CFS/ME remain elusive illnesses which require a thorough medical and psychiatric work-up to exclude treatable conditions before the diagnosis can be established. In contrast to what some people and even health care providers believe, CFS/ME is not a psychiatric or so called "psychosomatic illness", indicating that a cause should be looked for in psychosocial factors. It is rather a very complex, multifactorial syndrome in which the central nervous system, the autonomous nervous system, the endocrine system and the immune system (and the communication between these systems), are malfunctioning severely. Patients are severely impaired in their quality of life and their functioning. Currently, no clear cause has been identified and as in most complex illnesses, it is most likely multifactorial. The population and the course of the illness is very heterogeneous and no definite treatment, other than managing symptoms has been identified. In this powerpoint, a current overview of how the diagnosis should be established is given and an overview of the current pathophysiological findings, as well as the therapeutic posibilities, are discussed briefly.

1. Short Clinical Review
Chronic Fatigue Syndrome
Myalgic Encephalomyelitis
Philippe Persoons MD, PhD
Assistant Professor Katholieke Universiteit Leuven
Faculty of Medicine, Department of Neurosciences, Unit Mind-Body Research
Coordinator of the Multidisciplinary Diagnostic Center for ME/CFS, Leuven, Belgium

2. Overview
• What is the significance of (functional) fatigue
• Classification criteria of CFS/ME and characteristics of the illness
• Clinical diagnosis of CFS/ME
• Typical symptoms
• Etiology & Pathophysiology – hypotheses & experimental findings
• Stress Adaptability Model
• philippe.persoons@upckuleuven.be

3. Significance of
(Functional) Fatigue

4. Fatigue in Primary Care
• Fatigue: up to 25% of of primary care MD’s appointments
Komaroff A, 2015

5. A cluster of syndromes
characterized by
overlapping symptoms and
similar systemic vulnerabilities
“lumpers” versus “splitters”
discussion exists
Diagnosis can be dependent on
the consulted medical specialism
What about double diagnoses?

6. Classification criteria CFS/ME
Characteristics of the illness

7. What's in a name?
that which we call a rose
By any other name
would smell as sweet;

8. What’s in a name…
CFS/ME: criticisms on proposed names
• Not classified in DSM-5: not a psychiatric disorder
• Chronic Fatigue Syndrome (CFS)
– too trivializing? Too all inclusive
– Subgroup of patients with less severe illness? Further Research is Needed (FRIN)
• Myalgic Encephalomyelitis (ME)
– “presumed” inflammation of the central nervous system (brain/spinal cord) with symptoms of muscle pain and fatigue
– no definite proof
• however recent research shows slightly increased inflammatory activity which correlates with the severity of the symptoms in severe
cases (intracerebral inflammation, e.g. activated microglia)
• Interchangeability with the name CFS remains open for discussion: differences between authors and patients (FRIN)
• Post-viral fatigue syndrome (ICD-11 – 8E49) https://icd.who.int/dev11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f569175314
– Parent Category: Other disorders of the nervous system  advise for patients: go to neuro
– Includes: CFS, ME, epidemic neuromyasthenia, chronic fatigue (unspecific),…
– ICD-10: G93.3: CFS, benign myalgic encephalomyelitis http://apps.who.int/classifications/icd10/browse/2016/en#/G93.3
• Chronic Lyme’s disease
– no evidence of existence systematic/chronic Lyme infection – not classified in ICD-10 or ICD-11
• Systemic Exertion Intolerance Disease (SEID) – since 2015 (IOM)
– Not yet picked up in scientific community – criteria have not yet been used enough research (FRIN)

9. Haney et al. Ann Intern Med. 2015;162:834-840

10. Explanation of markings on previous slide
• Oxford Criteria are crossed out because they are not accepted anymore as a basis to include CFS/ME
patients in research protocols, because they might be too inclusive, thus also including patients with
depression and other psychiatric disorders. They can’t be included in meta-analyses to assess the effect of
a certain treatment (e.g. in the Cochrane database, American Institute for Medicine, NICE, etc.)
• CDC = Centers for Disease Control and Prevention; CFS = chronic fatigue syndrome; IOM = Institute of
Medicine; ME = myalgic encephalomyelitis;
• SEID = systemic exertion intolerance disease.
• * Defined functional impairment by Short-Form Health Survey (SF-36) scores, fatigue by Multidimensional
Fatigue Inventory (MFI), and symptoms by
• Symptom Inventory Case Definition subscale.
• † All 3 required.
• ‡ Impairment in function, fatigue, and new onset included as 1 of the 3 required symptoms.
• § Onset may be gradual.
• Eight of 11 minor symptoms.
• ¶ Four or more symptoms present concurrently for ≥6 months.
• ** At least 1 from 3 of the 4 symptom categories (neurocognitive, pain, sleep, neurosensory/motor).
• †† At least 1 of 3 symptoms.
• ‡‡ At least 2 neurologic/cognitive manifestations.
• §§ At least 1 of 2 required.
• At least 2 cognitive manifestations.
• ¶¶ At least 1 energy production/transportation impairment (cardiovascular, pulmonary, thermostatic,
temperature).
• *** At least 1 symptom from 2 of the categories of autonomic, neuroendocrine, and immune
manifestations.
• ††† At least 1 symptom for ≥3 categories of immune, gastrointestinal, and genitourinary impairments.
• ‡‡‡ Orthostatic intolerance.
Haney et al. Ann Intern Med. 2015;162:834-840

11. Prevalence of CFS
• Diagnostic criteria according to the CDC-criteria 1994 (Fukuda)
– Prevalence 0.2 – 0.4% up to 2.5% (!) - ± 20 000-30 000 in Belgium
– 12 month incidence 0.015%
– Variabele prevalence due to the different diagnostic criteria, setting, study design
– Onset 35-45 y/o
– Women (65-75%) >> men
– 50% of the patients need specialized care
– Severe functional impairment
• Controversy: use of Canadian Consensus Criteria  Biomedical(psychosocial) (?) view point
– DePaul Symptom Questionnaire
– Assessment of functioning by using the SF-36
– Better specificity: exclusion of treatable illnesses (especially psychiatric illnesses)
• Biopsychosocial view remains paramount in the assessment and management of patients

12. Biopsychosocial model briges “Health” and “Illness”
“The dominant model of disease today is
biomedical, and it leaves no room within its
framework for the social, psychological,
and behavioral dimensions of illness.
A biopsychosocial model is proposed that
provides a blueprint for research, a
framework for teaching, and a design for
action in the real world of health care.”
G. Engel. Science. 1977 Apr 8;196(4286):129-36

13. Prevalence:
Two age peaks
Bakken I et al. BMC Medicine 2014.

14. Difficult (differential) diagnosis
• Wide variety of case criteria / heterogenic sample
• No biomarkers – no diagnostic blood tests – no investegative tools
• Patients with severe functional impairment
• Very complex condition:
– high number of symptoms – complex to manage
– High number of co-morbidities (also psychiatric): stay alert for new diagnoses in CFS/ME patients!
• Time sensitive diagnostics
• Exclusion diagnosis exclusion of treatable medical conditions explaining fatigue
exclusion of treatable psychiatric conditions explaining fatigue
 NO exclusion of psychiatric co-morbidities of CFS/ME
exclusion diagnoses (e.g. severe drug abuse)
if necessary additional assessment

15. Prognosis of CFS/ME
• Variable prognosis – improvement is possible
– Level below premorbid level of functioning
• Premorbid level of functioning rendered them ill!
• Therapeutically we try to achieve a level below the premorbid level of functioning
– Evolution of CFS (Cairns RH. Occup Med 2005)
• Recovery 5% (0-31%)
• Improvement during follow-up 40% (8%-63%)
• Back to work 8%-30%
• Deterioration of symptoms 5%-20%
– Spectrum of functional impairment – variable days: good – bad - crash
• Mild - reduced or adapted work
• Moderate - staying at home; unable to work, but still functioning somewhat
• Severe - bedridden

16. Increased risk factors for severity of ME/CFS
• Severity at time of onset
• Standard of early management of illness
– Late Dx – overexertion in early stages  deterioration
• Mother with illness
• Comorbid fibromyalgia

17. Clinical diagnosis of CFS/ME

18. Diagnosis of CFS/ME
• Problem: identifying CFS/ME patients correctly
– No biomarkers – investigative tools
– Large number of case criteria
– Co-morbidity
• Diagnosis by exclusion
– Exclusion of treatable diseases as cause for fatigue
• Tests are to rule out other conditions
• First treatment for any treatable condition
• If symptom cluster and functional impairment remains  diagnosis can still be made
– Exclusion of certain psychiatric illnesses as possible cause for fatigue
– Criteria for CFS/ME
Bested & Marshall. Rev Environ Health 2015; 30(4): 223–249

19. Exclusion of treatable illnesses
Bested & Marshall. Rev Environ Health 2015; 30(4): 223–249

20. http://www.riziv.fgov.be/SiteCollectionDocuments/overeenkomst-diagnostische-centra-cvs.pdf
Internistisch Psychiatrisch
Belgian exclusion criteria for CFS

21. Suggested Routine Lab tests
Bested & Marshall. Rev Environ Health 2015; 30(4): 223–249

22. Extra tests – depending on the symptoms
Bested & Marshall. Rev Environ Health 2015; 30(4): 223–249

23. CDC Criteria of CFS (Fukuda, 1994)
Used in the Belgian CFS Multidisciplinary diagnostic convention
• Severe, persistent or returning fatigue > 6 months
• Not explained by an active medical illness, nor by certain psychiatric disorders,
which warrants a psychiatric screening (psychosis, psychotic depression, substance
abuse, cognitive disorder or eating disorder, type anorexia and bulemia nervosa)
• New or with a clear-cut start, not improved by rest
• Results in a significant decrease of activities and Quality of Life
• AND FOUR or MORE of the following symptoms which started at around the same
time and are currently present for > 6 months:
– Cognitive symptoms - Lymph node swelling/pain
– Sore throat - Myalgia
– Arthralgia (migratory) - New type headache
– Unrefreshing sleep - Post-exertional malaise (PEM)
Fukuda et al. Ann Intern Med. 1994; 121: 954-959

24. http://www.riziv.fgov.be/SiteCollectionDocuments/overeenkomst-diagnostische-centra-cvs.pdf
Fukuda et al. Ann Intern Med. 1994; 121: 954-959

25. Typical Symptoms of CFS
FUKUDA
Canadian criteria symptoms (ANS, neuro-endocrine system, immune system

26. Typical symptoms: FATIGUE
• Fatigue
– Different from “normal” tiredness – “Wired fatigue” (fatigued with pumping adrenaline)
– Cognitive/mental and physical exhaustion
– General Malaise
– Significant reduction of activity level (about 50% or more)
– New onset
– Fatigue is a spectrum complaint, i.e. from mild, moderate, severe to completely bedridden

27. Typical symptoms: POST-EXERTIONAL MALAISE (PEM)
• PEM: severe physical – mental/cognitive fatigue post-exertion
– Often seen as distinguishing symptom in CFS/ME: patients feel exhausted after exertion
– Worsening of symptoms CFS/ME in general: crash
– Relatively minimal physical and/or cognitive-mental exertion
• E.g. after shower, doing light computer work, ADL
• Experience of worsening of concentration and memory problems (brain fog)
• “Leaden feeling” in body and limbs
– Recovery pathologically slow: > 24H to weeks – Crash (near immobilizing PEM)
– Patient can become bedridden
– Pathophysiological experimental biological correlates on group level

28. Typical symptoms: SLEEP DYSFUNCTION
• Sleep dysfunction: unrefreshing – drowsy wakefulness – always chronic
– “Skimming under the surface” – “tired but wired”
• more severe when Fibromyalgia is co-morbid
– Paradoxically often insomnia: difficulty falling asleep & staying asleep
• NO HYPERSOMNOLENCE (DDx fatigue) – exception sometimes in younger patients
• Often paradoxical insomnia (impression of not sleeping – “seeing every hour” – while sleeeping
• Indicative of overactive autonomous nervous system
– Restoring/improving sleep is important in recovery process
– What about doing a polysomnography?
• Not all functional sleep disorders!
• In case of suspected sleep-breathing disorder, e.g. OSAS (exlusion criterion for diagnosis)
• other sleep-wake disorders: narcolepsia, idiopathic hypersomnolence, RLS

29. Sleep pattern in CFS: alpha-delta sleep
• Thirty second polysomnogram epoch showing stage N3 delta sleep (black arrows) with overriding
alpha frequency (red arrows): alpha-delta sleep: associated with psychiatric illness, fibromyalgia,
CFS, CWP
Manu P et al. Alpha-delta sleep in patients with a chief complaint of chronic fatigue.
South Med J. 1994; 87: 465-70.

30. Typical Symptoms: PAIN (headache, myalgia, joint pain)
• Pain range: mild to severe – chronic
– Often overlap with Fibromyalgia (typically the new ACR criteria for 2010)
– Most likely central sensitisation plays an important role in pain experienced by CFS/ME patients
• Hyperalgesia
• Allodynie
Bourke et al. J Psychosom Res. 2015. 78: 228-236

31. Typical Symptoms: OTHER SYMPTOMS
• Cognitive symptoms – linked to fatigue severity
– Impaired attention (objectively) – subjectively) Concentration difficulties
– Memory difficulties – word finding difficulties
– “Brain fog”  often experienced as very disabling
– Also linked with “high sensitivity” for sensory input/stimulation – irritability (all senses)
• Input/noise ratio < 1
• Can lead to emotional overload – anxiety – crash
• Flu-like symptoms/infection-like symptoms
– Possible due to failure of regulation of stress-response system
• Neuroendocrine system
• Immunological dysregulation

32. Symptoms to be considered from other Criteria
• Canadian criteria  linked to pathophysiological research findings (group level)
1. Autonomic dysfunction manifestation – certain syndromes have been hypothesized
– Malfunctioning of the Autonomic Nervous System
• Orthostatism, Decreased heart rate variability (exercise intolerance?), Changes in sweat production
• Functional dyspepsia – IBS symptoms, Urinary problems, Sexual problems
• Vision problems
– Hypothetical syndromes (most likely part of dysfunctioning stress response system)
• Chronic Orthotstatic Intolerance
– neurally mediated hypotension (NMH)
– Postural orthostatic tachycardia syndrome (POTS)
– Delayed postural hypotension (DPH)

33. • Canadian criteria  linked to pathophysiological research findings (group level)
2. Neuroendocrine manifestations
– Due to Hypothalamic-pituitary-adrenal (HPA) axis dysfunction
– Closely linked to ANS and immune system dysfunction (see pathophysiological mechanisms)
• Diurnal fluctuation of symptoms and fatigue
• Feeling of feverishness
• Weight change – change in appetite
• Loss of adaptability and tolerance for (chronic) biopsychosocial stress: recovery through HPA-axis fails
Symptoms to be considered from other Criteria

34. Symptoms to be considered from other criteria
• Canadian criteria  linked to pathophysiological research findings (group level)
3. Immune activation (see pathophysiology)
– General malaise symptoms
– Flu-like symptoms – recurring PEM
– Feeling feverish
– Tender lymphadenopathy
– Recurrent sore throat possibly with non-exudative pharyngitis
4. Possible consequences on biopsychosocial level
• Possibly highly sensitive to medication and other chemicals/food
• Increased general sensitivity
• Increased sensitivity to psychological/psychiatric co-morbidity
• Increased social isolation

35. Etiology and pathophysiology
Hypotheses & Experimental findings: What do we know on group level?

36. Research has gained momentum

37. www.unrest.film

38. Etiology of CFS
• No specific etiology/caus(es) of CFS/ME has been identified
• Remains exclusion diagnosis
– No clinically diagnostic test
– No biomarker
• Often a pivotal period/illness/event (precipitating)
– Flu-like illness/viral infection/bacterial infection  no recovery
• Prospective study: CFS in 11% of cases after array of viral and parasitical infections
– Burn-out or depression
– Allostatic load  “Allostatic Crash”

39. Etiology of CFS
• CFS/ME is just like any other chronic illness a biopsychosocial illness. Thus, we can identify
1. Predisposing factors (e.g. genetics, but also probably epigenetics and pre-morbid behavior, etc.)
2. Precipitating factors (e.g. viral infection, burn-out, but also possibly life event, etc.)
3. Perpetuating factors (e.g. pathophysiological factors such as sleep disorders, inflammation, HPA-axis
disruption, but also the constant fight because of frustrations, etc.)
4. Protective factors
• The etiopathogenesis of CFS/ME is very complex and without a doubt multifactorial. It is in
the brain and in the body (quote of Ron Davis in “Unrest”). It is definitely not a psychiatric
illness, but given the chronicity and the profound impact of the illness, it is important not to
lose sight of the psychosocial aspects which CFS/ME entails.
• Both for researchers and patients, it is important not to confuse (1) the cause/etiology
(etiopathogenisis) of the illness, (2) the tipping point or precipitation of the illness and (3)
the subsequent remaining pathofysiologic findings which are part of the ongoing illness
process and which might be correlated to the prevalent symptoms of the illness or the level
of dysfunction.

40. Is CFS/ME not another expression of (atypical) depression ?
- Formal psychiatric assessment: NO
- Major depressive disorder: clear diagostic criteria: AVOLITION/ANHEDONIA
- CFS: no criteria for CFS – possibly as co-morbidity: LOSS OF ADAPTABILITY
- Differences in neuro-endocrine studies: NO
- Major depressive disorder: hypercortisolaemia CFS: hypocortisoleamia
- MDD: dexamethasone: ACTH ↗ CFS: DXT: ACTH ↘
- Treatment: NO
- MDD: responsive to antidepressants
- CFS: no response to antidepressive drugs

41. Stress Adaptation Model
Chronic Fatigue Syndrome reflects loss of adaptability
(B Van Houdenhove & P Luyten. J Intern Med 2010; 268 :249-51)

42. Multisystemic Risk factors &
Pathophysiological consequenses
Risk factors (predisposing)
- Genetic predisposition – female gender – family
members increases RR (mother with CFS RR = 2.7)
- Gene-environment interaction: EPIGENETICS
- BioPsychoSocial “Stress”
- Environmental interactions
Pathophysiological processes through
Stress Respons System (perpetuating)
- Autonomic Nervous System
- Hypothalamic-Pituitary-Adrenal axis
- Immune system
- Central Sensitisation
- Changes in gray matter volumes and connectome

43. Activation of the components of the Stress Response System (SRS)
Immune
system
Endocrine
System
ANS

44. Consistent findings
• CFS/ME is not a psychiatric illness
– However calling it a “biomedical illness” is going back in time before George Engel (1970) and the introduction of the
all important “biopsychosocial approach of all medical illnesses
– Functional somatic illness  what does “functional” mean = disfunctional cooperation/communication between
different essential systems controlling our bodily functions, which are essentially operated by our central nervous
system
– High comorbidity with anxiety and depression
– most important mortality: suicide: SMR 6·85, 95% CI 2·22–15·98; p=0·002) (Roberts E et al. Lancet 2016)
• Multifactorial illness
– Possible trigger ?
– Stress Response System plays a role in at least the pathophysiology
• Relative Consistent Research findings on group level
1. Dysregulated immune system: aspecific low level immune activation (correlated with symptom severity); production
of pro-inflammatory cytokines
2. Disturbed function of the neuro-endocrine system (HPA-axis): hyporeactive with relatively low cortisol
3. Disturbed autonomous nervous system: sympathic dysregulation

45. 1. Dysfunction of the immune system in peripheral blood and CNS
• The evidence supports the finding of immune dysfunction in ME/CFS1
– Natural Killer cell function studies: reduction of NK cell numbers and function
• Predisposing signature?
• Result of initiating viral infection, thus unrelated to etiology of ME/CFS, i.e. part of pathophysiology
– Cytokines: altered cytokine levels in serum and cerebrospinal fluid – low consistency
• Role in cause or chronicity: cytokine-cytokine associations differ accoring to duraton²
• Recent study (Montoya et al, 2017 PNAS) confirmed increased TGF-beta to be increased (other studies:
IL-1AR, IL-6, IL-8, etc.) and an upward “trend” of pro-inflammatory cytokines with ME/CFS severity³
• NO BIOMARKERS found (yet?)
• Increased cytokines (possible increased inflammation) post-exercise
1. Mensah, F et al. (2017). Clin Neurophysiol 47(2), 131–138
2. Hornig M, et al (2015). Sci Adv; 1: e1400121: 1-10
3. Montoya, J. G. et al. PNAS, 2017: 105-19.

46. 1. Effect of moderate exercise on expression of sensory,
adrenergic and immune genes in CFS patiënts (Light et al. J Pain 2009)

47. 1. Cytokine co-expression networks in CFS
Cytokine co-expression networks were
constructed from the pair-wise mutual
information (MI) patterns found within
each subject group. Networks for HC
and CFS had visibly different topologies
(geometric arrangements). A weighted
spring-electrical embedding structurally
reveals the subject-subject (inset) and
cytokine-cytokine associations based on
measurements in 59 healthy control
subjects (A) and 40 CFS patients (B). All
edge weights are significant at p ≤ 0.01.
Separation of subjects was consistent
with their assignment to diagnostic
groups supporting the use of within-
group variation in the estimation of
mutual information for cytokine-
cytokine associations
Broderick G, et al. A Formal Analysis of Cytokine Networks in Chronic Fatigue Syndrome. Brain Behav Immun
2010;24(7): 1209–1217. doi:10.1016/j.bbi.2010.04.012.

48. 1. Dysfunction of the immune system: Neuroinflammation and
its consequences for the cognitive and affective functioning
(Nakatomi Y et al. J Nucl Med 2014; 55: 1-6)
• Activation of microglia or astrocytes is
related to neuroinflammation.
• The BPND values of 11C-(R)-PK11195
in the cingulate cortex, hippocampus,
amygdala, thalamus, midbrain, and
pons were 45%–199% higher in
CFS/ME patients than in HC
• CFS/ME patients, the BPND values of
11C-(R)-PK11195 in the amygdala,
thalamus, and midbrain positively
correlated with cognitive impairment
score, the BPND values in the
cingulate cortex and thalamus
positively correlated with pain score,
and the BPND value in the
hippocampus positively correlated
with depression score.
• Neuroinflammation is present in
widespread brain areas in
CFS/MEpatients and was
associated with the severity of
neuropsychologic symptoms.

49. 2. Neuroendocrine dysregulation
• Experimental findings illustrating dysfunction of the HPA-axis
– Reduced function (reduced “repair function”) with effects on adrenal, gonad and thyroid function
– Mild hypocortisolism, changed cortisol awakening response and attenuated diurnal variation
– Blunted DHEA response to ACTH injection despite normal basal levels
– Increased prolactin secretion/sensitivity for certain drugs (e.g. duloxetine, pregabaline)

51. 3. Autonomic dysfunction
• Orthostatic intolerance
• Heart rate variability (HRV) is abnormal in groups of patients with ME/CFS with
increased sympathetic nervous system tone and decreased parasympathetic tone
• Low blood volume has been found in patients with ME/CFS by between 10% and
15% compared to HC
• Increased HR + reduced HRV in ME/CFS during sleep coupled with higher
norepinephrine levels and lower plasma aldosterone suggest a state of sympathetic
autonomic nervous system predominance

52. Other systems which might play a role
• Mitochondrial/energy production abnormalities
– Impairment of oxidative phosphorylation including decreased ATP production by mitochondria 
reduced aerobic energy production + increased production lactic acid
• Oxidative & Nitrosative stress with consequences for TRYCAT pathways and central
and peripheral fatigue

53. Komaroff A, Lecture Karolinska Inst. 2015

54. Treatment modalities
CDC: There is no cure or approved treatment for myalgic encephalomyelitis/chronic
fatigue syndrome (ME/CFS). However, some symptoms can be treated or managed.
Treating these symptoms might provide relief for some patients with ME/CFS but not
others. Other strategies, like learning new ways to manage activity, can also be helpful.

55. Goals
• Improvement
– current symptoms
– functioning
– quality of life.
• Prevention
– Worsening of symptoms
– Development of psychopathology – high risk of suicide
– Iatrogenic/Dr. Google-induced/Quack-induced complications
• Coping with the emotional impact and grieve for the losses
• Validation of the patient’s experience and symptoms
– acknowledging the patient’s illness: ME/CFS. Having a diagnosis might the beginning of healing
for many patients who have been told “it’s all in your head” for many years.
– Acceptance of symptoms: ACT

56. Managment strategies
• Establish positive reinforcing, supportive therapeutic relationship with the patient
• Educate patient and family about the condition
• Collaborate with patient to develop an individualized treatment program
• Empower the patient to trust his/her own experiences and use his/her symptoms as
early warning devices to avoid PEM relapse/crash
• Symptomatic treatment begins with helping patients cope with their most
debilitating symptom
• Treatment = currently management of symptoms

57. Energy modulation

58. Individualized Management of symptoms
• Fatigue – minimalize risk of Post-exertional Malaise (PEM)
– Energy conservation exercise – exercise program tailored to individual patient
– GET  Risk PEM in CFS ?  controversial  no more classe 1 evidence
• Mixed evidence & results1,2
– “Adapted pacing”™: physical energy conservation:
• planning a day around breaks/rests, but not as rigourous as classic Pacing
• within energy envelope – but as active as possible in between w/o overexertion/crash
• Discovering new physical bounderies – putting the needs of their body first
• Plan exciting, relaxing, fun activities – adjust your life
– Medication: e.g. stimulants: e.g. methylphenidate³  very occasionally  PEM
• To manage exceptional events
1. McCrone et al. PLoS One 2012
2. Bested & Marshall. Rev Environ Health 2015; 30(4): 223–249
3. Blockmans et al. Am J Med 2006

59. Experiences of English CFS/ME patients (ME-association 2015)

60. Management of other symptoms
• Sleep
– Sleep hygiene
– Mind the circadian rhythm – “Zeitgebers”
– Medication with care
• Pain – co-morbid fibromyalgia – migraines – very sensitive to medication
– Needs to be managed – individually tailored
– OTC medication often less helpful
– Alternative medication with analgesic properties (e.g. anticonvulsants, antidepressants)
– Be careful with narcotic medication
– If necessary: pain specialist

61. Management of other symptoms
• Psychiatric disorders: high risk: depressive disorder, anxiety disorder
– Good differential diagnosis between CFS/ME and Psychiatric disorders, e.g. HADS, PHQ-9
• Depressive disorder: often severe anhedonia, avolition – not in ME/CFS
• ME/CFS: loss of health – difficult adaptation process
– However high risk of co-morbidity major depressive disorder, anxiety disorder, other
– In CFS: suicide is most common cause for mortality
– Treatment: lege artis – e.g. with antidepressants also useful in pain
• Venlafaxine 150mg or more (max 300mg)
• Duloxetine 60mg or more (max 120mg)
• Go low Go slow

62. Management of symptoms
• Cognitive behavioral therapy (CBT) for ME/CFS – Evidence Based Treatment ?
– Therapy with “clearest evidence” for ME/CFS to guide the path to recovery – NOT curative
– Psychotherapy: cognitive and behavioral interventions
– Aim: changing cognitive processes: increased self-efficacy with respect to fatigue, reduced
symptom focus, symptom perception, increased perceived activity
– Currently highly controversial, together with Graded exercise therapy (GET)
• See biological findings
• Many studies based on Oxford criteria which might have been too inclusive
• Falsly seen as a “cure” by some groups
• See as “beneficial” by other groups because it can reducse the emotional drain of negative emotions
• Thus “emotional energy conservation”
• To be continued Chalder T et al.Lancet Psychiatry 2015
Knoop H. Lancet Pscyhiatry 2015

63. Experimental therapy: Rituximab in ME/CFS
(Fluge et al, PLOS one 2011 and 2015)
• B cell depletion therapy in ME/CFS using rituximab (chimeric monoclonal antibody)
- decrease the number of harmful (auto)antibodies produced by
daughter plasmablasts or plasma cells
- may also act by depleting virus infected B cells in a direct
manner
- Results
- Single treatment of rituximab (2 infusions 2 weeks apart).
- Lasting improvement in operator and self-reported fatigue
scores, as well as other symptoms, in 10 out of 15 patients
(67%) in the rituximab group and two out of 15 (13%) in
the placebo group
- response was found to be ‘‘delayed’’ with clinical
improvement starting from 2—7 months
- Open label phase II: subset of patients had sustained
clinical response to prolonged B-cell depletion (11/29)

64. Future of Rituximab in ME/CFS: no continuation

65. Conclusion

66. Chronic Fatigue Syndrome/ME
• Controversial but real albeit heterogenic spectrum syndrome
• Syndrome with predisposing, precipitating and perpetuating factors
• Clinical diagnosis and an exclusion diagnosis: medical – psychiatric
• Experimental findings are not specific and selective for CFS/ME: no diagnostic tests
• FRIN: both fundamental etiopathogenetic and toward effective management
• Individual management of the patient is necessary