| |||||||
 | |||||||
| for Chronic Fatigue Syndrome, Fibromyalgia, and Orthostatic Intolerance | |||||||
| Home | News | Forum | Contribute | Store | Articles | Links |
|
| ||||||||||||||||||||||||||||||||
|
The Lyndonville Journal: Definitions and Clarifications: CFS or Psychiatric Illness David S. Bell, MD, FAAP Published in Lyndonville News, September 1999 The diagnosis of chronic fatigue syndrome (CFS) is important for many reasons, the most important being the need for the treating physician to establish a working diagnosis. It is also important in establishing disability, both with private insurers and Social Security. Many persons are denied disability on the basis of not meeting the current restrictive CDC diagnostic criteria, usually due to a misinterpretation of the definitions of excluded psychiatric illness. I thought it would be useful to clarify this issue based upon the original publications. The diagnosis for the chronic fatigue syndrome was first proposed in 1987, following a meeting at the Centers for Disease Control, and published in 1988 by sixteen authors (1). In this definition there were exclusion criteria for "chronic psychiatric disease, either newly diagnosed or by history (such as endogenous depression; hysterical personality disorder; anxiety neurosis; schizophrenia; or chronic use of major tranquilizers, lithium, or antidepressive medications)" (1) There is no other mention of psychiatric illness in this definition. In a separate publication, the lead author of the original criteria wrote, "...other chronic clinical conditions have been satisfactorily excluded, included preexisting psychiatric diseases." (2) It should be noted that this wording was not implied in the original criteria because it implies any psychiatric illnesses. Because of increasing confusion over this and other issues, a workshop was held in March 1991, at the National Institutes of Health. The recommended clarifications (Table 1) were that psychiatric exclusions were for "Psychoses; psychotic depression, bipolar disorder, schizophrenia" as well as "substance abuse"(3). No mention is made in this table of pre-existing disease or of situational depression. In the body of the paper is the statement, relating to the psychiatric exclusion, "fatigue that is not explained by the presence of other evident medical or psychiatric illness" (3). The intent of this clarification was to establish that the psychiatric disease had to be obvious, or "evident". Other statements in this paper include, "One recommended modification was that patients with certain psychiatric disorders be included regardless of the time of symptom onset, provided that they otherwise meet the case definition (see Table 1)." "All workshop participants agreed that a history of any of the following psychiatric disorders excluded the diagnosis of CFS: schizophrenia, bipolar disorder, psychotic depression, and substance abuse." (3). The remainder of the paper discussed how confounding diagnoses, (such as concurrent situational depression) should be handled. There are two important points in this clarification paper: 1) pre-existing illness is not specifically excluded, and 2) only major psychotic illnesses are excluded. The most recent case definition was published in 1994 (4). In this "conceptual framework" is the statement, "The following conditions exclude a patient from the diagnosis of unexplained chronic fatigue...Any past or current diagnosis of a major depressive disorder with psychotic or melancholic features; bipolar affective disorder; schizophrenia of any subtype; delusional disorders of any subtype, dementias of any subtype; anorexia nervosa; or bulemia nervosa." (4) Here the issue of pre-existing illness is clarified, with no lessening of the degree of severity of the psychiatric illness. The symptoms of depression or anxiety do not exclude a person from a diagnosis of CFS. "On the other hand, we did not use other psychiatric disorders, such as anxiety disorder and other less severe forms of depression, as a basis for exclusion." (4) The intent of the research criteria for CFS was clearly the exclusion of severe and obvious mental disease. The reason for this is stated, "care of these persons should focus on their chronic psychiatric disorder." (4). A second point is important: there is a difference between research criteria and clinical criteria. The research criteria cited above are meant to be restrictive and exclusive in order to create a uniform group of research subjects. A clinical diagnosis is meant to give the treating physician a working diagnosis. Therefore the treating physician should evaluate for the presence of psychiatric illness just as evaluating for other illnesses. If a patient has symptoms typical of CFS and is without severe, psychotic mental illness, the clinical diagnosis of CFS is appropriate. Many papers discussed the importance of good clinical judgement in establishing the diagnosis of CFS (5). References:
Return to the Lyndonville News Archive |
|
Disclaimer: The views in this website and forum are the feelings and opinions of the individual authors and do not necessarily reflect all of the current theories that are being explored and published. Ask your doctor or other health care provider about all medical information that you consider applying to your situation, including the information you read in our website and forum. We take no responsibility for the decisions you or your family members make about medical care. It is up to you to verify that the information you read is correct and applies to your unique situation. | |||||||||||||||||||
