CHRONIC-FATIGUE-SYNDROME - A PRACTICAL GUIDE TO ASSESSMENT AND MANAGEMENT

Chronic fatigue and chronic fatigue syndrome (CFS) have become increas ingly recognized as a common clinical problem, yet one that physicians often find difficult to manage. In this review we suggest a practical , pragmatic, evidence-based approach to the assessment and initial man agement of the patient whose presentation suggests this diagnosis. The basic principles are simple and for each aspect of management we poin t out both potential pitfalls and strategies to overcome them. The fir st, and most important task is to develop mutual trust and collaborati on. The second is to complete an adequate assessment, the aim of which is either to make a diagnosis of CFS or to identify an alternative ca use for the patient's symptoms. The history is most important and shou ld include a detailed account of the symptoms, the associated disabili ty, the choice of coping strategies, and importantly, the patient's ow n understanding of his/her illness. The assessment of possible comorbi d psychiatric disorders such as depression or anxiety is mandatory. Wh en the physician is satisfied that no alternative physical or psychiat ric disorder can be found to explain symptoms, we suggest that a firm and positive diagnosis of CFS be made. The treatment of CFS requires t hat the patient is given a positive explanation of the cause of his sy mptoms, emphasizing the distinction among factors that may have predis posed them to develop the illness (lifestyle, work stress, personality ), triggered the illness (viral infection, life events) and perpetuate d the illness (cerebral dysfunction, sleep disorder, depression, incon sistent activity, and misunderstanding of the illness and fear of maki ng it worse). Interventions are then aimed to overcoming these illness -perpetuating factors. The role of antidepressants remains uncertain b ut may be fried on a pragmatic basis. Other medications should be avoi ded. The only treatment strategies of proven efficacy are cognitive be havioral ones. The most important starting point is to promote a consi stent pattern of activity, rest, and sleep,followed by a gradual retur n to normal activity; ongoing review of any 'catastrophic' misinterpre tation of symptoms and the problem solving of current life difficultie s. We regard chronic fatigue syndrome as important not only because it represents potentially treatable disability and suffering but also be cause it provides an example for the positive management of medically unexplained illness in general. (C) 1997 by Elsevier Science Inc.