CHRONIC FATIGUE SYNDROME (CFS)

CHRONIC FATIGUE CHRONIC FATIGUE SYNDROME (CFS)SYNDROME (CFS)

DIAGNOSTICDIAGNOSTIC AND AND ASSESSMENT ASSESSMENT

ISSUESISSUES

Case Definition Case Definition [C.D.C., 1994][C.D.C., 1994]

A) A) Clinically evaluated, unexplained Clinically evaluated, unexplained persistent or relapsing chronic fatigue (persistent or relapsing chronic fatigue ( 6 months duration) that is of new or 6 months duration) that is of new or definite onset (has not been lifelong); is definite onset (has not been lifelong); is not the result of ongoing exertion, is not not the result of ongoing exertion, is not substantially alleviated by rest; and substantially alleviated by rest; and results in substantial reduction in results in substantial reduction in previous levels of occupational, previous levels of occupational, educational, social, or personal activities.educational, social, or personal activities.

Case Definition Case Definition [C.D.C., 1994][C.D.C., 1994]

• B)B) Four or more of the following symptoms are Four or more of the following symptoms are concurrently present for > 6 months:concurrently present for > 6 months:

• 1.1. Impaired memory or concentrationImpaired memory or concentration• 2.2. Sore throatSore throat• 3.3. Tender cervical or axillary lymph nodesTender cervical or axillary lymph nodes• 4.4. Muscle painMuscle pain• 5.5. Multi-joint painMulti-joint pain• 6.6. New headachesNew headaches• 7.7. Unrefreshing sleepUnrefreshing sleep• 8.8. Post-exertion malaisePost-exertion malaise

Diagnostic HintsDiagnostic Hints

• Diagnostic based on inclusion and Diagnostic based on inclusion and exclusion criteriaexclusion criteria

• No pathognomonic signs or diagnostic No pathognomonic signs or diagnostic tests validated in scientific studiestests validated in scientific studies

• Must have persistent or relapsing, Must have persistent or relapsing, debilitating fatigue for at least 6 mo.debilitating fatigue for at least 6 mo.

• In the absence of any current or past In the absence of any current or past medical condition that would explain the medical condition that would explain the clinical presentationclinical presentation

A discrete clinical entity?A discrete clinical entity?

This question raises 2 issues:This question raises 2 issues:

• Usefulness of the diagnosisUsefulness of the diagnosis• Overlap with other clinical Overlap with other clinical

conditionsconditions


• CFS, Fibromyalgia, Irritable Bowel CFS, Fibromyalgia, Irritable Bowel Syndrome or Idiopathic chronic Pain as Syndrome or Idiopathic chronic Pain as associated disorders (Goldenberg, 1999)associated disorders (Goldenberg, 1999)

• a diagnostic label promoting illness a diagnostic label promoting illness behavior and exaggeration of the behavior and exaggeration of the expression of disability and painexpression of disability and pain ( (Barsky Barsky and Borus, 1999)and Borus, 1999)


• However a useful diagnosis:However a useful diagnosis:– reassures patients on the absence of a reassures patients on the absence of a

degenerative diseasedegenerative disease– allow patients to concentrate on allow patients to concentrate on

getting better rather than getting a getting better rather than getting a diagnosis and searching for a cause or diagnosis and searching for a cause or a curea cure

(Goldenberg, 1999)(Goldenberg, 1999)


• 90% of patients believed that a 90% of patients believed that a diagnosis of CFS was the most helpful diagnosis of CFS was the most helpful factor in managing their symptomsfactor in managing their symptoms ((Hewett et al., 1995)Hewett et al., 1995)

• CFS, FM, and TMD shared many clinical CFS, FM, and TMD shared many clinical features (e.g., myalgia, fatigue, sleep features (e.g., myalgia, fatigue, sleep disturbances, impairment in daily disturbances, impairment in daily activities)activities)(Aaron et al., 2000)(Aaron et al., 2000)


• Frequent co-morbidity among CFS, FM, Frequent co-morbidity among CFS, FM, and TMD patients (e.g., 35 to 70% and TMD patients (e.g., 35 to 70% patients with CFS also had FM)patients with CFS also had FM)

• A stress-related illness, with onset A stress-related illness, with onset related to related to acute or chronic emotional acute or chronic emotional stressors, or to a combination of stressors, or to a combination of emotional and physical events emotional and physical events (Demitrack & Crofford, 1998)(Demitrack & Crofford, 1998)

Differential DiagnosisDifferential Diagnosis

Considerable phenomenological Considerable phenomenological overlap with other functional overlap with other functional somatic syndromessomatic syndromes

Therefore a discussion of a Therefore a discussion of a common set of psychosocial factors common set of psychosocial factors applies to all of themapplies to all of them

(Barsky and Borus, 1999) (Barsky and Borus, 1999)

Differential DiagnosisDifferential DiagnosisCFS and DepressionCFS and Depression

• CFS might be a variant of a CFS might be a variant of a neuropsychiatric disorder, such as major neuropsychiatric disorder, such as major depressiondepression

(Brickman and Fins, 1993) (Brickman and Fins, 1993) • Frequent comorbidity observed in the Frequent comorbidity observed in the

population of CFS patientspopulation of CFS patients

(Goodnick, 1993)(Goodnick, 1993)• Issue of directionality (cause or effect)Issue of directionality (cause or effect)


• Shared symptoms:Shared symptoms:

- persistent fatigue- persistent fatigue

- pain- pain

- sleep disturbance- sleep disturbance

- poor concentration- poor concentration

- psychomotor retardation- psychomotor retardation

- loss of sexual desire- loss of sexual desire

(Friedberg & Jason, 2001)(Friedberg & Jason, 2001)


• CFS more debilitating than depressionCFS more debilitating than depression• More severe neurocognitive symptoms More severe neurocognitive symptoms

in CFS (e.g., memory and concentration, in CFS (e.g., memory and concentration, mental confusion)mental confusion)

• Symptoms less likely to be reported in Symptoms less likely to be reported in primary depression (e.g., painful lymph primary depression (e.g., painful lymph nodes, flu-like symptoms, pressure-like nodes, flu-like symptoms, pressure-like headaches, alcohol intolerance)headaches, alcohol intolerance)


• Key distinction:Key distinction:

Postexertional malaise and Postexertional malaise and prolonged fatigue after exercise - prolonged fatigue after exercise - atypical in primary depression atypical in primary depression (often mood elevation with (often mood elevation with exercise)exercise)

(Moor & Blumenthal, 1998)(Moor & Blumenthal, 1998)


• Loss of interest (Depression) vs. Loss of Loss of interest (Depression) vs. Loss of ability (CFS)ability (CFS)Ask for 5 things they want to doAsk for 5 things they want to do

• Cognitive differences:Cognitive differences:- CFS: more likely to endorse tendencies - CFS: more likely to endorse tendencies to dwell on fatigueto dwell on fatigue- Depression: thoughts of worthlessness, - Depression: thoughts of worthlessness, self-criticism, suicidal ideation more self-criticism, suicidal ideation more commoncommon

Differential DiagnosisDifferential DiagnosisCFS and Somatization DisorderCFS and Somatization Disorder (SD)(SD)

• Differences in onset:Differences in onset:- CFS: often sudden onset, late - CFS: often sudden onset, late 20’s/early 30’s20’s/early 30’s- SD: progressive, starting in - SD: progressive, starting in adolescence, full-blown somatization by adolescence, full-blown somatization by 2525

• Medically unexplained symptoms in both Medically unexplained symptoms in both hard to delineate hard to delineate

Differential DiagnosisDifferential DiagnosisCFS and AnxietyCFS and Anxiety

• CFS often accompanied by CFS often accompanied by persistent anxietypersistent anxiety

• Focus on prominent feature to Focus on prominent feature to distinguish GAD from CFS:distinguish GAD from CFS:- CFS: severe fatigue- CFS: severe fatigue- GAD: excessive persistent - GAD: excessive persistent anxiety, not necessary w/pain or anxiety, not necessary w/pain or profound fatigue (treated w/CBT)profound fatigue (treated w/CBT)

Differential DiagnosisDifferential DiagnosisCFS and Activity-Induced Chronic FatigueCFS and Activity-Induced Chronic Fatigue

• 2 types of CFS patients:2 types of CFS patients:- - severe post exertional fatigue, slightly severe post exertional fatigue, slightly alleviated by restalleviated by rest- severe overall symptomatology, severe - severe overall symptomatology, severe postexertional fatigue, fatigue not alleviated by postexertional fatigue, fatigue not alleviated by restrest

• Healthy people: persistent fatigue due to Healthy people: persistent fatigue due to active schedules, high stress, lack of active schedules, high stress, lack of sleep – remission of symptoms with sleep – remission of symptoms with increase in rest and leisure timeincrease in rest and leisure time

HypothesesHypothesesto account for CFSto account for CFS

• Functional somatic syndromeFunctional somatic syndromeBarsky and Borus (1999); Sharpe and Wessely (1997)Barsky and Borus (1999); Sharpe and Wessely (1997)

• Abnormalitites in immune functionsAbnormalitites in immune functionsKlimas et al. (1990, 1994); Patarca et al. (1993)Klimas et al. (1990, 1994); Patarca et al. (1993)

• Viral etiology of CFSViral etiology of CFSJones et al. (1985); Straus et al. (1985Jones et al. (1985); Straus et al. (1985))

• Perturbations of the HPA axis function Perturbations of the HPA axis function Demitrack et al. (1991)Demitrack et al. (1991)

• Brain stem hypometabolismBrain stem hypometabolismBuskila (2000)Buskila (2000)

Physiological Physiological abnormalities in CFSabnormalities in CFS

• researchers have extensively tested for:researchers have extensively tested for:- immune status- immune status- infectious agents- infectious agents- disorders of the endocrine or central - disorders of the endocrine or central nervous systemsnervous systems

• No need for such testing in practice No need for such testing in practice unless as part of a protocol-based unless as part of a protocol-based research study or when the diagnosis is research study or when the diagnosis is in questionin question

Explanatory Models of CFSExplanatory Models of CFS

• Immune defect ModelImmune defect Model• Sleep disturbance ModelSleep disturbance Model• Neuroendocrine AbnormalitiesNeuroendocrine Abnormalities• ““Predisposing Personality” ModelPredisposing Personality” Model• Symptom Avoidance ModelSymptom Avoidance Model

The Mind & Body ApproachThe Mind & Body Approach

• Assessed and Treated in a non-Assessed and Treated in a non-specific mannerspecific manner

• But integrated medical-psychiatric But integrated medical-psychiatric approach the clinical assessment approach the clinical assessment and care of functional somatic and care of functional somatic syndromessyndromes

• Intervention model based on 4 Intervention model based on 4 axesaxes

A Multidimensional ModelA Multidimensional Model

• Distinguishes:Distinguishes:

- Predisposing factors- Predisposing factors

- precipitating factors- precipitating factors

- perpetuating factors- perpetuating factors

(Demitrack & Crofford, 1998)(Demitrack & Crofford, 1998)

A Conceptual FrameworkA Conceptual Frameworkand set of Guidelinesand set of Guidelines

• Need for a comprehensive, Need for a comprehensive, systematic, and integrated systematic, and integrated approach to the evaluation, approach to the evaluation, classification, and study of people classification, and study of people with CFS or other fatiguing with CFS or other fatiguing illnessesillnesses

(Fukuda et al., 1995)(Fukuda et al., 1995)


• Need for revised criteria to define Need for revised criteria to define CFSCFS

• Need for clinical evaluation Need for clinical evaluation standardsstandards

• Definition and Clinical evaluation of Definition and Clinical evaluation of Prolonged and Chronic fatigueProlonged and Chronic fatigue


• Prolonged FatigueProlonged FatigueSelf-reported, persistent fatigue of Self-reported, persistent fatigue of 1 month or longer1 month or longer

• Chronic FatigueChronic Fatigue• Self-reported, persistent or Self-reported, persistent or

relapsing fatigue of 6 or more relapsing fatigue of 6 or more consecutive monthsconsecutive months


• Clinical EvaluationClinical Evaluation

To identify underlying orTo identify underlying or contributing conditionscontributing conditions that require treatmentthat require treatment

For further diagnosis orFor further diagnosis or classification of chronicclassification of chronic fatigue casesfatigue cases


Areas to include in evaluation:Areas to include in evaluation:• History of medical and History of medical and

psychosocial circumstances at psychosocial circumstances at onsetonset

• Mental status ExsaminationMental status Exsamination• Physical ExaminationPhysical Examination• Minimum battery of lab screening Minimum battery of lab screening

teststests

ConclusionConclusion

• Specific and non-specific Specific and non-specific assessment: standard tools and assessment: standard tools and customized clinical interviewcustomized clinical interview

• Biopsychosocial ApproachBiopsychosocial Approach• Mastery of Case Definition CriteriaMastery of Case Definition Criteria• Diagnostic reevaluation based on Diagnostic reevaluation based on

initial treatment responseinitial treatment response

ConclusionConclusion

• Challenging diagnosis and Challenging diagnosis and treatment that will benefit from treatment that will benefit from continuous research and education continuous research and education of primary health care providersof primary health care providers

• Importance of experience with this Importance of experience with this specific population – requires specific population – requires special training (CEU)special training (CEU)

CHRONIC FATIGUE SYNDROME (CFS)

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