Chronic fatigue syndrome (also called
ME, Myalgic Encephalomyelitis,CFIDS, Chronic
Fatigue Immune Difficiency Syndrome) does not
appear to be new. In the 19th century there were
various reports of neurasthenia, or nervous
exhaustion. In the 1930s through the 1950s
outbreaks of disease marked by prolonged fatigue
were reported in the United States and many other
countries. Beginning in the early to mid-1980s
interest in chronic fatigue syndrome was revived
by reports in America and other countries of
various outbreaks of long-term debilitating
fatigue. Over six million patient visits are made
each year because of fatigue, although only a very
small percentage of these can be attributed to
chronic fatigue syndrome.
ME, Myalgic Encephalomyelitis,CFIDS, Chronic
Fatigue Immune Difficiency Syndrome) does not
appear to be new. In the 19th century there were
various reports of neurasthenia, or nervous
exhaustion. In the 1930s through the 1950s
outbreaks of disease marked by prolonged fatigue
were reported in the United States and many other
countries. Beginning in the early to mid-1980s
interest in chronic fatigue syndrome was revived
by reports in America and other countries of
various outbreaks of long-term debilitating
fatigue. Over six million patient visits are made
each year because of fatigue, although only a very
small percentage of these can be attributed to
chronic fatigue syndrome.
If no identifiable medical or psychological
problems account for fatigue that has lasted for
more than six months and impairs normal
activities, experts define the condition as
unexplained chronic fatigue. A group of experts
have developed criteria for further differentiating
this unexplained fatigue as either post viral
syndrom, chronic fatigue syndrome (CFS) or
idiopathic chronic fatigue. (Idiopathic simply
means that the cause is not known.) Chronic
fatigue syndrome is diagnosed in people meeting
the following criteria: If these criteria are not met,
then the condition is considered to be idiopathic
chronic fatigue.
problems account for fatigue that has lasted for
more than six months and impairs normal
activities, experts define the condition as
unexplained chronic fatigue. A group of experts
have developed criteria for further differentiating
this unexplained fatigue as either post viral
syndrom, chronic fatigue syndrome (CFS) or
idiopathic chronic fatigue. (Idiopathic simply
means that the cause is not known.) Chronic
fatigue syndrome is diagnosed in people meeting
the following criteria: If these criteria are not met,
then the condition is considered to be idiopathic
chronic fatigue.
Four or more of the following symptoms must
have been present for longer than six months: (1)
short-term memory loss or a severe inability to
concentrate that affects work, school, or other
normal activities; (2) sore throat; (3) swollen
lymph nodes in the neck or armpits; (4) muscle
pain; (5) pain without redness or swelling in a
number of joints; (6) intense or changing patterns
of headaches; (7) unrefreshing sleep; (8) after any
exertion, weariness that lasts for more than a day.
have been present for longer than six months: (1)
short-term memory loss or a severe inability to
concentrate that affects work, school, or other
normal activities; (2) sore throat; (3) swollen
lymph nodes in the neck or armpits; (4) muscle
pain; (5) pain without redness or swelling in a
number of joints; (6) intense or changing patterns
of headaches; (7) unrefreshing sleep; (8) after any
exertion, weariness that lasts for more than a day.
The fatigue must be severe: Sleep or rest does not
relieve it; the fatigue is not the result of excessive
work or exercise; and the fatigue substantially
impairs a person's ability to function normally at
home, at work, and in social occasions. Even mild
exercise often makes the symptoms, especially
fatigue, much worse.
relieve it; the fatigue is not the result of excessive
work or exercise; and the fatigue substantially
impairs a person's ability to function normally at
home, at work, and in social occasions. Even mild
exercise often makes the symptoms, especially
fatigue, much worse.
The fatigue must be a new--not lifelong--condition
with a definite time of onset. For instance, many
patients with chronic fatigue report having had a
flu-like illness that triggered the symptoms. (In
one study, 20% reported chronic fatigue following
a flu.) Often, the condition first appears as a viral
upper respiratory tract infection marked by some
combination of fever, headache, muscle aches,
sore throat, earache, congestion, runny nose,
cough, diarrhea, and fatigue. Typically, the initial
illness is no more severe than any cold or flu.
with a definite time of onset. For instance, many
patients with chronic fatigue report having had a
flu-like illness that triggered the symptoms. (In
one study, 20% reported chronic fatigue following
a flu.) Often, the condition first appears as a viral
upper respiratory tract infection marked by some
combination of fever, headache, muscle aches,
sore throat, earache, congestion, runny nose,
cough, diarrhea, and fatigue. Typically, the initial
illness is no more severe than any cold or flu.
The symptoms must persist. In ordinary
infections, symptoms go away after a few days,
but in CFS, fatigue and other symptoms recur or
continue for months to years. Many patients
experience symptoms as recurring bouts of
flu-like illness, with each attack lasting from hours
to weeks.
infections, symptoms go away after a few days,
but in CFS, fatigue and other symptoms recur or
continue for months to years. Many patients
experience symptoms as recurring bouts of
flu-like illness, with each attack lasting from hours
to weeks.
WHO GETS CHRONIC FATIGUE SYNDROME?
In studies of large patient groups, between 15%
and 27% of people complain of long-term fatigue,
but the majority of these cases are explained by
other medical or psychological problems.
According to a survey conducted by the Centers
for Disease Control and Prevention, chronic
fatigue syndrome is a serious public health
concern affecting about three in every 1000
Americans. This disorder occurs in both sexes
and all racial and ethnic groups, but is most
common in Caucasian women. In fact, among
white women, it is more prevalent than lung
cancer, breast cancer, and high blood pressure.
Some studies indicate that women with
gynecologic problems such as irregular menstrual
cycles may face an even higher risk than others.
There appears to be no difference in severity in
symptoms between men and women who already
have CFS. Chronic fatigue is most often
experienced by patients 20 to 50 years old. One
study of two boroughs reported that .07% of
children had symptoms of chronic fatigue, with
most occurring in one borough. Most studies
indicate that girls are more apt to develop CFS
than boys, although one found the incidence of
the syndrome to be equal. Chronic fatigue
syndrome is also more often reported in people
who are well educated. Such people, however, are
more likely to seek medical help, be aware of
chronic fatigue syndrome as a specific disorder,
and have health insurance. One study has
indicated that the problem is more widespread
and that the disease is under-diagnosed in lower-
income and some ethnic groups. One study of
nurses found that those who were exposed to
poor working conditions and threats of accidents
faced a higher risk for CFS symptoms, indicating
that people in very stressful jobs may be at risk.
and 27% of people complain of long-term fatigue,
but the majority of these cases are explained by
other medical or psychological problems.
According to a survey conducted by the Centers
for Disease Control and Prevention, chronic
fatigue syndrome is a serious public health
concern affecting about three in every 1000
Americans. This disorder occurs in both sexes
and all racial and ethnic groups, but is most
common in Caucasian women. In fact, among
white women, it is more prevalent than lung
cancer, breast cancer, and high blood pressure.
Some studies indicate that women with
gynecologic problems such as irregular menstrual
cycles may face an even higher risk than others.
There appears to be no difference in severity in
symptoms between men and women who already
have CFS. Chronic fatigue is most often
experienced by patients 20 to 50 years old. One
study of two boroughs reported that .07% of
children had symptoms of chronic fatigue, with
most occurring in one borough. Most studies
indicate that girls are more apt to develop CFS
than boys, although one found the incidence of
the syndrome to be equal. Chronic fatigue
syndrome is also more often reported in people
who are well educated. Such people, however, are
more likely to seek medical help, be aware of
chronic fatigue syndrome as a specific disorder,
and have health insurance. One study has
indicated that the problem is more widespread
and that the disease is under-diagnosed in lower-
income and some ethnic groups. One study of
nurses found that those who were exposed to
poor working conditions and threats of accidents
faced a higher risk for CFS symptoms, indicating
that people in very stressful jobs may be at risk.
WHAT CAUSES CHRONIC FATIGUE SYNDROME?
Theories abound about the causes of chronic
fatigue syndrome. Many physicians still doubt
that CFS is an actual disease but believe rather
that it is a component of a psychological disorder
or a symptom of other problems, similar to anemia
and high blood pressure. Indeed, no primary
cause has been found that explains all cases of
CFS, and a number of experts believe that it
develops from a combination of factors including
brain abnormalities, a hyper-reactive immune
system, and a viral or other infectious agent. Still,
although all of these elements appear to be at
work in many cases of CFS, it is not yet clear what
sequence of events actually leads to the fatigue
and other prominent symptoms of this disorder.
Other conditions that have been posited as
causes for certain CFS cases include
hypotension, hyperventilation, and defective
muscle tissue.
fatigue syndrome. Many physicians still doubt
that CFS is an actual disease but believe rather
that it is a component of a psychological disorder
or a symptom of other problems, similar to anemia
and high blood pressure. Indeed, no primary
cause has been found that explains all cases of
CFS, and a number of experts believe that it
develops from a combination of factors including
brain abnormalities, a hyper-reactive immune
system, and a viral or other infectious agent. Still,
although all of these elements appear to be at
work in many cases of CFS, it is not yet clear what
sequence of events actually leads to the fatigue
and other prominent symptoms of this disorder.
Other conditions that have been posited as
causes for certain CFS cases include
hypotension, hyperventilation, and defective
muscle tissue.
Central Nervous System and Hormone
Abnormalities
Abnormalities in the central nervous system,
including pinpoint spots of brain inflammation
and abnormal levels of certain hormones have
been reported in a number of patients with CFS,
but similar findings have also been found in those
without the illness. Of particular interest to
researchers are possible abnormalities in the
brain system known as the hypothalamus-
pituitary-adrenal axis, which controls important
functions, including sleep, response to stress,
and depression. A number of studies on CFS
patients have observed deficiencies in cortisol
levels, a stress hormone produced in the
hypothalamus. Cortisol is a powerful suppressor
.
of the immune system. One central hypothesis for
CFS suggests that after a person with cortisol
deficiency is exposed to a viral infection or some
other physical or emotional stress, the immune
system over responds and causes symptoms
typical of chronic fatigue syndrome.
(Unfortunately, drug trials that replace cortisol
have only reported modest improvement in
symptoms. One small but well-conducted study,
in fact, reported elevated levels of cortisol in the
saliva of CFS patients.) Other researchers have
observed that men with CFS had high levels of
serotonin, a neurotransmitter (chemical
messenger in the brain); such elevated levels in
the brain are associated with fatigue. If these
hormonal imbalances prove to be typical of CFS
patients, the low levels of cortisol and high levels
of serotonin may help distinguish CFS from major
depression, in which an opposite relationship of
these hormone levels occurs. Yet another study
reported that deficiencies in dopamine--another
important neurotransmitter--may underlie CFS.
Abnormalities
Abnormalities in the central nervous system,
including pinpoint spots of brain inflammation
and abnormal levels of certain hormones have
been reported in a number of patients with CFS,
but similar findings have also been found in those
without the illness. Of particular interest to
researchers are possible abnormalities in the
brain system known as the hypothalamus-
pituitary-adrenal axis, which controls important
functions, including sleep, response to stress,
and depression. A number of studies on CFS
patients have observed deficiencies in cortisol
levels, a stress hormone produced in the
hypothalamus. Cortisol is a powerful suppressor
.
of the immune system. One central hypothesis for
CFS suggests that after a person with cortisol
deficiency is exposed to a viral infection or some
other physical or emotional stress, the immune
system over responds and causes symptoms
typical of chronic fatigue syndrome.
(Unfortunately, drug trials that replace cortisol
have only reported modest improvement in
symptoms. One small but well-conducted study,
in fact, reported elevated levels of cortisol in the
saliva of CFS patients.) Other researchers have
observed that men with CFS had high levels of
serotonin, a neurotransmitter (chemical
messenger in the brain); such elevated levels in
the brain are associated with fatigue. If these
hormonal imbalances prove to be typical of CFS
patients, the low levels of cortisol and high levels
of serotonin may help distinguish CFS from major
depression, in which an opposite relationship of
these hormone levels occurs. Yet another study
reported that deficiencies in dopamine--another
important neurotransmitter--may underlie CFS.
INFECTIONS
In many instances, chronic fatigue syndrome
starts suddenly with a flu-like condition. Because
most of the features of CFS resemble those of a
lingering viral illness, many researchers have
focused on the possibility that a virus or some
other infectious agent causes the syndrome. In
the U.S. outbreaks of CFS occurring within the
same household, workplace, and community have
been reported but most have not been confirmed
by the Centers for Disease Control. A large British
study of people with both diagnosed CFS and
idiopathic chronic fatigue also found no evidence
of infection as a direct cause of either condition
but previous infections may play some role. Most
cases of CFS occur sporadically, cropping up
individually without appearing to be contagious,
and there is no consistent evidence that CFS is
spread through casual contact, such as shaking
hands or coughing, or by intimate sexual contact.
Well-designed studies of patients who met strict
criteria for chronic fatigue syndrome and of
patients with idiopathic chronic fatigue have also
not found an increased incidence of any
infections, including Lyme disease, candida
("yeast infection"), herpesvirus type 6 (HHV-6),
human T cell lymphotropic (HTLVs), Epstein-Barr,
measles, coxsackie B, cytomegalovirus, or
parvovirus. Some researchers are suggesting that
changes in normally harmless bacteria found in
the intestine may play a role in the development of
CFS symptoms. Another theory referred to as "hit
and run" suggests that chronic fatigue syndrome
might be the result of a virus or bacteria that
infects the body, causes immune abnormalities,
and is then eliminated. It leaves behind a
damaged immune system, however, that
continues to cause flu-like symptoms even in the
absence of the virus. Other theories posit that
immune system or neurologic abnormalities cause
a reactivation of a viral or bacterial infection that
had presumably resolved.
IMMUNE SYSTEM ABNORMALITIES
CFS has been referred to as the "chronic fatigue
immune dysfunction syndrome", because some
studies have found many irregularities of the
immune system, in which some components
appear to be overreactive, whereas others appear
to be underreactive. Researchers have detected a
number of immune abnormalities in CFS patients,
but no consistent or major abnormality that could
indicate a primary cause.
immune dysfunction syndrome", because some
studies have found many irregularities of the
immune system, in which some components
appear to be overreactive, whereas others appear
to be underreactive. Researchers have detected a
number of immune abnormalities in CFS patients,
but no consistent or major abnormality that could
indicate a primary cause.
Allergies and Contributing Factors. Allergies are
the only consistent immune system abnormality
among CFS patients. Researchers continue to
report that between 55% and 80% of CFS patients
have allergies to food, pollen, or other
substances, which in turn appear to make the CFS
symptoms worse. Most allergic people, however,
do not have CFS. Some research indicates that in
some cases people with both allergies and
emotional disorders, such as anxiety or
depression, are more vulnerable to the effects of
the inflammatory response, which is triggered by
allergens. This response produces a number of
immune factors, importantly cytokines--powerful
factors that can cause fatigue, joint aches, and
fever and which can also affect the hypothalamus-
pituitary-adrenal system in the brain. Another
recent study found a similar relationship between
depression, allergies and low back pain.
the only consistent immune system abnormality
among CFS patients. Researchers continue to
report that between 55% and 80% of CFS patients
have allergies to food, pollen, or other
substances, which in turn appear to make the CFS
symptoms worse. Most allergic people, however,
do not have CFS. Some research indicates that in
some cases people with both allergies and
emotional disorders, such as anxiety or
depression, are more vulnerable to the effects of
the inflammatory response, which is triggered by
allergens. This response produces a number of
immune factors, importantly cytokines--powerful
factors that can cause fatigue, joint aches, and
fever and which can also affect the hypothalamus-
pituitary-adrenal system in the brain. Another
recent study found a similar relationship between
depression, allergies and low back pain.
A theory that may help tie in the various
conditions associated with CFS suggests that a
combination of factors, including allergies, stress,
and infections, may impair metabolic function by
depleting adenosine triphosphate (ATP). This
enzyme stores energy in cells, and low levels are
common in CFS patients. One study showing
symptom improvement using a coenzyme called
NADH that increased ATP levels lends support to this theory.
conditions associated with CFS suggests that a
combination of factors, including allergies, stress,
and infections, may impair metabolic function by
depleting adenosine triphosphate (ATP). This
enzyme stores energy in cells, and low levels are
common in CFS patients. One study showing
symptom improvement using a coenzyme called
NADH that increased ATP levels lends support to this theory.
Other Immune Abnormalities. The risk profile for
chronic fatigue syndrome, i.e., being female,
Caucasian, and well-educated, is also the risk
profile for autoimmune diseases, such as
systemic lupus erythematosus, rheumatoid
arthritis, Sjgren's syndrome, and multiple
sclerosis, which also have early symptoms
resembling CFS. Common to such diseases are
the presence of high levels of autoantibodies--
antibodies that attack the patient's own cells.
Some studies are finding high levels of
autoantibodies directed against substances in cell
nuclei in CFS patients. Others have found low
levels of certain antibodies. Some patients,
particularly those with severe CFS symptoms,
have increased numbers of infection-fighting
white blood cells known as CD8 killer T cells,
which launch attacks on invading viruses and
other disease-causing microorganisms. However,
these same people have lower-than-normal
numbers of another type of white blood cell,
known as the suppressor T cell, which helps to
shut down the immune response once the
invading organisms have been killed. The immune
system then becomes persistently overactive and
produces fatigue, muscle aches, and other
symptoms of CFS. Other studies have indicated
lower amounts of so-called natural killer cells in
many CFS patients, which might make them more
susceptible to viruses.
chronic fatigue syndrome, i.e., being female,
Caucasian, and well-educated, is also the risk
profile for autoimmune diseases, such as
systemic lupus erythematosus, rheumatoid
arthritis, Sjgren's syndrome, and multiple
sclerosis, which also have early symptoms
resembling CFS. Common to such diseases are
the presence of high levels of autoantibodies--
antibodies that attack the patient's own cells.
Some studies are finding high levels of
autoantibodies directed against substances in cell
nuclei in CFS patients. Others have found low
levels of certain antibodies. Some patients,
particularly those with severe CFS symptoms,
have increased numbers of infection-fighting
white blood cells known as CD8 killer T cells,
which launch attacks on invading viruses and
other disease-causing microorganisms. However,
these same people have lower-than-normal
numbers of another type of white blood cell,
known as the suppressor T cell, which helps to
shut down the immune response once the
invading organisms have been killed. The immune
system then becomes persistently overactive and
produces fatigue, muscle aches, and other
symptoms of CFS. Other studies have indicated
lower amounts of so-called natural killer cells in
many CFS patients, which might make them more
susceptible to viruses.
HYPOTENSION
Studies are now finding that some people who fit
the strict criteria for chronic fatigue syndrome
may also have a condition known as neurally
mediated hypotension (NMH). One recent study,
for example, reported that 25 out of 26
adolescents with CFS experienced NMH. In
another small study of patients who met the
criteria for CFS, 96% showed signs of NMH
compared to only 29% of the comparison group. .
NMH causes a dramatic drop in blood pressure
when standing up, even for as short a time as ten
minutes. It is the result of an abnormality in the
central nervous system that signals the heart to
slow down and lower blood pressure when a
person stands up; blood pools in the feet and legs
before circulating back up to the heart, sometimes
causing light-headedness, nausea, and fainting.
NMH can explain many of the symptoms of
chronic fatigue, although the blood pressure
condition is most likely lifelong and chronic
fatigue usually occurs in midlife. Some experts
believe that in CFS patients, a virus or infection
may cause injury to the central nervous system
that results in the hypotension abnormality. This
could help explain why so many patients report a
viral infection before developing chronic fatigue
syndrome. A less severe condition known as
postural orthostatic tachycardia syndrome (POTS)
is also associated with CFS. Major studies need to
be done and the results repeated with larger
patient groups before they can be applied to the
majority of CFS patients.
OTHER THEORIES
Patients with CFS sometimes complain that they
feel so weak that it seems as if their muscles are
no longer working properly. It has been proposed
that a defect in skeletal muscle could be the cause
of the fatigue. However, physical, chemical, and
metabolic studies have not found any consistent
pattern of abnormalities in the muscles of these
patients. Another theory to account for some
cases of chronic fatigue syndrome is
hyperventilation--the tendency to "over-breathe",
which can be caused by many conditions,
including asthma, hyperthyroidism, infections,
and anxiety disorder. Chronic hyperventilation
may cause an imbalance in oxygen and carbon
dioxide, which can produce chest pain, faintness,
numbness in the fingers and toes, and motor
impairment. In one study, although a significant
number of CFS patients experienced
hyperventilation, there were no differences in CFS
symptoms between patients with hyperventilation
and patients who did not experience it.
Hyperventilation is very unlikely to be a cause of
many instances of chronic fatigue. One study
found that after CFS patients exercise, they exhibit
slight abnormalities in the activity of the vagus
nerves on the heart; the vagus nerves run down
each side of the neck and end at the intestines
and affect many bodily functions.
CAUSES OF CHRONIC FATIGUE LIKE SYMPTOMS AFTER THE GULF WAR
Gulf War veterans have been intensively studied
because of a high percentage reporting CFS
symptoms. One major study reported that 45% of
Gulf War veterans met the overall criteria for
chronic fatigue syndrome, with 6% having severe
cases. Women veterans had three times the risk as
men. Interestingly 15% of the noncombat
personnel--representing the general population--
reported the same problems although the cases in
general were less severe than in the veterans.
Because such symptoms have occurred in other
veteran groups, some experts suspect that
post-traumatic stress syndrome may be
responsible for the symptoms in some cases.
After finding that stress weakens the blood-brain
barrier, some experts believe that, in extremely
stressful situations such as the Gulf War, this
weakened barrier may allow agents, such as small
viruses, to pass into the brain causing damage
and triggering CFS symptoms . Whether
uncovering the causes of the syndrome in Gulf
War soldiers can be applied to civilian cases of
CFS, however, is not known. More than a dozen
different illnesses have been detected in over
70,000 soldiers examined for this problem. Some
researchers identified an unusual bacteria-like
organism known as Mycoplasma fermentans in
nearly half the veterans who suffered from Gulf
War syndrome, and one scientist speculated that
it might have been developed for biological
warfare. Some researchers suspect that the
symptoms were caused by an experimental
vaccine that contained a substance called
squalene. High levels of antibodies to this
compound have been found in the blood of
veterans with CFS symptoms. An investigation is
underway. Still other studies have found that up
to 20,000 troops may have been exposed to low
levels of the nerve gas sarin. Other possible
causes among these veterans include multiple
immunizations, oil well fires, and sleep apnea.
One study reported that the incidence of
hospitalization and death was no higher in these
veterans than in soldiers who had not been
stationed in the Persian Gulf, but this only proves
that the symptoms are not fatal or severe enough
to send a patient to the hospital. The study does
not disprove the condition itself.
HOW IS CHRONIC FATIGUE SYNDROME DIAGNOSED?
A physician should first take a careful personal
and family medical history, which may include a
psychological profile, as well as perform a
thorough physical examination. Patients should
be prepared to answer certain questions. When
did the fatigue first begin? Does anything make it
worse or better? Is it better at certain times of the
day? Does physical activity make it worse? Are
there any other symptoms? Has anyone else in the
family ever complained of fatigue? Is your
personal and professional life stressful? The
physician may also ask about any changes in
weight or request a patient to monitor morning
and afternoon body temperatures. The patient
should report any drugs being taken, including
vitamins and over-the-counter or herbal
medications.
and family medical history, which may include a
psychological profile, as well as perform a
thorough physical examination. Patients should
be prepared to answer certain questions. When
did the fatigue first begin? Does anything make it
worse or better? Is it better at certain times of the
day? Does physical activity make it worse? Are
there any other symptoms? Has anyone else in the
family ever complained of fatigue? Is your
personal and professional life stressful? The
physician may also ask about any changes in
weight or request a patient to monitor morning
and afternoon body temperatures. The patient
should report any drugs being taken, including
vitamins and over-the-counter or herbal
medications.
In most cases of chronic fatigue syndrome,
laboratory tests tend to be normal or if they are
abnormal (such as high cholesterol levels, which
tend to be common in patients with CFS), they are
not useful for diagnosing chronic fatigue
syndrome specifically. Inexpensive tests,
including thyroid and liver function tests, blood
count, and sedimentation rate, are recommended
to rule out other conditions but none can
diagnose CFS. Psychological profile testing may
be suggested. Since many insurance policies do
not cover this testing, the patient may want to
determine the cost beforehand (usually less than
$200).
laboratory tests tend to be normal or if they are
abnormal (such as high cholesterol levels, which
tend to be common in patients with CFS), they are
not useful for diagnosing chronic fatigue
syndrome specifically. Inexpensive tests,
including thyroid and liver function tests, blood
count, and sedimentation rate, are recommended
to rule out other conditions but none can
diagnose CFS. Psychological profile testing may
be suggested. Since many insurance policies do
not cover this testing, the patient may want to
determine the cost beforehand (usually less than
$200).
Simply measuring blood pressure will not identify
CFS patients whose condition might be caused by
neurally mediated hypotension (an abnormal drop
in blood pressure). A tilt test, whereby an
individual lies on a table tilted upright at a
70-degree angle for a prolonged period, may
confirm CFS caused by neurally mediated
hypotension if the patient feels lightheaded, sick,
and faint after several minutes.
CFS patients whose condition might be caused by
neurally mediated hypotension (an abnormal drop
in blood pressure). A tilt test, whereby an
individual lies on a table tilted upright at a
70-degree angle for a prolonged period, may
confirm CFS caused by neurally mediated
hypotension if the patient feels lightheaded, sick,
and faint after several minutes.
In academic centers where CFS is studied, a
series of tests may be performed to measure
immune function. Such testing is controversial,
because it is expensive and difficult to interpret.
Of interest are certain proteins called CFSUM1 that
are found in higher levels in the urine of CFS
patients with severe symptoms. Some experts are
hoping that this or other markers may reveal a
biologic basis for CFS and also establish a
method for diagnosing it.
series of tests may be performed to measure
immune function. Such testing is controversial,
because it is expensive and difficult to interpret.
Of interest are certain proteins called CFSUM1 that
are found in higher levels in the urine of CFS
patients with severe symptoms. Some experts are
hoping that this or other markers may reveal a
biologic basis for CFS and also establish a
method for diagnosing it.
Conditions That Rule Out Chronic Fatigue
Syndrome
Depression, infections, pregnancy, extreme
exercise, sleep disorders, and excessive
stress--these and many other common conditions
can lead to feelings of exhaustion. In many
instances, fatigue can be relieved with adequate
rest. It is important to note that because fatigue
can be the harbinger of a serious medical or
psychological problem, anyone who experiences
unexplained fatigue longer than one month
should see a physician.
Syndrome
Depression, infections, pregnancy, extreme
exercise, sleep disorders, and excessive
stress--these and many other common conditions
can lead to feelings of exhaustion. In many
instances, fatigue can be relieved with adequate
rest. It is important to note that because fatigue
can be the harbinger of a serious medical or
psychological problem, anyone who experiences
unexplained fatigue longer than one month
should see a physician.
EPSTEIN-BARR VIRUS.
Epstein-Barr virus (EBV) causes infectious
mononucleosis, which is marked by fatigue and
swollen glands; it primarily affects adolescents
and young adults. In the early to mid-1980s, what
is now called chronic fatigue syndrome was often
thought to be chronic Epstein-Barr virus infection,
because some patients who suffered from a bout
of apparent mononucleosis had lingering fatigue
that persisted for many months and a persistent
low-level EBV infection, indicated by virus
particles circulating in the blood. However,
researchers subsequently noted that many healthy
persons without CFS had the same signs of
low-level EBV infection and that other individuals
with CFS showed no signs of EBV infection.
Because of these and other findings, researchers
generally do not believe there is any direct link
between Epstein-Barr virus infection and CFS.
mononucleosis, which is marked by fatigue and
swollen glands; it primarily affects adolescents
and young adults. In the early to mid-1980s, what
is now called chronic fatigue syndrome was often
thought to be chronic Epstein-Barr virus infection,
because some patients who suffered from a bout
of apparent mononucleosis had lingering fatigue
that persisted for many months and a persistent
low-level EBV infection, indicated by virus
particles circulating in the blood. However,
researchers subsequently noted that many healthy
persons without CFS had the same signs of
low-level EBV infection and that other individuals
with CFS showed no signs of EBV infection.
Because of these and other findings, researchers
generally do not believe there is any direct link
between Epstein-Barr virus infection and CFS.
Long-Term Autoimmune Diseases. Some diseases
are caused by autoimmunity, a condition in which
the person's immune system attacks the body's
own tissues. Such diseases include systemic
lupus erythematosus, multiple sclerosis, Sjgren's
syndrome, and rheumatoid arthritis. The early
symptoms of these conditions may mimic some of
those that appear in CFS, such as muscle and
joint pain and fatigue. They also occur more often
in women than in men. These diseases evolve
slowly, and even if a diagnosis of chronic fatigue
syndrome is considered, physicians should keep
track of any changes in symptoms over time in
order to rule out these serious illnesses.
are caused by autoimmunity, a condition in which
the person's immune system attacks the body's
own tissues. Such diseases include systemic
lupus erythematosus, multiple sclerosis, Sjgren's
syndrome, and rheumatoid arthritis. The early
symptoms of these conditions may mimic some of
those that appear in CFS, such as muscle and
joint pain and fatigue. They also occur more often
in women than in men. These diseases evolve
slowly, and even if a diagnosis of chronic fatigue
syndrome is considered, physicians should keep
track of any changes in symptoms over time in
order to rule out these serious illnesses.
Post-Lyme Syndrome . A delayed response or
recurrence of previously treated Lyme disease
(called post-Lyme syndrome) may be mistaken for
chronic fatigue syndrome. Although the two
disorders are similar, one study found that CFS
patients reported more flu-like syndromes and
those with post-Lyme disease performed
significantly worse on tests of mental functioning
and motor control.
recurrence of previously treated Lyme disease
(called post-Lyme syndrome) may be mistaken for
chronic fatigue syndrome. Although the two
disorders are similar, one study found that CFS
patients reported more flu-like syndromes and
those with post-Lyme disease performed
significantly worse on tests of mental functioning
and motor control.
OTHER MEDICAL CONDITIONS.
Many diseases, both benign and serious, can fully
explain prolonged or chronic fatigue, including
hepatitis, anemia, infections, various forms of
cancer, neuromuscular diseases (such as
myasthenia gravis), hypothyroidism, and diabetes.
In addition, a number of illnesses also cause
arthritic symptoms and fever [ see Table, below].
Patients and physicians should also not overlook
other diseases that have been previously treated,
but which may not have completely resolved or
may cause residual fatigue, including cancer or
hepatitis. Physicians can usually distinguish
these diseases from CFS after a clinical evaluation
and laboratory testing.
explain prolonged or chronic fatigue, including
hepatitis, anemia, infections, various forms of
cancer, neuromuscular diseases (such as
myasthenia gravis), hypothyroidism, and diabetes.
In addition, a number of illnesses also cause
arthritic symptoms and fever [ see Table, below].
Patients and physicians should also not overlook
other diseases that have been previously treated,
but which may not have completely resolved or
may cause residual fatigue, including cancer or
hepatitis. Physicians can usually distinguish
these diseases from CFS after a clinical evaluation
and laboratory testing.
Psychosis and Severe Mental Disorders. The
Centers for Disease Control, which set up the
definitions in the U.S. for research in chronic
fatigue syndrome, recognize depression as one of
the symptoms of CFS, but rule out chronic fatigue
syndrome as a diagnosis for anyone with a history
of major depression or other severe psychiatric
disorders, including bipolar disorder and
schizophrenia. Depression or anxiety not
associated with a psychosis or severe mental
illness does not rule out CFS.
Centers for Disease Control, which set up the
definitions in the U.S. for research in chronic
fatigue syndrome, recognize depression as one of
the symptoms of CFS, but rule out chronic fatigue
syndrome as a diagnosis for anyone with a history
of major depression or other severe psychiatric
disorders, including bipolar disorder and
schizophrenia. Depression or anxiety not
associated with a psychosis or severe mental
illness does not rule out CFS.
SLEEP DISTURBANCES.
A common sleep disorder that can cause daytime
fatigue without the patient being aware of the
problem is sleep apnea, a breathing disorder often
marked by loud snoring and thrashing in bed. A
person may not realize the problem exists unless
it is brought to his or her attention by a sleeping
partner or observer. Other sleep disorders that
cause daytime fatigue include insomnia and
restless legs syndrome. Narcolepsy is a peculiar
and rare disorder in which a person suddenly falls
asleep without any previous signs of fatigue. [For
more information on sleep disorders , see
Well-Connected Report # 27 Insomnia and
Restless Legs Syndrome and Report #65 Sleep
Apnea and Narcolepsy .]
fatigue without the patient being aware of the
problem is sleep apnea, a breathing disorder often
marked by loud snoring and thrashing in bed. A
person may not realize the problem exists unless
it is brought to his or her attention by a sleeping
partner or observer. Other sleep disorders that
cause daytime fatigue include insomnia and
restless legs syndrome. Narcolepsy is a peculiar
and rare disorder in which a person suddenly falls
asleep without any previous signs of fatigue. [For
more information on sleep disorders , see
Well-Connected Report # 27 Insomnia and
Restless Legs Syndrome and Report #65 Sleep
Apnea and Narcolepsy .]
Drugs and Alcohol. Fatigue is a side effect of
many prescription and over-the-counter
medications, such as antihistamines. In addition,
dependency on or abuse of alcohol or illicit drugs
may manifest as chronic fatigue. Medications
should be considered as a possible cause of
fatigue if an individual has recently started,
stopped, or changed medications. Withdrawal
from caffeine can produce depression, fatigue,
and headache.
many prescription and over-the-counter
medications, such as antihistamines. In addition,
dependency on or abuse of alcohol or illicit drugs
may manifest as chronic fatigue. Medications
should be considered as a possible cause of
fatigue if an individual has recently started,
stopped, or changed medications. Withdrawal
from caffeine can produce depression, fatigue,
and headache.
SEVERE OBESITY .
People who are severely obese often have
symptoms of chronic fatigue because of the stress
imposed by the weight. People who are obese are
also at particular risk for sleep apnea, which can
confuse the diagnosis.
symptoms of chronic fatigue because of the stress
imposed by the weight. People who are obese are
also at particular risk for sleep apnea, which can
confuse the diagnosis.
DISEASES WHICH CAUSE FEVER WITH JOINT
AND MUSCLE PAIN
AND MUSCLE PAIN
INFECTIOUS ARTHRITIS.
Lyme disease, septic arthritis, bacterial
endocarditis, mycobacterial and fungal arthritis,
viral arthritis.
endocarditis, mycobacterial and fungal arthritis,
viral arthritis.
Postinfectious or Reactive Arthritis. Enteric
infection, Reiter's syndrome, rheumatic fever,
inflammatory bowel disease.
infection, Reiter's syndrome, rheumatic fever,
inflammatory bowel disease.
Rheumatoid Arthritis and Still's Disease (Juvenile
Rheumatoid Arthritis)
Rheumatoid Arthritis)
Systemic Rheumatic Illness. Systemic vasculitis,
systemic lupus erythematosus
systemic lupus erythematosus
Crystal Induced Arthritis. Gout and pseudogout
Other Diseases. Familial Mediterranean fever,
cancers, sarcoidosis, AIDS, leukemia, Whipple's
disease, dermatomyositis, Behcet's disease,
Henoch-Schonlein purpura, Kawasaki's disease,
erythema nodosum, erythema multiforme,
pyoderma gangrenosum, pustular psoriasis,
Sjgren's syndrome.
cancers, sarcoidosis, AIDS, leukemia, Whipple's
disease, dermatomyositis, Behcet's disease,
Henoch-Schonlein purpura, Kawasaki's disease,
erythema nodosum, erythema multiforme,
pyoderma gangrenosum, pustular psoriasis,
Sjgren's syndrome.
Data from New England Journal of Medicine,
March 17, 1994. Polyarthritis and fever, Robert S.
Pinals, M.D.
March 17, 1994. Polyarthritis and fever, Robert S.
Pinals, M.D.
Conditions That Accompany and Not Rule Out
Chronic Fatigue Syndrome
Chronic Fatigue Syndrome
Many conditions that can account for extreme
fatigue can be identified or diagnosed but may not
necessarily rule out the additional presence of
chronic fatigue syndrome.
fatigue can be identified or diagnosed but may not
necessarily rule out the additional presence of
chronic fatigue syndrome.
FIBROMYALGIA.
Fibromyalgia causes prolonged fatigue and
widespread muscle aches. A characteristic feature
is the existence of at least 10 distinct sites of deep
muscle tenderness that hurt when touched firmly;
the sites include the side of the neck, the top of
the shoulder blade, the outside of the upper
buttock and hip joint, and the inside of the knee.
Some patients with CFS exhibit similar tender
pressure points. Recurrent sore throat, headache,
low fever, and depression are also common
symptoms of fibromyalgia. Like CFS, fibromyalgia
is chronic and not curable; some, but not all,
experts believe it is simply another variant of
chronic fatigue syndrome, and one compared
fibromyalgia to chronic fatigue as the same
relationship as a migraine to a headache. [For
more information, see Well-Connected Report #
76, Fibromyalgia.]
widespread muscle aches. A characteristic feature
is the existence of at least 10 distinct sites of deep
muscle tenderness that hurt when touched firmly;
the sites include the side of the neck, the top of
the shoulder blade, the outside of the upper
buttock and hip joint, and the inside of the knee.
Some patients with CFS exhibit similar tender
pressure points. Recurrent sore throat, headache,
low fever, and depression are also common
symptoms of fibromyalgia. Like CFS, fibromyalgia
is chronic and not curable; some, but not all,
experts believe it is simply another variant of
chronic fatigue syndrome, and one compared
fibromyalgia to chronic fatigue as the same
relationship as a migraine to a headache. [For
more information, see Well-Connected Report #
76, Fibromyalgia.]
EXPOSURE TO CHEMICALS AND TOXINS.
Exposure to various chemicals and environmental
toxins--such as solvents, pesticides, or heavy
metals (cadmium, mercury, or lead, for example)
can cause fatigue and other symptoms of CFS,
including psychological changes. Identifying
such exposure, however, does not rule out the
possibility of chronic fatigue syndrome.
toxins--such as solvents, pesticides, or heavy
metals (cadmium, mercury, or lead, for example)
can cause fatigue and other symptoms of CFS,
including psychological changes. Identifying
such exposure, however, does not rule out the
possibility of chronic fatigue syndrome.
DEPRESSION OR ANXIETY DISORDERS.
A number of physicians believe that chronic
fatigue is not a physical illness but can be
attributed to emotional disorders. The link
between psychological disorders and chronic
fatigue syndrome is problematic because so many
of the symptoms overlap with each other and also
can occur as symptoms in other disorders.
Fatigue, listlessness, poor concentration, memory
deficits, agitation, and sleep disorders can all be
manifestations of depression and anxiety.
Stressful events--such as surgery, a significant
illness or injury, the birth of a child, divorce, the
death of a loved one, or other serious emotional
trauma--further complicate the picture, because
even everyday stress can contribute to fatigue and
may play a role in lowering the body's resistance
to infection. Certain screening tests, particularly
one called Short-Form General Health Survey
(SF-36), are fairly accurate in differentiating people
who have major depression from those with
chronic fatigue. Depression is very common,
affecting up to a fifth of all Americans at some
point in their lives, and most depressed people
feel fatigued. Unlike ordinary periods of sadness,
an episode of depression can last many months.
Symptoms of depression include (1) a depressed
mood everyday, (2) significant weight gain or loss
(of 10% or more of an individual's typical body
weight), (3) insomnia or excessive sleeping, (4)
restlessness or a sense of being slowed down, (5)
low energy daily, (6) worthless or inappropriately
guilty feelings, (7) an inability to concentrate or to
make decisions, and (8) suicidal thoughts. The
presence of several of these symptoms suggests
depression, rather than chronic fatigue,
particularly if physical symptoms, such as sore
throat, aches and pains, or fever, are not also
present. The longer fatigue has continued without
these other symptoms, the more likely the
diagnosis is depression and not chronic fatigue
syndrome. Depression is not necessarily present
in CFS, however. Although many patients who are
diagnosed with CFS report feeling depressed
before the onset of chronic fatigue, many feel alert
and well before experiencing chronic fatigue.
Depression in people with CFS is usually a
reaction to the disease. They are discouraged, but
not hopeless and wish to enjoy life, not avoid it.
Many of these previously healthy patients get
depressed and anxious because they feel so
exhausted all the time after coming down with the
syndrome.
fatigue is not a physical illness but can be
attributed to emotional disorders. The link
between psychological disorders and chronic
fatigue syndrome is problematic because so many
of the symptoms overlap with each other and also
can occur as symptoms in other disorders.
Fatigue, listlessness, poor concentration, memory
deficits, agitation, and sleep disorders can all be
manifestations of depression and anxiety.
Stressful events--such as surgery, a significant
illness or injury, the birth of a child, divorce, the
death of a loved one, or other serious emotional
trauma--further complicate the picture, because
even everyday stress can contribute to fatigue and
may play a role in lowering the body's resistance
to infection. Certain screening tests, particularly
one called Short-Form General Health Survey
(SF-36), are fairly accurate in differentiating people
who have major depression from those with
chronic fatigue. Depression is very common,
affecting up to a fifth of all Americans at some
point in their lives, and most depressed people
feel fatigued. Unlike ordinary periods of sadness,
an episode of depression can last many months.
Symptoms of depression include (1) a depressed
mood everyday, (2) significant weight gain or loss
(of 10% or more of an individual's typical body
weight), (3) insomnia or excessive sleeping, (4)
restlessness or a sense of being slowed down, (5)
low energy daily, (6) worthless or inappropriately
guilty feelings, (7) an inability to concentrate or to
make decisions, and (8) suicidal thoughts. The
presence of several of these symptoms suggests
depression, rather than chronic fatigue,
particularly if physical symptoms, such as sore
throat, aches and pains, or fever, are not also
present. The longer fatigue has continued without
these other symptoms, the more likely the
diagnosis is depression and not chronic fatigue
syndrome. Depression is not necessarily present
in CFS, however. Although many patients who are
diagnosed with CFS report feeling depressed
before the onset of chronic fatigue, many feel alert
and well before experiencing chronic fatigue.
Depression in people with CFS is usually a
reaction to the disease. They are discouraged, but
not hopeless and wish to enjoy life, not avoid it.
Many of these previously healthy patients get
depressed and anxious because they feel so
exhausted all the time after coming down with the
syndrome.
FATIGUE FOLLOWING ADEQUETLY TREATED DISORDERS.
If a physician can verify that a disease has been
treated adequately and yet symptoms of chronic
fatigue persist, then CFS or idiopathic chronic
fatigue cannot be ruled out. If hypothyroidism, for
example, is treated by replacement thyroid
hormone, and if fatigue and other relevant
symptoms continue after normal levels of thyroid
have been reached, then an additional diagnosis
of CFS is still possible.
treated adequately and yet symptoms of chronic
fatigue persist, then CFS or idiopathic chronic
fatigue cannot be ruled out. If hypothyroidism, for
example, is treated by replacement thyroid
hormone, and if fatigue and other relevant
symptoms continue after normal levels of thyroid
have been reached, then an additional diagnosis
of CFS is still possible.
WEAK RESULTS FROM LABORITORY TESTS.
Some tests for diseases that cause the same
symptoms as CFS or idiopathic chronic fatigue
may be ambiguous or weak. In such cases,
unexplained chronic fatigue should not be ruled
out.
symptoms as CFS or idiopathic chronic fatigue
may be ambiguous or weak. In such cases,
unexplained chronic fatigue should not be ruled
out.
HOW SERIOUS IS CHRONIC FATIGUE
SYNDROME?
SYNDROME?
Severity of Symptoms
The severity of chronic fatigue syndrome varies.
In extreme cases, patients are bedridden and can
do virtually nothing, including even light
housework. More often, CFS sufferers can work at
least part-time. Most commonly, patients with CFS
report that they have trouble fulfilling both home
and work responsibilities. Studies may under-
report the severity of the condition because
severely disabled patients may have difficulty
getting to and from the clinical study site and
would not be able to participate. The problem is
compounded by some medical centers that do not
accommodate the disabled CFS patients with the
same consideration or resources (e.g.,
wheelchairs, beds) that would be given patients
with more recognized disorders, such as multiple
sclerosis.
The severity of chronic fatigue syndrome varies.
In extreme cases, patients are bedridden and can
do virtually nothing, including even light
housework. More often, CFS sufferers can work at
least part-time. Most commonly, patients with CFS
report that they have trouble fulfilling both home
and work responsibilities. Studies may under-
report the severity of the condition because
severely disabled patients may have difficulty
getting to and from the clinical study site and
would not be able to participate. The problem is
compounded by some medical centers that do not
accommodate the disabled CFS patients with the
same consideration or resources (e.g.,
wheelchairs, beds) that would be given patients
with more recognized disorders, such as multiple
sclerosis.
Most patients say that while fatigue is the most
incapacitating symptom, those of mental
impairment, such as an inability to concentrate,
are the most distressing. Some studies indicate,
that, although general intelligence is not impaired,
CFS patients test lower in certain mental
functions, particularly speed and efficiency in
processing complex information. In such studies,
this impaired mental function occurs regardless of
the presence or absence of depression or other
psychiatric disorders. One study found that the
mental impairment in CFS patients parallels the
degree of their physical impairment, indicating
that the disease process itself may exert a
neurologic effect. Some studies indicate that there
is very little measurable difference in memory,
information processing, and concentration
between CFS patients and those without the
disorder and that the perceived differences are
due to emotional problems. It has been
suggested, however, that such results are due to
the tests being performed in an doctor's office or
clinical setting, which often do not accurately
reflect the burden that daily tasks place on
severely fatigued patients and which result in little
spare capacity for attention or mental flexibility.
incapacitating symptom, those of mental
impairment, such as an inability to concentrate,
are the most distressing. Some studies indicate,
that, although general intelligence is not impaired,
CFS patients test lower in certain mental
functions, particularly speed and efficiency in
processing complex information. In such studies,
this impaired mental function occurs regardless of
the presence or absence of depression or other
psychiatric disorders. One study found that the
mental impairment in CFS patients parallels the
degree of their physical impairment, indicating
that the disease process itself may exert a
neurologic effect. Some studies indicate that there
is very little measurable difference in memory,
information processing, and concentration
between CFS patients and those without the
disorder and that the perceived differences are
due to emotional problems. It has been
suggested, however, that such results are due to
the tests being performed in an doctor's office or
clinical setting, which often do not accurately
reflect the burden that daily tasks place on
severely fatigued patients and which result in little
spare capacity for attention or mental flexibility.
Long-term Outlook
Because the illness has been undefined and there
are few objective measures for recovery, experts
have found it difficult to determine the long-term
outlook of CFS. Some physicians have observed
that patients whose symptoms began abruptly
following a severe viral illness recovered
completely after six months to a year, whereas
patients whose problems developed slowly and
insidiously experienced symptoms for a longer
period of time. One recent study found that when
patients with severe CFS were treated with a
multidisciplinary rehabilitation program, nearly all
improved significantly and the gains were
maintained for at least a year afterward. Many
patients with less severe chronic fatigue have
reported turning a corner after a year or two and
slowly regaining energy despite some setbacks
along the way. Some patients get progressively
worse, but the disorder is not fatal. Although
children with symptoms of chronic fatigue have
not been rigorously studied, some studies
indicate that children generally have a better
prognosis than adults and recover after one to
four years in up to 95% of cases.
Because the illness has been undefined and there
are few objective measures for recovery, experts
have found it difficult to determine the long-term
outlook of CFS. Some physicians have observed
that patients whose symptoms began abruptly
following a severe viral illness recovered
completely after six months to a year, whereas
patients whose problems developed slowly and
insidiously experienced symptoms for a longer
period of time. One recent study found that when
patients with severe CFS were treated with a
multidisciplinary rehabilitation program, nearly all
improved significantly and the gains were
maintained for at least a year afterward. Many
patients with less severe chronic fatigue have
reported turning a corner after a year or two and
slowly regaining energy despite some setbacks
along the way. Some patients get progressively
worse, but the disorder is not fatal. Although
children with symptoms of chronic fatigue have
not been rigorously studied, some studies
indicate that children generally have a better
prognosis than adults and recover after one to
four years in up to 95% of cases.
HOW IS CHRONIC FATIGUE SYNDROME TREATED?
There is no proven or reliable cure for CFS;
studies have found that patients with the best
chance for improvement are those who remain as
active as possible and who seek to have some
control over the course of the disorder. Patients
should seek physicians who are willing to
consider the problem as a medical condition with
psychiatric components. They should be very
wary, however, if the physician recommends
excessive and expensive treatments that may have
serious adverse effects and that have no proven
benefits. For patients with severe CFS that cannot
be managed with lifestyle changes and standard
medications, asking the physician about enrolling
in any available clinical trials may be helpful.
LIFESTYLE CHANGES.
Exercise. Some patients experience profound
fatigue following even modest exercise, and it is
the primary factor in the low-activity levels in
these patients. A recent study found, however,
that 75% of patients who were able to engage in
exercise, particularly aerobic exercise, reported
improvement in fatigue, normal functioning, and
fitness after a year. It is necessary to go slowly,
however, to prevent relapse. Patients should
gradually increase activity level keeping within
limits and avoiding over-exertion. An incremental
program of activity, beginning with as little as
three to five minutes of moderate exercise a day,
is suggested, although capacity varies greatly
among CFS sufferers. The goal is to increase
activity by about 20% every two to three weeks.
Setbacks will occur, but patients should not
become discouraged. Rather, they should
experiment with various forms of physical activity
that suit their available energy levels. Some
patients report great benefits from Tai chi chuan,
an Eastern form of meditation and exercise.
DIET.
Chronic fatigue syndrome patients should
maintain a healthy diet low in animal fat and high
in fiber, with plenty of fresh fruits and vegetables.
Some fats may be beneficial, however. One study
found that 85% of patients with CFS experienced
improved symptoms using black current and fish
oils. (Another study, however did not confirm
these results.) These oils contain a
polyunsaturated fatty acid known as gamma
linolenic acid, which seems to block the release of
cytokines and prostaglandins--substances that
play major destructive roles in inflammatory
diseases. (Olive oil may have similar benefits and,
in any case, there is no downside in using it in
cooking.) For those with demonstrated low blood
pressure, increasing the amount of salt in the diet
may be helpful.
maintain a healthy diet low in animal fat and high
in fiber, with plenty of fresh fruits and vegetables.
Some fats may be beneficial, however. One study
found that 85% of patients with CFS experienced
improved symptoms using black current and fish
oils. (Another study, however did not confirm
these results.) These oils contain a
polyunsaturated fatty acid known as gamma
linolenic acid, which seems to block the release of
cytokines and prostaglandins--substances that
play major destructive roles in inflammatory
diseases. (Olive oil may have similar benefits and,
in any case, there is no downside in using it in
cooking.) For those with demonstrated low blood
pressure, increasing the amount of salt in the diet
may be helpful.
STRESS REDUCTION TECHNIQUES.
A number of relaxation techniques are available,
including deep breathing exercises, muscle
relaxation techniques, meditation, hypnosis,
biofeedback, and massage therapy. One panel of
experts concluded that a number of relaxation and
stress-reduction techniques were helpful in
managing chronic pain. They also can help relieve
the stress associated with the disease. They are
not useful, however, as the primary treatment for
CFS.
including deep breathing exercises, muscle
relaxation techniques, meditation, hypnosis,
biofeedback, and massage therapy. One panel of
experts concluded that a number of relaxation and
stress-reduction techniques were helpful in
managing chronic pain. They also can help relieve
the stress associated with the disease. They are
not useful, however, as the primary treatment for
CFS.
PERSONAL RELATIONSHIPS.
Strong, supportive, relationships with family and
friends may be an important factor in the overall
improvement of CFS patients.
friends may be an important factor in the overall
improvement of CFS patients.
COGNITIVE THERAPY.
Cognitive therapy is proving to have substantial
benefits for enhancing patients' beliefs in their
own abilities for dealing with stressful situations
and managing their disorder. The primary goal of
cognitive therapy is to change the distorted
perceptions that patients have of the world and of
themselves; for CFS patients, this means learning
to think differently about their fatigue. Cognitive
therapy is particularly helpful in defining and
setting limits--behaviors that are extremely
important for these patients. One study found that
patients who felt the least control over symptoms
reported more severe and chronic fatigue. Using
specific tasks and self-observation, patients
gradually shift their fixed ideas that they are
helpless against the fatigue that dominates their
lives to the perception that fatigue is only one
negative and, to a degree, a manageable
experience among many positive ones. Cognitive
therapy may be expensive and not covered by
insurance, although it is usually of short
duration--typically six to 20 one-hour sessions,
plus homework, which usually includes
attempting a task that the patient has avoided
because of negative thinking.
benefits for enhancing patients' beliefs in their
own abilities for dealing with stressful situations
and managing their disorder. The primary goal of
cognitive therapy is to change the distorted
perceptions that patients have of the world and of
themselves; for CFS patients, this means learning
to think differently about their fatigue. Cognitive
therapy is particularly helpful in defining and
setting limits--behaviors that are extremely
important for these patients. One study found that
patients who felt the least control over symptoms
reported more severe and chronic fatigue. Using
specific tasks and self-observation, patients
gradually shift their fixed ideas that they are
helpless against the fatigue that dominates their
lives to the perception that fatigue is only one
negative and, to a degree, a manageable
experience among many positive ones. Cognitive
therapy may be expensive and not covered by
insurance, although it is usually of short
duration--typically six to 20 one-hour sessions,
plus homework, which usually includes
attempting a task that the patient has avoided
because of negative thinking.
Homework also may include keeping an energy
diary, which can be a key component of CFS
cognitive therapy. The diary serves as a general
guide for setting limits and planning activities.
The patient uses the diary to track any factors,
such as a job or a relationship, that may be
making the fatigue worse or better. It is also used
to track the times of day when energy levels are at
their highest and lowest peaks and adjust
schedules accordingly. For instance, the patient
may plan low-energy times for taking a nap and
high-energy times for planning important
activities. Developing fairly rigid daily routines
around probable energy spurts or drops may help
establish a more predictable pattern. It should be
noted, however, that energy levels will most likely
never be entirely predictable; patients must also
be prepared to adapt to energy variations.
Flexibility is important. Instead of a long nap, for
instance, patients may need between five to 10
minutes rest periods every hour or more, during
which time relaxation or meditation methods are
useful. Cognitive therapy teaches patients how to
prioritize their responsibilities, dropping some of
the less critical tasks or delegating them to others.
Limits should be designed to keep both mental
and physical stress within a manageable
framework so that patients do not get discouraged
by forcing themselves into situations in which
they are likely to fail. As part of the therapeutic
process, patients learn to adapt even to impaired
concentration, a common CFS problem. For
example, the patient learns to choose activities
that are appealing, that will focus attention, and
will help increase alertness. CFS patients are
taught to request instructions that are given as
concise simple statements and to keep external
distractions, such as music or talking, to a
minimum.
diary, which can be a key component of CFS
cognitive therapy. The diary serves as a general
guide for setting limits and planning activities.
The patient uses the diary to track any factors,
such as a job or a relationship, that may be
making the fatigue worse or better. It is also used
to track the times of day when energy levels are at
their highest and lowest peaks and adjust
schedules accordingly. For instance, the patient
may plan low-energy times for taking a nap and
high-energy times for planning important
activities. Developing fairly rigid daily routines
around probable energy spurts or drops may help
establish a more predictable pattern. It should be
noted, however, that energy levels will most likely
never be entirely predictable; patients must also
be prepared to adapt to energy variations.
Flexibility is important. Instead of a long nap, for
instance, patients may need between five to 10
minutes rest periods every hour or more, during
which time relaxation or meditation methods are
useful. Cognitive therapy teaches patients how to
prioritize their responsibilities, dropping some of
the less critical tasks or delegating them to others.
Limits should be designed to keep both mental
and physical stress within a manageable
framework so that patients do not get discouraged
by forcing themselves into situations in which
they are likely to fail. As part of the therapeutic
process, patients learn to adapt even to impaired
concentration, a common CFS problem. For
example, the patient learns to choose activities
that are appealing, that will focus attention, and
will help increase alertness. CFS patients are
taught to request instructions that are given as
concise simple statements and to keep external
distractions, such as music or talking, to a
minimum.
In one study comparing patients receiving
standard treatment with those receiving the same
treatment plus cognitive therapy, 73% of the
cognitive group were spending less time in bed
and functionally normally after a year, as opposed
to only 27% of those who received standard
therapy. In another study, 70% of patients
improved significantly after six months of
cognitive therapy, compared to 19% who used
only relaxation techniques. Not all studies support
the benefits of cognitive therapy; the skill of the
therapist is very important in its success.
Psychoanalysis and other interpersonal
psychological therapies, which are concerned
with subconscious thoughts and early childhood
memories, are not generally helpful for the patient
with chronic fatigue syndrome. It is important to
note that even if chronic fatigue syndrome proves
to have a specific organic cause, the power of the
mind to improve or oppose health problems is
significant, and treatments that promote a positive
outlook are beneficial for any disease.
standard treatment with those receiving the same
treatment plus cognitive therapy, 73% of the
cognitive group were spending less time in bed
and functionally normally after a year, as opposed
to only 27% of those who received standard
therapy. In another study, 70% of patients
improved significantly after six months of
cognitive therapy, compared to 19% who used
only relaxation techniques. Not all studies support
the benefits of cognitive therapy; the skill of the
therapist is very important in its success.
Psychoanalysis and other interpersonal
psychological therapies, which are concerned
with subconscious thoughts and early childhood
memories, are not generally helpful for the patient
with chronic fatigue syndrome. It is important to
note that even if chronic fatigue syndrome proves
to have a specific organic cause, the power of the
mind to improve or oppose health problems is
significant, and treatments that promote a positive
outlook are beneficial for any disease.
ANTIDEPRESSANT AND ANTIANXIETY DRUGS.
The antidepressant amitriptyline (Elavil) is known
to relieve many of the symptoms of CFS,
including sleeplessness and low energy levels.
Patients with CFS normally respond to much
lower doses than those used to treat people with
other disorders, and, in fact, many CFS patients
cannot tolerate the higher doses commonly used
to treat depression. Improvement in symptoms
can take three to four weeks. Many researchers
report that other antidepressant medications have
also helped, including doxepin (Sinequan),
desipramine (Norpramin), nortriptyline (Pamelor),
clomipramine (Anafranil), and imipramine
(Tofranil, Janimine). (Popular antidepressants
known as selective serotonin-reuptake inhibitors
(SSRIs), such as fluoxetine (Prozac), sertraline
(Zoloft), and Paroxetine (Paxil), appear to have
little value for CFS beyond treating any
accompanying depression.) It often takes several
weeks for tricyclics to produce benefits. Common
side effects of many antidepressants include dry
mouth, restlessness, a slightly increased heart
rate, and constipation. If anxiety is also a problem,
an anxiety-relieving drug, such as alprazolam
(Xanax), may be prescribed, although anti-anxiety
drugs can become addictive if used for prolonged
periods and are not usually recommended.
PAIN RELIEVERS.
If muscle aches or pains persist, nonsteroidal
anti-inflammatory drugs (NSAIDs), such as aspirin
or ibuprofen (Advil, Motrin), or acetaminophen
(Tylenol) may help. Because chronic fatigue
syndrome can cause on-going joint pain, some
patients may abuse over the counter medications.
It is important to note that NSAIDs can cause
bleeding, and excessive use of acetaminophen
has been associated with liver or kidney damage
and even death. Those with ulcers should not take
NSAIDs without a physician recommendation. If
joint pain is not relieved with nonprescription
painkillers, local injections of lidocaine (an
anesthetic to relieve pain) may be administered.
Deep massage, hot and cold applications, topical
anesthetics, stretching, acupuncture, and
chiropractic treatment may also help minimize
symptoms.
anti-inflammatory drugs (NSAIDs), such as aspirin
or ibuprofen (Advil, Motrin), or acetaminophen
(Tylenol) may help. Because chronic fatigue
syndrome can cause on-going joint pain, some
patients may abuse over the counter medications.
It is important to note that NSAIDs can cause
bleeding, and excessive use of acetaminophen
has been associated with liver or kidney damage
and even death. Those with ulcers should not take
NSAIDs without a physician recommendation. If
joint pain is not relieved with nonprescription
painkillers, local injections of lidocaine (an
anesthetic to relieve pain) may be administered.
Deep massage, hot and cold applications, topical
anesthetics, stretching, acupuncture, and
chiropractic treatment may also help minimize
symptoms.
TREATMENT OF NEURALLY MEDIATED HYPOTENSION.
In one study, 76% of patients diagnosed with and
specifically treated for neurally mediated
hypotension (NMH) experienced improvement
within a month, and in 40% of these patients,
chronic fatigue symptoms completely or nearly
completely resolved. For treating NHM, the
physician might first recommend nonmedicinal
measures, such as increasing salt content in the
diet. Caffeinated beverages may be helpful.
Patients are instructed to perform exercises before
getting out of bed that flex the feet so that the
blood moves up toward the head. They are
encouraged to avoid excessive activity after
meals. They should not use medications that
reduce blood pressure. Special support garments
may help to prevent circulating blood from
pooling in the lower part of the body and to return
it to the heart. If the condition does not improve,
certain medications may be tried in combination
or alone. Midodrine (ProAmatine) is a drug that
increases smooth muscle tone and blood
pressure and reduces symptoms of NMH. Adverse
effects include itching, numbness, and tingling,
but the drug is well tolerated. A wide range of
drugs normally used for other disorders have
been used to treat NMH, but physicians have had
difficulty adjusting them so that they would be
effective for NMH without causing distressing side
effects. Such medications include fludrocortisone
(an oral steroid), phenylpropanolamine or
ephedrine (decongestants), indomethacin or
ibuprofen (nonsteroidal anti-inflammatory drugs
or NSAIDs), disopyramide (an anti-arrhythmic
drug), beta-blockers (drugs normally used to
prevent hypertension), and recombinant
erythropoietin epoetin alfa (used to increase red
blood cells). It should be stressed that no one
should take measures to raise blood pressure
without a clear diagnosis of NMH or without a
physician's approval, since increasing blood
pressure can be very dangerous in individuals
with existing normal or high blood pressure.
There is also no clear evidence yet that NMH is a
major cause of chronic fatigue syndrome.
specifically treated for neurally mediated
hypotension (NMH) experienced improvement
within a month, and in 40% of these patients,
chronic fatigue symptoms completely or nearly
completely resolved. For treating NHM, the
physician might first recommend nonmedicinal
measures, such as increasing salt content in the
diet. Caffeinated beverages may be helpful.
Patients are instructed to perform exercises before
getting out of bed that flex the feet so that the
blood moves up toward the head. They are
encouraged to avoid excessive activity after
meals. They should not use medications that
reduce blood pressure. Special support garments
may help to prevent circulating blood from
pooling in the lower part of the body and to return
it to the heart. If the condition does not improve,
certain medications may be tried in combination
or alone. Midodrine (ProAmatine) is a drug that
increases smooth muscle tone and blood
pressure and reduces symptoms of NMH. Adverse
effects include itching, numbness, and tingling,
but the drug is well tolerated. A wide range of
drugs normally used for other disorders have
been used to treat NMH, but physicians have had
difficulty adjusting them so that they would be
effective for NMH without causing distressing side
effects. Such medications include fludrocortisone
(an oral steroid), phenylpropanolamine or
ephedrine (decongestants), indomethacin or
ibuprofen (nonsteroidal anti-inflammatory drugs
or NSAIDs), disopyramide (an anti-arrhythmic
drug), beta-blockers (drugs normally used to
prevent hypertension), and recombinant
erythropoietin epoetin alfa (used to increase red
blood cells). It should be stressed that no one
should take measures to raise blood pressure
without a clear diagnosis of NMH or without a
physician's approval, since increasing blood
pressure can be very dangerous in individuals
with existing normal or high blood pressure.
There is also no clear evidence yet that NMH is a
major cause of chronic fatigue syndrome.
TREATMENT FOR LOW STRESS HORMONES.
Some evidence exists the patients with CFS may
be deficient in cortisol, a steroid hormone.
Studies testing the steroid drug hydrocortisone
have reported increased energy and less fatigue in
patients taking it. However, side effects including
insomnia, increase appetite and weight gain,
and--more seriously--suppression of the adrenal
gland--make this therapy unacceptable. A recent
study reporting improvement with very low doses
(5 mg to 10 mg daily) with only minor side effects
may make this therapy feasible for some patients,
but longer-term and larger studies are needed.
be deficient in cortisol, a steroid hormone.
Studies testing the steroid drug hydrocortisone
have reported increased energy and less fatigue in
patients taking it. However, side effects including
insomnia, increase appetite and weight gain,
and--more seriously--suppression of the adrenal
gland--make this therapy unacceptable. A recent
study reporting improvement with very low doses
(5 mg to 10 mg daily) with only minor side effects
may make this therapy feasible for some patients,
but longer-term and larger studies are needed.
ANTIVIRAL MEDICATIONS.
The antiviral drug, polyl:polyC12U (Ampligen) is
one of the most studied anti-CFS drugs at this
time. In an analysis of studies, after 24 weeks of
Ampligen therapy patients had a 31% improvement
in CFS symptoms compared to a 10%
improvement in patients on placebo. Patients
taking Ampligen progressed from needing daily
assistance of normal activities to needing
assistance only once a week. However, there has
been some controversy concerning the 25-year
old drug, which has been studied without success
for many cancers and for AIDS.
one of the most studied anti-CFS drugs at this
time. In an analysis of studies, after 24 weeks of
Ampligen therapy patients had a 31% improvement
in CFS symptoms compared to a 10%
improvement in patients on placebo. Patients
taking Ampligen progressed from needing daily
assistance of normal activities to needing
assistance only once a week. However, there has
been some controversy concerning the 25-year
old drug, which has been studied without success
for many cancers and for AIDS.
EXPRERIMENTAL TREATMENTS.
A natural agent called nicotinamide adenine
dinucleotide, or NADH (Enada), is also in trials.
This substance triggers adenosine triphosphate
(ATP) an enzyme found in every cell that is
necessary for conversion of food into energy. In
one well-conducted small study about 30% of
patients reported feeling better and having more
energy after taking NADH compared to 8% who
took a placebo. Although the study was small,
these results showed promise. Although there is
some indication that CFS patients may have low
magnesium levels, there has been no proven
benefit for magnesium sulfate. Because chronic
fatigue syndrome still has not been clearly defined
as a specific disorder, patients should approach
any experimental treatment cautiously and seek
more than one opinion before embarking on such
programs.
dinucleotide, or NADH (Enada), is also in trials.
This substance triggers adenosine triphosphate
(ATP) an enzyme found in every cell that is
necessary for conversion of food into energy. In
one well-conducted small study about 30% of
patients reported feeling better and having more
energy after taking NADH compared to 8% who
took a placebo. Although the study was small,
these results showed promise. Although there is
some indication that CFS patients may have low
magnesium levels, there has been no proven
benefit for magnesium sulfate. Because chronic
fatigue syndrome still has not been clearly defined
as a specific disorder, patients should approach
any experimental treatment cautiously and seek
more than one opinion before embarking on such
programs.
PHOTOTHERAPY.
The use of phototherapy may be effective
treatment for patients with CFS whose symptoms
have a seasonal variability that is similar to those
of patients with seasonal affective disorder (SAD).
Patients with SAD experience more depression
during winter than summer months. With
phototherapy is the patient sits a few feet away
from a box-like device that emits very bright
fluorescent light (10,000 lux) for about 30 minutes
every day. It is best performed immediately after
wakening in the morning.
ALTERNATIVE THERAPIES.
Because of the difficulties in treating chronic
fatigue syndrome, many patients seek alternative
therapies. Some, such as acupuncture and
relaxation techniques, may be helpful and are not
dangerous. But everyone should be wary of those
who promise a cure or urge the purchase of
expensive but useless and potentially dangerous
treatments, such as hydrogen peroxide injections
(which can cause blood clots or strokes),
megadoses of vitamins (which can be toxic), high
colonic enemas, and bee pollen (which can cause
an allergic reaction). No scientific evidence exists
that vitamin and mineral supplements will relieve
CFS, but taken in moderation, they are usually not
harmful. It should be noted, however, that
megadoses of vitamins can be toxic. A number of
herbal medicines have been used for chronic
fatigue syndrome; none have been proven to have
any benefit, and some can be harmful. Injections
of liver extract, folic acid, and vitamin B12 have
shown no benefit, nor have supplements of
vitamin B15 (also called pangamic acid) or
superoxide dismutase (SOD). It is extremely
important for patients to realize that herbal
medicine has as many potential side effects and
toxic reactions as standard drug therapy; in fact,
the dangers increase because no standards exist
for safe or effective dosages. Of particular note is
the product Nature's Nutrition Formula One; it
includes the ingredient Ma Huang, which contains
the stimulants ephedrine, and kola nut--a caffeine
source. Serious adverse reactions, including
seizures, psychosis, and several deaths, have
been reported in people taking this supplement
for increased energy or weight loss. Products that
have only one of these ingredients appear not to
have the same effect, but people should take
so-called energy boosting supplements only with
the knowledge and recommendation of their
physician.
fatigue syndrome, many patients seek alternative
therapies. Some, such as acupuncture and
relaxation techniques, may be helpful and are not
dangerous. But everyone should be wary of those
who promise a cure or urge the purchase of
expensive but useless and potentially dangerous
treatments, such as hydrogen peroxide injections
(which can cause blood clots or strokes),
megadoses of vitamins (which can be toxic), high
colonic enemas, and bee pollen (which can cause
an allergic reaction). No scientific evidence exists
that vitamin and mineral supplements will relieve
CFS, but taken in moderation, they are usually not
harmful. It should be noted, however, that
megadoses of vitamins can be toxic. A number of
herbal medicines have been used for chronic
fatigue syndrome; none have been proven to have
any benefit, and some can be harmful. Injections
of liver extract, folic acid, and vitamin B12 have
shown no benefit, nor have supplements of
vitamin B15 (also called pangamic acid) or
superoxide dismutase (SOD). It is extremely
important for patients to realize that herbal
medicine has as many potential side effects and
toxic reactions as standard drug therapy; in fact,
the dangers increase because no standards exist
for safe or effective dosages. Of particular note is
the product Nature's Nutrition Formula One; it
includes the ingredient Ma Huang, which contains
the stimulants ephedrine, and kola nut--a caffeine
source. Serious adverse reactions, including
seizures, psychosis, and several deaths, have
been reported in people taking this supplement
for increased energy or weight loss. Products that
have only one of these ingredients appear not to
have the same effect, but people should take
so-called energy boosting supplements only with
the knowledge and recommendation of their
physician.
page views: ###