Chapter 9：Neurosis(5)
Chronic Fatigue Syndrome
and Neurasthenia
Zhonghua Su, Ph.D, MD.
Jining Medical University
Neurasthinia
Introduction
introduced in the 1860s ( George Miller Beard )
 neurasthenia appear in psychiatric literature and
remains a diagnostic entity (ICD-10)
 neurasthenia is categorized as undifferentiated
somatoform disorder (DSM-IV)
 a prime example of cultural differences influencing the
classification and manifestations of diseases
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Europe and Asia
China
Epidemiology
Difficulties in investigating the epidemiology of
neurasthenia
 a prevalence rate of 12 percent (1994)
 more frequently in higher socioeconomic groups
 The age of onset childhood and middle age (40 to 50)
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Etiology
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Depletion Hypothesis.
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Freud Hypothesis
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neuroendocrine dysregulations
Common signs and symptoms(1)
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General fatigue
Exhaustion
General anxiety
Difficulty concentrating
Physical aches and pains
Dizziness
Headache
Intolerance of noise
(hyperacusis) or bright lights
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Chills
Indigestion
Constipation or diarrhea
Flatulence
Palpitations
Extrasystole
Tachycardia
Excess sweating
Flushing of skin
Dysmenorrhea
Common signs and symptoms(2)
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Sexual dysfunction, eg,
erectile disorder, anorgasmia
Paresthesia
Insomnia
Poor memory
Pessimism
Chronic worry
Fear of disease
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Irritability
Feelings of hopelessness
Dry mouth or hypersalivation
Arthralgias
Heat insensitivity
Dysphagia
Pruritus
Tremors
Back pain
CDC Criteria for neurasthenia(1)
A.
Either of the following must be present:
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persistent and distressing complaints of feelings of exhaustion after a
minor mental effort (such as performing or attempting to perform
everyday tasks that do not require unusual mental effort);
persistent and distressing complaints of feelings of fatigue and bodily
weakness after minor physical effort;
At least one of the following symptoms must be present:
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feelings of muscular aches and pains
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dizziness;
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tension headaches;
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sleep disturbances;
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inability to relax;
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irritability;
CDC Criteria for neurasthenia(2)
B.
C.
D.
The patient is unable to recover from the symptoms
in criterion A (1) or (2) by means of rest, relaxation,
or entertainment.
The duration of the disorder is at least 3 months.
Most commonly used exclusion clause. The disorder
does not occur in the presence of organic emotionally
labile disorder, postencephalitic syndrome,
postconcussional syndrome, mood disorders, panic
disorder, or generalized anxiety disorder.
Two types of the disorder
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One type
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a complaint of increased
fatigue after mental effort,
often associated with some
decrease in occupational
performance or coping
efficiency in daily tasks
an unpleasant intrusion of
distracting associations or
recollections
difficulty in concentrating
generally inefficient thinking.
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Another type
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on feelings of bodily or
physical weakness and
exhaustion after only minimal
effort
accompanied by muscular
aches and pains and inability to
relax
Differential Diagnosis
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distinguished from
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anxiety disorders
depressive disorder
somatoform disorders (somatization disorder, conversion
disorder, hypochondriasis, body dysmorphic disorder, and
pain disorder)
Hallmarks of neurasthenia
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fatigability
weakness
concern about lowered mental and physical efficiency
Course and prognosis
most often occurs during adolescence or middle age.
 usually chronic;
 all areas of functioning become impaired;
 with treatment (such as it was in the 1860s) "the
majority can be relieved or substantially cured."
 difficult to distinguish the prodromal signs of
schizophrenia or bipolar disorder from neurasthenia.
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Treatment
The key concept: symptoms are not imaginary
 be reassured that the administration of medication to
relieve medical symptoms
 helped to recognize the stresses in their lives and the
coping mechanisms
 psychopharmacological agents
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Serotonergic agents
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fluoxetine
nefazodone
Mirtazapine
Chronic fatigue syndrome
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characterized by 6 months or more of severe,
debilatating fatigue, often accompany by myalgia,
headaches, pharyngitis, low-grade fever, cognitive
complaints, gastrointestinal symptoms, and tender
lymphnodes.
Epidemiology
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The exact incidence and prevalence of chronic fatigue syndrome
are unknown, but the incidence has been estimated at 1 per
1,000.
The illness is observed primarily in young adults (ages 20 to 40).
Women are at least twice as likely as men to be affected.
In the United States, studies show that about 25 percent of the
general adult population experience fatigue lasting 2 weeks or
longer.
When the fatigue persists beyond 6 months, it is defined as
chronic fatigue. A study of patients in primary care clinics found
that 24 percent had experienced fatigue lasting over 1 year.
Etiology
no pathognomonic signs or diagnostic tests for this
condition.
 The diagnosis can be made only after all other medical
and psychiatric causes of chronic fatiguing illness have
been excluded
 Epstein-Barr herpesvirus, enteroviruses, herpesvirus,
and retroviruses;
 nonspecific markers of immune abnormalities
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Diagnosis and Clinical features
no pathognomonic features
 Because chronic fatigue syndrome has no
pathognomonic features, diagnosis is difficult .
 Physicians should attempt to delineate as many signs
and symptoms as possible to facilitate the process.
 These and other equivocal findings neither confirm nor
rule out the disorder.
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Signs and symptoms (1)
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Fatigue or exhauston
Headache
Malaise
Short-term memory loss
Muscle pain
Difficulty concentrating
Joint pain
Depression
Abdominal pain
Lymph node pain
Sore throat
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Lack of restful sleep
Muscle weakness
Bitter or metallic taste
Balance disturbance
Diarrrhea
Constipation
Bloating
Panic attacks
Eye pain
Scratchiness in eyes
Blurring of vison
Signs and symptoms (2)
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Double vison
Sensitivity to bright lights
Numbness and/or tingling in
extremities
Fainting spells
Light-headedness
Dizzness
Clumsiness
Insomnia
Fever or sensation of fever
Chills
Night sweats
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Weight gain
Allergies
Chemical sensitivities
Palpitations
Shortness of breath
Flushing rash of the face and
cheeks
Swelling of the extremities or
eyelids
Burning on urination
Sexual dysfunction
Hair loss
CDC Criteria
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A. Severe unexplained fatigue for over 6 months that is:
(1) of a new or definite onset
(2) not due to continuing exertion
(3) not resolved by rest
(4) functionally impairing
B. the presence of four or more of the following new symptoms:
(1) impaired memory or concentration
(2) sore throat
(3) tender lymph nodes
(4) muscle pain
(5) pain in several joints
(6) few pattern of headaches
(7) unrefreshing sleep
(8) postexertional malaise lasting more than 24 hours
Differential Diagnosis
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endocrine disorders
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neurological disorders
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multiple sclerosis
infectious disorders
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hypothyroidism
AIDS
infectious mononucleosis
psychiatric disorders
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depressive disorders
Course and Prognosis
Spontaneous recovery is rare
 63 percent of patients with the syndrome followed for
up to 4 years reported improvement
 Patients with the best prognosis
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no previous or concurrent psychiatric illness,
are able to maintain social contacts,
continue to work, even at reduced levels.
Treatment
establish rapport firstly
 A careful medical examination
 a psychiatric evaluation
 No effective medical treatment
 Psychiatric treatment
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supportive or insight-oriented psychotherapy
Cognitive behavioral therapy
Pharmacological agents
Self-help groups