The current definition of chronic fatigue syndrome requires that its duration is longer than 6 months. In a review paper, published in 2005, the consensus of the Royal Colleges of Physicians, Psychiatrists and General Practitioners in the UK was that “chronic fatigue is a biological syndrome which is not currently fully understood and does not require treatment with mood altering medications” (such as antidepressants). This view is also supported by the National Institute on Clinical Excellence (NICE).

Is it “all in the mind”?
80% of all people suffering with chronic fatigue have a history of classic allergies (i.e. allergy to dust mites, pollens and so on). This is way above the incidence of immediate allergy in the general population (5-15%).
Many have had recurrent infections during childhood (affecting ears, throat or lungs). An array of symptoms often appears to stem from different organs of the body, which are normally seen in Medicine as problems affecting a single organ such as skin conditions, irritable bowel, psychological or gynaecological problems (heavy, painful or irregular periods), without an obvious link with the immune system. Chronic fatigue, being part of a multi-symptomatic syndrome, seems to defy doctors’ diagnostic skills, which use the concept of “organ failure” as their disease-model. The fact that routine laboratory tests fail to detect any systemic problems, often reinforces the impression of a “psychosomatic” condition.

Whatever the possible triggers, the most consistent finding in patients with chronic fatigue is that most have markers or persistent dysfunction of their cell chemistry: During muscle effort, lactic acid is normally produced by the recycling of ATP (adenosine tri-phosphate) in the mitochondria of each cell, which metabolises to pyruvic acid. These chemicals are responsible for causing muscle cells to tire and force them to slow down or stop until they dispose of these substances; in this way, cells complete their recovery phase and get ready for more action. Under normal circumstances, the full recovery is brought on with rest or a good night’s sleep; however, those affected with chronic fatigue show persistently increased levels of lactic acid and a prolonged delay to dispose it and complete the recovery; this finding might explain the continual tiredness or exhaustion even after a minimum effort.

The study of lactic acid in fatigued patients fits in well with the concept that chronic fatigue is not a “psychosomatic” condition, whereby the individual suffers with imagined symptoms; it is supported further with some interesting laboratory findings: a) raised levels of extra-cellular DNA consistent with increased cell destruction (a finding common in patients with degenerative diseases and cancer) b) reduced perfusion of oxygen in areas of the brain e.g cortex and hypothalamus, controlling the secretion and activity of vital hormones c) the increased levels of some interleukins (cellular hormones) d) the misshapen appearance of red cells in electron microscopy e) non-specific abnormalities in routine blood tests such as low white cell count, raised liver enzymes, to mention but a few.

Many patients have been fit, young people prior to the start of their debility and deny any stressful circumstances in their lives. Many have symptoms of digestive problems.

So, what is causing such a derangement of the cellular chemistry?

Possible causes
i. A host of common and uncommon medical conditions can cause chronic fatigue, some as simple as iron deficiency or as severe as cancer or leukaemia. Detailed tests are important to rule out such conditions before the diagnosis of chronic fatigue is made
ii. Viruses or other infections – prolonged fatigue is known to follow glandular fever (Ebstein-Barr virus), poliomyelitis, influenza & coxackie A & B viruses, Lyme disease and some local epidemics (lake Taho USA, Royal Free Hospital and so on)
iii. Abnormal intestinal fermentation due to the build-up of yeasts, as in yeast overgrowth and “candida”; a depletion of “friendly” bacteria, important to safeguard a healthy environment in the gut; the presence of some amoebic parasites such as Dientamoeba fragilis or Blastosystis hominis.
iv. Type-B food reactivity (also known as “delayed” or “masked” allergy or “food intolerance”); this involves lymphocytes more often than histamine releasing cells and its symptoms are usually less acute or severe but can sometimes “mimic” immediate allergy such as nut allergy. In the last few decades, food intolerance has been fostered by the frequent use of a large number of chemicals used in the food industry and fast, repetitive diets
v. Adrenal stress and other hormone disturbances
vi. Prolonged stress or other life “stressors” such as major illnesses or surgery are known to alter the state of one’s immune system
vii. Several medications e.g. long term courses of antibiotics, oral steroids and female hormones especially oestrogens
viii. Allergies to common natural inhalants such as dust mites, animal dander, pollens and moulds by virtue of their taxing effect on the immune system
ix. Chemical sensitivity, i.e. delayed immune reactivity to a range of common environmental chemicals such as hydrocarbons, organophosphates, volatile organic compounds and so on
x. Deficiencies of important vitamins, minerals, essential fatty acids and other nutrients, whose presence is a priority for the smooth function and protection of the complex system of enzymes in each and everyone of the body cells.

In day-to-day practice, a number of these factors are found to be relevant. Reversal of chronic fatigue is possible when such factors are identified and are brought under control.

• Thyroid and adrenal function tests and other common laboratory tests – ordinary tests sometimes fail to identify dysfunction of important endocrine glands unless the problem becomes more advanced.
• Tests for abnormal intestinal fermentation – in several studies chronic fatigue has been linked with yeast overgrowth (also wrongly referred to as “candida”)
• Food reactivities – Type B food allergy is a common cause of chronic fatigue. We use specific dietary changes as a process of Elimination & Challenge to identify reactive from non reactive foods but if one’s circumstances are too restrictive, intracutaneous tests can be used for guidance
• Tests for toxicity or sensitivity to mercury, silver and nickel, metals used in dental amalgams; tests for organophosphates and other environmental chemicals (many of these are used in carpets and furniture as fire retardants, adhesives in electrical appliances, TV & computers and many others
• Parasitology screen – for protozoan (amoebic) parasites. Many people are unaware they carry these, because they do not cause acute/severe symptoms, however, up to 30% of chronic fatigue sufferers are found to have this type of parasites.

To save costs we often recommend that basic tests are carried out locally, by one’s GP or hospital laboratory. A “phased” process of specialist investigations is preferred in our clinics and a few are recommended, depending on one’s detailed history.

Management
The possibility of food intolerance and inhalant allergy is explored by modifying one’s diet and skin tests or intracutaneous tests. We use blood tests to assess the nutritional status and, if deficiencies are confirmed, they are corrected with appropriate supplements. Yeast and parasite problems are treated with courses of safe, modern medicines. In case of inhalant allergy and/or chemical sensitivity our patients are shown how to instigate thorough air purification at home. Patients who respond well and regain normal energy levels may not need any other intervention.

Those who don’t, are likely to have more complex problems and often require a safe method of desensitization, to stimulate natural immunity against a range of environmental factors be it foods, inhalants or chemicals.

Many of the above concepts and methods have been formulated by medical centres with specialist interest in treating chronic fatigue and allied disorders and are “unconventional”. Generally, multi-symptomatic patients require a combination of therapeutic measures, which address all relevant causative factors. The overall majority seem to respond well to this approach.

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