1. CHRONIC FATIGUE SYNDROME (CFS) DIAGNOSTIC AND ASSESSMENT ISSUES

2. Case Definition [C.D.C., 1994] A) Clinically evaluated, unexplained persistent or relapsing chronic fatigue (  6 months duration) that is of new or definite onset (has not been lifelong); is not the result of ongoing exertion, is not substantially alleviated by rest; and results in substantial reduction in previous levels of occupational, educational, social, or personal activities.

3. Case Definition [C.D.C., 1994] B) Four or more of the following symptoms are concurrently present for > 6 months:B) Four or more of the following symptoms are concurrently present for > 6 months: 1. Impaired memory or concentration1. Impaired memory or concentration 2. Sore throat2. Sore throat 3. Tender cervical or axillary lymph nodes3. Tender cervical or axillary lymph nodes 4. Muscle pain4. Muscle pain 5. Multi-joint pain5. Multi-joint pain 6. New headaches6. New headaches 7. Unrefreshing sleep7. Unrefreshing sleep 8. Post-exertion malaise8. Post-exertion malaise

4. Diagnostic Hints Diagnostic based on inclusion and exclusion criteriaDiagnostic based on inclusion and exclusion criteria No pathognomonic signs or diagnostic tests validated in scientific studiesNo pathognomonic signs or diagnostic tests validated in scientific studies Must have persistent or relapsing, debilitating fatigue for at least 6 mo.Must have persistent or relapsing, debilitating fatigue for at least 6 mo. In the absence of any current or past medical condition that would explain the clinical presentationIn the absence of any current or past medical condition that would explain the clinical presentation

5. A discrete clinical entity? This question raises 2 issues: Usefulness of the diagnosisUsefulness of the diagnosis Overlap with other clinical conditionsOverlap with other clinical conditions

6. A discrete clinical entity? CFS, Fibromyalgia, Irritable Bowel Syndrome or Idiopathic chronic Pain as associated disorders (Goldenberg, 1999)CFS, Fibromyalgia, Irritable Bowel Syndrome or Idiopathic chronic Pain as associated disorders (Goldenberg, 1999) a diagnostic label promoting illness behavior and exaggeration of the expression of disability and pain (Barsky and Borus, 1999)a diagnostic label promoting illness behavior and exaggeration of the expression of disability and pain (Barsky and Borus, 1999)

7. A discrete clinical entity? However a useful diagnosis:However a useful diagnosis: –reassures patients on the absence of a degenerative disease –allow patients to concentrate on getting better rather than getting a diagnosis and searching for a cause or a cure (Goldenberg, 1999)

8. A discrete clinical entity? 90% of patients believed that a diagnosis of CFS was the most helpful factor in managing their symptoms (Hewett et al., 1995)90% of patients believed that a diagnosis of CFS was the most helpful factor in managing their symptoms (Hewett et al., 1995) CFS, FM, and TMD shared many clinical features (e.g., myalgia, fatigue, sleep disturbances, impairment in daily activities)CFS, FM, and TMD shared many clinical features (e.g., myalgia, fatigue, sleep disturbances, impairment in daily activities) (Aaron et al., 2000)

9. A discrete clinical entity? Frequent co-morbidity among CFS, FM, and TMD patients (e.g., 35 to 70% patients with CFS also had FM)Frequent co-morbidity among CFS, FM, and TMD patients (e.g., 35 to 70% patients with CFS also had FM) A stress-related illness, with onset related to acute or chronic emotional stressors, or to a combination of emotional and physical events (Demitrack & Crofford, 1998)A stress-related illness, with onset related to acute or chronic emotional stressors, or to a combination of emotional and physical events (Demitrack & Crofford, 1998)

10. Differential Diagnosis Considerable phenomenological overlap with other functional somatic syndromes Therefore a discussion of a common set of psychosocial factors applies to all of them (Barsky and Borus, 1999)

11. Differential Diagnosis CFS and Depression CFS might be a variant of a neuropsychiatric disorder, such as major depressionCFS might be a variant of a neuropsychiatric disorder, such as major depression (Brickman and Fins, 1993) Frequent comorbidity observed in the population of CFS patients Frequent comorbidity observed in the population of CFS patients (Goodnick, 1993) Issue of directionality (cause or effect)Issue of directionality (cause or effect)

12. Differential Diagnosis CFS and Depression Shared symptoms:Shared symptoms: - persistent fatigue - pain - sleep disturbance - poor concentration - psychomotor retardation - loss of sexual desire (Friedberg & Jason, 2001)

13. Differential Diagnosis CFS and Depression CFS more debilitating than depressionCFS more debilitating than depression More severe neurocognitive symptoms in CFS (e.g., memory and concentration, mental confusion)More severe neurocognitive symptoms in CFS (e.g., memory and concentration, mental confusion) Symptoms less likely to be reported in primary depression (e.g., painful lymph nodes, flu-like symptoms, pressure-like headaches, alcohol intolerance)Symptoms less likely to be reported in primary depression (e.g., painful lymph nodes, flu-like symptoms, pressure-like headaches, alcohol intolerance)

14. Differential Diagnosis CFS and Depression Key distinction:Key distinction: Postexertional malaise and prolonged fatigue after exercise - atypical in primary depression (often mood elevation with exercise) (Moor & Blumenthal, 1998)

15. Differential Diagnosis CFS and Depression Loss of interest (Depression) vs. Loss of ability (CFS)Loss of interest (Depression) vs. Loss of ability (CFS) Ask for 5 things they want to do Cognitive differences:Cognitive differences: - CFS: more likely to endorse tendencies to dwell on fatigue - Depression: thoughts of worthlessness, self-criticism, suicidal ideation more common

16. Differential Diagnosis CFS and Somatization Disorder (SD) Differences in onset:Differences in onset: - CFS: often sudden onset, late 20’s/early 30’s - SD: progressive, starting in adolescence, full-blown somatization by 25 Medically unexplained symptoms in both  hard to delineateMedically unexplained symptoms in both  hard to delineate

17. Differential Diagnosis CFS and Anxiety CFS often accompanied by persistent anxietyCFS often accompanied by persistent anxiety Focus on prominent feature to distinguish GAD from CFS:Focus on prominent feature to distinguish GAD from CFS: - CFS: severe fatigue - GAD: excessive persistent anxiety, not necessary w/pain or profound fatigue (treated w/CBT)

18. Differential Diagnosis CFS and Activity-Induced Chronic Fatigue 2 types of CFS patients:2 types of CFS patients: - severe post exertional fatigue, slightly alleviated by rest - severe overall symptomatology, severe postexertional fatigue, fatigue not alleviated by rest Healthy people: persistent fatigue due to active schedules, high stress, lack of sleep – remission of symptoms with increase in rest and leisure timeHealthy people: persistent fatigue due to active schedules, high stress, lack of sleep – remission of symptoms with increase in rest and leisure time

19. Hypotheses to account for CFS Functional somatic syndromeFunctional somatic syndrome Barsky and Borus (1999); Sharpe and Wessely (1997) Abnormalitites in immune functionsAbnormalitites in immune functions Klimas et al. (1990, 1994); Patarca et al. (1993) Viral etiology of CFSViral etiology of CFS Jones et al. (1985); Straus et al. (1985 ) Perturbations of the HPA axis function Demitrack et al. (1991)Perturbations of the HPA axis function Demitrack et al. (1991) Brain stem hypometabolismBrain stem hypometabolism Buskila (2000)

20. Physiological abnormalities in CFS researchers have extensively tested for:researchers have extensively tested for: - immune status - infectious agents - disorders of the endocrine or central nervous systems No need for such testing in practice unless as part of a protocol-based research study or when the diagnosis is in questionNo need for such testing in practice unless as part of a protocol-based research study or when the diagnosis is in question

21. Explanatory Models of CFS Immune defect ModelImmune defect Model Sleep disturbance ModelSleep disturbance Model Neuroendocrine AbnormalitiesNeuroendocrine Abnormalities “Predisposing Personality” Model“Predisposing Personality” Model Symptom Avoidance ModelSymptom Avoidance Model

22. The Mind & Body Approach Assessed and Treated in a non- specific mannerAssessed and Treated in a non- specific manner But integrated medical- psychiatric approach the clinical assessment and care of functional somatic syndromesBut integrated medical- psychiatric approach the clinical assessment and care of functional somatic syndromes Intervention model based on 4 axesIntervention model based on 4 axes

23. A Multidimensional Model Distinguishes:Distinguishes: - Predisposing factors - precipitating factors - perpetuating factors (Demitrack & Crofford, 1998)

24. A Conceptual Framework and set of Guidelines Need for a comprehensive, systematic, and integrated approach to the evaluation, classification, and study of people with CFS or other fatiguing illnessesNeed for a comprehensive, systematic, and integrated approach to the evaluation, classification, and study of people with CFS or other fatiguing illnesses (Fukuda et al., 1995)

25. A Conceptual Framework and set of Guidelines Need for revised criteria to define CFSNeed for revised criteria to define CFS Need for clinical evaluation standardsNeed for clinical evaluation standards Definition and Clinical evaluation of Prolonged and Chronic fatigueDefinition and Clinical evaluation of Prolonged and Chronic fatigue

26. A Conceptual Framework and set of Guidelines Prolonged FatigueProlonged Fatigue Self-reported, persistent fatigue of 1 month or longer Chronic FatigueChronic Fatigue Self-reported, persistent or relapsing fatigue of 6 or more consecutive monthsSelf-reported, persistent or relapsing fatigue of 6 or more consecutive months

27. A Conceptual Framework and set of Guidelines Clinical EvaluationClinical Evaluation  To identify underlying or contributing conditions contributing conditions that require treatment that require treatment  For further diagnosis or classification of chronic classification of chronic fatigue cases fatigue cases

28. A Conceptual Framework and set of Guidelines Areas to include in evaluation: History of medical and psychosocial circumstances at onsetHistory of medical and psychosocial circumstances at onset Mental status ExsaminationMental status Exsamination Physical ExaminationPhysical Examination Minimum battery of lab screening testsMinimum battery of lab screening tests

29. Conclusion Specific and non-specific assessment: standard tools and customized clinical interviewSpecific and non-specific assessment: standard tools and customized clinical interview Biopsychosocial ApproachBiopsychosocial Approach Mastery of Case Definition CriteriaMastery of Case Definition Criteria Diagnostic reevaluation based on initial treatment responseDiagnostic reevaluation based on initial treatment response

30. Conclusion Challenging diagnosis and treatment that will benefit from continuous research and education of primary health care providersChallenging diagnosis and treatment that will benefit from continuous research and education of primary health care providers Importance of experience with this specific population – requires special training (CEU)Importance of experience with this specific population – requires special training (CEU)