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Chronic Fatigue Syndrome (CFS). A practical guide to assessment & management

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By Sharpe M, Chalder T, Palmer I, Wessely S • www.ProHealth.com • May 10, 1997


Chronic fatigue and chronic fatigue syndrome (CFS) have become
increasingly recognized as a common clinical problem, yet one
that physicians often find difficult to manage. In this review
we suggest a practical, pragmatic, evidence-based approach to
the assessment and initial management of the patient whose
presentation suggests this diagnosis. The basic principles are
simple and for each aspect of management we point out both
potential pitfalls and strategies to overcome them.

The first, and most important task is to develop mutual trust and
collaboration. The second is to complete an adequate
assessment, the aim of which is either to make a diagnosis of
CFS or to identify an alternative cause for the patient's
symptoms. The history is most important and should include a
detailed account of the symptoms, the associated disability,
the choice of coping strategies, and importantly, the
patient's own understanding of his/her illness. The assessment
of possible comorbid psychiatric disorders such as depression
or anxiety is mandatory. When the physician is satisfied that
no alternative physical or psychiatric disorder can be found
to explain symptoms, we suggest that a firm and positive
diagnosis of CFS be made.

The treatment of CFS requires that the patient is given a positive
explanation of the cause of his symptoms, emphasizing the distinction
among factors that may have predisposed them to develop the illness
(lifestyle, work stress, personality), triggered the illness (viral
infection, life events) and perpetuated the illness (cerebral
dysfunction, sleep disorder, depression, inconsistent
activity, and misunderstanding of the illness and fear of
making it worse). Interventions are then aimed to overcoming
these illness-perpetuating factors.

The role of antidepressants remains uncertain but may be tried on a
pragmatic basis. Other medications should be avoided. The only
treatment strategies of proven efficacy are cognitive
behavioral ones. The most important starting point is to
promote a consistent pattern of activity, rest, and sleep,
followed by a gradual return to normal activity; ongoing
review of any 'catastrophic' misinterpretation of symptoms and
the problem solving of current life difficulties. We regard
chronic fatigue syndrome as important not only because it
represents potentially treatable disability and suffering but
also because it provides an example for the positive
management of medically unexplained illness in general.




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