Chronic Fatigue Syndrome (CFS) is characterised clinically by constant, incapacitating fatigue (usually experienced as exhaustion and poor stamina) which is not relieved by bed rest and of at least six months duration. Onset is usually abrupt and often accompanies illness due to infection. Symptoms often wax and wane, but are usually severely debilitating and may last many months or even years.

 The 17th Edition of The Merck Manual of Diagnosis and Therapy lists CFS in its "Syndromes of Uncertain Origin" section and goes on to say that there is considerable heterogeneity among those who meet the definition of CFS, and that etiology is controversial^1..

Chronic Fatigue Syndrome was formally defined in 1988 by a consensus panel convened by the Centres For Disease Control (CDC) and a formal and controversial set of diagnostic criteria was established. One of the main complaints laid down against the set of criteria was that it was better suited to research than for clinical purposes^2..

Diagnostic Criteria For Chronic Fatigue Syndrome In Australia (After Faduka, et al. 1994): ^3.

1. Fatigue

Clinically evaluated, unexplained, persistent or relapsing fatigue persistent for six months or more, that:

• is of new or definite onset;
• is not the result of ongoing exertion;
• is not substantially alleviated by rest;
• results in substantial reduction in previous levels of occupational, educational, social or personal activities;

and

2. Other symptoms

Four or more of the following symptoms that are concurrent, persistent for six months or more and which did not predate the fatigue:

• Impaired short term memory or concentration
• Sore throat
• Tender cervical or axillary lymph nodes
• Muscle pain
• Multi-joint pain without arthritis
• Headaches of a new type, pattern, or severity
• Unrefreshing sleep
• Post-exertional malaise lasting more than 24 hours

Prolonged fatigue states are found in fibromyalgia, irritable bowel syndrome, anxiety and depression, as well as in chronic fatigue syndrome^4.

The following diagram from the above Medical Journal of Australia paper clearly illustrates this:

CFS is more common in women than men and in young adults. About 10-25% of patients presenting to general practitioners are diagnosed with CFS.

Since children and adolescents are in a dynamic developmental state, early diagnosis and intervention is vital when persistent, unexplained fatigue exists for three months or more (rather than six months as is the case with adults). Issues such as autonomy, self-esteem, body image, socialisation, sexuality and academic goals are of central importance and the longer the diagnosis is delayed, the greater the adverse consequences of these issues ⁴.

Neurologically, CFS is considered a disorder of the management of sensory input by the brain, whereby control of the sensory input/output to and from the brain is dysfunctional. ^5. What this means is that information from both inside and outside the body is misperceived by the brain, which results in inappropriate sensations being experienced by the person. For instance, the sensation of touch may be experienced as being painful; certain odours may cause the person to experience discomfort and even illness; walking up a flight of stairs may feel like they are climbing Mt. Everest.

This "brain misperception" seems to be centered in the prefrontal cortex which regulates sensory gating as well as neurotransmitter secretion by neurons which secrete the excitatory amino acid glutamate resulting in a decrease of the neurotransmitter norepinephirine.

Norepinepherine enhances the signal to noise ratio in the processing of sensory input by the brain⁵. Signal to noise ratio is inherently low in CFS sufferers. Norepinepherine and Substance P (which is largely involved in the sensation of pain) are reciprocal in relation to one another, in that if one is high, the other is low. Other substances which tend to be reciprocal in balance are the hormones Dehydroepiandrosterone (DHEA) and Cortisol (Cortisol is sometimes known as the stress hormone). Stress has an adverse reaction in the balance of Substance P/Norepinepherine and Cortisol/DHEA as indicated in the chart below from The Institute of HeartMath.

The vertical axis shows the activation of the Autonomic Nervous System (ANS), ranging from arousal (fight-flight) to relaxation. The ANS is a quick-acting system that affects the heart, digestive system, adrenaline secretion and many other bodily functions. Perceptions and emotions activate the ANS and subsequently affect the balance between its sympathetic and parasympathetic branches^6..

The horizontal axis represents what is called the hypothalamic-pituitary-adrenal or HPA system, which coordinates the release of several of the body’s major hormones, including cortisol which is commonly referred to as the stress hormone. This axis is influenced by the quality of our emotions - it is a slower-acting system than the ANS, but its effects are longer-lasting. DHEA promotes the healthy maintenance and regeneration of the body’s systems, including activation of osteoblasts and the inhibition of Interlukin-6 implicated in osteoporosis. Dysfunction of the HPA axis is implicated in CFS^7..

The cause of this type of prefrontal cortex dysfunction is usually an interaction of genetic, developmental and environmental factors. Additionally, due to the inherent reduction in neural plasticity associated with this type of dysfunction, there is usually an increased susceptibility to environmental stressors.

Neural plasticity is the ability of the brain to cope with changing demands by creating and doing away with neural pathways as necessary to meet those demands. This relates to the concept of allostatic loads being exceeded beyond the coping capacity of the person.

(Diagram from the Medical Journal of Australia- CFS: Clinical Practice Guidelines 2002)

 Sick Building Syndrome (SBS) is also another environmental factor which needs serious consideration in CFS. According to the Health Protection Agency in Washington, the following can be causes:-

It should also be noted that excessive exposure to cool white fluorescent light can cause fatigue as well as decreased immune function^14.. Therefore, cool white fluorescents should be replaced with full spectrum fluorescents which approximate the spectrum of light found in daylight.

Studies have shown that CFS sufferers are deficient in one or more vitamins and minerals including salt^15., certain B vitamins ^{16, 17, 18, 19 , 20 , 21 , 22.}, vitamin C^{23, 24.}, magnesium^{17 , 25 , 26 , 26 , 27 , 28.}, malate^{29 ,} , zinc^{17 , 30} , beta-carotene^{31 , 32 , 33.}, carnitine^{34 , 35, 36.} , coenzyme Q10³⁷, essential fatty acids^{38 , 39 , 40.} .

 As mentioned earlier, many sufferers report food intolerances and some of these include sugar, processed foods (additives), refined grains including wheat, maize and rice, milk, beef, pumpkins, tomatoes and pineapple. Provocative testing of CFS sufferers found that in many instances, specific foods are associated with specific symptoms^41..

 Interventions

In light of the above Nutritional Factors, a full metabolic workup will be necessary in order to formulate an individualised diet and supplementation regime specific to the needs of each individual.

A complete developmental and medical history during the diagnostic interview will need to be undertaken in order to better understand the underlying dynamics of your condition so as to plan the best approach for your individual needs.

Consultation is by appointment only, for further information please contact:-

 References:

1. 17th Edition of The Merck Manual of Diagnosis and Therapy

2. Murray, M & Pizzorno, J., The Encyclopedia of Nutritional Medicine, 2000, Little, Brown & Co. London, UK.

3. Fukuda K, Straus SE, Hickie I, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Sydnrome Study Group. Ann Intern Med 1994; 121: 953-959.

4. Chronic fatigue syndrome, Clinical practice guidelines — 2002, MJA 6 May 2002 176 (9 Suppl): S17-S55

5. Goldstein, J.A., Betrayal by the Brain, 1996, Haworth Medical Press, Binghampton, New York.

6. Childre, D.& Martin, H., The HeartMath Solution., 1999, Harpers Publishers, San Francisco.

7. Demitrack, M. A., et al. Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome. J Clin Endocrinol Metab. 73:1224-1234, 1991.

8. Lorensen, T. D. & Gow, K, M., Quantitative Electroencehalographic Comudulation: An investigation of patterns in Chronic Fatigue Syndrome., Journal of Neurotherapy, Vol. 7, No. 1, 3-18, 2003.

9. Loblay RH, Swain AR. The role of food intolerance in chronic fatigue syndrome. In: Hyde BM, editor. The clinical and scientific basis of myalgic encephalomyelitis/chronic fatigue syndrome. New York: The Nightingale Research Foundation, 1992.

10. Manu P, Matthews DA, Lane TJ. Food intolerance in patients with chronic fatigue. Int J Eat Disord 1993; 13: 203-209.

11. Aaron LA, Buchwald D. A review of the evidence for overlap among unexplained clinical conditions. Ann Intern Med 2001; 134: 868-881.

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13. Maisch, D., Podd, J. & Rapley, B., Changes in health status in a group of CFS and CF patients following removal of excessive 50Hz magnetic field exposure., J. Aust. Coll. Nutr. & Env. Med. Vol. 21. No. 1. April 2002

14. In-Tele-Health., Hyperhealth - Natural Health and Nutrition CD ROM- Fitzroy, Victoria. 2004.

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16. Jacobson, W., et al., Serum folate and chronic fatigue syndrome., Neurology, 43(12):2645-7, 1993.

17. Grant, J.E., et al., Analysis of dietary intake and selected nutrient concentrations in patients with chronic fatigue syndrome. J. Am. Diet. Assoc., 96(4):383-6, 1996.

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26. Howard, J.M., et al., Magnesium and chronic fatigue syndrome, Lancet, 340:426, 1992.

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29. Russell, I.J., et al., Treatment of fibromyalgia and chronic fatigue syndrome with Super Malic: a randomised, double blind placebo contreolled, crossover pilot study. J Rheumatol. 22(5):953-8, 1995.

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32. Caligiuri, M., et al., Phenotypic and functional deficiency of natural killer cells in patients with chronic fatigue syndrome., J Immunol, 139:3306-13, 1987.

33. Cunha, B.A., Beta-carotene stimulation of natural killer cell activity in adult patients with chronic fatigue syndrome, TheCFIDS Chronicle Physicians Forum, pp 18-19, Fall, 1993.

34. Kuratsune, H., et al., Acylcarnitine deficiency in chronic fatigue syndrome, Clin Infect Dis. 18(suppl 1):S62-7, 1994.

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