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Sleep Disorders

Good idea to get a MRI scan?

12/03/2010

Question:

Hi, I`ve had fatigue, muscle stiffness, and trouble going to sleep, staying asleep, and going back to sleep for about more than 3 years. My physician didn`t find anything physically wrong with me, except that he recently discovered I had Epstein-Barr virus and thought I could have CFS. I`ve been seeing a psychiatrist for about half a year and been taking venlafaxine (I`ve started taking the recommended dose since last month). He claims I have depression, but I`m skeptical and with the new finding of the virus, I`m quite doubtful now. By the way, the depression treatment hasn`t really been helpful at all. It doesn`t really help though knowing I have a virus since nothing can really be done, but I`d like to discuss testing for sleep disorders with my psychiatrist. Do you think it`d be a good idea to get a MRI scan?

Answer:

You are reporting fatigue and insomnia. These symptoms are indeed part of the presentation of chronic fatigue syndrome, but also of several other disorders. In particular depression is a mood disorder that often produces these symptoms. Chronic fatigue syndrome (CFS) is still not well understood, certainly in terms of its causes and natural course. The relationship between Epstein-Barr virus and CFS is suspected but not well proven. For example many individuals with Epstein-Barr virus (EBV) positive serology (blood test) do not manifest CFS, and conversely many patients with CFS do not have positive serological tests for Epstein-Barr virus. Recently, investigators have become interested with other potential causes of CFS, including other viruses and immune system dysfunction as causes of CFS. In any case, brain magnetic resonance imaging (MRI) is not likely to reveal anything in the absence of specific neurological symptoms. MRI is not part of the diagnostic work up of either CFS or EBV infection.

As far as the symptoms of fatigue you are reporting, I understand that you feel that adequate work up has been done otherwise. Fatigue and sleepiness can overlap greatly, and in some cases, patients presenting with fatigue but no other medical disorders should be evaluated for a sleep disorder. Intrinsic sleep disorder that can cause sleepiness and fatigue include idiopathic hypersomnia, restless legs syndrome and periodic limb movements of sleep. Obstructive sleep apnea is a frequent cause of sleepiness and fatigue as well. All these disorders, and a few less common ones, should be considered as part of the evaluation of fatigue.

Depression and fibromyalgia are common causes of fatigue without sleepiness. Some of the common medical disorders accounting for fatigue include liver disorders, hypothyroidism, anemia, lyme diseasae, autoimmunue disorders, myopathies, heart failure and malignancies. The diagnosis of CFS is made after excluding likely medical and mood disorders in patients presenting with fatigue and muscle aches following a viral syndrome. Unfortunately, there is no well-established effective treatment for this disorder.

You also report some problems with insomnia. Insomnia is very common in modern society. Fortunately, the majority of cases are short-term and resolve within weeks, rarely requiring prolonged therapy. However, up to 20 million Americans complain of problems with chronic insomnia that may significantly effects their life, so you are not alone.

Insomnia has multiple underlying causes. Identifying the issues that may lead to and contribute to insomnia are extremely important to ensure appropriate treatment. Insomnia can usually be divided into two broad categories: trouble falling asleep at the start of the night (also known as sleep onset insomnia) and difficulty staying asleep during the night (also known as sleep maintenance insomnia). Some individuals may experience problems with both, as you report. Factors affecting one’s ability to fall asleep at the start of the night are quite varied and may include one or more of the following; a poor sleep environment (i.e. the bedroom is too noisy, too bright or too warm), learned poor sleep habits (i.e. watching TV to fall asleep), excessive use of stimulants (both medications and common substances such as caffeine and nicotine), certain medications, stress or anxiety, pain, medical conditions that may make it uncomfortable or difficult to breath well when lying down, heartburn, restless legs syndrome (an irresistible need to move the legs when awake at night) and circadian rhythm disturbances (when the body’s biologic rhythms are out of synchrony or delayed). The problem of maintaining sleep, or staying asleep once you fall asleep, has other underlying causes such as; depression, substance abuse (especially alcohol use, that can result in withdraw in the middle of the night), certain medications, pain, medical conditions that cause frequent urination throughout the night, heartburn, breathing disturbances in sleep, leg jerks in sleep and circadian rhythm disturbances (when the biologic rhythms are advanced earlier in the night). Occasionally some individuals will not have any of these underlying causes contributing to their insomnia and their condition is often labeled as primary insomnia.

As you can see, insomnia is a complex problem that requires a detailed evaluation to help sort out important underlying factors that may need to be addressed. This type of evaluation often starts with your primary care physician, but may require the help of specialist in insomnia. Referral to a Sleep Specialist is necessary in some cases. A Sleep Specialist will take a detailed history and perform a physical examination. Based on this information, they will determine if further testing is needed or if a treatment strategy can be initiated.

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Response by:

Rami N Khayat, MD Rami N Khayat, MD
Clinical Associate Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University