Psychopathology

The initial psychiatric hypothesis to explain CFS was that it was identical to depressive disorder. This hypothesis relegated CFS to the status of mere misdiagnosis. However, this view was clearly an oversimplification, and more complex explanations are required.

Somatization

A process referred to as 'somatization' is commonly invoked as an additional process to explain why patients with emotional disturbances such as depression present with somatic complaints like fatigue and not with low mood. The term somatization implies that 'mental' processes are causing 'somatic' symptoms, and it is therefore essentially dualistic. The hypothesis that the somatic symptoms of CFS are readily understandable as part of an emotional disturbance is a parsimonious alternative to some of the more elaborate pathophysiological mechanisms outlined above. However, there is no 'marker' for somatization and its operation is difficult to prove. Therefore tests of this hypothesis require that observable aspects of this process are present in patients diagnosed as suffering from CFS.

Attribution

One of the components of somatization that can be measured is the patients' understanding of, and beliefs about, their illness. Systematic studies have confirmed that patients attending specialist clinics with CFS typically attribute their illness to organic disease even when no evidence of this can be found by their physicians. Perhaps more importantly, they may strongly resist psychological and psychiatric explanations for their symptoms. (22> Whether these patients are biased in their views about illness or simply wiser than their physicians is unclear. However, strong and exclusively physical disease attributions may be a marker for an important illness-perpetuating process in CFS as they predict a poorer clinical outcome. (23)

Perceptual processes

Patients with CFS report a greater sense of effort in response to both psychological and physical demands than is explicable from the objectively measurable impairments/2^ This observation raises the possibility that they are especially sensitive to bodily sensations, that is they 'amplify' them. It is possible that as in panic disorder, the patients' beliefs about their symptoms may lead them to focus attention on to bodily sensations. Although a plausible hypothesis, there is so far little evidence that this process is important in patients with CFS. The notion of a central disorder of the sense of effort merits further exploration.

Coping behaviour

A tendency to avoid activities that exacerbate symptoms has been shown to occur in patients with CFS. Activities avoided include not only physical activity but also the ingestion of certain foods, drugs, and alcohol.(25) Such avoidance is associated with persistent disability, and has been suggested as the mechanism by which disease attributions for symptoms predicts poor outcome.

Personality characteristics

Both studies and clinical experience suggest that many persons with CFS have a tendency towards hard driving, perfectionist, or obsessive- compulsive personalities, and overactive lifestyles. (26> Such persons may be both predisposed to becoming emotionally exhausted, and biased towards presenting emotional distress in a somatic form.

Stigma, misinformation, and communication

Patients with the aforementioned personality type may be more susceptible to those social pressures that lead to chronic fatigue, by being more fearful of the social stigma attached to a 'psychiatric' explanation for their distress. Another potentially important social factor is the availability of misleading information about the illness Both self-help books and the media have tended to emphasize 'medical' explanations for the symptoms of CFS at the expense of more psychiatric or psychological conceptualizations. It has also been suggested that CFS may serve a culturally defined function of social communication, allowing a socially acceptable and hence 'non-psychiatric' expression of distress and protest about intolerable occupational and personal pressures. Much the same has been said of neurasthenia in the People's Republic of China (see ChapteĀ£5.2.J 0).

Conclusions

Psychopathological explanations of CFS are clinically plausible and have enjoyed some degree of empirical support. In particular, a strong and exclusive medical disease attribution has been found to be a strong predictor of poor prognosis. (,23> Social factors may also be important in shaping the illness.

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