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There is no proven or reliable
cure for CFS, and no drug has been developed specifically for this
disorder. Because CFS remains poorly understood, many patients have
problems finding good care. Overall, the recommended strategy for treatment
includes combination of the following:
- Cognitive-behavioral
therapy and graded exercise. A 2001 review of 44 CFS trials found that
of all therapies available to CFS patients, only these two treatment
modalities showed conclusive benefits.
- Antidepressant drugs in
some cases, usually low-dose tricyclic.
- A healthy diet.
- Sleep management techniques.
Patients with the best chance
for improvement are those who remain as active as possible and who seek to
have some control over the course of the disorder. Patients should seek
physicians who are willing to consider the problem as a medical condition
with psychiatric components. They should be very wary, however, if the physician
recommends excessive and expensive treatments that may have serious adverse
effects and that have no proven benefits. For patients with severe CFS that
cannot be managed with lifestyle changes and standard medications, asking
the physician about enrolling in any available clinical trials may be
helpful. Little significant research, however, is being conducted on
treatments for CFS.
Cognitive-Behavioral Therapy
In one study, CFS patients who
reported the severest symptoms also believed they had the least control
over them. Cognitive-behavioral therapy is designed to help patients regain
a sense of control and is proving to have substantial benefits for these
patients. Three out of four rigorous studies have shown overall benefits
using this technique.
Some experts believe that patients who are diagnosed with CFS should
immediately be referred to therapists trained in cognitive-behavioral
therapy. (Psychoanalysis and other interpersonal psychological therapies,
which are concerned with subconscious thoughts and early childhood
memories, are not generally helpful for the CFS patient.)
The Goals of Cognitive-Behavioral Therapy. The primary goals of
cognitive-behavioral therapy (referred to below as just cognitive therapy)
are to change any distorted perceptions that individuals have of the world
and of themselves and to change their behavior accordingly. For CFS
patients, this means learning to think differently about their fatigue and
to improve their ability to deal with stressful situations and manage their
disorder. Cognitive therapy is particularly helpful in defining and setting
limits, behaviors that are extremely important for these patients.
The Procedure . Cognitive therapy may be expensive and not covered
by insurance, although it is usually of short duration, typically six to 20
one-hour sessions. Patients are also given homework, which usually includes
keeping a diary and attempting tasks that they have avoided because of
negative attitudes.
A typical cognitive therapy program may involve the following measures:
- Keep a Diary. The patient
is almost always asked to keep an energy diary, which can be a key
component of CFS cognitive therapy. The diary serves as a general
guide for setting limits and planning activities. The patient uses the
diary to track any factors, such as a job or a relationship, that may
be making the fatigue worse or better. It is also used to track the
times of day when energy levels are at their highest and lowest peaks.
- Adjust Schedule. The
patient adjusts schedules to conform to energy peaks and valleys
recorded in the diary. For instance, the patient may plan low-energy
times for taking a nap and high-energy times for planning important
activities. Developing fairly rigid daily routines around probable
energy spurts or drops may help establish a more predictable pattern.
- Confront Negative or
Discouraging Thoughts. Patients are taught to challenge and reverse
negative beliefs (e.g., "I'm not good enough to control this disease,
so I'm a total failure.") to using coping statements ("Where
is the evidence that I can control this disease?")
- Be Flexible. Energy levels
will most likely never be entirely predictable. Patients must also be
prepared to adapt to energy variations. Instead of a long nap, for
instance, patients may need five to 10 minutes rest periods every hour
or more, during which time relaxation or meditation methods are
useful.
- Set Limits. Limits are
designed to keep both mental and physical stress within a manageable
framework so that patients do not get discouraged by forcing
themselves into situations in which they are likely to fail. For
example, tasks are broken down into incremental steps and patients
focus on one at a time.
- Prioritize. Patients learn
to drop some of the less critical tasks or delegate them to others.
- Manage Impaired
Concentration. Patients seek out activities that are appealing, focus
attention, and help increase alertness. They learn to request
instructions given as concise simple statements. External
distractions, such as music or talking, are kept to a minimum.
- Accept Relapses. Over-coping and accomplishing too much too
soon can often cause a relapse of symptoms. Patients should respect
these relapses and back off. They should not consider them a sign of
treatment- or self-failure.
Using both self-observation
and specific tasks, patients gradually shift their fixed ideas that they
are helpless against the fatigue that dominates their lives to the
perception that fatigue is only one negative and, to a degree, a manageable
experience among many positive ones.
Success Rates. A 2001 review of CFS trials reported that, of all
therapies available to CFS patients, only cognitive behavior therapy and
graded exercise showed conclusive benefits. The following are some specific
studies reporting results on the cognitive therapy approach:
- In one study comparing
patients receiving standard medical care with those receiving the same
treatment plus cognitive therapy, 73% of the cognitive group were
spending less time in bed and functioning normally after a year, as
opposed to only 27% of those who received standard therapy.
- In another study, 70% of
patients improved significantly after six months of cognitive therapy,
compared to 19% who used only relaxation techniques. A follow-up study
done five years later and published in 2001 reported that 68% of the
cognitive group still rated themselves as "much" or
"very much" improved, compared to 38% of the relaxation
group; 80% of patients who had originally received cognitive therapy
continued to use it.
- In a 2001 study, even
health workers who had not been trained before in cognitive therapy
achieved improvement using these techniques in nearly half of the
patients they treated.
- Some experts believe that this approach may be particularly
important for victims of Gulf War syndrome, whether or not the cause
turns out to be the same as for CFS or nerve gas toxins, since there
are no other proven treatments for either condition.
Not all studies support the
benefits of cognitive therapy; the skill of the therapist is very important
in its success. It is important to note that even if chronic fatigue
syndrome proves to have a specific organic cause, the power of the mind to
improve or oppose health problems is significant, and treatments that
promote a positive outlook are beneficial for any disease.
Exercise
A number of studies are now demonstrating that a graded exercise program,
in which patients perform increasingly more intense levels of exercise
tailored to their individual abilities, has benefits for those with CFS. Exercise
is best performed in concert with cognitive behavioral therapy.
The following are specific studies attesting to the benefits of graded
exercise:
- In a 2001 study, patients were
provided with medical reports explaining that their disorder may be
due to disruptions of their biologic rhythms and sleep patterns, which
led to inactivity. This produced a cycle of poor physical condition
and subsequent CFS symptoms. The patient then engaged in a
self-managed graded exercise program. Over 80% of patients reported
improvement, and the benefits persisted for at least a year. (Still,
32% of patients still complained of fatigue at the end of this
period.) In this study, this approach was as successful as
cognitive-behavioral therapy.
- Another 2001 study reported
that patients recovering from mononucleosis who began a graded
exercise program were significantly less likely to develop chronic
fatigue syndrome within seven months than patients who did not
exercise. No proof exists, however, that CFS is actually caused by
physical unfitness; rather, most studies suggest that CFS itself
limits exercise and causes a cycle of poor conditioning and worsening
symptoms.
- Other reports have found that 75% of CFS patients who were able
to engage in exercise, particularly aerobic exercise, reported less
fatigue and better daily functioning and fitness after a year.
Unfortunately, CFS patients
have a lower exercise capacity than healthy individuals, and in fact
over-exercising can intensify symptoms. Some patients experience profound
fatigue following even modest exercise. It is the primary factor in
perpetuating the low-activity levels observed in these patients.
The following tips may be helpful for CFS patients when embarking on an
exercise program:
- Start slowly and
incrementally, beginning with as little as three to five minutes of
moderate exercise a day. The goal is to increase activity by about 20%
every two to three weeks. (Capacity varies greatly among CFS
sufferers, however, and some may not be able to achieve this.)
- Establish limits and keep
within them in order to avoid overexertion and relapse.
- Experiment with different
forms of physical activity that suit available energy levels. Some
patients report great benefits from yoga or Tai Chi, which combine
exercise with meditation.
- Setbacks will occur, but do not become discouraged.
Healthy Diet
Although there is no evidence
to support any specific dietary factors in CFS, patients should be sure to
maintain a healthy diet that includes the following:
- Plenty of fresh
dark-colored fruits and vegetables, which are rich in antioxidants.
- Fiber-rich foods.
- Some fats may be
beneficial, but avoid saturated fats (found in animal products). A few
studies reported some improved symptoms in patients who consumed black
currant and fish oils (sold in supplement form as EPA-DHA omega 3). These
oils contain fatty acids that help block certain immune factors
responsible for promoting damaging inflammation.
- For those with demonstrated low blood pressure, increasing the
amount of salt in the diet may be helpful.
Other Approaches to Managing
Chronic Fatigue Syndrome
Stress Reduction
Techniques. One panel
of experts concluded that relaxation and stress-reduction techniques were
helpful in managing chronic pain. They also can help relieve the stress
associated with the disease. They are not useful, however, as the primary
treatment for CFS. A number of
relaxation techniques are available:
- deep breathing exercises,
- muscle relaxation
techniques,
- meditation,
- hypnosis,
- biofeedback, and
- massage therapy.
[For more information, seeWell-Connected
Report #31 Stress.]
Light Therapy. The use of light therapy (phototherapy) may be
effective treatment for patients with CFS whose symptoms have a seasonal
variability that is similar to those of patients with seasonal affective
disorder (SAD). Patients with SAD experience more depression during the
winter, when the hours of sunlight wane. With phototherapy, the patient
sits a few feet away from a box-like device that emits very bright
fluorescent light (10,000 lux) for about 30 minutes every day. It is best
performed immediately after awakening in the morning.
Supportive Family and Groups. Strong, supportive, relationships with
family and friends may be an important factor in the overall improvement of
CFS patients. It should be strongly noted, however, that many CFS patients
are overly dependent and should not impose expectations that cannot be met
on loved ones. Ongoing support groups with fellow patients may be very
helpful. In one 2001 study, sharing experiences in a group therapy setting
proved to be the most valuable component and one that improved patients' coping
abilities.
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