Journal of Chronic Fatigue Syndrome: Volume 7, Issue 4, 2000

Volume 7, Issue 4, 2000

 * Editorial by Roberto Patarca-Montero
 * Doctor-Patient Relationship in Primary Care of Chronic Fatigue Syndrome: Perspectives of the Doctor and the Patient"'Abstract - Background: Chronic Fatigue Syndrome (CFS) is characterized by severe debilitating fatigue for at least six months. The lack of a known origin could have consequences for the way general practitioners deal with the diagnosis CFS and their perception of CFS patients. The aims of the study were to investigate the use of the diagnosis CFS by GPs and their reactions to self-diagnosis and to explore opinions of GPs about causes of CFS and the communication with CFS patients as well as opinions of CFS patients about their GPs. Method: One hundred twenty-one GPs completed questionnaires and 12 were interviewed. Data of 211 CFS patients were analyzed as well. Results: Only half of the GPs used the diagnosis CFS. The main reason for not diagnosing CFS was ignorance of the criteria. GPs reported self-diagnosis in 68% of the CFS patients. More than half of the GPs could sympathize less with the complaints of CFS patients compared with other patients. These GPs experienced more problems in communicating with CFS patients and judged co-operation and contact as poor. As to the causes for CFS a discrepancy was found. GPs mainly attributed the complaints to psychosocial factors, whereas patients mainly had physical attributions. Conclusion: In CFS, GPs should be explicit about the diagnosis. As to the discrepancy in presumed causes of CFS between GPs and CFS patients, it may be helpful for GPs to discuss the distinction between initiating and perpetuating factors of CFS. We argue that this attitude of GPs would be beneficial to the course of the complaints of CFS patients.'"
 * Differential Diagnosis: The Challenge of Chronic Fatigue"'Abstract - The chronic fatigue syndrome comprises one of the most challenging issues in contemporary medicine. The condition remains distressing for patients and perplexing to medical science. Clinicians face a management path which has no “gold standard” of investigational mileposts; and are locked into a progression where the extremes of either undertreatment or over-investigation may lead to iatrogenic disaster. The themes of investigation, diagnosis and management of patients with the chronic fatigue syndrome remain controversial. This condition joins in historical perspective a series of other diseases such as pink disease, post-traumatic stress disorder (by a variety of names), the Royal Free disease, Q Fever, Ross River disease and chronic ciguatera - all of which have occupied windows of historical time in the twentieth century during which their genesis remained an enigma. In some cases, they still do. New and puzzling diseases will undoubtedly arise in the future. Both patients and medical science are best served if the formal discipline of differential diagnosis is followed unswervingly under these circumstances or “new” diseases. The rigour of this discipline-the rank listing of formal possibilities after the clinical history and objective signs have been elicited-forms the pivot of best-practice contemporary medicine. An example of its power is no more dramatically illustrated by the example of a “new” enigmatic disease, chronic ciguatera, which “reappeared” in the 1950s. Ciguatoxins are some of the most potent biological substances known. Their neurotropic effects produce a protean array of symptoms which are distressing in the acute-phase syndrome and which are enervating throughout the often-prolonged progression of convalescence. It is now appreciated that such effects are due to sodium channel activation and subsequent dysfunction at the receptor sites on the cell surface of all excitable tissues. Dr. A. Melvin Ramsay, the Honorary Consultant Physician in Infectious Diseases at the Royal Free Hospital in London, was at the clinical epicentre of the presentation of another new disease in July 1955. His approach to its diagnosis, in the best traditions of differential diagnosis, is an exemplar of the objective response to the appearance of a new or enigmatic disease; and especially to that type in which experience has not generated sufficient case familiarity to define syndrome barriers or to establish pathogenesis. Under such conditions, the correct diagnostic paradigm is to follow the discipline of differential diagnosis, an evolved phenomenon of the last one hundred years of medicine. This paper traces the evolution of the process of differential diagnosis, in the perspective of the enigma of chronic fatigue, which remains an unmet challenge today.'"
 * Psychiatric Comorbidity and Somatic Distress in Sudden and Gradual Onset Chronic Fatigue Syndrome "'Abstract - The purpose of this study was to examine if type of Chronic Fatigue Syndrome (CFS) onset suggested two distinct illness patterns within CFS. One hundred and seventeen patients diagnosed with CFS by a multidisciplinary team were divided into two groups: sudden versus gradual onset of symptoms. These two subgroups were compared on the presence of lifetime comorbid Axis I diagnoses, the pattern of medically unexplained symptoms, and the number of patients who met criteria for Somatization Disorder (SD). The two subgroups did not differ in any of the experimental variables indicating that onset type is not distinguished by either comorbid psychopathology or medically unexplained symptoms. Implications of these findings are discussed.'"
 * Elevated Peroxynitrite as the Cause of Chronic Fatigue Syndrome: Other Inducers and Mechanisms of Symptom Generation"'Abstract - In an earlier paper, I proposed that chronic fatigue syndrome (CFS) is caused by a response to infection, involving the induction of inflammatory cytokines which induce, in turn, the inducible nitric oxide synthase, producing elevated nitric oxide. Nitric oxide reacts with superoxide to form the potent oxidant, peroxynitrite. Six positive feedback loops were proposed by which peroxynitrite may stay elevated, acting to increase levels of both nitric oxide and superoxide, which react to form more peroxynitrite. This vicious cycle based on known biochemistry is proposed to be the central cause of CFS. The current paper discusses additional inducers which may act by increasing nitric oxide (physical or psychological trauma) or increasing superoxide (hypoxia) and the role of orthostatic intolerance, Ehlers-Danlos syndrome, excessive exercise, exercise intolerance and carbon monoxide in inducing hypoxia and consequently superoxide and peroxynitrite. The major symptoms of CFS can all be interpreted as relatively direct consequences of the pathophysiology predicted by the elevated peroxynitrite theory of CFS. Attractive mechanisms are proposed by which elevated peroxynitrite, nitric oxide and/or related physiological changes may induce CFS symptoms including fatigue, immune dysfunction, learning and memory dysfunction, multi-organ pain, exercise intoler-ance/postexertional malaise and orthostatic intolerance. Roles are discussed for six factors likely to influence the frequency of CFS induction in response to infection or other inducing events.'"
 * Literature in Review by Roberto Patarca-Montero