“Chronic fatigue syndrome” (Sharpe et al, 1991) is an operational definition for conditions of disabling physical fatigue, of over six months duration, unexplained by primary physical or psychiatric causes. It encompasses nomenclature such as “myalgic encephalomyelitis” (Acheson, 1959), “post-viral fatigue syndrome” (Behan et al, 1985) and “chronic mononucleosis syndrome” (Straus, 1988).

It is hard to disagree with the principles of the care programme approach (SPCR, 1993; Kingdon, 1994) but it has been much harder to agree how to put them into practice. What should be ‘just good practice’ becomes more complex the more it is discussed by clinical teams.

The first electroconvulsive treatment was administered by Cerletti and Bini in 1938. The event was essentially an experiment, carried out like a military operation (Endler, 1988). The patient was stimulated three times, each time increasing the intensity of the stimulus before a generalised seizure was induced. He had been suffering from an acute psychosis with a poor prognosis, but responded to a course of 11 treatments and was discharged free of symptoms two months later. The first paper on electroconvulsive therapy (ECT) in English was published in the Lancet (Kalinowski) in 1939. At that time, somatic treatment alternatives for the severely ill in large mental institutions included lobotomy and insulin coma therapy. In comparison, unmodified ECT (albeit associated with a significant risk of serious physical morbidity) was predictable, efficient, quick and effective. It is understandable why the treatment became widely and fairly indiscriminately adopted before systematic objective evidence of its efficacy was collected.

Anxiety pervades every aspect of human activity and experience. It is a normal state and a spur to action, but readily exceeds normal limits in intensity, duration and appropriateness to the stimulus or situation. Anxiety is manifest by the mood of fearfulness, behaviour marked by restlessness and avoidance of situations, increased arousal with insomnia, excessive preoccupation with thoughts on the theme of insecurity, and a wide range of somatic symptoms which are based on muscular tension, hyperventilation leading to paraesthesiae and faintness, and symptoms based on overactivity of the autonomic nervous system. Excessive anxiety and situational avoidance leads to diminution of performance and limitation of endeavour. In the context of physical illness, anxiety increases the distress of symptoms, may confuse diagnostic procedure, prolong recovery time from acute illness, cause failure to comply with effective treatment and promote destructive habits such as reliance on alcohol or excessive use of sedative drugs.