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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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The
Whole Story