Chronic Fatigue Syndrome is not a new disease process but there is a clearer appreciation now of the pattern of symptoms which had previously been appreciated in many different ways. 

- Distinguishing Features of Chronic Fatigue Syndrome:

• New onset of unexplained fatigue
• Lasts for over 6 months
• Not related to on-going exertion
• Not substantially alleviated by rest
• Associated with other symptoms (i)

- Prevalence of patient fulfilling this criteria is about 0.5% - 2.6%.

• Can affect either sex
• Any age
• Any social group
• Severity and duration resulting disability can vary.

Many have profound ill-health, reduced physical and cognitive functions and daily living activities are reduced.  Affects employment and education. Exact causation and pathogens  -  unknown, but for many onset is related to infection. Epstein-Barr virus is associated for 10%.  Also herpes virus, enterovirus, hepatitis virus.  Also non viral infections such as Q fever; toxoplasmosis; salmonella; brucellosis. No consistent evidence of abnormal viral persistence, but non-specific immunological changes resembling acute infection may persist. 60% of patients have no previous psychiatric diagnosis but Chronic Fatigue Syndrome patients are shown to have increased psychosocial stressors.

- Relationship with Chronic Fatigue Syndrome & Depression

Both have interactive stigmas. Patients with primary depression have fatigue, as in Chronic Fatigue Syndrome.  Patients with Chronic Fatigue Syndrome may also show symptoms of depression.  Patients can develop secondary depression/anxiety especially if Chronic Fatigue Syndrome is denied or not diagnosed.  Patients with a history of depression can later develop Chronic Fatigue Syndrome.  However, clinical features suggest that they are distinct and Chronic Fatigue Syndrome can usually be distinguished from somatisation disorder

(Psychological Medicine 1995, 25, 925-35, Hickie I. et al)

Diagnosis

Diagnosis is usually from history - no validated lab tests.  Normally worsening of fatigue is delayed usually starting in a day or two after increased physical or mental activity and lasts for days or weeks.

Post exertional malaise.  Psychological stresses also precipitate setbacks like this.  Worsening of tiredness can also occur the day after drinking alcohol.  Physical and psychological symptoms can vary and may be present continuously or intermittently.  Psychological symptoms include reduced concentration, short term memory loss, inability to cope, mood swings, panic attacks, depression and inability to cope.  Sleep disturbances - hypersomnia, insomnia, early morning wakening and waking up unrefreshed. 

- Other Conditions to Exclude

• Thyroid disease
• Chronic inflammatory conditions
• Metabolic disorders
• Primary depression
• Somatising disorder

Over investigation can be harmful or counter-productive as patient may develop inappropriate concerns, causing them to be looking for abnormal test results to validate their "illness".

- Investigations that may be needed

Full blood counts, c-reactive protein or ESR, urea, creatinine, electrolytes, urine analysis, LFT's, thyroid functions, creatinine kinase, rheumatoid factor, antinuclear antibodies. 

Specialised Tests

• Neuroendocrine function
• Muscle function
• Electromyography
• ECG
• EEG
• Tests for exclusions of coeliac disorder

Management

• Support and reassurance about lack of serious underlying disease.
• Reassurance when real symptoms arise and explanations.
• Activity levels need to be 'managed' to avoid cycles of over and under-activity.
• Cognitive therapy.
• Behaviour modification.
• CBT to assist adjustment and recovery.
• Input from: physiotherapist :

1. Occupational therapist
2. Dietician
3. Social therapist (old style social worker)
4. Clinical psychologist (if the psychiatrist or nurse therapist is not able to do this type of work)

Drug Treatment

• Patients with Chronic Fatigue Syndrome seem to have more adverse drug reactions. Therefore to be careful in dose and type of medication.
• Low dose TCA to improve sleep in patients with early morning wakening.
• Short term non-benzodiazepines.
• Analgesics.
• Avoid caffeine and alcohol.
• Low dose sodium valproate
• SSRI's do not help patients with Chronic Fatigue Syndrome, without diagnosable depression and less well tolerated.
• Modify intake of fibre to help irritable bowel syndrome.
• Mebeverine to reduce bloating, cramps and diarrhoea.
• Low dose steroids can at times help but data on this is limited.

We also have a leaflet available with the above information on Chronic Fatigue Syndrome - if you would like us to send this to you, please get in touch and we will be happy to do so.