chronic fatigue syndrome

Psychiatric asPects of general medicine

Chronic fatigue syndromemichael sharpe

Abstractfatigue is a common symptom. When it is chronic, disabling and unex-

plained by another condition, a diagnosis of chronic fatigue syndrome

(cfs) may be appropriate. there is no known simple cause for cfs, but

there is evidence for multiple contributing factors. illness perpetuating

factors include inactivity, a fear of making oneself worse and belief that

the illness is permanent, and depression. management should be directed

to the perpetuating factors relevant to the particular patient. much can be

achieved by education and gentle encouragement back to normal activity.

if specialist management is required, graded exercise therapy (get) or

cognitive–behavioural therapy (cBt) are of proven value.

Keywords cognitive–behavioural therapy; exercise; fatigue; medically

unexplained symptoms

Chronic fatigue syndrome (CFS) is a syndrome with a core symp-tom of fatigue.1

Fatigue – this is a poorly defined feeling that may be described as ‘lack of energy’,’ tiredness’ or ‘exhaustion’.

CFS – as the symptom of fatigue is common2 a specified sever-ity and duration is required to define a case. The International Research Case Definition requires fatigue to be disabling, of at least 6 months duration accompanied by at least four of the following3,4: • subjective memory impairment • sore throat • tender lymph nodes • muscle pain • joint pain • headache • unrefreshing sleep • post-exertional malaise lasting >24 hours.CFS shares symptoms, aetiological factors and treatment response with other so-called ‘functional somatic syndromes’ include fibromyalgia and irritable bowel syndrome.5 Myalgic encephalomyelitis (or myalgic encephalopathy; ME) is another name for CFS (as in CFS/ME), but some regard it as a distinct condition.6

Michael Sharpe MA MD FRCP FRCPsych is Professor of Psychological

Medicine at the University of Edinburgh, Scotland, UK. Competing

interests: none declared.

medicine 36:9 45

Epidemiology

The population prevalence of CFS as defined above is less than 1% and it is much more common in women.7

Aetiology

There is no known simple cause for CFS, but there is evidence for multiple contributing factors (biological, psychological and social).8,9 These factors are usefully divided into predisposing, precipitating and perpetuating (Table 1).

Diagnosis

Medical diagnoses associated with fatigue (Table 2) – whilst it is important to seek evidence of underlying medical conditions, these are found in only a minority of those patients who present with predominant fatigue.

Psychiatric diagnoses associated with fatigue (Table 2) – fatigue is a symptom of many psychiatric disorders, particularly depression and anxiety and these are the main differential diag-noses. Psychiatric diagnoses equivalent to CFS are neurasthe-nia (ICD-10; persistent and distressing complaints of increased fatigue after mental effort or bodily weakness and exhaustion after minimal effort) and somatoform disorder (DSM-IV; where no cause is found for the patient’s physical symptoms).

The nature of the fatigue is an important clue to diagnosis. • Loss of interest and enjoyment (anhedonia) suggests depression. • Episodic fatigue associated with rapid onset of multiple symp-toms and anxiety suggests panic. • Prominent sleepiness, such that the patient repeatedly falls asleep during the day, suggests a sleep disorder such as obstruc-tive sleep apnoea (obese middle-aged men who snore) or, rarely, narcolepsy (younger patients who also suffer cataplexy).

History – the history should cover: • symptoms of medical conditions commonly associated with

fatigue • symptoms of depression, anxiety and sleep disorders • the patients’ understanding and coping behaviour • social stresses and obstacles to recovery.

Examination – both a physical and a mental state exami-nation must be performed. Basic investigations are required (including full blood count, erythrocyte sedimentation rate,

• cognitive–behavioural therapy, incorporating a rehabilitative

approach, and graded exercise therapy have both been shown

to be effective in chronic fatigue syndrome (cfs) and have

been recommended by nice

• there is some evidence of a genetic vulnerability to cfs but

no specific genes have been identified

• there is increasing evidence that a key abnormality in cfs is

heightened awareness of fatigue and other symptoms

What’s new?

2 © 2008 elsevier ltd. all rights reserved.


factors to consider in a formulation of chronic fatigue syndrome

Predisposing cause Precipitating cause Perpetuating cause

Biological Biological vulnerability (including

genetic factors)

acute disease (e.g. epstein-Barr

infection)

Pathophysiology (mainly neuroendocrine)

excessive inactivity (or oscillation between

activity and inactivity)

sleep disorder

Psychological Vulnerable personality (perhaps

including perfectionism)

stress (especially work stress) depression and anxiety

Unhelpful beliefs (such as ‘activity is harmful’)

avoidance of activity

heightened perception of fatigue and other

symptoms

social lack of social support life events (such as bereavement) reinforcement of unhelpful beliefs (e.g. by

misleading information)

chronic social or work stress

Table 1

c-reactive protein, creatinine phosphokinase, urea and electro-lytes and thyroid function) (see also pages 393–398). Immunolog-ical and virological tests are rarely helpful. Other investigations (e.g. sleep studies) are undertaken only when indicated.

Formulation – a formulation that identifies predisposing, pre-cipitating and perpetuating factors (based on that in Table 1) is valuable for providing an explanation to the patient and for plan-ning management.

Management

Management can usually be achieved in primary care or as an outpatient. Admission is occasionally required for very disabled patients. The patient may need to be seen on a number of occa-sions to cover the essential steps outlined below.10

Explanation and education – ensure it is clear that you accept the reality of the patient’s symptoms and that you do not think they are imagined or ‘all in the mind’ Then to agree the formula-tion and management plan to address the identified perpetuating

Differential diagnoses

general anaemia, chronic infection, autoimmune

disease, cancer

endocrine disease diabetes mellitus, hypothyroidism,

hypoadrenalism

sleep disorders obstructive sleep apnoea and other sleep

disorders

neuromuscular myositis, multiple sclerosis

gastrointestinal liver disease, coeliac disease

cardiovascular chronic heart disease

respiratory chronic lung disease

Psychiatric depression, anxiety and panic, eating

disorders, somatoform disorders

Table 2

medicine 36:9 45

factors (recommending an appropriate self-help book may save time).11

Managing sleep, activity, and avoidance – stabilizing activity and normalizing sleep is important and is often called ‘pacing’. Once this is achieved, carefully graded increases in activity can be suggested (not simply a request to exercise more).

Depression and anxiety – a trial of an antidepressant drug is worthwhile in patients with symptoms of depression. it is useful to begin with a small dose.

Managing occupational and social stresses – a problem- solving approach to managing work demands, achieving return to work or planning an alternative career may be required.

Specialist managementRehabilitation based on behavioural principles is recommended by the National Institute of Health and Clinical Excellence (NICE)12: • Graded exercise therapy (GET) is a structured progressive activity programme usually administered by a physiotherapist.13

• Cognitive–behavioural therapy (CBT) for CFS includes both graded increases in activity and discussion of the patient’s ill-ness beliefs and concerns. It is usually given by a psychologist or nurse therapist.14

Prognosis

The prognosis of untreated CFS is poor; only 10% of patients recover over 2–4 years.15 However about two-thirds improve with CBT and graded-exercise therapy. Poor pre-morbid func-tioning or a strong belief that activity is harmful predict a poor response to treatment. Much can be done to help patients with CFS but it is important to accept that some patients will remain ill despite your efforts. ◆

REfEREnCES

1 Wessely s, hotopf mh, sharpe m. chronic fatigue and its

syndromes. oxford: oxford University Press, 1998.



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Practice points

• ensure it is clear to the patient that you are taking their

symptoms seriously

• look carefully for other diagnoses, especially depression and

anxiety disorders

• Work with the patient to create a formulation based on their

history

• agree a management plan to address the identified illness-

perpetuating factors

• consider referral for graded exercise therapy or cognitive

behaviour therapy

• accept that some patients will remain ill despite your best

efforts


chronic fatigue syndrome

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