Chronic Fatigue Syndrome

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Chronic, persistent fatigue is one of the hallmark symptoms of Fibromyalgia Syndrome, along with muscle pain and body aches. Fatigue occurs in up to 90% of Fibromyalgia patients. It can be so severe as to impact an individual’s ability and desire to be active and engaged in life. This may lead to self-imposed isolation, depression, and anxiety. The type of fatigue that many Fibromyalgia sufferers describe is comparable to that of the flu – debilitating and exhausting in nature. Others may describe it as brain fatigue, or “Fibro Fog,” which is characterized by decreased ability to think and concentrate. Fatigue may be easily tolerated on days when other Fibromyalgia symptoms are not as prominent; however, on days when Fibromyalgia symptoms are in full swing, fatigue may be much more difficult to deal with. One difficult aspect of fatigue and Fibromyalgia is that most people with Fibromyalgia also experience sleep disturbances that prevent restful sleep. This lack of deep restorative sleep can further aggravate the ongoing fatigue. Fatigue may also be made worse by excess stress.

Fatigue in Fibromyalgia is problematic in that it feeds on itself through a process known as negative feedback. Negative feedback is a cycle in which an event leads to another event, which leads to another and so on. The cycle continues until something terminates it. For example, an individual who experiences severe fatigue may begin to feel stressed and anxious if they are unable to carry out their normal daily activities. This increased stress and anxiety – along with the body aches and pains associated with Fibromyalgia – keep the individual awake and unable to get rest via a nap or at night. The lack of restful sleep causes the individual to become even more fatigued, which perpetuates the stress and anxiety. This cycle continues until something occurs to stop it, such as the individual using relaxation techniques every night prior to bed.

Fibromyalgia and Chronic Fatigue Syndrome

Many researchers believe that there are similarities between the fatigue associated with Fibromyalgia and a condition known as Chronic Fatigue Syndrome (CFS). CFS is a disorder that causes extreme fatigue that does not improve upon receiving rest. It presents a number of clinical features similar to Fibromyalgia, including muscle pain, memory impairment, headaches, joint pain, sleep problems, and painful lymph nodes in the neck. In addition, it most commonly affects women, predominantly those in their 40s and 50s. CFS lasts for a long time and impairs one’s ability to carry out the normal activities of daily living.

CFS is hard to diagnose due to the overlap of its symptoms with other diseases, such as Fibromyalgia. Due to their frequency in women and co-occurring symptoms, Fibromyalgia and CFS are often mis-diagnosed as each other or diagnosed together in the same patient (either correctly or in error). A diagnosis of CFS requires persistent or relapsing fatigue for at least six consecutive months, as well as a minimum of four of the following symptoms:

  • Impaired memory or concentration*
  • Tender lymph nodes in the neck*
  • Sore throat
  • Muscle pain*
  • Pain in multiple joints that is not arthritis*
  • New-onset (meaning not lifelong) headaches, either tension or migraine*
  • Sleep that is not refreshing*
  • General fatigue, pain, and flu-like symptoms following exercise

The symptoms marked with an * are frequently present in patients with Fibromyalgia, illustrating the difficulty in differentiating the diagnosis between Fibromyalgia and CFS. Based on certain diagnostic criteria and the exclusion of other potential causes for these symptoms (such as low iron, arthritis, etc.), if an individual has CFS based on these criteria and still meets established diagnostic criteria for Fibromyalgia, both CFS and Fibromyalgia are generally considered to be co-existing (occurring together) in the same patient. According to Light et al. (2011) the incidence of Fibromyalgia and Chronic Fatigue Syndrome occurring together in the same patient varies depending on the diagnostic criteria used for each condition, however it generally ranges from as low as 21% to as high as 80% of all patients.

It is important to note, however, that many researchers continue to maintain that Fibromyalgia and Chronic Fatigue Syndrome are in fact the same condition, citing the overlapping symptoms, lack of a definitive cause for either condition, and the significant mental health component that accompanies each condition. Not surprisingly, individuals with a diagnosis of both CFS and Fibromyalgia are generally more disabled, including having lower levels of physical functioning, overall health, and increased pain (Brown and Jason, 2007).

Treatment for Chronic Fatigue Syndrome

CFS is a complex illness to treat. There are currently no prescription drugs specifically approved to treat CFS, and since symptoms vary over time it can be very difficult to approach treatment from a symptomatic angle. Much like the treatment of Fibromyalgia, treatment for CFS is most effective when it is individualized to each patient and involves a combination of conventional medical therapies (e.g., professional counseling, drug therapy) and complementary and alternative therapies (e.g., natural and herbal medications).

Some of the traditional medical therapies used to treat the symptoms associated with Chronic Fatigue Syndrome include drug therapy (antidepressants and other medications), professional counseling such as cognitive behavioral therapy (a type of psychological therapy that helps patients understand how their thoughts and feelings affect behavior), exercise, support groups, sleep therapy, and pain management.

Among complementary and alternative therapies, there is some research to suggest that magnesium may possibly help improve the symptoms of Chronic Fatigue Syndrome (Cox et al., 1991). In addition, a number of other natural products have been investigated as treatments for CFS, including: DHEA, evening primrose oil, fish oil, melatonin, NADH, propionyl-L-carnitine, and ribose; unfortunately, findings from these research studies are conflicting and there is insufficient evidence at this time to clearly determine if any of these products is an effective treatment for CFS (Himmel & Seligman, 1999; Behan et al., 1990; Warren et al., 1999;van Heukelom et al., 2006; Williams et al., 2002; Forsyth et al., 1999; Vermeulen et al., 2004; Teitelbaum et al., 2006).

Research Related to Chronic Fatigue Syndrome and Fibromyalgia

There is a fair amount of scientific literature regarding both Chronic Fatigue Syndrome and Fibromyalgia. As both disorders are poorly understood, some research has been conducted to in an attempt to determine a common cause for the co-occurrence of both conditions. Culprit triggers such as biochemical disturbances (Pall, 2001) and viruses (Lund-Olesen and Lund-Olesen, 1994), as well as genetics (Light et al., 2012) have all been investigated.

Since fatigue is the primary overlapping symptom of both CFS and Fibromyalgia, additional research has looked at the similarities and differences with regard to the sleeping patterns and impact of sleep on both conditions separately and together. A recent article by Kishi et al. (2011) evaluated the differences in sleep disturbances among 14 patients with CFS, 12 patients with a concurrent diagnosis of CFS and Fibromyalgia, and 26 healthy control subjects. The researchers found evidence to suggest that those who suffer from CFS alone have greater difficulty awakening, whereas those who have both CFS and Fibromyalgia have greater difficulty transitioning between the various stages/cycles of sleep as well as transitioning from sleep to awake. Spitzer and Broadman (2010) conducted a medical chart review of 118 patients with a diagnosis of either CFS or Fibromyalgia to determine the difference in sleep-related characteristics of both patients and to see if any such detectable differences might be a useful diagnostic tool for physicians. The researchers found excessive amounts of sleepiness as well as narcoleptic symptoms (narcolepsy is a disorder that causes periods of severe sleepiness during the daytime, as well as muscle weakness and difficulty sleeping at night) in both groups.

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References

1.        Light KC, White AT, Tadler S, Iacob E, Light AR. Genetics and gene expression involving stress and distress pathways in Fibromyalgia with and without comorbid Chronic Fatigue Syndrome. Pain Res Treat. 2012;2012:427869.

2.        Kishi A, Natelson BH, Togo F, Struzik ZR, Rapoport DM, Yamamoto Y. Sleep-stage dynamics in patients with Chronic Fatigue Syndrome with or without Fibromyalgia. Sleep. 2011;34(11):1551-1560.

3.        McKay PG, Duffy T, Martin CR. Are Chronic Fatigue Syndrome and Fibromyalgia the same? Implications for the provisions of appropriate mental health intervention. J Psychiatr Ment Health Nurs. 2009;16(10):884-894.

4.        Spitzer AR, Broadman M. A retrospective review f the sleep characteristics in patients with Chronic Fatigue Syndrome and Fibromyalgia. Pain Pract. 2010;10(4):294-300.

5.        Brown MM, Jason LA. Functioning in individuals with Chronic Fatigue Syndrome: increased impairment with co-occurring multiple chemical sensitivity and Fibromyalgia. Dyn Med. 2007;6:6.

6.        Pall ML. Common etiology of posttraumatic stress disorder, Fibromyalgia, Chronic Fatigue Syndrome and multiple chemical sensitivity via elevated nitric oxide/peroxynitrite. Med Hypotheses. 2001;57(2):139-145.

7.        Lund-Olesen LH, Lund-Olesen K. The etiology and possible treatment of Chronic Fatigue Syndrome/Fibromyalgia. Med Hypotheses. 1994;43(1):55-58.

8.     Cox IM, Campbell MJ, Dowson D. Red blood cell magnesium and Chronic Fatigue Syndrome. Lancet. 1991;337:757-760.

9.     Himmel PB, Seligman TM. A pilot study employing dehydroepiandrosterone (DHEA) in the treatment of Chronic Fatigue Syndrome. [Abstract]. J Clin Rheumatol. 1999:5:56-59.

10.     Behan PO, Behan WM, Horrobin D. Effect of high doses of essential fatty acids on the postviral fatigue syndrome. Acta Neurol Scand. 1990;82:209-216.

11.     Warren G, McKendrick M, Peet M. The role of essential fatty acids in Chronic Fatigue Syndrome. A case-controlled study of red-cell membrane essential fatty acids (EFA) and a placebo-controlled treatment study with high dose of EFA. Acta Neurol Scand. 1999;99:112-116.

12.     van Heukelom RO, Prins JB, Smits MG, Bleijenberg G. Influence of melatonin on fatigue severity in patients with Chronic Fatigue Syndrome and late melatonin secretion. Eur J Neurol. 2006;13:55-60.

13.     Williams G, Waterhouse J, Mugarza J, et al. Therapy of circadian rhythm disorders in Chronic Fatigue Syndrome: no symptomatic improvement with melatonin or phototherapy. Eur J Clin Invest. 2002;32:831-837.

14.     Forsyth LM, Preuss HG, MacDowell AL, et al. Therapeutic effects of oral NADH on the symptoms of patients with Chronic Fatigue Syndrome. Ann Allergy Asthma Immunol. 1999;82:185-191.

15.     Vermeulen RC, Scholte HR. Exploratory open label, randomized study of acetyl- and propionylcarnitine in Chronic Fatigue Syndrome. Psychosom Med. 2004;66:276-282.

Teitelbaum JE, Johnson C, St Cyr J. The use of D-ribose in Chronic Fatigue Syndrome and Fibromyalgia: a pilot study. J Altern Complement Med. 2006;12:857-862.

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