Entries in Chronic Fatigue (1)


Troubles of Chronic Fatigue Syndrome or Fibromyalgia

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Disabling fatigue, sleep disorders, muscle pain, joint pain, headaches, tender lymph nodes, sore throat, “postexertional malaise” ? I treat patients with fibromyalgia or chronic fatigue with ultrahigh-dose vitamin D, brief therapy (EMDR, neuroimagination) and whole-body vibration training - with excellent results!

Thomas Hartmann. Erstbesteigung. 2010. Oil on canvas. Gallery Georg Nothelfer, Berlin. 


From the New York Times

March 4, 2011

By David Tuller

...Once a disease can be diagnosed reliably through lab tests, creating an accurate case definition becomes easier. But when an ailment has no known cause and its symptoms are subjective — as with chronic fatigue syndromefibromyalgia and other diseases whose characteristics and even existence have been contested — competing case definitions are almost inevitable.

Now a new study of chronic fatigue syndrome has highlighted how competing case definitions can lead to an epidemiologic “Rashomon” — what you see depends on who’s doing the looking — and has stoked a fierce debate among researchers and patient advocates on both sides of the Atlantic.

The study, published last month in The Lancet, reported that exercise and cognitive-behavioral therapy could help people with the illness. Advocates and some leading experts dismissed the findings and said the authors’ case definition was largely to blame.

The British scientists who conducted the research identified study participants based largely on a single symptom: disabling and unexplained fatigue lasting at least six months. But many researchers, especially in the United States, say that definition takes in many patients whose real illness is not the syndrome but depression — which can often be eased with psychotherapy and exercise.

The Lancet authors “have written their case definition to include both people with major depressive disorders and patients who clearly have received an insult to their immune systems and are depressed because they can no longer do things that they used to,” said Dr. Andreas Kogelnik, an infectious disease specialist in Mountain View, Calif., who treats many people with chronic fatigue syndrome.

In studying the condition, he and other researchers exclude patients whose only symptom is fatigue, however disabling, and instead rely on a case definition that includes other cognitive, neurological and physiological symptoms. Those symptoms, they believe, indicate a complex immune system disorder possibly caused by a virus or another agent.

Since 2009, studies have produced contradictory results over whether viruses related to mouse leukemia are associated with chronic fatigue syndrome, which is also called myalgic encephalomyelitis. A recent study found that people with the illness have distinct proteins in their spinal fluid, raising hope that a diagnostic test can someday be developed.

No case definition is perfect; every disease has outliers. But whether a definition is broadly or narrowly drawn can profoundly affect the statistics vital for public health planning.

No one disputes that many people with chronic fatigue syndrome also suffer from depression. The question is which came first. Are patients depressed because a terrible disease has robbed them of their lives, or is the illness itself a somatic expression of an underlying depression?

To researchers who believe that chronic fatigue syndrome is merely a psychological condition, that distinction may not seem important. But it matters deeply to those convinced it is a viral disease, who say the exercise therapy advised by the Lancet study can cause major relapses in people with chronic fatigue syndrome — a claim supported by some patient surveys.

The single-symptom case definition used by the Lancet authors, known as the Oxford criteria, was developed in Britain in 1991. Like the team that conducted the current study, the 1991 group included prominent mental health professionals.

But many scientists and clinicians view a multisymptom case definition published in 1994 by the Centers for Disease Control and Prevention in the United States as the international standard.

In addition to six months of unexplained, disabling fatigue, the C.D.C. definition requires at least four of eight common symptoms: cognitive problems, sleep disordersmuscle painjoint pain, headaches, tender lymph nodes, sore throat and what is called “postexertional malaise”— a relapse that occurs after even minimal activity.

In 2005, the agency unveiled an “empirical” case definition that recommended specific screening questionnaires and cutoff scores for measuring fatigue, physical dysfunction and other symptoms. Critics challenged these newer guidelines on the same grounds as the Oxford criteria, arguing that the questionnaires and scoring methods were too ambiguous.

In contrast, a 2003 case definition from Canada is considered the most restrictive and is preferred by many patients. It elevates postexertional malaise to a central role in the illness and requires a range of neurological, cognitive, endocrine or immunological symptoms. In 2009, researchers from DePaul University in Chicago reported that 38 percent of patients in a study sample suffering from depression alone were given misdiagnoses of chronic fatigue syndrome using the C.D.C. screening tools but not the narrower Canadian definition.

The study suggests that the disease centers’ “empirical case definition has broadened the criteria such that some individuals with a purely psychiatric illness will be inappropriately diagnosed” with chronic fatigue syndrome, wrote Leonard A. Jason, a professor of community psychology at DePaul, and his colleagues. The authors also noted that using the new screening tools, the C.D.C. had greatly increased its estimate of the prevalence of the illness, to 2.5 percent of the population, or four million Americans.

So the question remains: can therapy and exercise help patients with chronic fatigue syndrome, as the Lancet study reported?

Yes, apparently — if the illness is identified with a case definition relying on fatigue alone. But does the evidence from that study prove that these strategies would help patients identified as having chronic fatigue syndrome through very different criteria? That is a much tougher argument to make.

From the marvelous new book by Heinz Storrer, Stille Orte der Schweiz. Zürich 2010 (Werd Verlag). The beautiful photographic volumes I usually find at my favorite Zurich bookseller, Buchhandlung am Hottingerplatz, Cornelia Schweizer, Hottingerstrasse 35.