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

Fluoxetine open + Johnson 1997 Fluoxetine db ± Wolfe et al 1994 Citalopram db - Norregaard et al 1995 Amitriptyline db + Carette et al 1994 Amitriptyline db + Goldenberg et al 1996 Amitriptyline db + Goldenberg et al 1986 Naproxen plus Amitriptyline db + Goldenberg et al 1986 Ondansetron db + Hrycaj et al 1996 Fluoxetine plus Cyclobenzaprine open + Cantini et al 1994 Cyclobenzaprine db + Carette et al 1994 Cyclobenzaprine db + Bennett 1988 Carisoprodol plus acetaminophen plus caffeine db + Vaeroy et al 1989 Zolpidem db ± Moldofsky et al 1996 ibprofen plus alprazolam db + Russell et al 1991 naproxen db ± Goldenberg et al 1986 tolmetin db + Balme et al 1980 aspirin db + Donald & Molla 1980 ibuprofen db + Le Gallez et al 1988 topical capsaicin open + Mathias et al 1995 local trigger point injection open ± Hong & Hsueh 1996 Antibiotics specific for Lyme disease open - Dinerman & Steere 1992 prednisone db - Clark et al 1985 acetaminophen db - Hrycaj et al 1991 S-adenosylmethionine db + Jacobsen et al 1991 malic acid plus magnesium db + Russell et al 1995 Flupirtine open + Stoll 1999 * *Study Method: db = double blind

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.