Treatment of Chronic Fatigue Syndrome: Findings, Principles and Strategies

Chronic fatigue syndrome (CFS) is a debilitating condition characterized by serious medically unexplained mental and physical fatigue. The high prevalence and both direct and indirect health costs of CFS patients represent a huge problem for contemporary health care. Moreover, the prognosis of CFS, even when treated, is often poor. In this paper, we first critically review current evidence based treatments of CFS. Second, we discuss the growing insights into the etiopathogenesis of CFS, and the need to translate and integrate these insights into future treatments. In particular, we formulate a pragmatic and empirically testable treatment approach, tailored to the individual needs of patients, which aims at restoring the mental and physical equilibrium of CFS patients by trying to bring about sustained life style changes.     

Illness Beliefs in Chronic Fatigue Syndrome: A Study Involving Affected Adolescents and their Parents

Background:  The aim of the study was too investigate the beliefs of young people with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) and their parents, about illness causes and management.
Method:  Twenty-one young people with CFS/ME and their parents participated in an open-ended interview.
Results:  Infective causes were identified by the majority of respondents, and psychological ones by a minority. Many highlighted reducing activity and resting in symptom management. Positive and negative experiences of psychiatric and psychological treatments were recorded.
Conclusion:  Professionals should carefully explore the illness related beliefs of young people with CFS/ME and parental beliefs in order to agree treatment plans.     

The Effects of Galantamine Hydrobromide Treatment on Dehydroepiandrosterone Sulfate and Cortisol Levels in Patients with Chronic Fatigue Syndrome

Objective

Mental fatigue, cognitive disorders, and sleep disturbances seen in chronic fatigue syndrome (CFS) may be attributed to cholinergic deficit. A functional deficiency of cholinergic neurotransmission may cause the hypothalamic-pituitary-adrenal axis hypoactivity seen in CFS. Therefore, we investigated the alterations in stress hormones such as cortisol and dehydroepiandrosterone sulfate (DHEAS) in CFS patients before and after 4-week administration of galantamine hydrobromide, a selective acetylcholinesterase inhibitor, and aimed to investigate whether there are any relationships between the probable hormonal changes and cholinergic treatment.

Methods

Basal levels of cortisol and DHEAS were measured in 29 untreated CFS patients who were diagnosed according to Centers for Disease Control (CDC) criteria and in 20 healthy controls. In the patient group, four weeks after 8 mg/d galantamine hydrobromide treatment, cortisol and DHEAS levels were measured again. After the treatment 22 patients who stayed in study were divided into two subgroups as responders and nonresponders according to the reduction in their Newcastle Research Group ME/CFS Score Card (NRG) scores.

Results

Important findings of this study are lower pre-and post-treatment cortisol levels and in all CFS patients compared to controls (F=4.129, p=0.049; F=4.803, p=0.035, respectively); higher basal DHEAS values and higher DHEAS/cortisol molar ratios which were normalized following four weeks'' treatment with 8 mg/d galantamine hydrobromide in the treatment-respondent group (F=5.382, p=0.029; F=5.722, p=0.025, respectively).

Conclusion

The findings of the decrease in basal DHEAS levels and DHEAS/cortisol molar ratios normalizing with galantamine treatment may give some support to the cholinergic deficit hypothesis in CFS.     

EEG Patterns and Chronic Fatigue Syndrome

Abstract

This study examined the relationship between EEG recordings of 28 females with Chronic Fatigue Syndrome (CFS) and age matched controls of the same gender. CFS subjects' EEG recordings were also compared to their responses on the Profile of Fatigue Related Symptoms, and two questionnaires developed specifically for this study. EEG electrodes were placed in a monopolar arrangement (active lead at CZ, ground lead in the center of the forehead, and two reference electrodes clipped to the earlobes) according to the international 10–20 system, and impedance was kept below 6 kohms. The data were collected under two conditions: eyes closed and serial sevens (while the subjects silently counted backward from 900 by seven).

CFS EEG microvolt levels were significantly higher in the 5–7 Hz range in both conditions and were significantly lower in the 9–11 Hz range during the serial sevens task. In the eyes closed condition, peak alpha (the frequency between 8 to 13 Hz at which the greatest amount of energy was observed) correlated negatively with the “fatigue today” rating and the peak frequency (the frequency between 4 to 20 Hz at which the greatest amount of energy was observed) correlated negatively with the theta to beta ratio and the total fatigue score. During the serial sevens task, peak frequency correlated negatively with the total cognitive difficulty rating. No EEG differences were found between employed and non-employed CFS subjects nor between CFS subjects who were taking antidepressant medications versus those who were not. Subjective symptom ratings and EEG comparisons suggest that CFS symptomology is displayed physiologically in the EEG. Implications are discussed.     

Cerebral and Systemic Hemodynamics Changes During Upright Tilt in Chronic Fatigue Syndrome

BACKGROUND AND PURPOSE: During head-up tilt (HUT), patients with chronic fatigue syndrome (CFS) have higher rates of neurally mediated hypotension (NMH) and postural tachycardia syndrome (POTS) than healthy controls. The authors studied whether patients with CFS were also more likely to have abnormal cerebral blood flow velocity (CBFV) compared with controls in response to orthostatic stress. METHODS: Transcranial Doppler monitoring of middle cerebral artery (MCA) CBFV was performed during 3-stage HUT prospectively in 26 patients with CFS and 23 healthy controls. At the same time, continuous monitoring of arterial blood pressure (BP), heart rate (HR), endtidal CO2 (ET-CO2) were performed. Results are reported as mean +/- SD. RESULTS: NMH developed in 21 patients with CFS and in 14 controls (P = .22). POTS was present in 9 CFS patients and 7 controls (P = .76). Supine HR was higher in CFS patients, but all other hemodynamics and CBFV measures were similar at baseline. The median time to hypotension did not differ, but the median time to onset of orthostatic symptoms was shorter in those with CFS (P < .001). The CBFV did not differ between groups in the supine posture, at 1 or 5 minutes after upright tilt, at 5 or 1 minute before the end of the test, or at termination of the test. Mean CBFV fell at termination of tilt testing in those with CFS and controls. ET-CO2 was lower at termination of the test in those with CFS versus controls (P = .002). CONCLUSIONS: The results of this study are not consistent with the hypothesis that patients with CFS have a distinctive pattern of MCA CBFV changes in response to orthostatic stress.     

Fatigue after breast cancer and in chronic fatigue syndrome: Similarities and differences

Objective: Fatigue is investigated in 57 severely fatigued disease-free breast cancer patients and in 57 gender- and age-matched patients with chronic fatigue syndrome (CFS) using multidimensional and multimethod assessment. A comparison between these groups of patients is important to determine whether a cognitive behavioural intervention to reduce fatigue in CFS patients would be appropriate as well for severely fatigued disease-free breast cancer patients. Methods: Measurement included computerised questionnaires and a standardised neuropsychological test. Furthermore, patients filled out a daily Self-Observation List (SOL) and wore an actometer during a period of 12 days. Results: In comparison to severely fatigued disease-free breast cancer patients, CFS patients score more problematic with regard to the level of fatigue, functional impairment, physical activity, pain and self-efficacy. However, a subgroup of severely fatigued disease-free breast cancer patients reports the same amount of problems as CFS patients with regard to psychological well-being, sleep and concentration. Finally, CFS patients and severely fatigued breast cancer patients score equal on measures of social support. Conclusion: There seem to be some similarities but also many differences between severely fatigued breast cancer survivors and females with CFS. Therefore, cognitive behaviour therapy (CBT) to reduce fatigue after treatment for cancer should also differ in certain aspects from cognitive behaviour therapy as it has been developed for patients with CFS.     

Fatigue after breast cancer and in chronic fatigue syndrome: similarities and differences

Objective: Fatigue is investigated in 57 severely fatigued disease-free breast cancer patients and in 57 gender- and age-matched patients with chronic fatigue syndrome (CFS) using multidimensional and multimethod assessment. A comparison between these groups of patients is important to determine whether a cognitive behavioural intervention to reduce fatigue in CFS patients would be appropriate as well for severely fatigued disease-free breast cancer patients. Methods: Measurement included computerised questionnaires and a standardised neuropsychological test. Furthermore, patients filled out a daily Self-Observation List (SOL) and wore an actometer during a period of 12 days. Results: In comparison to severely fatigued disease-free breast cancer patients, CFS patients score more problematic with regard to the level of fatigue, functional impairment, physical activity, pain and self-efficacy. However, a subgroup of severely fatigued disease-free breast cancer patients reports the same amount of problems as CFS patients with regard to psychological well-being, sleep and concentration. Finally, CFS patients and severely fatigued breast cancer patients score equal on measures of social support. Conclusion: There seem to be some similarities but also many differences between severely fatigued breast cancer survivors and females with CFS. Therefore, cognitive behaviour therapy (CBT) to reduce fatigue after treatment for cancer should also differ in certain aspects from cognitive behaviour therapy as it has been developed for patients with CFS.     

Children and adolescents with Chronic Fatigue Syndrome in non-specialist settings

Abstract Background Adolescents with Chronic Fatigue Syndrome (CFS) seen in specialist centres have substantial psychological and functional impairment. Beliefs about activity levels may be important in the development of CFS. Method The aim was to investigate psychological and functional impairment, and beliefs in children and adolescents with CFS recruited from non-specialist services. A total of 30 such individuals participated, and 30 young people with Inflammatory Bowel Disease (IBD) formed the comparison group. Results Emotional symptoms and disorder were high in both groups. In all, 50% of those with CFS and 30% with IBD reached the threshold for emotional disorder according to the Strengths and Difficulties Questionnaire (SDQ) parent report, although this difference did not reach statistical significance. Participants with CFS scored statistically significantly higher on measures of functional impairment, including school non-attendance, compared to those with IBD. According to questionnaire responses, those with CFS were statistically significantly more likely to favour rest rather than exercise compared to those with IBD. Comparison of parental beliefs did not show such a difference. Conclusions These young people with CFS were at high risk of psychiatric disorder. They were substantially disabled when compared to individuals with a known chronic illness. Also, as a group, they were characterised by a preference for rest rather than exercise.     

Chronic fatigue syndrome and sexual dysfunction

OBJECTIVE: The study was undertaken to determine if ambulant female patients with the chronic fatigue syndrome (CFS) report problems with their sexual functioning. METHODS: We studied 35 female CFS patients and 36 healthy female controls. The severity of CFS was measured with a fatigue questionnaire and the presence and severity of sexual dysfunction with a questionnaire about sexual functioning. RESULTS: The mean fatigue score was 24.8 in the CFS patients and 11.9 in the controls (P=.000). No increase in sexual dysfunction was found in the CFS group. The control group showed negative correlations between the score of the fatigue questionnaire and the frequency of "sexual fantasies," "(desire for) sexual contact" and "satisfaction with sex life." Such correlations were absent in the CFS group. CONCLUSION: The satisfaction with sex life was similar in patients and controls. The results suggest that patients and controls have a different perception of fatigue.     

Chronic fatigue syndrome: labels, meanings and consequences

In this month's issue, we report a survey of members of the Association of British Neurologists, which asked if they viewed chronic fatigue syndrome (CFS) as a neurological condition—84% of respondents did not. This is at odds with current classification in ICD-10. We discuss the difficulties of classifying CFS and myalgic encephalopmeylitis (ME), including historical and sociological factors, the pitfalls of the physical/psychological dichotomy and why classification matters to doctors and patients.     

Depression and Somatic Symptoms May Influence on Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Preliminary Study

The present study is the first one to investigate the impacts of depression and somatization on the disease severity and quality of life (QoL) in patients with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). The Korean version of National Institutes of Health (NIH)- Chronic Prostatitis Symptom Index (CPSI) for severity of CP/CPPS. Korean version of Patient Health Questionnaire-9 (PHQ-9) for depression, Korean version of Patient Health Questionnaire-15 (PHQ-15) for somatization, and Korean version of EuroQol Questionnaire-5 Dimensions (EQ-5D)- [(EQ-5D utility index and visual analog scale (EQ-5D VAS)] for QoL, were administered. Eighty patients were enrolled. The NIH-CPSI total scores were significantly higher in those with depression (25.3%, p=0.01) or somatization (23.2%, p=0.03) than in those without. These trends toward significantly negative influence of depression and somatic symptoms on QoL were also observed. Our preliminary results indicate that depression and somatization may have negative influence on the symptom severity and QoL in patients with CP/CPPS. However, adequately-powered and more well-designed studies are mandatory to prove our results.     

Chronic fatigue syndrome: A qualitative investigation of patients'' beliefs about the illness

The chronic fatigue syndrome is a disabling chronic condition of uncertain cause. Previous studies have found that patients seen in hospital clinics with the syndrome often strongly believe that their illness is physical in nature and minimize the role of psychological and social factors. There is also evidence that patients cope by avoiding activity. However, almost all of these studies have assessed illness beliefs only by questionnaire. The aim of this study was to explore the nature and origin of illness beliefs in more detail using in-depth interviews and a qualitative analysis of patient responses. Sixty-six consecutive referrals meeting Oxford criteria for chronic fatigue syndrome were recruited. Analysis of responses indicated that, whereas the most commonly described explanation for the illness was a physical one, more than half the patients also believed “stress” had played a role. Patients believed that they could partially control the symptoms by reducing activity but felt helpless to influence the physical disease process and hence the course of the illness. Patients reported that they had arrived at these beliefs about the illness after prolonged reflection on their own experience combined with the reading of media reports, self-help books, and patient group literature. The views of health professionals played a relatively small role. There is potentially a considerable opportunity to help patients arrive at a wider and more enabling explanation of their illness when they first present to primary care.     

Chronic fatigue syndrome and personality: A case-control study using the alternative five factor model

Neuroticism is the personality dimension most frequently associated with chronic fatigue syndrome (CFS). Most studies have also shown that CFS patients are less extraverted than non-CFS patients, but results have been inconsistent, possibly because the facets of the extraversion dimension have not been separately analyzed. This study has the following aims: to assess the personality profile of adults with CFS using the Alternative Five-Factor Model (AFFM), which considers Activity and Sociability as two separate factors of Extraversion, and to test the discriminant validity of a measure of the AFFM, the Zuckerman–Kuhlman Personality Questionnaire, in differentiating CFS subjects from normal-range matched controls. The CFS sample consisted of 132 consecutive patients referred for persistent fatigue or pain to the Department of Medicine of a university hospital. These were compared with 132 matched normal population controls. Significantly lower levels of Activity and significantly higher levels of Neuroticism-Anxiety best discriminated CFS patients from controls. The results are consistent with existing data on the relationship between Neuroticism and CFS, and clarify the relationship between Extraversion and CFS by providing new data on the relationship of Activity to CFS.     

Efficacy of Peripheral Nerve Field Stimulation for the Management of Chronic Low Back Pain and Persistent Spinal Pain Syndrome: A Narrative Review

ObjectivesVarious approaches have been developed with a view to treating the back pain component in patients with chronic low back pain (CLBP) and persistent spinal pain syndrome (PSPS). Emerging evidence shows that peripheral nerve field stimulation (PNFS) may be an efficacious therapeutic modality against axial low back pain. Hence, the aim of the review was to evaluate the analgesic efficacy and safety of PNFS, when used alone or as an adjunct to spinal cord stimulation (SCS), for managing CLBP and PSPS.Materials and MethodsA comprehensive search for clinical studies on PNFS and PNFS + SCS used for the management of CLBP and/or PSPS was performed using PubMed, EMBASE, MEDLINE via Proquest, and Web of Science.ResultsA total of 15 studies were included, of which four were randomized controlled trials (RCTs), nine were observational studies, and two were case series. For patients receiving PNFS, a significant decrease in back pain intensity and analgesic consumption, together with a significant improvement in physical functioning, was observed upon implant of the permanent system. Meanwhile, the addition of PNFS to SCS in refractory cases was associated with a significant reduction in back and leg pain, respectively.ConclusionsThis review suggests that PNFS, when used alone or in combination with SCS, appears to be effective in managing back pain. However, high-quality evidence that supports the long-term analgesic efficacy and safety is still lacking. Hence, RCTs with a larger patient population and of a longer follow-up duration are warranted.     

An extended concept of altered self: chronic fatigue and post-infection syndromes

Sickness behavior in active infectious diseases is defined here as the responses to cytokines and other mediators of inflammation as well as the adaptability of a pre-existing integrated immunological, psychological, neurological, and philosophical self. These complex behaviors are biologically advantageous to the afflicted individual, but they also impact surrounding individuals. If chronic conditions, such as chronic fatigue syndrome or post-infection fatigue, exhibiting these behaviors follow infection in the absence of ongoing changes in immunological self associated with an active infection or subsequent injury, they are currently considered illness states rather than true diseases. Self-referential recognition (interoception) of bodily processes by the brain and subsequent unconscious and conscious adaptive responses arising in the brain, i.e., in the endocrine system and immune systems, which are initiated during the infection and would normally lead to positive maintenance, may become maladaptive and lead to an "extended altered self state." Exploratory measurements of such alterations using a "top-down" approach such as monitoring responses to appropriate challenges can be obtained using functional brain imaging techniques. Once identified, processes remediable to biological/pharmacologic and/or psychological intervention can be targeted in directed trials.     

Deviations in daily physical activity patterns in patients with the chronic fatigue syndrome: a case control study

Objectives

Deviations in daily physical activity patterns may play an important role in the development and maintenance of fatigue in the chronic fatigue syndrome (CFS). The aim of this study is to gain insight into the objective daily physical activity pattern of patients with CFS in comparison with healthy controls. The secondary objective is studying the awareness in performing physical activities.

Methods

The objective daily physical activity pattern was measured with a tri-axial accelerometer in 35 patients with CFS and in 35 age- and gender-matched healthy controls. The objective daily physical activity level and distribution of physical activities at low, medium and high intensity levels during the day were measured. Moreover, variability in performing physical activities within and between subjects was computed. Subjective ratings of self-reported daily physical activity levels were assessed at a visual analog scale.

Results

CFS patients were significantly less physically active in the afternoon and evening, and spent fewer activities at high intensity levels and more at low intensity levels. Moreover, CFS patients showed more variability in their own physical activity pattern during the afternoon. The heterogeneity in the physical activity pattern between subjects within the CFS and control group did not differ. Finally, CFS patients were more aware about their daily physical activity level than healthy controls.

Conclusion

CFS patients showed deviations in the objectively measured daily physical activity pattern. Future research should elucidate the relation between impaired balances in daily physical activity patterns and fatigue severity in CFS.     

Illness and disability in Danish Chronic Fatigue Syndrome patients at diagnosis and 5-year follow-up

OBJECTIVE: Evaluation of the life impact of Chronic Fatigue Syndrome (CFS) over 5 years. METHODS: Thirty-three adult patients meeting 1988 and 1994 CDC case criteria answered identical questionnaires at diagnosis and 5 years later, when a retrospective questionnaire was also completed. RESULTS: Work disability was very high and increased further, social isolation remained high, emotional adjustment improved. There were increased problems with reading and with allergies. Two measures of improvement were used: The relation between these measures was weak. Length of illness, extent of disability and emotional adjustment were poorly related to measures of improvement. Average illness scores were unchanged, but most individuals improved in some ways while worsening or remaining the same in others. Only one participant (3%) neared recovery, one other was substantially better but still severely disabled. CONCLUSION: CFS patients exhibit severe, long-term functional impairment. Substantial improvement is uncommon, less than 6%. Allergies and aspects of cognition may worsen, emotional adjustment often improves.     

Chronic fatigue: electromyographic and neuropathological evaluation

Single fibre electromyography of extensor digitorum communis muscle (EDC) was performed on 35 patients with chronic fatigue, the majority of whom also had creatine kinase estimation and biopsy of EDC. The subjects were categorised as having an acute-onset post-viral fatigue syndrome, a non-specific chronic fatigue or possible muscle disease in view of pronounced myalgia. Of 11 subjects who had myalgia as a significant symptom, abnormalities in fibre density were found in 6, and 5 of these had some non-specific abnormalities on muscle biopsy, with creatine kinase levels being normal in all cases. Fibre density estimation may be a useful way of identifying a subgroup of chronic fatigue sufferers with a possible primary muscle disorder.     

Prison Industry and Desistance from Crime: An Australian Programme

Prison industries represent an important component of service delivery for correctional administrations around the world and yet there have been few attempts to articulate the specific role that they play in prisoner reintegration. This article describes the operation of an Australian prison industry programme. It identifies key programme characteristics that are thought to be associated with success before applying a desistance framework to understand the mechanisms by which change occurs and identify possible areas for improving efficacy. It is concluded that significant opportunities exist to enhance reintegration outcomes in this type of programme.