Chronic Fatigue Syndrome and Posttraumatic Stress Disorder

To the Editor: In his Contempo Updates article about chronic fatigue syndrome (CFS), Dr Natelson¹ did not discuss the relationship between CFS and posttraumatic stress disorder (PTSD). The 2 diagnoses share many features, including fatigue, hypocortisolism,^{2 - 3} abnormalities of immune function,⁴ unrefreshing restless sleep, fluctuations in concentration or memory, headaches, muscle pain, joint pain, and withdrawal from occupational, educational, and social activities.^{5 - 6}

Psychiatrists tend to use different terminology to describe some of these signs and symptoms. One example would be the term "leaden paralysis" for the profound fatigue and inertia of CFS. Additionally, patients with PTSD sometimes describe pain and/or dysesthesias that are eventually found to be manifestations of "flashbacks."

Many of the treatments for PTSD and CFS are similar, as well. Examples include psychodynamic psychotherapy, cognitive behavioral therapy,¹ selective serotonin reuptake inhibitors, β-blockers, and α-agonists.⁷ Patients who have these concurrent diagnoses often report a decrease in symptoms when treated specifically for PTSD with an appropriate combination of psychotherapy and medication.^{6 ,8} Anecdotally, if these patients can articulate their emotional pain, the physical complaints begin to resolve.

Unfortunately many physicians, including many psychiatrists, interview patients without realizing that past traumatic events may trigger emotional and physical repercussions for months or years afterward. Such patients often frustrate their physicians with a litany of somatic and functional preoccupations. Physicians inquire about PTSD in combat veterans and holocaust survivors, but may not consider manifestations of PTSD from civilian trauma such as physical or sexual abuse/assault, motor vehicle collisions, and natural disasters. Simply screening for intrusive thoughts, avoidant behaviors, autonomic hyperarousal, and easy startling may be sufficient for triage purposes.

In essence, I wonder if the cascading immunologic and neuroendocrine disturbances seen in both illnesses begin with reactions to trauma. Perhaps CFS is another of the protean manifestations of PTSD.