The Hidden Truth About Chronic Fatigue That Doctors Never Tell You

I'd like to welcome everybody to today's presentation on chronic fatigue syndrome. This is the 2025 version and we will be talking about how to help people live their richest and most meaningful life even if they have CFS. I'm your host, Dr. Donnellice Snipes. In this presentation I'm going to describe CFS because you may not even be familiar with exactly what it is. We'll explore other similar diagnoses that may have, that may overlap with cfs. We'll review the prevalence and impacts of CFS and persistent fatigue and identify current evidence based treatments for CFS and persistent fatigue. Why am I separating those? Because there are a lot of things that cause persistent fatigue that are not chronic fatigue syndrome doesn't mean that that fatigue is any less debilitating. And if it's caused by something else, something that may have a treatment, then obviously we want to make sure people are being adequately seen by a specialist to help them differentially diagnose what's going on and address anything they can. About 2 million Americans have chronic fatigue syndrome and it's twice as likely in women as in men. They think that there is a connection in women between the gonadal hormones, between estrogen and the sensitivity to developing or the propensity to developing cfs. There's also a theory out there that women are experience violence and are victims more often than men. Therefore their stress response may already be dysregulated and which lowers the immune system. So when they are exposed to whatever causes CFS and they think it's a virus then they are more likely to get it. Ultimately how it happens, not as important as diagnosing it. And figure out, figuring out how to help people live their rich and meaningful life. Approximately 40%. Let that sink in for a minute. Almost half, approximately 40% of healthy community dwelling adults. So this isn't people that are in hospitals, this isn't people who are in ALFs or nursing homes or anything like that. Community dwelling adults in the U. S Japan and the UA UK report chronic fatigue. Wow. So this is not something that is uncommon. Therefore it is something that we should be screening for. With every patient that walks into our offices. We should be screening for this. And we should not underscore, absolutely should not automatically assume that that fatigue is due to depression. There are a lot of things that can cause that fatigue. Now ongoing fatigue itself often causes people to feel hopeless and helpless and depressed. But the depression may not be the only thing causing the fatigue. So we need to look at that whole bi directional thing. In a survey of 22,323 people with chronic fatigue, 7% had chronic fatigue syndrome. Which is why I said not everybody who has chronic fatigue and has CFS, but 7% do, means the other 93% have another cause of their CFS or I'm sorry, have another cause of their chronic fatigue, which may be very, very treatable. What is the criteria for chronic fatigue syndrome? Unfortunately, still to this day, chronic fatigue syndrome tends to be what they call a diagnosis of exclusion. That means that you've ruled out everything else and this is what you're left with. Criteria number one, severe fatigue lasting longer than six months and present more than 50% of the time. Now, of course, we need to take into consideration the things that are going on in the person's life. If they just are recovering from open heart surgery, yeah, they're going to get winded easier, they're going to get fatigued easier. If they're grieving, they may experience a lot more fatigue. So we want to be cognizant of what's going on holistically with the person. But the severe fatigue longer than six months, more than 50% of the time. So they can have some good days. Just because they have a good day doesn't mean that they don't have cfs. They have to have the presence of at least four of the following symptoms post exertional fatigue. This includes mental exertion. And a lot of people don't think of mental exertion as exhausting. But if you've ever sat in a classroom or done really intensive cognitive work for, you know, a few hours, you know, you feel like you ran a mile or a marathon, depending on how long you were doing it. And so people can go to work and work all day long and just really try or even work a half day and come home and they're just, they're done, they're, they're past exhausted. And we want to recognize this, the person post exertional fatigue is somebody experiencing fatigue greater than what one would expect for the amount of effort that they output. And part of that's also going to have to do with the person's level of conditioning. If they have been, you know, relatively inactive for a long time and then suddenly they get a full time job and they're on their feet for four, six hours a day, yeah, they're gonna feel like, you know, they got hit by a truck when they get home. Sometimes they're going to be plumb exhausted. It's all on a continuum for this person in their condition, does this seem like their fatigue is more than what would be expected? And I try to avoid the word excessive but because that implies that they are maybe making it up or exaggerating, it's not excessive. We want to look at, look at exertion or exhaustion that is more than what we would expect based on what, what's going on with them. And it's important when we have this discussion that we make sure they understand we're hearing them. We are not minimizing their level of fatigue. We are trying to understand where on the continuum it falls. They have unrefreshing sleep, they may sleep 8, 10, 12 hours and they wake up and they're ready to go back to bed again. A lot of things can cause that and we're going to talk about that today. Muscle pain, pretty self explanatory. When we don't move around a lot we can tend to get achy. But people with CFS tend to have a lot of just muscle muscle pain and kind of everywhere that is not attributable to exercise or straining, something polyarthralgia, having arthritis, having problems in your joints, pain in your joints, sore throat, tender lymph nodes, headaches and impaired memory or concentration. Well, guess what, if you've got unrefreshing sleep, you're going to have impaired memory and concentration. So I would expect the those things to go together. Imagine if you have never had cfs, which I'm hoping you haven't because it is a really devastating condition to have to try to figure out how to live with in a less than adaptable world. But thinking about having pain, exhaustion, not getting enough sleep, don't feel like no matter what you do, you feeling like you don't have the energy to get out of bed. Think about how that's going to impact your mood. Think about the grief as you can't do the things that you had dreamed of doing, you had wanted to do. Think about the guilt when you just don't. You truly do not have the energy to get out of bed and go to your kid's recital or, or make dinner tonight, let alone not even getting out of the house, just getting up and making dinner, the prospect is just overwhelming. You don't have the energy. It's important as we talk about these things today to remember that the effects of chronic fatigue are bidirectional. So somebody can have chronic fatigue syndrome and have these symptoms and those symptoms are likely going to impact their every aspect of their life which is going to further exacerbate their chronic fatigue. So P stands for physical. People with chronic fatigue have exhaustion, sleep, difficulties, deconditioning because they just don't have the energy. It's not that they're being lazy, they don't have the energy, pain and stiffness. Now they do have, I think most of us have probably seen the ad for that little seated pedal exercise machine that has a motor to it. I don't know how much that actually does if the motor's doing all the work to help with conditioning. But it certainly can help with reducing stiffness for people who have difficulty moving. And, and again, the one with the motor is actually ideal for somebody with chronic fatigue because you don't have to use the motor or you can slow it down or whatever. But for a lot of people with cfs, they don't have the energy to sit there and pedal for any period of time. And keeping the blood moving, keeping the joints mobile is really important. Adolescent chronic fatigue syndrome is associated with altered autonomic cardiovascular control, which means they have difficulty controlling their blood pressure, heart rate and pulse, or blood pressure and heart rate. It's characterized by enhanced sympathetic stress and attenuated parasympathetic, the digest, rest and digest doesn't kick in. So excessive stress, not enough relaxation, nervous system activity. And we've talked about this in other videos in relation to postural orthostatic tachycardia syndrome syndrome. People with pots, when they stand up, their heart rate goes up, their blood pressure goes up, I mean way up in response to standing. They're not doing anything unusual, they're not standing with a 40 pound rucksack on them, they're just standing up. And when your body responds like that, it takes a lot of energy. So people with POTS or often struggle with exhaustion on top of everything else. In addition to imbalanced sympathetic and parasympathetic nervous system activity, the person may have, prior to developing these symptoms, had an episode of mono or Epstein Barr virus. And this is where they started believing that CFS may be related to, to a viral infection. Interestingly enough though, most people with pots, particularly and adolescent CFS, often have normal cyto kind levels. So the inflammation level in their body isn't more than what is expected. Which is why for so long doctors said, oh, it doesn't exist because we can't see the inflammation. Well, it's there, so we need to understand the symptoms and try to figure out what else might be going on interpersonally. People with CFS experience isolation and withdrawal because they don't have the energy. And a lot of people, since it's what we call an invisible disability, a lot of people may not understand or they may think that the person is overreacting or milking it. And that can cause a lot of resentment, guilt, grief and, and just simply relational changes. If you used to go to the gym with somebody or go hiking with somebody, you can't do that now. And if they don't want to do something else with you, then that relationship may start to dwindle. People's relationship with themselves, their self esteem, their self concept changes as they start recognizing their new normal and recognizing that there are some things that they thought they were going to be able to do that they are not actually going to be able to do now. And that involves a grieving process, the, the loss, the death of their vision of their rich and meaningful life. And that's one of the places we can help people step in and say, okay, well, maybe you can't do this the way you thought you were going to. Let's look at, are there any modifications we can make? Let's look at what other things are important in your rich and meaningful life that you can still do, albeit with modifications. Helping people become aware of what CFS is and educate their, their loved ones, their friends, their co workers and their employers is also really important. And as clinicians, we can advocate for them, obviously, release of information, blah, blah, blah. But we can also just go out and do public presentations and say, hey, this is what CFS is. The person's not making it up. It is a very challenging condition emotionally. The person with CFS often struggles with depression, anxiety, anger and grief due to the severity of their chronic fatigue syndrome. You know, more severity, more grief, more helplessness, more anger, uncertainty. If they have more flares than someone else, then they may have more emotional distress as a result because it is more disruptive to their life. The ambiguity of what's causing it can also be very frustrating. It's like, okay, there's something wrong with me. You've got to be able to fix it, but we don't know how to do that yet. And that can be exasperating for somebody with cfs, especially because it often seems to come on kind of out of nowhere. It's like they had a virus and then they got better, but they were never quite the same again. And then a chronicity in patients, and they call it ME cfs. ME stands for Mild Myalgic Encephalitis or cfs. So CFS is what we typically Refer to it as. But it's important to understand that when people have distress, guess what? That's that sympathetic nervous system triggering and the parasympathetic nervous system getting weaker. The sympathetic nervous system triggers, increases inflammation, increases the chances of a, a flare of the cfs. It can make it a lot worse. It can impair sleep, it can impair, you know, relationships, which is going to increase stress, increase inflammation, it worsen CFS symptoms. People with CFS have difficulty concentrating and difficulty with their memory. Okay. And we're going to talk about interventions in I think starting on the next slide. But I do want to highlight the fact that a lot of that is due to the inflammation and the lack of restful quality sleep. When we don't clear out the adenosine in our brain through quality sleep, we feel sluggish the next day. We have more difficulty controlling our thoughts and preventing negative ruminations, all of which increases stress. When we're stressed, we are in fight orf flight, not think clearly, not learn things. We are trying to survive. And one would expect that concentration, memory, attention, all those executive functionings would probably be worse. What do we do? Encourage people to mitigate this. Write things down if you're not, if you're trying to remember something. It takes energy. The person with cfs, that's the one thing that they ain't got. So encourage them to write it down so they don't have to remember. Encourage them to use push notifications as much as possible. Encourage them to create a concentration environment, learning environment, whatever it is they need for. If they're doing schoolwork or at work, that removes as many distractions as possible so they're not using energy, trying to block out the extraneous stuff. It takes more energy if you're having to work to focus than if you don't have to work as hard. It imp, it affects the person environmentally because people with CFS often cannot work. Some can work part time, some can't work at all. There are very few with a, with milder cases of CFS that can work full time. But that is the exception, not the rule. Therefore, housing becomes. And financial situations become much more tenuous, which is stressful. You see the connection here. It can become more difficult to access good nutrition because it's expensive and medical services. The inability unfortunately in our society to work a full time job definitely negatively impacts a lot of people's environment. And when you think of Maslow's hierarchy, what's the bottom? Those biological needs, Housing, shelter, food, water, medical care. And those become More difficult to access loss of connection with one's personal meaning and purpose is the spiritual effect. And I refer to spirituality in a much broader term. We're not talking about religion, but we're talking about a person's sense of a lack of connection with the world. It's like the world's going on without me. I'm just sitting here and I can't. I don't even have the energy to get up. Causes and consequences of chronic fatigue syndrome. Something we don't exactly know what in all cases, but something causes dysfunction in the nervous, endocrine and immune systems. And which one comes first doesn't really matter because they all impact each other. When your immune system is overactive or underactive, it's a stressor. When your endocrine system, your, your hormones are imbalanced, it's a stressor. When your nervous system is imbalanced. When the stress response is way stronger than the relaxation response, then the stress response stays turned on a lot longer because you can't balance it out. We can help people work on strengthening their vagus nerve. We can help people work on strengthening their nervous system and reducing unnecessary sources of stress and minimizing inevitable stress. When the person's nervous system starts to balance out, cortisol will be more effective. The endocrine system will balance out somewhat, assuming there's not an underlying pathology in, in the endocrine system. And the immune system tends to chill out a little bit. And, and we've seen this in people with autoimmune disorders. When they get stressed, their immune system, you know, kicks into overdrive. And when they're not stressed, they can typically manage their symptoms. So helping people heal their nervous system is one of our key jobs. And as that autonomic nervous system heals, a lot of things will start to balance again. Again. It may not be a complete reversal, but it will help. It will help a lot in terms of gonadal hormone imbalances in chronic fatigue syndrome. And when I talk about gonadal hormones, I'm talking about testosterone, estrogen, progesterone, dhea, excess corticotropine releasing hormone, estrogen, follicle stimulating hormone, and luteinizing hormone are often present in women with cfs, so they have high levels of, of a lot of these hormones. It's important to understand, though, we've talked about Goldilocks and too little is bad and too much is bad. Exposure for too long is bad or too short of a time is bad. And when it comes to estrogen, short term increases in estrogen showed a decrease in something called the serotonin reuptake transporter and that is the enzyme that breaks down serotonin, so it can be reuptaken. So a short term increase in estrogen isn't bad, it's actually beneficial and can help people have a little more energy and feel a little bit brighter. Long term exposure, more than 28 days caused an increase in serotonin reuptake transporter which led to reduced serotonin. Because the more S we have, the quicker it breaks down the serotonin in the synapse. So it doesn't give the serotonin as much time to do its job. Low serotonin leads to sleep changes, unrestful sleep, fatigue and increased pain. Low serotonin impacts the availability of oxytocin, which is an anti inflammatory and helps regulate the autonomic nervous system. It affects the availability of estrogen in the body and it affects the availability of dopamine and our natural painkillers which we call endogenous opioids. Which is why people with depression who have low serotonin experience a lot of these things. There is a neurochemical basis resolution of fatigue and decrease of inflammatory mediators in patients with chronic fatigue syndrome often occurs after the discontinuation of hormone therapy. That doesn't mean that hormone therapy is bad. It means if the hormones are pushing the person to having too much, then it can be bad. We want to have the person where it's just right, it's not too low, not too high. Additionally, insufficient DHEA which helps make gonadal hormones can also contribute to these problems. If you don't have the precursors, you can't make the final product. There is a clear relationship between sleep disorders and chronic fatigue syndrome. There's also a clear relationship between sleep disorders and inflammation and sleep disorders and diabetes. But those are other presentations. We'll talk about Identifying sleep disorders in our patients when they come in for their intake is important and that can mean fragmented sleep. Are they having difficulty getting to sleep, difficulty staying, staying asleep, etc. Are they having other issues that are fragmenting their sleep, like they have to get up and pee eight times a night or they are sleeping in a room where there's something that's waking them up, whether it's a dog or a spouse or whatever, or their sleep is becoming fragmented because of sleep apnea. Sleep apnea is associated with increased likelihood of chronic fatigue syndrome as well as an increased likelihood of diabetes. Because chronic. Because sleep apnea is stressful on the body, when you quit breathing, the body kind of freaks out. Makes sense. Which increases stress hormones, which also increases blood sugar. So every time the person quits breathing, they have a blood sugar spike. That's not good for your insulin resistance. Chronic fatigue syndromes are also related to dysfunction in the autonomic nervous system and the hypothalamic pituitary adrenal axis. We've talked about this a lot already, so I'm not going to belabor it. Suffice it to say that increased stress or trauma, whether it be prenatally, in childhood, during adolescence, or right now, increases the risk of chronic fatigue syndrome. As the person's autonomic nervous system becomes dysregulated, as the sympathetic nervous system becomes overly powerful, then cortisol starts to lose its ability to do what it does so well, which is reduce inflammation. And we start to see inflammation creep up and, and all kinds of neurochemical and hormonal changes in the body that are not changes that we want. Helping people reduce their stress is essential. Helping them feel safe and empowered is essential. Somebody with CFS may not have the energy, let's be brutally honest. They may not have the energy to do a bunch of trauma work. They may explore EMDR on a good day, but that again is going to take a lot of energy. And one of the things that we can do as therapists when we're seeing somebody who's struggling with cfs, we want to help them build their reserves. Trauma's been there, it'll still be there six months from now, a year from now. Let's help the person get to the place where they feel safe, they feel empowered, they feel, feel like they have an increased quality of life. Unless of course, they're just hell bent on working on their trauma. Then of course we're not going to negate or disempower them emotionally and cognitively. Perfectionism, self sacrificial tendencies. So kind of codependency, unhelpful beliefs about emotions, thinking that being angry is bad, being anxious is bad. And perceived stress may present to a greater extent premorbidly in people with cfs. So people who tend to be perfectionistic, anxious, insecurely attached are at a much higher risk of developing CFS. Exclusion. Remember I said this was a diagnosis of exclusion and I'm sure I missed some, but these are some of the common things that guess what we can screen for in our intake? Sleep apnea. Anemia. Now we're not going to be able to tell about anemia, but we can encourage People to go to the doctor and get a blood test to identify their nutritional status and their hormonal status, which takes us to malnutrition. If they have anemia, they've got some level of malnutrition that'll show up in a blood test. That's something a doctor can handle, you know, relatively simply. Cardiovascular issues, whether it is really bad cardiovascular conditioning or some sort of congestive heart failure, if the person is exhausted because of cardiovascular issues, that's something that can be addressed in most cases. Pots. Postural orthostatic tachycardia syndrome. It's exhausting. Y' all know, my daughter has it, and I've watched how absolutely wrecked she can be when her POTS is flaring up because it takes so much energy just to stand up, just to move around, just to stay upright. Hypothyroid. When we get stressed, we are much more likely to trigger an endocrine reaction in our body. If the stress is chronic, that can lead to hypothyroid. And if you watch the videos I have on the impact of trauma on the body, I go into great detail about that. But just suffice it for now to recognize that stress will cause changes in thyroid hormone availability and gonadal hormone availability. Severe obesity. When people have a lot of adipose tissue fat, it increases the estrogen levels. And we've talked earlier about how too much estrogen, estrogen dominance, too much estrogen for too long actually reduces the availability of serotonin. Lyme disease and diabetes are other physical issues that we need to sort of rule out. We also want to recognize chronic fatigue syndrome can occur concurrently with these things. Just because somebody has POTS doesn't mean they don't also have cfs. But once we get the POTS under control, then if the CFS remains, we can start addressing that. Hypothyroid. We know that hypothyroid looks a lot like depression. And when people have hypothyroid and fatigue and they get exhausted easily, it's frustrating and it's going to cause stress and it's going to impact every piece of their life. As that stress goes up, they become their. Their immune system becomes less effective, if you will, and they become more at risk for developing cfs. So it is a bi directional thing. Interpersonally, interpersonal stress, relationship stressors that we talked about, they can be exhausting. It doesn't mean you have chronic fatigue if you're living with somebody who has a uncontrolled mental health issue. If you're in a conflictual relationship. If you work in a place that is just toxic, as I'll get out, you're going to be exhausted. It's stressful. Does it make you more at risk for getting cfs? Yes. But it also can in and of itself cause chronic fatigue. When you're laying down at night and you're replaying all those conversations or done me wrongs in your head. Relationships can be stressful and exhausting. Insecure attachment is a source of interpersonal stress. But I wanted to highlight it on its own. We when people don't feel safe and loved in their relationships, when people don't feel like they can count on somebody to support them, then it creates a lot of anxiety. And as we get older, as we become adults, we have multiple somebodies that we believe we can rely on and that's wonderful. However, if we don't believe we're worthy of love, if we don't believe we can trust other people, then there's always a level of anxiety, there's always a fear of abandonment that increases stress, increases inflammation, increases the likelihood of cfs. And in somebody with cfs, it worsens their symptoms. Addressing attachment is something we can do in, in treatment. And it's not something as exhausting as maybe addressing the trauma that caused that attachment or attachment issue. We can help people focus on in what way are you safe and empowered in your relationships now? What relationships do you have that are important to you? Let's look at how they may be safe, how they may be. The mnemonic I use for secure attachment is cares. How they're consistent, attentive, consistent, attentive, responsive, encouraging and safe. Let's look at those. No, most relationships aren't perfect. So we want to help people look at the positives in the relationship and acknowledge the, the negatives or things that may need a little bit of work. Emotionally and cognitively. People may have depression and depression looks like chronic fatigue syndrome a lot of times. And chronic depression can co occur with chronic fatigue syndrome. Bipolar disorder increases people's risk of chronic fatigue syndrome. But we need to evaluate, you know, and with bipolar, the depressive episodes don't usually last for six months or more. So we need to look at the duration of how long are these episodes lasting. Anxiety, anger, both of those are exhausting. That anxiety and anger are our stress responses. And when we feel stressed, when our stress, our sympathetic nervous system, sympathetic nervous system is triggered, we're using a whole lot of energy. And when people feel chronically anxious or chronically angry, chronically guilty, chronically Resentful, it uses a whole lot of energy and it's exhausting. People who are negative tend to be a lot more tired. Trauma, as I mentioned earlier, can cause people to develop something called hypocortisolism, which happens as I described earlier, when the stress response is on for too long, cortisol becomes ineffective and reduces its ability to, to suppress inflammation, which affects the entire system. And they call that hypocortisolism. Grief is exhausting. Many people when they're grieving, they don't sleep well, they may experience more pain, aches and pains. They're not sleeping well, they have difficulty concentrating. It overlaps like completely with cfs. So we need to evaluate is this person grieving or is it cfs or is it both? And, and, and a lot of people with CFS have a lot that they're grieving. Bi directionally, environmentally, too much noise, too much light, overly strong smells, not feeling safe, all of these things can cause stress and exhaustion. If you're in an environment that is over stimulating, a lot of times you'll come home and you're just like, oh my gosh, you know, finally some relief. But I'm exhausted because I've been fending off all that overstimulation all day long. And as I mentioned earlier, sleep disruptors, we do need to check people's sleep hygiene and there's sleep habits to make sure that there's not something going on besides like apnea that may be keeping them up. I've mentioned before that, you know, I have animals, I live on a farm, I'll, I let the cats sleep in the bedroom and sometimes they have an overly active night like they did last night and they were up and down and they were playing with each other. They got the zoomies at 2 o' clock in the morning and I'm like, y', all, I gotta work tomorrow. But that doesn't happen with regularity. And if it does happen like tonight, they ain't sleeping in the bedroom because I know I need to get a good night's sleep. Recognizing what is important in reducing stress and maintaining your sleep and your circadian rhythms in terms of treatment, stress management. And when I talk about stress, I'm not just talking about emotional stress. I'm talking about any source of stress on the body. You're in pain, it's stressful, you didn't get enough sleep. Your body thinks it's a stressor, you're malnourished, your body registers that as a stressor. All of those things are going to Require more energy, they're going to trigger the sympathetic nervous system and they may impair your body's ability to make and balance the hormones and neurotransmitters you need to live your rich and meaningful life. We want to help people manage these stressors so they can re regulate that autonomic nervous system and restore the anti inflammatory effects of cortisol and allow their body to re regulate all of those symptoms systems. We've talked before in other videos about the different axes we've got in our nervous system. We have the hypothalamic pituitary adrenal axis, which is the stress response. We have the hypothalamic pituitary gonadal axis and we have the hypothalamic pituitary thyroid axis. Not sure exactly why they decided to separate all three of them, but they all three work together. And when one gets out of whack, like the adrenal axis, it brings its buddies along with them. And then the gonadal axis and the thyroid axis get out of whack. So strengthening that parasympathetic, parasympathetic nervous system and reducing unnecessary stress of all types is essential. Physically help people improve their sleep, address circadian rhythm issues. Remember, circadian rhythms regulate our hormones. It regulates our enzymes. It regulates everything, not just our sleep. Circadian rhythms are regulated by light levels. Light means be awake. Dark means go to sleep. It's regulated by temperature. Warm means be awake. Cold means go to sleep and hibernate. And our activity levels. When you are engaged in activities, you are more likely, especially activities with other people. You are more likely to keep that awake signal going. Which is why it's helpful to have a sleep routine where you do the same thing, couple of things each night before bed, Eat dinner, take a bath, read a book, go to sleep. So your body starts getting primed as soon as you start eating dinner. It's like, oh, I know what comes next. We're going to get to go to bed pretty soon. We want to help people reduce inflammation as much as possible through good nutrition and stress reduction. And we want to help people balance their autonomic nervous system interpersonally. We want to help them develop secure attachment with their self and others, learning how to be consistent, attentive, responsive, encouraging and safe. Which means unconditional positive regard with themselves first. How can I be accepting of myself and with others? We want to also help them work on disability acceptance. CFS may never go away for them. So how can we help them? As Hayes says in acceptance and commitment therapy. How can we help them live in the and I have CFS and I'm going to do this. I have CFS and I can do this. Helping people develop their emotional quotient or emotional intelligence whatever phrase you like and distress tolerance skills are really important in terms of working with this. People need to be able to do what I call I use the mnemonic idea Identify the feeling they're having anxious, angry, grieving, curious whatever it is identify the feeling if it's a stressful feeling have skills distress tolerance skills to help them down regulate get into their wise mind get out of fight orf flight and into their wise mind explore the trigger or the cause of the feeling using the facts in this context at this time or fit cat so I identified my feeling I downregulated so I could think more clearly about what's going on. Now what the heck did happen? What triggered my anxiety right now and is it actually an issue? And then address the feeling. Figure out what I need to do. Whether I need to do something to address the trigger or I need to recognize that it wasn't a big deal, it was just triggering a memory or maybe it was something in in the present that made me feel a little bit unsafe but it's not worth my energy to address. Those are kind of our options. And so identify the feeling I down regulate d explore the trigger or cause e and address the feeling A idea cognitively helping people address their cognitive distortions and most of your cognitive distortions Personalization all or nothing thinking, jumping to conclusions, emotional reasoning. You list them off. Most of them can be addressed by looking at the facts in this context at this time. Looking at the probability versus the possibility. Anything's possible. But what is the probability that this worst thing is going to happen? Finding exceptions when you think everything's going wrong. Finding exceptions to that or when you think somebody never does something. Find exceptions and find alternate explanations. And this is a big one for jumping to conclusions as well as personalization. What are three other reasons why this might be happening besides what you what you're afraid it is? Besides this conclusion that you jump to or besides the fact that you think it's about you environmentally helping people achieve safe, stable housing and adjust the environment both at home and at work or wherever they spend most of their time to be compatible with their senses? Compatible light levels, noise levels, temperature levels, smells. All of those things when they are either too little or too great, but especially too great, trigger that stress response. So we need to help people figure out how Can I modify my environment so I feel comfortable, so I'm not overwhelmed or overstimulated? And help them spiritually define their rich and meaningful life and create connectedness with how they're using their energy and so they can see how it's helping them move toward the things, people and experiences that are important to them. Exercise and reconditioning. Now, a lot of people get upset when I say this, but movement is essential. Exercise doesn't mean going to the gym. Exercise may mean getting out of bed and walking over to the chair and sitting down and sitting up straight for a few minutes each day. Start off, start off with what you can do, what can you do? And then build on that a little bit at a time. Five minutes. If you can sit up on your own for five minutes right now and you don't feel completely exhausted, great. Tomorrow try 10 minutes. If that goes well, the next day, try 15. When you reach the place where it starts triggering tiredness, not exhaustion, tiredness, that's where you need to stop for a little while and you need to hold there. So maybe it's 25 minutes. After 25 minutes, you need to lay back down. Okie dokie, that's great. So keep doing that 25 minutes until you realize that, hey, maybe I can do 30, maybe I'll try that. But give yourself time, take it slow, and be compassionate with yourself when you have setbacks. You may be doing 25 minutes at a time for two weeks. And then one day after 15 minutes, you're just like, I gotta lay back down. Okay? Being compassionate with yourself is essential because if the person starts getting angry or pushing themselves and saying, well, I should be able to do 25 minutes. That's what I've been doing. It uses a whole lot more energy between being angry or frustrated and pushing through the body is telling them what they need to do as they move. It can help build muscle. And anybody who has worked with patients that are in hospitals, in hospital beds, in rehab, will tell you that people need to move to prevent bed sores as well as to keep those muscles strong. Muscles get weak. You know, you have your arm in a cast for six weeks, it's going to get weak. It's going to take a minute to build that muscle back. We want to encourage people with CFS working with their physical therapist to identify a plan for reconditioning. And that may mean literally laying in bed and clenching their hands like that. That may be as much energy as they have right now, but it's better than nothing. And eventually, maybe they'll get to the place where they're doing unweighted bicep curls. Okay, great. You know, but start low and slow. Don't overwhelm the person. Don't push them to the point. Or they shouldn't push themselves to the point where they're exhausted. Push themselves to where they think what they know they can do. And then maybe a minute, two minutes, five minutes, more than that. And if it goes well, great. Then maybe consider advancing it later. Being too sedentary negatively impacts circadian rhythms. Remember I said one of the things that impacts our circadian rhythms in addition to light and temperature, is our activity levels. And a lot of times in the evening when we're getting ready for bed, we're winding down, we're becoming more sedentary. So if you're sitting, laying, sleeping all day long, your circadian rhythms have no clue what's going on. So the brain doesn't prepare to release melatonin at the right time. Circadian abnormalities are a common symptom of many diseases and may aggravate several neuropsychiatric disorders. Circadian rhythms negatively impact the balance of thyroid hormones, gonadal hormones, cortisol, and our ability to get good quality sleep. Melatonin, with a doctor's approval, has been suggested for circadian rhythm regulation, depressive symptoms and inflammation, and caffeine reduction at least six hours before bed. Some people with CFS swear by caffeine to help them get through the day. And you know, if it's working for you and it's not causing harm, yes, caffeine's a stressor on the body, but we've got to pick and choose our battles. Antidepressants and specific agonists or drugs that increase 5ht1a receptors counteract serotonin reduction caused by inflammation. Inflammation causes a reduction in serotonin. Reduction in serotonin contributes to fatigue and CFS symptoms. So increasing serotonin can be helpful. Making sure people's hormones are in balance, getting those blood tests done, same thing with their nutrients. As counselors, social workers, we aren't going to be doing that. But if somebody's presenting with physical symptoms like fatigue and sleep difficulties, it is really essential that they get blood work done. Nutritional deficiencies also can occur not only due to poor diet. They don't have the energy to get up and make a healthy meal, so they're just kind of eating out of bags. But it can also be due to poor absorption when the intestines are inflamed or when the Gut microbiome is out of whack. It's not going to allow the body to absorb nutrients as effectively. Microbiome alterations this bacteria in the gut. It can be helpful with people with CFS to help them enhance butyrate producing microbes. And they can do this by adding resistant starches like cooked and cooled potatoes or rice. They eat it cooled, not hot. And legumes, inulin, which is found in chicory root, which you can make chicory root tea. It's also found in garlic. Oh, love my garlic. And leeks. Fructooligosaccharides are also found in asparagus and onions. These can also help increase butyrate producing microbes. Polyphenols that come from berries, green tea, apples, cocoa, and my favorite coffee. Caffeic acid actually has polyphenols in it that enhance the health of the microbiome to increase the number of butyrate producing microbes. Galactoolsaccharides are found in legumes and nuts. Xylen is found in whole grains. Pairing prebiotics like resistant starch or any of these other things that we just talked about with probiotics like yogurt or kefir enhance butyrate levels more effectively than either alone. Other fatigue interventions, Medications commonly associated with fatigue. So medications with a side effect of fatigue include sedative hypnotics, antidepressants, muscle relaxants, antihypertensives like beta blockers, antihistamines, statins, and many antibiotics. So statins, yeah, your cholesterol medication, in addition to your blood pressure medication can be contributing to your fatigue. Again, encouraging. In people who can exercise, getting some daily movement, even if that is done from your bed, even if that is moving your arms or moving your foot back and forth, you know, using your, your calf and your shin muscles, that's still exercise. Start with what you can do. Work on helping the person sustain their interpersonal relationships so they feel connected with other people. These interpersonal relationships will also help increase oxytocin when they're with the person, when they're talking to the person. Oxytocin helps regulate the nervous system, the autonomic nervous system, which is one of the things we're trying to regulate. And oxytocin is a powerful anti inflammatory. So you get, you know, double the work for your money by helping them increase that oxytocin. And it's not on here, but I'm going to add it can also be increased with animal assisted therapy, because we know that petting animals actually and playing with animals Being nice to animals increases our oxytocin and that is something that can be helpful. Unfortunately for people with chronic fatigue syndrome, they may have difficulty maintaining a pet because they don't have the energy to change the litter box. They don't have the energy to take the dog out. Therefore, telling them to own a pet is overly simplistic unless they've got somebody who can help them care for the pet. When they don't have, when they're, when they don't have the energy to do what needs to be done. Encourage people with fatigue, chronic fatigue or otherwise to maintain a routine. They may not be able to go back to full time work, but maintaining a routine helps set those circadian rhythms and getting up about the same time each day or waking up even if you don't have the energy to get up and doing similar things, opening the blinds, keeping it light with whatever you can do in terms of circadian rhythm regulation. We've talked about that sort of ad nauseam. There are no recommendations for the American associ from the American association of Sleep Medicine for routinely effective treatments for sleep phase disorder. Which means you got to go see a sleep specialist. If adjusting if looking at your sleep hygiene and I do have videos on improving your sleep. If improving your sleep hygiene isn't working or isn't doing enough, then getting a sleep study done can be incredibly helpful. Nearly half of adults experience persistent fatigue. Fatigue itself is caused by a variety of biopsychosocial factors. We can't identify just one thing that causes persistent fatigue in people. Chronic fatigue syndrome is present in up to 7% of adults that have persistent fatigue. There is no single known cause for chronic fatigue syndrome. Sorry, we still aren't there yet. However, we recognize that nutritional, immunological so your immune system, autonomic, your nervous system and endocrine factors, your hormones have all been implicated in the development of chronic fatigue syndrome as well as in the exacerbation of symptoms. We want to help people reduce stress in any piece of life. Current treatments we have address the presenting symptoms with the goal of improving sleep quality, regulating circadian rhythms, ensuring adequate nutrition, balancing hormones, reducing inflammation, managing stress and disease adaptation. Are there any questions? Exactly. Southern girl. And if you go back to the slide that we've got on other conditions that may contribute to or may masquerade as cfs, Lyme disease is definitely one of those. Time My husband was joking right before this presentation that I should be multitasking doing that too. But you know I can't teach and watch a video at the same time. So I'm going to have to catch up. Next life maybe. And I hear that a lot from people with chronic fatigue syndrome. They're almost afraid to do anything sometimes because they feel okay right now and they're like, well, if I do this next task, is it going to push me over the edge? And good charting. And I didn't talk a lot about that today, so thank you for bringing that up. Good charting of their sleep, their nutrition, their energy levels, what they did and for how long, and for what intensity can help people start to understand a little bit more about what may be causing their exhaustion. For me, for example, and, and I don't have cfs, but I have struggled with adrenal fatigue and persistent fatigue. And I know that there are certain things that I do that are not physical in nature. They're cognitive, but they wipe me out. If I record, for example, if I record three or four hours worth of classes in a day, I'm pretty much done for the next two days, which is why I try not to do more than an hour or two a day now, because that is my, my thresh. And I can respect the person's anxiety about what's going on and encouraging if, if they were my patient or my friend, I would validate their concerns and encourage them to be compassionate with themselves. Sunny summer. I'm not sure why the CFS is different. And, and I'm not sure on, on holiday, if you mean like over the winter months when it's cooler or when you are on vacation and you're less stressed, so you have less energy going to other stressors and you have more energy that you can devote to being outside. So without knowing a whole lot more, I wouldn't be able to even fathom a guess. Southern Girl in Healing the adrenals means healing the autonomic nervous system. Check out the video I have on healing your nervous system and releasing stress and trauma from your body. Those will provide you a lot of helpful tips that can help you move toward healing your adrenals, strengthening your vagus nerve, strengthening your relaxation response is going to be a big part of that. But there's only so much that your vagus nerve can do if you're constantly stressing your nervous system out. And I do have. Southern Girl, I do have. It's a very old video. Old video, but I do have one on adrenal fatigue. Everybody have an absolutely fabulous rest of your day and I will see you next week, same time, same station.