Chronic Fatigue Syndrome
Chronic Fatigue Syndrome
John Medina's column, "Chronic Fatigue Syndrome—A Lesson in Big Science" (Psychiatric Times, April 2007, page 12), focuses on recent research by the CDC on the genetic aspects of chronic fatigue syndrome (CFS) as reported in Pharmacogenetics and Nature. His commentary—understandably, given his particular interests—critiques the research design of these studies and the complexity of coming to conclusions when many genes are involved.
Another problem, as he rightly observes, is the more basic matter of the diagnostic criteria used in studying such a complicated disorder. The criteria to which he was apparently referring are the Fukuda 1994 criteria1 that were used for years in the increasingly numerous studies of CFS and are now being replaced in some countries by the Canadian consensus criteria—"Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols."2 The very important issue that Dr Medina touches on in his column is the strong and increasingly specific basis for CFS.
The January 2007 conference of the International Association for Chronic Fatigue Syndrome (renamed with the addition of myalgic encephalopathy [ME] to acknowledge the overwhelming evidence of brain pathology) in Fort Lauderdale, Fla, provided an amazing array of data from 28 countries showing that CFS/ME is a biological disorder in which many body systems are affected by abnormalities in the brain and neuroimmune systems.
There is clear evidence that true CFS is not a primarily psychological disorder. If psychological symptoms appear, they occur after illness onset. It is time to discard the old and false notions that CFS is the "yuppie flu" or a "functional disorder."
Certainly, there is good evidence of genetic factors that do need to be better understood, but there are many other factors that are currently being studied. Psychiatrists can contribute to a proper diagnosis by taking careful medical, developmental, and psychiatric histories of their patients as well as by becoming familiar with the wealth of new research available.
Alan Gurwitt, MD Newton Highlands, Mass
Dr Medina responds:
Dr Gurwitt brings up a very important point. CFS carries with it numerous social prejudices that are potentially as debilitating as the disorder itself. The ability to solidly characterize its biological underpinnings is the only sure way to put these prejudices to rest. Finding the genetic basis behind the disease is an important component of that effort.
As mentioned in the column, I deeply admire the approach that the CDC took to address this complex problem. Multigene linkage analyses are very difficult to complete, even when a clinical profile is unanimously accepted by the research community—and it is all the worse when there is disagreement. It is frustrating when something that is so obviously biological escapes biological explanation.
John J. Medina, PhD Seattle
1. Fukuda K, Straus SE, Hickie I, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med. 1994;121:953-959.
2. Carruthers BM, Jain AK, De Meirleir KL, et al. Myalgic encephalomyelitis/chronic fatigue syndrome: clinical working case definition, diagnostic and treatment protocols. J Chron Fatigue Synd. 2003;11. Available at: http://www.cfids-cab.org/MESA/ccpccd.pdf. Accessed on July 13, 2007.