A 38-year-old woman comes to the office due to an 8-month history of fatigue and difficulty performing work-related tasks. The patient works as a cashier and is unable to stand for a long time due to exhaustion and muscle aches. After unloading stock, she feels tired and has no energy for hours. The patient tries to rest at home after her shift but doesn't think this helps. She gets 7-8 hours of sleep a night but awakens feeling unrefreshed. Other than a viral infection 3 months ago, the patient has been in good health and takes no medication. She does not use tobacco, alcohol, or illicit drugs. She has no depression or anxiety. Family history is significant for hypertension in her father and depression in her mother and brother.
Vital signs and physical examination are unremarkable.
Laboratory results, including complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody, TSH, and rheumatoid factor, are negative.
Which of the following is the most effective treatment for this patient's symptoms?

Question

A 38-year-old woman comes to the office due to an 8-month history of fatigue and difficulty performing work-related tasks.  The patient works as a cashier and is unable to stand for a long time due to exhaustion and muscle aches.  After unloading stock, she feels tired and has no energy for hours.  The patient tries to rest at home after her shift but doesn't think this helps.  She gets 7-8 hours of sleep a night but awakens feeling unrefreshed.  Other than a viral infection 3 months ago, the patient has been in good health and takes no medication.  She does not use tobacco, alcohol, or illicit drugs.  She has no depression or anxiety.  Family history is significant for hypertension in her father and depression in her mother and brother.
Vital signs and physical examination are unremarkable.
Laboratory results, including complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibody, TSH, and rheumatoid factor, are negative.
Which of the following is the most effective treatment for this patient's symptoms?

Quizplus · Accepted Answer

This patient's history of fatigue, exhaustion after exertion, lack of restful sleep, and inability to function at work is suggestive of chronic fatigue syndrome (CFS), also known as systemic exertion intolerance disease (SEID). CFS primarily affects young to middle-aged adults who had a high level of functioning prior to the onset of illness; it is twice as common in women. Diagnosis involves excluding other causes of fatigue, including psychiatric disorders and medical conditions, with a thorough history, physical examination, and laboratory evaluation (including complete blood count, comprehensive metabolic panel, TSH, and erythrocyte sedimentation rate). First-line treatment for CFS includes cognitive-behavioral therapy (CBT) to target thoughts or behaviors that hinder recovery and graded exercise therapy (ie, slowly increasing exercise tolerance over time under the supervision of a physical therapist). (Choice A) Although viral infections may precede the onset of CFS, there is no proven causal association between viral etiologies and CFS. Antiviral treatments have not been shown to be beneficial. (Choice B) Biofeedback includes the use of electronic devices to help patients recognize and control physiological processes. It is commonly used in the treatment of pain. There is insufficient evidence for its use in CFS. (Choice D) Depression is commonly seen with CFS either as a comorbid condition or secondary to the limitations associated with CFS itself. It can worsen symptoms of CFS and should be screened for and treated. However, this patient does not report depressed mood. Antidepressants are not indicated in the treatment of CFS without comorbid depression or anxiety. (Choice E) Patients with CFS are optimally treated with a combination of graded exercise and cognitive behavioral therapy. Increased rest is not recommended and should be discouraged. Educational objective: Management of chronic fatigue syndrome includes excluding other medical and psychiatric causes of fatigue followed by referral for cognitive-behavioral therapy and graded exercise therapy. __________ References: Chronic fatigue syndrome: diagnosis and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/23062157) Cognitive remediation training improves performance in patients with chronic fatigue syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/28830024)

A 38-Year-Old Woman Comes to the Office Due to an 8-Month