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January 24, 2003
By John W. Addington
Persons with Chronic Fatigue Syndrome (CFS) can be thankful that Dr. Anthony Komaroff is on their side. To begin with, he is a staunch advocate of the disorder's legitimacy. He is also a Professor of Medicine at Harvard Medical School, the Senior Physician at Brigham and Women's Hospital, and the Editor-in-Chief of Harvard Health Publications. Thus, Dr. Komaroff has the right clout to influence others to accurately understand this disorder.
Dr. Komaroff has put that clout to good use in his roll as member of the U.S. Department of Health and Human Services CFS Coordinating Committee. Aided by Komaroff, a particularly noteworthy accomplishment of that committee was the identification of CFS funds that had been misallocated for other purposes by the Centers for Disease Control. The committee's work led to the restoration of those funds for CFS research as originally designated.
Research
Dr. Komaroff publishes and lectures widely on research that he and other experts have conducted regarding CFS. His own CFS research has addressed immune dysfunction, viral involvement, allergies, and nervous system problems including cognitive difficulties and hormonal imbalances. Dr. Komaroff explains that "the most exciting area of research in the past 5 years has been the many studies finding neuroendocrine [hormone related] abnormalities in CFS. These studies provide further evidence of a biological process involving the central nervous system in CFS."
Distinguishing Other Ailments
When it comes to patients with fatigue, Dr. Komaroff advises doctors to be concerned about making the proper diagnosis. In fact only two to five percent of patients who complain of fatigue to their doctors actually have CFS. Others problems that should be ruled out are anemia, hypothyroidism and hidden malignancies. In some cases, Dr. Komaroff believes simply overworking can be the cause of fatigue.
Psychological problems should also be considered. This is because, as Komaroff notes "depression and anxiety appear to be the most common underlying causes…of chronic fatigue." Thus, this Harvard expert on fatigue says that doctors "should carefully evaluate the possibility of an underlying primary psychiatric disorder in any patient with fatigue." (As will be seen below, however, this does not mean that Komaroff believes that CFS is really just a manifestation of a psychological problem.)
Drug Therapy
Dr. Komaroff is frustrated that the current state of CFS research has only yielded therapies of limited value. Nonetheless, since tricyclic drugs such as amitriptyline (Elavil) has helped in a number of cases he feels patients should consider their use. "In the very low doses we use, these medicines help improve the quality of sleep and thereby improve some of the symptoms of CFS," Dr. Komaroff states.
Although Dr. Komaroff recommends tricyclics, drugs normally used for depression, it is not an endorsement by him of the assertion that CFS is a form of depression. A reason Komaroff sees for the distinction is the difference in time and dosage required for tricyclics to benefit CFS as opposed to depression. Thus, Dr. Komaroff notes that with CFS the "rapid effect and the low doses used (relative to doses used in the treatment of depression) are not consistent with an effect on an underlying depression."
Other CFS symptoms can be addressed with medications as well. For pain and headaches, Dr. Komaroff feels nonsteroidal anti-inflammatory drugs (aspirin, Ibuprofen, naproxen, etc.) may be the best bet. In patients with anxiety or panic problems, anxiolytic drugs (Buspar, Klonopin, Paxil, etc.) can be used. Regarding hypotension, Dr. Komaroff explains, "some patients with fatigue after long periods of standing improve with added salt or fludrocortisone, but none has completely recovered [using these treatments]."
Although research seems to support viral activity in a portion of CFS patients, studies on antiviral medications have not proven the merit of this therapy. Likewise, no drugs have been able to relieve the immune system dysfunction often seen with CFS. Further, Dr. Komaroff thinks the side effects of hydrocortisone weigh against its use in counteracting diminished cortisone levels.
Cognitive Behavioral Therapy & Exercise
Dr. Komaroff recognizes the benefits of cognitive behavioral therapy (CBT) with some patients. A British doctor, Michael Sharpe, has studied cognitive behavior therapy and its implications for CFS extensively. He explains that CBT is "based upon the hypothesis that inaccurate and unhelpful beliefs, ineffective coping behavior, negative mood states, social problems, and pathophysiological [abnormal functioning] processes all interact to perpetuate illness. Treatment aims at helping patients re-evaluate their understanding of the illness and to adopt more effective coping behaviors."
CBT therapists encourage patients to modestly increase their activity, even including light exercise. Dr. Komaroff explains that "the diagnosis of CFS can encourage an unnecessarily restricted level of physical activity that leads, in turn, to deconditioning and further physical dysfunction. Graded, modest, regular physical activity is encouraged and found to be beneficial." He also cautions, however that, "the success of [CBT] therapy is very therapist-dependent."
Psychological Issues
That Dr. Komaroff acknowledges the value of cognitive behavioral therapy is no indication patients have just imagined their symptoms. Komaroff commented on this issue in a special issue of The American Journal of Medicine devoted to CFS. He said, "there is now considerable evidence of an underlying biological process in most patients who meet the CDC definition of chronic fatigue syndrome."
Continuing, Dr. Komaroff stated that recent research "is inconsistent with the hypothesis that chronic fatigue syndrome involves symptoms that are only imagined or amplified because of underlying psychiatric distress symptoms that have no biological basis. It’s time to put that hypothesis to rest and pursue biological clues…in our quest to find answers for patients suffering from this syndrome."
Research that Dr. Komaroff has personally been involved in has helped to distinguish CFS from depression. In a recent study, Komaroff and his associates compared the cognitive functioning (thinking ability, memory, language skills) and psychological symptoms of depressed patients and patients with CFS. While both groups had symptoms of depression as well as cognitive problems, the researchers found that, "the depressed patients were significantly more impaired overall compared to CFS patients." Thus, Komaroff and his associates concluded that the cognitive difficulties experienced by CFS did not appear to relate to depression but rather were more "consistent with…brain alterations."
Conclusion
Dr. Anthony Komaroff's dedicated research efforts have brought us further in understanding the exact nature of this perplexing malady. His sage treatment guidelines have also proven their value. Just as remedial for many CFS patients, however, has been Dr. Komaroff's respect for the legitimacy of the ailment. With his help, the battle against CFS is a little easier.
Sources:
Evengard, Schacterle, Komaroff: Chronic fatigue syndrome: new insights and old ignorance, J Intern Med, 246(5):455-69 (1999)
Fisher, Interview with Anthony L. Komaroff, M.D., in Chronic Fatigue Syndrome (1997)
Komaroff, A 56-year-old woman with chronic fatigue syndrome, JAMA, 278(14);1179 (1997)
Komaroff, Buchwald, Chronic fatigue syndrome: an update, Annu Rev Med, 49:1-13 (1998)
Komaroff, The Biology of Chronic Fatigue Syndrome, Am J Med, 108(2):169-171 (2000)
Komaroff, The Physical Basis of CFS, CFIDS Assoc. Am. (2000)
www.cfids.org/archives/2000rr/2000-rr2-articlel01.asp
Komaroff, Lecture to Mass. CFIDS (2000)
www.ncf-net.org/conferences/komaroff1200.html
Komaroff, et. al, Neuropsychological Function in Patients With Chronic Fatigue Syndrome, Multiple Sclerosis, and Depression, Applied Neuropsychology 8(1);12-22 (2001)
Komaroff, The Biology of Chronic Fatigue Syndrome, Lecture, Myalgic Encephalopathy /Chronic Fatigue Syndrome-"The Medical Practitioners' Challenge in 2001"
www.ahmf.org/01komaroff.html
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