PEER-REVIEW | NEUROSCIENCE | Of the 4 million Americans who have CFS, less than
20% have been diagnosed owing to the lack of sufficient diagnostic laboratory tests or biomarkers2
. Usually, the
complaints are of vague aches and pains without any known aetiology and are often
underestimated until
other symptoms such as depression,
difficulty sleeping, and lack of
concentration manifest.
Aetiology Fatigue is commonly attributed to a variety of causes such as immunological, genetic, post-viral and even neuropsychological, but definitive evidence is still lacking. Nutritional deficiency may be another contributing factor to symptoms of fatigue; however, more evidence is needed to determine what nutritional defects can lead to fatigue. According to recent controlled studies3, 4
, CFS has been associated
with the impairment of the hypothalamic-pituitary- adrenal axis (HPA) that corrects the normalisation of the imbalance. Whether these changes are primary or because of any other underlying aetiology is still under debate.
Clinical manifestations A previously healthy individual usually notices fatigue. This leads to a medical visit. Usually, the complaints are of vague aches and pains without any known aetiology and are often underestimated until other symptoms such as depression, difficulty sleeping, and lack of concentration manifest, affecting personal, social, and work life. This can
eventually lead to isolation, frustration, anger and even the inability to work. The symptoms of fatigue and burnout can be divided
into three categories: ■ Physical symptoms, including difficulty sleeping, fatigue and exhaustion, gastrointestinal problems, headaches, and increased vulnerability to illnesses such as cold or flu
■ Emotional symptoms, including anxiety, depression, guilt, irritability, and a sense of helplessness
■ Behavioural symptoms, including aggression, callousness, cynicism, defensiveness, pessimism, and substance abuse. Continued fatigue can change work-related behaviour causing decreased or poor work performance, absenteeism, misuse of work breaks, tardiness, or attrition thefts. Interpersonal behaviour changes include dehumanisation, reduced communication with colleagues and friends, and withdrawal.
Diagnosis Fatigue is a subjective phenomenon, but it is the main complaint of burn-out or CFS. There is no diagnostic test to confirm fatigue. A thorough medical history, exclusion of other underlying pathology, physical examination, and the use of CDC criteria is the best way in which to make the diagnosis.
Discussion As more evidence correlates the HPA axis with fatigue, this article will discuss the relationship of fatigue, stress, adrenal gland hormones, and neurotransmitters. It will also establish treatments based on evidence-based medicine, focusing on balance of the neuroendocrine system, hormones and neurotransmitters to reduce the consequences of chronic fatigue or burnout. Acute stress or delayed effects of chronic stress and
related conditions are significant reasons for patients ro visit primary care physicians. This can account for up to 75–90% of cases5
. Originally, stress was more physical in
nature. Without stress man would have turned into food for predators or would have died as a result of starvation. Before the establishment of agrarian societies, stress conferred protection from imminent danger or any situation mimicking it. Now stress is multi-factorial and stems from mental, emotional, psychological, social, and environmental sources. The body does not distinguish between real or perceived stress, thus the consequences of mental strain can be the same as physical strain. In a study of 29 burnt-out, 33 work-engaged, and 26 healthy managers it was noticed that burnt-out and work-engaged managers only differ marginally in HPA axis functioning6 to a study7
. According and press release in 2008 by The American
Psychological Association, eight of 10 Americans cite the economy as the leading cause of stress.
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