| Chronic Fatigue Syndrome
We all get tired; most of us at times have
felt depressed. But the enigma known as chronic fatigue syndrome (CFS) is
not the ups and downs we experience in everyday life, or even the
temporary persistence of such feelings in response to exceptional physical
or emotional stress. The early hallmark of the illness is a pronounced
fatigue that comes on suddenly and is relentless or relapsing, causing
debilitating tiredness or easy exhaustion in someone who has no apparent
reason for feeling this way. Unlike the mind fog of a serious hangover, to
which CFS has been compared, the profound weakness of CFS does not go away
with a few good nights of sleep but instead slyly steals a person's vigor
over months and sometimes years.
How It Begins
People diagnosed with CFS often describe
its onset as sudden but not alarming because many of the syndrome's
symptoms--headache, tender lymph nodes, fatigue and weakness, muscle and
joint aches, inability to concentrate--mimic those of the flu. But
whereas flu symptoms usually go away in a few weeks, CFS symptoms either
persist or recur frequently for more than six months.
For many people, CFS begins after an
acute infection such as a cold, bronchitis, hepatitis, or an intestinal
bug. For some, it follows a bout of mononucleosis, the "kissing
disease" that temporarily saps the energy of teenagers and young
adults. In others, CFS develops more gradually, with no clear triggering
event. Often a patient reports that the illness emerged during a period
of high stress.
Who Gets It
Contrary to the popular stereotype, CFS
is not a new "yuppie flu." Similar syndromes, known by
different names, date back to the late 1800s. The modern stereotype
arose because those who sought help for and stimulated scientific
interest in CFS in the early 1980s were mainly well-educated, affluent
women in their thirties and forties. Since then, physicians have seen
the syndrome in people of all ages, races, and socioeconomic classes
from several countries around the world.
Still, CFS is diagnosed two to four times
more often in females than in males, which may be the result of
biological, psychological, and social influences. For example, a real
gender difference may exist in CFS, similar to diseases such as lupus
and multiple sclerosis that affect more women than men. Or, women may be
more likely than men to consult doctors about CFS-like symptoms. Also,
some members of the medical community and the public remain unaware or
skeptical of the syndrome. An increasingly diverse patient population
will likely emerge as more physicians recognize CFS as a legitimate
disorder.
The Diagnosis
Diagnosing CFS is difficult because it
shares symptoms with many other diseases. When evaluating patients,
physicians must first rule out diseases that look similar, such as
multiple sclerosis and lupus in which diagnostic symptoms can take years
to develop. In follow-up visits, physicians need to be alert to any new
cues or symptoms that might indicate a diagnosis other than CFS.
After rigorously excluding people with
other diseases, however, a large group of people with symptoms
associated with debilitating fatigue remain. If they meet other criteria
as well, these people can be considered to have CFS (see The CFS Case
Definition).
How Many People Have It?
Note: For the latest CFS prevalence data, please
consult the Centers
for Disease Control and Prevention Web site.
The lack of a clinical or laboratory
marker for CFS has muddled efforts to determine how many people the
illness affects. NIAID and the Centers for Disease Control and
Prevention (CDC) fund prevalence studies. Based on the first three years
of an ongoing surveillance study in four U.S. cities, the CDC estimates
the minimum prevalence rate of CFS in the United States is 4 to 10 cases
per 100,000 adults 18 years of age or older (although children can have
CFS, too.) This estimate, however, relies on cases referred to CDC study
sites by primary physicians, a method that can result in either an
underestimate or overestimate of actual cases.
Historical Perspective
Clinical portraits of diseases similar to
CFS have been reported under different medical guises for more than a
century. In the l860s, Dr. George Beard named the syndrome neurasthenia,
believing it to be a neurosis characterized by weakness and fatigue.
Succeeding generations have favored but not proved different
explanations--iron-poor blood (anemia), low blood sugar (hypoglycemia),
environmental allergy, or a bodywide yeast infection (candidiasis)--for
this baffling malaise.
In the mid-1980s, the illness became
labeled "chronic EBV" when laboratory clues led scientists to
speculate that this cluster of symptoms might be caused by the
Epstein-Barr virus (EBV). But new evidence casts doubt on the theory
that EBV could be the sole agent causing CFS. Elevated levels of EBV
antibodies have now been found in some healthy people as well as in some
people with CFS. Likewise, some people who lack EBV antibodies, and who
thus have never been infected with the virus, can display CFS symptoms.
The CFS Case Definition
The EBV work rekindled interest in the
syndrome among a small group of medical researchers. It became apparent
that a standard CFS case description was needed so that scientists could
more easily compare research results.
In the late 1980s, CDC convened a group
of CFS experts to tackle this problem. Based on the best information
available at the time, this group published in the March 1988 Annals
of Internal Medicine strict symptom and physical criteria--the first
case definition--by which scientists could evaluate CFS study patients.
Not knowing the cause or a specific
marker for the disease, the group agreed to call the illness
"chronic fatigue syndrome" after its primary symptom.
"Syndrome" means a group of symptoms that occur together but
can result from different causes. (Today, CFS also is known in other
countries as myalgic encephalomyelitis, postviral fatigue syndrome, and
chronic fatigue and immune dysfunction syndrome.)
After using this definition for several
years, CFS researchers realized some criteria were vague or redundant.
CDC had an international group of CFS experts review the criteria. This
led to the first changes in the case definition, published in the same
journal in December 1994 (see attached article).
Besides revising the CFS case
criteria--which reduced the required minimum number of symptoms to four
out of a list of eight possible symptoms--the new report also proposes a
conceptual framework for studying the syndrome. This framework
recognizes CFS as part of a continuum of illnesses that have fatigue as
a major symptom. Although primarily intended for researchers, the new
guidelines should help clinicians better diagnose CFS.
How to Manage and Cope With the Disease
No specific treatment has proved
effective for CFS. Scientists hope that research will help them identify
markers for the illness. These markers would enable them to target
treatments to specific abnormalities and to objectively follow the
course of the illness. How well different therapies work can then be
gauged by measuring changes in those markers in treated patients.
Anecdotally, physicians have reported
successes in small numbers of patients with various treatments including
antivirals, antidepressants, and immunomodulators (drugs that boost the
immune system). Few drugs have undergone rigorous clinical testing,
however. NIAID researchers tested the antiviral drug acyclovir in a
double-blind, placebo-controlled trial and found that as many CFS
patients reported feeling better when taking a placebo as when taking
acyclovir. This outcome lessens claims of a therapeutic role for
acyclovir in CFS. Carefully controlled studies also have revealed
conflicting data regarding the value of high-dose intravenous
immunoglobulin.
Because well-designed clinical trials
have found that patients with fibromyalgia (an illness similar to CFS)
benefit from low-dose tricyclic antidepressants, doctors often prescribe
these drugs for people with CFS with generally positive results. Some
researchers believe that these drugs improve the quality of sleep.
Patients also have benefitted from other kinds of antidepressants,
including the newer serotonin reup-take inhibitors. Therapeutic doses of
antidepressants often increase fatigue in CFS, so doctors may have to
escalate the dosage very slowly, or prescribe the so-called more active
antidepressants. In addition, some people with CFS benefit from the
benzodiazepines, a class of drugs used to treat acute anxiety and sleep
problems. Patients often try more than one drug before finding one that
works and can be tolerated.
Even though no specific CFS treatments
exist, symptomatic treatment still can be quite helpful. Nonsteroidal
anti-inflammatory drugs may benefit the body aches or fever associated
with the illness, and nonsedating antihistamines may help relieve any
prominent allergic symptoms.
Learning how to manage fatigue enables
people with CFS to improve their level of functioning and quality of
life despite their symptoms. A rehabilitation medicine specialist can
evaluate individuals and teach them how to plan activities to take
advantage of times when they usually feel better.
The lack of any proven effective
treatment can be frustrating to both patients and their physicians.
Experts recommend that people with CFS try to maintain good health by
eating a balanced diet and getting adequate rest. Physical conditioning
should be preserved by exercising regularly but without causing more
fatigue. It is important that people with CFS learn to pace
themselves--physically, emotionally, and intellectually--since too much
stress can aggravate symptoms.
The course of CFS varies from patient to
patient. For most people, CFS symptoms plateau early in the course of
the illness and thereafter wax and wane. Some people get better but not
completely. Others spontaneously recover. Emotional support and
counseling can help patients and their loved ones cope with the
uncertain prognosis and ups and downs of the illness.
Conclusion
Several different routes to chronic
fatigue syndrome may exist. In some people, a persistent viral infection
may provoke CFS symptoms, and virologists continue to explore this
possibility. Vulnerability to CFS may be associated with a subtle immune
system defect. It also appears likely, however, that CFS involves
interactions between the immune and central nervous systems,
interactions about which relatively little is now known. Scientists'
concerted efforts to penetrate the complex neuroimmunologic events in
CFS have created a challenging new concept of the pathology of this and
other illnesses.
Natural Treatments:
Nutrients can play roles in treating chronic
fatigue syndrome. Here's what some doctors recommend.
NUTRIENTS, DAILY AMOUNTS, and APPLICATIONS
Antioxidant-complex supplement containing...
B-complex
supplement containing...
MEDICAL ALERT!
- If you have been diagnosed with chronic fatigue syndrome, you
should be under a doctor's care. If you have heart or kidney
problems, you should always check with your doctor before taking
magnesium supplements. Doses of vitamin C in excess of 1,200
milligrams a day can cause diarrhea in some people, so it's a good
idea to check with your doctor before taking more than that amount.
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