Kaplan and Sadock's Comprehensive Textbook of Psychiatry

1. Prepared by:

2. Chronic Fatigue Syndrome
• Chronic fatigue syndrome (CFS) (referred to as
myalgic encephalomyelitis in the
United Kingdom and Canada) is characterized
by 6 months or more of severe, debilitating
fatigue, often accompanied by myalgia,
headaches, pharyngitis, low-grade fever,
cognitive complaints, gastrointestinal
symptoms, and tender lymph nodes.

3. Infectious etiology?????
• The search continues for an infectious cause
of chronic fatigue because of the high
percentage of patients who report abrupt
onset after a severe flu-like illness.

4. ICD-10
• The disorder is classified in the 10th revision
of International Statistical Classification of
Diseases and Related Health Problems (ICD-
10) as an ill-defined condition of unknown
etiology under the heading “Malaise and
Fatigue” and is subdivided into asthenia and
unspecified disability.

5. Epidemiology
• Incidence- 0.007 percent to 2.8 percent in the
general adult population.
• The illness is observed primarily in young
adults (ages 20 to 40).
• Women are at least twice as likely as men to
be affected.
• The symptoms often coexist with other
illnesses, such as fibromyalgia, irritable bowel
syndrome, and temporomandibular joint
disorder.

6. Etiology
• The cause is unknown.
• Viral infection- Ebstein-Barr virus implicated- not
conclusive.
• Reports have shown of disruption in the
hypothalamic-pituitary-axis (HPA) with mild
hypocortisolism.
• Chronic fatigue syndrome may be familial. In one
study, the correlation within twin pairs for
monozygotic twins was more than 2.5 times
greater than the correlation for dizygotic twins.
Further studies are needed, however.

7. Diagnosis and Clinical Features
• Because chronic fatigue syndrome has no
pathognomonic features, diagnosis is difficult. 
• Although chronic fatigue is the most common
complaint, most patients have many other
symptoms.
• The physical examination is also an unreliable
source of diagnostic certainty. Some patients had
neurally mediated hypotension. Hence tilt-table
test should be done.

8. Tilt-table test

13. Differential Diagnosis
• Chronic fatigue must be differentiated from
endocrine disorders (e.g., hypothyroidism),
neurological disorders (e.g., multiple sclerosis
[MS]), infectious disorders (e.g., acquired
immune deficiency syndrome [AIDS], infectious
mononucleosis), and psychiatric disorders (e.g.,
depressive disorders).
• Up to 80 percent of patients with chronic fatigue
syndrome meet the diagnostic criteria for major
depression.

14. Course and Prognosis
• Spontaneous recovery is rare  in patients
with chronic fatigue syndrome, but
improvement does occur. 
• Patients with the best prognosis have had no
previous or concurrent psychiatric illness, are
able to maintain social contacts, and continue
to work, even at reduced levels.

15. Treatment
• It is mainly supportive.
• A few patients have shown a lessening of
fatigue with the antiviral drug
amantadine (Symmetrel).
• Symptomatic treatment (e.g., analgesics for
arthralgias and muscular pain).
• Several studies have reported a positive effect
from graded exercise therapy (GET).

16. When does psychiatric treatment
comes in?
• Patients must be encouraged to continue their
daily activities and to resist their fatigue as
much as possible. A reduced workload is far
better than absence from work.
• Psychiatric treatment is desirable, especially
when depression is present.
• Cognitive-behavioral therapy is especially useful.

17. Pharmacology
• Pharmacological agents, especially
antidepressants with nonsedating qualities,
such as bupropion (Wellbutrin), may be
helpful. Nefazodone (Serzone) was reported
to decrease pain and improve sleep and
memory in some patients.
• Analeptics (e.g., amphetamine or
methylphenidate [Ritalin]) may help reduce
fatigue.

18. Neurasthenia
• Also called “nervous exhaustion”.
• Introduced in the 1860s by the American
neuropsychiatrist George Miller Beard, who
applied it to a condition characterized by
chronic fatigue and disability.
• This disorder is a prime example of cultural
differences influencing the classification and
manifestations of diseases.

19. Epidemiology
• A World Health Organization (WHO) study
found an incidence of about 2 percent, which
increased to 6 percent when depressive
symptoms were present.

20. Etiology
• According to Beard, the cause of neurasthenia
was “nervous exhaustion,” which referred to
depletion of the “stored nutrient” in the nerve
cell (neuron). This depletion resulted from stress,
such as overwork.
• Freud agreed with Beard that stress was involved,
but Freud thought that neurasthenia was
produced by a disturbance in sexual functioning
(one of the neuroses), specifically the inadequate
discharge of sexual energy that occurred when
masturbation replaced normal intercourse.

22. Differential Diagnosis
• Neurasthenia must be distinguished from anxiety
disorders, depressive disorder, and the
somatoform disorders.
• Hallmarks of neurasthenia are a patient's
emphasis on fatigability and weakness and
concern about lowered mental and physical
efficiency (in contrast to the somatoform
disorders, in which bodily complaints and
preoccupation with physical disease dominate
the picture).
• Chronic fatigue syndrome must also be
considered.

23. Course and Prognosis
• Untreated, the disorder is usually chronic, and
patients may become incapacitated by one or
more symptoms so that all areas of
functioning become impaired.
• With treatment, the prognosis should be
favorable; but the long-term prognosis is
unknown.

24. Treatment
• The key concept in the current treatment of
neurasthenia is clinicians' understanding that
a patient's symptoms are not imaginary.
• Medical workup should be done.
• Reassurance that medications (analgesics,
laxative, etc) + Psychotherapeutic intervantion
will be useful.
• Identification of stressors and coping
mechanisms.

25. Psychopharmacological Agents
• Serotonergic agents (e.g., fluoxetine)
• Other antidepressants- nefazodone and
mirtazapine (Remeron)
• Benzodiazepines
• Similarly, small doses of analeptics, such as
amphetamine or methylphenidate,
may help to treat chronic fatigue and
anhedonia.

26. •Thank u for listening