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“But what is CFS really? Schaffner’s view is that it’s the newest explanation for an age-old set of linked experiences that people have suffered and written about for thousands of years.”

This doesn’t count as an “explanation” to me, just a characterization. *Why* are they linked, what if anything unites the cases? A viral agent, a hormonal imbalance, a psychological cause, mere malingering? Perhaps a combination of the above, different ones for different people? Perhaps none of the above, maybe people are mistaking causally and experientially distinct phenomena for a single thing and inventing a false category?

It’s fine, even advisable, for the author of a book on the topic to remain agnostic on this question, since it seems unsettled. But that refusal to explain shouldn’t be presented as an explanation in itself. I can’t tell if this is principally the book’s or the reviewer’s failing.

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Did she work in "My Year of Rest and Relaxation" by Ottessa Moshfegh?

That's a good book.

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I don't really get what's meant to be wrong with Shorter - he just seems to be arguing that it’s a psychosomatic condition, which seems to be the likeliest explanation. What all the people with the various historical versions of this seem to have in common is that they can get away with it: monks, Oscar Wilde, people with access to disability benefits etc. A certain type of person (myself entirely included) will have an almost overwhelming bias against doing anything that involves getting out of bed; up to and including going to sleep hungry because ordering takeout is too much of a faff. This will include everyone you meet who only shaves intermittently or smells like they don't shower. We can force ourselves to get up and do things when we have to (whatever that means). Some people can get away with not doing anything, so they don't do anything. The people who cant get away with it don’t, so we don’t hear about them (Marcus Aurelius is the only historical figure in this camp who springs to mind).

The post-viral side of it obviously flows from this; when you’re off work with covid or whatever, you get to do nothing, so the temptation is always to stretch it out (I definitely kept testing positive long after I started testing negative). I doubt its a conscious fraud, but more a desire to believe there’s something medical to justify your overwhelming preference for inactivity.

(Going back to the Shorter point, I think he’s taking a way more moderate position than I am and just saying it’s psychosomatic.)

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Aug 5, 2022·edited Aug 5, 2022

The description made this book sound quite similar to Elaine Showalter's "Hystories", but that covered multiple conditions of which CFS/fibromyalgia was one.

The link for "sexism" reminded me of this recent oddity regarding monkeypox: https://twitter.com/LizHighleyman/status/1555216192582942721

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I believe the rage about graded exercise is about being prescribed the very thing that makes symptoms worse. If ordinary walking is exhausting, more walking might just lead to more exhaustion.

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Aug 5, 2022·edited Aug 5, 2022

Is it just me, or does the picture accompanying this review really not describe it so well? If, like me, you're one of the people described in the first paragraph of the review, I bet your bedroom doesn't look like something from HGTV - mine certainly doesn't.

I was hoping for some useful information for dealing with exhaustion, but no such luck.

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> This is particularly pronounced in men, for whom the loss of seminal fluid is allegedly forty times more damaging to vital energy than losing an equivalent amount of blood.

This is obviously true. Take a pint of blood from me, give me a cookie and some orange juice and I'll be good as new the next day. But take a pint of seminal fluid from me, and I'll be bedridden for a month.

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Sometimes I wonder how migraine would be treated if it created all the same symptoms *except* pain. Sporadic episodes of partial blindness, brain fog, numbness, lethargy, confusion? Occurring mainly when you’re overexerted or annoyed by stimuli? Sounds like it’s all in your head.

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Good review, I’d like to have read more about what the author was referring to with regard to “Saturn” though.

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>the initial thoughts that EBV was a robust cause of CFS, the subsequent discovery that about 95% of the population has had EBV so this explanation couldn’t be complete

Minor nitpick: there is no "has had" EBV, EBV is a lifelong infection so either you have it or don't.

Also I wouldn't rule out EBV, since it's definitely known to cause rare things like cancer (Hodgkin's lymphoma) and multiple sclerosis even though most infected people don't get them. See: https://denovo.substack.com/p/epstein-barr-virus-more-maladies

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I've read a book called Acedia, and wondered whether what was knocking people out was that the rules made life so drab that some people stopped functioning, or possibly stopped obeying the rules.

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This was wonderful, thankyou.

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Aug 5, 2022·edited Aug 5, 2022

It's interesting to me that explanations popular in previous eras are simply dismissed out of hand. That would be reasonable if we found the causative agent behind CFS and could cure it with a pill, but we haven't. We still have no idea what causes it. And so when I read this:

"Occurring as it did in monastic orders, the explanation for acedia was moral in nature – it was due to weak willpower or a moral defect. Schaffner, quoting Thomas Aquinas:

...

…which is something that might reasonably be referred to today as victim-blaming."

I wonder how we know it's *not* due to weak willpower or a moral defect at least some of the time . Yes, it's victim blaming--and sometimes, the victim is to blame. There is no logical reason to not take this explanation seriously just because it's no longer politically correct.

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For another take on this topic, I reviewed a Shorter book for the contest:

https://apsychiatryblogger.substack.com/p/from-paralysis-to-fatigue-a-history

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Aug 5, 2022·edited Aug 6, 2022

This was mercifully short compared to the competition, which was a nice change of pace. No footnotes or addenda or appendices or nothing! Only 3 chapters!

Went into the topic expecting a reference to Chronic Lyme and Long Covid; good to see those both covered. I do find it fascinating that CFS is possibly the single biggest determinant of whether Long Covid is A Thing to worry about or not[1][2] - even aside from the exhaustion knocking people out of the workforce, the potential for permanent...IQ loss? brain damage?...is pretty alarming. Whether it's ultimately psychosomatic or not, the grab bag of disabilities is no joke, the bureaucratic diagnostic process is onerous, and losing lots of QALYs for young otherwise healthy sufferers is potentially Big If True. (Although it continues to look like the supposed "9%" figure being out of work due to Long Covid just isn't showing up in aggregate statistics, and therefore suspicious, so I've been updating the other way.)

The lack of any conclusion as to "what is CFS really?" is a bit disappointing; it's certainly okay to look at all the competing theories, decide there's not-especially-distinguishable probabilities for each, and say I Don't Know. Historical intractability certainly leans in this direction. But one generally expects, going into a book like this, that there will be some author-favoured hypothesis. Even if it's totally wrong and off the wall, seeing that thought pocess of selection is useful for calibrating other parts of a book. (Or a review, for that matter.) For my money, I'd be interested to see the anthropological angle of "do pre-agricultural societies suffer exhaustion?" (since pre-industrial is already a yes).

Lastly, I thought the New Big Idea with EBV is that it's got helpful explanatory power because Infections Are Bad Actually? That is, this is one of the viruses we do know is sometimes linked with EBV, and it turns out way more people are infected than we originally supposed. So, even if any given infection is a tiny probability to progress into CFS, there are suddenly a lot more coin flips. I seem to remember reading that this was getting expanded into a new Paradigm, where rather than looking at particular pathogens of concern, generic infection and suboptimal recovery itself is the culprit. So preventing preventable diseaes and infections in general is more important than previously thought, even for things with seemingly-mild acute symptoms. (One could easily mix this with another thing off the Fad Dartboard and declare "ah, it's inflammation that causes CFS!")

[1] https://astralcodexten.substack.com/p/long-covid-much-more-than-you-wanted

[2] https://thezvi.wordpress.com/2022/02/10/the-long-long-covid-post/

EDIT: also curious whether the New Model of Stress making the rounds helps explain clinical-grade exhaustion: http://www.frontiersin.org/articles/10.3389/fpsyt.2019.00379/full

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I’m thinking of doing a book review on Oxfordians next time. But it’s better if multiple books, on the same subject, are reviewed. Anyone know if that’s possible.

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Just a note on shinkeisuijaku (神経衰弱) which you say is still diagnosed in Japan. Actually this term is rarely used in a medical context anymore; instead it is typically used to refer to the card game where you have to pick up identical pairs of cards, which are placed face down, by remembering their position. In my experience most CFS-type presentations in Japan are blamed on overwork or stress.

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Surprised the reviewer didn't mention the popular Spoon Theory. I assume that means that the author didn't, either.

Hopefully with long covid being acknowledged as a real and ubiquitous condition there will be some research and resources into figuring out where the missing spoons go.

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It has seemed obvious to me since medical school that there could be more than one distinct cause of these symptoms. Lots of patients have fever and we know not to treat all fevers as one clinical entity but with fatigue we seem to keep looking for a single cause. It is very believable that these different entities are different or that there are different patients within any one entity.

Speaking for myself I’ve had disablingly severe fatigue for 27 years but it was diagnosed simultaneously with my very unmistakable brain full of multiple sclerosis lesions. So I have what sure seems familiar to what I hear other fatigue patients go through but I never get the faintest skepticism from any provider about it. I’m lucky to have a clear diagnosis. But it’s easily possible to have far fewer lesions and far more subtle MS. Someone with nearly invisible lesions but my fatigue symptoms could easily be lumped into the chronic fatigue category and not taken seriously despite having the exact same etiology for fatigue.

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founding

I wonder ... scratch that, google is my friend. It seems like people did think to use stimulants (amphetamines, modafinil and such) with some success, albeit with risk of long term crashes. This suggests it's not a purely psychosomatic problem - if it were, you'd expect either failure or better long term response, instead of the murky, success-crash cycles google seems to suggest.

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(Banned)
Aug 6, 2022·edited Aug 6, 2022

So far this is one of the best of the reviews. (Or so I think before reading the actual book.)

But the review and the program of reviews has made me think about the process of rating reviews. Is it possible to properly rate a review without reading some or most of what is being reviewed?

But if a review is critical of a book AND a "well done review", it is unlikely that one would read the underlying tome. (And for good reason.) On the other hand a book review that leads one to pick up the book is planting seeds for its own critique.

For example, the review of Debord's The Society of the Spectacle lead me to actually read GD's work, but it made me think a bit less of review because I'm slightly doubtful how well the reviewer understood Hegel, Marx, the history of post-Marx socialist theoreticians, the situationalists and letterists, and philosophy of art, which are prerequisite to understanding and critique of GD.

Is the purpose of a good review to be a substitute for reading the text or is it something else? A synopsis that is a good starting point for careful consideration of the value of the underlying text. Should book reviews always be read in pairs or groups of reviews?

I will probably seek out "Exhaustion" . The review was a good read. But does make it a good review?

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n=1

I got this cluster of fatigue symptoms 3.5 times in my life. Twice, after getting ACL surgeries. Lasted about 5 weeks each time. It was very distinct when it ended, like a light switch got turned back on in my brain.

Then last summer I got a milder case of "blehs" that led me on a blood test wild goose hunt. I found my Vitamin D low and thyroid antibodies high. Macrodosing with Vitamin D for a couple months raised Vitamin D to supraphysiological level with no other symptoms or signs. Thyroid antibodies still aren't all the way down. Sometime last fall, the blehs faded away.

The 0.5 time was this June when I tweaked my back and was on ibuprofen and muscle relaxants over a weekend. I eventually dragged my bum to the gym and did a kettlebell workout for lower back pain. Pain didn't come back, and fatigue cleared the morning after.

Based on personal experience, I conclude that fatigue (at least in some people) is the body's natural convalescence mechanism that is failing to shut down.

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Ok, yes, but if I feel exhausted, what should I do?

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The stories I hear about CFS/ME seem to be about extremely energetic people-- high pressure job, athlete, raising a family, possibly another hobby in addition.

It is just that CFS is a strong contrast when it hits that sort of person, or is it less likely to hit people with low or average energy expenditure?

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Aug 6, 2022·edited Aug 6, 2022

I'd just like to add that this book is from 2016 and is thus missing the last 6 years of thought and research on CFS/ME. One of the greatest findings in the last 6 years is that a number of people with severe CFS/ME have their symptoms disappear following cranial traction.

For a couple startling anecdotes for anyone interested in reading more about this, check out Jen Brea's account here https://jenbrea.medium.com/cci-tethered-cord-series-e1e098b5edf and Jeff Wood's account here https://www.mechanicalbasis.org/mystory

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I didn't read the whole thing yet - but I think I did have this 'syndrome' when I was a teenager. It mostly went away - through possibly I have timing wrong\* - when I started using modafinil. Before I started earning income to purchase it through _unofficial_ channels I wanted to try it - few annoying doctor's visits later I was just told I'm lying by some neurologist (IIRC) and gave up. I hate the guild system which enables state paternalism.

\* seems unlikely because if I don't use it or other stims, I think I function much the same as I did before I started (sleepy/tired most of the time, despite adequate sleep). Unless my memory is faulty and it's just substance dependence.

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Review-of-the-review: 8/10

Writing in which disparagement of Christian intellectual history outstrips understanding of it is a pet peeve of mine, and this review's superficial treatment of "acedia something something sexual sin something something Protestant ethic" certainly qualifies. (I suspect this is mostly the reviewer's fault and not Schaffner's because Alan Jacobs cites her approvingly: https://blog.ayjay.org/exhaustion-its-causes-and-treatments/) Between that and the generally disappointing level of engagement and critique in this review, I don't expect to vote for it. On the other hand, it's well written (except for the last sentence), covers an interesting and relevant topic informatively, and does a great job of communicating the book's overall argument concisely. It made me want to actually read the book to understand the topic better, which is how an effective review of a good book should work. As always, many thanks for contributing!

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There are some comments accusing historical monks of malingering, being able to “get away with fatigue”, and this is so magnificently incorrect that I had to make an account to comment. (If you don’t know what life was like for a member of a monastic order, you really shouldn’t produce such terrible opinions, which is a true intellectual version of malingering.)

A medieval monk existed in a culture that prioritized obligation to the order over everything. It took on spiritual importance, literally: everything that a medieval religious person valued was associated with God, and failure to adequately worship God would be the most punishing and shameful thing imaginable, something that could lead eternal damnation, virtual eternal suffering. In other words, all psychological and spiritual value would be motivating the monk to continue his duties. It’s hard for us moderns to grasp how significant religion was to a medieval person, but failing to meet one’s religious duties would be worse than an immigrant student disappointing his parents’ wishes to become a doctor, while also disappointing all of his teachers, while also disappointing most celebrities and his favorite musicians, while also disappointing the producer of all of your favorite art and media (the church).

But not only is the monk maximally motivated to fulfill his obligations in a psychological and emotional sense. He was also maximally motivated because he would face social punishment and physical punishment if he failed. He would be disappointing virtually everyone that he interacted with (his brethren). He would be criticized by his order’s leadership. Last but not least, the monk would face punishments that are no longer found in the modern era: long daily fasts, long painful hours kneeling in prayer, and corporal punishment which may include self-flagellation or the wearing of rough painful hairshirts and “bracelets” that stabbed the thighs.

So to sum up, a monk is not someone who can “get away” with malingering. This betrays profound ignorance of history. A monk is someone who existed within one of the most sensitive contexts of reward and punishment in history. The fact that monks suffered from this means we ought to exclude malingering entirely from the options.

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What the victims had in common was intense intellectual work. Lots of abstract creative and wordy work. The cures invariably reduced the amount of intellectual labor, both the “Rest” and the “West” cures. True deep creative work is costly. We’re not talking about “reading a passage and replying with the answer”, which is schoolwork and non-intellectual. We’re talking about creative insight which relies on stressing the mind to produce new answers, something very different than the rote response of normal reading/writing.

The masturbation passages are interesting. Insofar as intercourse is a motivator in human behavior, masturbation would reduce motivation and thus perceived energy. This is obvious. But the overemphasis on masturbation was likely (1) moralistic and (2) confusion over cause/correlation. Many mentally I’ll men compulsively masturbate and this may have lead doctors to believe masturbation was the cause. These combined likely explain the emphasis on masturbation in some of the 18th century literature. Frequent sex is not a social “demotivator” because it requires pro-social actions for coitus with a woman to occur. Even going to a prostitute requires much more physical effort than masturbation.

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One more comment: low dose naltrexone, an opioid *ant*agonist has recently been used with some success in treating CFS. This implicates pain sensitivity in CFS, as naltrexone induces the body to upregulate opioid receptors. This calls back to historical views on intellectual activity and “sensitivity”: for most of European history it was believed intellectual activity required a sensitivity to pain (and all stimuli). This is where “nervous” diseases come from, the belief that the nerves were particularly sensitive. If CFS is indeed linked to a long-developed hyper-sensitivity to pain and stimuli (likely), it does sort of justify the old view on neurasthenia as sensitive nerves.

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Scott, are you sure these reviews are written by other people? :D

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