In these cases, Stein does not consider the mood symptoms to be “comorbid” because they arise “as a direct result of the large number of losses and adjustments caused by the illness.”

Stein recommended psychosocial interventions as the first line approach for these patients. “They are struggling with existential issues and grief. Fear is common because of the uncertainty associated with the course of the illness. Stigma leads to a sense of isolation.”

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Practical symptom management, supportive counseling, psychoeducation, and psychotherapy are most helpful, she said. Symptom management addresses issues such as poor sleep, post-exertional malaise, and coping with chronic pain. Stein has developed a modular manual for leading these groups.

“Groups are helpful not only because of the practical tools and suggestions but because patients are in the same room with other people who ‘get’ what they are going through, which is incredibly therapeutic,” she commented. Stein’s manual and other resources can be found in Table 3.

Table 3.
Modular-based approaches Eleanor Stein, MD
Let Your Light Shine

Daniel Clauw, MD

Organizations Solve CFS Initiative

The National CFIDS Foundation

CFIDS and Fibromyalgia Self-Help

National Fibromyalgia and Chronic Pain Association

National Fibromyalgia Association

American Chronic Pain Association

My Invisible Fight

Recommended reading for patients, families and caregivers Joanna J Charnas. Living Well with Chronic Illness.
Hollister, CA: MSI Press, 2015

Toni Bernhard. How to Be Sick. Somerville, MA:
Wisdom Publications, 2010

Patricia A Fennell. The Chronic Illness Workbook.
Albany, NY: Albany Health Management Publishing,

The choice of psychotherapy should be specific to each patient, Stein advised. For example, cognitive interventions may be helpful for patients who catastrophize or have errors in thinking. Supportive therapies may be useful for patients who simply need someone to talk to or help them go through the grieving process.

Comorbid mood disorders: Stein regards patients with a previous history of depression or anxiety, or patients with a new presentation of very severe symptoms sufficient to warrant a separate diagnosis of depression or anxiety as having a “comorbid” mood disorder. “I treat these patients as I would treat any other psychiatric patient by prescribing the same drugs or other interventions.”

Patients whose depression and anxiety components of the illness: “This is the smallest percentage of the patients I see,” Stein recounted.

In these patients, “the mood symptoms developed at the same time as the  symptoms of their illness and continue to vary in parallel with symptoms of the illness,” she said. This contrasts with “those who have secondary mood symptoms, where there is usually a ‘lag time’ between the illness symptom and the mood symptom.”

Tips for Psychiatrists

Use correct terminology: “Chronic fatigue,” for example, connotes a vague condition characterized by “simply being tired,” Stein noted. Myalgic encephalomyelitis, the name chosen by the Institute of Medicine, recognizes that this is a ‘real” illness and “is not, as many clinicians believe,” a psychological problem.8

Make appropriate referrals: When a patient presents with unexplained symptoms, refer the patient to primary care physicians or specialists who can rule out medical illnesses before diagnosing a somatic disorder, advised Charnas, who practices social work at Naval Medical Center in San Diego.