Chronic Fatigue Syndrome: What Should I Know, How is it Treated?
October 27, 2003
What should I know about Chronic Fatigue?
Chronic fatigue syndrome is the current name for a disease that has been described for three centuries. It is characterized by a debilitating fatigue and a variety of other physical, constitutional, and neuropsychological complaints. Certain individuals, who were labeled in the past with various diagnoses ranging from neurasthenia to encephalomyelitis,(1) are now thought to have chronic fatigue syndrome.
The diversity of names is a reflection of the number and controversy of theories of the disease. Whatever the cause, there seems to be several common themes that occur. It is often postinfectious, it is associated with immunological disturbances, and it is frequently accompanied by depression.
Currently, the lymphotropic herpes viruses, retroviruses, and enteroviruses are being studied as potential causes of chronic fatigue. Multiple factors have led investigators to believe one or more of these viruses causes chronic fatigue syndrome. Chronic fatigue can be precipitated by a variety of acute infections, and some of these organisms have the ability to persist in humans, causing chronic illness.
Experience suggests that, while viruses may precipitate the syndrome, it is unlikely that they contribute to its long-term features. There have been several immunologic disturbances reported in patients with chronic fatigue syndrome; however, none of them appear in all patients, nor have any been correlated with the severity of the illness.
An interesting finding that has been observed in controlled studies in recent years is that patients with chronic fatigue syndrome have a reduced production of a hormone called corticotropin-releasing hormone which is found in the hypothalamus.(2) Hypothetically, these endocrine abnormalities could contribute to the mood and impaired energy level of patients. It is unclear what significance this finding may have in determining the cause of this syndrome. It does, however, further indicate the complex nature of the illness.
Cases in childhood and middle age have been described; however, the greatest frequency of cases occurs in people aged 25 to 45, and women develop chronic fatigue syndrome approximately twice as often as men. There have been no infectious or environmental causes identified; however, throughout history, there have been sporadic occurrences of "outbreaks" in specific geographical areas. A few examples are Los Angeles County Hospital in 1934; in Akureyri, Iceland, in 1948; in the Royal Free Hospital in London, in 1955; in Punta Gorda, Florida in 1956; and in Incline Village, Nevada, and surrounding communities in 1985.
The typical case of chronic fatigue syndrome arises suddenly, in a previously active individual. Usually the patient can describe an otherwise unremarkable flu-like illness or stressful occurrence as the triggering event. Patients usually seek medical treatment because they believe that they have a persistent infection. There may be a continued feverishness, sore throat, swollen lymph nodes, headache, joint aches, and unbearable exhaustion. As the syndrome continues, usually there is disturbed sleep, difficulty in concentrating, and depression.
Many patients will make the rounds of allergists, homeopaths, psychiatrists, rheumatologists, and others seeking help, frequently with unsatisfactory results. Patients often complain that times of greatest fatigue also equate with times of greatest pain and difficulty in concentrating. Most patients finally balance their obligations of family, work, and other factors. Some patients actually feel they can no longer engage in gainful employment. Quite often there is isolation, a resignation to the illness, and frustration.
Many patients express anger with members of the medical community for not recognizing their illness, or not resolving their plight. Fortunately, chronic fatigue syndrome does not seem to progress, and in fact, over time, most patients gradually improve.
1. Straus SE. Chronic Fatigue Syndrome. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison’s Principles of Internal Medicine 14th ed. New York: McGraw-Hill; 1998:2483-2485.
2. Scott LV, Medbak S, Dinan TG. Desmopressin augments pituitary-adrenal responsivity to corticotropin-releasing hormone in subjects with chronic fatigue syndrome and in healthy volunteers. Biol Psychiatry. Jun1999;45(11):1447-54.
Once the possibility of other illness is ruled out, the patient must be informed of the syndrome, its prognosis, and its potential impact on the patient’s life. Patients are often relieved when their complaints are taken seriously. Many symptoms of chronic fatigue syndrome may respond to treatment. Nonsteroidal anti-inflammatory medications relieve headache, diffuse pain, and relieve feverishness. Antihistamines and decongestants are helpful for allergic rhinitis and sinusitis.
Although many patients are averse to psychiatric diagnoses, depression is a prominent symptom that may be alleviated with nonsedating antidepressants. Frequently, they not only improve mood, they also help with sleep disturbances, thereby relieving the fatigue somewhat. Many times, even modest improvement can make a vast difference in a patient’s degree of self-sufficiency and ability to enjoy life.
Consumption of heavy meals, caffeine, and alcohol in the evening can make it harder to sleep, compounding fatigue. Also, total rest is not good as it leads to further de-conditioning and contributes to the feeling of being an invalid. Strenuous exercise only leads to greater fatigue, so a well-planned, moderate exercise regimen should be a part of the treatment plan.
Nicotinamide Adenine Dinucleotide (NADH)
NADH was studied in a randomized, double-blind, placebo-controlled crossover study in patients with chronic fatigue syndrome. Twenty-six subjects were randomly assigned to receive either 10 mg of NADH or placebo for a 4-week period. After a 4-week washout period, subjects were crossed to the alternate regimen for a final 4-week period. In this study, 8 of 26 patients (31%) responded favorably to NADH while only 2 of 26 (8%) subjects taking the placebo improved. Although longer term follow-up studies are needed, the favorable results in this preliminary study indicate that NADH may be a valuable therapy in the management of the chronic fatigue syndrome.(1)
Coenzyme Q10 (CO-Q10)
Chronic fatigue syndrome has been identified as a symptom or condition that frequently precedes by years the development of congestive heart failure. In one study, administration of coenzyme Q10 resulted in improvement of cardiovascular function and fatigue.(2)
One group of researchers reported that individuals with chronic fatigue syndrome were found to have lower red cell magnesium concentrations compared to matched controls. In a double-blind study, 32 patients with chronic fatigue syndrome were either given 50% magnesium sulfate in a 1 gm/2 ml I.M. weekly injections or a placebo of 2 ml of injectable water. Patients treated with magnesium claimed to have improved energy levels, better emotional states, and less pain. Twelve of 15 patients reported benefiting from the therapy and 7 patients reported significant energy improvement.
In the placebo group only 3 of 17 patients said they felt better and one patient had improvement in energy. Red cell magnesium normalized in all patients receiving the injection, but only 1 patient returned to normal in the placebo group. The authors conclude that chronic fatigue syndrome patients have slightly lower magnesium levels than healthy controls and that magnesium therapy appeared to be of benefit. They cautioned that their trial was small and only had a follow-up of 6 weeks.(3)
Investigation of 35 patients with chronic fatigue syndrome (27 females and 8 males) revealed that CFS patients have statistically significantly lower serum total carnitine, free carnitine, and acylcarnitine levels.(4)
Omega-3 Fatty Acids and Omega-6 Fatty Acids
Sixty-three adults with postviral chronic fatigue syndrome were studied in a double-blind, placebo-controlled study of essential fatty acid therapy. The patients had been ill for from one to three years, suffering from severe fatigue, myalgia, and a variety of psychiatric symptoms. Patients were given capsules containing linoleic, gamma-linolenic, eicosapentaenoic, and docosahexaenoic acids (8 x 500 mg capsules per day over a 3-month period) or a placebo.
After 3 months, 85% of patients on active treatment assessed themselves as improved over the baseline compared to 17% of placebo patients reporting improvement. The essential fatty acid levels were abnormal at the baseline and corrected by active treatment. These results suggest that essential fatty acids may provide a rational, safe, and effective treatment for patients with post-viral chronic fatigue syndrome.(5)
Researchers assayed the serum folic acid levels of 60 patients with chronic fatigue syndrome (CFS) and found that 50% had values below 3.0 micrograms/l. The results of this study indicate that a substantial percentage of patients with chronic fatigue syndrome may be deficient in folic acid.(6)
Ashwagandha root, also known as winter cherry or Indian ginseng, is an important herb from the Ayurvedic or Indian system of medicine. Ashwagandha has been traditionally used for the treatment of debility, emaciation, impotence, and premature aging.(7) This dietary supplement is used to enhance mental and physical performance, improve learning ability, and decrease stress and fatigue. Ashwagandha is a general tonic to be used in stressful situations, especially insomnia, overwork, nervousness, restlessness, and chronic fatigue syndrome.(8)
Rhodiola has long been used in traditional folk medicine in China, Serbia, and the Carpathian Mountains of the Ukraine. In the former Soviet Union, it has long been used as an adaptogen, decreasing fatigue and increasing the body’s natural resistance to various stresses. In Siberia it is said that "those who drink rhodiola tea regularly will live more than 100 years."
Rhodiola seems to enhance the body's physical and mental work capacity and productivity, working to strengthen the nervous system, fight depression, enhance immunity, elevate the capacity for exercise, enhance memorization, and improve energy levels.(9) In Siberia it was taken regularly especially during the cold and wet winters to prevent sickness.
Eleuthero, Siberian Ginseng
Eleuthero is a different genus than other popular ginsengs such as the American and Panax or Asian varieties. The use of eleuthero root dates back 2,000 years in the records of Chinese medicine. It was used for respiratory tract infections, as well as colds and influenza.(10) The Chinese also believed that eleuthero provided energy and vitality. In Russia, it was originally used by the Siberian people to increase physical performance and to increase the quality of life and decrease infections. Eleuthero has been studied extensively since the 1940's. The root has been found to have many adaptogenic benefits.(11, 12)
Eleuthero has been reported to increase stamina and endurance and protect the body systems against stress-induced illness.(13, 14) It is rumored that Soviet Olympic athletes have used eleuthero successfully to enhance sports performance and concentration.
Astragalus has been valued by the Chinese for centuries for its immune-enhancing and adaptogenic properties. As an adaptogen, it may modify and improve the body’s response to stress through action on the adrenal cortex.(15, 16)
Cordyceps is a unique black mushroom that extracts nutrients from and grows only on a caterpillar found in the high altitudes of Tibet and China. Cordyceps is one of the most valued medicinal agents in the Chinese Materia Medica. Cordyceps has been used in traditional Chinese medicine as the herb of choice in lung and kidney problems, and as a general tonic for promoting longevity, vitality, and endurance.(17) Cordyceps is reputedly beneficial in helping individuals with decreased energy restore their capacity to function at a greater level of activity. Cordyceps has traditionally been used for its improvement in respiration and in individuals with decreased lung function by increasing oxygenation (improving VO2 max by 9-15%).(18)
Reishi mushroom is called the “mushroom of immortality” in China and has been used as a tonic and strengthening medicine for thousands of years. Uses in traditional healing include increasing intellectual capacity and memory, promoting agility and lengthening of the life span.(19) Reishi is reported to have some of the most active polysaccharides in the plant kingdom. Polysaccharides are claimed to have immunomodulating activity. Reishi is also reported beneficial as an antioxidant, antihypertensive, hypoglycemic, antiviral, and hepatoprotective agent.
Schisandra has been used in Chinese medicine for centuries as a kidney tonifying agent and sedative. It has historically been used to treat cough and wheezing, spontaneous sweating, chronic diarrhea, insomnia, and forgetfulness.(20) In Russia, schisandra has been used as an adaptogen, increasing the body’s natural ability to fight off disease and stresses from chemical, physical, mental, and environmental sources.(21) Schisandra has been reported to increase human endurance and mental and physical performance.(22)
1. Forsyth LM, et al. Therapeutic effects of oral NADH on the symptoms of patients with chronic fatigue syndrome. Ann Allergy Asthma Immunol. Feb1999;82(2):185-91.
2. Langsjoen PH, et al. Isolated diastolic dysfunction of the myocardium and its response to CoQ10 treatment. Clin Investig. 1993;71(8 Suppl):S140-4.
3. Cox IM, et al. Red Blood Cell Magnesium and Chronic Fatigue Syndrome. Lancet. Mar1991;337:757-760.
4. Plioplys AV, Plioplys S. Serum levels of carnitine in chronic fatigue syndrome: clinical correlates. Neuropsychobiology. 1995;32(3):132-8.
5. Behan PO. Effect of high doses of essential fatty acids on the postviral fatigue syndrome. Acta Neurol Scand. Sep1990;82(3):209-16.
6. Jacobson W, et al. Serum folate and chronic fatigue syndrome. Neurology. Dec1993;43(12):2645-7.
7. Boone K. Withania – The Indian Ginseng and Anti-aging Adaptogen. Nutrition and Healing. Jun1998;5(6):5-7.
8. Singh A, Naidu PS, Gupta S, Kulkarni SK. Effect of natural and synthetic antioxidants in a mouse model of chronic fatigue syndrome. J Med Food. Dec2002;5(4):211-20.
9. Rege NN, et al. Adaptogenic Properties of Six Rasayana Herbs Used in Ayurvedic Medicine. Phytother Res. Jun1999;13(4):275-91.
10. Foster S, et al. Herbal Emissaries. Rochester VT: Healing Arts Press; 1992:73-79.
11. Medon PJ. Effects of Eleutherococcus senticosus extracts on hexobarbital metabolism in vivo and in vitro. J Ethnopharmacol. Apr1984;10(2):235-41.
12. Davydov M. Eleutherococcus senticosus (Rupr. & Maxim.) Maxim. (Araliaceae) as an adaptogen: a closer look. J Ethnopharmacol. Oct 2000;72(3):345-93.
13. Fulder SJ. Ginseng and the Hypothalamic-pituitary Control of Stress. Am J Chin Med. 1981;9(2):112-18.
14. Asano K, et al. Effect of Eleutherococcus senticosus Extract on Human Physical Working Capacity. Planta Med. 1986;3:175-77.
15. Chang CY, et al. Effects of Astragalus membranaceus on Enhancement of Mouse Natural Killer Cell Activity. Chung Kuo I Hsueh Ko Hsueh Yuan Hsueh Pao. Aug1983;5(4):231-34.
16. Zhao KS, et al. Positive Modulating Action of Shengmaisan with Astragalus membranaceus on Anti-tumor Activity of LAK Cells. Immunopharmacology. Nov1990;20(3):471.
17. Sun YH. Cordyceps sinensis and Cultured Mycelia. Chung Yao Tung Pao. Dec1985;10(12):3-5.
18. Lei J, et al. Pharmacological Study on Cordyceps sinensis (Berk.) Sacc. and ze-e Cordyceps. Chung Kuo Chung Yao Tsa Chih. Jun1992;17(6):364-66.
19. Jong SC, et al. Medicinal Benefits of the Mushroom Ganoderma. Adv Appl Microbiol. 1992;37:101-34.
20. Liu GT. Pharmacological Actions and Clinical Use of Fructus Schizandrae. Chin Med J. Engl. Oct1989;102(10):740-49.
21. Suprunov NI, et al. Determination and Study of Lignan Distribution in the Fruits of Schisandra chinensis (Turcz.) Baill. Farmatsiia. May1972;21(3):34-37.
22. Nishiyama N, et al. An Herbal Prescription, S-113m, Consisting of Biota, Ginseng and Schizandra, Improves Learning Performance in Senescence Accelerated Mouse. Biol Pharm Bull. Mar1996;19(3):388-93.
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