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Chronic Fatigue Syndrome Introduction
There is no evidence that heredity, genetic or developmental factors play a part in the onset of CFS. Nor is there any consistent evidence that the condition is associated with particular types of occupation, lifestyle, mental or physical stress or pre-existing psychiatric illness. . The evidence that stress has a contributing role is considered to be equivocal. In particular, there are no studies to show a role for work-related stress in the development of CFS. None of the authorities make mention of either physical or mental stress as a cause of CFS. The mean age of onset in most series is reported as being 35 years. The large majority of cases are said to occur between the ages of 18 and 60 years. Most studies report a predominance of females although the ratios vary widely Diagnostic criteria for chronic fatigue syndrome For diagnosis, both major criteria must be present, plus the following minor criteria: (1) at least 6 of 11 symptoms and at least 2 of 3 physical signs or (2) at least 8 of 11 symptoms. Major criteria . New-onset fatigue lasting longer than 6 months with a 50% reduction in activity 2. No other medical or psychiatric conditions that could cause symptoms. Minor criteria Symptoms (must begin at or after the onset of fatigue)
Physical signs (documented by a medical practitioner twice at least 1 month apart) 1. Low-grade fever. 2. Pharyngitis (non-exudative) 3. Cervical or axillary lymphadenopathy Psychiatric diseases and chronic fatigue syndrome
In more recent times, a number of other authorities have adopted the view that pre-existing or co-existing psychiatric disease should not exclude a person from inclusion in the CFS diagnostic group if the other criteria are met. Misconceptions of the role of physical and mental stress in the development of CFS Whilst there is a common perception in the lay community that the title of Chronic Fatigue Syndrome infers a role for either mental or physical stress or both in the development of the condition, there is little evidence in the literature to support such a view. Whilst a number of authors have investigated the role of stress in relation to a number of other conditions characterised by chronic fatigue, none of these conditions appear to satisfy the criteria for CFS promulgated by the major authorities cited in this work.
Investigations Investigation of CFS patients is aimed mainly at excluding other illnesses as the cause of fatigue. There are no tests which can be considered to be diagnostic of the condition. Accordingly, there would appear to be no justification for undertaking sophisticated serological investigations nor highly technical radiological investigations in the ordinary course of investigation of the disease unless there are good reasons to suspect a serious occult disease (such as malignancy) as the cause of fatigue. Medical investigation of patients suspected of having CFS has two main objectives. The first objective is to exclude the existence of other diseases known to cause chronic fatigue. The second objective is to search for evidence of co-existing infections such as the viruses listed above. Since there are no tests to date to corroborate a clinical diagnosis of CFS, investigations should be limited to satisfying these two objectives and need not be extensive unless an individual patient's history justifies it.
Differential diagnosis Since chronic fatigue syndrome is essentially a diagnosis of exclusion, a comprehensive differential diagnosis schedule is presented here to (a) assist in identifying a range of other serious and life-threatening ataemia, hypoglycaemia, myophosphorylase deficiency and phosphofructokinase deficiency. Muscle pain made worse by exercise is seen in metabolic muscle disorders, in illnesses giving rise to myoglobinuria and in some lipid storage myopathies, particularly in patients with carnitine palmityltransferase deficiency. Many of the metabolic and endocrine conditions listed above are rare. In some cases, the differential diagnosis needs to be expanded to take account of unusual presenting symptoms in addition to profound fatigue. This is especially so when a patient reports symptoms such as (1) balance disturbances, (2) claudication, (3) gastrointestinal symptoms or (4) fluid retention. The differential diagnosis in the first category should include recurrent, acute and chronic labyrinthitis. In the second category, ischaemia of the cauda equina and occult spinal multiple sclerosis bear consideration. In
the third group, occult gastro-intestinal malignancies need to
be excluded. In the fourth category, fluid retention and fatigue
are prominent symptoms of the fluid retention syndrome Finally,
exclusion of a range of psychiatric ailments is indicated when
a patient presents with one or more psychiatric symptoms. The
onset of psychiatric illness in CFS is shown to be secondary to
the impairment of body function in general and the chronic pain
that is part of the condition. There is little, if any, evidence
to support a role for any form of psychiatric illness or personality
type in the onset of chronic fatigue syndrome. Treatment of the condition is aimed at ensuring an adequate degree of rest in conjunction with a supervised course of gentle graded exercises throughout the course of the illness. Treatment of specific symptoms such as muscle pains and depression are recommended as being appropriate but the use of narcotic and other addictive forms of medication would appear to be inappropriate in all cases. A range of other therapies have been trialed at various times but none have yet to be shown to offer any particular benefit. Whilst it is not possible to provide specific guidelines to assist in determining the prognosis of individual patients, there is reasonable uniformity of opinion that an improved prognosis is associated with early treatment (including work and lifestyle modifications). Conversely, when the illness is severe or has been present for more than one year or both, the prognosis is generally held to be poorer. Accordingly, early identification of CFS patients is important. In many cases, temporary removal from the work place is recommended (especially those with severe disease) until there is good evidence of a sustained recovery. For the remainder, it is recommended that placement on lighter duties and/or reduced working hours be initiated early in the course of the illness. Unless the patient has severe disease however, there would appear to be little justification for recommending mandatory removal from the work place if the person is not required to undertake moderate or strenuous duties and if suitable changes to the work environment can be made.
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The
major criteria of chronic fatigue syndrome is new-onset fatigue
lasting more than 6 months in the absence of any other medical
or psychiatric cause of fatigue. 
The
question of what is the exact nature of the relationship between
psychiatric disease and chronic fatigue syndrome remains one of
the most controversial aetiological issues concerning CFS.
