Fibromyalgia and chronic fatigue syndrome

Fibromyalgia and chronic fatigue syndrome

Fibromyalgia (also known as myofascial syndrome or fibrositis) is characterized by pain and achiness in muscles, tendons, and ligaments. There are 18 locations on the body where patients typically feel sore. These locations include areas on the lower back and along the spine, neck, and thighs. A diagnostic criterion for fibromyalgia (FM) is that at least 11 of the 18 sites are painful. In addition to pain, people with FM may experience sleep disorders, fatigue, anxiety, and irritable bowel syndrome. Some researchers maintain, however, that when fatigue is severe, chronic, and persistent, FM is indistinguishable from chronic fatigue syndrome (CFS). The care that patients receive for FM or CFS depends in large measure on whether they were referred to a rheumatologist (a doctor who specializes in treating diseases of the joints and muscles), neurologist, or psychiatrist.

Some doctors do not accept CFS (also known as myalgic encephalomyelitis in Great Britain) as a legitimate medical problem. This refusal is stigmatizing and distressing to the person who must cope with disabling pain and fatigue. It is not uncommon for people with CFS to see a number of different physicians before finding one who is willing to diagnose CFS. Nevertheless, major health agencies, such as the Centers for Disease Control (CDC) in the United States, have studied the syndrome. As a result, a revised CDC case definition for CFS was published in 1994 that lists major and minor criteria for diagnosis. The major criteria of CFS include the presence of chronic and persistent fatigue for at least six months; fatigue that does not improve with rest; and fatigue that causes significant interference with the patient's daily activities. Minor criteria include such flu-like symptoms as fever; sore throat; swollen lymph nodes; myalgia (muscle pain); difficulty with a level of physical exercise that the patient had performed easily before the illness; sleep disturbances; and headaches. Additionally, people often have difficulty concentrating and remembering information; they experience extreme frustration and depression as a result of the limitations imposed by CFS. The prognosis for recovery from CFS is poor, although the symptoms are manageable.

Psychological disorders

While fatigue may be caused by many organic diseases and medical conditions, it is a chief complaint for several mental disorders, including generalized anxiety disorderand clinical depression. Moreover, mental disorders may coexist with physical disease. When there is considerable symptom overlap, the differential diagnosis of fatigue is especially difficult.

GENERALIZED ANXIETY DISORDER.People are diagnosed as having generalized anxiety disorder (GAD) if they suffer from overwhelming worry or apprehension that persists, usually daily, for at least six months; and if they also experience some of the following symptoms: unusual tiredness, restlessness and irritability, problems with concentration, muscle tension, and disrupted sleep. Such stressful life events as divorce, unemployment, illness, or being the victim of a violent crime are associated with GAD, as is a history of psychiatric problems. Some evidence suggests that women who have been exposed to danger are at risk of developing GAD; women who suffer loss are at risk of developing depression, and women who experience danger and loss are at risk of developing a mix of both GAD and depression.

While the symptoms of CFS and GAD overlap, the disorders have different primary complaints. Patients with CFS complain primarily of tiredness, whereas people with GAD describe being excessively worried. In general, some researchers believe that anxiety contributes to fatigue by disrupting rest and restorative sleep.

DEPRESSION.In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV), the presence of depressed mood or sadness, or loss of pleasure in life, is an important diagnostic criterion for depression. Daily fatigue, lack of energy, insomnia and hypersomnia are indicators of a depressed mood. The symptoms of depression overlap with those of CFS; for example, some researchers report that 89% of people with depression are fatigued, as compared to 86%100% of people with CFS. The experience of fatigue, however, seems to be more disabling with CFS than with depression. Another difference between CFS and depression concerns the onset of the disorder. Most patients with CFS experience a sudden or acute onset, whereas depression may develop over a period of weeks or months. Also, while both types of patients experience sleep disorders, CFS patients tend to have difficulty falling asleep, whereas depressed patients tend to wake early in the morning.

Some researchers believe that there is a link between depression, fatigue, and exposure to too much REM sleep. There are five distinct phases in human sleep. The first two are characterized by light sleep; the second two by a deep restorative sleep called slow-wave sleep; and the last by rapid eye movement or REM sleep. Most dreams occur during REM sleep. Throughout the night, the intervals of REM sleep increase and usually peak around 8:30 A.M. A sleep deprivation treatment for depression involves reducing the patient's amount of REM sleep by waking him or her around 6:00 A.M. Researchers think that some fatigue associated with disease may be a form of mild depression and that reducing the amount of REM sleep will reduce fatigue by moderating depression.

Managing fatigue

The management of fatigue depends in large measure on its causes and the person's experience of it. For example, if fatigue is acute and normal, the person will recover from feeling tired after exertion by resting. In cases of fatigue associated with influenza or other infectious illnesses, the person will feel energy return as they recover from the illness. When fatigue is chronic and abnormal, however, the doctor will tailor a treatment program to the patient's needs. There are a variety of approaches that include:

Aerobic exercise. Physical activity increases fitness and counteracts depression. Hydration (adding water). Water improves muscle turgor or tension and helps to carry electrolytes.

Improving sleep patterns. The patient's sleep may be more restful when its timing and duration are controlled.

Pharmacotherapy (treatment with medications). The patient may be given various medications to treat physical diseases or mental disorders; to control pain; or to manage sleeping patterns.

Psychotherapy. There are several different treatment approaches that help patients manage stress; understand the motives that govern their behavior; or change maladaptive ideas and negative thinking patterns.

Physical therapy. This form of treatment helps patients improve or manage functional impairments or disabilities.

In addition to seeking professional help, people can understand and manage fatigue by joining appropriate self-help groups; reading informative books; seeking information from clearinghouses on the Internet; and visiting web sites maintained by national organizations for various diseases.

See also Brain; Breathing-related sleep disorder; Caffeine and related sleep disorders; Circadian rhythm sleep disorder; Pain disorder; Self-help groups; Somatization and somatoform disordersBOOKS

Beers, Mark H., and Robert Berkow, eds. The Merck Manual of Diagnosis and Therapy.17th ed. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Glaus, A. Fatigue in Patients with Cancer: Analysis and Assessment.Recent Results in Cancer Research, no. 145. Berlin, Germany: Springer-Verlag, 1998.

Hubbard, John R., and Edward A. Workman, eds. Handbook of Stress Medicine: An Organ System Approach.Boca Raton, FL: CRC Press, 1998.

Natelson, Benjamin H. Facing and Fighting Fatigue: A Practical Approach.New Haven, CT: Yale University Press, 1998.

Winningham, Maryl L., and Margaret Barton-Burke, eds. Fatigue in Cancer: A Multidimensional Approach.Sudbury, MA: Jones and Bartlett Publishers, 2000.

PERIODICALS

Natelson, Benjamin H. "Chronic Fatigue Syndrome." JAMA: Journal of the American Medical Association285, no. 20 (May 23-30 2001): 2557-59.