For Medical Practitioners:

(Particulary British/European Doctors)

UPDATE ON THE DIAGNOSIS AND TREATMENT OF CHRONIC FATIGUE

Chronic fatigue is a ubiquitous symptom, affecting an estimated 10-15% of the general population. In most cases, routine tests are sufficient to identify the cause. However, unexplained chronic fatigue appears to be an increasing problem, and it has been estimated that 2-3% currently meet the British criteria for chronic fatigue syndrome (CFS)*.

According to the latest research, it is neither valid nor helpful to regard CFS as a single entity. Indeed, CFS has been linked to a number of conditions, including psychiatric and personality disorders (nb. symptoms generally not exacerbated by minimal exertion), chronic stress (particularly at work), primary sleep disorders (symptoms are worse a.m.), subclinical hypothyroidism, adrenal dysfunction (low cortisol), food sensitivities (symptoms better before breakfast and after long gap between meals), nutritional deficiencies (e.g. vitamins D and B₁₂), neurally mediated hypotension and post-viral syndromes. Some patients develop several of the above over time. The illness known as myalgic encephalomyelitis (ME) may be regarded as a comparatively rare subgroup of CFS**. In a sense, ME is to CFS what migraines are to headaches. It is characterised by:

1. muscle fatigability after trivial exertion which takes longer than normal to resolve;

2. CNS involvement (look for unsteadiness, blurred vision, fine tremors, cognitive dysfunction, emotional lability) and impaired circulation (e.g. ask relatives about facial pallor, cold extremities).

Over 90% of these patients develop intolerance to alcohol and many report a flu-like malaise. NB. ME is a fluctuating condition, thus differentiating it from CFS due to sleep disorders, 'burn-out' etc. Onset tends to follow 'summer bugs' rather than winter ones.

Post-influenza debility is both less severe and less chronic.

Treatment depends on the type of fatigue syndrome. Nutritional and hormonal deficiencies should be checked for and corrected. There is a small subgroup of patients with fatigue (max. 24% of the total), who spent long periods in bed without signs of improvement. They avoid activity out of fear, and may have unrealistic or inaccurate beliefs, e.g. that they have an illness for which the treatment (in their view) is "total rest", or that a little exertion will do permanent harm. In these cases, CBT plus graded exercise is the treatment of choice. It should be noted however, that all recent trials of graded exercise have included some type of heart monitoring, to improve efficacy and avoid relapse.

Most cases of ME and post-viral fatigue require a different approach. Lifestyle changes are important, e.g. advice on pacing, gentle exercise as tolerated, a sound diet (low sugar, low fat, no alcohol, check for sensitivity to wheat/gluten), and assess for appropriate aids. Supplements e.g. anti-oxidants are recommended by some specialists. Low dose antidepressants (e.g. amitryptiline, dothiepin) may help with pain, sleep disturbance and 'brain fog'. Supportive counselling is also useful, and can prevent secondary depression and adjustment disorder. Flu vaccinations may lead to relapse. Finally, patients should be monitored for complications e.g. osteoporosis, heart disease, low cortisol levels (result of chronic stress?) and sensitivities to foods and drugs. However, be cautious about attributing all new symptoms to ME.

The majority of patients who are treated in this way should show some improvements within 6 months and 70-80% of acute onset, post-infectious cases will feel significantly better within two years. What will not help this subgroup is a dismissive attitude, or confusing them with the misguided minority holding maladaptive beliefs.

For more detailed medical information, see the Guidelines for the Care of Patients, by Dr. Charles Shepherd. This can be obtained, free of charge, from the ME Association, 4 Corringham Rd., Stanford-le-Hope, Essex, SS17 OAH.

The latest and most accurate book for patients is Living with ME by Dr. C. Shepherd (Vermilion 1999).

Up-to-date medical information on CFS can be found on:
http://freespace.virgin.net/david.axford/me/me.htm

Compiled by Dr. Ellen Goudsmit. Editor, ME Medical Update. Available from the British Library and online.

January 2000

Notes:

* It is now generally acknowledged that the name CFS is too misleading (e.g. because it covers a number of aetiologically disparate conditions). The American government's CFS co-ordinating committee and CDC is currently considering an alternative term.

** ME and post-viral fatigue were recognised by the WHO in 1992 and are listed in ICD-10 under 'Diseases of the Nervous System'.

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