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normal. Thyroid function should be assessed in any patient with unexplained acute toxic illness.
REFERENCES
1 Askkar FS, Millesh A, Gibson AJ. Thyroid function and serum thyroxine in thyroid storm. South MedJ 1972;65:372-4 2 Chopra IJ, Teco GN, Nguyen AH. In search of an inhibition of thyroid hormone binding to serum proteins in non-thyroid illnesses. J Clin Endocrinol Metab 1979;49:63--9

3 Coulombe P, Dussault JH, Walker P. Plasma catecholamine concentrations in hyperthyroidism and hypothyroidism. J Clin Endocrinol Metab 1 977;44: 1185-9 4 Bilezikian JP, Loeb JN. The influence of hyperthyroidism and hypothyroidism on alpha and beta adrenergic receptor systems and adrenergic responsiveness. Endocr Rev 19834:378-88 5 Burch HB, Wartofsky L. Life threatening thyrotoxicosis: thyroid storm. Endocrinol Metab Clin N Am 1993;22:263-77 6 Brooks MH, Waldstein SS. Free thyroxine concentrations in thyroid storm. Ann Intern Med 1980;93:694-7

Hypnosis in chronic fatigue syndrome

Vernon H Gregg PhD CPsychol
J R Soc Med 1997;90:682-683

SECTION OF HYPNOSIS & PSYCHOSOMATIC MEDICINE, 13 MAY 1996

Chronic fatigue syndrome (CFS) is characterized by medically unexplained chronic and disabling physical and mental fatiguel. There is growing evidence of organic abnormalities2 but the involvement of psychological factors in its aetiology and chronicity should also be recognized3. One approach to the complaint assumes it is post-viral in origin with psychiatric and social antecedents4. The sufferer attributes the fatigue and myalgia which persist beyond an initial infectious episode to a continuing viral infection, and interprets them as indicating that activity hinders recovery. A vicious circle is established in which avoidance of activity leads to deconditioning, depression and the perpetuation of symptoms. This view has encouraged the use of cognitive behaviour therapy to increase exercise in graded stages by inducing a more positive attitude towards activity an approach that has met with encouraging results5. Nevertheless, it would seem wrong to attribute CFS entirely to inactivity and sufferers' illness attributions, if only because there are sufferers who are moderately active and working part-time. Such a model also has difficulty explaining why the symptoms fluctuate within a day, or over longer periods. Furthermore, many sufferers strongly believe that exercise, even in a carefully controlled schedule, will make

them feel ill and prolong the complaint. They refuse to contemplate any such therapy6. In view of the controversy over models of CFS and some sufferers' resistance to increased physical effort, it was decided to encourage direct cognitive control of the fatigue and myalgia that form a prominent feature of the syndrome. Importantly, such control should help break the vicious cycle of fatigue, inactivity and depression described by Wessely4. To these ends hypnosis was chosen, primarily because of its success in the control of pain8 and the perception of muscular effort8. Other advantages of hypnosis include the speed with which experiential control can be established. In addition, posthypnotic suggestions can be given for the control of fatigue and myalgia, effective coping, increased wellbeing and regular practice of prescribed techniques. Here I report three cases in which hypnosis was used in the hope of alleviating CFS.
CASE I Patient 1, born in 1943, had led an active outdoor life. He became ill in November 1986 with severe muscle and joint pains and complete exhaustion. CFS was diagnosed in 1991. In 1992 he was discharged from hospital after 10 weeks' complete rest without improvement. When we first saw him in 1992 he was in an extremely debilitated state, avoiding light and sound. Despite his reluctance to make any physical or mental effort he could perform mental arithmetic competently for short periods and had high scores on both immediate and delayed tests of visual and verbal memory, but he performed poorly on a test of logical
reasoning.

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Department of Psychology, Birkbeck College, Malet Street, London WC1 E 7HX, UK

Hypnotic induction involved progressive muscular relaxation with imagery to achieve deepening. He was a good hypnotic subject. The intervention had four components: (1) involve patient and his wife in the process of assessment and recovery; (2) control sensations of fatigue and myalgia; (3) enhance mental activity by imagining enjoyable scenes of activity, both fantasy and remembered;

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(4) enable patient to experience control without hypnosis. Hypnosis was employed in (2) and (3). For (1), the patient kept a daily diary with his wife's help. This included an eight-item mood and vitality scale. There were spaces for comments on daily events, and achievements such as success with the techniques we had introduced. He also recorded positive thoughts and symptoms. He readily accepted an analogy based loosely on Hilgard's dissociative theory7 to help understand hypnosis. According to this theory, attention can be switched away from feelings of pain, and muscular exertion can be made to appear automatic and effortless. He was helped to control resting myalgia, pain with movement, and the after-effects of effort by the demonstration of simple hypnotic phenomena such as hands being pulled together, hand anaesthesia, and arm levitation. Suggestions were given for increased mental activity through fantasized and remembered activities. Posthypnotic suggestions were included for practising the technique on his own, and for general feelings of wellbeing. He reported enjoying subsequent sessions and was encouraged to practise control over sensations using self-hypnosis. Ten weeks after our first contact the diary sheets recorded increased activity and social interaction. Although his level of activity and quality of life has improved since then, progress has been slow (as with many other sufferers9). His most distressing complaints now are cognitive limitations, particularly in sustaining attention, and these are less amenable to hypnosis than the myalgia and feelings of fatigue.
CASE 2 Patient 2, a 31-year-old man with a PhD, had suffered chronic fatigue for 12 years. Initially, after extensive physical examination, he had been given a psychiatric diagnosis and encouraged to be more active. This, he insisted, led to a marked deterioration in his condition. He had good insight into his illness, refused any form of medication, and had used meditation but without success. Importantly, he was working part-time some distance from home and carefully controlling his energy expenditure. His performance was poor on cognitive tests involving speed, sustained attention and working memory. He was very hypnotically susceptible so the intervention was broadly similar to that described for patient 1. Despite his familiarity with the published work, he was surprised at his ability to control feelings of fatigue and myalgia. He uses the technique regularly but has difficulty when feeling very ill, even when supported by an audiotape. Recently, he has suffered increasingly from joint pains which are relieved by hypnotic suggestions. He still experiences severe relapses and has been forced

over at least some aspects of the complaint is important for his general wellbeing and ability to cope with the illness.
CASE 3

The third patient is a 29-year-old graduate who developed CFS in 1986 after glandular fever and an extremely active and stressful period of study and work. When we first saw her in 1993 she had had several periods of full-time work followed by relapses. She had a very good knowledge of research into CFS and good insight into her own circumstances. She proved very hypnotically susceptible. Although she had tried meditation she was surprised by her ability to control the sensations of fatigue after intervention. She is now working full-time with an increasingly full social life.
COMMENT

The striking point about the cases reported here is the degree of control facilitated by hypnosis over the feelings of fatigue and myalgia that characterize CFS. There is a need for a randomized controlled study on the effectiveness of hypnotic intervention in CFS, as has recently been conducted with relaxation5. Possibly, however, hypnosis will be most effective as an adjunct to other interventions, such as cognitive behaviour therapy, as it has been with other complaints10.
REFERENCES
1 Sharpe MC. A report-chronic fatigue syndrome: guidelines for research. J R Soc Med 1991;84:118-21 2 Buchwald D, Komaroff AL. Review of laboratory findings for patients with chronic fatigue syndrome. Rev Infect Dis 1991 ;13(Suppl 1): 12-18 3 Wood GC, Bentall RP, Gopfert M, Edwards RHT. A comparative psychiatric assessment of patients with chronic fatigue syndrome and muscle disease. Psychol Med 1991;21:619-28 4 Wessely S, Butler S, Chalder T, David A. The cognitive behavioural management of the post-viral fatigue syndrome. In: Jenkins J, Mowbray J, eds. Post-viral Fatigue Syndrome. Chichester: Wiley, 1991:305-34 5 Deale A, Chalder T, Marks I, Wessely S. Cognitive behaviour therapy for chronic fatigue syndrome: a randomized controlled trial. Am J Psychiatry 1997;154:408-14 6 Sarawy C, Hackman A, Hawton K, Sharpe M. Chronic fatigue syndrome: a cognitive approach. Behav Res Ther 1995;33:535-44 7 Hilgard ER, Hilgard JR. Hypnosis in the Relief of Pain. Los Altos: Kaufman, 1983 8 Morgan WP. Ergogenic Aids and Muscular Performance. New York: Academic Press, 1972 9 Sharpe M, Hawton K, Simkin S, et al. Cognitive behaviour therapy for the chronic fatigue syndrome: a randomised controlled trial. BMJ 1996;312:22-6 10 Kirsch I, Montgomery G, Sapirstein G. Hypnosis as an adjunct to cognitive behavioral psychotherapy: a meta-analysis. J Consult Clin Psychol 1995;63:214-20

to give up work. Nevertheless, he maintains that his control

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