Chronic Fatigue

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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The patient with a symptom of chronic fatigue must identify whether this symptom is caused by a health problem such as a clinical or subclinical hypothyroidism, adrenal insufficiency, depression, sleep disorder, anemia, liver disease or dysfunction, various chronic inflammatory diseases, neurological diseases such as multiple sclerosis or amyotrophic lateral sclerosis, various autoimmune disorders, hepatitis C or other viral disease, or even medication side effects, especially from psych drugs and statins, but also from immune suppressing and steroidal medications. Serious chronic diseases that were unheard of a short number of years ago, such as mitochondrial syndromes are now being diagnosed in cases of chronic fatigue as well. 

A thorough medical analysis and a number of tests should be conducted, and a careful differential diagnosis considered. When none of these causes or underlying conditions are evident a primary chronic fatigue syndrome is suspected. Chronic Fatigue Syndrome is not confirmed by objective tests at this time, but is a diagnosis of exclusion. Hence, this syndrome, or these syndromes, have been under-diagnosed and dismissed in standard medicine for a number of decades, despite growing evidence that they are increasing in occurrence in the population. Public health authorities worldwide are now seriously investigating the possible causes of these syndromes and research is revealing more and more each year. Since these chronic fatigue syndromes are so debilitating, many patients have become desperate, as their medical doctors have no effective therapy to offer them. Consequently, a number of causes of chronic fatigue have been touted as the probable culprit, some of which are themselves hard to objectively diagnose. It is improbable, though, that the growing large number of cases of chronic fatigue syndrome are caused by just one pathogen, such as the spirochete bacterium Borrelia burgdorferi, now infamous as the cause of the tick-born infection in Lyme disease. A careful and persistent differential diagnosis is very important when assessing chronic fatigue. If the actual factor or factors causing each individual case are not assessed properly, the best therapeutic protocol cannot be devised.

Since standard medicine has failed to properly treat so many patients with chronic fatigue, more and more patients now are turning to an integrative approach with Complementary and Integrative Medicine (CIM), especially with the array of therapies available in the specialty of Traditional Chinese Medicine (TCM). The professional Licensed Acupuncturist and herbalist is able to add to the professional diagnosis, offer a unique perspective that integrates well with standard medicine, and offer an array of evidence-based traditional and modern therapies, including herbal and nutrient medicine, acupuncture, instruction in diet and lifestyle changes, help with cognitive and behavioral changes, and physiotherapies. Each individual TCM physician offers a unique set of skills, knowledge and clinical experience, and many are able to provide an effective course of therapy in difficult diseases. In these chronic fatigue pathologies the patient that takes a proactive approach and becomes the main director of a team of integrated physicians often achieves the best outcome. By becoming well educated to the suspected underlying pathology, and utilizing various physicians to provide their best skills and knowledge, these patients often overcome the difficulties seen in these often elusive and persistent diseases.

Chronic Fatigue Syndrome (CFS) has been an elusive health problem to understand and to define, yet the World Health Organization (WHO) and the National Institutes of Health (NIH) recognize this syndrome as a widespread, growing and cohesive syndrome of symptoms seen worldwide. The syndrome has also been classified as Neuroendocrineimmune Dysfunction and Chronic Fatigue Immunodeficiency Syndrome, and recently has been called Myalgic Encephalomyelitis (CFS/ME) after research has revealed more specific mechanisms of pathology. A term that is used by most experts to describe Chronic Fatigue Syndrome today is an Encephalomyopathy, referring to a pathology of the brain stem physiology that affects the muscle function, nerve sensation and firing, or a functional somatic syndrome. Other functional somatic syndromes appear to overlap with CFS at an alarming frequency, suggesting perhaps a related underlying etiopathology. These include fibromyalgia, multiple chemical sensitivity, chronic pelvic pain syndrome, irritable bowel syndrome (IBS), temporomandibular joint dysfunction (TMD), and Gulf War illness. Current research more closely ties Chronic Fatigue Syndrome with Fibromyalgia and implicates hypofunction of the hypothalamus adrenal axis, as well as more specific findings of neurotransmitter and neuroreceptor problems in the brainstem, especially a hyperserotonergic imbalance. As research progresses we may find that there are a number of roots of this elusive syndrome, though, and patients may be differentiated with greater clarity. Clearly, a more holistic approach to care, and one that delivers a more affordable treatment strategy, is needed. CIM/TCM delivers this needed integrative approach.

Chronic fatigue may be secondary to various health problems, or may be a primary functional somatic syndrome, perhaps related to other functional somatic syndromes, such as fibromyalgia, multiple chemical sensitivity, irritable bowel syndrome, or chronic pelvic pain syndrome. As research progresses scientists are more clearly understanding the key functional problems, which relate to the central nervous system, particularly the brainstem transmission, and the centers of control and coordination at the top of the brainstem, such as the hypothalamus, amygdala and hippocampus. Insufficiency of the hypothalamic adrenal axis, imbalance of inflammatory cytokines and the T helper cell 2 (Th2) dominance, an imbalance of serotonin over dopamine in both neurotransmitter production and receptors, and neurodegeneration with both loss of volume in certain sections of the brain and a decrease in mitochondrial function, are all hallmarks of Chronic Fatigue Syndrome (CFS). Often, these various elusive causes are combined in a chronic case of CFS/ME, demanding a more thorough and holistic treatment plan. Obviously, a more complex and holistic treatment protocol is vitally needed to restore health and function for most patients. Complementary Medicine should play a key role in the integration of standard medicine with such a comprehensive strategy, and the medical specialty of Traditional Chinese Medicine offers an array of treatment protocols that can be individualized for each patient.

The difficulties in understanding the complex multifactorial nature of functional somatic syndromes, as well as the overlapping dysfunctions in multiple systems, the central nervous, immune, and endocrine systems, has led to an understandable dismissal of these difficult to treat, and even more difficult to diagnose and understand functional pathologies. Without a clear disease classification in allopathic medicine, and without clear treatment options, most of these cases have been treated with a dismissive attitude. Restoration of normal homeostatic function, integrating Complementary Medicine into standard treatment protocol, is the answer to success in treating any functional somatic disorder. With a pathology that demonstrates no abnormality of structure to explain ill health, and is shown to include functional problems between multiple systems, a holistic approach to assessment and treatment seems logical. Complementary Medicine, especially Traditional Chinese Medicine, offers an arrray of treatment options that research is proving effective to restore homeostatic functional balance between the hypothalamus, amygdala, and hippocampus, restore immune function, and potentially treat the multiple underlying health problems with an individualized approach. Acupuncture, herbal and nutrient medicine, and even deep soft tissue physiotherapies are now shown to affect the central nervous system, immune responses, and bioavailability of neurotransmitter production to achieve greater success in restoration of homeostatic health.

There is a growing concern that standard medicine is not addressing this widespread problem of chronic fatigue syndromes worldwide. Chronic Fatigue Syndrome as an encephalomyopathy is still not being understood, diagnosed, and treated effectively. Many patients, desperate for a diagnostic answer to their debilitating disease, are convinced that they have Chronic Lyme Disease, or various other infectious or metabolic disorders, often without sufficient evidence to support the diagnosis. Of course, many patients with Lyme Disease or Post-Lyme Disease Syndrome have acquired a chronic fatigue syndrome that is often quite debilitating, and a number of other chronic syndromes, such as Gilbert's Syndrome and mitochondrial disease, often go undiagnosed as well. These syndromes themselves may be complicated by a variety of health problems, though, that contribute to a multifactorial syndrome. The lack of sound scientific study of these various chronic fatigue syndromes has prompted patient advocates to initiate legislative action on the subject of Lyme disease that now has created government guidelines advocating the use of extended antibiotic therapy that is not supported by various Lyme disease organizations, or by top university researchers. In fact, experts at Johns Hopkins University School of Medicine, Division of Infectious Diseases, suggested in 2007 that prolonged antibiotic therapy, or even the long course of initial antibiotic therapy, in Lyme disease, could be the cause, or a cause, of many chronic fatique syndromes with inexplicable musculoskeletal pain and neurocognitive dysfunction. Experts around the world, studying the rising incidence of Lyme Disease, have found that in almost all cases of definitively diagnosed Lyme Disease with symptoms, that a single short course of antibiotics effectively cured the infection, with only about 5% requiring a second course. These experts at Johns Hopkins suggested that the term "Chronic Lyme Disease" should be replaced with the term "Post-Lyme Disease Syndrome" to indicate that the chronic fatique syndrome following an episode of Lyme disease not be attributed to a current infectious state. The complexity of chronic fatique syndromes, and the systemic and holistic aspects to the disease, have resulted in an avoidance of a sound diagnostic and treatment regimen based on current scientific evidence.

Diagnosis and clarification of this confusing array of potential causes of chronic fatigue is difficult, and often exhausting, eventually leading to a 'diagnosis of exclusion'. Use of the functional PET scan to see if levels of neuroinflammation are present may be useful, and recent research has shown that analysis of the health of the Microbiome with stool analysis, and of bacterial endotoxins (LPS) in blood circulation, could be useful markers. Of course, definitive tests for Lyme Disease, hormonal analysis, and other tests of immune response may all be helpful to both rule out causes and to add data to the differential diagnosis. After this process is completed, the team of physicians you select can be more specific in designing an individualized and holistic treatment protocol.

Chronic somatic diseases and Somatoform Syndromes have long been ignored in standard medicine, often falsely judged as malingering, "hypochondriasis", or treated like a purely psychological disease or mood disorder. With the prevalence of Chronic Fatigue Syndrome, and syndromes of idiopathic chronic pain, the medical community has taken advantage of the increasing prevalence of Somatoform Syndromes, and often suggested in the last decade that the patient has a Lyme Disease Syndrome without evidence of infection. It is estimated that up to 20 percent of syndromes of chronic pain and chronic fatigue are Somatoform Syndromes, but with the denial of care in cognitive and behavioral psychology, this is now rarely diagnosed, and almost always treated with the wrong therapeutic protocols, often with prolonged antibiotics with no justification, or chronic use of anti-depressants, benzodiazepines and atypical anti-psychotics. When a Somatoform Syndrome, such as Somatic Pain Syndrome, Body Dysmorphic Disorder, or Somatization Disorder occurs, or is suspected, a thorough diagnostic evaluation and differential diagnosis is required, and the patient needs to gain an understanding of their disease or syndrome objectively, and treated with a Mind-Body approach. The difficulty inherent in these health problems, both for the physician and the patient, should not result in inadequate care and malpractice.

As stated, a growing concern in medicine is that many patients with a chronic fatigue syndrome, and possibly with a Post-Lyme Disease Syndrome, are being unnecessarily treated with a prolonged course of antibiotics that has not demonstrated success in treating these disorders, and itself may present side effects, or affect the symbiotic microbial balance in the intestines and allow other chronic infections, such as systemic candidiasis, to occur, which itself may create symptoms of chronic fatigue. In addition, these prolonged courses of antibiotics may have significantly contributed to the alarming evolution of antibiotic-resistant bacteria in the community. In such difficult and complex disease presentations, the patient should take a proactive approach, learn as much about these conditions as they can, and perhaps take a greater role in insuring that a logical and credible diagnosis and treatment plan is achieved. A patient that suspects that Lyme disease is the cause of his or her Chronic Fatigue Syndrome should assess the initial presentation of signs and symptoms to see if there was indeed evidence of an actual Lyme disease preceding the onset of chronic fatigue. Studies (cited below) have indicated, when an initial Lyme disease is definitively diagnosed, that the initial signs and symptoms include a red rash that resembles a bull's eye or a moving red skin rash (erythema migrans), often mild, seen in about 90 percent of cases, headaches in about 31 percent, joint pain or inflammation in about 28 percent, peripheral neuropathies related to nerve root inflammation in about 11 percent, and cranial nerve palsies, or facial paralysis, seen in about 4.6 percent. The lack of initial signs and symptoms implies that the chronic condition may not have been caused by Lyme Disease, and that a number of other causes and physiological problems need to be fully explored. The desire to have a chronic fatigue syndrome explained should not prompt an incomplete or erroneous diagnosis and course of therapy.

What is confusing is that many patients diagnosed with Lyme disease as a cause of chronic fatigue have not clearly identified that the initial spirochete infection actually occurred. An optimized PCR test (polymerase chain reaction) can be ordered to definitively determine whether the spirochete is present in the body. Other tests are less definitive, and screening enzyme immunoassay tests may be falsely negative in about 39% of cases, and reference immunoblot tests falsely negative in about 31%. If this analysis is carried out, the patient can be reasonably assured that Lyme disease is present or not, although often these tests are not performed due to cost. If Lyme disease is not objectively diagnosed, one should look for other causes for the chronic fatigue syndrome. Even if Lyme disease has been definitively diagnosed in the patient's past, the chronic fatigue syndrome is not necessarily linked to a present infection, and attempts to treat with this simplistic approach of antibiotics may be misguided. Research has shown that the pathology in chronic Lyme disease appears to relate to altered immune responses, especially an excess Th1 (T-helper cell) response with decreased IL-10 and increased IL-6, IL-12, and interferon gamma, and a dysregulation of TNF-alpha. This dysfunctional chronic inflammatory response is similar to those seen in various autoimmune disorders. Treatment with prolonged antibiotics may be too simplistic to correct this immune dysfunction, and will result in chronic health problems caused by the antibiotic course. A thorough assessment, differential diagnosis, and most importantly a proactive approach on the part of the patient is recommended when uncovering the multifactorial causes of most cases of Chronic Fatigue Syndrome. Other potential underlying causes of chronic fatigue syndromes should also be adequately tested, diagnosed and assessed.The cost of future treatment and debility dramatically outweighs the cost of these diagnostic tests in many cases.

As research progresses, diagnostic differentiation is making progress. Large studies of patients with a definitively diagnosed Lyme Disease with chronic fatigue, and patients without the positive diagnosis afforded by enhanced PCR, but with Chronic Fatigue Syndrome, have identified a large number of differing proteins in the cerebral spinal fluids that distinguish the Posttreatment Lyme Disease Syndrome from Chronic Fatigue Syndrome (CFS/ME), and from healthy control subjects. Presently, this data is being analyzed to discover reliable protein biomarkers that may distinguish these diseases. In addition, researchers specializing in syndromes related to Lyme disease are trying to find clinical guidelines and objective tests that will distinguish the various pathological manifestations of chronic conditions associated with Lyme Disease, including lymphocytic meningitis, multifocal inflammation of the nervous system, Lyme encephalopathy, Posttreatment Lyme Disease Syndrome, and Chronic Lyme Disease. Prominent medical doctors are also presenting evidence of the efficacy of integrating acupuncture, herbs and nutrient medicine into the treatment protocols for these various syndromes (Dr. Dillard at the 2010 Lyme Disease Association/Columbia University Scientific Conference). The persistence on the part of patients and their advocates is finally producing progress in distinguishing and elucidating various chronic fatigue syndromes, distinguishing CFS/ME from Post-Lyme Disease Syndrome, and giving patients more guiding information on how to devise an effective and comprehensive treatment protocol.

This article is not about Lyme Disease, though, but about patient understanding of Chronic Fatigue Syndrome. This introductory section alerts the patient to the growing problem of standard medicine now creating more and more clinics that simply prescribe long courses of antibiotics, rather than fully test, explore differential diagnosis, and more importantly explore an integrative approach to a full restoration of health and function. Complementary Medicine may be integrated into the treatment even when the prolonged antibiotic regimen is chosen, not only to restore health after a long antibiotic course, but to also address the many physiological dysfunctions seen in chronic fatigue syndromes that the antibiotics do not address. A famous antitrust suit by the attorney general of Connecticut, Richard Blumenthal, addressed the question of illegally denying a type of proven medical care by an array of standard medical businesses. This suit concerned the denial of Complementary Medicine by the medical associations and insurance companies despite evidence of efficacy, although it has been touted as a proponent of prolonged pharmaceutical antibiotic therapy, not Complementary Medicine. There is well-founded suspicion that the issue of prolonged antibiotic therapy, the lack of medical proof of benefit, and the denial of coverage for this treatment, has been promoted in some sense to take the emphasis off the constitutional rights of patients to choose therapies in Complementary Medicine that are proven, and have them paid for. These expensive and elaborate tactics are not new in the business of medicine. The following article is not intended to guide therapy, but to merely contribute to patient education, and is by no means considered by the author to be a definitive last statement on the the enormous challenge of Chronic Fatigue Syndrome. Other articles on this website provide information that may be valuable to the patient as well, with articles on Fibromyalgia, Neurodegenerative diseases, and Brain health and function, as well as articles on Irritable Bowel Syndrome, Piriformis Syndrome (Pelvic pain syndromes), Hormonal pathology, Superantigens, and Candidiasis. Often, the challenges are overwhelming to patients with a chronic fatigue syndrome, but with greater education and understanding, a more refined proactive approach on the parts of patients with this devastating health problem will be the key to future success in treatment for all patients.