Is CFS a psychological illness?

While fatigue is a common complaint, those individuals who have chronic fatigue lasting more than six months and who meet the CDC criteria for chronic fatigue syndrome have a condition than can be serious and disabling. Recent research does show laboratory abnormalities in the CFS patient population, although the search continues for a specific biomarker that will identify the illness.

U.S. Assistant Secretary for Health Dr. Philip R. Lee has stated

although we have not yet been able to fully describe the basis for CFS, nor do we fully understand the mechanisms of CFS, it is very real and it is not a figment of anyone's imagination. CFS is devastating to many who have it.

Dr. Paul Levine, M.D. of the National Institutes of Health writes

there is general agreement that CFS is a severe debilitating illness that deserves the utmost attention of the clinical and scientific communities.

Prof. Anthony Komaroff M.D. of Harvard Medical School has recently written

a growing number of physicians ... have studied the scientific literature on chronic fatigue syndrome -- which now numbers several thousand research articles.

There is no evidence of any psychiatric disorder in a sizable number of patients with this illness. However, in laboratory tests, there is evidence of abnormalities in the brain and immune system of many of these patients.... We still do not understand the cause of chronic fatigue syndrome, but studies around the world show it is not ... "all in their heads".

This web page contains medical references and advice from clinicians for diagnosing and treating CFS.

An up-to-date background about CFS was published as a supplement of the American Journal of Medicine (see Am J Med 1998 Sep 28;105(3A). The supplement contains 19 scientific articles. For purchase information and/or online viewing, see the web page at http://www.cfs-news.org/ajm98.htm.

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DIAGNOSIS

Dr. Paul Levine of NIH writes: "the case definition for CFS is a research definition, and as a result there are a number of exclusions (e.g., a history of neoplastic or other disorders) that are routinely invoked to define a more homogeneous group of patients as study subjects. Clinically, however, there is no reason why a patient excluded by a research protocol should not be managed for CFS if that is the apparent clinical diagnosis."

In addition, "patients presenting with fatigue who do not quite meet the case definition for CFS would still benefit from the management techniques appropriate for CFS."

CFS is defined somewhat differently by various medical groups in different countries. The 1994 research definition published by the U.S. Centers for Disease Control and Prevention recommends a step-wise approach for identifying CFS cases. The first step is to clinically evaluate the presence of chronic fatigue, i.e. "self-reported persistent or relapsing fatigue lasting 6 or more consecutive months".

Conditions that explain chronic fatigue should exclude a diagnosis of CFS. These are:

- "any active medical condition that may explain the presence of chronic fatigue ..."

- any previous condition which might explain fatigue and which has not documentably come to an end;

- "any past or current diagnosis of a major depressive disorder with psychotic or melancholic features; bipolar affective disorders; schizophrenia of any subtype; delusional disorders of any subtype; dementias of any subtype; anorexia nervosa; or bulimia";

- substance abuse within 2 years prior to onset;

- severe obesity.

The following should not exclude a diagnosis of chronic fatigue:

- conditions which cannot be confirmed by lab tests, "including fibromyalgia, anxiety disorders, somatoform disorders, nonpsychotic or nonmelancholic depression, neurasthenia, and multiple chemical sensitivity disorder";

- any condition which might produce chronic fatigue but which is being sufficiently treated;

- any condition which might produce chronic fatigue but whose treatment has already been completed;

- any finding which on its own is not sufficient to strongly suggest one of the exclusionary conditions.

After the above criteria are met, the following core criteria for CFS are applied: "A case of the chronic fatigue syndrome is defined by the presence of the following:

1) clinically evaluated, unexplained persistent or relapsing chronic fatigue that is of new or definite onset (has not been lifelong); is not the result of ongoing exertion; is not substantially alleviated by rest; and results in substantial reduction in previous levels of occupational, educational, social or personal activities; and

2) the concurrent occurrence of four or more of the following symptoms, all of which must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue:

- self-reported impairment in short term memory or concentration severe enough to cause substantial reduction in previous levels of occupational, educational, social or personal activities;

- sore throat;

- tender cervical or axillary lymph nodes;

- muscle pain;

- multi-joint pain without joint swelling or redness;

- headaches of a new type, pattern or severity;

- unrefreshing sleep;

- and post exertional malaise lasting more than 24 hours."

The journal citation for the CDC definition article is: Keiji Fukuda, Stephen Straus, Ian Hickie, Michael Sharpe, James Dobbins, Anthony Komaroff, and the International CFS Study Group. "The Chronic Fatigue Syndrome: A Comprehensive Approach to Its Definition and Study". Ann Intern Med. 1994;121:953-959. The full text of this paper can be viewed online at http://www.lifelines.com/cfstxt.html .

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TREATMENTS

There is not yet any consensus on a treatment protocol for CFS. Two surveys of physicians have been conducted to show which treatments are commonly applied in CFS cases, one of doctors who gather at the bi-annual meetings of the American Association for Chronic Fatigue Syndrome (AACFS) as reported in CFS-NEWS, and a mail survey of AACFS members conducted by Jonathan Rest MD.

From these two sources, the following appear to be typical prescriptions:

- teaching the patient energy management and recognition of limits

- SSRIs such as Zoloft, Paxil and Prozac, used to address fatigue, cognitive dysfunction and depression

- low dose tricyclic anti-depressants such as doxepin and amitriptyline, for sleep disorder, and muscle and joint pain and

- NSAIDs such as ibuprofen and naproxen for headache, and muscle and joint pain.

Other treatments often prescribed are Klonopin, intra-muscular gamma globulin (IMgG), nutritional supplements (particularly anti-oxidants, B-vitamins generally and B-12 specifically), herbs, and acupuncture. Less often prescribed were chiropractic therapy, intravenous gamma globulin (IVgG), kutapressin, antivirals, interferon, and transfer factor.

A number of CFS cases have been linked to neurally mediated hypotension as reported in JAMA and the Lancet. Some CFS patients respond to NMH treatments when that condition is indicated. For more information, see the Johns Hopkins CFS web page and also the interview with Hopkins researcher Peter Rowe MD that appeared in CFS-NEWS #45.

It will be useful to read "What we know about chronic fatigue syndrome and its relevance to the practicing physician" by Paul Levine, Am J Med. 1998;105(3A):100S-103S.

Note the following online links:

• How is CFS treated?, by doctors from Harvard Medical School and Massachusetts General Hospital
• CFS patient management, from NIH
• CFS Treatments, from the CDC
• CFS management, from the American Association for Chronic Fatigue Syndrome
• New Jersey CFS Center -- Research page
• Chronic Fatigue and CFS: A Practical Self Help Guide, from the CFS Research and Treatment Unit, Kings College Hospital, London
• CFS: A Primer for Physicians, by the Health Professionals Committee of the Massachusetts CFIDS Association, 1992
• Pain Management web page

The following hardcopy references are also helpful:

Conservative approaches

"Management of a Patient with Chronic Fatigue Syndrome" by Nelson Gantz; appears as Chapter 14 in the book "Chronic Fatigue Syndrome" edited by David Dawson and Thomas Sabin, 1993, Little, Brown & Co.

"Treatment of the Chronic Fatigue Syndrome: A Review and Practical Guide", Edith Blonde-Hill and Stephen D. Shafran, Drugs 46(4):639-651, October 1993.

"Psychotropic Treatment of Chronic Fatigue Syndrome and Related Disorders", PJ Goodnick and R Sandoval; J Clin Psychiatry 54(1):13-20 January 1993

Moderate and aggressive approaches

Book: "The Doctor's Guide to Chronic Fatigue Syndrome ", Dr. David Bell, Perseus / Harper Collins, 1995. (To purchase in the USA, tel. 800-331-3761, Canada, 800 387 0117, world +1-201-967-5817.)

Book: "Facing and Fighting Fatigue", Dr. Benjamin Natelson, Yale University Press, 1998. (To purchase in the USA, tel. 800-987-7323, world +1-203-432-0940.)

Book: "From Fatigued to Fantastic!", Dr. Jacob Teitelbaum. Avery Publishing, 1995. (To purchase in the USA, tel. 800-333-5287, world +1-410-266-6958.)

Book: "Chronic Fatigue Syndrome: A Treatment Guide ", Erica F. Verrillo and Lauren M. Gellman, Quality Medical Publishing, 1997. (To purchase in the USA, tel. 800-348-7808, world +1-314-878-9937.)

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CFS RESOURCES

CFS info on the web

NIH:  resources on CFS

NIH:  CFS Information for Physicians

CDC:  CFS Home Page

CDC Case Definition, 1994

American Association for Chronic Fatigue Syndrome

Bibliographic Database, from Michael McGoodwin, M.D.

CFS/M.E. Information web page

News and Journals

Journal of Chronic Fatigue Syndrome, a quarterly medical journal

CFS-NEWS Electronic Newsletter, free e-mail newsletter that emphasizes medical research

The CFIDS Chronicle, published bi-monthly, has articles of interest to both clinicians and patients. USA $35, Canada $45, overseas $60 yearly. Send to CFIDS Association of America, Inc., P.O. 220398, Charlotte, NC 28222-0398, USA.

Doctors private discussion group on the Internet

There is a private e-mail discussion group for doctors that wish to discuss CFS issues with their professional peers. To join the group, see the web page at http://www.cfs-news.org/cfs-doc.htm or write to the listowner via e-mail at cfs-doc-request@maelstrom.stjohns.edu.

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