Chronic Fatigue Syndrome/Myalgic Encephalomyelopathy Christopher Chiu MRCP PhD

Introduction Common condition Common condition –1 in 250 sufferers –80% undiagnosed –More common in women & middle-aged/elderly –Cause unclear despite >3000 research papers Causes Causes Definitions Definitions Other causes of fatigue Other causes of fatigue Treatments Treatments

Causes Genetic Genetic –More common within families –More likely in identical twins Infectious Infectious –Many pathogens linked –Chronic or post-infective Endocrine Endocrine Psychosocial Psychosocial

Definitions Center for Disease Control Center for Disease Control –Unexplained, persistent fatigue not due to ongoing exertion, not substantially relieved by rest, of new onset and resulting in significant reduction in previous levels of activity AND –Four or more for 6 months or more  Impaired memory/concentration  Postexertional malaise  Unrefreshing sleep  Muscle pain  Multijoint pain without swelling/redness  Headaches of new type/severity  Sore throat  Tender lymph nodes

NICE guidelines 2007 Additional symptoms Additional symptoms –Dizziness –Nausea –Palpitations Symptoms fluctuate & change over time Symptoms fluctuate & change over time Signs of other serious conditions Signs of other serious conditions –Neurological signs –Inflammation of joints –Heart/lung disease –Weight loss –Enlarged lymph nodes

Other causes of fatigue Infectious Infectious –EBV, CMV, HHV-6, HIV, Influenza –Lyme disease, TB –Toxoplasmosis Endocrine Endocrine –Hypothyroidism –Diabetes –Adrenal disease Vitamin deficiency Vitamin deficiency –B12, folate, D, iron Haematologic Haematologic –Anaemia –Occult malignancy Autoimmune Autoimmune Psychiatric Psychiatric

Diagnosis History History Examination Examination Urinalysis Urinalysis Blood tests Blood tests –Liver & thyroid function tests –Glucose Radiology Radiology

Management Acknowledgement of the condition Acknowledgement of the condition Shared decision-making Shared decision-making No known pharmacological treatment No known pharmacological treatment Symptom relief if necessary Symptom relief if necessary Sleep management Sleep management Rest periods & relaxation techniques Rest periods & relaxation techniques Diet Diet Attempt to maintain work/education Attempt to maintain work/education Graded Exercise Therapy Graded Exercise Therapy

Cognitive Behavioural Therapy Individualised programme Individualised programme Psychological therapy Psychological therapy Used widely in other settings including cardiac rehab & diabetes management Used widely in other settings including cardiac rehab & diabetes management Addresses situations can cause thoughts, actions & feelings that perpetuate problems Addresses situations can cause thoughts, actions & feelings that perpetuate problems

Not recommended Most drugs Most drugs Unstructured vigorous exercise Unstructured vigorous exercise Prolonged/complete daytime rest Prolonged/complete daytime rest Rigid schedule of activity & rest Rigid schedule of activity & rest

Conclusion CFS/ME is difficult to diagnose & treat CFS/ME is difficult to diagnose & treat Underlying causes are not known Underlying causes are not known Important to rule out other severe conditions Important to rule out other severe conditions May have prolonged course with relapses May have prolonged course with relapses Most improve over time & return to work Most improve over time & return to work