Chronic Fatigue Syndrome

Description

Treatment

There is no proven or reliable cure for CFS, and no drug has been developed specifically for this disorder. Because CFS remains poorly understood, many patients have problems finding good care. Overall, the recommended strategy for treatment includes combination of the following:

• Cognitive-behavioral therapy (CBT) and graded exercise may be helpful for certain patients.
• Antidepressant drugs in some cases, usually low-dose tricyclic.
• A healthy diet.
• Sleep management techniques and/or drugs.

Patients with the best chance for improvement are those who remain as active as possible and who seek to have some control over the course of the disorder. Patients should seek physicians who are willing to consider the problem as a medical condition with psychiatric components. They should be very wary, however, if the physician recommends excessive and expensive treatments that may have serious adverse effects and that have no proven benefits. For patients with severe CFS that cannot be managed with lifestyle changes and standard medications, asking the physician about enrolling in any available clinical trials may be helpful.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT is designed to help patients regain a sense of control and is proving to have substantial benefits for some patients. Some experts believe that patients who are diagnosed with CFS should immediately be referred to therapists trained in cognitive-behavioral therapy. (Psychoanalysis and other interpersonal psychological therapies, which are concerned with subconscious thoughts and early childhood memories, are not generally helpful for the CFS patient.)

The Goals of Cognitive-Behavioral Therapy. The primary goals of cognitive-behavioral therapy (referred to below as just cognitive therapy) are to change any distorted perceptions that individuals have of the world and of themselves and to change their behavior accordingly. For CFS patients, this means learning to think differently about their fatigue and to improve their ability to deal with stressful situations and manage their disorder. Cognitive therapy is particularly helpful in defining and setting limits, behaviors that are extremely important for these patients.

The Procedure. Cognitive therapy may be expensive and not covered by insurance, although it is usually of short duration, typically six to 20 one-hour sessions. Patients are also given homework, which usually includes keeping a diary and attempting tasks that they have avoided because of negative attitudes.

A typical cognitive therapy program may involve the following measures:

• Keep a Diary. The patient is almost always asked to keep an energy diary, which can be a key component of CFS cognitive therapy. The diary serves as a general guide for setting limits and planning activities. The patient uses the diary to track any factors, such as a job or a relationship that may be making the fatigue worse or better. It is also used to track the times of day when energy levels are at their highest and lowest peaks.
• Adjust Schedule. The patient adjusts schedules to conform to energy peaks and valleys recorded in the diary. For instance, the patient may plan low-energy times for taking a nap and high-energy times for planning important activities. Developing fairly rigid daily routines around probable energy spurts or drops may help establish a more predictable pattern.
• Confront Negative or Discouraging Thoughts. Patients are taught to challenge and reverse negative beliefs (e.g., I'm not good enough to control this disease, so I'm a total failure.") to using coping statements ("Where is the evidence that I can control this disease?")
• Be Flexible. Energy levels will most likely never be entirely predictable. Patients must also be prepared to adapt to energy variations. Instead of a long nap, for instance, patients may need five to 10 minutes rest periods every hour or more, during which time relaxation or meditation methods are useful.
• Set Limits. Limits are designed to keep both mental and physical stress within a manageable framework so that patients do not get discouraged by forcing themselves into situations in which they are likely to fail. For example, tasks are broken down into incremental steps and patients focus on one at a time.
• Prioritize. Patients learn to drop some of the less critical tasks or delegate them to others.
• Manage Impaired Concentration. Patients seek out activities that are appealing, focus attention, and help increase alertness. They learn to request instructions given as concise simple statements. External distractions, such as music or talking, are kept to a minimum.
• Accept Relapses. Over-coping and accomplishing too much too soon can often cause a relapse of symptoms. Patients should respect these relapses and back off. They should not consider them a sign of treatment- or self-failure.

Using both self-observation and specific tasks, patients gradually shift their fixed ideas that they are helpless against the fatigue that dominates their lives to the perception that fatigue is only one negative and, to a degree, a manageable experience among many positive ones.

Success Rates. A 2001 review of CFS trials reported that, of all therapies available to CFS patients, only cognitive behavior therapy and graded exercise showed conclusive benefits. The following are some specific studies reporting results on the cognitive therapy approach:

• One study compared patients receiving standard medical care with those receiving the same treatment plus cognitive therapy. Nearly three quarters of the cognitive group were spending less time in bed and functioning normally after a year. Only 27% of those who received standard therapy improved.
• In another study, 70% of patients improved significantly after six months of cognitive therapy, compared to 19% who used only relaxation techniques. A follow-up study done five years later reported that 68% of the cognitive group still rated themselves as much or very much improved, compared to 38% of the relaxation group. Furthermore, 80% of patients who had originally received cognitive therapy continued to use it.
• In a 2001 study, even health workers who had not been trained before in cognitive therapy achieved improvement using these techniques in nearly half of the patients they treated.
• Some experts believe that this approach may be particularly important for victims of Gulf War syndrome, regardless of the cause, since there are no other proven treatments for this condition.

Not all studies support the benefits of cognitive therapy for CFS. It is important to note that different therapists may have different fundamental assumptions about CBT and may employ dissimilar techniques. For instance, some therapists believe that CFS is purely a psychological problem and that patients must reject the notion of physical causes, abandon all reliance on assistive devices, and participate in challenging exercise programs. In contrast, other therapists do not attempt to change patients underlying beliefs at all, but instead focus on helping patients conserve energy and better cope with the limitations of their illness. When considering CBT, patients and their families must be aware of such important differences.

Regardless of whether specific organic causes of CFS are identified, the power of the mind to improve or oppose health problems is significant, and treatments that promote a positive outlook are beneficial for any disease.

Graded Exercise

A number of studies have suggested that a graded exercise program, in which patients perform increasingly more intense levels of exercise tailored to their individual abilities, has benefits for many patients with CFS. Exercise is best performed in concert with cognitive behavioral therapy.

The following are specific studies attesting to the benefits of graded exercise:

• In two 2001 studies, between 69% and 80% of patients who engaged in a self-managed graded exercise program reported improvement. In one of the studies, the benefits persisted for at least a year. (Still, 32% of patients complained of fatigue at the end of this period.)
• Another 2001 study reported that patients recovering from mononucleosis who began a graded exercise program were significantly less likely to develop chronic fatigue syndrome within seven months than patients who did not exercise. No proof exists, however, that CFS is actually caused by physical unfitness. Rather, most studies suggest that CFS itself limits exercise and causes a cycle of poor conditioning and worsening symptoms.

Other reports have found that 75% of CFS patients who were able to engage in exercise, particularly aerobic exercise, reported less fatigue and better daily functioning and fitness after a year.

Some patient groups and experts contend that such studies use only patients with less severe conditions and do not apply to many CFS patients. Many patients have severe conditions and some are very incapacitated (e.g., wheel-chair bound). Such patients are unlikely to undergo even graded exercise. All CFS patients, in fact, have a lower exercise capacity than healthy individuals, and over-exercising can intensify symptoms. Some patients experience profound fatigue following even modest exercise. It is the primary factor in perpetuating the low-activity levels observed in these patients.

The following tips may be helpful for CFS patients when embarking on an exercise program:

• Start slowly and incrementally, beginning with as little as three to five minutes of moderate exercise a day. The goal is to increase activity by about 20% every two to three weeks. (Capacity varies greatly among CFS sufferers, however, and some may not be able to achieve this.)
• Establish limits and keep within them in order to avoid overexertion and relapse. In one study, a CFS patient reported significant improvement in mood and increased the duration of the exercise from 0 to 155 minutes a week. However, he only modestly increased the actual number of steps taken. In other words, he improved by exercising longer but at the same down he slowed down.
• Experiment with different forms of physical activity that suit available energy levels. Some patients report great benefits from yoga or Tai Chi, which combine exercise with meditation.
• Setbacks will occur, but do not become discouraged.

Healthy Diet

Although there is no evidence to support any specific dietary factors in CFS, patients should be sure to maintain a healthy diet that includes the following:

• Plenty of fresh dark-colored fruits and vegetables, which are rich in antioxidants.
• Fiber-rich foods.
• Some fats may be beneficial, but avoid saturated fats (found in animal products). A few studies reported some improved symptoms in patients who consumed black currant and fish oils (sold in supplement form as EPA-DHA omega 3). These oils contain fatty acids that help block certain immune factors responsible for promoting damaging inflammation.
• For those with demonstrated low blood pressure, increasing the amount of salt in the diet may be helpful.

Other Approaches For Managing Chronic Fatigue Syndrome

Stress Reduction Techniques. One panel of experts concluded that relaxation and stress-reduction techniques were helpful in managing chronic pain. They also can help relieve the stress associated with the disease. They are not useful, however, as the primary treatment for CFS. A number of relaxation techniques are available:

• Deep breathing exercises.
• Muscle relaxation techniques.
• Meditation.
• Hypnosis.
• Biofeedback.
• Massage therapy.

Light Therapy. Light therapy (phototherapy) has been used by some CFS patients. A 2002 study, however, reported no improvement in symptoms with its use. It may still help some patients with CFS whose symptoms have a seasonal variability that is similar to those of patients with seasonal affective disorder (SAD). (Patients with SAD experience more depression during the winter, when the hours of sunlight wane.) With phototherapy, the patient sits a few feet away from a box-like device that emits very bright fluorescent light (10,000 lux) for about 30 minutes every day. It is best performed immediately after awakening in the morning.

Fasting. Short-term fasting has been helpful for some patients with chronic fatigue syndrome. Such behavior may help restore certain immune factors and brain chemicals that may be involved with regulating fatigue.

Supportive Family and Groups. Strong, supportive relationships with family and friends may be an important factor in the overall improvement of CFS patients. It should be strongly noted, however, that many CFS patients are overly dependent and should not impose expectations that cannot be met on loved ones. Ongoing support groups with fellow patients may be very helpful. In one 2001 study, sharing experiences in a group therapy setting proved to be the most valuable component and one that improved patients coping abilities.