Read the review and am now reading/trying to read/might leave for another day the actual paper he wrote: http://jnnp.bmj.com/content/52/8/940.full.pdf html

    Tis, I believe, a case of him going back to his roots and the root 'cause' of our troubles if my suspicion is correct. I wasn't diagnosed until 1999 or there abouts so this is all new to me.

    Do you think he regards 'depression' as having a biological cause? I mean that's where the psychiatrists all seem to be aiming these days I think.

    It's a 'get-out-of-trouble-with-patients free card' isn't it? Because any e.g. chemical imbalance is 'physical' I guess. Or maybe I'm reading too much into it.
  9. oceanblue

    oceanblue Senior Member

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    Yes, I was really struck by the blas way he said he basically made up Chalder Fatigue questions with depression as a reference - and no attempt to understand what it was that was unique to ME/CFS. And certainly no input from patients that might have given him some useful insight. All the more worrying that this on-the-fly scale (later 'validated', if that's the right word, on non-CFS patients) should be used as a primary outcome for PACE etc.

    edit: By contrast, Lenny Jason has spent a lot of time developing questionnaires that probe the nature of fatigue in ME and how it differes from other illnesses, and is in the process of validating that questionnaire in people with ME. How novel.
    Antares in NYC and WillowJ like this.
  10. jimells

    jimells Senior Member

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    My 'gut-brain' doesn't care what those pesky astronomers claim. It tells me subjectively that the earth is, indeed, flat. So that scientifically proves it!

    Now if I could just get a research grant...
    Kati, Valentijn, ahimsa and 1 other person like this.
  11. Enid

    Enid Senior Member

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    I think you've just coined a new title jimells "astronomers" (even astrologers).
  12. Sean

    Sean Senior Member

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    I have always thought Wessely was actually a bit of a narcissistic intellectual flyweight, with a vastly overinflated sense of his own importance*. He is highly articulate and extraordinarily politically adroit, and possessing astounding stamina and an almost monomaniacal dedication to his cause. But lacking any genuine real world understanding of what he is dealing with, and the carnage he is causing along the way.

    *I recall him writing a puff piece in which he declared that psychiatry was the most important branch of medicine.
    oceanblue and Enid like this.
  13. SilverbladeTE

    SilverbladeTE Senior Member

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    Sounds like a description of a psychopath, doesn't it? :p
  14. Valentijn

    Valentijn Activity Level: 3

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    We should know better than to diagnose psychological problems without proof.

    It's just as likely that his issues stem from physiological damage caused by being repeatedly dropped on his head as a child.
    alex3619 likes this.
  15. Don Quichotte

    Don Quichotte Don Quichotte

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    I probably wrote this is the wrong place, so copy it here.

    I read the original article and was amazed to see the significant number of methodological flaws:

    First- you can't create your own questionnaire and use it in serious research without validating it first. (Not to mention that you don't usually diagnose diseases by questionnaires of this sort. quite likely if he used a similar questionnaire in patients with pancreatic cancer, lymphoma or thyroid disorders and not CFS patients, he would have reached similar conclusions, but he didn't validate his questionnaire on any control group of that sort).

    Second- when you compare one group of patients to another group of patients, you have to use clear criteria to define those groups. And as the distinction between normal sadness and depression is still not well-defined, using a group of patients with the diagnosis of depression as a group of comparisson is at the least problematic. (also as I have mentioned many diseases can be mistakes for depression, because of significant overlap in many symptoms; also to complicate matters even more, having a serious/debliltating illness is many times accompanied by a normal reactive sadness/depression).

    Third-the above is even more important when you have mixed and overlapping symptoms of diagnoses. Or else you can easily enter a loop of proving your hypothesis with what you have to prove. (which is basically what happened here).

    Fourth- you can't use a heterogenous group of patients with symptoms varying from mild eye symptoms to being on a respirator in the ICU (such as myasthenia gravis) as your group of comaparisson without clearly defining the severity of the illness in your group of patients. There is no mention of how many had a mild disease, how many had only limb involvement, how many had bulbar symptoms, how many had respiratory problems and sleep disturbances? He also didn't take into account (and probably didn't know) that myasthenia itself (now known to be an autoimmune and rarely a genetic disease) was initially thought to be a non-organic illness (hysteria) because there were no anatomic findings in this disease.

    Further more, patients with atypical variants of myasthenia, or unrecognized respiratory muscle involvement are often diagnosed as suffering from psychiatric problems. In general it is exceedingly common for patients with neurological illnesses to also "have" psychiatric problems. (which in other words means that some of their symptoms are atypical and can't be explained by the current knowledge and understanding of their illness).

    So, the only valid conclusions that can be reached from this paper are that patients with CFS are in many ways similar to patients with less typical forms of myasthenia. And that neurologists commonly attribute symptoms they do not have a good explanation for to psychiatric problems, such as "depression" and "anxiety".

    This does not prove or disprove the validity of this approach and only shows what was already known without this study.
    Without realizing it, the non-organic nature of the disease studied was based on the initial assumption of the non-organic nature of this disease. The fact that there was significant overlap with symptoms of patients with depression did not prove or disprove this assumption. This overlap was obvious without the study, as it was the original hypothesis based on wessley's (right or wrong) observations and impressions, which were validated by his own questionnaire.

    The fact that others readily agreed with his findings and this paper was cited numerous times, only proves (again) the ingeniousness of Lewis Carol in the "Hunting of the Snark" -

    "Just the place for a Snark!" the Bellman cried,
    As he landed his crew with care;
    Supporting each man on the top of the tide
    By a finger entwined in his hair.
    "Just the place for a Snark! I have said it twice:
    That alone should encourage the crew.
    Just the place for a Snark! I have said it thrice:
    What i tell you three times is true."
    WillowJ, SOC, alex3619 and 1 other person like this.
  16. SilverbladeTE

    SilverbladeTE Senior Member

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    Hm, true, very true...

    Could also be because he picked the wrong week to stop sniffing glue? :p

    sniffing-glue.jpg
  17. alex3619

    alex3619 Senior Member

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    Is there an implication that ANY study depending on the Chalder Fatigue Scale is methodologically flawed and so is invalid? I think its likely that this is the case.

    This issue arises in part due to medical ignorance. It is presumed that fatigue is the dominant symptom. It isn't. By attempting to measure only fatigue it gives a highly distorted and biased view of the data. Where is pain? Where are the neurological signs?

    Its like comparing birds on the basis of their having wings, and then concluding they must all fly. Under this kind of reasoning ostriches, penguins and emus must be able to fly. If they can't, clearly they have mental issues - they could if they wanted to. We need more animal trainers with tastier fishy sticks in order to train them out of their false flying beliefs.

    If Wessely had properly asked the question "what are the differences between ME and depression?" instead of "what is the same between ME and depression?" the answers he drew might have been very different. A more interesting question would have been what are the differences and similarities between post viral fatigue and ME?

    Another problem is this: post viral fatigue has known physical associations, probably causal. Only about ten percent of these patients go on to develop something like ME. The only reliable predictor is severity of the initial infection. Post viral fatigue, CFS, and ME are three different categories - they may overlap a little, but they are not the same. This deliberate conflation of categories is a major problem.

    This multiple definition issue plagues this entire field of research. Their CFS is not CFS, pacing is not pacing, CBT is not CBT, normal is not normal, and recovered is the new name for disabled. Now we can add depression is not depression. Oh, and the other day I read something that supported my view that neurasthenia is not neurasthenia. People are being conned on the basis of NAMES and the issue of DEFINITIONS is being spun into obscurity.

    Vascillating between definitions to support arguments is a primary (and deliberately misleading) argument tool used in this field of research. One of the reasons it is so misleading is they can always go back and redefine terms - oh, no, you must have misunderstood.

    Bye, Alex
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  18. Esther12

    Esther12 Senior Member

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    I've not had time to read this whole thread, but...

    I don't think so.

    It is important to remember that any study using the Chalder fatigue scale is measuring answers to the Chalder fatigue questionnaire, and not 'fatigue'.

    This is the same for lots of measures though, and I'm often annoyed by the way in which researchers will write as if these sorts of questionnaires can be assumed to to be accurately measuring whatever it is they're designed to measure.

    I don't think the Chalder Fatigue Scale is that good for measuring the fatigue CFS patients tend to complain of... but it's really difficult to meaningfully measure fatigue, and that needs to be born in mind when criticising studies that use the Chalder Fatigue Scale (could they not have come p with something whose acronym is not 'CFS' - having to type it out in full to avoid confusion is really irritating!)
  19. alex3619

    alex3619 Senior Member

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    Hi Esther12, that is part of it. Another tangential reference. I doubt its coincidence that CFS and the Chalder Fatigue Scale share the same abbreviation, though I could be wrong.

    My comment on the methodological validity of the Chalder scale refers directly to ME and CFS of course. It does not refer to any other use.

    I would like to add the use of the word "functional" to the double-speak list.

    Bye, Alex
  20. PhoenixDown

    PhoenixDown Senior Member

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    Depression is just another waste-basket diagnosis really, no objective proof, extremely vague, some people naturally heal from it, when people get treated successfully we don't actually know what they got treated of, etc, etc.

    The diagnosis dishonestly includes sleep disorders, pain, fatigue. It's a mess.

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