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Chronic fatigue syndrome

Description

An in-depth report on the causes, diagnosis, and treatment of chronic fatigue syndrome.

Treatment

There is no proven or reliable cure for CFS, and no drug has been developed specifically for this disorder. Because CFS remains poorly understood, many patients have problems finding good care. Overall, the recommended strategy for treatment includes a combination of the following:

• Cognitive-behavioral therapy (CBT) and graded exercise may be helpful for certain patients
• Antidepressant drugs in some cases, usually low-dose tricyclic
• A healthy diet
• Sleep management techniques
• Medication

Patients with the best chance for improvement are those who remain as active as possible and who seek to have some control over the course of the disorder. Patients should seek physicians who are willing to consider the problem as a medical condition with psychiatric components. They should be very wary, however, if the physician recommends excessive and expensive treatments that may have serious adverse effects and that have no proven benefits. For patients with severe CFS that cannot be managed with lifestyle changes and standard medications, asking the physician about enrolling in any available clinical trials may be helpful.

Cognitive-Behavioral Therapy

CBT is designed to help patients regain a sense of control and is proving to have substantial benefits for some patients. Some experts believe that patients who are diagnosed with CFS should immediately be referred to therapists trained in cognitive-behavioral therapy. (Psychoanalysis and other interpersonal psychological therapies, which are concerned with subconscious thoughts and early childhood memories, are not generally helpful for the CFS patient.)

The Goals of Cognitive-Behavioral Therapy. The primary goals of cognitive-behavioral therapy (referred to below as just cognitive therapy) are to change any distorted perceptions that individuals have of the world and of themselves and to change their behavior accordingly. For CFS patients, this means learning to think differently about their fatigue and to improve their ability to deal with stressful situations and manage their disorder. Cognitive therapy is particularly helpful in defining and setting limits, behaviors that are extremely important for these patients.

The Procedure . Cognitive therapy may be expensive and not covered by insurance. It is usually performed over 6 - 20 sessions, each which last about an hour. Patients are also given homework, which usually includes keeping a diary and attempting tasks that they have avoided because of negative attitudes.

A typical cognitive therapy program may involve the following measures:

• Keep a Diary. The patient is almost always asked to keep an energy diary, which can be a key component of CFS cognitive therapy. The diary serves as a general guide for setting limits and planning activities. The patient uses the diary to track any factors, such as a job or a relationship that may be making the fatigue worse or better. It is also used to track the times of day when energy levels are at their highest and lowest peaks.
• Adjust Schedule. The patient adjusts schedules to conform to energy peaks and valleys recorded in the diary. For instance, the patient may plan low-energy times for taking a nap and high-energy times for planning important activities. Developing fairly rigid daily routines around probable energy spurts or drops may help establish a more predictable pattern.
• Confront Negative or Discouraging Thoughts. Patients are taught to challenge and reverse negative beliefs (e.g., "I'm not good enough to control this disease, so I'm a total failure.") to using coping statements ("Where is the evidence that I can control this disease?")
• Be Flexible. Energy levels will most likely never be entirely predictable. Patients must also be prepared to adapt to energy variations. Instead of a long nap, for instance, patients may need 5 - 10 minutes rest periods every hour or more, during which time relaxation or meditation methods are useful.
• Set Limits. Limits are designed to keep both mental and physical stress within a manageable framework so that patients do not get discouraged by forcing themselves into situations in which they are likely to fail. For example, tasks are broken down into incremental steps and patients focus on one at a time.
• Prioritize. Patients learn to drop some of the less critical tasks or delegate them to others.
• Manage Impaired Concentration. Patients seek out activities that are appealing, focus attention, and help increase alertness. They learn to request instructions given as concise simple statements. External distractions, such as music or talking, are kept to a minimum.
• Accept Relapses. Over-coping and accomplishing too much too soon can often cause a relapse of symptoms. Patients should respect these relapses and back off. They should not consider them a sign of treatment- or self-failure.

Using both self-observation and specific tasks, patients gradually shift their fixed ideas that they are helpless against the fatigue that dominates their lives to the perception that fatigue is only one negative and, to a degree, a manageable experience among many positive ones.

Success Rates. A 2001 review of CFS trials reported that, of all therapies available to CFS patients, only cognitive behavioral therapy (CBT) and graded exercise showed conclusive benefits. A 2005 study found that cognitive therapy is an effective treatment for adolescents with CFS. Patients who received CBT reported improvements in fatigue, functional status, and school attendance.

Not all studies support the benefits of cognitive therapy for CFS. It is important to note that different therapists may have different fundamental assumptions about CBT and may employ dissimilar techniques. For instance, some therapists believe that CFS is purely a psychological problem and that patients must reject the notion of physical causes, abandon all reliance on assistive devices, and participate in challenging exercise programs. In contrast, other therapists do not attempt to change patients' underlying beliefs at all, but instead focus on helping patients conserve energy and better cope with the limitations of their illness. When considering CBT, patients and their families must be aware of such important differences.

Regardless of whether specific organic causes of CFS are identified, the power of the mind to improve or oppose health problems is significant, and treatments that promote a positive outlook are beneficial for any disease.

Graded Exercise

A number of studies have suggested that a graded exercise program, in which patients perform increasingly more intense levels of exercise tailored to their individual abilities, has benefits for many patients with CFS. Exercise is best performed in combination with cognitive behavioral therapy.

The following are specific studies attesting to the benefits of graded exercise:

• In two 2001 studies, between 69 - 80% of patients who engaged in a self-managed graded exercise program reported improvement. In one of the studies, the benefits persisted for at least a year. (Still, 32% of patients complained of fatigue at the end of this period.)
• Another 2001 study reported that patients recovering from mononucleosis who began a graded exercise program were significantly less likely to develop chronic fatigue syndrome within 7 months than patients who did not exercise. No proof exists, however, that CFS is actually caused by physical unfitness. Rather, most studies suggest that CFS itself limits exercise and causes a cycle of poor conditioning and worsening symptoms.

Other reports have found that 75% of CFS patients who were able to engage in exercise, particularly aerobic exercise, reported less fatigue and better daily functioning and fitness after a year. A 2004 review of clinical trials found that exercise therapy is beneficial for CFS, particularly when combined with patient education.

Some patient groups and experts contend that such studies use only patients with less severe conditions and do not apply to many CFS patients. Many patients have severe conditions and some are very incapacitated (such as being wheel-chair bound). These patients are unlikely to undergo even graded exercise. All CFS patients, in fact, have a lower exercise capacity than healthy individuals, and over-exercising can intensify symptoms. Some patients experience profound fatigue following even modest exercise. It is the primary factor in perpetuating the low-activity levels observed in these patients.

The following tips may be helpful for CFS patients when embarking on an exercise program:

• Start slowly and incrementally, beginning with as little as 3 - 5 minutes of moderate exercise a day. The goal is to increase activity by about 20% every 2 - 3 weeks. (Capacity varies greatly among CFS sufferers, however, and some may not be able to achieve this.)
• Establish limits and keep within them in order to avoid overexertion and relapse.
• Experiment with different forms of physical activity that suit available energy levels. Some patients report great benefits from yoga or Tai Chi, which combine exercise with meditation.
• Setbacks will occur, but do not become discouraged.

Healthy Diet

Although there is no evidence to support any specific dietary factors in CFS, patients should be sure to maintain a healthy diet that includes:

• Plenty of fresh dark-colored fruits and vegetables, which are rich in antioxidants
• Fiber-rich foods
• Limited saturated fats (found in animal products)
• Omega 3 essential fatty acids, found in certain fish and oils
• Increased salt ( only for those with demonstrated low blood pressure)

Other Approaches For Managing Chronic Fatigue Syndrome

Stress Reduction Techniques. One panel of experts concluded that relaxation and stress-reduction techniques were helpful in managing chronic pain. They also can help relieve the stress associated with the disease. They are not useful, however, as the primary treatment for CFS. A number of relaxation techniques are available:

• Deep breathing exercises
• Muscle relaxation techniques
• Meditation
• Yoga
• Hypnosis
• Biofeedback
• Massage therapy

Light Therapy. Light therapy (phototherapy) has been used by some CFS patients. A 2002 study, however, reported no improvement in symptoms with its use. It may still help some patients with CFS whose symptoms have a seasonal variability that is similar to those of patients with seasonal affective disorder (SAD). Patients with SAD experience more depression during the winter, when the hours of sunlight decrease. With phototherapy, the patient sits a few feet away from a box-like device that emits very bright fluorescent light (4,000 lux) for about 30 minutes every day. It is best performed immediately after awakening in the morning.

Supportive Family and Groups. Strong, supportive relationships with family and friends are an important factor in the overall improvement of CFS patients. However, CFS patients should try not to impose unreasonable expectations on loved ones that cannot be met. Ongoing support groups with fellow patients may be very helpful. In a 2001 study, sharing experiences in a group therapy setting proved to be the most valuable component and one that improved patients' coping abilities.

• Review Date: 1/4/2007
• Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital

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