Cognitive Behavioral Therapy and Fasting Therapy for a Patient with Chronic Fatigue Syndrome

Cognitive behavioral therapy temporarily alleviated symptomsof a chronic fatigue syndrome patient but the anxiety about rehabilitation into workbecamestronger and his symptomsworsened. This patient was successfully rehabilitated by fasting therapy. Natural killer cell activity and serum acylcarnitine levels recovered after fasting therapy. Though fasting therapy transiently increased physical and mental subjective symptoms, the patient gained self-confidence by overcoming difficulties after fasting therapy. A combination of cognitive behavioral therapy and fasting therapy is promising as a treatment for chronic fatigue syndrome.


Introduction
Patients with chronic fatigue syndrome (CFS) have a poor outcome: only 3%of patients spontaneously recover at 18 months of follow-up (1).A study showed improvement in 65 (63%) of 103 patients after symptomatic therapy, but complete disappearance of symptomswere observed only in 3, suggesting a poor prognosis in the presence of primary psychiatric disorders and whenpatients were convinced that their symptoms were due to physical diseases (2).Another study showed improvement and resumption of work in 22 (69%) of 32 patients treated by cognitive behavioral therapy (3).In the present study, the symptomswere alleviated temporarily by cognitive behavioral therapy but the patient's anxiety after resuming work led to worsening of symptoms.This patient was successfully rehabilitated after fasting therapy (4).

Case Report
A 25-year-old male came to our hospital with general fatigue and fever (38.7°C) in August 1998.Liver dysfunction (AST 312 IU/Z, ALT378 IU/Z) was noted, and viral antibody titers were as follows: HBs-Ag (-), HCV(-), IgM anti-cytomegalovirus (CMV) (x40), and IgG anti-CMV (x640).The patient was hospitalized for 2 months, with a diagnosis of liver dysfunction due to CMVinfection.Although he returned to work one month later, he complained of general fatigue and low grade fever.Six months later (May 1999), he was re-hospitalized because of severe fatigue, arthralgia, headache, insomnia and depression.There were no abnormal laboratory findings or physical examinations on his second admission.However, he had many of the physical and mental subjective complaints listed in the Cornell Medical Index (5) (Table 1).He had titers for IgM anti-CMV(x20) and IgG anti-CMV (x640).Natural killer (NK) cell activity was ruduced (Table 2).After admission, the IgM anti-CMV titer dicreased to 10-fold or less.The IgG anti-CMV titer was 640-fold (Table 3).Changes in the CMVantibody titers suggested that there was no CMVactivity.In addition, his symptoms and laboratory findings met the criteria for CFS (6), suggesting CFS related to CMVinfection.Three years before the onset, his brother's child had died from CMV infection at five months of age and he was shocked when he was diagnosed with the same disease.For treatment, cognitive behavioral therapy was performed.Medication and relaxation were performed to ameliorate his anxiety, depression, and insomnia.Massageand hyperthermia were used to treat his myalgia and arthralgia.His symptomsimproved after 3 months of therapy (Fig. 1).He tentatively went home from the hospital but his anxiety about rehabilitation to work and fear of CMV infection becamestronger, and his symptoms deteriorated.Hence, fasting therapy (4) was proposed to divert his attention, and to decrease anxiety.A 10-day fasting therapy was initiated after he gave fully informed consent.He drank two liters of water per day, and was told to stay in bed except when taking a bath or using the toilet.Television, radio, read-  1 m E q / / M e n t a l c o m p l a i n t s 3 1 i t e m s C l 1 0 4 m E q / l A s se s sm e n t IV ( N eu ro t ic a r ea )  ing, telephone, letters, and interview were prohibited.Drip infusion of Ringer solution (500 ml) was initiated when his urinary ketone body became positive.After the 10-day fasting therapy, he was given a fluid-based diet for five days, followed by rice gruel and a normal diet in a stepwise manner.The fasting therapy transiently worsened his physical and mental subjective symptoms (Fig. 1).The activity and proportion of NK cells and serum acylcarnitine levels were recovered as well (Table 4).Ten days after therapy, his physical and mental sub-jective symptoms subsided, and his fatigue was also alleviated.

Table 2. Viral and Immunological Data on Second Admission
Stepwise exercise therapy was prescribed and then he was discharged.There has been no recurrence one year after he returned to work.

Discussion
The treatment for CFShas not been established due to the obscurity of its cause and the diversity of its symptoms.We treated a patient with CFSafter CMVinfection by a combination of cognitive behavioral therapy and fasting therapy.The patient was rehabilitated and enabled to continue his work by resolving long-standing fatigue and depressive moods.Straus has reported three patients, among143, in whomthe initial findings were compatible with primary CMVinfection, as discerned by acute seroconversions of IgM and IgG anti-CMVantibodies (7).Salit recorded one case in which CMV precipitated chronic fatigue from among 50 subjects (8).Buchwald et al reported instances of low-positive IgM anti-CMVtiters (9).Levels of IgG anti-CMV above an arbitary threshold were taken by some as evidence of omgoing infection ( 10).Somereports state that the geometric mean IgG anti-CMVlevels in CFS patients are higher than in controls (ll).Thus, acute CMVinfection may precede CFS, and non-specifically elevated levels of antibodies are common.In the present patient, low-positive IgM anti-CMV titer and a high level of IgG anti-CMV titer were found.CMVinfection may have been involved in the onset of CFS.
NKcell activity for immunefunction and the acylcarnitine level for energy metabolism were increased by fasting therapy.CFSpatients often show reduced NKcell activity (12).Stress (13), depression (14), and fatigue (15) depress NK cell activity but it increases with exercise (16).In this patient, NKcell activity increased about three-fold after fasting therapy of ten  days.Although the mechanism of the increase in the NKcell activity due to fasting therapy is unknown, we were able to restore the patient's confidence in his physical strength by informing him of these positive changes.He was also given comprehensive explanations on the natural healing powerof the body.The increase in the NKcell activity and the associated restoration of self-confidence are considered to have reduced the anxiety over rehabilitation.
In patients with CFS, serum acylcarnitine is decreased, and this decrease has been reported to be closely correlated with the degree of fatigue (17).Carnitine has been shown to play important roles in the uptake of long-chain fatty acids, which are used as the primary source of energy by the body, and the regulation of the short-chain fatty acids in mitochondria (18).Acylcarnitine, a conjugate of carnitine and fatty acids, is primarily acetylcarnitine ( 19), but its physiological significance remains unclear.Starvation is knownto cause a markedincrease in the concentration of serum acylcarnitine in mice (20).Our patient's acylcarnitine level also increased after fasting therapy.However, the physiologic significance of acylcarnitine, which increases during fasting therapy, has not been established.With the reduced carbohydrate levels during fasting, long-chain fatty acids are oxidized as an alternate source of energy and ketone body is produced.Acylcarnitine may also be used as an alternative source of energy by peripheral tissues since the arterio-venous gradient of its serum concentration widens during a fast ( 19).Wespeculate that the increase in the acylcarnitine level may have alleviated some of the fatigue symptomsin our patient.
Lowcortisol (21) and hypoactivity of the hypothalamuspituitary-adrenal (HPA) axis ( 22) have been reported in CFS patients.For treatment, low-dose hydrocortisone therapy was effective in reducing fatigue (23), but long-term administration of hydrocortisone is considered inappropriate because of side effects.Fasting therapy has been reported to enhance serum cortisol and to activate the HPAaxis (24).These results suggest that the benefical effects of the fasting therapy may include alleviation of fatigue due to elevation of serum cortisol, NKcell activity and serum acylcarnitine.The mechanism of the effect of fasting therapy is generally interpreted as follows (25).Physiologically, metabolic stress such as ketosis and hypoglycemia markedly disturb the autonomic nervous system, endocrine systems, immunological systems, and emotional center.These systems are involved in body homeostasis.Psychologically, social isolation as well as hunger and anxiety cause intense stress.This sharpens the attention of the patients to their inner self, causing marked agitation.Physicians, nurses, and clinical psychotherapists visit the patients, listen to their complaints, and encourage them to overcomethese difficulties.The sense of accomplishment that the patients feel after completion of fasting therapy mayincrease their satisfaction and confidence in themselves.In this case report, the physical and psychological symptoms of the patient worsened during the 10-day fast, but, after completing the fasting therapy, he gained selfconfidence by overcoming this crisis.
The combination of cognitive behavioral therapy and fasting therapy is promising as a treatment of CFS from both physiological and psychological aspects.

P
er i p he r al b lo o d c o un t U rin a ly s is W O H C S 1 8 .9 m g / d a y C re a tin in e l. O m g /d l P sy c h o lo g ic al te st (C M I te st) N a 1 4 2 m E q / / P h y sic a l c o m p la in ts 7 0 ite m s K 4.
Vi ral a nti bo dy ti ter s I m m u n o l o g i c a l d a t a C y to m e g a lo v iru s-Ig Mx g / d l E ps t ei n -B a rr vi r us I p e s S i m p l e x I g G x 1 6 0 C D 5 6 6 .9% H B s -A g ( -) Na tur al k ill er c ell ac tivi ty H C V a n t i b o d y ( -) Eff ec tor /t ar get ce ll (E /T ) A n t i H T L V -1 a n t i b o d y (

Table 1 .
Laboratory Data on Second Admission

Table 4 .
Changes in Laboratory Data