Chronic fatigue syndrome and women: can therapy help?

Abstract:

This article presents current research on chronic fatigue syndrome, which currently afflicts mostly females between the ages of 25 and 55. Because depression is a common symptom of chronic fatigue syndrome, mental health practitioners are often involved with the victims and must formulate an appropriate treatment strategy that considers the physiological, intrapsychic, interpersonal, and environmental aspects of the client. This article includes case material focusing on a woman who was medically diagnosed with the Epstein-Barr virus and was in psychotherapy with the author. The difficulty of managing the interplay of the real health problems and the emotional issues presented by the client is highlighted.

Comment in:

“Chronic fatigue syndrome and women: can therapy help?”. [Soc Work. 1992]

“Chronic fatigue syndrome and women: can therapy help?”. [Soc Work. 1992]

“Chronic fatigue syndrome and women: can therapy help?”. [Soc Work. 1992]

Source: Burke SG. Chronic fatigue syndrome and women: can therapy help? Soc Work. 1992 Jan;37(1):35-9.  http://www.ncbi.nlm.nih.gov/pubmed/1542805

 

Alleged link between hepatitis B vaccine and chronic fatigue syndrome

In 1989, 3456 cases of hepatitis B were reported in Canada. It is generally accepted that the true incidence of the disease is about 10 times the reported incidence.

Hepatitis B virus is a major cause of acute and chronic hepatitis, cirrhosis and primary hepatocellular carcinoma. Chronic hepatitis may develop in 10% of infected adults and 90% of infected infants and may progress to cirrhosis and hepatocellular carcinoma. In its acute form hepatitis B is fatal in a small number of cases. The disease is transmitted through sexual contact and infected blood and other body fluids. Carriers frequently show no symptoms until later in life and may therefore infect others unknowingly.

Hepatitis B vaccine has been used in populations that have an established risk of infection with known consequences (e.g., health care workers, male homosexuals and injection drug users).

Recent attention in the Canadian press has focused on the possible association between hepatitis B vaccination and chronic fatigue syndrome (CFS).

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1488229/pdf/cmaj00290-0039.pdf

 

Source: [No authors listed] Alleged link between hepatitis B vaccine and chronic fatigue syndrome. CMAJ. 1992 Jan 1;146(1):37-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1488229/

 

Chronic fatigue syndromes in clinical practice

Abstract:

Chronic fatigue is a common and difficult challenge in clinical practice. The majority of patients with this chief complaint have treatable mood or anxiety disorders, complicated by a tendency toward somatization. A minority of patients suffer from sleep disorders, endocrinologic abnormalities, or chronic inflammatory conditions. Prolonged recovery after viral infections is only rarely the cause of chronic fatigue. Specific pharmacologic interventions and cognitive-behavioral therapy are effective in an environment that is sensitive to the patient’s interpretation of symptoms and avoids unproven medical investigations and therapies.

 

Source: Manu P, Lane TJ, Matthews DA. Chronic fatigue syndromes in clinical practice. Psychother Psychosom. 1992;58(2):60-8. http://www.ncbi.nlm.nih.gov/pubmed/1484921

 

The pathophysiology of chronic fatigue syndrome: confirmations, contradictions, and conjectures

Abstract:

OBJECTIVE: To examine published data regarding patient cohorts with the recently defined chronic fatigue syndrome.

METHOD: Review of thirty-two peer-assessed research publications that included full disclosure of the methodology employed; classification of the findings as confirmed, contradictory, or non-duplicated.

RESULTS: Research studies have confirmed that the majority of patients with the chronic fatigue syndrome: 1) are white middle-aged women, 2) have a high prevalence of current major depression and somatization disorder, 3) have abnormal personality traits, 4) believe that their fatigue has a physical cause, and 5) show mild abnormalities of humoral immunity. Contradictory data have been presented with regard to: 1) the time of onset of depressive disorders, 2) the etiologic role of herpetic and enteroviral infections, 3) the presence of abnormal cellular immunity, and 4) the clinical utility of immunoglobulin therapy. Non-duplicated research has indicated 1) hypothalamic-pituitary-adrenal axis dysfunction, 2) abnormalities on magnetic resonance images of the brain, 3) altered cytokine production, and 4) the possibility of retroviral infection.

CONCLUSIONS: As presently defined, the chronic fatigue syndrome has many of the clinical and biological features associated with depressive and somatoform disorders. A specific etiologic role for infections or immune dysfunction has not been confirmed.

 

Source: Manu P, Lane TJ, Matthews DA. The pathophysiology of chronic fatigue syndrome: confirmations, contradictions, and conjectures. Int J Psychiatry Med. 1992;22(4):397-408. http://www.ncbi.nlm.nih.gov/pubmed/1338059

 

Tired all the time

General practitioners often see a syndrome they call “tired all the time.” How often doctors see it depends on how tiredness is defined and where it is measured. Morrell recorded fatigue as the most important reason for consultation in 24 per 2000 registered patients in one year 1; Jerrett recorded fatigue as a presenting or supporting symptom in 150 per 2000 registered patients.2 Yet patients may not necessarily mention fatigue when they consult. A survey of patients waiting in one surgery found that a tenth reported “substantial fatigue” for a month or more 3; 18-34% of respondents in a community survey reported always feeling tired in the past month 4; and when young women patients were asked to record symptoms in diaries 400 episodes of fatigue were recorded for every one reported to the doctor.5 Clinicians may regard this iceberg as a puzzle, and a blessing. But how should they manage the cases that do present?

Little has been published on tiredness in primary care, with only one prospective study from Britain2 and two retrospective ones from American family practice.67 The results suggest that psychosocial causes are paramount in 40-51% of cases and physical causes in 21-39%.267 The remaining cases are of mixed or undetermined cause. Fatigue presents three times more often in women of childbearing age,2 who often have a working day that is long and difficult to organise, with no boundary between home and work.8 The wise doctor steers between the extremes of trivialising and medicalising such “social” fatigue. If the cause is existential rather than medical counselling may help the patient consider various alternatives and make new choices.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1671843/pdf/bmj00157-0008.pdf

 

Source: Ridsdale L. Tired all the time. BMJ. 1991 Dec 14;303(6816):1490-1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1671843/

 

Neurasthenia and chronic fatigue syndrome: the role of culture in the making of a diagnosis

Abstract:

Chronic fatigue syndrome is an increasingly popular diagnosis consisting of multiple psychiatric and somatic symptoms. It bears a striking resemblance to the nineteenth-century diagnosis of . Both disorders arose during periods characterized by a preoccupation with commerce and material success and major changes in the role of women. They illustrate the role of culture in the development of a new diagnosis that emphasizes a “medical” rather than “psychiatric” etiology. The authors argue that chronic fatigue syndrome will meet the same fate as neurasthenia–a decline in social value as it is demonstrated that the majority of its sufferers are experiencing primary psychiatric disorders or psychophysiological reactions and that the disorder is often a culturally sanctioned form of illness behavior.

Comment in:

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

 

Source: Abbey SE, Garfinkel PE. Neurasthenia and chronic fatigue syndrome: the role of culture in the making of a diagnosis. Am J Psychiatry. 1991 Dec;148(12):1638-46. http://www.ncbi.nlm.nih.gov/pubmed/1957925

 

Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome

Abstract:

Chronic fatigue syndrome is characterized by persistent or relapsing debilitating fatigue for at least 6 months in the absence of a medical diagnosis that would explain the clinical presentation. Because primary glucocorticoid deficiency states and affective disorders putatively associated with a deficiency of the arousal-producing neuropeptide CRH can be associated with similar symptoms, we report here a study of the functional integrity of the various components of the hypothalamic-pituitary-adrenal axis in patients meeting research case criteria for chronic fatigue syndrome.

Thirty patients and 72 normal volunteers were studied. Basal activity of the hypothalamic-pituitary-adrenal axis was estimated by determinations of 24-h urinary free cortisol-excretion, evening basal plasma total and free cortisol concentrations, and the cortisol binding globulin-binding capacity. The adrenal cortex was evaluated indirectly by cortisol responses during ovine CRH (oCRH) stimulation testing and directly by cortisol responses to graded submaximal doses of ACTH. Plasma ACTH and cortisol responses to oCRH were employed as a direct measure of the functional integrity of the pituitary corticotroph cell. Central CRH secretion was assessed by measuring its level in cerebrospinal fluid.

Compared to normal subjects, patients demonstrated significantly reduced basal evening glucocorticoid levels (89.0 +/- 8.7 vs. 148.4 +/- 20.3 nmol/L; P less than 0.01) and low 24-h urinary free cortisol excretion (122.7 +/- 8.9 vs. 203.1 +/- 10.7 nmol/24 h; P less than 0.0002), but elevated basal evening ACTH concentrations.

There was increased adrenocortical sensitivity to ACTH, but a reduced maximal response [F(3.26, 65.16) = 5.50; P = 0.0015). Patients showed attenuated net integrated ACTH responses to oCRH (128.0 +/- 26.4 vs. 225.4 +/- 34.5 pmol/L.min, P less than 0.04). Cerebrospinal fluid CRH levels in patients were no different from control values (8.4 +/- 0.6 vs. 7.7 +/- 0.5 pmol/L; P = NS).

Although we cannot definitively account for the etiology of the mild glucocorticoid deficiency seen in chronic fatigue syndrome patients, the enhanced adrenocortical sensitivity to exogenous ACTH and blunted ACTH responses to oCRH are incompatible with a primary adrenal insufficiency. A pituitary source is also unlikely, since basal evening plasma ACTH concentrations were elevated.

Hence, the data are most compatible with a mild central adrenal insufficiency secondary to either a deficiency of CRH or some other central stimulus to the pituitary-adrenal axis. Whether a mild glucocorticoid deficiency or a putative deficiency of an arousal-producing neuropeptide such as CRH is related to the clinical symptomatology of the chronic fatigue syndrome remains to be determined.

 

Source: Demitrack MA, Dale JK, Straus SE, Laue L, Listwak SJ, Kruesi MJ, Chrousos GP, Gold PW. Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome. J Clin Endocrinol Metab. 1991 Dec;73(6):1224-34. http://www.ncbi.nlm.nih.gov/pubmed/1659582

 

Chronic fatigue syndrome

Comment in: Chronic fatigue syndrome. [Br J Gen Pract. 1992]

Comment on: Antidepressant therapy in the chronic fatigue syndrome. [Br J Gen Pract. 1991]

 

Sir, The adoption of the term chronic fatigue syndrome for conditions like myalgic encephalomyelitis and effort syndrome in the paper by Lynch and colleagues (August Journal, p.339) is difficult to understand. The differences between these disorders are so marked, that an umbrella term is destined to be both confusing and misleading.

The emphasis on the term fatigue is unfortunate for many reasons. First; research has shown that only a tiny proportion of people with unexplained fatigue fulfil the standard diagnostic criteria for myalgic encephalomyelitis. (1) Secondly, Lynch and colleagues’ definition of chronic fatigue syndrome is too broad to distinguish people with myalgic encephalomyelitis from those who are feeling run down or depressed or suffering from the more common and less severe post-viral syndrome. Thirdly, the term trivializes the illness. Everyone gets tired now and then and most people find it hard to understand how some may be disabled by it. In our view, the name suggests something which is tolerable and volitional, requiring little more than adequate rest and a positive attitude. What the term fails to communicate is that the fatigue reported by people with myalgic encephalomyelitis is severe and debilitating; that it is unlike anything most of them have experienced before and that it is often associated with an intense influenza-like malaise. (2’3) We therefore agree with English that as far as myalgic encephalomyelitis is concerned, ‘fatigue is the most pathetically inadequate term’. (2)

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371802/pdf/brjgenprac00062-0041.pdf

 

Source: Goudsmit EM, Macintyre A, Sullivan M. Chronic fatigue syndrome. Br J Gen Pract. 1991 Nov;41(352):479-80. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371802/

 

Chronic fatigue syndrome

Comment on:

Antidepressant therapy in the chronic fatigue syndrome. [Br J Gen Pract. 1991]

General practitioners’ experience of the chronic fatigue syndrome. [Br J Gen Pract. 1991]

 

Sir, I read with interest the papers on the chronic fatigue syndrome (August Journal, p.324, 339). This syndrome has become an important diagnosis in both general practice and psychiatry. With the awareness of such a diagnostic entity, more patients are being recognized and managed (although the aetiology still remains unknown).

Depression as an inherent feature of chronic fatigue syndrome remains a controversial issue and great care is needed in treating these patients as ‘depressed’. Subjectively, many patients with the chronic fatigue syndrome describe their mood state as depressed, probably because of lack of any other socially approved metaphor. For a practitioner, however, it is important to make an objective assessment about the significance of this expression in terms of the range and reactivity of affect and the disproportion of depressive presentation in the context of the patient’s life situation and experiences. If depression is significant, the diagnosis of chronic fatigue syndrome becomes secondary to that of depressive disorder as fatigue may be a feature of depression. However, if chronic fatigue syndrome remains the primary diagnosis, one must remember that antidepressant drugs are neither euphoriants nor stimulants and that there is no empirical evidence for the benefit of antidepressant treatment in this syndrome, although there is a recommendation for it to be tried as an alternatp mode of treatment.

 

Source: Arya DK. Chronic fatigue syndrome. Br J Gen Pract. 1991 Nov;41(352):480. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371803/

 

Chronic fatigue syndrome

Comment on: General practitioners’ experience of the chronic fatigue syndrome. [Br J Gen Pract. 1991]

 

Sir, Ho-Yen and McNamara give an interesting account of general practitioners’ experience of the chronic fatigue syndrome (August Journal, p.324). However, many of the conclusions which they draw are not supported by their study.

The problem lies in the method by which cases were identified. It seems unlikely that the doctors who responded to the questionnaire would have screened every patient on their practice lists for the condition. Even to screen only those patients who attended the surgery would have been a massive undertaking. There is no evidence that the practices involved kept a case register for this illness. I presume therefore that the cases reported were identified from memory by the doctors who responded to the survey. Thus, for patients who meet the criteria for this illness to be identified as a ‘case’ they must: decide that they are ill, decide to visit the doctor, be correctly identified as a case by the general practitioner and leave such an impression on the doctor’s mind as to be easily recalled later. It is very unlikely that, having passed through such a selection procedure, the cases identified would represent either the true number or display the typical characteristics of patients with this condition in the general population.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371804/pdf/brjgenprac00062-0042b.pdf

 

Source: Plummer WP. Chronic fatigue syndrome. Br J Gen Pract. 1991 Nov;41(352):480. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371804/