Chronic Fatigue
Questions Received:
Responses:
What are your opinions on chronic fatigue syndrome/post viral fatigue/ME - how closely related are they and are they a 90's phenomenon?
June 24th 1999
Chronic fatigue syndrome, post-viral fatigue, and ME are all names for prolonged periods of fatigue for which there is no obvious organic cause or which may follow a viral infection. Often the terms are used interchangeably. (For reviews see Houde and Kampfe-Leacher, 1997; Wessely, 1997.)
The first term to be applied to chronic fatigue was myalgic encephalomyelitis (ME), introduced in 1956 by Ramsey in the UK medical journal Lancet, but little attention was paid to the condition at that time. Interest was kindled in the subject in 1984 when several cases of chronic fatigue were reported in Nevada, USA. When preliminary evidence of a viral association was found three years later, the name chronic Epstein-Barr syndrome was introduced and used for a while. In 1988 the Centre for Disease Control in America developed a working definition for the condition and recommended calling it the chronic fatigue syndrome. In 1996 the Royal Colleges in the UK also advised a change from myalgic encephalomyelitis to chronic fatigue syndrome. However, not everyone is happy with this name - particularly those who suffer from the condition and wish to see more research into the causes - and in recent years there has been intensive discussion about alternative names.
A significant number of people visit their general practitioners because they are worried about feeling fatigued (Elliott, 1999). There may be associated symptoms such as impaired concentration and muscle pain (Sharpe, 1996). Some observations suggested that the syndrome derives from damage to the reticular activating system of the brain stem and its projections to the cerebral cortex after a viral infection (Dickinson, 1997). For example, magnetic resonance imaging studies revealed small lesions in these areas in some cases. Similar lesions are found after poliomyelitis and in multiple sclerosis, in both of which fatigue is a symptom. There have also been reports of changes in the immune and endocrine systems, in mitochondrial function, and in blood flow through the brain in people experiencing chronic fatigue. However, in most cases there are no signs or symptoms other than fatigue, and many physicians are sceptical about an underlying physical cause - they consider the condition to be a psychological or psychiatric problem.
It seems likely from current research that both pathological and psychosocial factors are involved (Holmwood and Shannon, 1992; Rikard-Bell and Waters, 1992; Dickinson, 1997; Barsky and Borus, 1999). Evidence for the existence of an ongoing chronic infection is now not convincing except in a small proportion of cases. There is no specific therapy, but it is important for the patient's recovery that the symptoms are taken seriously by the doctor and society in general (Sharpe et al, 1997). In this sense, chronic fatigue is comparable to pain - it is a subjective experience and the absence of any obvious cause does not make it any less real for the sufferer. Treatment should be based on counselling, explanation, psychiatric help, and a graded programme of increased activity to bring about a return to normal life.
References
Barsky, A.J., and Borus, J.F. (1999) Functional somatic syndromes. Annals of Internal Medicine, 130(11), 910-921 (Jun 1).
Dickinson, C.J. (1997) Chronic fatigue syndrome - aetiological aspects. European Journal of Clinical Investigation, 27(4):257-267 (Apr).
Elliott, H. (1999) Use of formal and informal care among people with prolonged fatigue: a review of the literature. British Journal of General Practice, 49(439), 131-134 (Feb).
Holmwood, C., and Shannon, C. (1992) Chronic fatigue syndrome. A review from the general practice perspective. Australian Family Physician, 21(3), 278-279, 283-285 (Mar).
Houde, S.C., and Kampfe-Leacher, R. (1997) Chronic fatigue syndrome: an update for clinicians in primary care. Nurse Practitioner, 22(7), 30, 35-6, 39-40 passim (Jul).
Mechanic, D. (1993) Chronic fatigue syndrome and the treatment process. Ciba Foundation Symposium, 173, 318-327; discussion 327-341.
Rikard-Bell, C.J., and Waters, B.G. (1992) Psychosocial management of chronic fatigue syndrome in adolescence. Australia and New Zealand Journal of Psychiatry, 26(1), 64-72 (Mar).
Sharpe, M. (1996) Chronic fatigue syndrome. Psychiatric Clinics of North America, 19(3), 549-573 (Sep).
Sharpe, M., Chalder, T., Palmer, I., and Wessely, S. (1997) Chronic fatigue syndrome. A practical guide to assessment and management. General Hospital Psychiatry, 19(3), 185-199 (May).
Wessely, S. (1997) Chronic fatigue syndrome: a 20th century illness? Scandinavian Journal of Work and Environmental Health, 23 Suppl 3, 17-34.
Have there been any studies conducted on the use of vitamin B injections as a treatment for CFS?
20th January 2000
So far we have come across only very limited studies of the effect of vitamin B injections in the treatment of chronic fatigue syndrome. For example, there is a report of a single patient with chronic fatigue syndrome who received high-dose vitamin B12 injections without a measurable effect (Wiebe, 1996). In another study, injection of a bovine liver extract containing folic acid and vitamin B12 produced favourable responses in patients with chronic fatigue syndrome, but a comparable response was also observed in the control group, indicating a strong placebo effect (Kaslow, Rucker, and Onishi, 1989).
There does however seem to be some evidence in support of the suggestion that people with this condition have a vitamin B deficiency. For example, Heap, Peters, and Wessely (1999) studied the levels of pyridoxine, riboflavin and thiamine in patients with chronic fatigue syndrome and found preliminary evidence of reduced pyridoxine activity. Also, some patients with chronic fatigue syndrome are deficient in folic acid, which is another member of the vitamin B family (Jacobson et al, 1993).
Since a number of marginal nutritional deficiencies have been implicated in chronic fatigue syndrome in addition to vitamin B, and Werbach (2000) suggests in a recent review that supplementation with B vitamins, vitamin C, magnesium, sodium, zinc, L-tryptophan, L-carnitine, coenzyme Q10, and essential fatty acids may be worthwhile, at least for a trial period.
References
Heap, L.C., Peters, T.J., and Wessely, S. (1999) Vitamin B status in patients with chronic fatigue syndrome. Journal of the Royal Society of Medicine, 92(4), 183-185 (Apr).
Jacobson, W., Saich, T., Borysiewicz, L.K., Behan, W.M., Behan, P.O., and Wreghitt, T.G. (1993) Serum folate and chronic fatigue syndrome. Neurology, 43(12), 2645-2647 (Dec).
Kaslow, J.E., Rucker, L., and Onishi, R. (1989) Liver extract-folic acid-cyanocobalamin vs placebo for chronic fatigue syndrome. Archives of Internal Medicine, 149(11), 2501-2503 (Nov).
Werbach, M.R. (2000) Nutritional strategies for treating chronic fatigue syndrome. Alternative Medicine Review, 5(2), 93-108 (Apr).
Wiebe, E. (1996) N of 1 trials. Managing patients with chronic fatigue syndrome: two case reports. Canadian Family Physician, 42, 2214-2217 (Nov).