Chronic fatigue syndrome: the fundamentals still apply.
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Cognition↗
Biomedical subjects
P Manu
Publications and source records attributed to P Manu.
Alpha-delta sleep in patients with a chief complaint of chronic fatigue.
Our prospective, standardized cohort study was designed to assess the presence of alpha wave intrusions during non-rapid eye movement sleep (alpha-delta sleep) and its relationship to fibromyalgia, major depression, and chronic fatigue syndrome (CFS) in patients with a chief complaint of chronic fatigue. The study group comprised 30 consecutive patients seen at a university hospital referral clinic for evaluation of chronic fatigue. All patients had nocturnal polysomnography, dolorimetric tender point assessment for fibromyalgia, a comprehensive history, physical, and laboratory evaluation, and a structured psychiatric interview. Alpha-delta sleep was identified in 8 of the 30 patients (26%), major depression in 20 (67%), CFS in 15 (50%), and fibromyalgia in 4 (13%). Ten of the 30 patients (33%) had a primary sleep disorder (sleep apnea, periodic limb movements, or narcolepsy). Alpha-delta sleep was not significantly correlated with fibromyalgia, CFS, major depression, or primary sleep disorders, but was significantly more common among patients who had chronic fatigue without major depression. We conclude that primary sleep disorders are relatively common among patients with chronic fatigue and must be diligently sought and treated. Alpha-delta sleep is not a marker of fibromyalgia or CFS, but may contribute to the illness of nondepressed patients with these conditions.
Adolescent↗
Food intolerance in patients with chronic fatigue.
Intolerance to various foods is reported often by patients seeking evaluation for chronic fatigue, a common symptom in primary care practice. To assess the prevalence and significance of this phenomenon we studied 200 consecutive patients with chronic fatigue who were given a comprehensive medical and psychiatric evaluation. Intolerance to foods from at least three different groups was reported by 27 patients (13.5%). We compared these patients with 27 age- and gender-matched patients from the same cohort of fatigued patients. Physical examination and laboratory testing showed few abnormalities in either group. The two groups were similar with respect to the duration and severity of fatigue, lifetime depressive symptoms, and prevalence of current depressive disorders (67% vs. 63%) and anxiety disorders (11% vs. 15%). Patients with multiple food intolerance had more lifetime functional somatic symptoms (p < .05) and a significantly higher (33% vs. 7%) prevalence of somatization disorder (p < .025). These data suggest that intolerance to multiple foods is probably not a cause or the effect of chronic fatigue, but rather one of the manifestations of the somatization trait expressed in these patients.
Adult↗
Chronic fatigue and chronic fatigue syndrome: clinical epidemiology and aetiological classification.
To determine the medical and psychiatric diagnoses that have an aetiological role in chronic fatigue we conducted a prospective study of 405 (65% women) patients who presented for evaluation with this chief complaint to an academic medical centre. The average age was 38.1 years and the average duration of fatigue at entry in the study was 6.9 years. All patients were given comprehensive physical and laboratory evaluations and were administered a highly structured psychiatric interview. Psychiatric diagnoses explaining the chronic fatigue were identified in 74% of patients and physical disorders were diagnosed in 7% of patients. The most common psychiatric conditions in this series were major depression, diagnosed in 58% of patients, panic disorder, diagnosed in 14% of patients, and somatization disorder, diagnosed in 10% of patients. Primary sleep disorders, diagnosed in 2% patients, and chronic infections, confirmed in 1.6% patients, explained the majority of cases whose chronic fatigue was attributed to a physical disorder. Thirty per cent of patients met the criteria used to define the chronic fatigue syndrome (CFS). Compared with age- and gender-matched control subjects with chronic fatigue, CFS patients had a similarly high prevalence of current psychiatric disorders (78% versus 82%), but were significantly more likely to have somatization disorder (28% versus 5%) and to attribute their illness to a viral infection (70% versus 33%). We conclude that most patients with a chief complaint of chronic fatigue, including those exhibiting the features of CFS, suffer from standard mood, anxiety and/or somatoform disorders. Careful research is still needed to determine whether CFS is a distinct entity or a variant of these psychiatric illness.
Adult↗
Chronic fatigue syndromes in clinical practice.
Chronic fatigue is a common and difficult challenge in clinical practice. The majority of patients with this chief complaint have treatable mood or anxiety disorders, complicated by a tendency toward somatization. A minority of patients suffer from sleep disorders, endocrinologic abnormalities, or chronic inflammatory conditions. Prolonged recovery after viral infections is only rarely the cause of chronic fatigue. Specific pharmacologic interventions and cognitive-behavioral therapy are effective in an environment that is sensitive to the patient's interpretation of symptoms and avoids unproven medical investigations and therapies.
Adult↗
The pathophysiology of chronic fatigue syndrome: confirmations, contradictions, and conjectures.
OBJECTIVE: To examine published data regarding patient cohorts with the recently defined chronic fatigue syndrome. METHOD: Review of thirty-two peer-assessed research publications that included full disclosure of the methodology employed; classification of the findings as confirmed, contradictory, or non-duplicated. RESULTS: Research studies have confirmed that the majority of patients with the chronic fatigue syndrome: 1) are white middle-aged women, 2) have a high prevalence of current major depression and somatization disorder, 3) have abnormal personality traits, 4) believe that their fatigue has a physical cause, and 5) show mild abnormalities of humoral immunity. Contradictory data have been presented with regard to: 1) the time of onset of depressive disorders, 2) the etiologic role of herpetic and enteroviral infections, 3) the presence of abnormal cellular immunity, and 4) the clinical utility of immunoglobulin therapy. Non-duplicated research has indicated 1) hypothalamic-pituitary-adrenal axis dysfunction, 2) abnormalities on magnetic resonance images of the brain, 3) altered cytokine production, and 4) the possibility of retroviral infection. CONCLUSIONS: As presently defined, the chronic fatigue syndrome has many of the clinical and biological features associated with depressive and somatoform disorders. A specific etiologic role for infections or immune dysfunction has not been confirmed.
Adrenocorticotropic Hormone↗
Depression and somatization in the chronic fatigue syndrome.
PURPOSE: To report the prevalence, clinical features, and diagnostic associations of the proposed chronic fatigue syndrome (CFS) in a cohort of patients with chronic fatigue and to assess the usefulness of a structured psychiatric interview for detecting previously unrecognized psychiatric morbidity in patients with CFS. PATIENTS AND METHODS: A consecutive sample of 200 adult patients with a chief complaint of chronic fatigue was prospectively evaluated in a referral-based clinic within a university general medicine practice. All patients received a thorough medical history, physical examination, diagnostic laboratory testing, and portions of the Diagnostic Interview Schedule, version III-A. The criteria for CFS were applied, and patients with CFS were compared with matched control subjects from the inception cohort. RESULTS: The 60 patients with CFS had similar likelihoods of current psychiatric disorders (78% versus 82%), active mood disorders (73% versus 77%), and preexisting psychiatric disorders (42% versus 43%) when compared with fatigued control subjects. Patients with CFS were more likely to have somatization disorder (p less than 0.001) and to attribute their illness to a physical cause (p less than 0.005) than fatigued controls. Patients with CFS also displayed functional symptoms, often lifelong, which are not part of the case definition of CFS. Depressive features in patients with CFS were similar to those of control subjects, but a trend toward suicidal behavior was noted. CONCLUSIONS: Patients with CFS have a high prevalence of unrecognized, current psychiatric disorders, which often predate their fatigue syndrome. Assessment of patients with CFS should include a structured psychiatric evaluation.
Adult↗
Evaluation and management of patients with chronic fatigue.
Chronic fatigue is a common and disabling problem in primary care practice. The differential diagnosis of chronic fatigue is extensive and includes medical disorders, altered physiologic states (eg, pregnancy, exertion), psychiatric disorders, lifestyle derangements, drugs, and controversial entities (eg, chronic candidiasis, food allergies, environmental illness, and chronic fatigue syndrome). The most common diagnoses are psychiatric disorders, including mood, anxiety, and somatoform disorders. A comprehensive approach to diagnosis and management is necessary, including structured psychiatric interviewing, functional assessment, and elicitation of the patient's diagnostic beliefs. Patients often believe they are suffering from an organic medical disorder (eg, viral or immunologic) and resist psychiatric labelling of their symptoms and referral to mental health practitioners. Establishing and maintaining rapport, having a flexible approach, and demonstrating a personal concern for the patient is essential. Drug therapy for specific psychiatric and medical illnesses and cognitive-behavioral approaches for enhancing coping mechanisms are effective.
Adult↗
Panic disorder among patients with chronic fatigue.
Among 200 adults with a chief complaint of chronic fatigue evaluated in an internal medicine practice, currently active panic disorder was diagnosed in 26 patients (13%), a frequency tenfold greater than that in the general population. Panic disorder preceded or was coincidental with the onset of chronic fatigue in 21 of these patients. In comparison with the rest of the study cohort, significantly more patients with panic disorder had a history of severe depression, including persistent thoughts of death or suicide. Moreover, more patients with panic disorder showed a lifetime tendency to have physical symptoms that remained unexplained after medical evaluation. Our findings suggest that treatable panic disorder is an important contributor not only to major depression and somatization, but also to the etiology and clinical presentation of chronic fatigue in patients in an outpatient practice.
Adult↗
Antibodies to Epstein-Barr virus in patients with chronic fatigue.
To clarify the role of Epstein-Barr virus (EBV) infection and the value of EBV antibody testing in evaluating patients with chronic fatigue, we studied 200 consecutive patients with chronic fatigue (mean duration, 9 years). Complete EBV serologic panels were obtained for 154 patients, 35 (23%) of whom met serologic or clinical criteria for chronic or reactivated EBV infection. We compared these patients with chronic EBV infection (CEBV cases) to 35 age- and sex-matched patients who were selected from the same cohort of fatigued patients but who did not meet the criteria (CEBV control subjects). We found few differences between groups in demographic characteristics, clinical features, and symptoms; CEBV cases were more likely to meet criteria for the proposed chronic fatigue syndrome (14% vs 0%), and to report that they suffered from an influenza-like illness at the onset of their fatigue syndrome (34% vs 12%), that they lost their job because of their fatigue (37% vs 11%), and that their fatigue was improved by recreational activity (26% vs 3%). Physical examination and laboratory testing showed few abnormalities in either group. Psychiatric morbidity was common in both groups, including mood disorders (63% of CEBV cases vs 54% of CEBV controls), anxiety (11% vs 9%) and somatization disorder (9% in each group). We conclude that EBV serologic patterns have little clinical usefulness in evaluating patients with chronic fatigue.
Adult↗
Substance use disorders in patients with chronic fatigue.
A high prevalence of mood disorders has been found among persons with chronic fatigue. The comorbidity of mood disorders and substance use disorders has long been recognized. In this study, the prevalence of substance use disorders among 100 patients with chronic fatigue was examined. Twenty-eight patients met DSM-III-R criteria for a lifetime diagnosis of substance abuse or dependence; ten of these patients had a current diagnosis. Forty-nine patients had no history of substance abuse or dependence but had other lifetime psychiatric diagnoses. Twenty-three patients had no history of substance abuse or psychiatric illness. No differences in demographic characteristics or in the features of chronic fatigue were found among the three groups. Patients with chronic fatigue who had a lifetime history of a substance use disorder reported more lifetime depressive symptoms and were more likely to have had suicidal ideation or attempts.
Adult↗
The low yield of physical examinations and laboratory investigations of patients with chronic fatigue.
Fatigue is a common symptom but guidelines for its appropriate evaluation are lacking. The authors prospectively studied 100 adults with a chief complaint of fatigue lasting at least 1 month in order to determine the diagnostic contribution of physical examinations and laboratory investigations. The evaluations were performed in the specialized clinic of a faculty practice. Physical examinations produced diagnostic information in 2% of patients, and laboratory investigations elucidated the cause of fatigue in 5% of patients. Structured follow-up evaluations after an average interval of 10 months failed to reveal any new organic causes for the fatigue symptom. Minor laboratory abnormalities were relatively common but did not contribute to the diagnostic process and did not seem to influence the clinical outcome. The authors conclude that the traditional medical evaluation of patients complaining of chronic fatigue has a low yield in discovering treatable physical disorders.
Adult↗
How much practice makes perfect? A quantitative measure of the experience needed to achieve procedural competence.
Based on the general learning curve formula, the authors have devised a method to estimate the experience needed to achieve competence in the performance of medical and surgical procedures. The method quantitates the learning ability of the trainee, the technical difficulty of the procedure, and the expected level of competence. Two retrospective applications demonstrate the ease of use and reliability of the method.
Clinical Competence↗
Yeast connection among 100 patients with chronic fatigue.
PURPOSE: Patients with the "yeast connection" are characterized by fatigue and multiple systemic symptoms. The purpose of our study was to compare patients with chronic fatigue who believed they had the yeast connection to patients with chronic fatigue without the yeast connection. PATIENTS AND METHODS: One hundred consecutive patients with a chief complaint of chronic fatigue were evaluated in a specialty clinic setting at the University of Connecticut Health Center. A complete history was obtained from each patient, and a 168-item review of systems and a complete physical examination were performed. RESULTS: Eight patients believed that their fatigue was due to chronic candidiasis. Of these eight, seven had psychiatric diagnoses that were judged to underlie their fatigue. Of the remaining 92 patients with chronic fatigue, 59 had underlying psychiatric diagnoses. We were unable to find historical, physical, or laboratory differences between chronic fatigue patients with or without the yeast connection. CONCLUSION: From this study and a review of the literature, we are unable to identify findings that are specific for the yeast connection.
Adult↗
Screening for cancer and coronary risk factors through a nurse practitioner-staffed preventive health clinic.
The Preventive Health Examination (PHE) program was designed to screen for cancer of the lung, colon, skin, and prostate (or breast) and to detect the risk factors for coronary artery disease, i.e., arterial hypertension, hypercholesterolemia, cigarette smoking, and obesity. To investigate the cost-effectiveness of PHE performed by nurse practitioners, the first 176 subjects enrolled in the PHE program at a northeastern, suburban VA Medical Center were evaluated prospectively. The subjects were recruited through random mailing. The direct cost of PHEs was $80 per patient. PHEs were performed on 171 men and 5 women, mean age 57.2 years, divided into groups according to the date of evaluation. Nine percent of patients had findings highly suspicious of cancer (lung nodules in 7, skin lesions in 9). As a consequence, one patient underwent lobectomy for squamous carcinoma of the lung and another underwent prostatectomy for adenocarcinoma of the prostate. Fifty-five percent of patients had high cholesterol levels, 53% were obese, 30% were heavy cigarette smokers, and 19% were hypertensive. Nineteen percent of the patients had three or more coronary artery disease risk factors. We conclude that low cost PHEs performed by nurse practitioners have a high yield in detecting risk factors for coronary artery disease, and for detecting potentially treatable malignancies.
Adult↗
Screening for somatization disorder in patients with chronic fatigue.
The current definition of Somatization Disorder requires the assessment of each of 35 symptoms, 13 of which have to be scored as meeting special criteria (e.g., not due to medical reasons) in order to make the diagnosis. The detailed questioning and probing about each symptom can be quite elaborate--hence the interest in developing briefer screening indexes. This study evaluated two sets of screening indexes for Somatization Disorder (those of Othmer and DeSouza and Swartz and colleagues) that had been previously developed in psychiatric and community samples. One hundred medical outpatients with chronic fatigue constituted the study sample. The patients underwent thorough medical evaluations and were administered the Diagnostic Interview Schedule (DIS) to make the psychiatric diagnoses. Of the two screening sets, the one developed in a psychiatric outpatient sample (Othmer and DeSouza's) had the best sensitivity. Although a screening index derived from the DIS interviews of this group of patients also had excellent sensitivity, we support the use of Othmer and DeSouza's index in medical outpatients with a chief complaint of chronic fatigue.
Fatigue↗
Somatization disorder in patients with chronic fatigue.
One hundred adults with a chief complaint of chronic fatigue were evaluated in an outpatient setting to determine a possible association with somatization disorder. Somatization disorder was diagnosed in 15 patients. Eight functional somatic symptoms were reported more frequently by these patients: pain in extremities, joint paint, chest pain, other pain, shortness of breath, blurred vision, muscle weakness, and sexual indifference (p less than 0.001). Current mood disorders, anxiety disorders, and psychoactive substance use disorders were less common in patients with somatization disorders than in patients without this diagnosis (p less than 0.01).
Adult↗
Medically unexplained physical symptoms, somatization disorder and abridged somatization: studies with the Diagnostic Interview Schedule.
This paper reviews recent research that used the Diagnostic Interview Schedule (DIS) to characterize medically unexplained symptoms and their clustering in clinical and community populations. While the type of symptom(s) differed little across samples, the distribution of a less restrictive construct of somatization ('abridged' somatization) showed interesting differences across the various groups. The authors propose that in view of its relatively high prevalence, abundant psychiatric comorbidity and the simple and unintrusive nature of the assessment, use of the abridged construct may have practical value particularly when exploring psychopathology among medical and community populations.
Fatigue Syndrome, Chronic↗