Date sent:      	Wed, 29 Aug 2001 

JAMA review paper on CFS (2)

Source: Journal of the American Medical Association (JAMA)
        Vol 286, #8, pp 916-917
Date:   August 22/29, 2001
URL:    http://jama.ama-assn.org/issues/v286n8/toc.html
        http://jama.ama-assn.org/issues/v286n8/ffull/jlt0822-2.html
Ref:    The review paper itself can be found here:
        http://listserv.nodak.edu/scripts/wa.exe?A2=ind0105D&L=co-cure&P=R1343


[Letters]


Chronic Fatigue Syndrome and Posttraumatic Stress Disorder
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To the Editor: In his Contempo Updates article about chronic fatigue syndrome
(CFS), Dr Natelson1 did not discuss the relationship between CFS and
posttraumatic stress disorder (PTSD). The 2 diagnoses share many features,
including fatigue, hypocortisolism,2, 3 abnormalities of immune function,4
unrefreshing restless sleep, fluctuations in concentration or memory,
headaches, muscle pain, joint pain, and withdrawal from occupational,
educational, and social activities.5,6

Psychiatrists tend to use different terminology to describe some of these
signs and symptoms. One example would be the term "leaden paralysis" for the
profound fatigue and inertia of CFS. Additionally, patients with PTSD
sometimes describe pain and/or dysesthesias that are eventually found to be
manifestations of "flashbacks."

Many of the treatments for PTSD and CFS are similar, as well. Examples include
psychodynamic psychotherapy, cognitive behavioral therapy,1 selective
serotonin reuptake inhibitors, beta -blockers, and alpha -agonists.7 Patients
who have these concurrent diagnoses often report a decrease in symptoms when
treated specifically for PTSD with an appropriate combination of psychotherapy
and medication.6, 8 Anecdotally, if these patients can articulate their
emotional pain, the physical complaints begin to resolve.

Unfortunately many physicians, including many psychiatrists, interview
patients without realizing that past traumatic events may trigger emotional
and physical repercussions for months or years afterward. Such patients often
frustrate their physicians with a litany of somatic and functional
preoccupations. Physicians inquire about PTSD in combat veterans and holocaust
survivors, but may not consider manifestations of PTSD from civilian trauma
such as physical or sexual abuse/assault, motor vehicle collisions, and
natural disasters. Simply screening for intrusive thoughts, avoidant
behaviors, autonomic hyperarousal, and easy startling may be sufficient for
triage purposes.

In essence, I wonder if the cascading immunologic and neuroendocrine
disturbances seen in both illnesses begin with reactions to trauma. Perhaps
CFS is another of the protean manifestations of PTSD.

Eve L. Lipschitz, MD
St Louis, Mo


1. Natelson BH. Chronic fatigue syndrome. JAMA. 2001;285:2557-2559.
2. Yehuda R. Biology of posttraumatic stress disorder. J Clin Psychiatry.
   2000;61(suppl 7):14-21.
3. Cleare AJ, Blair D, Chambers S, Wessely S. Urinary free cortisol in chronic
   fatigue syndrome. Am J Psychiatry. 2001;158:641-643.
4. Kawamura N, Kim Y, Asukai N. Suppression of cellular immunity in men with a
   past history of posttraumatic stress disorder. Am J Psychiatry.
   2001;158:484-486.
5. Beers MH. Chronic fatigue syndrome. In: Beers MH, Berkow R, eds. The Merck
   Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck
   Research Laboratories; 1999:2841-2482.
   6. Allen JG. Coping With Trauma. Washington, DC: American Psychiatric Press;
   1995.
7. van der Kolk BA. Psychological Trauma. Washington, DC: American Psychiatric
   Press; 1987.
8. Allen JG, Coyne L, Console DA. Course of illness following specialized
   inpatient treatment for women with trauma-related psychopathology. Bull
   Menninger Clinic. 2000;64:235-256.

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In Reply: Dr Lipschitz asks whether CFS is one of the protean manifestations
of PTSD. In the course of doing our medical entry evaluation on our patients,
we perform a computerized psychiatric diagnostic interview (Q-DIS).1 One of
the Q-DIS modules queries patients about the specific symptoms, listed by
Lipschitz, which would allow for the diagnosis of PTSD. As might be expected,
PTSD is common in veterans of the Persian Gulf War having CFS; we have found
it in 50% of the health care-seeking Gulf War veterans whose symptoms fulfill
the 1994 case definition for CFS.2 In contrast however, PTSD is very unusual
in nonveterans with CFS. Of 240 nonveteran CFS Cooperative Research Center
patients who also fulfill the 1994 case definition for CFS3 and who were
negative for any axis I psychopathology in the 5 years prior to the onset of
their illness, only 3 were positive for PTSD.2 Thus while CFS and PTSD
frequently occur together in Gulf War veterans having CFS, this is not the
case for nonveterans with CFS.

Benjamin H. Natelson, MD
VA Medical Center
East Orange, NJ


1. Marcus S, Robins LN, Bucholz K. Quick Diagnostic Interview Schedule 3R,
   Version 1. St Louis, Mo: Washington University School of Medicine; 1990.
2. Natelson BH, Tiersky L, Nelson J. The diagnosis of posttraumatic stress
   disorder is not uncommon in Gulf veterans with medically unexplained fatiguing
   illness. J Nerv Ment Dis. In press.
3. Fukuda K, Straus SE, Hickie I, et al, for the International Chronic Fatigue
   Syndrome Study Group. The chronic fatigue syndrome: a comprehensive approach
   to its definition and study. Ann Intern Med. 1994;121:953-959.

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(c) 2001 American Medical Association