Chronic Fatigue Is Normal Aspect

Chronic Fatigue

Fatigue is normal aspect of the human condition. It can be an essential response to lack of proper sleep or diet, physical exertion, emotional stress, allergies or boredom. When the fatigue is chronic, or continues on a regular basis in a more serious manner, it can be a sign of a psychological or physical disorder. Today, chronic fatigue syndrome (CFS) is becoming a commonly diagnosed condition, and healthcare providers are learning how to better manage the variety of symptoms. Although there is no specific cure for the ailment, a number of studies are presently being conducted to find new therapies. Also, because the condition is a relatively new defined condition, controversy exists regarding its definition, etiology, treatment, and pathogenesis in the medical community (Swenson, 2000, p. 37). A great deal more studies have to be conducted in order to better determine how to help individuals cope while they have the illness -- some suffering for their entire lives -- to find ways to reduce the symptoms and, perhaps to eventually find a treatment for the condition itself.

When an outbreak of serious fatigue and lack of physical functioning occurred at the Royal Free Hospital in the United Kingdom in 1955, the condition was called myalgic encephalomyelitis. Based on this incident, epidemiologists later suggested that this was not caused by an infectious agent but instead it was a mass hysteria transmitted by emotional distress (Wessely, 1998, p. 118). During the mid-1980s in the United States, the condition was linked to other chronic illnesses such as mononucleosis and Epstein-Barr virus (EBV) infection (Wessley, 1998, p. 124). It was also informally labeled the "yuppie flu." Soon, too many cases were being diagnosed to be considered part of a different illness or to be ignored.

In 1988, the Center for Disease Control (CDC) assembled a group of clinicians and researchers to formally define and classify these cases. In1994, an international group of researchers proposed clinical and research guidelines for the condition (Demitrack and Abbey, 1996, p.24).

The international panel of research experts who met in 1994 agreed to the official name of Chronic Fatigue Syndrome and provided a definition of that would be useful both to those studying and diagnosing the illness. In order to receive a diagnosis of chronic fatigue syndrome, a patient must satisfy two specific criteria: 1) Have severe chronic fatigue for a duration of six months or longer with other known medical conditions excluded by clinical diagnosis; and 2) Concurrently have four or more of these symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern or severity; unrefreshing sleep; and post-exertional malaise lasting more than 24 hours. The symptoms must persist or reoccur during six or more consecutive months of the illness and not have predated the fatigue (CDC, 2006).

Today, CDC defines the illness as: "a debilitating and complex disorder characterized by profound fatigue that is not improved by bed rest and that may be worsened by physical or mental activity." Individuals having CFS most often function at a substantially lower level of activity than capable of prior to the illness. In addition to these key defining characteristics, patients also report a number of nonspecific symptoms, such as weakness, muscle pain, impaired memory and/or mental concentration, insomnia, and post-exertional fatigue lasting more than 24 hours. Mental health professionals also recognize that CFS often relates to depression. In some cases, CFS can persist for years (CDC, 2006).

No diagnostic tests exist for CFS, but it recommended that specific laboratory tests be taken to exclude other possible causes of illness. This would include, for example serologic tests for EBV. A positive on this test is interpreted as being diagnostic of CFS; there is disagreement on this.

The definition of CFS was derived from research of selected populations who received specialist care. In these populations, 20 to 50% of the patients had chronic fatigue as the most prevalent symptom, affecting between. In the primary care setting, 10% of the patients suffered from significant fatigue that lasted over six months (Wessely, 1998, p 135). Unexplained fatigue of two weeks' duration or longer has been reported to affect up to 24% of adults in the general population (Walker, 1998, 135). The CDC reported that the prevalence of CFS ranged between 4 and 11 cases per 100,000 population. In the United States, most reported cases of CFS occur in young to middle-aged white women.

No one theory is agreed upon as to the cause of CFS, especially because of the complexity of the illness and the number of different symptoms. Commonly proposed theories include a persistent viral infection, primary muscle disorder, chronic immune dysfunction, neuroendocrine disorder, primary sleep disorder, and neuropsychiatric disorders (Komaroff & Fagioli, 1996, p.154). Those who believe it is part of a persistent viral infection report that patients could have chronic Epstein-Barr, chronic enterovirus infection, herpes virus type 6, or T-lymphotrophic virus type II retrovirus infection, cytomegalovirus, hepatitis a, varicella zoster, influenza, and rubella. However, many CFS patients do not have any clinical or laboratory evidence of viral infections (Komaroff & Fagioli, 1996, p.162). Muscle fatigue and pain has been another CFS primary symptom, but research was unable to show a specific abnormality in the muscle of CFS patients. Although Chronic Fatigue is not an autoimmune disease, the infection often seen at the beginning of the illness and the high incidence of allergies suggests this. It is also believed that CFS may partly be due to depression (Lubkin & Larsen, 2006, pg. 167).

Similarly, it was proposed that functionality problems with the hypothalamic pituitary system was a possible cause. However, this evidence is far from certain (Wessely, 1998, p. 248) Also, primary sleep disorder was suggested based on the fact that most CFS patients have disorders that cause considerable daytime fatigue. Research has found that a disruption of the circadian rhythm contributes significantly to the CFS (Wessley, 1998, p. 51).

At this point in time, there is also no agreed upon or accepted treatment for chronic fatigue. It is realized that no one treatment exists, in some cases the condition improves on its own, and in some instances it remains at varying levels or improves and then reoccurs. Thus, most recently, research has investigated the effectiveness of several approaches to treatment. One of the more acceptable answers is cognitive behavioral therapy (CBT).

For example, according to Prins et. al. (2001) thus far, CBT and graded exercise therapy (GET) are the only two found to be beneficial. Prins et. al. compared treatments for chronic fatigue syndrome patients, using support groups, natural course, and cognitive behavior therapy (CBT). They found the patients using CBT showed significantly more improvement after 14 months than those in the other groups, with better prognosis for the future beyond the test. CBT is a type of psychotherapy that stresses the important role of thinking in how people see life and themselves. In this approach, it is believed that the brains are healthy, but is a person's thinking that causes them to feel and act the way they do. Therefore, if they are experiencing feelings of being unwanted, it is essential that they recognize this thought patter and learn how to replace it with positive thoughts. This will lead to positive behavior and better physical and mental health.

Hyland et. al. (2006) believe that the results that Prins finds through her studies on CBT are not actually the cognitive or behavioral aspects of the CBT, but rather from the psychotherapeutic benefits. Prins (Hyland et. al, 2006) disagrees with Hyland, stating that they raise an important issue about the therapy. However, "As they state, we have no idea exactly why and how cognitive behavioral therapy works for chronic fatigue syndrome. In our randomised controlled trial, the treatment effect was not merely the result of the therapeutic alliance, since we controlled for this by looking at support groups who rated the contact with the therapist and the atmosphere in the group as good."

Prins (2006) also recommends using graded exercise theory (GET) as a means for improvement along with the CBT. Graded exercise therapy (GET) involves progressive scheduling of activities starting with low effort physical and social tasks and increasing to more demanding endeavors as tolerance to exertion improves. Over the several years, a number of studies have been published in the British Medical Journal that concluded that a program of graded aerobic exercise is beneficial for CFS patients. The results have led to discussions and debate as with the CBT.

For example Powell (2001) et. al. also looked at CBT and graded exercise as a treatment, because of studies that show that cognitive behavioral therapy and graded exercise administered by highly skilled therapists in specialist centers is an effective intervention for people with chronic fatigue syndrome, with a number needed to treat. Their research findings compared favorably with this outcome.

Wessley (1998, p. 370) states it may be true that exercise may lead to a significant and lasting improvement in some CFS patients. However, he questions the research that has been done in this area. First, he wonders whether the exercise is a placebo effect based on the anticipation of improvement. The second question is the acceptability of this treatment. Many CFS patients actively avoid exercise and many healthcare providers in fact recommend rest at all costs rather than a concern of relapse. However, the positive aspect of the CBT and the exercise is that it has the patients question their fears. In both cases, there is a psychotherapeutic affect that may be beneficial.

The use of antidepressants is another approach that has been suggested and studied. However, the results on this have also been mixed. As Demitrack (1996, p. 282) states, "At the present time, it is unrealistic to present medication as a sole treatment for this disease." It may be that medications could work in the short-term and provide enough symptomatic relief to allow other more lasting nonpharmaceutical therapeutic interventions to help. Future studies should look at combined pharmaceutical and nonpharmaceutical approaches used together.