Special Feature
CFS and Fibromyalgia: True Disorders Coming of Age
By Andrew L. Stoll, MD
Chronic fatigue syndrome (cfs) and fibromyalgia (FM) are two distinct but often overlapping conditions. Physicians have a checkered past when it comes to the care of patients with CFS and/or FM. The constellation of symptoms of these two disorders are often nonspecific, no laboratory tests are available for reliable diagnosis, and no generally effective treatments yet exist. For these and other reasons, the majority of allopathic physicians either dismissed these patients as "crocks" or believed CFS and FM were some form of psychosomatic disorder. This short essay will describe the clinical features of CFS and FM and review what is known about the etiology, pathophysiology, and treatment of these chronic disorders. (See Tables 1 and 2.)
| Table 1-Diagnostic Features of Chronic Fatigue Syndrome | |||
| Chronic or intermittent fatigue of unclear origin, not related to activity | |||
| Clear impairment in social, academic, or vocational functioning | |||
| Four or more of the following symptoms are consistently present for more than six months: | |||
| • Significant memory, attention, or concentration difficulties | |||
| • Persistently unrefreshing sleep | |||
| • Pain in muscles | |||
| • Diffuse arthralgias | |||
| • Episodes of headache of long duration | |||
| • Sore throat | |||
| • Tender lymph nodes (cervical or axillary) | |||
| • Worsening fatigue following physical activity | |||
| • Frequent concurrent major depression | |||
| Table 2-Diagnostic Features of Fibromyalgia | |||
| • Chronic or intermittent pain in the muscles, fascia, and joints in multiple areas of the body. | |||
| • Discrete tender points in muscles in specific areas of the body, apparent by palpation | |||
| • Sleep disturbance | |||
| • Chronic fatigue | |||
| • Frequent concurrent major depression | |||
CFS and FM are chronic conditions of unknown etiology and pathophysiology but appear to involve some unspecified central nervous system interaction with the immune system. There are no current specific treatments for CFS or FM. Some patients obtain relief from analgesic drugs, either singly or in combination with other agents, such as antidepressants. Adjunctive treatments, such as moderate exercise, proper diet, and stress reduction techniques also appear to help. However, many patients continue to suffer despite these efforts.
For many years, fibromyalgia was a controversial diagnosis, with proponents describing the unique features of this disorder, and critics arguing that fibromyalgia and related conditions are merely manifestations of psychiatric illnesses, such as major depression, somatoform pain disorder, and other so-called psychosomatic conditions. The history of medicine is full of disorders initially dismissed as "psychological," but then validated once the pathophysiology is identified (e.g., syphilis, Lyme disease, etc.), or when an effective somatic treatment is devised. Fibromyalgia is one of the most common conditions seen by rheumatologists and is also commonly seen in primary care practices. (See Table 3.)
| Table 3-Elements of the Medical Work-up for CFS and FM | |||
| Detailed history and physical, including deep palpation for trigger points | |||
| Thorough review of systems, including screening for psychiatric disorders | |||
| Review patient's current medications, including OTC and herbal preparations, to rule-out a medication adverse effect causing symptoms | |||
| Basic laboratory studies | |||
| • CBC/differential | |||
| • Chemistries (transaminases, creatinine) | |||
| • TSH | |||
| Referral to specialists for specific work-up of positive findings, particularly for psychiatric disorders | |||
The treatment for CFS and FM mainly consists of clinical management and empathic support, combined with specific lifestyle changes and selective pharmacotherapy. Empathic support is a critical element of the treatment of patients with CFS and FM, because a patient who feels their physician "understands" what they are experiencing can tolerate much more physical distress than a patient who feels brusquely dismissed. Patients with CFS and FM may benefit from support groups, certain forms of psychotherapy (e.g., cognitive-behavioral therapy or CBT), stress management programs, reasonable exercise (with or without physical therapy or a personal trainer), and possibly improved diet. (See Table 4.)
| Table 4 -Selected Pharmacological Approaches to FM and CFS | ||||
| Treatment | Study Method | Efficacy | Reference | |
The precise diagnosis and effective treatment of CFS and FM have eluded us because the current knowledge base and technology of allopathic medicine is inadequate to detect the presumably subtle pathophysiological events occurring within the bodies of our afflicted patients. Despite the lack of generally effective treatments for CFS and FM, research is active and continuing. The search for the etiology, pathophysiology, accurate diagnostic tests, and effective treatments is sure to succeed, hopefully soon. In the meantime, just as with any chronic, debilitating, and hard-to-treat illness, patients with CFS and/or FM should be given adequate trials of the most promising treatments currently available, and they deserve our attention, empathy, and care.
Suggested Reading
1. Komaroff A. Chronic fatigue syndrome. In: Rakel RE, ed Conn’s Current Therapy. Philadelphia: W.B. Saunders Company; 1998:112-115.
2. Fukuda K, Straus, et al. The chronic fatigue syndrome: A comprehensive approach to its definition and study. Ann Intern Med 1994;121:953-959.
3. Goldenberg DL. Fibromyalgia syndrome a decade later: What have we learned? Arch Intern Med 1999;159(8):777-785.
4. Powers R. Fibromyalgia: An age-old malady begging for respect. J Gen Intern Med 1993;8:93-105.
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