Reply
We thank Dr Harvey and colleagues for their comments
regarding our recent editorial [1]. In fact, we believe that
we are reaching, albeit from different directions, the same
conclusion that fatigue is a complex symptom and that it
is frequently multifactorial requiring a multidisciplinary
approach to management.
We were disappointed at the suggestion that we might
'dichotomise mind and body' particularly as our editorial
clearly states that depression and anxiety are key factors
that are important to manage in patients with fatigue.
Furthermore, our published work underlines that our
clinical management strategies (that quantitatively improve
quality of life in fatigued patients [2]) include assessment
of both physical as well as fatigue-associated
psychological parameters [3-5].
The manner in which Harvey et al. pose their response
to our editorial could be interpreted as underlining what
a proportion of the patient population believe happens in
clinical practice in the UK, where when patients present
with fatigue, the diagnostic paradigm assumes that their
symptoms are primarily psychological in origin rather
than physical. Our editorial was aimed at readdressing
this imbalance or simply to suggest that there may be
an alternative argument.
As a cardiovascular physiologist and immunologist, we
have come to understand the impact that fatigue has for
our patients in the context of chronic diseases, particularly
the autoimmune liver disease and primary biliary cirrhosis
(PBC) where fatigue is accepted by the clinical
community to be biological in its origin [6-10]. Of
course, there are psychological consequences of the debilitating
symptom of fatigue, but studies strongly support
that in PBC, this is a secondary rather than a primary
phenomena [11].
As physicians whose interest is in the physical aspects
of fatigue, we are happy to acknowledge the importance of
psychological as well as physical factors in fatigue and utilise
psychological assessment tools in our normal clinical
practice. Perhaps, in the spirit of this new desire for a balanced
approach, we should review whether all clinics perform
formal autonomic assessment or a 12-lead ECG in
their patients who present with fatigue.
Julia L. Newton and
David E. J. Jones
UK National Institute for Health Research Biomedical
Research Centre, Newcastle University
e-mail:
Julia.Newton@nuth.nhs.uk
References
1. Newton JL, Jones DE. Making sense of fatigue. Occup Med
(Lond) 2010;60:326-329.
2. Jones DEJ, Sutcliffe K, Pairman J, Wilton K, Newton JL. An
Integrated care pathway improves quality of life in primary
biliary cirrhosis. Q J Med 2008;101:535-543.
3. Newton JL, Jones DE, Henderson E et al. Fatigue in nonalcoholic
fatty liver disease (NAFLD) is significant and
associates with inactivity and excessive daytime sleepiness
but not with liver disease severity or insulin resistance.
Gut 2008;57:807-813.
4. Newton JL, Jones DEJ. The population prevalence of autonomic
dysfunction and daytime somnolence in primary
biliary cirrhosis. Hepatology 2007;47:1496-1505.
5. Newton JL, Jones DEJ, Brown A, Sheerin N. Fatigue in
early renal disease. Br J Ren Med 2009;14:10-14.
6. Cauch-Dudek K, Abbey S, Stewart DE, Heathcote EJ.
Fatigue in primary biliary cirrhosis. Gut 1998;43:705-710.
7. Prince MI, James OFW, Holland NP, Jones DEJ. Validation
of a fatigue impact score in primary biliary cirrhosis: towards
astandardforclinicalandtrialuse.JHepatol2000;32:368-373.
8. Huet PM, Deslauriers J, Tran A, Faucher C,
Charbonneau J. Impact of fatigue on the quality of life in
patients with primary biliary cirrhosis. Am J Gastroenterol
2000;95:760-767.
9. Goldblatt J, Taylor PJS, Lipman Tet al. The true impact of
fatigue in primary biliary cirrhosis: a population study. Gastroenterology
2002;122:1235-1241.
10. Newton JL, Bhala N, Burt JA, Jones DEJ. Characterisation
of the associations and impact of symptoms in primary
biliary cirrhosis using a disease specific quality of life
measure. J Hepatol 2006;44:776-783.
11. Van Os E, Van den Broek WW, Mulder PGH, ter Borg PC,
Bruijn JA, van Buuren HR. Depression in primary biliary
cirrhosis and primary sclerosing cholangitis. J Hepatol
2007;46:1099-1103.