Tag: chronic fatigue

Panic disorder among patients with chronic fatigue

Abstract:

Among 200 adults with a chief complaint of chronic fatigue evaluated in an internal medicine practice, currently active panic disorder was diagnosed in 26 patients (13%), a frequency tenfold greater than that in the general population. Panic disorder preceded or was coincidental with the onset of chronic fatigue in 21 of these patients.

In comparison with the rest of the study cohort, significantly more patients with panic disorder had a history of severe depression, including persistent thoughts of death or suicide. Moreover, more patients with panic disorder showed a lifetime tendency to have physical symptoms that remained unexplained after medical evaluation.

Our findings suggest that treatable panic disorder is an important contributor not only to major depression and somatization, but also to the etiology and clinical presentation of chronic fatigue in patients in an outpatient practice.

 

Source: Manu P, Matthews DA, Lane TJ. Panic disorder among patients with chronic fatigue. South Med J. 1991 Apr;84(4):451-6. http://www.ncbi.nlm.nih.gov/pubmed/2014428

 

Chronic fatigue in children: clinical features, Epstein-Barr virus and human herpesvirus 6 serology and long term follow-up

Abstract:

During a 2-year period, 23 patients (14 girls, 9 boys) with chronic fatigue were referred to the Pediatric Infectious Disease Clinic of a tertiary care center, representing 19% of all out-patients seen in that clinic during that time. The median age was 14 years and the median duration of symptoms before referral was 6 months; 65% had missed at least 2 weeks of school and 30% required a home tutor.

There were few positive physical findings and no elevation of white blood cell count (median, 7000/mm3) or erythrocyte sedimentation rate (median, 5 mm/hour). Twenty-five percent had no evidence of Epstein-Barr virus infection, 15% had current or recent infection and 60% had past infection; 33% of the latter had detectable antibody to early antigen but the titers were low. Human herpesvirus 6 titers in 8 patients were similar to those in age- and sex-matched controls.

Of 17 patients contacted after a median of 26 months, 76% reported definite improvement, although 38% of these still experienced occasional symptoms. In this referral population chronic fatigue was a common presenting complaint, was associated with marked degrees of dysfunction and bore no relationship to Epstein-Barr virus or human herpesvirus 6 infection. In most children the disorder was self-limited, although a minority were persistently or severely affected.

 

Source: Marshall GS, Gesser RM, Yamanishi K, Starr SE. Chronic fatigue in children: clinical features, Epstein-Barr virus and human herpesvirus 6 serology and long term follow-up. Pediatr Infect Dis J. 1991 Apr;10(4):287-90. http://www.ncbi.nlm.nih.gov/pubmed/1648198

 

Clinical and laboratory findings in the Paul-Bunnell negative glandular fever-fatigue syndrome

Abstract:

Forty-one patients with recurrent fatigue were studied for evidence of symptom clustering, abnormal laboratory findings and infection with novel viruses. Symptom enquiry and investigations were repeated 4 months later.

Four patients were found to have diseases compatible with their symptoms. In those remaining, an initial acute onset of symptoms was associated with an intermittent course, tender glands and a raised number of T suppressor lymphocytes. Raised numbers of T suppressor lymphocytes at follow-up correlated with resolution of symptoms. Antibodies to human herpesvirus 6 (HHV-6) were found in 75% of the patients as compared to 53% of a control group and more patients than controls were strongly seropositive.

Some patients with chronic fatigue have a pattern of illness which suggests glandular fever, although acute infection with Epstein-Barr virus (EBV) is not demonstrated. Primary or reactivation infection with HHV-6 may have a role in this syndrome.

 

Source:  Read R, Larson E, Harvey J, Edwards A, Thomson B, Briggs M, Fox J. Clinical and laboratory findings in the Paul-Bunnell negative glandular fever-fatigue syndrome. J Infect. 1990 Sep;21(2):157-65. http://www.ncbi.nlm.nih.gov/pubmed/2172387

 

Chronic fatigue. A prospective clinical and virologic study

Abstract:

To evaluate the clinical and virologic course of patients with chronic fatigue who had elevated Epstein-Barr virus (EBV) titers, we prospectively followed up 26 patients with serial cultures for EBV in blood and saliva and serial EBV serologic and clinical and psychiatric evaluations, and we compared these results with those for healthy controls.

The frequency of isolating EBV in blood or demonstrating EBV infection by in situ hybridization in blood lymphocytes or in saliva was similar in patients and controls. The prevalence and titers of antibody to human herpesvirus type 6 were also similar in the two populations. Patients with chronic fatigue did demonstrate higher in vitro natural killer activity and lower in vitro interleukin 2 production than controls, and patients had a high frequency of DSM-III depressive illness. Over 50% of patients with chronic fatigue improved over the course of follow-up. Improvement was not associated with any discernible change in titers of EBV proteins.

No evidence of ongoing EBV infection with either transforming or nontransforming strains was demonstrated in this population of patients with chronic fatigue. Clinically, most patients gradually improve over time.

 

Source: Gold D, Bowden R, Sixbey J, Riggs R, Katon WJ, Ashley R, Obrigewitch RM, Corey L. Chronic fatigue. A prospective clinical and virologic study. JAMA. 1990 Jul 4;264(1):48-53. http://www.ncbi.nlm.nih.gov/pubmed/2162397

 

The low yield of physical examinations and laboratory investigations of patients with chronic fatigue

Abstract:

Fatigue is a common symptom but guidelines for its appropriate evaluation are lacking. The authors prospectively studied 100 adults with a chief complaint of fatigue lasting at least 1 month in order to determine the diagnostic contribution of physical examinations and laboratory investigations.

The evaluations were performed in the specialized clinic of a faculty practice. Physical examinations produced diagnostic information in 2% of patients, and laboratory investigations elucidated the cause of fatigue in 5% of patients. Structured follow-up evaluations after an average interval of 10 months failed to reveal any new organic causes for the fatigue symptom. Minor laboratory abnormalities were relatively common but did not contribute to the diagnostic process and did not seem to influence the clinical outcome.

The authors conclude that the traditional medical evaluation of patients complaining of chronic fatigue has a low yield in discovering treatable physical disorders.

 

Source:  Lane TJ, Matthews DA, Manu P. The low yield of physical examinations and laboratory investigations of patients with chronic fatigue. Am J Med Sci. 1990 May;299(5):313-8. http://www.ncbi.nlm.nih.gov/pubmed/2337122

 

Usefulness of a standard battery of laboratory tests in investigating chronic fatigue in adults

Abstract:

Twenty-two adults with chronic fatigue were studied to determine the clinical usefulness of commonly applied laboratory tests. Subjects with the chief complaint of fatigue persisting for more than one year were followed for an average of seven months at a university family health centre.

During this time a group of commonly recommended tests were carried out and the patients had repeated physical examinations. Physical diseases and laboratory abnormalities were few, and patients with abnormal values and active problems were followed until their fatigue resolved or their abnormalities reverted to normal following therapy. The study demonstrated that the presence of an abnormal laboratory result in a fatigued individual does not necessarily indicate the cause of fatigue.

A psychiatric history was also performed and patients were tested with the symptom check list 90-R (SCL-90-R), a 90-item psychological symptom check list. Seven patients were receiving psychotherapy when they enrolled in the study. Two additional subjects entered therapy after the start of the study. Results on the symptom check list for the study group were largely abnormal, with a majority scoring in the highest quartile for depression, paranoid ideation and psychoticism.

It is concluded that the investigation of patients with fatigue which has lasted for longer than one year should focus on psychological causes. In this group of patients laboratory abnormalities are not useful in guiding evaluation or treatment for their fatigue.

 

Source: Valdini A, Steinhardt S, Feldman E. Usefulness of a standard battery of laboratory tests in investigating chronic fatigue in adults. Fam Pract. 1989 Dec;6(4):286-91. http://www.ncbi.nlm.nih.gov/pubmed/2632306

 

Chronic fatigue syndrome

I was surprised that CMAJ published the letter from Drs. Gerald H. Ross and Jean A. Monro (Can Med Assoc J 1989; 140: 361) supporting such a vague, descriptive and unscientific term as “chronic fatigue syndrome”. As a practising psychiatrist I have attempted to emphasize that there are also primary psychologic causes of chronic fatigue such as depression and panic disorder (ibid: 361, 364); thus, it is more prudent to consider the relative causes of chronic fatigue than to create a “syndrome” that imposes a diagnostic life sentence of an incurable disease.

That a minuscule percentage of cases of chronic fatigue are due to chronic mononucleosis, other chronic infections and chemical sensitivity is not disputed. What is disputed is the number so diagnosed, particularly now that panic disorder – a primarily psychologic condition that causes chronic fatigue but is more amenable to treatment (antidepressant medication and dynamic insight-oriented psychotherapy) – appears to be reaching epidemic proportions. (1) Therefore, at the risk of considerable ideologic unpopularity, it would seem, I must repeat: “Primum non nocere.”

The statement by Ross and Monro that magnesium deficiency is associated with chemical sensitivity means just that and only that.

Ross and Monro’s six references are not definitive enough, the possible exception being the article of Tosato and colleagues (2) if – and only if – the chronic infectious mononucleosis referred to in the title was confirmed by serologic evidence of an acute attack. (3)

Ross and Monro display psychologic “sympathy” with “empathy” and quote me as referring to the term “psychosomatic” when I used the term “psychologic”.

“Syndromes” like “chronic fatigue syndrome” lessen the burden of introspection. In reverence to the “father” of nosology, Thomas Sydenham, and the “father” of psychiatry, Sigmund Freud, I must state, as a traditionally oriented psychiatrist, that it is nontherapeutic to condone self-defeating behaviour.

~Ray Holland, MD, FRCPC Box 458 Port Colborne, Ont.

References

1. Introduction. In Summary Proceedings of “Panic Disorder – Relative Merits of Pharmacotherapy and Psychotherapy” (satellite symposium of 1988 American Psychiatric Association annual meeting), Medical Group, Mississauga, Ont, 1988
2. Tosato G, Straus SE, Werner H et al: Characteristic T cell dysfunction in patients with chronic active EpsteinBarr virus infection (chronic infectious mononucleosis). J Immunol 1985; 134:3082-3088
3. Evans AS: A virus for all seasons.Buffalo Phys Biomed Sci 1988; 22 (2):14-15

 

Source: R Holland. Chronic fatigue syndrome. CMAJ. 1989 May 1; 140(9): 1016. PMCID: PMC1268972
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1268972/pdf/cmaj00190-0022b.pdf