Michael L. Tuggy, MD Swedish Family Medicine

Unraveling the Fatigue Syndromes:Multiple Chemical Sensitivity SyndromeChronic Fatigue SyndromeFibromyalgiaGulf War Syndrome(etc., etc.) Michael L. Tuggy, MD Swedish Family Medicine

How many patients have you seen this past week with: • Unexplained fatigue • Subjective fever • Joint aches, body aches, • “I’m afraid I might have cancer” • Chronic pelvic or abdominal pain

Illustrative Case • 58 y.o. female with a history of body aches, joint pains, abdominal pain, marked fatigue and asthma. • Diagnosed with chronic fatigue and fibromyalgia on the east coast. • She has been on repeated doses of steroid for her asthma and fibromyalgia because she reports it improves her symptoms.

History (Con’t) • Previous evaluations by GI, rheumatology, cardiology and previous PMD. • Laboratory studies: CBC, TSH, ANA, RF, Lytes, LFT’s, all normal. • ESR = 28 • EGD = negative

PE • Mildly anxious appearing • BP 118/76, HR = 86 • Normal exam except for obesity • “Nobody knows what’s wrong with me.”

Laboratory Evaluation of Fatigue • CBC • TSH, Free T4 • Ferritin • Na, K, Ca, BUN, Cr. • LFT’s • Urinalysis • ESR or CRP

Where do you go from here? • What questions do you want answered? • Additional labs? • Psychiatric evaluation? • Beck’s depression inventory? • MMPI? • Other referrals? Pros and cons ...

The Epidemics • 25-75% of primary care visits with somatic complaints due to psychosocial distress. • Conservative estimates are that 10% of all medical services provided for patients with no evidence of organic disease.

The Well Known Syndromes • MCS: up to 100,000+ litigation claims • CFS: up to 1,000,000 + disability claims • GWS: est. 50-100,000 (out of 697,000 deployed to Persian Gulf) – (not present in 2003 Iraq War) and • …82% of patients with somatization stop working. • $20+ billion dollars a year in health care costs

Symptoms • Subjective symptoms are predominant • Reproduction of objective findings not consistent • Symptoms common to common illnesses (URI, depression) • Multi-system involvement not related to know systemic illnesses.

Symptom comparison

Co-morbidity

Reality check! • What evidence do we have for physical illness? • What evidence to we have for psychological illness? • Is there a social/cultural pattern to these syndromes?

Multiple Chemical Sensitivity Environmental Medicine -testing: • Are they reliable indicators of disease and/or sensitivity? • Controlled trials have not substantiated any evidence of chemical sensitivity. • CDC declassified MCS as a valid diagnosis.

War syndromes • Similar post-war syndromes have occurred after every conflict: • Civil War- irritable heart • WWI - Soldier’s heart • WWII - Effort syndrome • Korea - Da Costa Syndrome • Vietnam -Agent Orange • Gulf War – GWS • Where did it go with the current wars? • Not classified as PSTD – very different symptoms. • Mimics the other chronic illness syndromes

GWS • Six epidemiologic studies reviewed by expert panels have concluded that GWS is not caused by any biologic, chemical or toxic agent • Illness rates have occurred as one would expect in the general population (including birth defects) • Responsibility of media in hysteria - see Frontline report in 1998.

CFS • No clear definition • No definable cause that has stood test of time (EBV, mycoplasma, chlamydia) • Laboratory findings inconsistent, not matched with healthy population or severity of illness. • Strong advocacy groups tied with Fibromyalgia groups.

Historical Patterns of “Hysterical Illness” • Strong belief in illness state • Physician or authority figure publicizes, defines, and names illness • Vulnerable patients with wide variety of symptoms (multi-system) • Supportive cultural environment with activist leadership. E. Showalter, 1997

Complicating factors • “Research” bias - many studies strongly tainted or biased. • Lack of interdisciplinary approach • Non-holistic view of patient • Lack of uniform diagnostic criteria or objective testing.

Social Factors • Increased incidence of these illness in times of economic hardship • Increased reporting of disease when public media attention focused on syndrome • Financial incentives to remain disabled. • Medical system encourages utilization if insured.

Political Aspects • Strong advocacy groups • Websites- Yahoo • CFS - 54 sites • MCS - 12 sites • GWS - 6 sites • Congressional actions • Death threats (!)

So what do we do with these patients??

Model of Illness and Disease • Illness - sense of being “unwell”. • Based on perception and belief. • Disease - definable process with coherent physiologic parameters. • Physical sensations of no consequence are frequent occurrences but can be interpreted in many ways.- assigned meaning by patient.

The 3 P’s 1. Predisposing Factors: - physiologic reactivity to stress, childhood experiences, poor coping skill, poor social skills, poor self esteem, poor intellectual insight.

The 3 P’s (Con’t) 2. Precipitating Factors: - stressor - medical illness, social, occupational event. 3. Perpetuating Factors: - financial gain, personal attention, healthcare system, maladaptive coping skills. - social support for being ill

How do we help these patients • Recognize them early- especially in pediatric patients (illness by proxy) • Control perpetuating factors • reduce disability and expectation of further disability. • Treat underlying depression • Work on changing illness belief • Refer with caution ** ( illness assignment)** • Educate patient on being a smart consumer.

Help - II • Limit precipitating factors • Treat comorbid conditions (anxiety, depression) • Teach common sense approach to problem solving • Increase healthy social support • beware of the co-dependent family members. • Health maintenance

Help - III • Decrease impact of predisposing factors. • Explain what is normal (normal variant) • Discuss previous illness or illness exposures • Carefully screen for childhood abuse • Coping skills • Psychotherapy

Treatment - CFS • CBT • Exercise • Avoid debate over psychological vs. physical with the patient • Methylphenidate • Fluoxetine – if depressed

Treatment - Fibromyalgia • Exercise • CBT • TCA’s - amitriptyline • SSRI’s – Fluvoxamine, Paroxetine • Pregabalin – (Lyrica) • Cyclobenzaprine – (TCA effect) • Tramadol (for pain)

Treatment – Gulf War Syndrome • No longer a medical diagnosis considered viable • Search of Up to Date – no results…

What doesn’t work • Specialized treatment centers (big money though…)

Treating yourself... • Frustration levels of providers can be high • “Just go see a specialist…”- do no harm? • Avoid fad cures- if you don’t know it will work, don’t recommend it. • Avoid labeling for convenience. • Avoid labeling children with parents insisting on a diagnosis- “CFS by proxy ”.

Prognosis • Very high rates of chronic disability • Over utilization of the health system • Increased suicide risk • Best outcomes in patient treated by a primary care physician, not a specialist. • No change in overall mortality when compared to general population (excluding suicide).

Summary • Exceedingly common problem in outpatient medicine • Coexists with medical and other psychological illness (“cry wolf “ problem) • Provider’s actions are equally likely to hurt as much as help if not careful • Early recognition of syndromes and re-inserting patient back into the mainstream is essential.

Michael L. Tuggy, MD Swedish Family Medicine