Chapter 2.8: Symptomatic Treatment

Average completion time for Chapter 2 is 25 minutes.

Supportive treatment goes hand-in-hand with symptomatic treatment. People with CFS present with varying primary symptoms. Health care professionals should query patients about which symptoms are of greatest concern to them and tailor the management plan accordingly. Many CFS patients are extremely sensitive to medicines—particularly sedating drugs—and health care professionals are advised to start with very low doses and increase gradually to tolerance. Therapeutic benefits may be achieved at lower than normal dosages (Evengard and Klimas, 2002).

Sleep Disturbances

Unrefreshing sleep is a major CFS symptom. Sleep abnormalities are an important differential diagnosis and comorbidity for CFS. In one study, CFS subjects were 28 times more likely to have non-restorative sleep and 16 times more likely to have restlessness, compared to non-fatigued subjects (Unger et al., 2004). Such problems require evaluation by a sleep specialist. Sleep disturbances may cause or exacerbate other symptoms, and may also be a side effect of certain medications, including those used to treat mood disorders.

Sleep deprivation or disruption produces many features of CFS, including fatigue, impaired cognition and even joint pain and stiffness. Primary sleep disorders such as sleep apnea and narcolepsy exclude the diagnosis of CFS and most people with such disorders respond to therapy. Thus, it is imperative that a careful sleep history be obtained. The Pittsburg Sleep Questionnaire (Buysse et al., 1989), a validated 19 question tool, or a brief sleep survey, adapted for clinical use can be helpful in assessing sleep problems and tracking effectiveness of sleep management interventions.

Sleep complaints common among people with CFS include difficulty falling asleep, hypersomnia, frequent awakening, intense and vivid dreaming, restless legs, periodic leg movements and nocturnal myoclonus. Most patients experience non-restorative sleep, a feeling of profound fatigue, achiness and mental "fogginess" that lasts 1–2 hours after rising.

Health care professionals can help people with CFS adopt better sleep habits, in accordance with standard sleep hygiene techniques. These techniques are often incorporated in a comprehensive CBT program, but can also be useful outside the scope of such programs. Specifically, patients are advised to incorporate an extended wind-down period, use the bed only for sleep and sex, schedule regular sleep and wake times and complete even light exercise at least 4 hours before going to bed.

Unmedicated sleep is best, but when sleep hygiene measures are not successful, the use of pharmaceuticals may be indicated. Initial medications to consider are simple antihistamines (such as diphenhydramine) or over-the-counter sleep products. As noted earlier, because of possible medication sensitivity, it is best to start with low doses and increase to tolerance. If this is not beneficial, then start with a prescription sleep medicine in the smallest possible dose and for a brief period. Hypnotics are to be avoided. Patients need to be informed that sleep and sedative medications may produce their own problems and undesirable side effects. Judicious use of these drugs is important. Non-restorative sleep can be present even though medications may allow requisite hours of sleep.

A sleep specialist should evaluate patients whose sleep remains nonrestorative following the above interventions.

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Depression

As discussed above, depression commonly accompanies CFS and should be treated when present. It is incorrect to assume that all people with CFS have depression or that CFS is a form of depression.

Health care professionals are advised to use caution in prescribing antidepressants. Antidepressant drugs of various classes have other effects that may act on other CFS symptoms and/or cause side effects. There are brief psychiatric screening tools available that can be administered and scored in the primary care setting, such as the Beck Depression Inventory (Beck et al., 1961; Steer et al., 1999) and the Patient Health Questionnaire nine-item depression scale, the PHQ-9 (Spitzer et al., 1999). Results of these screening tools that point to a possible underlying depression or other psychological disorder necessitate a referral to a mental health professional.

Finally, as noted previously, many people with chronic illnesses, including those with CFS, may suffer from depression. Feelings of worthlessness, inappropriate guilt, recurrent thoughts of death, recurrent suicidal ideation, suicide attempts or a specific plan for committing suicide define major depressive disorders. Mental health professionals in particular should be aware of and address this as necessary. All health care professionals who are responsible for treatment and rehabilitation of CFS patients should also be aware that inappropriately counseled CFS patients can become suicidal.

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Pain

CFS pain may be in muscles (sometimes described as "deep pain") or joints (arthralgias). Patients may also complain of headaches (typically pressure-like) and allodynia, which is generalized hyperalgesia or soreness of the skin to touch.

Therapy may begin pharmacologically with simple analgesics like acetaminophen, aspirin or NSAIDS and should include non-pharmacological modalities, such as graded exercise, paced activity, gentle massage, physical therapy, transcutaneous electric nerve stimulation (TENS) units, cool or hot packs, meditation, relaxation, deep-breathing and biofeedback.

Counseling for pain management techniques is advisable for people with severe, unremitting pain. Narcotics should be considered an option only in consultation with a pain management specialist.

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Orthostatic Problems

Some patients with CFS may also exhibit symptoms of orthostatic instability, in particular frequent dizziness and light-headedness. Depending on severity and clinical judgment, these patients should be referred for evaluation by a cardiologist or a neurologist. Specific treatment for orthostatic instability should only be initiated following confirmed diagnosis and by clinicians experienced in evaluating therapeutic results and managing possible complications.

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