Chronic fatigue syndrome: study of the clinical course of 28 cases

Abstract:

BACKGROUND: Chronic fatigue syndrome (CFS) is an entity of unknown etiopathogenesis without specific markers. The diagnosis is based on clinical criteria. There are few studies evaluating the natural evolution and prognosis-related factors in CFS.

OBJECTIVES: a) to evaluate the outcome of patients suffering from CFS, and b) to detect predictive factors associated with a better prognosis.

MATERIAL AND METHODS: Clinical records of all patients diagnosed of CFS between January 1986 and December 1992 were retrospectively reviewed. Of these patients, we included those fulfilling the CDC criteria for CFS, with a follow-up period greater than one year. We evaluated epidemiological, clinical and evolutive data recorded by their usual physicians. Moreover, the patients were interviewed in order to know their own appreciation with respect to their current clinical status, as well as their present working situation.

RESULTS: Twenty-eight patients were included in the present study. Their mean age was 38 +/- 7. Seventy-five percent of them were women. The mean time of clinical follow-up was of 3.2 +/- 1.8 years. According to evaluation, 21% of patients improved or became asymptomatic. A similar percentage (28%) of improvement was obtained from the interview. Forty-eight percent of cases had transitory or definitive laboral incapacity. Regarding to prognostic factors, we could not find any statistical differences among the analyzed variables except for marital status. In this variable, married patients had better outcome than unmarried patients.

CONCLUSION: CFS is an entity with a poor outcome, since it evolves towards to chronicity in an important number of cases. In addition, strong functional disability may be present, leading frequently to laboral incapacity.

Comment in: Chronic fatigue syndrome. To be or not to be? [Med Clin (Barc). 1997]

 

Source: Miró O, Font C, Fernández-Solà J, Casademont J, Pedrol E, Grau JM, Urbano-Márquez A. Chronic fatigue syndrome: study of the clinical course of 28 cases. Med Clin (Barc). 1997 Apr 19;108(15):561-5. [Article in Spanish] http://www.ncbi.nlm.nih.gov/pubmed/9395421

 

Definition of “chronic fatigue syndrome” (CFS)

Abstract:

The definition of “Chronic Fatigue Syndrome” (CFS) in 1988 was an attempt to establish a uniform basis for the previously heterogeneous approaches to research of this severe and inexplicable state of fatigue. At the same time, researchers wished to narrow down a pathogenetically founded disease entity a priori by specifying precise disease criteria.

The empirical data gathered in accordance with the CFS definition, however, have failed to confirm the assumption that the disease entity is pathogenetically uniform. Furthermore, the originally selected criteria have proven to be impracticable ore theoretically questionable. In the period that followed, modifications that permitted a more comprehensive and yet more differentiated classification of fatigue states of unclear etiology were proposed.

The new research approach avoids postulation of causal entities and puts CFS back in a category with other descriptive states of fatigue.

 

Source: Heyll U, Wachauf P, Senger V, Diewitz M. Definition of “chronic fatigue syndrome” (CFS). Med Klin (Munich). 1997 Apr 15;92(4):221-7. [Article in German] http://www.ncbi.nlm.nih.gov/pubmed/9221305

 

Epidemic neuromyasthenia and chronic fatigue syndrome in west Otago, New Zealand. A 10-year follow-up

Abstract:

BACKGROUND: In 1984, an outbreak of an illness characterized by prolonged unexplained fatigue was reported in West Otago, New Zealand. This outbreak resembled other reported outbreaks of epidemic neuromyasthenia in that affected individuals presented with a spectrum of complaints ranging from transient diarrhea and upper respiratory disorders to chronic fatigue syndrome (CFS).

OBJECTIVE: To obtain a perspective on the natural history of CFS not possible in clinic-based studies.

METHODS: Twenty-three of the 28 patients in the original report were contacted and asked to complete written questionnaires. Interviews were obtained in person or via telephone.

RESULTS: Ten (48%) of the 21 patients with satisfactory interviews appeared to meet the current Centers for Disease Control and Prevention (CDC) case definition of CFS, and 11 were classified as having prolonged or idiopathic fatigue. A return to premorbid activity was seen in most (n = 16 patients, although some reported the need to modify their lifestyle to prevent relapses. A female predominance was noted in those meeting the CDC case definition for CFS, whereas males predominated in patients diagnosed as having prolonged or idiopathic fatigue.

CONCLUSIONS: The high proportion of patients recovering from CFS in the West Otago cluster suggests that epidemic-associated CFS has a better prognosis than sporadic cases. Female sex was confirmed as an important risk factor for CFS.

 

Source: Levine PH, Snow PG, Ranum BA, Paul C, Holmes MJ. Epidemic neuromyasthenia and chronic fatigue syndrome in west Otago, New Zealand. A 10-year follow-up. Arch Intern Med. 1997 Apr 14;157(7):750-4. http://www.ncbi.nlm.nih.gov/pubmed/9125006

 

Does the chronic fatigue syndrome involve the autonomic nervous system?

Abstract:

PURPOSE: To investigate the role of the autonomic nervous system in the symptoms of patients with chronic fatigue syndrome (CFS) and delineate the pathogenesis of the orthostatic Intolerance and predisposition to neurally mediated syncope reported in this patient group.

PATIENTS AND METHODS: Twenty-three CFS patients and controls performed a battery of autonomic function tests. The CFS patients completed questionnaires pertaining to autonomic and CFS symptoms, their level of physical activity, and premorbid and coexisting psychiatric disorders. The relationship between autonomic test results, cardiovascular deconditioning, and psychiatric disorders was examined with multivariate statistics and the evidence that autonomic changes seen in CFS might be secondary to a postviral, idiopathic autonomic neuropathy was explored.

RESULTS: The CFS subjects had a significant increase in baseline (P < 0.01) and maximum heart rate (HR) on standing and tilting (both P < 0.0001). Tests of parasympathetic nervous system function (the expiratory inspiratory ratio, P < 0.005; maximum minus minimum HR difference, P < 0.05), were significantly less in the CFS group as were measures of sympathetic nervous system function (systolic blood pressure decrease with tilting, P < 0.01; diastolic blood pressure decrease with tilting, P < 0.05; and the systolic blood pressure decrease during phase II of a Valsalva maneuver, P < 0.05). Twenty-five percent of CFS subjects had a positive tilt table test. The physical activity index was a significant predictor of autonomic test results (resting, sitting, standing, and tilted HR, P < 0.05 to P < 0.009); and the blood pressure decrease in phase II of the Valvalsa maneuver, P < 0.05) whereas premorbid and coexistent psychiatric conditions were not. The onset of autonomic symptoms occurred within 4 weeks of a viral infection in 46% of patients-a temporal pattern that is consistent with a postviral, idiopathic autonomic neuropathy.

CONCLUSION: Patients with CFS show alterations in measures of sympathetic and parasympathetic nervous system function. These results, which provide the physiological basis for the orthostatic intolerance and other symptoms of autonomic function in this patient group, may be explained by cardiovascular deconditioning, a postviral idiopathic autonomic neuropathy, or both.

 

Source: Freeman R, Komaroff AL. Does the chronic fatigue syndrome involve the autonomic nervous system? Am J Med. 1997 Apr;102(4):357-64. http://www.ncbi.nlm.nih.gov/pubmed/9217617

 

A view of the violence contained in chronic fatigue syndrome

Abstract:

In this paper I ask whether there might be any one particular psychopathology likely to be linked specifically with the physical illness known as chronic fatigue syndrome (CFS) or myalgic encephalomyelitis (ME), and whether CFS/ME aids and abets and “fits’ an original mental state. I think the question cannot yet be answered.

However it is my hypothesis that in some personality structures the onset of CFS/ ME following a physical illness exacerbates negativity and is an aspect of ordinary depression where there is a lowering of energy levels and a loss of zest for life, or it may reveal the pathological aspect of unresolved rage. Depending on the degree of pathological disturbance, working with and through the rage may or may not result in a resolution of the symptoms of ME.

In this paper I consider some of the problems in the transference and countertransference relationship, which make it extremely difficult to separate out reality from phantasy. There is then the further problem of the denial of the psyche by the patient as part of the violence inherent in the illness. One case is presented, an example of ME in a borderline male patient in whom resolution could not be achieved.

 

Source: Bennett A. A view of the violence contained in chronic fatigue syndrome. J Anal Psychol. 1997 Apr;42(2):237-51. http://www.ncbi.nlm.nih.gov/pubmed/9161123

 

Coniunctio–in bodily and psychic modes: dissociation, devitalization and integration in a case of chronic fatigue syndrome

Abstract:

Three years of analytical psychotherapy with a professional woman in mid-life, suffering from chronic fatigue syndrome (CFS), is described. Gradual recovery merged into mid-life changes; marriage, along with a new balance of maternal and paternal imagos, enabled her to trust enough to become pregnant-coniunctio in the most primal bodily and psychic modes. Her life-long, schizoid type pattern, “the pendulum of closeness and isolation’, with its extreme of psycho-physical collapse and devitalization, was replayed in therapy.

The analyst’s symbolic attitude is emphasized, containing the patient’s initial affective explosion and validating the physicality of her condition. Mirroring and steady rhythmic attunement became a new, pre-verbal, source of trust-vitalization; differentiation and separation replaced defensive splitting and dissociation. Then the overwhelmingly powerful bodily/maternal could be counterbalanced by the masculine, and a transitional space emerged for symbolic work. Both the regressive and the dynamic aspects of CFS are located in the earliest undifferentiated, archetypal, bodily/psychic modes, when the frustration of primary needs evokes the defences of the self.

It is argued that our psychodynamic understanding can contribute to the stalemate in seeing chronic fatigue syndrome as either an organic illness or depression, and that a new linking of the somatic and psychic calls for a new professional collaboration.

 

Source: Holland P. Coniunctio–in bodily and psychic modes: dissociation, devitalization and integration in a case of chronic fatigue syndrome. J Anal Psychol. 1997 Apr;42(2):217-36. http://www.ncbi.nlm.nih.gov/pubmed/9161122

A body with chronic fatigue syndrome as a battleground for the fight to separate from the mother

Abstract:

I describe the therapy of a 20-year-old women who believed that her difficulties in concentrating and remembering were caused by her “ME’ (Myalgic encephalomyelitis, Chronic fatigue syndrome, or CFS). She had been fathered by a man who never left his own wife. Work with her dreams revealed a within-body drama in which she was locked in an unspeakable fight to the death with her mother. Her symptoms improved after parallels between a dream and an accident showed her own self-destructive hand in her story.

Another dream, reflecting her first ‘incestuous’ affair, showed her search for her original father-self as someone separate from mother, and a later affair provided a between-body drama, helping her to own the arrogant and abject traits she had before seen only as her mother’s. I show how we worked in the area of Winnicott’s first ‘primitive agony’ as experienced by a somatizing patient, stuck in a too-close destructive relationship with her mother-body. I discuss how analytical work can be done with the primitive affects and conflicts against which the ME symptoms may be defending.

 

Source: Simpson M. A body with chronic fatigue syndrome as a battleground for the fight to separate from the mother. J Anal Psychol. 1997 Apr;42(2):201-16. http://www.ncbi.nlm.nih.gov/pubmed/9161121

 

Chronic fatigue syndrome/myalgic encephalomyelitis as a twentieth-century disease: analytic challenges

Abstract:

The challenges of chronic fatigue syndrome (often called myalgic encephalomyelitis, especially in the UK) (CFS/ME) to analytical and medical approaches are connected with our inability to understand its distressing somatic symptoms in terms of a single identifiable and understandable disease entity. The evidence for the roles of viral aetiologies remains inconclusive, as does our understanding of the involvement of the immune system.

The history and social context of CFS/ME, and its relation to neurasthenia and psychasthenia are sketched. A symbolic attitude to the condition may need to be rooted in an awareness of psychoid levels of operation, and the expression and spread of CFS/ME may sometimes be aided by the ravages of projective identification. Psychic denial, sometimes violent, in sufferers (especially children and adolescents) and their families may be important in the aetiology of CFS/ME. We draw out common threads from psychodynamic work with five cases, four showing some symptomatic improvement, analytic discussions of three cases being presented elsewhere in this issue of JAP.

 

Source: Simpson M, Bennett A, Holland P. Chronic fatigue syndrome/myalgic encephalomyelitis as a twentieth-century disease: analytic challenges. J Anal Psychol. 1997 Apr;42(2):191-9. http://www.ncbi.nlm.nih.gov/pubmed/9161120

 

Physical fatigability and exercise capacity in chronic fatigue syndrome: association with disability, somatization and psychopathology

Abstract:

Physical fatigability and avoidance of physically demanding tasks in chronic fatigue syndrome (CFS) were assessed by the achievement or nonachievement of 85% of age-predicted maximal heart rate (target heart rate, THR) during incremental exercise. The association with functional status impairment, somatization, and psychopathology was examined.

A statistically significant association was demonstrated between this physical fatigability variable and impairment, and a trend was found for an association with somatization. No association was demonstrated with psychopathology. These results are in accordance with the cognitive-behavioral model of CFS, suggesting a major contribution of avoidance behavior to functional status impairment; however, neither anxiety nor depression seem to be involved in the avoidance behavior.

Aerobic work capacity was compared between CFS and healthy controls achieving THR. Physical deconditioning with early involvement of anaerobic metabolism was demonstrated in this CFS subgroup.

Half of the CFS patients who did not achieve THR did not reach the anaerobic threshold. This finding argues against an association in CFS between avoidance of physically demanding tasks and early anaerobic metabolism during effort.

 

Source: Fischler B, Dendale P, Michiels V, Cluydts R, Kaufman L, De Meirleir K. Physical fatigability and exercise capacity in chronic fatigue syndrome: association with disability, somatization and psychopathology. J Psychosom Res. 1997 Apr;42(4):369-78. http://www.ncbi.nlm.nih.gov/pubmed/9160276

 

Chronic fatigue syndrome–aetiological aspects

Abstract:

The chronic fatigue syndrome (CFS) has been intensively studied over the last 40 years, but no conclusions have yet been agreed as to its cause. Most cases nowadays are sporadic. In the established chronic condition there are no consistently abnormal physical signs or abnormalities on laboratory investigation.

Many physicians remain convinced that the symptoms are psychological rather than physical in origin. This view is reinforced by the emotional way in which many patients present themselves. The overlap of symptoms between CFS and depression remains a source of confusion and difficulty. But even if all CFS patients were rediagnosed as depressives, this would not negate the possibility of an underlying organic cause for the condition, in view of the growing evidence that depression itself has a physical cause and responds best to physical treatments.

There is some evidence both for active viral infection and for an immunological disorder in the CFS. Many observations suggest that the syndrome could derive from residual damage to the reticular activating system (RAS) of the upper brain stem and/or to its cortical projections. Such damage could be produced by a previous viral infection, leaving functional defects unaccompanied by any gross histological changes.

In animal experiments activation of the RAS can change sleep state and activate or stimulate cortical functions. RAS lesions can produce somnolence and apathy. Studies by modern imaging techniques have not been entirely consistent, but many magnetic resonance imaging (MRI) studies already suggest that small discrete patchy brain stem and subcortical lesions can often be seen in CFS.

Regional blood flow studies by single photon-emission computerized tomography (SPECT) have been more consistent. They have revealed blood flow reductions in many regions, especially in the hind brain. Similar lesions have been reported after poliomyelitis and in multiple sclerosis–in both of which conditions chronic fatigue is characteristically present. In the well-known post-polio fatigue syndrome, lesions predominate in the RAS of the brain stem. If similar underlying lesions in the RAS can eventually be identified in CFS, the therapeutic target for CFS would be better defined than it is at present. A number of logical approaches to treatment can already be envisaged.

Comment in:

Chronic fatigue syndrome. [Eur J Clin Invest. 1997]

Similarity of symptoms in chronic fatigue syndrome and Addison’s disease. [Eur J Clin Invest. 1997]

 

Source: Dickinson CJ. Chronic fatigue syndrome–aetiological aspects. Eur J Clin Invest. 1997 Apr;27(4):257-67. http://www.ncbi.nlm.nih.gov/pubmed/9134372