CHRONIC FATIGUE SYNDROME (CFS)

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CHRONIC FATIGUE SYNDROME (CFS)

• DIAGNOSTIC AND ASSESSMENT
• ISSUES

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Case Definition C.D.C., 1994

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

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Case Definition C.D.C., 1994

• B)     Four or more of the following symptoms are
  concurrently present for gt 6 months
• 1.    Impaired memory or concentration
• 2.    Sore throat
• 3.   Tender cervical or axillary lymph nodes
• 4.    Muscle pain
• 5.    Multi-joint pain
• 6.    New headaches
• 7.    Unrefreshing sleep
• 8.    Post-exertion malaise

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Diagnostic Hints

• Diagnostic based on inclusion and exclusion
  criteria
• No pathognomonic signs or diagnostic tests
  validated in scientific studies
• Must have persistent or relapsing, debilitating
  fatigue for at least 6 mo.
• In the absence of any current or past medical
  condition that would explain the clinical
  presentation

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A discrete clinical entity?

• This question raises 2 issues
• Usefulness of the diagnosis
• Overlap with other clinical conditions

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A discrete clinical entity?

• CFS, Fibromyalgia, Irritable Bowel Syndrome or
  Idiopathic chronic Pain as associated disorders
  (Goldenberg, 1999)
• a diagnostic label promoting illness behavior and
  exaggeration of the expression of disability and
  pain (Barsky and Borus, 1999)

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A discrete clinical entity?

• However a useful diagnosis
• reassures patients on the absence of a
  degenerative disease
• allow patients to concentrate on getting better
  rather than getting a diagnosis and searching for
  a cause or a cure
• (Goldenberg, 1999)

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A discrete clinical entity?

• 90 of patients believed that a diagnosis of CFS
  was the most helpful factor in managing their
  symptoms (Hewett et al., 1995)
• CFS, FM, and TMD shared many clinical features
  (e.g., myalgia, fatigue, sleep disturbances,
  impairment in daily activities)
• (Aaron et al., 2000)

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A discrete clinical entity?

• Frequent co-morbidity among CFS, FM, and TMD
  patients (e.g., 35 to 70 patients with CFS also
  had FM)
• A stress-related illness, with onset related to
  acute or chronic emotional stressors, or to a
  combination of emotional and physical events
  (Demitrack Crofford, 1998)

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Differential Diagnosis

• Considerable phenomenological overlap with other
  functional somatic syndromes
• Therefore a discussion of a common set of
  psychosocial factors applies to all of them
• (Barsky and Borus, 1999)

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Differential DiagnosisCFS and Depression

• CFS might be a variant of a neuropsychiatric
  disorder, such as major depression
• (Brickman and Fins, 1993)
• Frequent comorbidity observed in the population
  of CFS patients
• (Goodnick, 1993)
• Issue of directionality (cause or effect)

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Differential DiagnosisCFS and Depression

• Shared symptoms
• - persistent fatigue
• - pain
• - sleep disturbance
• - poor concentration
• - psychomotor retardation
• - loss of sexual desire
• (Friedberg Jason, 2001)

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Differential DiagnosisCFS and Depression

• CFS more debilitating than depression
• More severe neurocognitive symptoms in CFS (e.g.,
  memory and concentration, mental confusion)
• Symptoms less likely to be reported in primary
  depression (e.g., painful lymph nodes, flu-like
  symptoms, pressure-like headaches, alcohol
  intolerance)

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Differential DiagnosisCFS and Depression

• Key distinction
• Postexertional malaise and prolonged fatigue
  after exercise - atypical in primary depression
  (often mood elevation with exercise)
• (Moor Blumenthal, 1998)

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Differential DiagnosisCFS and Depression

• Loss of interest (Depression) vs. Loss of ability
  (CFS)
• Ask for 5 things they want to do
• Cognitive differences
• - CFS more likely to endorse tendencies to
  dwell on fatigue
• - Depression thoughts of worthlessness,
  self-criticism, suicidal ideation more common

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Differential DiagnosisCFS and Somatization
Disorder (SD)

• Differences in onset
• - CFS often sudden onset, late 20s/early 30s
• - SD progressive, starting in adolescence,
  full-blown somatization by 25
• Medically unexplained symptoms in both ? hard to
  delineate

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Differential DiagnosisCFS and Anxiety

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

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Differential DiagnosisCFS and Activity-Induced
Chronic Fatigue

• 2 types of CFS patients
• - severe post exertional fatigue, slightly
  alleviated by rest
• - severe overall symptomatology, severe
  postexertional fatigue, fatigue not alleviated by
  rest
• Healthy people persistent fatigue due to active
  schedules, high stress, lack of sleep remission
  of symptoms with increase in rest and leisure
  time

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Hypothesesto account for CFS

• Functional somatic syndrome
• Barsky and Borus (1999) Sharpe and Wessely
  (1997)
• Abnormalitites in immune functions
• Klimas et al. (1990, 1994) Patarca et al.
  (1993)
• Viral etiology of CFS
• Jones et al. (1985) Straus et al. (1985)
• Perturbations of the HPA axis function Demitrack
  et al. (1991)
• Brain stem hypometabolism
• Buskila (2000)

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Physiological abnormalities in CFS

• researchers have extensively tested for
• - immune status
• - infectious agents
• - disorders of the endocrine or central nervous
  systems
• No need for such testing in practice unless as
  part of a protocol-based research study or when
  the diagnosis is in question

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Explanatory Models of CFS

• Immune defect Model
• Sleep disturbance Model
• Neuroendocrine Abnormalities
• Predisposing Personality Model
• Symptom Avoidance Model

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The Mind Body Approach

• Assessed and Treated in a non-specific manner
• But integrated medical-psychiatric approach the
  clinical assessment and care of functional
  somatic syndromes
• Intervention model based on 4 axes

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A Multidimensional Model

• Distinguishes
• - Predisposing factors
• - precipitating factors
• - perpetuating factors
• (Demitrack Crofford, 1998)

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A Conceptual Frameworkand set of Guidelines

• Need for a comprehensive, systematic, and
  integrated approach to the evaluation,
  classification, and study of people with CFS or
  other fatiguing illnesses
• (Fukuda et al., 1995)

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A Conceptual Frameworkand set of Guidelines

• Need for revised criteria to define CFS
• Need for clinical evaluation standards
• Definition and Clinical evaluation of Prolonged
  and Chronic fatigue

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A Conceptual Frameworkand set of Guidelines

• Prolonged Fatigue
• Self-reported, persistent fatigue of 1 month or
  longer
• Chronic Fatigue
• Self-reported, persistent or relapsing fatigue of
  6 or more consecutive months

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A Conceptual Frameworkand set of Guidelines

• Clinical Evaluation
• To identify underlying or
• contributing conditions
• that require treatment
• For further diagnosis or
• classification of chronic
• fatigue cases

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A Conceptual Frameworkand set of Guidelines

• Areas to include in evaluation
• History of medical and psychosocial circumstances
  at onset
• Mental status Exsamination
• Physical Examination
• Minimum battery of lab screening tests

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Conclusion

• Specific and non-specific assessment standard
  tools and customized clinical interview
• Biopsychosocial Approach
• Mastery of Case Definition Criteria
• Diagnostic reevaluation based on initial
  treatment response

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Conclusion

• Challenging diagnosis and treatment that will
  benefit from continuous research and education of
  primary health care providers
• Importance of experience with this specific
  population requires special training (CEU)