Table 2 Summary of the therapeutic strategies that were used for this patient

(1) To minimize the potentially harmful effects of oxidative stress

She was advised to eat a vegetable-based diet and to take ascorbic acid daily

(2) To maximize adaptive coping and self-management skills

The patient’s initial coping strategies against fatigue were evaluated. We endeavored to understand and acknowledge her beliefs and feelings that led to the initial strategies; encouraged the acquisition of new coping strategies, e.g., “self-pacing”; encouraged awareness of thresholds resulting in “crashing” and PEM; taught meditative-relaxing movements; taught minimization of cognitive fatigue due to habitual rumination of negative thoughts; and encouraged improvement in self-esteem and self-efficacy (see Fig. 1a for details)

(3) To reverse deconditioning and to improve deconditioning-associated symptoms

She was advised to start exercising gradually, taking precautions (see Fig. 1b for details)

(4) Pharmacotherapy

Amitriptyline (10 mg) and hochuekkito (7.5 g) were prescribed