LETTERS
SIR: Drs. Abbey and Garfinkel torical review of neurasthenia,
provide but their
chronic
speculative,
fatigue
inaccurate
syndrome
in the
I . The authors ology of chronic chain
reaction
seem
following
an interesting conclusions
hisabout
demeaning,
and
ways:
omitted fatigue
recent medical research into the etisyndrome. This includes polymer
techniques
that
show
a possible
association
be-
tween mune
chronic fatigue syndrome and a retrovirus ( I ) and imsystem abnormalities and activation markers (2). 2. The authors failed to examine the research on neuropsy-
chological abnormalities. MRI scans have revealed malities (3), as have single photon emission computed graphy (SPECT) and brain electrical activity mapping
(4). Reduced
ability
to acquire
new
information,
drop in IQ, have been seen (unpublished Bastien). 3. The authors concluded that a majority syndrome patients will have an identifiable
der.
Patients
acquire
may
chronic
shown
that
chiatric
develop fatigue
but
of prc-illness
is no greater
ofchronic psychiatric
than
in the
they
study
has
psy-
experience
4. The authors
suggests
that
there
among
seasoned
and
the
by clients
similar
injuries
neurasthenics
imply
that chronic
fatigue
price
of chronic
fatigue
syndrome,
syndrome
is loss and estrangement syndrome engenders
from shame,
as with “normal” frustration,
portrayed
is both
other
chronic
life. Chronic and stress
attitude
toward
conclusion,
which is purely speculative and not labeled as such, that chronic fatigue syndrome represents an escape from the stress of balancing work and family obligations. This notion is Victorian. The authors fail to apprise us of how and where they
obtained
their
data
on chronic
fatigue
syndrome,
of their study sample, and how they gained pcrtise in chronic fatigue syndrome. Finally,
dude that neurasthenia was psychosomatic? We hope that the authors, in pursuit
the nature
their clinical how did they
of their
cxcon-
metaphors,
will recall Koranyi, who surveyed 4,000 psychiatric patients and found that half had major medical illnesses. One-third of primary care physicians and half of the psychiatrists missed
the physical
diagnoses.
REFERENCES 1. DeFreitas E, Hilliard B, Cheney PR, Bell DS, Kiggundu E, Sankey D, Wroblewska Z, Palladino M, Woodward JP, Koprowski H: Retroviral sequences related to human T-lymphotropic virus type II in patients with chronic fatigue immune dysfunction syndrome. Proc Nail Acad Sci USA 1991; 88:2922-2926 2. Landay AL,Jessop C, Lennette ET, LevyJA: Chronic fatigue syndrome: a clinical condition associated with immune activation. Lancet 1991; 338:707-712
Psychiatry
149:12,
December
1992
monies
spot
familiar
by Drs.
Abbey
and Garfinkel.
Drs.
SIR:
linking
Abbey
chronic
and
fatigue
Garfinkel
produced
syndrome
to
posed that rapid changes in female syndromes. We have demonstrated, sive femalc:malc sex ratio is largely
F. SHEELEY, Phoenix,
another
M.D. Ariz.
review
neurasthenia
and
pro-
roles may explain such however, that any excesan artifact of tertiary re-
ferral
practice, as the sex ratio in primary care is only 1.3:1 were dismissive of evidence of immunological dysfunction (2, 3), suggesting that these data simply represent medical fashion. We have demonstrated immunological abnormalitics in patients with chronic fatigue syndrome as corn-
(1
). They
pared
with
pression cytokinc
drome derpin
their
claiming
will
arc substantial
over not functioning at pre-illness levels. 5. Particularly offensive is the authors’ women with chronic fatigue syndrome and
Am]
scenarios
attorneys
industrial
WILLIAM
clinical
attractive to and has social value for chronic fatigue syndrome patients. This is simply absurd. We have rarely seen secondary gain or social value associated with chronic fatigue syndrome. illnesses, fatigue
Plaintiffs’
SIR:
for alleged
population
differences between chronic fatigue syndrome-related depression and primary major depression. For example, in the former, sleep disorders may involve non-REM sleep rather than the REM disturbance found in major depression (6). The fatiguc in chronic fatigue syndrome is accompanied by intense frustration at not functioning well, rather than the apathy and anhedonia experienced by patients with major depressive disorder.
The
SALTZSTEIN, M.S.W. ALAN GURWITF, M.D. WARNIE WEBSTER, M.D. SHARON N. BARRE1T, M.D. Cambridge, Mass.
as
or other
general
BARBARA
by S.
once
a recent
affective
SA, Henry BA, Peterson DL, Swarts RL, Basticn 5, RS: Chronic fatigue syndrome in northern Nevada. Rev Infect Dis 1991; 13(suppl 1):S39-S44 4. GoldsteinJ: Chronic Fatigue Syndrome: The Struggle for Health. Beverly Hills, Calif, Chronic Fatigue Syndrome Institute, I 990 S. Hickie I, Lloyd A, Wakefield D, Parker G: The psychiatric status of patients with the chronic fatigue syndrome. Br J Psychiatry 1990; 156:534-540 6. Moldovsky H: Nonrestorative sleep and symptoms after a febrile illness in patients with fibrositis and chronic fatigue syndrome. J Rheumatol 1989; 16(suppl 19):91-93
Thomas
fatigue disor-
difficulties
syndrome,
the incidence
disorders
(5). Our
psychiatric
paper
EDITOR
3. Daugherty
abnortomoscans
as well
1989
TO THE
exist,
both
normal
controls
and patients
with
(2, 4). Further, the demonstration production in patients with chronic (5) suggests that an intriguing “acquired neurasthenia.” While
psychiatrists
such data. With regard
should to natural
be more history
pathogenesis before
treatment
de-
may
no conclusive
cautious and
major
of abnormal fatigue syn-
un-
studies
dismissing
outcome,
Dr.
Abbey and Dr. Garfinkel ignored available studies (1, 6) and relied solely on “clinical experience.” Interpretative hypotheses were proposed, despite others’ reservations that treatments based on such hypotheses are largely unsubstantiated (7). Pronouncements that improvement depends on resolution of “a major family or work problem” are not consistent with the response of some patients to intravenous immunoglobin (6). Although the debate concerning chronic fatigue is one to which psychiatrists ses that arbitrarily
should ignore
contribute, or discount
psychological other models
avoided. We (8), like others (9), have emphasized collaborative efforts in which immunological, neurohormonal, and psychological hypotheses concurrently.
hypotheshould be
the need for vi rological, arc evaluated
REFERENCES I . Lloyd AR, Hickie I, Boughton prevalence of chronic fatigue tion. MedJ
Aust
1990;
CB, Spencer 0, Wakefield syndrome in an Australian
D: The popula-
153:522-528
2. Lloyd A, Wakefield D, Boughton abnormalities in the chronic fatigue 151:122-1 24
C, Dwyer syndrome.
J: Immunological Med J Aust I 989;
1755
SIR: Drs. Abbey and Garfinkel torical review of neurasthenia,
provide but their
chronic
speculative,
fatigue
inaccurate
syndrome
in the
I . The authors ology of chronic chain
reaction
seem
following
an interesting conclusions
hisabout
demeaning,
and
ways:
omitted fatigue
recent medical research into the etisyndrome. This includes polymer
techniques
that
show
a possible
association
be-
tween mune
chronic fatigue syndrome and a retrovirus ( I ) and imsystem abnormalities and activation markers (2). 2. The authors failed to examine the research on neuropsy-
chological abnormalities. MRI scans have revealed malities (3), as have single photon emission computed graphy (SPECT) and brain electrical activity mapping
(4). Reduced
ability
to acquire
new
information,
drop in IQ, have been seen (unpublished Bastien). 3. The authors concluded that a majority syndrome patients will have an identifiable
der.
Patients
acquire
may
chronic
shown
that
chiatric
develop fatigue
but
of prc-illness
is no greater
ofchronic psychiatric
than
in the
they
study
has
psy-
experience
4. The authors
suggests
that
there
among
seasoned
and
the
by clients
similar
injuries
neurasthenics
imply
that chronic
fatigue
price
of chronic
fatigue
syndrome,
syndrome
is loss and estrangement syndrome engenders
from shame,
as with “normal” frustration,
portrayed
is both
other
chronic
life. Chronic and stress
attitude
toward
conclusion,
which is purely speculative and not labeled as such, that chronic fatigue syndrome represents an escape from the stress of balancing work and family obligations. This notion is Victorian. The authors fail to apprise us of how and where they
obtained
their
data
on chronic
fatigue
syndrome,
of their study sample, and how they gained pcrtise in chronic fatigue syndrome. Finally,
dude that neurasthenia was psychosomatic? We hope that the authors, in pursuit
the nature
their clinical how did they
of their
cxcon-
metaphors,
will recall Koranyi, who surveyed 4,000 psychiatric patients and found that half had major medical illnesses. One-third of primary care physicians and half of the psychiatrists missed
the physical
diagnoses.
REFERENCES 1. DeFreitas E, Hilliard B, Cheney PR, Bell DS, Kiggundu E, Sankey D, Wroblewska Z, Palladino M, Woodward JP, Koprowski H: Retroviral sequences related to human T-lymphotropic virus type II in patients with chronic fatigue immune dysfunction syndrome. Proc Nail Acad Sci USA 1991; 88:2922-2926 2. Landay AL,Jessop C, Lennette ET, LevyJA: Chronic fatigue syndrome: a clinical condition associated with immune activation. Lancet 1991; 338:707-712
Psychiatry
149:12,
December
1992
monies
spot
familiar
by Drs.
Abbey
and Garfinkel.
Drs.
SIR:
linking
Abbey
chronic
and
fatigue
Garfinkel
produced
syndrome
to
posed that rapid changes in female syndromes. We have demonstrated, sive femalc:malc sex ratio is largely
F. SHEELEY, Phoenix,
another
M.D. Ariz.
review
neurasthenia
and
pro-
roles may explain such however, that any excesan artifact of tertiary re-
ferral
practice, as the sex ratio in primary care is only 1.3:1 were dismissive of evidence of immunological dysfunction (2, 3), suggesting that these data simply represent medical fashion. We have demonstrated immunological abnormalitics in patients with chronic fatigue syndrome as corn-
(1
). They
pared
with
pression cytokinc
drome derpin
their
claiming
will
arc substantial
over not functioning at pre-illness levels. 5. Particularly offensive is the authors’ women with chronic fatigue syndrome and
Am]
scenarios
attorneys
industrial
WILLIAM
clinical
attractive to and has social value for chronic fatigue syndrome patients. This is simply absurd. We have rarely seen secondary gain or social value associated with chronic fatigue syndrome. illnesses, fatigue
Plaintiffs’
SIR:
for alleged
population
differences between chronic fatigue syndrome-related depression and primary major depression. For example, in the former, sleep disorders may involve non-REM sleep rather than the REM disturbance found in major depression (6). The fatiguc in chronic fatigue syndrome is accompanied by intense frustration at not functioning well, rather than the apathy and anhedonia experienced by patients with major depressive disorder.
The
SALTZSTEIN, M.S.W. ALAN GURWITF, M.D. WARNIE WEBSTER, M.D. SHARON N. BARRE1T, M.D. Cambridge, Mass.
as
or other
general
BARBARA
by S.
once
a recent
affective
SA, Henry BA, Peterson DL, Swarts RL, Basticn 5, RS: Chronic fatigue syndrome in northern Nevada. Rev Infect Dis 1991; 13(suppl 1):S39-S44 4. GoldsteinJ: Chronic Fatigue Syndrome: The Struggle for Health. Beverly Hills, Calif, Chronic Fatigue Syndrome Institute, I 990 S. Hickie I, Lloyd A, Wakefield D, Parker G: The psychiatric status of patients with the chronic fatigue syndrome. Br J Psychiatry 1990; 156:534-540 6. Moldovsky H: Nonrestorative sleep and symptoms after a febrile illness in patients with fibrositis and chronic fatigue syndrome. J Rheumatol 1989; 16(suppl 19):91-93
Thomas
fatigue disor-
difficulties
syndrome,
the incidence
disorders
(5). Our
psychiatric
paper
EDITOR
3. Daugherty
abnortomoscans
as well
1989
TO THE
exist,
both
normal
controls
and patients
with
(2, 4). Further, the demonstration production in patients with chronic (5) suggests that an intriguing “acquired neurasthenia.” While
psychiatrists
such data. With regard
should to natural
be more history
pathogenesis before
treatment
de-
may
no conclusive
cautious and
major
of abnormal fatigue syn-
un-
studies
dismissing
outcome,
Dr.
Abbey and Dr. Garfinkel ignored available studies (1, 6) and relied solely on “clinical experience.” Interpretative hypotheses were proposed, despite others’ reservations that treatments based on such hypotheses are largely unsubstantiated (7). Pronouncements that improvement depends on resolution of “a major family or work problem” are not consistent with the response of some patients to intravenous immunoglobin (6). Although the debate concerning chronic fatigue is one to which psychiatrists ses that arbitrarily
should ignore
contribute, or discount
psychological other models
avoided. We (8), like others (9), have emphasized collaborative efforts in which immunological, neurohormonal, and psychological hypotheses concurrently.
hypotheshould be
the need for vi rological, arc evaluated
REFERENCES I . Lloyd AR, Hickie I, Boughton prevalence of chronic fatigue tion. MedJ
Aust
1990;
CB, Spencer 0, Wakefield syndrome in an Australian
D: The popula-
153:522-528
2. Lloyd A, Wakefield D, Boughton abnormalities in the chronic fatigue 151:122-1 24
C, Dwyer syndrome.
J: Immunological Med J Aust I 989;
1755
