End Fatigue

Recognizing Chronic Fatigue and Fibromyalgia

By Jacob Teitelbaum, MD

November 2002

We're entering a new understanding of hypothalamic and limbic dysfunction and their association with chronic fatigue syndrome and fibromyalgia. This is now allowing effective treatments for a large majority of these patients.1 As always, however, it's critical to recognize the presence of these syndromes so that proper treatment can be instituted.
Chronic fatigue syndrome and fibromyalgia often coexist and present with a very large number of symptoms, including chronic widespread pain, fatigue that doesn't go away with the rest (sometimes to the point of the patient being bedridden), cognitive dysfunction and insomnia with severely disordered sleep. To those unfamiliar with these processes, the symptoms seem unrelated, and patients are mistakenly diagnosed as having psychosomatic disorders.
In many cases, multiple chemical sensitivity, chemical intolerance and sick building syndrome often overlap chronic fatigue and fibromyalgia. In one study, 75 percent of patients with multiple chemical sensitivity also had physician-diagnosed chronic fatigue syndrome. Conversely, approximately 30 percent of chronic fatigue syndrome/fibromyalgia patients also have chemical intolerance.2
Multiple chemical sensitivity is a chronic idiopathic condition attributed to low-level chemical exposures. Symptoms include dyspnea with bronchospasm and bronchitis, and/or cough with bronchial irritation and inflammation. In the aggregate, the symptoms are severely disabling and have lead people to live in the woods in cabins made without any chemicals or chemically treated contents. Milder forms are known as chemical intolerance.
Sick building syndrome is when a specific building triggers symptoms, including asthma and upper respiratory irritation, in susceptible people. Sick building syndrome has been linked to exposure to low levels of a mix of volatile organic compounds, airborne fungal infections or allergens, or other triggers, such as chemicals from copying machines.
Chronic fatigue syndrome/fibromyalgia conservatively cripple 2 percent of the population.3 Clinically, severe multiple chemical sensitivity affects approximately 4 percent of the adult population, with milder forms of chemical sensitivity affecting between 15 percent and 30 percent.2 The widespread nature of these problems underscores the importance of their proper recognition and diagnosis.
This is especially important because the largest epidemiologic study of chronic fatigue syndrome found that 90 percent of patients suffering from this condition hadn't been given the correct diagnosis.4 The severity of these patients' symptoms, combined with not knowing their causes, can lead to severe disability and anxiety while preventing people from getting effective treatment.

Differential Diagnosis and Respiratory Treatment

The diagnosis of multiple chemical sensitivity is usually fairly clear because these patients often have severe dyspnea and respiratory distress, and they directly associate these symptoms as being triggered by different chemical exposures or in specific locations. Pulmonary function testing often shows reversible obstructive airway disease (ROAD), and the patients usually respond to bronchodilators. The key to effective treatment, however, is exposure avoidance, and these patients should be referred to someone who specializes in multiple chemical sensitivity.
Chemical intolerance may or may not be associated with ROAD and bronchitis. If these are present, the chemical sensitivity more likely falls into the multiple chemical sensitivity category, and the treatment is the same.
If the breathlessness isn't associated with chemical exposure and the patient has normal pulmonary function test results, they more likely fall under the category of chronic fatigue syndrome/fibromyalgia. Research has shown that one out of eight patients experienced hyperventilation with their chronic fatigue syndrome/fibromyalgia.1 Arterial blood gases drawn during dyspnea can help make the diagnosis of hyperventilation. The dyspnea usually responds to treatment of the hypothalamic dysfunction.
In a recently published randomized controlled study in which the effects of hypothalamic dysfunction (hormonal deficiencies, disordered sleep, and opportunistic infections with secondary malabsorbtion and nutritional deficiencies) were treated, 91 percent of active patients improved (P < .0001 vs. placebo).1

Underlying Problems

Four main underlying problems also need to be treated: disordered sleep, nutritional support, infections and hormonal deficiencies.
Because the hypothalamus controls sleep, these patients are unable to fall and stay asleep adequately. They're especially lacking in deep sleep (Stage 3 and Stage 4), and therefore most benzodiazepines that keep patients in Stage 2 light sleep are counterproductive. The medications zolipidem tartrate (Ambien®, Sanofi-Synthelabo Inc.) and trazodone (Desyrel®, Bristol Myers Squibb) are most likely to be effective. In addition, many natural sleep aids can be very helpful.1
Sleep apnea and restless leg syndrome also are common in chronic fatigue syndrome/fibromyalgia and need to be treated appropriately.5 Zolipidem tartrate, clonazepam (Klonopin®, Roche Laboratories Inc.), gabapentin (Neurontin®, Pfizer Inc.) and treatment of iron deficiency are especially helpful for restless legs syndrome.5
Multiple nutritional deficiencies have been demonstrated in chronic fatigue syndrome/fibromyalgia. This occurs largely because of malabsorbtion associated with opportunistic infections, associated gastrointestinal disturbances resulting in poor appetite, and increased nutrient needs because of their illness. Because of the widespread nutritional deficiencies, supplementation with high potency powders is strongly recommended.6
Many opportunistic infections, including bacterial, human herpes virus-6, Epstein-Barr virus, mycoplasma, chlamydia, fungi and parasitic infections, have been documented in these syndromes secondary to the immune dysfunction. These need to be looked for and treated aggressively.1,6
Because of the hypothalamic dysfunction, subtle but clinically important deficiencies in thyroid, adrenal and gonadal function often are present. Because blood test norms are based on primary gland failure and not hypothalamic dysfunction, routine blood tests can miss many cases of hormonal deficiency.1,6
When all of these underlying problems are looked for and treated, 91 percent of these patients see an average improvement in quality of life of 90 percent.1 In addition, the pulmonary symptoms usually resolve with these treatments based on clinical experience with more than 2,000 chronic fatigue syndrome/fibromyalgia patients.

References

1. Teitelbaum JE, Bird B, Greenfield RM, Weiss A., Muenz L, Gould L. Effective treatment of CFS and fibromyalgia: a randomized, double-blind, placebo-controlled, intent to treat study. Journal of Chronic Fatigue Syndrome. 2001;8(2):3-28.
2. Bell IR, Baldwin CM, Schwartz GE. Illness from low levels of environmental chemicals: relevance to chronic fatigue syndrome and fibromyalgia. Am J Med. 1998 Sep 28;105(3A):74S-82S.
3. Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum. 1995 Jan;38(1):19-28.
4. Jason LA, Richman JA, Rademaker AW, Jordan KM, Plioplys AV, Taylor RR, et al. A community-based study of chronic fatigue syndrome. Arch Intern Med. 1999 Oct 11;159(18):2129-37.
5. Teitelbaum JE. From Fatigued to Fantastic. New York: Avery/Penguin-Putnam; 2001.
6. http://www.endfatigue.com
Dr. Teitelbaum is a board certified internist and director of the Annapolis Research Center for Effective CFS/Fibromyalgia Therapies in Maryland. He lectures internationally and is the author of "From Fatigued to Fantastic!" Visit his Web site at http://www.endfatigue.com.