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Treatment of Chronic Exhaustion and Chronic Fatigue Syndrome

Cognitive behavioral therapy and an exercise program appear to be the best treatments to improve function and symptoms of fatigue in patients with CFS.
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The so-called functional somatic syndromes—such as fibromyalgia (FM) and chronic fatigue syndrome (CFS)—share many characteristics. They are quite common, with population estimates of 2% to 5% for FM, 0.26% to 0.78% for CFS (1% to 3% using older definitions), and 10% to 30% for irritable bowel syndrome (IBS).1,2

These syndromes have similar symptoms, notably chronic pain, exhaustion, headaches, and bowel and bladder complaints, as well as mood and sleep disturbances. None of these common disorders are well understood, and no causative agent has ever been identified. Therefore, they have been controversial disorders, especially in regard to their “mind or body” underpinnings.

Pain management in patients with for chronic exhaustion and chronic fatigue syndrome

CFS is the most perplexing of these chronic illnesses, especially for patients. Even the diagnostic term CFS has been a source of frustration for health care providers and patients. In the United Kingdom in the 1800s, the term neurasthenia was coined for patients with chronic exhaustion and neurocognitive symptoms. Subsequently, the term myalgic encephalomyelitis (ME) became popular.3 Then, following a cluster of cases of unexplained exhaustion in Lake Tahoe, Nevada, the term CFS became widely used, especially in the United States.4

In 2015, a committee organized by the Institute of Medicine (IOM) concluded that the terms CFS/ME did not reflect the main symptoms or the serious nature of the condition.5 The committee concluded that the terms fostered a psychogenic focus to CFS and recommended a new term, systemic exertion intolerance disease (SEID). Based on this new definition, it was estimated that 836,000 to 2.5 million Americans have CFS/SEID, with direct and indirect economic costs between $17 billion and $24 billion annually (Table 1).5

The IOM committee hoped that the new diagnostic term SEID would foster the notion that this is a discrete and legitimate physical disorder. However, the new terminology does not change CFS/SEID’s poorly understood nature or overlap with other common functional illnesses. A number of investigators have concluded that the new term and diagnostic criteria of SEID have not strengthened the understanding or acceptance of CFS.6 Therefore, for this article, I will refer to this illness as CFS and focus on its overlap with FM.

The Road to Diagnosis

Both CFS and FM often take years to diagnose. Only recently have physicians understood that these are not diagnoses of exclusion but can and should be diagnosed primarily by a complete history and physical examination. The cardinal symptom of CFS is profound exhaustion—for FM, the main symptom is generalized body pain. These symptoms must be present for 6 months and be unrelieved by rest. Exhaustion is present in 60% to 90% of subjects with FM. Furthermore, 60% to 90% of subjects diagnosed with CFS have widespread body pain, and pain was a part of all previous definitions of CFS/ME. Yet the IOM committee concluded that the pain of CFS is not specific for this disorder and elected not to include pain as a required element for the newly recommended diagnostic criteria for CFS/ME.

Much of the controversy in CFS may relate to the long-held notion, popularized in the United States in the 1980s, that CFS was caused by the Epstein-Barr virus (EBV).4 However, more extensive research failed to find a causal association of chronic fatigue with the EBV. The IOM report concluded that EBV may trigger CFS, but CFS is not sustained by ongoing EBV infection.5 Other potential viral associations with CFS have been proposed, but none have held up to careful scrutiny. In a prospective, multisite study, researchers were unable to confirm an association between murine retroviral DNA signature and CFS.7 The results showed low frequency in both CFS and control subjects (5/72; 6.7% vs 2/37; 5.4%, respectively).

Management of CFS

CFS has been one of the most controversial and challenging functional somatic syndromes to treat. In the 1980s and early 1990s, most treatments for CFS were based on a possible infectious or immune pathogenesis. When such efforts failed, more holistic therapies were pursued, with approaches similar to the treatment of FM and IBS. CFS patient organizations, however, have been critical of many of these trials and have interpreted these studies differently than physicians.

In addition, physicians and patients score various CFS therapies very differently.8 In a recent survey conducted in the United Kingdom, 75% of patients and 16% of health care providers supported alternative and complementary treatments; 71% of patients and 42% of providers supported medication management; 91% of patients and 50% of providers supported pacing exercise; and 28% of patients and 94% of providers supported rehabilitative therapy (Figure 1).8

To help understand the literature, this review begins with a look at nonpharmaceutical treatments that have been shown to be effective.

Cognitive Behavioral Therapy

There is evidence that cognitive behavioral therapy (CBT) is effective in the management of CFS. There are a number of reports demonstrating the efficacy of CBT for CFS.

Last updated on: March 17, 2017
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