Chronic Fatigue

"I feel tired all the time," is a common complaint among those who present for Ayurvedic treatment. Tiredness, fatigue or lethargy may have a wide range of causes, one of which is Chronic Fatigue Immune Dysfunction Syndrome, (CFIDS) also known in some countries as Myalgic Encephalomyelitis or (ME). In this article we will examine the Ayurvedic diagnosis and management of CFIDS/ME, looking at how we can recognize this illness among myriad other situations that can also lead to complaints of fatigue and lethargy.

CFS/ME is believed to affect 2-5 million Americans of all ages, races, socioeconomic groups and genders.(1) Although the condition can affect any age group, it most commonly starts between the early 20s and mid 40s, and, like many auto-immune conditions, is twice as common in women. CFIDS also affects children, often between the ages of 13-15, although it has been found in very young children. CFS presents as an overwhelming feeling of fatigue that follows any form of physical exertion, together with issues involving memory and concentration and a constellation of multi-system dysfunctions involving the neurological, endocrine and immune systems. (2) Related symptoms include unrefreshing sleep, pain and twitching in muscles, pain in joints without redness or swelling, migraine-type headaches, recurrent flu-like symptoms, tender armpit and/or neck lymph nodes, recurrent sore throat, postural hypotension, palpitations, sensitivity to noise and lights, and alcohol intolerance. It is a disabling condition that can destroy the affected individual's work, home and social life and financial status. (1) In one case in our experience, a woman suffering from CFIDS had been forced to place her teenage son in Boys Town as she was unable to care for him.

CFIDS is known in Ayurveda as bala kshaya and typically involves both qualitative and quantitative changes in ojas. As its name, "Immune Dysfunction" suggests, CFIDS is a disorder of ojo kshaya or depleted ojas. This situation is typically preceded by ojo-vyapat or qualitative changes in ojas. Vata entering into ojas can lead to vatagenic ojo-kshay and vata type of chronic fatigue syndrome. (3) Vata CFIDS is accompanied by sleep disorder, disturbed diurnal rhythm, such that the individual is wired by night and sleepy all day, anxiety, panic disorder, short term memory loss, emaciation, dry skin, uneven energy, and visham agni symptoms. Irritable bowel syndrome or fibromyalgia may complicate the situation. Pitta entering into ojas can cause tejas to burn ojas, resulting in ojo kshay with an array of auto-immune symptoms. Pitta type chronic fatigue shows typical symptoms of tender lymph nodes, recurrent fevers and sore throats, extreme muscle tenderness, alcohol intolerance, migraine headaches, tender, swollen liver and accompanying conditions such as pitta depression, MS and lupus. When kapha forms part of the CFIDS situation, there is often systemic candidiasis, a kapha ama condition.

So how do we evaluate the patient who complains, "I feel tired all the time"? Many of these individuals do not have chronic fatigue at all. Some may have a krumi or ama condition such as giardiais, ameobiasis or candidiaisis and some may have another serious underlying pathology such as anaemia, celiac disease, liver disease, Lyme disease, low thyroid function, depression or an auto-immune condition such as lupus, Shogren's syndrome or multiple sclerosis. Anaemia is signalled by an insidious onset of fatigue and lethargy accompanied by pale lips, tongue and nails. Examine the inner eyelids, nails and tongue carefully to see if you may suspect anaemia. A full blood count will easily confirm the diagnosis. On the other hand, CFIDS typically is of sudden onset, often traced to an episode of mononucleosis.

In terms of celiac syndrome, many kapha individuals have poor tolerance for gluten and cow dairy since the gunas of these foods (shita, guru, manda, sthira, slakshna and picchila) are the same as the gunas of kapha. It will become clear that they do not have CFIDS when they report an amazing transformation within days of eliminating gluten and casein and implementing a kapha soothing diet and herbal regimen. CFIDS patients of any prakruti will also typically feel rather better when they follow a gluten and casein free diet, (or will notice they are significantly worse on gluten and casein) but the improvement will not be as dramatic.

Krumi conditions, particularly candidiasis, may exist as co-morbidity with CFIDS, or may simply be mimicking the CFIDS symptoms. Time, patience and upashaya (therapeutic trial) of anti-krumi herbs such as Para Cleanse may be needed to unravel the situation. If the problem is resulting from krumi and ama alone, it should typically be resolved within three months of herbal, dietary and lifestyle chikitsa for krumi and ama. If on the other hand it is co-morbidity, Para Cleanse or other anti-krumi herbs will be necessary and helpful but will not fully resolve the issue.

If there is a history of blood transfusion before 1986, IV drug use, cocaine or methamphetamine snorting with shared straws or working in a hospital with potential exposure to infected blood, a Hepatitis C test should be done. Lyme disease can be suspected if there is exposure to areas where this condition is endemic. West Nile can similarly lead to a CFS-type syndrome. To determine whether fatigue accompanied by headaches, muscle aches and depression are in fact due to a hypothyroid condition, you may ask the patient to record basal temperatures, which should be in a range above 97.8 degrees. Again, time and patience are needed as CFIDS, fibromyalgia and hypothyroidism frequently exist as co-morbidities. If the condition is simply due to hypothyroidism, it will quickly resolve with either thyroid medication or a good herbal regimen to improve thyroid function. Depression may be a cause of feeling "tired all the time" but will not produce the muscle symptoms and poor exercise tolerance typical of CFIDS. On the other hand, depression is a typical co-morbidity which serves only to increase the fatigue experienced by the CFIDS patient. Brahmi tea may thus form a valuable part of the CFIDS regimen and will also be helpful for the memory and cognitive symptoms.

Patient A. A thirty year old woman of vata prakruti complained of chronic fatigue for the past five years, forcing her to take four years to complete a two year master's degree. She had a textbook history of sudden onset of fatigue, beginning with a severe episode of mononucleosis that put her in bed for nine months. She never recovered her energy, sleeping nine hours a night and four hours during the day. Accompanying symptoms included sore throats, muscle aches, palpitations and generalized throbbing, difficulty taking a full breath and irritable bladder syndrome. Based on pulse reading it appeared that pitta had invaded ojas leading to ojo kshay and symptoms of pitta chronic fatigue. Her prana was also depleted. She was initially treated with shodhan herbs that were anti-viral and anti-pitta, such as turmeric and neem, as well as with Guduchi, a key herb for pitta chronic fatigue and dosha pratyanika for pitta. She then did ten days of pancha karma, using vata massage oil for abhyanga and shirodhara oil for shirodhara. Svedan was done with steam medicated with Dashamoola, virechan was done using Amlaki and for basti she alternated Sesame oil and Dashamoola-Guduchi decoction. After this treatment pulse reading indicated that ojas was improving and pitta had resolved. However she complained of the same levels of fatigue, aside from some "flashes of clarity". Based on vata prakruti, she was given Ashwagandha, Vidari and Guggulu in her rejuvenative formula. She also took Chyavanprash to strengthen prana. With the help of Chyavanprash she found breathing easier. Her generalized throbbing slowly began to diminish and her naps became slightly shorter. Although progress was slow, she continued to comply with her Ayurvedic treatment and recently did her spring pancha karma, with the hope of continued progress.

Patient B. A fifty six year old woman of Vata prakruti complained of lifelong depression, eating disorders, Hashimoto's thyroiditis, Shogren's syndrome, previous cancer treatment, history of closed head injuries and chronic fatigue with poor exercise tolerance, muscle and joint pains and memory and cognitive impairment. She provides a perfect example of multiple co-morbidities of hypothyroidism, depression, auto-immune connective tissue disease, osteoporosis and Chronic Fatigue. She was severely vata provoked and pulse reading indicated vata type chronic fatigue with invasion of vata into ojas leading to ojo kshay. Her prana was also depleted. She noticed a dramatic effect from taking Kaishore Guggulu, which immediately eliminated the joint and muscle pains typical of both CFIDS and Shogren's syndrome. Her rheumatologist noted that "Shogren's is synonymous with joint pain," and encouraged her to continue "whatever you are doing." The patient also stopped binge eating once she settled into a vata soothing diet. Ashwagandha was a key herb in acting as dosha pratyanika for vata, reducing fatigue and improving neurological and muscle function. It was extremely difficult to steer her in the direction of consistency and compliance because vata type chronic fatigue leads to overwhelm, difficulty assimilating new information, poor short term memory and inconsistency. Hence, these patients are more difficult to work with than those with pitta type chronic fatigue. Simply keeping appointments was challenging and on occasion she showed up on the wrong day or skipped her appointment. Nevertheless, after some months of hesitancy and overwhelm, she managed to do a ten day pancha karma using vata massage oil for abhyanga, with Mahanarayana oil on painful areas of her body. After pancha karma she noted that her energy and mood had significantly improved. For rasayana she took a formula that included Ashwagandha, Vidari, Licorice and Dashamoola. She also took Brahmi ghee as a rasayana for majja dhatu. Her condition continued to improve slowly and she recently did another five-day pancha karma.

Patient C. A twenty-eight year old vata-kapha woman presented with candida overgrowth, low-body temperature, mood swings and chronic fatigue. She was able to work only twelve hours a week and found even that exhausting. She was chronically constipated, had almost no appetite and developed nausea and bloating whenever she ate. Over the past two years, her weight had dropped from an optimum of 135 lb to only 116 lb. She slept nine hours a night and craved sweets and chocolate. She had a past history of jaw surgery at age seventeen and of five car accidents, which had occurred between three and five years ago. Onset of typical symptoms of Chronic Fatigue began shortly after her last car accident. Pulse diagnosis indicated that pitta was vitiating ojas, while her history of chronic systemic candidiasis showed a build up of kapha toxins. Initially she was given a cleansing formula which included Vidanga, Musta and Turmeric, all excellent anti-yeast herbs. She then did seven consecutive days of abhyanga with vata massage oil, svedana herbalized with dashamoola and shirodhara with brahmi oil. She did three consecutive days of virechan using a tablespoon of castor oil in orange juice. Three bastis were performed, the first and third with four ounces of sesame oil and the second being a decoction basti using dashamoola and Guduchi. Rejuvenative herbs given after pancha karma included Ashwagandha and Vidari to rejuvenate vata and build strength and Punarnava to rejuvenate Kapha. Her recovery was dramatic and she now leads a normal life, no longer disabled by her condition.

As these case histories illustrate, Ayurvedic therapy for CFIDS begins with a cleansing diet-- removing all toxic foods, suspected allergens and lifestyle deviations--as well as detoxifying herbs such as Para Cleanse (when yeast overgrowth or krumi is suspected) or Blood Cleanse (when persistent vial infection seems to play a part). Since candidiasis and bowel dysbiosis are typical of Chronic Fatigue Syndrome, it is important that patients are carefully prepared for pancha karma for one to six months, with special reference to treating candida overgrowth, parasites and chronic bladder infections and calming provoked doshas. Once symptoms of parasites and yeasts are greatly reduced, pancha karma is indicated. A typical initial PK for CFIDS may last for up to ten days of consecutive treatments, followed by weekly abhyanga, svedan and basti for a month. This is followed by the rejuvenative phase for building ojas and dhatus. Continued pancha karma series and rasayana therapy every six months in spring and fall maintains the improvement and prevents relapse. Yoga therapy can be extremely helpful but in the beginning, when the patient is extremely weak, it should be limited to Restorative Yoga. CFIDS should be regarded as a yapya condition, persisting throughout the lifetime, yet capable of being managed to a level of near normality (as patient C illustrates) provided Ayurvedic preventative measures are followed continuously.

1. Barrows DM. Functional capacity evaluations of persons with chronic fatigue immune dysfunction syndrome Am J Occup Ther. 1995 Apr;49(4):327-37.Dietert RR,

2. Dietert JM. Possible role for early life immune insult including developmental immunotoxicity in chronic fatigue syndrome (CFS) or myalgic encephalomyelitis (ME) Toxicology. 2008 May 2;247(1):61-72.

3. Vasant Lad, Textbook of Ayurveda, Fundamental Principles, p 218-219. The Ayurvedic Press 2002

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Case Study

Preface
My first experience of the dramatic potential of Pancha Karma in Chronic Fatigue (Bala kshaya) came in 1997, when a patient who was suffering from fatigue and vitiated ojas decided to try a traditional ayurvedic preconception protocol. After seven days of purvakarma and pancha karma she returned glowing and radiant. "As I was showering off after my final sweat," she announced, "My energy returned through the crown of my head." Weeks later she was happily pregnant and is now the mother of an exceptionally gifted six-year-old. In the years that followed, we have seen many patients recover from Chronic Fatigue with the help of judiciously administered Pancha Karma. The following is a fairly typical case history.

Case Presentation
A twenty-eight year old woman presented with candida overgrowth, low-body temperature, mood swings and fatigue. She was able to work only twelve hours a week and found even that exhausting. She was chronically constipated, had almost no appetite and developed nausea and bloating whenever she ate. Over the past two years, her weight had dropped from an optimum of 135 lb to only 116 lb. She regretted the loss of her full figure. She also suffered from hives, acne and allergies. She slept nine hours a night and craved sweets and chocolate. Her menstrual cycle was regular.

She had a past history of jaw surgery at age seventeen and of five car accidents, which had occurred between three and five years ago. Onset of typical symptoms of Chronic Fatigue began shortly after her last car accident.

Her emotional history was significant, as she had experienced minimal nurturance as a child. Her mother was extremely neurotic and fitted a diagnosis of primary narcissism. Whatever our patient did was never good enough for her mother, who constantly expected more in terms of both filial devotion and worldly success. The emotional abuse from the mother was ongoing, with guilt being the context of every telephone call. In her depleted state, she was unable to process the emotions of suppressed anger, rage and hatred toward her mother, and remained in a generally flattened affective state. Although both the accidents and the systemic Candidiasis appear to be closely related to the onset of Chronic Fatigue, suppressed emotions and longstanding abuse appear to have been the most significant factors.

A year prior, she had seen an osteopathic physician who diagnosed Chronic Fatigue and yeast overgrowth. The treatments recommended by this practitioner were extremely helpful, but she was unable to continue, as she had to spend two hundred and fifty dollars a month on herbs and supplements.

On examination, she had a vata-kapha dual prakruti. Pulse diagnosis: Prakruti V3 P1 K3. Vikruti: V4 P2 K2.5 Udana and apana vayu, pachak pitta and avalambak kapha showed impaired function. Ojas was weak with pitta vitiation, tejas was excessively high. The liver, stomach and bladder pulses were very week with pitta. Rasa and majja dhatus were impaired. Her tongue was thickly coated and had tooth marks indicating malabsorption. Her nails had deep vertical ridges.

Preparation for Panchakarma
She was prepared for panchakarma with one month of herbal therapies aimed at treating her candida overgrowth, helping her bladder--as we suspected latent bladder infection--and getting some initial degree of doshic balance. Her initial formula consisted of kaishore guggulu 2; Four Fragrances 0.5 each: Guduchi 5: Mustha 2: Vidanga 1: Dashamoola 2: Purnarnava 3: Haridra 3: Shankhabhasma 1. This was to be taken half teaspoon three times daily with two tablespoons Aloe Vera and a pinch of black pepper. She also took triphala tea at bedtime and a teaspoon of tikta grtam twice daily to help reduce tejas.

Her lifestyle was pretty healthy, with a wholesome vegetarian diet and no addictions or unhealthy habits. She was encouraged to continue her yoga practice and to begin to learn to be gentle with herself.

Initial Pancha Karma
In light of her severe combination of physical and financial depletion, she was awarded seven days of low cost purvakarma and panchakarma through a sliding scale program. She did three days of internal oleation with tikta grtam, and seven consecutive days of abhyanga with an in house vata oil formula, svedana herbalized with dashamoola and chandan and shirodhara with brahmi oil. Vaman was omitted due to her kapha depletion. She did three consecutive days of virechan using a tablespoon of castor oil in orange juice. Three bastis were performed, the first and third with four ounces of sesame oil and the second being a decoction basti using dashamoola and guduchi. Because of her complaint of burning eyes with peeling eyelids, she was given netra basti with shatavari ghee.

Response
At her initial appointment after her panchakarma, she was not very happy. Old emotions from childhood had been bubbling to the surface during and since her cleanse. She felt as fatigued as ever and was quite discouraged. Her ojas was still vitiated and tejas was still high, though the pitta in her vikruti pulse had reduced. She was given a rejuvenative formula: Ashwagandha 5: Bala 5: Vidari 5: Guduchi 5: Purnarnava 5: Yasti Madhu 2 as well as Ashwagandhadi lehyam

At this time she also began post-panchakarma treatments: a month of weekly snehan, svedan and basti. Within three weeks her energy began to dramatically improve and she was feeling better than she could ever remember feeling. Her vata was lower and her kapha had returned to a normal level. Two months after panchakarma, her ojas was no longer vitiated, her energy was good and her emotions had calmed. "It feels wonderful to just be 'tired' at times in place of the consistent deep fatigue," she remarked. "Before, I was in prison. Now I am moving forward."

Continuing Progress
In the six-month period following her panchakarma, she entered a phase of rapid physical and psychological changes and growth. Old emotions unable to move during her years of chronic fatigue bubbled to the surface and her symptoms became transitory, with rapid alternations of vata and pitta manifestations. She regained an interest in life and began seeking work and pursuing her purpose.

All the anger and rage that she had been unable to feel when fatigued now made itself apparent. She was advised to use journal techniques to help process her feelings, devoting time each day to freewriting, unsent letters to her mother and other methods to help organize and synthesize her feelings. She was also taught to relate to her emotions in an Ayurvedic manner, neither suppressing nor indulging, criticizing nor condemning but simply bringing the light of awareness to bear upon them.

Six months after her initial panchakarma, she elected to do a three day home cleanse, using a step-by-step manual. Her protocol at this time was essentially the same as in the previous panchakarma, except that, having determined that orange juice was too acidic for her, She took her castor oil in ginger tea. She also received a marma point massage in-house. During this panchakarma more deep-seated emotions, including intense hatred, were released. Her appetite and hunger returned at a level she had not experienced in years.

Discussion
This case history is fairly typical of our experience with using panchakarma for Chronic Fatigue Syndrome. A sense of initial disgruntlement immediately after panchakarma may often occur. It has been our experience that full benefits of panchakarma are rarely obtained immediately after the initial protocol, but seem to depend upon the follow up treatments to clear residual toxins from the system. In addition, for those suffering from Chronic Fatigue, there may be a level of depletion experienced after panchakarma, which is remedied by the rejuvenation plan. Usually, great improvement is noted within a month of panchakarma. In women of childbearing age, the end of the first menstrual period following panchakarma often marks a significant change. Some women with Chronic Fatigue Syndrome express that this menstrual period was more copious or had an unusual smell, suggesting that additional toxins are being released. At the far end, one patient took six months to recover his energy after panchakarma, but then recovered fully and permanently from Chronic Fatigue Syndrome.

Panchakarma is not a panacea for fatigue. As Dr. Lad points out [Ayurveda today, XII # 4] extremely weak patients are better suited to shamanam than to shodhan. Since candidiasis and bowel dysbiosis are typical of Chronic Fatigue Syndrome, it is important that patients are carefully prepared for panchakarma for between one and six months, with special reference to treating candida overgrowth, parasites and chronic bladder infections. As we did in this patient's case, it is valuable to reduce pitta by herbal means before pancha karma, so that there is the possibility of better svedan treatments, which could otherwise be severely limited due to the provoked pitta.

Not all cases of fatigue should be managed as Chronic Fatigue Syndrome. A variety of conditions including HIV, Hepatitis C and clinical depression can mimic Chronic Fatigue Syndrome. Although panchakarma may be beneficial in these situations too, the same dramatic benefit may not be found due to the persistent underlying condition. Furthermore, it is not enough simply to treat chronic fatigue without addressing the underlying beliefs and behavior patterns. Chronic Fatigue tends to occur in people who are adrenaline addicts or are extremely driven and hard on themselves. In the case we have been describing, we worked consistently over a six-month period to encourage our patient to conserve her newfound energy for deeper healing, to resolve underlying anger and self-hatred and to cultivate a kinder and more relaxed way of dealing with herself. Without such deep changes, the condition will simply be recreated in the course of time. Emotional work, such as the awareness practices and journalling we used, are extremely valuable for those suffering from Chronic Fatigue Syndrome, for in our experience, in the majority of cases there has been significant childhood trauma, with a residue of suppressed anger and hatred. Auxiliary therapies such as flower essences can be helpful in creating a new energetic pattern focussed on self-love, while, for those patients who are willing, meditation is an invaluable tool.

Conclusion
Chronic Fatigue Syndrome may often be a metaphor for an inability, rooted in childhood abuse, to tap the abundant cosmic energies. Our patient felt herself a prisoner of the "sick, tired and poor" syndrome. She needed, initially, an infusion of energy, in this case, in the form of sliding scale panchakarma. Later, she began to learn to tap into the source of energy, becoming more vibrant, positive and self-sufficient. This was illustrated by her choice of a home cleanse for her second panchakarma. She is learning step by step, to give herself the nurturance her mother was unable to give her.

Peer-reviewed article first published in Light on Ayurveda Journal.

Alakananda Ma M.B., B.S. (Lond.) is an Ayurvedic Doctor (NAMA) and graduate of a top London medical school. She is co-founder of Alandi Ayurveda Clinic and Alandi Ayurveda Gurukula in Boulder Colorado, as well as a spiritual mother, teacher, flower essence maker and storyteller. Alakananda is a well known and highly respected practitioner in the Ayurveda community both nationally and internationally.

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