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Psychiatry
Understanding
chronic fatigue
syndrome
Maria Frampton advises on diagnosis and
treatment of chronic fatigue syndrome
CHRONIC FATIGUE SYNDROME (CFS) is a debilitating and
complex disorder characterised by profound mental and/or
physical fatigue present for at least six months. It is not
improved by bedrest and may be worsened by physical or
mental activity. The cause or causes are unknown and there
is no specific diagnostic test.
People with CFS usually function at a lower level of activity than they were capable of before illness onset. Given that
fatigue forms part of the symptom complex of many illnesses, it is important to exclude other treatable conditions
before a diagnosis of CFS is made.
Alternative names for the disorder are: yuppie flu; myalgic
encephalomyelitis; postviral fatigue syndrome; chronic
fatigue and immune dysfunction syndrome (CFIDS).
Characteristic features
In addition to the key defining characteristics of persistent or excessive tiredness and postexertional malaise
(flu-like symptoms) lasting more than 24 hours, patients
report many non-specific symptoms. These include cognitive impairment affecting attention, concentration and
short-term memory; and sleep disturbance such as insomnia, hypersomnia or disturbed sleep/wake cycle.
Pain is persistent and may be muscular, rheumatic or neuropathic. Recurrent sore throat, gastrointestinal
disturbances such as nausea, loss of appetite, abdominal
pain/bloating, diarrhoea and constipation, intolerance of
alcohol, food, medications or ‘multiple chemical sensitivity’
may also be seen.
Neurological or endocrine symptoms such as temperature
disturbance, dizziness, increased sensitivity to sensory stimuli, blackouts, atypical convulsions and loss of speech may
occur.
Epidemiology
CFS has also been called ‘yuppie flu’ because those who
originally sought help for and generated interest in CFS in
the early 1980s were mainly well-educated women in their
30s and 40s.
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CFS affects twice as many women as men. The age of
onset in the majority of adult cases is early 20s to mid-40s
while in children it is 13-15 years, though children as young
as five years have been diagnosed. A report recently published by the British Department of Health gives prevalence
figures of 0.2%-0.4% for the general population.
Aetiology
While the cause or causes remain unknown, there is evidence for predisposing, triggering and maintaining factors
in the aetiology of CFS.
Predisposing factors include:
• Female gender
• Family: familial incidence is higher than expected
• Personality: tendency towards high standards and
perfectionism
• Previous mood disorder
• Other disorders: some patients have a history of
fibromyalgia or irritable bowel syndrome.
Triggering factors include:
• Infections: certain infections are more likely than others
to act as triggers for CFS. The prime candidates, glandular fever (Epstein Barr virus), viral meningitis and viral
hepatitis are followed by CFS in approximately 10% of
cases
• Immunisations: there have been a few case reports of post
immunisation CFS, though intercurrent infection may have
played a part
• Life events such as redundancy
• Physical injury or overtraining among sports people.
Maintaining factors include
• Sleep problems: sleep disturbance exacerbates fatigue
and other symptoms
• Mood disorders: about two-thirds of patients have comorbid anxiety and depression
• Inactivity: can result in physical deconditioning of muscles
• Overactivity: can result in worsening of symptoms
• Latrogenic illness: delay in diagnosis or failure to provide
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supportive care causes additional stress
• Beliefs about CFS: strongly held beliefs about the cause
of the illness can hinder progress, a positive attitude
towards the illness and its treatment results in the best
outcome.
Clinical evaluation
This involves:
• A thorough clinical history is essential for reaching a
diagnosis focusing on current disability as compared to
previous level of functioning.
• Sleep evaluation in order to exclude a primary sleep disorder such as sleep apnoea
• Mental health evaluation focusing on the patient’s mental
state and their psychosocial history
• A physical examination which helps exclude other physical conditions
• Basic laboratory investigations including full blood count,
biochemistry, c-reactive protein (normal is <10), thyroid
function and urinalysis.
• More specific tests for differential diagnosis including
blood markers for rheumatic disease and antibodies to
gliadin or endomysium as occur in coeliac disease.
It may be helpful to do (neuro)psychological testing to
assess the impact of the disease on the patient’s cognitive
function, eg. attention, concentration and short-term
memory. This is particularly relevant to children and
adolescents whose educational needs require attention.
While the initial assessment may be undertaken by the primary care team, confirmation of diagnosis or a second
opinion can be sought from an expert in the area – a
consultant psychiatrist, immunologist or in rehabilitative
medicine in the case of adult patients and a paediatrician
for children.
Management
There is no ‘cure’ for CFS, however most achieve some
degree of improvement with time and treatment. Each
patient should have a unique and flexible management plan
tailored to need.
The most important aspect of care is providing advice on
symptom relief, balancing rest and activity and maximising
potential. In primary care, this usually involves advice on
medication, pacing and basic lifestyle management.
The three forms of therapy for which there is some evidence of benefit in patients with CFS are:
• Graded exercise therapy
• Cognitive behaviour therapy
• Pacing.
Graded exercise therapy is a structured and supervised
programme of gradual and progressive increase in aerobic
activities.
It is based on the theory that inactivity and its consequent
physical deconditioning maintain illness and that graded,
supervised exercise can reverse this process.
Controversy over this treatment stems from the view held
by some physicians that these patients have a primary disease process that could actually progress with graded
exercise.
Cognitive behaviour therapy (CBT) is a form of psychotherapy that focuses on identifying and finding strategies
for managing current problems. It does not pursue
underlying physical and psychological causes but rather
Psychiatry
seeks to explain the aetiology and maintenance of the
condition. Through the modification of behaviour (eg. stress
levels, excess alcohol, smoking,) and belief systems, CBT
aims to empower individuals to improve their own general
well-being.
Pacing is a strategy for managing energy in order to
achieve a balance between rest and activity. The aim is to
prevent a ‘vicious cycle’ of overactivity and setbacks.
Despite a lack of evidence to suggest harmful effects,
some clinicians are of the opinion that like graded exercise
therapy, it may perpetuate the illness. Pacing however
remains very popular amongst patients.
Counselling, symptom control and complementary
approaches
Providing a supportive environment which allows the
opportunity to explore, clarify and work towards resolving
personal issues may benefit some individuals.
Further research is needed to evaluate the benefits of
counselling.
Symptoms commonly causing the greatest problems in
patients with CFS include:
• Sleep
• Mood disturbance
• Pain.
In addition to relaxation techniques, anxiety management,
massage, meditation or yoga, medication may be needed to
prevent further deterioration.
Though antidepressants don’t help CFS on its own, they
may be beneficial in the treatment of co-morbid symptoms
such as anxiety, depression or sleep disorder.
If anxiety or depression are associated with excessive
sleeping an energising antidepressant such as a selective
serotonin reuptake inhibitor (sertraline, fluoxetine or
paroxetine) may be helpful.
However, if mood disturbance is accompanied by a lack of
sleep, a sedative antidepressant (trazodone or lofepramine)
is more useful.
In the case of sleep disturbance occurring without mood
disorder, sedative antihistamines (cyproheptadine, promethazine) or low dose hypnotic antidepressants (dothiepin
25mg-50mg, amitriptyline 10mg-30mg) are beneficial in
improving slow wave (deep healing) sleep.
People with CFS tend to be very sensitive to side effects
from centrally acting drugs, and should therefore be started
on the lowest possible dose which should be gradually
increased.
All medication should be chosen with due consideration
to side-effect profile, tolerance and potential for interaction
with concomitant medications.
Prognosis
The course of CFS varies from person to person. While
most people show some degree of improvement with
treatment over time, a minority become permanently disabled. A gradual and progressive deterioration is not usual
in CFS and should always merit further investigation to
ensure no other physical illness has been missed.
Finally, education and involvement of family and friends
in the treatment plan can be vital to success.
f
Maria Frampton is consultant in old age psychiatry for
Carlow/Kilkenny
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