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Chronic fatigue syndrome

The non-specific symptoms of CFS pose a problem for GPs. In the second part of our mental health series, consultant psychiatrist Dr Jeanette Downie offers a guide to diagnosis and treatment

The non-specific symptoms of CFS pose a problem for GPs. In the second part of our mental health series, consultant psychiatrist Dr Jeanette Downie offers a guide to diagnosis and treatment

Chronic fatigue syndrome (CFS) is a collection of physical and psychological syndromes, rather than one problem, which makes it difficult for GPs to diagnose.

Unfortunately, CFS brings out a dogmatic streak in both healthcare professionals and patient organisations, who insist on viewing it as either a physical or a psychological condition when often it is both.

Although the precise causes remain unknown, it is believed that CFS develops when several factors including genetics, brain abnormalities, a hyper-reactive immune system and viral or other infections come together. CFS often begins with a viral-type infection such as an acute respiratory or flu-like illness. Instead of recovering, the patient's health deteriorates and other symptoms appear.

Personality and/or mental health issues may increase susceptibility to onset or perpetuation of CFS. Some clinicians believe CFS can be attributed to depression, with half of all CFS patients experiencing at least one major episode. It should also be noted that CFS promotes psychological and social dysfunction.

There are some conditions that rule out CFS, including depression, pregnancy, punishing exercise regimens, severe stress, infectious mononucleosis and Epstein-Barr virus and autoimmune diseases, particularly systemic lupus erythematosus, multiple sclerosis and rheumatoid arthritis.

To rule out specific conditions causing persistent fatigue, take TFTs and LFTs, FBC and ESR. No blood, urine or other lab test can specifically diagnose CFS, so if any test results are abnormal, GPs need to look for other causes.

Diagnosis and treatment
Diagnosis can be difficult, as there is no specific test for CFS and longstanding fatigue may indicate another serious medical or psychological problem.

A thorough physical examination and clear psychological profile of the patient will help to clarify the diagnosis (see below).

Diagnosis is usually arrived at by excluding other illnesses with similar symptoms (see below) and reviewing the patient's symptoms with the 1994 ICD-10 definition. The ICD says four of eight symptoms have to be present, together with fatigue that interferes with physical, mental, social and educational activities. Both fatigue and the symptoms must have occurred for at least a six-month period.

CFS patients are at high risk of developing additional health problems with similar symptoms, such as fibromyalgia, irritable bowel syndrome, chronic pelvic pain, chemical sensitivities and temporomandibular disorder.

Patients who remain as active as possible and who try to exert control over the disorder have the best chance of improvement.Since no cause has been identified and the pathophysiology remains unknown, treatment programmes directed towards symptom relief help the patient regain as much pre-existing functioning as possible. Mixed serotonin and noradrenaline re-uptake inhibitors, particularly venlafaxine, can be helpful with psychological symptoms, and NSAIDs can help alleviate body aches and fever. Non-sedating antihistamines may relieve allergic symptoms.

Any treatment programme should be based on assessment of the patient's overall medical condition and current symptoms, and be regularly modified to meet the patient's changing requirements.Patients are often frightened about exercising in case they become totally debilitated, so it is essential to build up slowly and ensure that there is a positive outcome for each effort. Most patients respond well to a programme that begins with just three to five minutes of moderate exercise daily.

It may be beneficial for patients to incorporate different types of exercise into their regimens to improve overall fitness and relieve the psychological pressure to 'improve' each day. A mixture of walking, swimming, gentle stretching or yoga (DVDs can be very useful), and gardening may be effective. If patients have been passionate about a particular activity in the past, being encouraged to take it up again, even at a greatly reduced level, may bring positive psychological benefits.

Psychological aids
Most people with CFS feel terribly helpless, so it is important that they learn to feel empowered and in control again. A lot of psychological input and encouragement will be needed to help them move forward. Cognitive behaviour therapy (CBT), anxiety management, assertiveness training, problem-solving and self-awareness therapy all help patients understand how they react to life events and how to change this successfully, which usually brings enormous benefits. Individual CBT has been shown to be helpful, but there is no evidence on whether online CBT is effective in CFS.

Education about the importance of optimum nutrition and the use of sleep management techniques may also be beneficial.CFS is a chronic condition, so patients must not be allowed to write themselves off – it's essential to maximise their potential and keep momentum going. The prognosis for patients with CFS varies considerably, but is usually improved by graded exercise and individual CBT.

Research suggests no particular advantage in treating with oral nystatin, and there is no conclusive evidence to support prescription of modafinil or use of EPA fish oil supplements.

Patients who do not respond to treatment in primary care should be referred to a consultant who specialises in treating CFS.

Diagnosis questions
•When did the fatigue first begin?
•Does anything make it better or worse?
•Is it better at certain times of the day?
•Does physical activity make it worse?
•Are there any other symptoms?
•Has anyone else in the family ever complained of fatigue?
•Is either your personal or professional life stressful?
•Any changes in weight?
•Any drugs being taken?

Symptoms of CFS
•Post-exertion malaise and/or fatigue
•Memory and concentration problems
•Sleep dysfunction
•Joint pain without swelling or tenderness
•Continuous flu-like feelings
•Headaches
•Sore throat
•Enlarged glands
•Alcohol intolerance
•Low blood pressure
•Sensitivity to bright lights and/or loud noises

Conditions to exclude
•Hypothyroidism
•Adrenal insufficiency
•Heart disorders
•Sleep apnoea or narcolepsy
•Side-effects of medications
•Cancer
•Hepatitis C or hepatitis G
•Certain psychiatric disorders, particularly major depression, bipolar disorder, schizophrenia and delusional disorders and dementia
•Anorexia nervosa and bulimia nervosa
•Drug misuse, including alcohol
•Severe obesity

Dr Jeanette Downie is a consultant psychiatrist, the Priory Hospital, Glasgow.
Competing interests: None declared

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