How to deal effectively with chronic fatigue syndrome
Mrs Benton, 48, has been attending for over three years complaining of recurrent sore throats, tiredness, depression, aches and pains and forgetfulness, which she blames on the menopause. She has had to give
up her job, is separated and has had her house repossessed. She says she is now convinced that what she has been suffering from all this time is ME. She has brought some information from
a self-help group and she wants
to know whether you can confirm the diagnosis and suggest any treatment.
Dr Richard Stokell discusses.
Why is this a difficult presentation?
This presentation is likely to test your knowledge about an unfamiliar condition. It may challenge your beliefs about the validity of the illness and requires good communication skills to obtain a satisfactory outcome.
How can you arrive at a diagnosis patient?
Although there are no specific physical signs or diagnostic tests, a good history and comparison with established descriptions of the syndrome should allow accurate diagnosis.
The primary symptoms are severe chronic fatigue of six months or longer with other known medical conditions excluded by clinical diagnosis, combined with concurrently four or more of:
-substantial impairment in short-term memory or concentration
-tender lymph nodes
-multi-joint pain without swelling or redness
-headaches of a new type, pattern or severity
-post-exertional malaise lasting more than 24 hours.
The symptoms must have persisted or recurred during six or more consecutive months of illness and must not have pre-dated the fatigue.
What steps can be taken to exclude a serious medical condition?
The disease definition has the catch-all phrase 'with other known medical conditions excluded' but how far should you take investigation of this? Continued observation of the patient over at least six months is often the best way to exclude other conditions and investigation varies depending on the patient.
Referring to a general physician who will perform a battery of tests before sending the patient back saying 'no serious medical problem found' may relieve your anxiety but makes the patient feel disbelieved. Great care is needed when choosing when and where to refer.
What skills can be used to improve the outcome of this consultation?
You might not believe that chronic fatigue syndrome is a valid disease but my advice would be, if the patient meets the diagnostic criteria, avoid arguments of this type and allow the patient the label. This encourages the patient to feel believed and can facilitate progress. Questions such as 'what were the symptoms that made you suspect you had this?' can provide insight into the patient's own knowledge and beliefs.
It may then be possible to create a more useful diagnosis which includes the physical, psychological and social consequences of the syndrome, so you can say to the patient 'we can't really tell you what causes it but we may be able to help with some of the symptoms'.
Physical symptoms may benefit from analgesia such as ibuprofen while gentle graded exercise can improve exercise tolerance. Psychological treatment includes diagnosis and treatment of depression if found. Support by listening within a good doctor-patient relationship can be valuable.
Are there any other sources of help?
Many primary care teams have citizens' advice workers who can help with benefits, debts, legal issues and sometimes relationships. Psychology can also be of benefit. Cognitive behaviour therapy combined with physiotherapy has shown promise in helping these patients. Unfortunately access to these treatments is patchy. In our area it can be accessed either by entering patients into an ongoing clinical trial or via a specialist clinic with a two-year wait for therapy!
lThere are reasonably clear diagnostic criteria to help diagnosis of CFS
lYou can help these patients
lPatients value a relationship with the doctor based on trust and on being believed
lReferral to an unsympathetic consultant can harm the doctor-patient relationship
lPsychological treatment may be beneficial for this group of patients