What are the recommended evaluation and treatment options for chronic fatigue syndrome?

Chronic Fatigue Syndrome Evaluation and Treatment

Cognitive behavioral therapy (CBT) and mindfulness-based therapies are the first-line treatments for chronic fatigue syndrome (CFS), showing the strongest evidence for improving functional status, quality of life, and symptom management. 1, 2

Diagnostic Evaluation

When evaluating patients with suspected CFS, focus on:

• Core symptoms: substantial functional impairment, post-exertional malaise, unrefreshing sleep
• Additional required symptoms: either orthostatic intolerance or cognitive impairment ("brain fog") 1
• Duration: fatigue lasting at least 6 months 3
• Exclusion of other medical conditions that could explain symptoms

Key assessments:

• Quantify fatigue severity (0-10 scale)
• Screen for comorbid conditions: pain, depression, anxiety, sleep disturbances
• Evaluate for treatable contributing factors: anemia, thyroid dysfunction, medication side effects, nutritional deficits

Treatment Algorithm

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT)

   • Strong evidence for improving health function, quality of life, and physical function 2, 1
   • Particularly effective for patients with post-treatment fatigue who have been screened for fatigue 2
   • Web-based versions of effective in-person programs may increase accessibility 2, 1

2. Mindfulness-Based Therapies

   • Demonstrated small to moderate improvements in quality of life outcomes 1
   • Effective during and after treatment 2

Second-Line Treatments for Specific Symptoms

• For pain-predominant symptoms:

  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) 2, 1
  • Pregabalin 2, 1
  • Avoid NSAIDs for chronic pain related to CFS 2, 1
  • Avoid long-term opioid use 2, 1

• For sleep disturbances:

  • Sleep hygiene education
  • Consider CBT specifically for insomnia 2

• Movement-based therapies:

  • Yoga or tai chi 2, 1
  • Manual acupuncture for patients with fibromyalgia-like symptoms 2, 1
  • Avoid graded exercise therapy as it may worsen symptoms 1

Interventions Not Recommended

• Stimulants (methylphenidate, modafinil) 2, 1
• Corticosteroids 1
• Antivirals and antibiotics 1
• Mifepristone 2, 1
• Antidepressants for fatigue alone (without depression) 2
• Progestational steroids 2

Monitoring and Follow-up

• Regular reassessment of fatigue levels and treatment response
• Monitor for development of new symptoms or comorbidities
• Adjust treatment plan based on response and changing symptom patterns

Special Considerations

• Digital interventions may increase accessibility for patients with limited mobility or access to specialists 2, 1
• Emotion-focused therapy may be beneficial for some patients 2, 1
• Psychoeducational interventions can be helpful but may not be sufficient alone for significant fatigue 2

Treatment Efficacy

The evidence strongly supports psychosocial interventions over pharmacological treatments for CFS. Multiple meta-analyses have demonstrated that CBT and mindfulness-based approaches provide more consistent benefits than medication-based approaches 2, 4, 5. While some medications may help with specific symptoms (particularly pain), there are no FDA-approved medications specifically for CFS 1.

Common Pitfalls to Avoid

• Focusing solely on symptom management without addressing functional improvement
• Recommending graded exercise therapy, which may worsen post-exertional malaise
• Prescribing stimulants for fatigue, which lack evidence of benefit
• Using long-term opioids for pain management
• Failing to address comorbid conditions like depression, anxiety, and sleep disorders

By implementing this evidence-based approach to CFS management, clinicians can help improve patients' quality of life, functional status, and symptom burden while avoiding interventions that may be ineffective or potentially harmful.