Chronic Fatigue Syndrome: Wessely S

Harvey SB, Wessely S. · No affiliation provided · Br J Gen Pract. · Pubmed #19341551 No free full text.

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Cho HJ, Wessely S. · No affiliation provided · Rev Bras Psiquiatr. · Pubmed #16224602 links to  free full text

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Hotopf M, Wessely S. · No affiliation provided · Psychol Med. · Pubmed #10218916 No free full text.

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Reid S, Chalder T, Cleare A, Hotopf M, Wessely S. · St Mary's Hospital, London, UK. · Clin Evid. · Pubmed #16620458 No free full text.

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Cho HJ, Skowera A, Cleare A, Wessely S. · Department of Psychological Medicine, Institute of Psychiatry, King's College London, London, UK. · Curr Opin Psychiatry. · Pubmed #16612182 No free full text.

Abstract: PURPOSE OF REVIEW: Chronic fatigue syndrome is a controversial condition especially concerning its clinical definition and aetiopathogenesis. Most recent research progress has been made in phenomenology and pathophysiology and we focused our review on these two areas. RECENT FINDINGS: The phenomenology research supports the notion of a discrete fatigue syndrome which can be distinguished from depression and anxiety. The current case definition, however, may need an improvement based on empirical data. Recent advances in understanding the pathophysiology of chronic fatigue syndrome continue to demonstrate the involvement of the central nervous system. Hyperserotonergic state and hypoactivity of the hypothalamic-pituitary-adrenal axis constitute other findings, but the question of whether these alterations are a cause or consequence of chronic fatigue syndrome still remains unanswered. Immune system involvement in the pathogenesis seems certain but the findings on the specific mechanisms are still inconsistent. Genetic studies provide some evidence of the syndrome being a partly genetic condition, but environmental effects seem to be still predominant and identification of specific genes is still at a very early stage. SUMMARY: The recent findings suggest that further research is needed in improving the current case definition; investigating overlaps and boundaries among various functional somatic syndromes; answering the question of whether the pathophysiologic findings are a cause or consequence; and elucidating the involvement of the central nervous system, immune system and genetic factors.

Huibers MJ, Wessely S. · Department of Medical, Clinical & Experimental Psychology, Maastricht University, The Netherlands. · Psychol Med. · Pubmed #16403245 No free full text.

Abstract: BACKGROUND: One of the many controversies surrounding chronic fatigue syndrome (CFS) is the possible impact of the diagnostic label: is it disabling or enabling? In this paper, we discuss the pros and cons of labelling CFS. METHOD: A narrative synthesis of the literature. RESULTS: Diagnosed CFS patients have a worse prognosis than fatigue syndrome patients without such a label. The ways in which CFS patients perceive themselves, label their symptoms and appraise stressors may perpetuate or exacerbate their symptoms, a process that involves psychological, psychosocial and cultural factors. Labels can also lead to conflicts with doctors who fear diagnosis might lead to worse outcomes. However, on the other hand, finding a label that fits one's condition can provide meaning, emotional relief and recognition, whilst the denial of the diagnosis of CFS in those who have already reached their own conclusion can be very counter productive. The act of diagnosis therefore seems to be a trade-off between empowerment, illness validation and group support, contrasted with the risk of diagnosis as self-fulfilling prophecy of non-recovery. CONCLUSIONS: The answer to the question of 'to label or not to label' may turn out to depend not on the label, but on what that label implies. It is acceptable and often beneficial to make diagnoses such as CFS, provided that this is the beginning, and not the end, of the therapeutic encounter.

Reid S, Chalder T, Cleare A, Hotopf M, Wessely S. · St Mary's Hospital, London, UK. · Clin Evid. · Pubmed #15865734 No free full text.

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Cho HJ, Hotopf M, Wessely S. · Section of General Hospital Psychiatry, Institute of Psychiatry, King's College London, United Kingdom. · Psychosom Med. · Pubmed #15784798 links to  free full text

Abstract: OBJECTIVE: The placebo response is conventionally asserted to be high in chronic fatigue syndrome (CFS) because of the latter's subjective nature and obscure pathogenesis, but no systematic review of placebo responses has been undertaken. We report such a study. Patient expectation is known to be important in the placebo response. It is also known that CFS patients attending specialist clinics often have strong physical attributions regarding causation and hence skepticism about psychological or psychiatric interventions. If so, the placebo response in CFS may be influenced by the type of intervention according to its perceived rationale. We aimed to estimate the summary placebo response in clinical trials of CFS and to determine whether intervention type influences the placebo response in CFS. METHODS: We searched Medline, Embase, Cochrane Library, PsychInfo, and the references of the identified articles, and contacted experts for controlled trials (randomized or nonrandomized) of any intervention on CFS patients reporting the placebo response as a clinical improvement in physical or general outcomes. Data were extracted from the articles and validity assessment conducted by one reviewer and checked by a second. Meta-analysis and metaregression were performed. RESULTS: The pooled placebo response was 19.6% (95% confidence interval, 15.4-23.7), lower than predicted and lower than in some other medical conditions. The meta-regression revealed that intervention type significantly contributed to the heterogeneity of placebo response (p = .03). CONCLUSION: In contrast with the conventional wisdom, the placebo response in CFS is low. Psychological-psychiatric interventions were shown to have a lower placebo response, perhaps linked to patient expectations.

Reid S, Chalder T, Cleare A, Hotopf M, Wessely S. · St Mary's Hospital, London, UK. · Clin Evid. · Pubmed #15555147 No free full text.

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Luthra A, Wessely S. · King's College School of Medicine, Institute of Psychiatry, 103 Denmark Hill, London SE5 8AZ, UK. · Soc Sci Med. · Pubmed #15047091 No free full text.

Abstract: The aetiologies of both chronic fatigue syndrome (CFS) and its predecessor neurasthenia, have been linked to technological advances in 'developed' countries. This paper discusses how this has led to a form of race thinking within discussions about fatigue which has persisted for more than a century. We review the historical development of this race thinking from neurasthenia to CFS and describe how it is manifested in both the lay- and medical literature. We also review the epidemiological literature on CFS and ethnicity to better understand the relatively low percentage of non-white patients seen in tertiary referral clinics for CFS. The aim of this paper is to act as a starting point for a debate on race and CFS.

Lyall M, Peakman M, Wessely S. · Department of Psychological Medicine, Guy's, King's and St. Thomas' School of Medicine, 103 Denmark Hill, London SE5 8AZ, UK. · J Psychosom Res. · Pubmed #12932505 No free full text.

Abstract: OBJECTIVE: Immune dysfunction in patients with chronic fatigue syndrome (CFS) has been widely but inconsistently reported. Traditional reviews of the literature have produced a variety of conclusions. We present the results of the first systematic review of the subject. METHODS: EMBASE, MEDLINE and PSYCHINFO databases were searched, and leading researchers in the field were contacted. Inclusion criteria were applied, and studies were then divided into groups based on the quality of their methodology. Study results were collated and described. RESULTS: Studies ranged widely in quality. There was an inverse association between study quality and finding low levels of natural killer cells, suggesting that the association may be related to study methodology. On the other hand, reports of abnormalities in T cells and cytokine levels were not related to study quality. CONCLUSIONS: The conclusions of this systematic review differ from a recent traditional narrative review of the immunology of CFS. No consistent pattern of immunological abnormalities is identified.

Reid S, Chalder T, Cleare A, Hotopf M, Wessely S. · St Mary's Hospital, London, UK. · Clin Evid. · Pubmed #12603930 No free full text.

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Candy B, Chalder T, Cleare AJ, Wessely S, White PD, Hotopf M. · Department of Psychological Medicine, Guy's, King's and St. Thomas' School of Medicine, London. · Br J Gen Pract. · Pubmed #12392128 links to  free full text

Abstract: Infectious mononucleosis is usually an acute, transiently incapacitating condition, but for some sufferers it precipitates chronic illness. It is unclear which patients are at risk of a prolonged state of illness following onset of infectious mononucleosis and if there are any useful preventive measures that would facilitate recovery. The aim of this study was to review all cohort studies and intervention trials that provide information on: (a) the longitudinal course of ill health subsequent to the onset of infectious mononucleosis; (b) the relationship between psychosocial and clinical factors and recovery rate; and (c) the effect of interventions on recovery. A systematic review was conducted, based on a search of the PSYCHINFO, MEDLINE, EMBASE and CINHAL databases up to October 2001, and ISI Science and Social Sciences Citation Indices up to 22 November 2001. Eight papers were identified that gave data on illness following onset of infectious mononucleosis. The best evidence concluded that there is a distinct fatigue syndrome after infectious mononucleosis. Eight papers explored risk factors for prolonged illness following acute infectious mononucleosis. Results varied on the association of acute illness characteristics and psychological features with prolonged ill health. Poor physical functioning, namely lengthy convalescence and being less fit or active, consistently predicted chronic ill health. Three trials reported on interventions that aimed to shorten the time taken to resolve symptoms after uncomplicated infectious mononucleosis. None of the drug trials found any evidence that drug therapy shortens recovery time. The trial that compared the effect of activity with imposed bed rest, found that those patients allowed out of bed as soon as they felt able reported a quicker recovery. More information is needed on the course of ill health subsequent to the onset of infectious mononucleosis. Certain risk factors associated with delay may be amenable to a simple intervention in primary care.

Reid S, Chalder T, Cleare A, Hotopf M, Wessely S. · Guy's, King's and St Thomas' School of Medicine, Institute of Psychiatry, London, UK. · Clin Evid. · Pubmed #12230719 No free full text.

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Parker AJ, Wessely S, Cleare AJ. · Department of Psychological Medicine, Guy's, King's and St Thomas' School of Medicine and the Institute of Psychiatry, London. · Psychol Med. · Pubmed #11722149 No free full text.

Abstract: BACKGROUND: Disturbance of the HPA axis may be important in the pathophysiology of chronic fatigue syndrome (CFS) and fibromyalgia. Symptoms may be due to: (1) low circulating cortisol; (2) disturbance of central neurotransmitters; or (3) disturbance of the relationship between cortisol and central neurotransmitter function. Accumulating evidence of the complex relationship between cortisol and 5-HT function, make some form of hypothesis (3) most likely. We review the methodology and results of studies of the HPA and other neuroendocrine axes in CFS. METHOD: Medline, Embase and Psychlit were searched using the Cochrane Collaboration strategy. A search was also performed on the King's College CFS database, which includes over 3000 relevant references, and a citation analysis was run on the key paper (Demitrack et al. 1991). RESULTS: One-third of the studies reporting baseline cortisol found it to be significantly low, usually in one-third of patients. Methodological differences may account for some of the varying results. More consistent is the finding of reduced HPA function, and enhanced 5-HT function on neuroendocrine challenge tests. The opioid system, and arginine vasopressin (AVP) may also be abnormal, though the growth hormone (GH) axis appears to be intact, in CFS. CONCLUSIONS: The significance of these changes, remains unclear. We have little understanding of how neuroendocrine changes relate to the experience of symptoms, and it is unclear whether these changes are primary, or secondary to behavioural changes in sleep or exercise. Longitudinal studies of populations at risk for CFS will help to resolve these issues.

Wessely S. · Guy's, King's, and St Thomas's School of Medicine and Institute of Psychiatry, London, United Kingdom. · Ann Intern Med. · Pubmed #11346319 No free full text.

Abstract: Chronic fatigue is common, is difficult to measure, can be associated with considerable morbidity, and is rarely a subject of controversy. The chronic fatigue syndrome also presents problems in definition and measurement, is associated with even more morbidity than chronic fatigue itself, and is often controversial. Particularly unclear is the way in which chronic fatigue and the chronic fatigue syndrome relate to each other: Is one the severe form of the other, or are they qualitatively and quantitatively different? We know that many things can cause chronic fatigue, and this is probably true for the chronic fatigue syndrome, too. We can anticipate that discrete causes of the chronic fatigue syndrome will be found in the future, even if these causes are unlikely to fall neatly along the physical-psychological divide that some expect. The causes of chronic fatigue are undoubtedly many, both in a population and in any individual person, even when a discrete cause, such as depression or cancer, is identified. Social, behavioral, and psychological variables are important in both chronic fatigue and the chronic fatigue syndrome. Interventions that address these general variables can be successful, and currently they are often more successful than interventions directed at specific causes.

Reid S, Chalder T, Cleare A, Hotopf M, Wessely S. · Guy's, Kings, and St Thomas's School of Medicine and Institute of Psychiatry, London SE5 8AZ. · BMJ. · Pubmed #10650029 links to  free full text

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Wessely S, Hotopf M. · Academic Department of Psychological Medicine, Guy's, King's and St Thomas' School of Medicine, London, UK. · Baillieres Best Pract Res Clin Rheumatol. · Pubmed #10562373 No free full text.

Abstract: Most medical specialities have defined medically unexplained syndromes such as fibromyalgia, to categorize patients with prominent but unexplained symptoms. Other such syndromes include irritable bowel syndrome, chronic fatigue syndrome and atypical chest pain. In this chapter we present evidence to suggest that fibromyalgia is not a unique clinical entity, but shares much with these other syndromes. We use historical, clinical and epidemiological evidence to illustrate this idea. The historical data emphasize the essentially arbitrary way in which fibromyalgia developed. The clinical evidence shows the considerable overlap between patients with fibromyalgia and those with other unexplained syndromes. From an epidemiological perspective we emphasize the strong associations between symptoms such as myalgia and fatigue. We conclude by suggesting that fibromyalgia is one of many medically unexplained syndromes which have more similarities than differences between them.

Wessely S, Nimnuan C, Sharpe M. · Department of Psychological Medicine, Guy's, King's and St Thomas' School of Medicine, London, UK. · Lancet. · Pubmed #10489969 No free full text.

Abstract: We review the concept and importance of functional somatic symptoms and syndromes such as irritable bowel syndrome and chronic fatigue syndrome. On the basis of a literature review, we conclude that a substantial overlap exists between the individual syndromes and that the similarities between them outweigh the differences. Similarities are apparent in case definition, reported symptoms, and in non-symptom association such as patients' sex, outlook, and response to treatment. We conclude that the existing definitions of these syndromes in terms of specific symptoms is of limited value; instead we believe a dimensional classification is likely to be more productive.

Brunello N, Akiskal H, Boyer P, Gessa GL, Howland RH, Langer SZ, Mendlewicz J, Paes de Souza M, Placidi GF, Racagni G, Wessely S. · Center of Neuropharmacology, Institute of Pharmacological Sciences, University of Milan, Italy. · J Affect Disord. · Pubmed #10357046 No free full text.

Abstract: Dysthymia, as defined in the American Psychiatric Association and International Classification of Mental Disorders, refers to a prevalent form of subthreshold depressive pathology with gloominess, anhedonia, low drive and energy, low self-esteem and pessimistic outlook. Although comorbidity with panic, social phobic, and alcohol use disorders has been described, the most significant association is with major depressive episodes. Family history is loaded with affective, including bipolar, disorders. The latter finding explains why dysthymia, especially when onset is in childhood, can lead to hypomanic switches, both spontaneously and upon pharmacologic challenge in as many as 30%. Indeed, antidepressants from different classes -tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), reversible inhibitors of monoamine oxidase A (RIMAs), selective serotonin-reuptake inhibitors (SSRIs) and, more recently, amisulpride, and spanning noradrenergic, serotonergic as well as dopaminergic mechanisms of action - have been shown to be effective against dysthymia in an average of 65% of cases. This is a promising development because social and characterologic disturbances so pervasive in dysthymia often, though not always, recede with continued pharmacotherapy beyond acute treatment. Despite symptomatic overlap of dysthymia with chronic fatigue syndrome - especially with respect to the cluster of symptoms consisting of low drive, lethargy, lassitude and poor concentration - neither the psychopathologic status, nor the pharmacologic response profile of the latter syndrome is presently understood. Chronic fatigue today is where dysthymia was two decades ago. We submit that the basic science - clinical paradigm that has proven so successful in dysthymia could, before too long, crack down the conundrum of chronic fatigue as well. At a more practical level, we raise the possibility that a subgroup within the chronic fatigue group represents a variant of dysthymia.

Candy B, Chalder T, Cleare AJ, Wessely S, Hotopf M. · Department of Psychological Medicine, Guy's, King's and St. Thomas' School of Medicine, 103 Denmark Hill, London SE5 8AZ, UK. · J Psychosom Res. · Pubmed #15256300 No free full text.

Abstract: OBJECTIVES: Glandular fever is associated with an approximate fivefold increase in fatigue at 6 months. Reduced levels of fitness and illness beliefs may be important predictors of fatigue following glandular fever. We therefore developed a brief psycho-educational intervention aimed at improving recovery from infectious mononucleosis, and piloted a randomised controlled trial to evaluate the intervention. METHODS: We performed a randomised-controlled trial in primary health care in Southeast London and Kent. Sixty-nine patients aged between 16 and 45 years who were diagnosed, serologically and clinically, with acute infectious mononucleosis between December 1999 and December 2000 were randomised. The control group received a standardised fact-sheet about infectious mononucleosis, which gave no advice on rehabilitation. Patients who were randomised to the intervention received an individual treatment session, two follow-up telephone calls, and an information booklet. Fatigue score 6 months after the onset of infectious mononucleosis was the main outcome measure. RESULTS: Sixty-nine out of 139 patients referred were recruited and randomised. Eighty-seven percent of those recruited completed the Fatigue Questionnaire at 6 months. The intervention was acceptable to all who received it. There were fewer fatigue cases in the intervention group than the control group at 6 months follow-up (odds ratio 0.31, 95% confidence interval 0.09-0.91). CONCLUSIONS: A brief intervention at the diagnosis of infectious mononucleosis is acceptable, and may help prevent the development of chronic fatigue. Definitive randomised controlled trials are required to test the intervention.

Chalder T, Godfrey E, Ridsdale L, King M, Wessely S. · Department of Psychological Medicine, Guy's, King's and St Thomas's School of Medicine, London. · Psychol Med. · Pubmed #12622306 No free full text.

Abstract: BACKGROUND: The objective of this study was to examine factors that predicted outcome in a chronically fatigued group of patients who were randomized to cognitive behaviour therapy or counselling in primary care. METHOD: Illness perceptions, attributions, fatigue, disability and demographic variables were recorded at assessment and levels of fatigue and disability were measured at 6 months post randomization. Logistic regression was used to examine associations. RESULTS: Factors that predicted a poor outcome (four or more on the fatigue questionnaire) were: poor social adjustment at assessment; the patients self-report that they had never seen the GP for an emotional reason; a physical illness attribution; and, a long perceived future illness duration. CONCLUSIONS: Patients who are more psychologically minded are more likely to improve with psychological treatments in primary care. General practitioners need to assess this before referring to an appropriate therapist.

Deale A, Husain K, Chalder T, Wessely S. · Academic Department of Psychological Medicine, Guy's, King's, and St. Thomas's School of Medicine, London, UK. · Am J Psychiatry. · Pubmed #11729022 links to  free full text

Abstract: OBJECTIVE: This study evaluated the long-term outcome of cognitive behavior therapy versus relaxation therapy for patients with chronic fatigue syndrome. METHOD: Sixty patients who participated in a randomized controlled trial of cognitive behavior therapy versus relaxation therapy for chronic fatigue syndrome were invited to complete self-rated measures and participate in a 5-year follow-up interview with an assessor who was blind to treatment type. RESULTS: Fifty-three patients (88%) participated in the follow-up study: 25 received cognitive behavior therapy and 28 received relaxation therapy. A total of 68% of the patients who received cognitive behavior therapy and 36% who received relaxation therapy rated themselves as "much improved" or "very much improved" at the 5-year follow-up. Significantly more patients receiving cognitive behavior therapy, in relation to those in relaxation therapy, met criteria for complete recovery, were free of relapse, and experienced symptoms that had steadily improved or were consistently mild or absent since treatment ended. Similar proportions were employed, but patients in the cognitive behavior therapy group worked significantly more mean hours per week. Few patients crossed the threshold for "normal" fatigue, despite achieving a good outcome on other measures. Cognitive behavior therapy was positively evaluated and was still used by over 80% of the patients. CONCLUSIONS: Cognitive behavior therapy for chronic fatigue syndrome can produce some lasting benefits but is not a cure. Once therapy ends, some patients have difficulty making further improvements. In the future, attention should be directed toward ensuring that gains are maintained and extended after regular treatment ends.

Ridsdale L, Godfrey E, Chalder T, Seed P, King M, Wallace P, Wessely S, Anonymous00230. · Department of General Practice, Guy's, King's and St Thomas's School of Medicine, King's College, 5 Lambeth Walk, London SE11 6SP. · Br J Gen Pract. · Pubmed #11271868 links to  free full text

Abstract: BACKGROUND: Fatigue is a common symptom for which patients consult their doctors in primary care. With usual medical management the majority of patients report that their symptoms persist and become chronic. There is little evidence for the effectiveness of any fatigue management in primary care. AIM: To compare the effectiveness of cognitive behaviour therapy (CBT) with counselling for patients with chronic fatigue and to describe satisfaction with care. DESIGN OF STUDY: Randomised trial with parallel group design. SETTING: Ten general practices located in London and the South Thames region of the United Kingdom recruited patients to the trial between 1996 and 1998. Patients came from a wide range of socioeconomic backgrounds and lived in urban, suburban, and rural areas. METHOD: Data were collected before randomisation, after treatment, and six months later. Patients were offered six sessions of up to one hour each of either CBT or counselling. Outcomes include: self-report of fatigue symptoms six months later, anxiety and depression, symptom attributions, social adjustment and patients' satisfaction with care. RESULTS: One hundred and sixty patients with chronic fatigue entered the trial, 45 (28%) met research criteria for chronic fatigue syndrome; 129 completed follow-up. All patients met Chalder et al's standard criteria for fatigue. Mean fatigue scores were 23 on entry (at baseline) and 15 at six months' follow-up. Sixty-one (47%) patients no longer met standard criteria for fatigue after six months. There was no significant difference in effect between the two therapies on fatigue (1.04 [95% CI = -1.7 to 3.7]), anxiety and depression or social adjustment outcomes for all patients and for the subgroup with chronic fatigue syndrome. Use of antidepressants and consultations with the doctor decreased after therapy but there were no differences between groups. CONCLUSION: Counselling and CBT were equivalent in effect for patients with chronic fatigue in primary care. The choice between therapies can therefore depend on other considerations, such as cost and accessibility.

Cleare AJ, Heap E, Malhi GS, Wessely S, O'Keane V, Miell J. · Department of Psychological Medicine, Guy's King's and St Thomas' School of Medicine and the Institute of Psychiatry, London, UK. · Lancet. · Pubmed #9989716 No free full text.

Abstract: BACKGROUND: Reports of mild hypocortisolism in chronic fatigue syndrome led us to postulate that low-dose hydrocortisone therapy may be an effective treatment. METHODS: In a randomised crossover trial, we screened 218 patients with chronic fatigue. 32 patients met our strict criteria for chronic fatigue syndrome without co-morbid psychiatric disorder. The eligible patients received consecutive treatment with low-dose hydrocortisone (5 mg or 10 mg daily) for 1 month and placebo for 1 month; the order of treatment was randomly assigned. Analysis was by intention to treat. FINDINGS: None of the patients dropped out. Compared with the baseline self-reported fatigue scores (mean 25.1 points), the score fell by 7.2 points for patients on hydrocortisone and by 3.3 points for those on placebo (paired difference in mean scores 4.5 points [95% CI 1.2-7.7], p=0.009). In nine (28%) of the 32 patients on hydrocortisone, fatigue scores reached a predefined cut-off value similar to the normal population score, compared with three (9%) of the 32 on placebo (Fisher's exact test p=0.05). The degree of disability was reduced with hydrocortisone treatment, but not with placebo. Insulin stress tests showed that endogenous adrenal function was not suppressed by hydrocortisone. Minor side-effects were reported by three patients after hydrocortisone treatment and by one patient after placebo. INTERPRETATION: In some patients with chronic fatigue syndrome, low-dose hydrocortisone reduces fatigue levels in the short term. Treatment for a longer time and follow-up studies are needed to find out whether this effect could be clinically useful.