can be found below.
This is the FRIEDMAN AWARD winner. Please see the pictures at=20
http://www.co-cure.org/Jason.htm
Isn't it just wonderful?
Pat
_______________________________________
2009 Medical Scholarship - The Friedman Award
Initiative created by Betty McConnell and Dr. Kenneth Friedman, New=20
Jersey CFS Association, duplicated by the Vermont CFIDS Association,=20
and Pandora (Patient Alliance for Neuoendocrineimmune Disorders -=20
Florida). In 2008, "The Friedman Award" was named, adopted, and=20
funded by the Wisconsin ME/CFS Association, Inc.
_______________________________________
This is Jason's essay:
Diagnosis and Treatment of Myalgic Encephalomyelitis / Chronic Fatigue Sy=
ndrome
Jason M Habeck
University of Wisconsin School of Medicine and Public Health
Introduction:
Myalgic Encephalomyelitis (ME) and Chronic Fatigue Syndrome (CFS) are=20
chronic, complicated disorders that involve multiple sites and organ=20
systems throughout the body. This condition is one of the most=20
difficult to diagnose and treat because little is known about its=20
etiology. Additionally, no tests have been proven to diagnose it=20
consistently and effectively. This condition is so complex even its=20
name portrays its ambiguity. "ME has not been proven to include=20
myelitis (spinal cord inflammation) or encephalitis (brain=20
inflammation)" (Scott et. al, 1995), yet the name "myalgic=20
encephalomyelitis" remains. There are many symptoms that can be=20
associated with ME/CFS. Muscular fatigue is the most common and=20
widely recognized symptom associated with ME/CFS, as indicated by the=20
name "chronic fatigue syndrome". Some of the other common symptoms=20
displayed are cognitive diminution, depression, musculoskeletal pain,=20
and sleep abnormalities. While these deficits are typical symptoms,=20
they are not necessary to diagnose ME/CFS and also do not represent=20
all of the possible symptoms associated with the=20
illness. Furthermore, the spectrum of ME/CFS ranges greatly from=20
mild to severe. Mild cases typically exhibit discomfort after=20
exertion. In extremely severe cases, "patients may be confined to=20
bed or a wheelchair" (Chambers et. al, 2006).
Although much research has been done, the etiology of ME/CFS remains=20
largely unknown. Possible causes include "neurological, endocrine,=20
immunological, genetic, psychiatric, and infectious" (Baker et. al,=20
2007) problems. This is precisely what makes ME/CFS so hard to=20
diagnose and even more difficult to treat. Most treatments target=20
the source or root of a condition. ME/CFS treatment is more=20
palliative than curative because of its unknown etiology. There are=20
many theories as to how ME/CFS manifests itself, however there is no=20
"accepted disease model that can explain signs and symptoms in terms=20
of specific pathophysiological abnormalities" (White et. al, 2000).
Physicians are often hesitant to diagnose ME/CFS since there is no=20
proven etiology, no definitive set of symptoms, and little guidance=20
for treatment. It should seem evident that "problems in=20
doctor-patient relationships may be a factor in persistent disability=20
in fatigue states" (Scott et. al, 1995). In fact, studies have shown=20
that half of physicians do not even believe the condition exists=20
(Thomas et. al, 2005). While it is apparent that this trend of=20
disbelief is changing for the better, it is crucial that all primary=20
care physicians realize this is a prevalent illness. The point=20
prevalence of chronic fatigue in 1997 was 2.6%, "falling to 0.5% if=20
co-morbid psychological disorders were excluded" (Wessely et. al,=20
1997). Even excluding chronic fatigue cases coupled with=20
psychological disorders, 0.5% prevalence indicates a very significant=20
condition that should be taken seriously by primary care=20
physicians. The most important step to improve the treatment and=20
quality of care of patients with ME/CFS revolves around the primary=20
care physician. Physicians need to recognize that ME/CFS is a very=20
real and highly debilitating condition affecting patients=20
drastically. Until physicians realize the impact of ME/CFS, patients=20
will continue to suffer by not receiving the same dedication and=20
standard of care as someone with a similar widely-recognized=20
condition, such as Duchenne muscular dystrophy.
The complexity of ME/CFS is portrayed by the 7 different subtypes=20
used to classify a patient with ME/CFS. While there is no need to=20
explain all 7 subtypes, it is important to note the huge range of=20
symptoms and severity that are displayed by the different=20
subtypes. For example, subtype 7, the most severe, includes "pain,=20
infectious, musculoskeletal, sleep, neurological, gastrointestinal,=20
neurocognitive, and anxiety/depression" (JR Kerr et. al, 2007)=20
issues. On the other hand, subtype 4 is purely cognitive and subtype=20
5 patients display only musculoskeletal and gastrointestinal problems=20
(JR Kerr et. al, 2007). This huge discrepancy in the classification=20
of ME/CFS sheds light on the huge range and variation of symptoms=20
that can occur. Given that ME/CFS has no known etiology, this=20
variation of symptoms compounds the complexity of trying to diagnose=20
and treat the condition.
Diagnosis:
Diagnosing ME/CFS is extremely difficult. "CFS/ME is diagnosed=20
clinically as insufficient evidence exists for routinely using=20
diagnostic tests (Baker et. al, 2007). A few diagnostic exams have=20
shown promise but have not yet proven to be reliable in diagnosing=20
the general population. For example, the head-up tilt test proved to=20
be predictive in a small subset of patients with clinically diagnosed=20
CFS. However, in the general population a person presenting with=20
fatigue that displayed a positive head-up tilt test exhibited a=20
positive predictive value of "only 0.37 =AD 1.15" (Ghosh et. al,=20
2003). Similarly, a study "showed that the stapedial reflex together=20
with the auditory brainstem response test could be useful" in the=20
diagnosis of ME/CFS (Neri et. al, 1996). However, the study was=20
performed in a specific subset of patients with clinically diagnosed=20
ME/CFS and its utility in the general population is very questionable.
In the absence of diagnostic exams, a physician must conduct a method=20
of "process of elimination" to truly derive a confident clinical=20
diagnosis of ME/CFS. A multitude of symptoms are associated with=20
ME/CFS as well as many other illnesses. No symptoms are found=20
exclusively in ME/CFS. In addition, each symptom may or may not be=20
present in ME/CFS due to the extreme variation among inflicted=20
patients. The most common symptoms associated with ME/CFS are=20
muscular fatigue, impaired concentration and memory, depression,=20
sleep abnormalities, and musculoskeletal pain. A final diagnosis of=20
ME/CFS can be reached with a relative degree of certainty only after=20
all pertinent common conditions with similar symptoms have been ruled=20
out. There are many diagnostic exams that are extremely useful in=20
ruling out these other conditions.
Urine analysis is one exam that should be conducted to exclude other=20
conditions before a diagnosis of ME/CFS is made. Urinalysis for=20
protein, blood, and glucose can indicate many conditions with similar=20
symptoms to ME/CFS. While it is normal for small amounts of protein=20
to be found in the urine of children or after strenuous exercise,=20
proteinuria in high levels in adults may indicate kidney=20
disease. Blood in the urine, hematuria, may also indicate problems=20
other than ME/CFS. Hematuria can result from numerous causes, such=20
as urinary tract infections, kidney stones, medications, or even=20
cancer. Similarly, glucose in the urine can indicate a potential for=20
diabetes mellitus. Anything more than trace amounts should be=20
followed up with further testing for a possible diagnosis of=20
diabetes. Urinalysis is conducted to exclude ME/CFS from other=20
diagnoses because kidney problems, diabetes, and many other=20
conditions convey very similar symptoms to ME/CFS, especially=20
fatigue. A positive exam will allow a physician to focus on=20
diagnosing and treating these other conditions, which generally have=20
approved methods of treatment. Urinalysis should always be performed=20
before clinically diagnosing ME/CFS.
A complete blood count (CBC) should be conducted to rule out other=20
conditions with associated symptoms similar to ME/CFS. High white=20
blood cell numbers in CBC results can detect infections. Similarly,=20
anemia and leukemia can be detected through CBC's. Erythrocyte=20
sedimentation is also a useful blood exam because of its ability to=20
detect inflammation in the body. Rheumatoid arthritis, a=20
degenerative inflammation of joints and surrounding tissue, can be=20
discovered through this sedimentation process. Infections, anemia,=20
leukemia, and arthritis can all provide symptoms of chronic fatigue=20
and musculoskeletal pain. These conditions should be confidently=20
excluded before a presumptive diagnosis of ME/CFS is made.
C reactive protein (CRP) is another valuable laboratory exam used to=20
rule out illnesses that present similarly to ME/CFS. CRP is similar=20
to erythrocyte sedimentation in that it signals the presence of=20
inflammation in some portion of the body. CRP is often thought to be=20
a good predictor of coronary heart disease, although it is unable to=20
pinpoint the exact location of inflammation. High levels of CRP in the a
bsence of a coronary emergency can indicate an array of other=20
conditions including but not limited to cancer, infection, lupus,=20
fever, and tuberculosis (Danesh et. al, 2004). These illnesses have=20
all been shown to be associated with muscle aches and pains as well=20
as many other symptoms commonly associated with ME/CFS.
Testing the serum for various elements such as creatinine,=20
electrolytes, calcium, and urea is useful to ensure other conditions=20
are not bringing about symptoms commonly seen in ME/CFS. Serum=20
creatinine exams can reveal underlying renal function problems,=20
nephritis, or muscle diseases. Serum electrolyte counts can signal a=20
disruption in patients' intrinsic homeostatic mechanisms. Serum=20
calcium is a very tightly controlled substance and can often indicate=20
thyroid conditions. Thyroid problems are linked to abnormal energy=20
metabolism and irregular baseline activity levels of the body,=20
commonly perceived as chronic fatigue. Serum urea, or BUN, is used=20
as another indicator of kidney function. Abnormal amounts should not=20
be present unless someone has recently undergone rigorous=20
exercise. All of these conditions can exhibit symptoms similar to=20
ME/CFS. Consequently, only after excluding all of these possible=20
ailments through serum analysis should a diagnosis of ME/CFS be made.
Random blood glucose is another exam useful in ruling out conditions=20
other than ME/CFS. It is well known that blood glucose can identify=20
problems in the body's mechanisms of controlling energy storage and=20
production. Diabetes is the most common condition that can be=20
diagnosed from abnormal blood glucose results. Improper sugar=20
balance in the body can lead to many symptoms very similar to ME/CFS=20
such as fatigue, headaches, and even cognitive impairments when=20
glucose levels become too low.
Creatine kinase is an exam that monitors if there has been a recent=20
traumatic event to a muscle or group of muscles in the body. CK is=20
specifically used to help diagnose a myocardial infarction (MI). In=20
the absence of an MI, abnormal results can indicate that there has=20
been some other muscle deterioration. Muscle deterioration and=20
weakness present similarly to symptoms commonly associated with=20
ME/CFS, particularly chronic fatigue and musculoskeletal pain. A=20
diagnosis of ME/CFS should only be made after other muscular=20
conditions are ruled out.
A liver panel is a useful laboratory exam to rule out many liver=20
conditions that have like symptoms with ME/CFS. A standard liver=20
panel should include total protein, bilirubin, albumin, alanine=20
aminotransferase, alkaline phosphatase, and aspartate=20
aminotransferase. All of these individual tests in concert can=20
produce a holistic view of liver function. Hepatitis, hemolytic=20
anemia, and pancreatic cancer are some of the many conditions with=20
symptoms similar to ME/CFS that can be diagnosed using this liver=20
panel. Each of these conditions can produce one or more symptom(s)=20
commonly associated with ME/CFS.
Thyroid function should be analyzed through T3, T4, and TSH testing=20
before a diagnosis of ME/CFS is made. The thyroid gland is crucial=20
for basal metabolic rate and activity levels. Disruptions can mirror=20
many of the symptoms of ME/CFS. Some of the most common symptoms=20
associated with thyroid disorders are fatigue and weakness, lowered=20
basal body temperature, and cognitive impairments such as=20
forgetfulness or even dementia. By testing the T3, T4, and TSH=20
levels in blood, one can properly assess thyroid function and rule=20
thyroid abnormalities out before proceeding to a diagnosis of ME/CFS.
In children and young adults, serum ferritin is a valuable exam used=20
to rule out issues of iron homeostasis. Serum ferritin reveals how=20
much iron is carried in the blood and can be an indicator of=20
conditions such as anemia or hemochromatosis (Jacobs et. al,=20
1972). Anemia is simply a lack of adequate red blood cells. It is=20
very common for patients with this condition to feel extremely tired=20
and to also display cognitive problems due to the lack of proper=20
oxygen transport. Hemochromatosis is a condition in which the body=20
stores and absorbs too much iron. Iron overload often damages organs=20
in the body such as the liver, pancreas, or thyroid. This leads to=20
conditions that typically display symptoms similar to ME/CFS.
Finally, to correctly diagnose ME/CFS one must attempt to distinguish=20
ME/CFS from fibromyalgia (FM), the most similar condition. Symptoms=20
commonly associated with FM are extremely similar to ME/CFS. These=20
symptoms include chronic pain, sleep abnormalities, psychological=20
impairment, and debilitating muscle fatigue. The striking=20
similarities in the clinical presentation of CFS and FM "suggest that=20
these conditions have extensive overlap or may even be different=20
presentations of the same condition" (Buchwald, 1996). Like ME/CFS,=20
there is currently no way to diagnose FM through biological=20
markers. It is highly debatable whether the two conditions can be=20
clinically separated because of their similar symptoms as well as the=20
broad range of severity displayed by both. Some experts believe the=20
defining characteristic is that "only persons with FM alone exhibit=20
abnormal pain responses to mild levels of stimulation, or allodynia"=20
(Bradley et. al, 2000). However, definition criteria of both ME/CFS=20
and FM put a large emphasis on severity instead of focusing on actual=20
characteristics, which allows for the extensive overlap between the=20
two. In fact, a recent study has shown that "70-80% of patients with=20
CFS/ME also fulfill the 1990 criteria for FM" (Garcia-Fructuoso et.=20
al, 2008).
While differentiating between these two very similar conditions may=20
not be of utmost importance, there are current studies looking to=20
objectively distinguish ME/CFS and FM. A recent study has shown that=20
predictor single nucleotide polymorphism (SNP) mapping can make a=20
distinction between these two conditions. It was found that "from=20
the [20] SNPs analysed, a combination of 15 were found that could=20
very efficiently discriminate between FM and CFS/ME patients" in the=20
subset of patients studied (Garcia-Fructuoso et. al, 2008). Since=20
both ME/CFS and FM have no proven method of treatment, this absolute=20
diagnosis between the two is not nearly as important as ruling out=20
the other diagnoses noted above.
Once all other options have been exhausted, a diagnosis of ME/CFS can=20
be made. According to the National Institute for Health and Clinical=20
Excellence, "CFS/ME should be diagnosed in an adult only after=20
symptoms have persisted for four months and after exclusion of other=20
likely causes of the symptoms" (NICE, 2007).
Treatment:
There are no clinically proven methods to treat=20
ME/CFS. Consequently, treatment of ME/CFS becomes less important=20
than treatment of the actual patient. After diagnosis, a physician=20
must conduct "patient-centered medicine" and focus on a treatment=20
plan that is individually tailored to that patient's precise=20
needs. In reality, even if a diagnosis of ME/CFS is not made for any=20
particular reason, the treatment of individual symptoms will remain=20
virtually the same. A patient may benefit from the relief of a=20
diagnosis instead of the apprehension of an unknown affliction if no=20
diagnosis is made. However, the real focus now shifts away from the=20
diagnosis and directly to the individualized treatment of symptoms.=20
If a patient is suffering from muscular fatigue and pain, the primary=20
care physician must treat the muscular fatigue and pain. If a=20
patient is suffering from psychological problems such as depression,=20
the physician must treat the depression through psychological=20
care. To this date, there is no proven standard of care for=20
ME/CFS. Thus, a primary care physician's most important resource in=20
treating a patient with ME/CFS is the patient himself/herself. A=20
collaborative approach between the care team and patient can most=20
effectively provide reprieve to all or most of a patient's symptoms.
Holistic methods of treating ME/CFS require a large amount of=20
collaboration between a primary care physician, the patient, the care=20
team, and oftentimes a group of specialists. This can include but is=20
certainly not limited to "neurologists, immunologists, specialists in=20
infectious disease, pediatricians, nurses, clinical psychologists,=20
liaison psychiatrists, dietitians, physiotherapists, and occupational=20
therapists" (NICE, 2007). The extensiveness of this list portrays=20
the wide variety of treatments that can be incorporated into a=20
patient's regimen to combat ME/CFS. It is crucial to note that these=20
forms of treatment are not intended to cure ME/CFS, but rather only=20
to alleviate the symptoms. Some of the most common methods of=20
treating ME/CFS include exercise therapy, pharmacotherapy, dietary=20
changes, and cognitive behavior therapy.
There are two main forms of treatment for dealing with physical=20
exertion problems in ME/CFS: exercise therapy and rest. Exercise=20
therapy typically consists of graded exercise treatment. Graded=20
exercise treatment involves beginning to exercise at a slow, minimal=20
exertion level and slowly progressing to more demanding and longer=20
workouts. This means strictly adhering to a program mapped out=20
specifically by a physiologist. The most important part of these=20
graded programs is not overexerting or exercising more than planned=20
on "good days", as this can incur large setbacks. The graded=20
exercise program will allow the body ample time to recuperate and=20
adjust to activity changes in a slow and progressive manner. In=20
numerous studies, graded exercise therapy was found to be more=20
beneficial than rest alone (Fulcher et. al, 1997, Moss-Morris et. al,=20
2005). Many studies note the simple effect of distracting the=20
patient from their symptoms and focusing on exercise as a goal. "A=20
decrease in symptom focusing rather than an increase in fitness=20
mediated the treatment effect" (Moss-Morris et. al, 2005) in a study=20
based on self-surveys. This is not to say that exertion levels and=20
overall fitness are not inherently improved as well in graded=20
exercise therapy. On the contrary, "fatigue, functional capacity,=20
and fitness were significantly better after exercise" in an objective=20
study (Fulcher et. al, 1997). Therefore, an exercise program can=20
have multiple modes of improvement in the symptoms of ME/CFS. Graded=20
exercise appears to be a multi-faceted approach for ME/CFS because=20
"it operates in part by reducing the degree to which patients focus=20
on their symptoms" (Moss-Morris et. al, 2005) as well as improving=20
overall fitness.
Pharmacotherapy has often been used to treat the psychological=20
symptoms of ME/CFS. It has been documented that a large number of=20
patients with ME/CFS display symptoms most commonly identified with=20
depression. In fact, almost half of all patients with ME/CFS express=20
depression-like symptoms (Hickie et. al, 1990). Patients who have=20
been diagnosed with ME/CFS display similar pre-morbid depression=20
statistics when compared to the general population. This indicates=20
"psychological disturbance is likely to be a consequence of, rather=20
than an antecedent risk factor to the syndrome" (Hickie et. al, 1990).
Many physicians treat ME/CFS patients with=20
anti-depressants. Currently, the most oft-used anti-depressant is=20
fluoxetine. Fluoxetine is a selective serotonin reuptake inhibitor,=20
which results in more serotonin being available to postsynaptic=20
cells. Fluoxetine is "recommended in preference to tri-cyclic agents=20
because it has fewer sedative and autonomic nervous system effects"=20
(Vercoulen et. al, 1996). Its effectiveness has been proven in=20
clinically depressed individuals; therefore, patients with ME/CFS=20
displaying depressive symptoms have often been given=20
fluoxetine. However, despite this seemingly logical thought process=20
fluoxetine has not proven to be effective in the treatment of=20
depression-like symptoms in ME/CFS. A study showed that patients=20
with ME/CFS who were given an 8-week treatment of fluoxetine did not=20
show any significant improvements over a placebo control group=20
(Vercoulen et. al, 1996). No improvements were seen in many aspects=20
including sleep disturbances, activity levels, functional impairment,=20
and neuropsychological function. This indicates "processes=20
underlying the presentation of depressive symptoms in CFS may differ=20
from those in patients with major depressive disorder" (Vercoulen et.=20
al, 1996).
Galantamine hydrobromide has many pharmacological properties that=20
would appear to benefit ME/CFS patients. Galantamine hydrobromide is=20
a cholinesterase inhibitor. It increases acetylcholine activity by=20
down-regulating cholinesterase, the enzyme which breaks acetylcholine=20
down. Galantamine hydrobromide has been proven to be effective in=20
neurological conditions such as Alzheimer's and mania as well as=20
improving REM sleep density and decreasing REM sleep latency (Blacker=20
et. al, 2004). These positive effects would certainly appear to=20
improve many symptoms associated with ME/CFS. However, a trial in=20
2004 "did not demonstrate any benefit of galantamine over placebo in=20
the treatment of patients with CFS" (Blacker et. al, 2004).
To date, there is no evidence that anti-depressant medication such as=20
fluoxetine or galantamine hydrobromide have any benefit on patients=20
suffering from ME/CFS. Until this "virtually unbroken series of=20
failed drug trials for CFS" (Straus, 2004) ends, anti-depressant=20
pharmacotherapy should not be considered a viable option in the=20
treatment of ME/CFS.
Patients with ME/CFS, especially those with documented bowel=20
irritation, often benefit from dietary therapy. Dietary changes and=20
recommendations are one of the least researched forms of treatment=20
for ME/CFS but have shown early signs of utility. There are two=20
common types of dietary treatment in ME/CFS. Normal healthy dieting=20
is encouraged in patients with ME/CFS for the obvious reasoning that=20
people who eat healthier generally feel better and have more energy=20
than those with unhealthy (high fat, high calorie) diets. The other=20
form of ME/CFS treatment involves specific types or categories of=20
food that may have specific methods of improving the symptoms=20
associated with ME/CFS.
There is little dispute that an overall balanced and healthy diet=20
following common guidelines can have great benefits in energy level,=20
weight, and mood. It has been reiterated in the literature that "a=20
diet plan for patients with CFS should be based on sound nutritional=20
principles and common sense" (Morris et. al, 1993).
There have been many specific diet therapies prescribed to patients=20
with ME/CFS that have claimed to be beneficial. However, most of=20
these plans are purely anecdotal and do not stand in the face of=20
clinical research. These treatments include supplements such as=20
megavitamins or royal jelly. Other treatments include general=20
guidelines such as elimination, rotation, and avoidance=20
dieting. These diets are "not supported by clinical evidence and are=20
not practical for patients with CFS" (Morris et. al, 1993). Strict=20
diets and "miracle" supplements are not proven to be effective=20
because of the lack of evidence as well as the unreasonable dietary=20
expectations given to patients with ME/CFS.
Recently, a few studies have discovered a select few dietary=20
supplements that display positive effects on patients with=20
ME/CFS. For example, lactic acid producing bacteria, like those=20
found in yogurt, have recently been found to have positive effects on=20
symptoms associated with ME/CFS. One of the many possible causes of=20
ME/CFS includes disturbances in both the intestinal bacterial flora=20
as well as the flora of the immune system of the patient. Treatments=20
of lactic acid producing bacteria have been proven to "prevent and=20
alleviate gastrointestinal disturbances and to normalize the cytokine=20
profile which might be of an advantage for patients suffering from=20
chronic fatigue syndrome" (Sullivan et. al, 2009). The study showed=20
that some patients exhibited improvement in both physical and=20
neurocognitive function after a regimen of bacterial flora. However,=20
some patients showed no improvement through bacterial yogurt=20
therapy. It appears that "improvement of health is possible to=20
achieve and should encourage further studies with interventions with=20
probiotics in patients with CFS" (Sullivan et. al, 2009). The future=20
of research in this method of treatment will aim to identify those=20
patients with ME/CFS who will respond to dietary therapy such as=20
this. Dietary therapy appears promising for treatment but it is=20
important to remember that not every patient will respond to the method.
Cognitive behavior therapy (CBT) has been shown to benefit patients=20
with ME/CFS. CBT is a type of psychotherapeutic therapy intended to=20
affect patients' conscious emotions, behaviors, and attitudes. It=20
requires instructing the patient extensively about ME/CFS, then=20
focusing on effectively coping with the illness. It promotes=20
actively combating the condition rather than inactivity. Studies=20
have shown that any recommendation "to chronic patients to avoid=20
physical and mental activity is counterproductive" (Butler et. al,=20
1991). It is important to note that "[CBT] for chronic fatigue=20
syndrome can produce some lasting benefits but is not a cure" (Deale=20
et. al, 2001). Patients who received CBT compared to control groups=20
(no therapy) showed many improvements spanning multiple aspects of=20
life. Improvements were seen as a "decline in functional disability=20
correlated with a decrease in mood and anxiety related symptoms and=20
also somatic symptoms" (Butler et. al, 1991).
CBT has also been proven to be more effective than other types of=20
psychotherapy. For example, a study in 2001 concluded "CBT was more=20
effective than guided support groups and the natural course" (Prins=20
et. al, 2001) in over 250 patients. The positive outcomes were seen=20
in both functional impairment as well as fatigue severity=20
categories. Also, CBT has been shown to be more productive than=20
relaxation therapy. Patients with ME/CFS "receiving CBT, in relation=20
to those in relaxation therapy, experienced symptoms that had=20
steadily improved or were consistently mild or absent since treatment=20
ended" (Deale et. al, 2001). Furthermore, these same patients in CBT=20
were working more hours per week than those receiving relaxation=20
therapy. The evidence shows that CBT is a valuable method for=20
combating the symptoms associated with ME/CFS and is more beneficial=20
than other types of psychotherapy.
Conclusion:
In conclusion, ME/CFS is a very complicated disorder that is not well=20
understood. Its etiology is largely unknown and there are no=20
universally approved treatments that are proven to work. It is=20
extremely important for primary care physicians to accept that this=20
is a true condition affecting a significant portion of the=20
population. ME/CFS has physical, cognitive, and psychological=20
effects. In order to properly diagnose ME/CFS, one has to first=20
eliminate all other possibilities that could display similar=20
symptoms. Once this has been accomplished, it becomes more important=20
to treat the patient's precise set of symptoms rather than focusing=20
on a standardized form of treatment. This individualized=20
"patient-centered medicine" approach will allow a more thorough and=20
precise method of treatment designed to specifically alleviate the=20
patient's symptoms instead of a generalized list of symptoms commonly=20
associated with ME/CFS. This individualized and dedicated approach=20
has been shown to improve patients with ME/CFS partly through the=20
extra attention and focus provided by physicians. It allows patients=20
to shift their focus from their debilitating condition and associated=20
symptoms to a more positive and determined mindset focused on a=20
specific goal or routine.
If nothing else, ME/CFS reminds physicians of the importance of the=20
patient in medicine. Too often physicians focus on treating an=20
illness instead of treating the patient. The most effective way to=20
treat ME/CFS is to treat the patient individually. Only through this=20
focused method will symptoms be most effectively reduced.
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Baker, R. & Shaw, E.J. (2007) Diagnosis and management of chronic=20
fatigue syndrome or myalgic encephalomyelitis (or encephalopathy):=20
summary of NICE guidance. BMJ, 335, 446-448.
Blacker, C.V.R., Greenwood, D.T., Wesnes, K.A., Wilson, R., Woodward,=20
C., Howe, I. & Ali, T. (2004) Effect of Galantamine Hydrobromide in=20
Chronic Fatigue Syndrome: A Randomized Controlled Trial. Journal of=20
the American Medical Association, 292, 1195-1204.
Bradley, L.A., McKendree-Smith, N.L. & Alarcon, G.S. (2000) Pain=20
complaints in patients with fibromyalgia versus chronic fatigue=20
syndrome. Current Review of Pain, 4, 148-157.
Buchwald, D. (1996) Fibromyalgia and Chronic Fatigue Syndrome:=20
Similarities and Differences. Rheumatic Diseases Clinics of North=20
America, 22(2), 219-243.
Butler, S., Chalder, T., Ron, M. & Wessely, S. (1991) Cognitive=20
behaviour therapy in chronic fatigue syndrome. Journal of Neurology,=20
Neurosurgery, and Psychiatry, 54, 153-158.
Chambers, D., Bagnall, A.M., Hempel, S., & Forbes, C.=20
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