Chronic fatigue: What investigations? And what for? 2023 Gramont et al

Abstract

Chronic fatigue is a frequent complaint, expressed at all levels of the healthcare system. It is perceived as disabling in a high proportion of cases, and internists are frequently called upon to find “the” cause.

The etiological diagnostic approach of an unexplained state of fatigue relies on the careful search for more specific clues by questioning and clinical examination. It is necessary to recognize the limited place of complementary examinations apart from the basic biological parameters. Simple rating scales can be useful in the etiological and differential diagnosis of fatigue.

Chronic fatigue syndrome (CFS), in the current state of knowledge, cannot be considered as a specific pathological entity distinct from idiopathic chronic fatigue states, and does not have validated biomarkers. It is important to know that a state of chronic asthenia often results from several intricated etiological factors (biological, psychological and social), to be classified as predisposing, precipitating and perpetuating.

The metabolic and cardiorespiratory exercise test has a major place in the assessment and management of fatigue, as a prerequisite for personalized retraining or adapted physical activity (APA), which are the treatments of choice for chronic fatigue.

Paywall, https://www.sciencedirect.com/science/article/abs/pii/S0248866323005933

Section snippets in French are available at link.

 

The senior author is Pascal Cathébras, a fierce BPS proponent. It is unsurprising that the Journal of Internal Medicine published this piece as it is a hotspot for BPS internists — they have published dreadful opinion pieces on long Covid, too.

Edit: I read the article briefly and the authors essentially recommend GET and CBT on the basis that there have been “well conducted trials” and that NICE only stopped recommending these treatments because it capitulated against the pressure of patients. Similarly, they posit that the US IOM’s decision to rename CFS to SEID was “ideological”.

Perhaps the most stunning point is that they recommend a CPET for both investigating the source of chronic fatigue and for devising an adapted physical activity (APA) plan for the patient, but they completely omit to mention the 2 day CPET (which the IOM recommended) and say that there is no biomarker for CFS, even though the 2 day CPET findings have been replicated by multiple independent research groups.

 

From the English abstract:

"Chronic fatigue syndrome (CFS), in the current state of knowledge, cannot be considered as a specific pathological entity distinct from idiopathic chronic fatigue states, and does not have validated biomarkers."

"The metabolic and cardiorespiratory exercise test has a major place in the assessment and management of fatigue, as a prerequisite for personalized retraining or adapted physical activity (APA), which are the treatments of choice for chronic fatigue." ​

The snippets also includes this section (translated from French):

To feel and complain of fatigue, as psychiatrist Henri Ey put it, is both to experience incapacity and to surrender to it. This volitional component makes it a complaint that is always suspect of complacency, and the doctor called in has a hard time escaping this judgment of responsibility, which he or she can defend by minimizing, normalizing and psychiatrizing the symptom without examining it, or by interpreting it as a sign of social suffering (motivating, for example, the prescription of a work stoppage).​