At this time of year it seems like we are all tired; however chronic fatigue syndrome (CFS) is a debilitating fatigue that is not helped with rest.
Thought in years past to be a psychiatric diagnosis or findings more compatible with emotional disease, chronic fatigue syndrome affects from one to four million U.S. adults, according to 2010 Center for Disease Control Statistics. CFS is more common in women than men and in those older than 40. It can truly be disabling to those who suffer from it.
The primary symptom of CFS is, obviously enough, fatigue. There is a definite onset of symptoms, and the fatigue is disabling, quite severe, and affects both mental and physical functioning. The diagnosis is made mainly by exclusion—meaning that all other known medical causes for symptoms are ruled out before the diagnosis is established.
The Center for Disease Control Diagnosis criteria for CFS includes severe fatigue for more than six months, headache, multi-joint pain without swelling or redness, muscle pain, post-exertional discomfort for more than 24 hours, significant impairment in short term memory or concentration, tender lymph nodes, and disturbed sleep. Four of these criteria must be present for CFS to be considered.
When doctors are looking for the physical signs of CFS, their exam often fails to reveal any specific findings. Occasionally, lymph nodes will be tender and there will be trigger point pain in specific muscles on palpation. Basically there are no other physical findings specific to the disease. The differential diagnosis is extensive, including blood diseases, endocrine disorders, neurologic problems, psychiatric disorder (particularly depression) and rheumatologic disease.
Blood testing is done for the most obvious cases and viral studies are ordered when the history suggests exposure to a certain pathogen. People with CFS generally endure rigorous work-ups before a diagnosis is settled on.
The cause of CFS is still unknown. A major thought is that the immune system is involved and that the same virus that causes mononucleosis might be involved, but there is only passive association. Genetics have been looked into, as has involvement of the adrenal system, because cortisol levels have been found to be low in those with CFS. Depression and sleep disorder as primary causes for CFS have also been explored, but without clear-cut evidence of a cause and effect relationship.
Sadly, to date, there hasn’t been an effective treatment for CFS. Most pharmacologic and medical treatments have been unsuccessful—antiviral agents, cortisone replacement, melatonin, antidepressants, and medicine used in neurologic problems have not shown consistent benefit.
Cognitive behavior therapy, which emphasizes the role of thought and resulting action, has helped somewhat, as has progressive exercise therapy. Some people respond to treatment, some respond to time, and some don’t respond at all.
Clinical trials are ongoing with newer medications to see if there is any long-lasting beneficial effect.
CFS generally doesn’t have an increased mortality, although resulting depression and inactivity can cause other medical problems which may require a rating. There is also a significantly increased incidence of unemployment with CFS, and disability is quite common. There should always be a work-up for other causes of serious and treatable disease before the diagnosis of CFS is given as a lasting one.
Robert Goldstone, MD, FACE, FLMI
Goldstone, board certified internist and endocrinologist, is vice president and chief medical officer for Pacific Life and Pacific Life and Annuity. He has extensive brokerage and life insurance experience, having been medical director at both MetLife Brokerage and Transamerica Occidental Life. Goldstone is board certified in insurance medicine and the inaugural recipient of the W. John Elder Award for Insurance Medicine Journalism Excellence. He was also honored as a fellow of the prestigious American College of Endocrinology and has written monthly for Broker World since 1990. Goldstone can be reached by telephone at 949-420-8390. Email: firstname.lastname@example.org.