Hi Everyone! Welcome to Hub Bites! I'm Sanil
Rege, Consultant Psychiatrist. If you're new to this channel, we cover all things Psychiatry
and Mental Health related. So if that's your thing don't forget to subscribe! Today I'm going
to be talking about a really really important disorder called Chronic Fatigue Disorder. Some
may also know it as Myalgic Encephalomyelitis. Now one of the important things
with chronic fatigue syndrome and more recently, there is a big overlap between
the symptoms of chronic fatigue syndrome and ME and long covid. So quite a bit of what I talk
about not all but quite a bit of what I talk about is sort of will be applicable
to long covid as well. All right so without further ado let's jump into knowing
more about chronic fatigue syndrome. So what is chronic fatigue syndrome? As I mentioned it's
also referred to as Myalgic Encephalomyelitis, it is a disorder characterised by extreme
fatigue or tiredness that doesn't go away with rest and can't be explained by an
underlying medical condition purely, that's not to say that there aren't a number
of underlying medical conditions that need to be treated. They absolutely need to
be treated, so in clinical practice I do see a lot of chronic fatigue syndrome and
Myalgic Encephalomyelitis. One thing I've learned is that every patient is different and every
patient has a range of different risk factors, their symptoms are very different for example some
may have pots, some may have prominent brain fog, some may have a combination of both, some
may have infections, some may have organic conditions or medical conditions such as thyroid
autoimmunity or other autoimmune disorders this is one of the most complex disorders I would
say in medicine that results in a huge burden overall and to be quite honest we still don't
know enough about it. The other thing is many patients can be dismissed as well, say that with
diagnosis such as dysfunctional neurological disorder or conversion disorder and many patients
often feel dismissed that you know being told that it's just in their head so it's really important
that we do take it seriously, we recognize the limits of medicine and psychiatry as a whole
and and listen carefully. We know that there are a number of aspects that can help patients
in this particular condition. So again there is a lot to know about chronic fatigue syndrome I've
written a detailed article on Psychscenehub.com where I go into much more detail but here I'm
going to give you a snapshot of what is CFS or ME. Now what is the cause of CFS, causality in
medicine is a very very complex issue so there's never one single thing that can lead that leads to
CFS, there's a combination of things, but what we find when we take a history of individuals with
chronic fatigue syndrome we ask them about their past we often see certain exposures that might
be present and that's where we look at certain associations or links. Now one of the things that
we find very prominently is viral infections so Epstein-Barr virus glandular fever often tends
to be quite a prominent part in individuals histories. So exposure to glandular fever and then
onset of chronic fatigue syndrome subsequently and this is where covid comes in as well. The
coronavirus exposure and long covid a very very similar pathogenesis may be involved and we know
that there are you know long covid is a documented entity and many many patients now presenting
with it. We then have genetics, some individuals just seem more prone to the development of
chronic fatigue syndrome sometimes there's a family history as well of chronic fatigue syndrome
or other pain syndromes that's present. Stress and trauma is also a risk factor in fact childhood
trauma tends to be individuals childhood trauma tend to have higher rates of chronic fatigue
syndrome as well. Now weakened immune system I've talked about weakened immune system because part
of it is related to certain immune factors tend to be lower in individuals with chronic fatigue
syndrome but on the other hand there also seems to be neural inflammation which means there's
excessive release of cytokines excitotoxicity cytokines that aren't needed that affect the
brain and we know that certain parts of the brain where the fatigue areas are for example where
the frontal lobe the cognition is affected dopamine goes down so it's a really really
complex pathogenesis all of this pathogenesis has been covered in a lot more detail. Then we
have hormonal imbalances so hormonal imbalances as I mentioned the HPA axis dysfunction
which is a hypothalamic pituitary adrenal axis dysfunction seems to be linked to this
and there's links between HPA axis, trauma, and then chronic fatigue syndrome because we
know trauma disrupts HPA axis it's something I've covered in the in the other video on Neurobiology
of PTSD or Neurobiology of stress as well. So these are some of the factors that are associated
with chronic fatigue syndrome. So how is chronic fatigue syndrome diagnosed I'll go through the
specific canadian consensus criteria but generally let's look at some of the domains so firstly we've
got a reduced ability to do usual activities for six months or more because of fatigue so fatigue
is one really important chronic fatigue syndrome and so fatigue is an important part and one
of the things with this fatigue it's quite peculiar because you see in depression
individuals can be lethargic and feel tired but in depression individuals tend to improve with
activity and that's why behavioural activation tends to be a strategy chronic fatigue syndrome
individuals tend to worsen with activity and exertion many many occasions so that's one, second
we have worsening of symptoms after usual physical mental activity as I mentioned could be difficulty
thinking, problem sleeping, sore throat, headaches, feeling dizzy or severe tiredness.
Then we have trouble falling asleep circadian rhythm dysfunction tends to be a very prominent
part of chronic fatigue syndrome then there should be other things such as problems with thinking
and memory individuals talk about a brain fog this is the cognitive components, then worsening
of symptoms while standing or sitting upright this is the autonomic nervous system dysfunction that
occurs you know diagnosis of pots for example. So in order to receive a chronic fatigue
syndrome diagnosis your doctor will rule out other potential causes and review your
medical history this is so so important to really go through a detailed medical history
and then we talk about the main symptoms, the duration, the severity and then
using the canadian consensus criteria is one of the criteria to that can be used
to confirm the diagnosis so what are they and this CFS criteria is quite useful. As you can
see the illness length here adults six months, children three months fatigue as I mentioned
prominent, next post-exertional fatigue and malaise, then sleep dysfunction this is a
characteristic individuals describe what's known as a wired fatigue they're very tired they want
to fall asleep but they're wired. individuals talk often about racing thoughts they just can't sleep
this is hyper arousal that is very different from individuals not being able to sleep due to other
causes of insomnia and we'll talk about some of the potential medications that could address this
because this sort of hyper arousal also occurs in post-traumatic stress type symptoms. then we
have pain, now fibromyalgia can be comorbid with CFS right so fibromyalgia symptoms which is really
fibromyalgia characterized but I'll do separate video another time but it's characterized
by what's known as allodynia which is a heightened sensitivity to pain so many individual
fibromyalgia will often complain of pain all over the body and can be very tender to touch all
right and there's more evidence recently that particularly from long Covid where individuals
have had this fibromyalgia so a type of pain a chronic fatigue syndrome where
they're talking about endothelium in the vessels being affected and micro clotting
so there's more to know you know and then chronic fatigue syndrome and covid as well I've done the
video on Covid Neuropsychiatry as well and one of the pathogenesis with covid is this increased
sticky blood type aspect very similar to what happens in anti-phospholipid syndrome increased
antiphospholipid antibodies. I know i digress but it's a really fascinating sort of pathogenesis
and there's overlap here as well so fibromyalgia tends to be really important often diagnosed by
a rheumatologist as well by testing the pressure points. Then we have cognitive dysfunction so this
is another really really important part of the chronic fatigue syndrome and in cognitive
dysfunction individuals describe what's known as a brain fog and this affects memory,
multitasking, affects executive function, attention, concentration can be very very
disabling. and then one symptom from two of the following categories and you can see here
autonomic nervous dysfunction we know that pots is closely linked with chronic fatigue syndrome
sometimes the diagnosis just gets put down as pots and one just focuses on the pots but it's
important to look at whether pots occurs with fibromyalgia whether it occurs with a brain fog
etc. then we have neuroendocrine dysfunction this is where it becomes the HPA axis dysfunction
cortisol, adrenal function, thyroid autoimmunity ruling out Addison's disease which is you know
antibodies against the adrenals so many things need to be ruled out adequately and then immune
dysfunction so individuals can be very prone to infections as well in this condition. now one
other thing i would also bring in here individuals tend to have quite a prominent mood component here
so this can you can put it either in fatigue or sleep dysfunction or cognitive but mood and
often the mood tends to have a fluctuating sort of pattern. depression can present anxiety
can pretend present but also mood instability can present .so how is it treated now again as in
every treatment i say this is something that is general only it is not medical advice because
every patient's different so crucial that you discuss this with your doctors. but what are
some of the things that are evidence-based so firstly when we look at it we have lifestyle
changes, so diets mito protective diets so there's some evidence that you know intermittent
fasting increasing ketone levels neuroplasticity some of those things can be beneficial um
lifestyle modification so again removing certain toxic elements such as alcohol say cannabis
use other substances etc, then pacing really important to pace oneself and not push so in my
experience I've had patients where even sometimes during the initial phases of treatment they tend
to improve and then because they improve they can feel well and do a little bit too much and go a
few steps back so I often mention it's crucial to pace yourself. the other thing I often find is
in terms of personality factors individuals can often have higher levels of perfectionism they're
driven individuals higher levels of perfectionism you previously high functioning sometimes driven
and that can sometimes be a double-edged sword because when they're getting better they can
really push themselves that's some a personality sort of factor that I've identified in some
cases. And then energy conservation exercise, then we have nutritional supplements and here
evidence-based vitamin D i would say vitamin D is so so important in treating chronic fatigue
syndrome often would look a you know keeping levels at the higher end of the lab values
and sometimes you know significantly over it so you know greater than 70 at least I would
say. And then probiotics evidence base and this is where the gut brain axis comes in because gut
brain axis is linked to Neuroinflammation as well you know I'm sure I'll do another video on the
gut brain axis but I've done a short animated sort of video on that so you can check that out.
but probiotics show some evidence magnesium again really important anywhere between 200
to 400 milligrams can be utilized and over the count of vitamin b12 b complex so
folate is important vitamin b12 is important essential fatty acids so this is where you
have the omega-3 fatty acids and we know that you know EPA eicosapentanic acid versus the
DHA often the ones with higher levels of epa tend to be more evidence based on psychiatric
disorders then we have coenzyme Q coenzyme q and then you know this is basically what niacin
gets converted to so the nicotinamide adenosine dinucleotide nadh is evidence-based
acetyl-l-carnitine and antioxidants now of course all of these on their own are
unlikely in the severe cases to change things and this is where we're looking at a cumulative
effect right then we have psychotherapies in psychotherapy cbt and graded exercise therapy one
of the things i find here is that you know sure [ Sorry I should have said Graded Exercise Therapy] patients get referred to graded exercise therapy [ Sorry I should have said Graded Exercise Therapy]
or cbt but when a person sometimes is extremely fatigued justice doesn't cut it um individuals
might be experiencing autonomic dysfunction significant brain fog they might not actually
be able to engage in cbt and this is where we've got a deconstruct the syndrome and address each
component of the syndrome which i'll touch on in a bit then we have uh pharmacological treatments
now pharmacological treatments antidepressants and and i'll talk about you know how we sort
of target things now remember we have fatigue we have post-exertional fatigue or malaise
we have mood components either depression or anxiety or instability we have sleep
circadian rhythm dysfunction right and we have cognitive aspects we have pain right
so i've got to look at all of these things when treating it now one of the things i find is
addressing the hyperarousal symptoms first right which can help with the sleep and bring
down the overall level of tension that individuals generally have some of the medications that can
be useful here are clonidine and prazosin - the alpha 1 alpha 2 antagonists that I've covered previously [Clonidine is alpha 2 agonist/ prazosin is alpha 1 antagonist]
again another video can be extremely useful in promoting sleep and reducing their hyperarousal we know that they are agents that actually promote deep sleep
and non REM sleep right which is important for memory consolidation to reduce the fatigue
during the day now of course it's crucial to rule out medical conditions obstructive sleep apnea
for example thyroid dysfunction restless leg syndrome all of these need to be treated as well
because chronic fatigue syndrome can be comorbid so when we think about um this this wired fatigue
we can address that but let's say a person with chronic fatigue syndrome with pots you see
prescribing agents like clonidine or prazosin will drop blood pressure so that's something
i won't do at that stage it can be introduced later on this is based on my clinical experience
of having treated patients so what tends to happen it occurs as a balance and one of the things that
i tend to do in severe cases of chronic fatigue or fibromyalgia is i consider an admission because
the environmental stresses need to be taken out it is i find it extremely difficult to carry
out outpatient treatment because there's so many stressors that are there i and also
individuals can be very very sensitive to changes in medications so they have heightened
side effects and that might be a combination of a few things allodynia the hypersensitivity
the fibromyalgia components so often they're so attuned to their body that small changes can
particularly be changes medication changes can be misinterpreted sometimes as side effects so
there's a lot of reassurance therapeutic alliance understanding and trust that needs to be built
through this treatment this is one of the most important things I've found and time is a big
factor we're looking at six months to one year process the admission of course might be
shorter but we're looking at it as a process because each person's different i need to see how
each medication change results and how patients react so when we're thinking about antidepressants
for example if the individual's got fibromyalgia i can consider antidepressants that are evidence
based for pain so duloxetine for example or milnacipran now these are very very helpful
in pain but duloxetine also assists with the cognition component right than some other agents
such as we're looking at here antivirals now of course antivirals monoclonal antibodies
this is where liaison with a rheumatologist can help right steroids same liaison with a
rheumatologist can help there's some evidence for staphylococcal vaccine as well anti-inflammatories
can be prescribed particularly again for pain etc there's some evidence for low-dose
naltrexone really low-dose naltrexone analgesics can be prescribed again for
pain but from a psychiatric component i'll talk about some of the things the strategy that tends
to work so treating the wired fatigue treating the pain and sometimes using combinations so sometimes
agents such as stimulants are also evidence-based and what's really really interesting is stimulants
such as dexamphetamine or methylphenidate are also evidence-based in POTS with brain
fog in fact a 2019 article talked about brain fog and POTS and there's very good evidence
for agents such as modafinil or modafinil these also are agents that
stimulate the orexin neurons which promote wakefulness right in the
neurobiology of sleep I've covered orexin neurons and you know these uh wakefulness components
so modafinil armodafinil can be very useful or stimulants such as methylphenidate and
dexamphetamine and they actually do not cause so trials have shown no significant effects
no prob problems with the pots so i've used them successfully in many cases and what happens
is as the blood pressure starts going up that's when the wired fatigue can be
treated by using clonidine and you get an optimal balance but this is something
that needs to be done in a specialist care and of course you know in a supervised
environment as well now for mood components uh mood stabilizers anti-convulsive
lamotrigine can play a very big part and in the initial stages a multi-pronged effect
is needed in order to provide good benefits and medication then the graded excercise therapy and
cbt tends to work really well but if fatigue brain fog is so significant then there's a big barrier
and that's where medication needs to come in so this is all about this is not about saying
one thing will work and this is one of the things I've learnt in chronic fatigue requires a
multi-pronged approach and a multi-disciplinary team as well physicians rheumatologists general
practitioner nurses nurse colleagues occupational therapists physiotherapists multi-prong approach
in order to address this particular condition and there is of course some evidence for
complementary therapies acupuncture rehabilitation abdominal tuina and fecal microbiota transplant
but all of these things are of course experimental as you can see this is you know this is from the
reviews um the references down here uh that i've covered this but i hope that this has given you
an understanding of how complex this particular condition is and you know everything that i've
covered today i've covered it as a general sort of overview right every person's different
so each aspect needs to be targeted appropriately in discussion with the doctor
but i hope that this will help you and anyone else you know that might be experiencing this
condition a lot of this is also relevant to long covid as well so if you've liked
this video please leave us a like hit the like button of course don't forget
to subscribe and i look forward to seeing you in another edition of hub bites until then
take care stay safe I'll see you next time bye you
