Don’t worry about the label. Diagnose underlying perpetuating factors in chronic fatigue syndrome

When patients walk through your door and declare they have “chronic fatigue syndrome” (CFS), they could well be chronically fatigued and need your help, but it is unlikely they fit the National Institute of Health’s (NIH) criteria for CFS, according to Dr Derrick Thompson, a Clinical Associate Professor in the University of Calgary’s Department of Medicine.

“Most patients with complaints of chronic fatigue don’t have CFS, but rather one or often a combination of overlapping sleep disorders, soft tissue pains, allergies, or autonomic nervous system disruptions, such as labile blood pressure, panic attacks, and irritable bowel,” he says.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2146574/pdf/canfamphys00088-0180.pdf

 

Source: Kermode-Scott B. Don’t worry about the label. Diagnose underlying perpetuating factors in chronic fatigue syndrome. Can Fam Physician. 1995 Jun;41:1126-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2146574/pdf/canfamphys00088-0180.pdf (Full article)

 

A clinical study of chronic fatigue syndrome

Abstract:

BACKGROUND: This study examines the hypothesis that more recently ill patients with chronic fatigue syndrome (CFS) might have different characteristics from more chronic patients in tertiary referral centres.

METHOD: Sixty-four patients who fulfilled strict diagnostic criteria for CFS had detailed medical, viral, immunological and psychiatric assessment. Patients were advised to remain within their energy limits. Patient and doctor monitored progress using a scoring system.

RESULTS: Using the Schedule for Affective Disorders and Schizophrenia, patients were placed into four groups: group A (no psychiatric disorder, 35 patients), group B (psychiatric disorder before onset of CFS, 7 patients), group C (coincident psychiatric disorder and CFS, 11 patients), and group D (psychiatric disorder after onset of CFS, 11 patients). There were no viral or immunological differences between the groups. Patients in groups B, C and D had more severe illness than those in group A (P < 0.05), but patients in group A had more muscle pain (P < 0.05) than patients in group C. Counselling resulted in 52 patients becoming better; nine remained the same and three became worse.

CONCLUSIONS: A lower incidence of psychiatric disorder may characterise patients who are more recently ill, as may the type of associated emotional disorder and better outcome.

Comment in: Chronic fatigue syndrome. [Br J Psychiatry. 1995]

 

Source: Shanks MF, Ho-Yen DO. A clinical study of chronic fatigue syndrome. Br J Psychiatry. 1995 Jun;166(6):798-801. http://www.ncbi.nlm.nih.gov/pubmed/7663831

 

Chronic fatigue syndrome in the community. Prevalence and associations

Abstract:

BACKGROUND: Chronic fatigue syndrome (CFS) is a poorly understood condition, apparently related to both psychiatric disturbance and infectious illness. Little progress has been made in identifying aetiology, owing to a lack of epidemiological studies using case-definition criteria.

METHOD: A community postal survey of a random sample of over 1000 patients registered at a local health centre comprised a fatigue questionnaire and the 12-item General Health Questionnaire (GHQ).

RESULTS: Total fatigue scores were modestly higher in women than men. Fatigue was most frequently attributed to psychosocial factors. Fatigue and GHQ scores were strongly correlated. Two men and two women satisfied British criteria for CFS, a prevalence of 0.56% (95% Cl 0.16-1.47%); three were probable psychiatric cases.

CONCLUSIONS: Previously reported sociodemographic associations of CFS may reflect medical referral patterns. A strong association exists with psychological morbidity, but relabelling CFS as a psychiatric disorder is not justified.

 

Source: Lawrie SM, Pelosi AJ. Chronic fatigue syndrome in the community. Prevalence and associations. Br J Psychiatry. 1995 Jun;166(6):793-7. http://www.ncbi.nlm.nih.gov/pubmed/7663830

 

Human herpesvirus 6 and human herpesvirus 7 in chronic fatigue syndrome

Abstract:

We analyzed lymphocytes of patients with chronic fatigue syndrome (CFS) for the presence of human herpesvirus 6 (HHV-6) and HHV-7 DNA. HHV-7 was present in over 80% of CFS patients and healthy controls, while the prevalence of HHV-6 variant A increased significantly in CFS cases (22 versus 4%; P = 0.05).

 

Source: Di Luca D, Zorzenon M, Mirandola P, Colle R, Botta GA, Cassai E. Human herpesvirus 6 and human herpesvirus 7 in chronic fatigue syndrome. J Clin Microbiol. 1995 Jun;33(6):1660-61. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC228240/pdf/331660.pdf (Full article)

 

Diagnosis in chronic illness: disabling or enabling–the case of chronic fatigue syndrome

Abstract:

This paper examines doctors’ and patients’ views on the consequences of an increasingly common symptomatic diagnosis, chronic fatigue syndrome (CFS).

Two studies were conducted: the first comprised interviews with 20 general practitioners; the second was a longitudinal study, comprising three interviews over a period of 2 years with 50 people diagnosed with CFS. Contrasts were apparent between doctors’ practical and ethical concerns about articulating a diagnosis of CFS and patients’ experiences with and without such a diagnosis.

Seventy per cent of the doctors were reluctant to articulate a diagnosis of CFS. They felt constrained by the scientific uncertainty regarding its aetiology and by a concern that diagnosis might become a disabling self-fulfilling prophecy. Patients, by contrast, highlighted the enabling aspects of a singular coherent diagnosis and emphasized the negative effects of having no explanation for their problems.

Comment in: Diagnosis in chronic illness. [J R Soc Med. 1995]

 

Source: Woodward RV, Broom DH, Legge DG. Diagnosis in chronic illness: disabling or enabling–the case of chronic fatigue syndrome. J R Soc Med. 1995 Jun;88(6):325-9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1295234/ (Full article)

Chronic fatigue syndrome

Comment on: Chronic fatigue syndrome: a follow up study. [J Neurol Neurosurg Psychiatry. 1994]

 

Chronic fatigue syndrome: a follow up study by Bonner et al’ reported that 47 patients initially diagnosed with “chronic fatigue” were contacted for follow up four years later. The authors indicated that “These patients were initially assessed before the current criteria for chronic fatigue syndrome became available, but most would have satisfied the criteria retrospectively” (p 617). At the outset, all patients were offered cognitive behavioural treatment and some were offered antidepressant medications. Each patient then made a decision to either undergo or decline cognitive behavioural treatment. Four years later, those patients who reported functional improvement were more likely to have elected to receive the cognitive behavioural treatment. Additionally, patients in the group that did not report any functional improvement were more likely to score higher on measures of depression.

The US Centers for Disease Control and Prevention (CDC) case definition,2 the proposed revisions to the CDC case definition,3 and the guidelines for research set forth by Sharpe et al4 were cited, but the researchers did not make it clear as to which criteria were used to diagnose which patients. Thus it is unknown whether uniform criteria were applied to diagnose all patients at the outset. Moreover, the authors did not specify just how many of the initial 47 patients met any of the cited criteria for chronic fatigue syndrome, as opposed to chronic fatigue. In short, they did not differentiate the exact number of chronic fatigue syndrome v chronic fatigue cases.

Only 29 of the original 47 patients (62%) agreed to be interviewed for the follow up. Thus 18 (38%) of the original patients were not included in the outcome data, where 10 subjects reported little or no improvement and 19 subjects reported improvement or recovery. The authors acknowledged that the small patient sample size constituted a methodological shortcoming, but nevertheless concluded “that there is a strong association between successful completion of [cognitive] treatment and the absence of functional disability at the four year follow up” (p 620). They further suggest that costs associated with long term disability could be reduced by the utilisation of cognitive therapy in the treatment of chronic fatigue syndrome. We would like to emphasise that the small patient sample size, together with the lack of availability of almost 40% of the initial patients for interview at follow up, make such conclusions highly inappropriate.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1073573/pdf/jnnpsyc00030-0116.pdf

 

Source: Lipkin DM, Robin R, Vasquez L, Plioplys AV, Plioplys S. Chronic fatigue syndrome. J Neurol Neurosurg Psychiatry. 1995 Jun;58(6):764-5. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1073573/

 

Chronic fatigue syndrome: a cognitive approach

Abstract:

Observations concerning the characteristics of patients who presented to a medical clinic with a principal complaint of chronic medically unexplained fatigue (Chronic Fatigue Syndrome or CFS) are described, including the cognitions (thoughts and assumptions) elicited from a sample of these patients who were treated using cognitive behavioural therapy. On the basis of these observations a cognitive theory of the aetiology of CFS is proposed. These observations have implications for the treatment of patients with CFS.

 

Source: Surawy C, Hackmann A, Hawton K, Sharpe M. Chronic fatigue syndrome: a cognitive approach. Behav Res Ther. 1995 Jun;33(5):535-44. http://www.ncbi.nlm.nih.gov/pubmed/7598674

 

Vagal tone is reduced during paced breathing in patients with the chronic fatigue syndrome

Abstract:

Patients with chronic fatigue syndrome (CFS) often complain of an inability to maintain activity levels and a variety of autonomic-like symptoms that make everyday activity intolerable at times. The purpose of the study was to determine if there were differences in vagal activity at fixed breathing rates in women with CFS.

Twelve women with the diagnosis of CFS between the ages of 32 and 59 years volunteered for the study. Healthy women, who were between the ages of 30 and 49, served as controls. Full signal electrocardiograph and respiratory signals were collected during a paced breathing protocol of three fixed breathing rates (8, 12 and 18 breaths/min) performed in the sitting and standing postures. Vagal activity was analyzed by means of heart rate spectral analysis to determine the subject’s response to specific breathing rates and postures. Heart rate variability was used as a non-invasive method of measuring the parasympathetic component of the autonomic nervous system.

Using this method, although there was significantly less vagal power in the sitting versus the standing postures for both groups, the overall vagal power was significantly lower (p < 0.034) in the CFS group versus healthy controls. Vagal power was also significantly lower (p < 0.01 to p < 0.05) at all breathing rates in both postures except while standing and breathing at 18 breaths/min. Knowledge of the differences in vagal activity for CFS patients may allow stratification for the analysis of other research variables.

 

Source: Sisto SA, Tapp W, Drastal S, Bergen M, DeMasi I, Cordero D, Natelson B. Vagal tone is reduced during paced breathing in patients with the chronic fatigue syndrome. Clin Auton Res. 1995 Jun;5(3):139-43. http://www.ncbi.nlm.nih.gov/pubmed/7549414

 

The disease associations of the antibody response against the Epstein-Barr virus transactivator protein ZEBRA can be separated into different epitopes

Abstract:

The BamHI-Z-encoded Epstein-Barr virus (EBV) replication activator (ZEBRA) is a key mediator of the switch from latency to productive cycle in EBV virus. Antibodies against ZEBRA are a marker of EBV reactivation and are regularly found among patients with infectious mononucleosis (IM) or nasopharyngeal carcinoma (NPC), but are only rarely found among healthy EBV-seropositive donors.

In order to define the serologically reactive epitopes in the ZEBRA protein, we synthesized a set of overlapping peptides and tested them for reactivity with serum samples from EBV-seronegative persons, patients with NPC, IM, chronic fatigue syndrome, lymphoma or from healthy donors. Three major EBV-specific epitopes were found.

These epitopes were further defined and optimized using substitution or truncation analogues of the peptides. Reactivity with epitope number 22 was found in 63% of NPC patients’ sera, with < 2% of healthy donors’ sera being positive. Serological reactivity with epitope number 19 was associated with IM (57% positive, 5% healthy donors positive).

Serum antibodies against epitope 1 were found among healthy donors, but were significantly elevated among patients with NPC, IM or lymphomas. In conclusion, different serologically reactive epitopes in the ZEBRA protein associate with different EBV-associated diseases.

 

Source: Tedeschi R, Foong YT, Cheng HM, dePaoli P, Lehtinen T, Elfborg T, Dillner J. The disease associations of the antibody response against the Epstein-Barr virus transactivator protein ZEBRA can be separated into different epitopes. J Gen Virol. 1995 Jun;76 ( Pt 6):1393-400. http://www.ncbi.nlm.nih.gov/pubmed/7540196

Note: You can read the full study HERE.

 

Chronic intestinal candidiasis as a possible etiological factor in the chronic fatigue syndrome

Abstract:

The chronic candidiasis syndrome, also known as the Candida-related complex, putatively caused by the overgrowth of Candida albicans in the gastrointestinal tract and secondarily in the genital organs, is briefly described.

Patients with this disorder have many of the same symptoms as those with the chronic fatigue syndrome, except for the recurrent flu-like symptoms of the latter disorder. The positive response of a large number of patients with the chronic fatigue syndrome (CFS) to an oral antifungal agent and a diet for intestinal candidiasis has been described by another clinician.

There is evidence that Candida albicans infection of the mucous membranes depresses T cell and natural killer (NK) cell function. Similar abnormalities of immune function are found in the CFS. The function of cytotoxic T cells, T helper cells, and NK cells is important in preventing reactivation of infections from Epstein-Barr virus, cytomegalovirus, and other herpesviruses.

Reactivation of one or more of these viruses could lead to the expression of the flu-like symptoms in the CFS. Yet the immune dysfunction found in this disorder has been considered the primary underlying causal factor.

It is proposed that chronic intestinal candidiasis may be an agent which leads to immune depression in many CFS patients and therefore that it could be a causal factor in CFS.

 

Source: Cater RE 2nd. Chronic intestinal candidiasis as a possible etiological factor in the chronic fatigue syndrome. Med Hypotheses. 1995 Jun;44(6):507-15. http://www.ncbi.nlm.nih.gov/pubmed/7476598