ABSTRACT: Because there is no specific therapy yet for chronic fatigue syndrome (CFS), management focuses on symptomatic relief and on treatment of coexisting conditions. Antidepressants and anxiolytics are effective in treating co-occurring psychiatric disorders. First-line management of sleep disturbances consists of sleep hygiene techniques. If these strategies are not effective, consider the possibility of an underlying sleep disorder. An important aspect of managing CFS is to help the patient achieve an appropriate balance between rest and daily physical and mental activities. Useful nonpharmacological approaches include graded exercise therapy, relaxation techniques, participation in self-help groups, cognitive-behavioral therapy, and mindfulness-based cognitive-behavioral therapy.
Key words: chronic fatigue syndrome, management, treatment
The treatment of chronic fatigue syndrome (CFS) is mainly supportive. The key to effective management is to establish a therapeutic alliance with patients and to convey a consistent message that their complaints are taken seriously. Although spontaneous recovery is rare, it does occur in some patients with CFS.
In the second part of this 2-part series, the various treatments are described, with emphasis on those that are most commonly used in the primary care setting. In part 1 (CONSULTANT, February 2011, page 73), the diagnostic criteria for CFS and the differential diagnosis were described and discussed.
GENERAL MANAGEMENT PRINCIPLES
In patients with CFS, treatment goals are based on the stage and severity of the disability, as well as the type of symptom complex that is present.1-7 In most cases, primary care practitioners are best equipped to initiate and coordinate treatment. Referral to subspecialists—such as infectious disease specialists, dietitians, occupational therapists, physiotherapists, and psychiatrists—is based on patients’ needs; the type, duration, complexity, and severity of their symptoms; and the presence of co-occurring medical and psychiatric conditions. The decision to refer to a subspecialist should be made jointly with the patient. An individualized, patient-centered treatment plan with specific objectives should be offered in order to:
• Sustain or gradually extend, if possible, the level of physical, emotional, and cognitive functioning.
• Manage the physical and psychosocial impact of the symptoms.
• Provide the evidence-based interventions that have the clearest benefit.
Because there is no specific therapy for CFS, management focuses on symptomatic relief and on treatment of co-occurring conditions.
Patient education is an essential element of treatment. It is important to reassure patients that CFS is a non–life-threatening condition and that extensive medical workups and diagnostic testing are unnecessary and could cause increased stress as a result of their financial impact. A frank discussion that encompasses the nature and prognosis of CFS as well as available therapies enables patients to become active participants in selecting an acceptable treatment plan.
An important aspect of managing CFS is to help the patient achieve an appropriate balance between rest and daily physical and mental activities.1,7-9 This balance depends on the stage and severity of the illness as well as the degree of variability of the symptoms.
Pacing approach. Several reports found the pacing approach to be the most helpful.9 Despite patients’ resistance to physical activity because of their ongoing fatigue, exercise is a helpful treatment modality. Although the absolute advantages of exercise are still unclear, the key is to encourage inactive patients to follow a simple, regular, and not overly aggressive program that does not exacerbate their feelings of tiredness and frustration. Graded exercise therapy that is supervised by a physical therapist or physiatrist has demonstrated benefits in mobile patients.9 A balance between exercise and rest may be an essential component of gradually increasing physical activity as tolerated.
Pacing is based on finding a level of activity at which patients feel comfortable. Physical and mental activity can then be gradually increased and interspaced with periods of rest—but always within individual limitations.
Relaxation techniques. These can be used to manage pain, sleep problems, and co-occurring stress or anxiety. Various relaxation techniques (such as guided imagery and breathing exercises) can be incorporated during periods of rest.
Diet. Educating patients about the value of a well-balanced diet is important. A dietary plan should address the complications associated with the CFS symptoms of nausea, dysphagia, and sore throat as well as the difficulties patients may have in buying and preparing food. The importance of eating regularly also needs to be emphasized.
Self-help groups. Patients with CFS have benefited from self-help groups that instill hope, offer an opportunity to share experiences and exchange information and, most of all, enable patients to identify with others who face the same difficulties. Because many patients with CFS often feel that they are not taken seriously by their physicians, the cohesiveness among self-help group members rebuilds the self-esteem that is usually impaired in these patients.10 Self-help groups also provide social support to patients with CFS, because many of their family members and friends do not believe that they are ill.
Cognitive-behavioral therapy (CBT). In this form of therapy, patients perform a cognitive assignment that entails gathering background details and identifying automatic thoughts and cognitive errors. The patients then engage in homework assignments and propose experiments that challenge their perception of illness and generate alternative ways to view their problems with chronic fatigue and to cope with their symptoms.
Although some studies show that CBT improves functioning in patients with CFS, other studies found CBT to be no more beneficial than regular follow-up appointments. These different outcomes may reflect differences in study design rather than ineffectiveness of CBT.7,11,12
Various CBT techniques can improve coping skills and psychosocial functioning. The central components of CBT that lead to reduction in fatigue and improvement of mood are associated with enhancing motivation, challenging and changing fatigue-related cognitions, achieving and maintaining an appropriate level of physical activity, gradually increasing physical activity, and achieving work rehabilitation. Factors that reduce the effectiveness of CBT are the receipt of medical leave or disability-related benefits, a low sense of control, a strong focus on symptoms, and a pervasively passive activity pattern.11,12
Mindfulness-based cognitive-behavioral therapy (MCBT). This therapy is based on the mind-body interaction and on practicing mindfulness meditation. Mindfulness meditation teaches how to focus on the present moment and act with purpose rather than letting judgments about past events or fears about what may happen in the future affect current feelings. Being focused only on the present in this way helps patients respond positively to situations rather than react in a negative way. As a result, the use of mindfulness may better prepare patients with CFS to implement the changes in thought. The combination of CBT and MCBT can be a powerful tool in certain CFS patients in whom CBT alone could not achieve its intended goals.13
Education and employment. The inability to pursue education or to maintain employment is generally detrimental to the health and overall well-being of patients with CFS.14 Advise patients about their fitness for work and education, and recommend referral to occupational health services, disability services, home education services, and disability advisers in schools and colleges. The goal is to initiate flexible adjustments to work or studies to help patients resume their employment or education whenever possible.
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Acknowledgments: The author thanks the VA Medical Center director, Mr Al Perry, FACHE, for his leadership and the chief of staff, Dr Wessel Meyer, for his support; Drs Robert Hierholzer, Nestor Manzano, Scott Ahles, and Craig C. Campbell, for their clinical guidance; Dr Avak A. Howsepian for his constructive criticism; Matthew Battista, PhD, and Leonard Williams, PA, for their encouragement; and Ms Ruth A. Cowell for her secretarial assistance.