Chronic fatigue syndrome

Definition

Chronic fatigue syndrome (CFS) is a condition that causes extreme tiredness. People with CFS have debilitating fatigue that lasts for six months or longer. CFS does not have a known cause, but appears to result from a combination of factors.

Description

CFS is the most common name for this disorder, but it also has been called chronic fatigue and immune disorder syndrome (CFIDS), myalgic encephalomyelitis, low natural killer cell disease, post-viral fatigue syndrome, Epstein-Barr disease, and yuppie flu. Reports of a CFS-like syndrome called neurasthenia date back to 1869. Later, people with similar symptoms were said to have fibromyalgia because one of the main symptoms is myalgia, or muscle pain. Because of the similarity of symptoms, fibromyalgia and CFS are considered to be overlapping syndromes.

In the early to mid-1980s, there were outbreaks of CFS in some areas of the United States. Although many CFS patients had high levels of antibodies to the Epstein-Barr virus (EBV), which causes mononucleosis , many healthy people also had high levels of EBV antibodies. Scientists have also found high levels of other viral antibodies in the blood of CFS patients. These findings have led many scientists to believe that a virus or combination of viruses may trigger CFS.

Although CFS can affect people of any gender, age, race, or socioeconomic group, most patients diagnosed with CFS are 25–45 years old and female. Estimates of how many people are afflicted with CFS vary due to the similarity of CFS symptoms to other diseases and the difficulty in identifying it. The Centers for Disease Control and Prevention (CDC) has estimated that 4–10 people per 100,000 in the United States have CFS. According to the CFIDS Foundation, about 500,000 adults in the United States (0.3% of the population) have CFS. This probably is a low estimate since these figures do not include children and are based on the CDC definition of CFS, which is very strict for research purposes.

Causes & symptoms

There is no single known cause for CFS. Studies have pointed to several different conditions that might be responsible. These include:

• viral infections
• chemical toxins
• allergies
• immune abnormalities
• psychological disorders

Many doctors and researchers think that CFS may not be a single illness but a group of symptoms caused by several conditions. One theory is that a microorganism, such as a virus, or a chemical injures the body and damages the immune system, allowing dormant viruses to become active. When these viruses start growing again, the immune system may overreact and produce chemicals called cytokines that can cause flu-like symptoms. Immune abnormalities have been found in studies

of people with CFS, although the same abnormalities are also found in people with allergies, autoimmune diseases, cancer , and other disorders.

In late 2001, a panel of experts convened and concluded that a virus or bacteria acting on the immune system may indeed cause CFS and the experts agreed that the published evidence is now substantial enough to prove that the immune system is involved in CFS. They said infections may also play a role in the condition, but have still not identified one single agent common to all patients with CFS and they have encouraged further research. The panel also concluded that reproductive hormones may play a role in the condition, which might explain a higher prevalence among women.

The role of psychological problems in CFS is very controversial. Because many people with CFS are diagnosed with depression and other psychiatric disorders, some experts conclude that the symptoms of CFS are psychological. However, many people with CFS did not have psychological disorders before getting the illness. Many doctors think that patients become depressed or anxious because of the effects of the symptoms of their CFS. One recent study concluded that depression was the result of CFS, not its cause.

People with CFS have severe fatigue that keeps them from performing their normal daily activities. They may have sleep disturbances that keep them from getting enough rest or they may sleep too much. When they exercise or try to be active in spite of their fatigue, people with CFS experience debilitating exhaustion that can confine them to bed for days.

Other symptoms of CFS include:

• muscle pain (myalgia)
• joint pain (arthralgia)
• sore throat
• headache
• fever and chills
• tender lymph nodes
• trouble concentrating
• memory loss

A recent study at Johns Hopkins University found an abnormality in blood pressure regulation in 22 of 23 patients with CFS. This abnormality, called neurally mediated hypotension, causes a sudden drop in blood pressure when a person has been standing, exercising, or exposed to heat for a while. When this occurs, patients feel lightheaded and may faint. They often are exhausted for hours to days after one of these episodes. When treated with salt and medications to stabilize blood pressure, many patients in the study had marked improvements in their CFS symptoms.

Diagnosis

CFS is diagnosed by evaluating symptoms and eliminating other causes of fatigue. Doctors carefully question patients about their symptoms, any other illnesses they have had, and medications they are taking. They also conduct a physical examination, neurological examination, and laboratory tests to identify any underlying disorders or other diseases that cause fatigue. In the United States, many doctors use the CDC case definition to determine if a patient has CFS.

To be diagnosed with CFS, patients must meet both of the following criteria:

• Unexplained continuing or recurring chronic fatigue for at least six months that is of new or definite onset, is not the result of ongoing exertion, and is not mainly relieved by rest, and causes occupational, educational, social, or personal activities to be greatly reduced.
• Four or more of the following symptoms: loss of short-term memory or ability to concentrate; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern, or severity; nonrefreshing sleep; and post-exertional malaise (a vague feeling of discomfort or tiredness following exercise or other physical or mental activity) lasting more than 24 hours. These symptoms must have continued or recurred during six or more consecutive months of illness and must not have started before the fatigue began.

Treatment

There is no specific cure for CFS, but many treatments are available to help relieve the symptoms. Treatments usually are individualized to each person's particular symptoms and needs. The first treatment recommended is a combination of rest, exercise, and a balanced diet. Prioritizing activities, avoiding overexertion, and resting when needed are key to maintaining existing energy reserves. Treatment of airborne allergies is an important facet in the treatment of CFS.

Diet

Drinking eight to 12 glasses of water daily helps fight fatigue. Food allergies can worsen CFS symptoms. Common food allergies include milk, wheat, eggs, citrus, alcohol, chocolate, and coffee. An extract from shiitake mushrooms (LEM) has been shown in Japanese studies to benefit CFS patients.

Ayurvedic medicine stresses that energy is derived from food. Energy-producing foods include: fresh fruits and vegetables, whole milk, wheat and wheat products, rice, barley, honey, olive oil, mung bean soup, raisins, dates, figs, almonds, clarified butter, and yogurt. Foods that deplete energy include: red meat, aged or fermented foods, onions, garlic , mushrooms, potatoes, sugar, alcohol, and coffee.

Ayurvedic medicine dictates that complete digestion of food is necessary to obtain the maximum amount of energy. The following measures can be taken to optimize digestion:

• eating in a quiet place
• following established mealtimes
• sitting while eating
• not eating while upset
• eating only until satiety (fullness)
• avoiding ice cold foods and drinks
• not talking while chewing
• eating at a moderate pace

Supplements

The following supplements have been used in treating CFS.

• Vitamin B₁₂ deficiency causes fatigue, muscle aches, confusion, poor memory, and arm and leg numbness.
• Magnesium helps muscles to relax. Persons with kidney or heart disease should not take magnesium.
• Iron treats anemia , which can cause tiredness, and improve mental clarity. This should only be taken if a physician has diagnosed an iron deficiency.
• Manganese works with the supplements above to relieve CFS symptoms.
• Copper deficiency can cause inflammation. Maximum recommended daily dose for adults is 2–3 mg. Pregnant women should consult a physician before taking copper supplements.
• Zinc may boost the immune system.
• Coenzyme Q₁₀ can increase immune health.
• NADH led to improvement in energy, cognitive ability, sleep patterns, headaches, and depression in a small study of CFS patients.
• Carnitine helps to better utilize fats for energy production. The recommended daily dose is 500–3,000 mg.
• Alpha lipoic acid enhances energy.
• 5-HTP helps to regulate sleep patterns.
• DHEA deficiency causes fatigue in females and low sex drive in males. It should only be taken under the direction of a physician.

Fluoride is a potentially toxic substance and should be avoided.

Other treatment options

Chinese medicine, including acupuncture and cupping , works to bring the body back into balance. Herbals which may help relieve symptoms of CFS include:

• astragalus (huang chi) to increase energy
• licorice (gan t'sao) for stomach and liver problems, adrenal exhaustion, and blood pressure warming
• ginger root for digestion
• turmeric for inflammation
• linden flowers for the heart
• echinacea stimulates the immune system, but should only be taken daily for 10–14 consecutive days
• Siberian ginseng (Eleutherococcus senticosus ) to increase resistance to stress and boost the immune system
• ginkgo to increase blood flow through the brain, but also thin the blood
• evening primrose (Oenothera biennis ) oil to increase energy levels
• borage seed (Borago officinales ) oil
• quercetin
• flaxseed oil

Some CFS patients use fasting only under the direction of a healthcare practitioner. Probiotics using Lactobacillus acidophilus can restore a normal balance to the intestinal bacterial.

Chiropractic adjustments can help relieve symptoms of CFS. Osteopathy helps some CFS patients. Osteopaths developed the craniosacral method which involves manipulation of the bones and membrane attachments of the head. Naturopathic physicians routinely treat CFS patients. Components of Ayurvedic treatment of CFS include stress reduction, daily oil massage, improving sleep, improving bowel function, and light to moderate exercise.

Mental health, psychological, and spiritual counseling are important facets of CFS treatment. Cognitive behavior therapy helps patients manage activity levels to reduce fatigue. The type of psychotherapy employed is less important than having good rapport with the therapist.

For patients who are employed, modifications to the workplace are essential to maintaining good health. Vocational rehabilitation counseling allows the patient to maximize his or her work potential.

Exercise and physical therapy can have a dramatic impact on the health of CFS patients. Stretching exercises and moderate aerobic activity are beneficial. Too much exercise can worsen fatigue and other CFS symptoms. Exercise programs such as physical therapy, t'ai chi, yoga , chi kung, the Alexander technique , and muscle balance and function development (MBF) are all options.

There is a lengthy list of therapies used by CFS patients to find relief. None are cures and most have not been tested in clinical studies. CFS patients may find relief, if only temporarily, in the following:

• healing sessions with a spiritual healer
• yoga
• reflexology
• hydrotherapy
• sound therapy
• chocolate therapy
• magnet therapy
• meditation
• visualization
• spiritual cleansing rituals
• biofeedback

A 2002 report noted a study that showed some results from homeopathy for CFS patients. For the study, patients underwent six months of treatment chosen by one of four homeopaths and changed as needed. Sixty-five percent of patients reported some improvement, feeling fitter, more rested, and less tired.

Allopathic treatment

Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, may be used to relieve pain and reduce fever. Another medication that is prescribed to relieve pain and muscle spasms is cyclobenzaprine (Flexeril).

Many doctors prescribe low dosages of antidepressants for their sedative effects and to relieve symptoms of depression. Antianxiety drugs, such as benzodiazepines or buspirone may be prescribed for excessive anxiety that has lasted for at least six months.

Other medications that have been tested or are being tested for treatment of CFS are:

• Fludrocortisone (Florinef), a synthetic steroid, has helped some CFS patients who have neurally mediated hypotension.
• Beta-adrenergic blocking drugs, including atenolol (Tenoretic, Tenormin) and propranolol (Inderal), are sometimes prescribed for neurally mediated hypotension.
• Gamma globulin, which contains human antibodies has been used experimentally to boost immune function in CFS patients.
• Ampligen, a drug which stimulates the immune system and has antiviral activity, improved mental function in CFS patients.

Expected results

The course of CFS varies widely for different people. Some get progressively worse over time, while others gradually improve. Some persons have periods of illness that alternate with periods of good health. While some people with CFS do fully regain their health, those that do not find relief from symptoms and adapt to the demands of the disorder by carefully following a treatment plan combining adequate rest, nutrition , exercise, and other therapies.

Prevention

Because the cause of CFS is not known, there are no recommendations for preventing the disorder.

Resources

BOOKS

Chopra, Deepak. Boundless Energy: The Complete Mind/Body Program for Overcoming Chronic Fatigue. New York: Harmony Books, 1995.

Demitrack, Mark A., and Susan E. Abbey. Chronic Fatigue Syndrome: An Integrative Approach to Evaluation and Treatment. New York: The Guilford Press, 1996.

Fisher, Gregg Charles. Chronic Fatigue Syndrome: A Comprehensive Guide to Symptoms, Treatments, and Solving the Practical Problems of CFS. New York: Warner Books, 1997.

Skelly, Mari, and Andrea Helm. Alternative Treatments for Fibromyalgia & Chronic Fatigue Syndrome: Insights from Practitioners and Patients. Alameda, CA: Hunter House, Inc., 1999.

PERIODICALS

Gibson, Sheila L. M., and Robin G. Gibson. "A Multidimensional Treatment Plan for Chronic Fatigue Syndrome." Journal of Nutritional & Environmental Medicine 9 (March 1999): 47+.

"Immune System Dysfunction May Play a Key Role." Medical Letter on the CDC & FDA (January 20, 2002): 5.

Johnson, Susan K., John DeLuca, and Benjamin H. Natelson. "Chronic Fatigue Syndrome: Reviewing the Research Findings." Annals of Behavioral Medicine 21 (1999): 258–271.

"New Treatment for Chronic Fatigue Syndrome." Tufts University Diet & Nutrition Letter 13 (February 1996): 1–2.

Walsh, Nancy. "Homeopathy May Help Patients with Chronic Fatigue Syndrome." Clinical Psychiatry News (March 2002): 27.

Weiss, Rick. "A Cure for Chronic Fatigue? If New Research Proves Right, Some Sufferers Have Nothing More than an Easy-to-Fix Blood Pressure Problem." The Nurse Practitioner 22 (July 1997): 30–40.

ORGANIZATIONS

American Association for Chronic Fatigue Syndrome. 7 Van Buren Street, Albany, NY 12206. (518) 435-1765. <http://weber.u.washington.edu/~dedra/aacfs1.html>.

The CFIDS Association. Community Health Services, P.O. Box 220398, Charlotte, NC 28222-0398. (704) 362-2343.

The National CFIDS Foundation. 103 Aletha Road, Needham, MA 02192. (781) 449-3535. <http://www.cfidsfoundation.org>.

The National CFS Association. 919 Scott Avenue, Kansas City, KS 66105. (913) 321-2278.

OTHER

Centers for Disease Control and Prevention "The Facts about Chronic Fatigue Syndrome." CFS Research group, Mailstop A15, Centers for Disease Control and Prevention, Atlanta, GA 30333. (404) 639-1338. <http://www.cdc.gov/ncidod/diseases/cfs/facts1.htm>.

National Institutes of Health, Public Service Resources "Chronic Fatigue Syndrome." <http://www.niaid.hih.gov/publications/cfs/complete.htm>.

Belinda Rowland

Teresa G. Odle

Chronic Fatigue Syndrome

Definition

Chronic fatigue syndrome (CFS) is a condition that causes extreme tiredness. People with CFS have debilitating fatigue that lasts for six months or longer. They also have many other symptoms. Some of these are pain in the joints and muscles, headache, and sore throat. CFS does not have a known cause, but appears to result from a combination of factors.

Description

CFS is the most common name for this disorder, but it also has been called chronic fatigue and immune disorder (CFIDS), myalgic encephalomyelitis, low natural killer cell disease, post-viral syndrome, Epstein-Barr disease, and Yuppie flu. CFS has so many names because researchers have been unable to find out exactly what causes it and because there are many similar, overlapping conditions. Reports of a CFS-like syndrome called neurasthenia date back to 1869. Later, people with similar symptoms were said to have fibromyalgia because one of the main symptoms is myalgia, or muscle pain. Because of the similarity of symptoms, fibromyalgia and CFS are considered to be overlapping syndromes.

In the early to mid-1980s, there were outbreaks of CFS in some areas of the United States. Doctors found that many people with CFS had high levels of antibodies to the Epstein-Barr virus (EBV), which causes mononucleosis, in their blood. For a while they thought they had found the culprit, but it turned out that many healthy people also had high EBV antibodies. Scientists have also found high levels of other viral antibodies in the blood of people with CFS. These findings have led many scientists to believe that a virus or combination of viruses may trigger CFS.

CFS was sometimes referred to as Yuppie flu because it seemed to often affect young, middle-class professionals. In fact, CFS can affect people of any gender, age, race, or socioeconomic group. Although anyone can get CFS, most patients diagnosed with CFS are 25-45 years old, and about 80% of cases are in women. Estimates of how many people are afflicted with CFS vary due to the similarity of CFS symptoms to other diseases and the difficulty in identifying it. The Centers for Disease Control and Prevention (CDC) has estimated that four to 10 people per 100,000 in the United States have CFS. According to the CFIDS Foundation, about 500,000 adults in the United States (0.3% of the population) have CFS. This probably is a low estimate since these figures do not include children and are based on the CDC definition of CFS, which is very strict for research purposes.

Causes and symptoms

There is no single known cause for CFS. Studies have pointed to several different conditions that might be responsible. These include:

• viral infections
• chemical toxins

• allergies
• immune abnormalities
• psychological disorders

Although the cause is still controversial, many doctors and researchers now think that CFS may not be a single illness. Instead, they think CFS may be a group of symptoms caused by several conditions. One theory is that a microorganism, such as a virus, or a chemical injures the body and damages the immune system, allowing dormant viruses to become active. About 90% of all people have a virus in the herpes family dormant (not actively growing or reproducing) in their bodies since childhood. When these viruses start growing again, the immune system may overreact and produce chemicals called cytokines that can cause flu-like symptoms. Immune abnormalities have been found in studies of people with CFS, although the same abnormalities are also found in people with allergies, autoimmune diseases, cancer, and other disorders.

The role of psychological problems in CFS is very controversial. Because many people with CFS are diagnosed with depression and other psychiatric disorders, some experts conclude that the symptoms of CFS are psychological. However, many people with CFS did not have psychological disorders before getting the illness. Many doctors think that patients become depressed or anxious because of the effects of the symptoms of their CFS. One recent study concluded that depression was the result of CFS and was not its cause.

Having CFS is not just a matter of being tired. People with CFS have severe fatigue that keeps them from performing their normal daily activities. They find it difficult or impossible to work, attend school, or even to take part in social activities. They may have sleep disturbances that keep them from getting enough rest or they may sleep too much. Many people with CFS feel just as tired after a full night's sleep as before they went to bed. When they exercise or try to be active in spite of their fatigue, people with CFS experience what some patients call "payback"—debilitating exhaustion that can confine them to bed for days.

Other symptoms of CFS include:

• muscle pain (myalgia)
• joint pain (arthralgia)
• sore throat
• headache
• fever and chills
• tender lymph nodes
• trouble concentrating
• memory loss

A recent study at Johns Hopkins University found an abnormality in blood pressure regulation in 22 of 23 patients with CFS. This abnormality, called neurally mediated hypotension, causes a sudden drop in blood pressure when a person has been standing, exercising or exposed to heat for a while. When this occurs, patients feel lightheaded and may faint. They often are exhausted for hours to days after one of these episodes. When treated with salt and medications to stabilize blood pressure, many patients in the study had marked improvements in their CFS symptoms.

Diagnosis

CFS is diagnosed by evaluating symptoms and eliminating other causes of fatigue. Doctors carefully question patients about their symptoms, any other illnesses they have had, and medications they are taking. They also conduct a physical examination, neurological examination, and laboratory tests to identify any underlying disorders or other diseases that cause fatigue. In the United States, many doctors use the CDC case definition to determine if a patient has CFS.

To be diagnosed with CFS, patients must meet both of the following criteria:

• Unexplained continuing or recurring chronic fatigue for at least six months that is of new or definite onset, is not the result of ongoing exertion, and is not mainly relieved by rest, and causes occupational, educational, social, or personal activities to be greatly reduced.
• Four or more of the following symptoms: loss of short-term memory or ability to concentrate; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern, or severity; unrefreshing sleep; and post-exertional malaise (a vague feeling of discomfort or tiredness following exercise or other physical or mental activity) lasting more than 24 hours. These symptoms must have continued or recurred during six or more consecutive months of illness and must not have started before the fatigue began.

Treatment

There is no cure for CFS, but many treatments are available to help relieve the symptoms. Treatments usually are individualized to each person's particular symptoms and needs. The first treatment most doctors recommend is a combination of rest, exercise, and a balanced diet. Prioritizing activities, avoiding overexertion, and resting when needed are key to maintaining existing energy reserves. A program of moderate exercise helps to keep patients from losing physical conditioning, but too much exercise can worsen fatigue and other CFS symptoms. Counseling and stress reduction techniques also may help some people with CFS.

Many medications, nutritional supplements, and herbal preparations have been used to treat CFS. While many of these are unproven, others seem to provide some people with relief. People with CFS should discuss their treatment plan with their doctors, and carefully weigh the benefits and risks of each therapy before making a decision.

Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, may be used to relieve pain and reduce fever. Another medication that is prescribed to relieve pain and muscle spasms is cyclobenzaprine (sold as Flexeril).

Many doctors prescribe low dosages of antidepressants for their sedative effects and to relieve symptoms of depression. Antianxiety drugs, such as benzodiazepines or buspirone may be prescribed for excessive anxiety that has lasted for at least six months.

Other medications that have been tested or are being tested for treatment of CFS are:

• Fludrocortisone (Florinef), a synthetic steroid, which is currently being tested for treatment of people with CFS. It causes the body to retain salt, thereby increasing blood pressure. It has helped some people with CFS who have neurally mediated hypotension.
• Beta-adrenergic blocking drugs, often prescribed for high blood pressure. Such drugs, including atenolol (Tenoretic, Tenormin) and propranolol (Inderal), are sometimes prescribed for neurally mediated hypotension.
• Gamma globulin, which contains human antibodies to a variety of organisms that cause infection. It has been used experimentally to boost immune function in people with CFS.
• Ampligen, a drug which stimulates the immune system and has antiviral activity. In one small study, ampligen improved mental function in people with CFS.

Alternative treatment

A variety of nutritional supplements are used for treatment of CFS. Among these are vitamin C, vitamin B₁₂, vitamin A, vitamin E, and various dietary minerals. These supplements may help improve immune and mental functions. Several herbs have been shown to improve immune function and have other beneficial effects. Some that are used for CFS are astragalus (Astragalus membranaceus ), echinacea (Echinacea spp.), garlic (Allium sativum ), ginseng (Panax ginseng ), gingko (Gingko biloba ), evening primrose oil (Oenothera biennis ), shiitake mushroom extract (Lentinus edodes ), borage seed oil, and quercetin.

KEY TERMS

Arthralgia— Joint pain.

Cytokines— Proteins produced by certain types of lymphocytes. They are important controllers of immune functions.

Depression— A psychological condition, with feelings of sadness, sleep disturbance, fatigue, and inability to concentrate.

Epstein-Barr virus (EBV)— A virus in the herpes family that causes mononucleosis.

Fibromyalgia— A disorder closely related to CFS. Symptoms include pain, tenderness, and muscle stiffness.

Lymph node— Small immune organs containing lymphocytes. They are found in the neck, armpits, groin, and other locations in the body.

Lymphocytes— White blood cells that are responsible for the actions of the immune system.

Mononucleosis— A flu-like illness caused by the Epstein-Barr virus.

Myalgia— Muscle pain.

Myalgic encephalomyelitis— An older name for chronic fatigue syndrome; encephalomyelitis refers to inflammation of the brain and spinal cord.

Natural killer (NK) cell— A lymphocyte that acts as a primary immune defense against infection.

Neurally mediated hypotension— A rapid fall in blood pressure that causes dizziness, blurred vision, and fainting, and is often followed by prolonged fatigue.

Neurasthenia— Nervous exhaustion—a disorder with symptoms of irritability and weakness, commonly diagnosed in the late 1800s.

Many people have enhanced their healing process for CFS with the use of a treatment program inclusive of one or more alternative therapies. Stress reduction techniques such as biofeedback, meditation, acupuncture, and yoga may help people with sleep disturbances relax and get more rest. They also help some people reduce depression and anxiety caused by CFS.

Prognosis

The course of CFS varies widely for different people. Some people get progressively worse over time, while others gradually improve. Some individuals have periods of illness that alternate with periods of good health. While many people with CFS never fully regain their health, they find relief from symptoms and adapt to the demands of the disorder by carefully following a treatment plan combining adequate rest, nutrition, exercise, and other therapies.

Prevention

Because the cause of CFS is not known, there currently are no recommendations for preventing the disorder.

Resources

ORGANIZATIONS

American Association for Chronic Fatigue Syndrome. 7 Van Buren St., Albany, NY 12206. (518) 435-1765. 〈http://weber.u.washington.edu/∼dedra/aacfs1.html〉.

The CFIDS Association. Community Health Services, P.O. Box 220398, Charlotte, NC 28222-0398. (704) 362-2343.

National CFIDS Foundation. 103 Aletha Road, Needham, MA 02192. (781) 449-3535. 〈http://www.cfidsfoundation.org〉.

National CFS Association. 919 Scott Ave., Kansas City, KS 66105. (913) 321-2278.

OTHER

"Chronic Fatigue Syndrome." National Institutes of Health. 〈http://www.nih.gov〉.

"The Facts about Chronic Fatigue Syndrome." Centers for Disease Control. 〈http://www.cdc.gov/ncidod/diseases/cfs/facts1.htm〉.

CHRONIC FATIGUE SYNDROME

DEFINITION

Chronic fatigue syndrome (CFS) is a condition that causes extreme tiredness. People with CFS are so tired that they are unable to carry on normal activities for a period of at least six months. They also have other symptoms, such as pain in the joints and muscles, headaches, and sore throat. There is no single known cause for CFS; it appears to result from a number of factors.

DESCRIPTION

Chronic fatigue syndrome is known by many different names. These names include chronic fatigue and immune disorder (CFIDS), myalgic encephalomyelitis (pronounced my-AL-jik en-SEF-uh-lo-MY-uh-LY-tiss), low natural killer cell disease, post-viral syndrome, Epstein-Barr disease, and Yuppie flu. Such names suggest a number of possible causes for CFS. Researchers have not been able to find out which of these causes, or which combination of factors, is responsible for the disease.

Reports of a CFS-like disease date back to 1869. People with the disease were said to have neurasthenia ("nerve weakness," pronounced noor-ess-THEE-nee-uh) or fibromyalgia ("muscle pain," pronounced FI-bro-my-AL-ja). These disorders are now thought to be related to chronic fatigue syndrome.

Another clue to the cause of CFS appeared in the mid-1980s when doctors found antibodies to the Epstein-Barr virus (EBV) in the blood of many people with CFS. Antibodies are produced by the body when it needs to fight off an infection. Some doctors believed that these antibodies meant that chronic fatigue syndrome was caused by the Epstein-Barr virus. It was soon discovered, however, that many people who did not have CFS also had EBV antibodies in their blood. Some scientists now think that EBV may contribute to CFS, but it is not the only factor.

The term Yuppie flu became popular because so many young, middle-class people developed the disease. More detailed studies showed that people of every age, gender, race, and income group can get CFS. The group most at risk for the disease, however, is women aged 25 to 45 years.

Estimating the number of people with CFS is difficult because its symptoms are so similar to those of other diseases. The U.S. Centers for Disease Control and Prevention (CDC) now believe that 4 to 10 out of every 100,000 Americans have CFS. The CFIDS Foundation estimates that about 500,000 adults (0.3 percent of the population) have CFS. These estimates do not include children.

CAUSES

There is no single known cause for chronic fatigue syndrome. Some factors that are thought to be responsible for the disease are:

• Viral infections
• Chemical toxins (poisons)
• Allergies
• Abnormalities in the immune system
• Psychological disorders

Chronic Fatigue Syndrome: Words to Know

Depression:

A psychological condition with feelings of sadness, sleep disturbance, fatigue, and inability to concentrate.

Epstein-Barr virus (EBV):

A virus that causes mononucleosis and other diseases.

Fibromyalgia:

Pain, tenderness, and stiffness in muscles.

Lymph nodes:

Small organs of the immune system in the neck, armpits, groin, and other parts of the body.

Myalgia:

Muscle pain.

Myalgic encephalomyelitis:

An inflammation of the brain and spinal cord.

Natural killer cells:

Cells in the immune system that help fight off infections.

Neurasthenia:

Nervous exhaustion.

Many doctors now believe that CFS is not one illness, but a combination of symptoms caused by several factors. According to one theory, the first step in chronic fatigue syndrome is infection by a virus. About 90 percent of all people have a virus in the herpes family in their bodies. Herpes viruses (see herpes infections entry) cause a number of problems, including cold sores and a painful inflammation of the nerves called shingles (see chickenpox entry).

These viruses are usually dormant (not active) in the body. The viruses can become active again, however, if the body is disturbed in some way. Certain chemicals in the air, for example, can cause the viruses to become active and begin to grow. When that happens, the body's immune system starts to fight off the viral infection. It produces chemicals designed to kill the virus. But these chemicals can cause other effects, too. Those effects are similar to ones observed in people with CFS.

The role of psychological factors in CFS is very controversial. Some think that people who are depressed are more likely to develop CFS. A person's mental state, they believe, may influence the way his or her body works. For example, depression (see depressive disorders entry) might cause dormant viruses to become active again. Other experts disagree with this analysis. They say a person's mental state is more likely to be caused by the disease, rather than being a cause of the disease.

SYMPTOMS

Some people think that chronic fatigue syndrome means only that a person is very tired, but the disease involves much more than that. A person may become so tired that he or she cannot go to work, attend school, or take part in social activities. CFS can also cause problems with sleeping. A person may wake up being just as tired as before he or she went to sleep.

Some CFS patients try to keep up with their normal daily activities, but they may experience "payback." Payback is a state of being even more exhausted than usual. The person may have to stay in bed for days to recover.

Other symptoms of CFS include:

• Muscle pain (myalgia)
• Joint pain (arthralgia)
• Sore throat
• Headache
• Fever and chills
• Tender lymph nodes
• Problems with concentrating
• Memory loss
• Hypotension (low blood pressure)

DIAGNOSIS

One step in diagnosing CFS is taking a medical history. Doctors ask patients about their symptoms, about other illnesses they have had, and about medications they are taking. They also conduct a physical examination and may order laboratory tests. They try to eliminate causes of the person's symptoms other than CFS. In the United States, many doctors use a standard created by the CDC for defining CFS. According to this standard, patients have chronic fatigue syndrome if they meet both of the following criteria:

• Chronic (continuous and ongoing) fatigue for at least six months. The condition is not caused by activity and is not relieved by rest. It greatly interferes with the person's job, school, social, or personal activities.
• Four or more of the following symptoms: loss of short-term memory or the ability to concentrate; sore throat; tender lymph nodes; muscle pain; pain in more than one joint without swelling or redness; headaches not previously experienced by the patient; failure of sleep to help the patient feel better; and a feeling of discomfort or tiredness that lasts more than twenty-four hours following exercise. In addition, these symptoms must occur more than once over a six-month period.

TREATMENT

There is no cure for chronic fatigue syndrome, but most symptoms can be treated successfully. The first treatment most doctors recommend is a combination of rest, exercise, and proper diet. The patient is advised to attempt only the most important activities, to avoid over-exerting himself or herself, and to rest whenever necessary. A moderate amount of exercise is important, but too much exercise can make the disease worse. Counseling and stress reduction (learning how to better handle the pressures of everyday life) can also be helpful.

Many medications, nutritional supplements (like vitamins and minerals), and herbal preparations have been used to treat CFS. Doctors and patients should work together to arrange the best plan for each individual.

Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (pronounced i-byoo-PRO-fuhn) and naproxen, can be used to relieve pain and reduce fever. Antidepressants can be used to help patients relax and feel less depressed. Antianxiety drugs, such as benzodiazepines (pronounced benzo-die-A-zuh-peenz), are prescribed for people with anxiety that has lasted for at least six months.

A number of other drugs are being tested for use with CFS patients. These include fludrocortisone (pronounced FLOO-dro-KOR-tih-zone, trade name Florinef) and beta-adrenergic drugs, such as atenolol (pronounced uh-TEN-uh-lol) and propranolol (pronounced pro-PRAN-uh-lol), to control blood pressure, and gamma globulin (pronounced GA-muh GLAH-byu-lun) and ampligen (pronounced AM-plih-jen), to help fight off infections.

Alternative Treatment

Nutritional supplements such as vitamins A, B₁₂, C, and E, as well as some minerals, are used to treat CFS. These supplements are thought to improve the immune system and improve mental functions. Some CFS patients report improvement after using certain herbal medicines, such as echinacea (pronounced ek-i-NAY-see-uh), garlic, ginseng, ginkgo, evening primrose oil, shiitake mushroom extract, and borage seed oil.

Other therapies that have been tried in the treatment of CFS include meditation, acupuncture (a Chinese therapy treatment involving the puncturing of small needles into the body), and yoga. These therapies sometimes help people to relax and get more rest. They may also help reduce depression and anxiety.

PROGNOSIS

The course of CFS varies widely for different people. Some patients get progressively worse over time. Others improve slowly. Some individuals have periods of illness that alternate with periods of good health. Many people never fully recover from CFS. Most patients, however, find some relief by following a treatment plan that includes adequate rest, nutrition, exercise, and other therapies.

PREVENTION

There are currently no recommended ways of preventing CFS.

FOR MORE INFORMATION

Books

Hoffman, Ronald L. Tired All the Time. New York: Poseidon Press, 1993.

Johnson, Hillary. Osler's Web: Inside the Labyrinth of the Chronic Fatigue Syndrome Epidemic. New York: Crown Publishers, 1996.

Periodicals

Weiss, Rick. "A Cure for Chronic Fatigue Syndrome?" The Nurse Practitioner (July 1997): pp. 30–40.

Organizations

American Association for Chronic Fatigue Syndrome. 7 Van Buren Street, Albany, NY 12206. (518) 435–1765.

The CFIDS Association. Community Health Services. PO Box 220398, Charlotte, NC 28222–0398. (704) 362–2343.

The National CFS Association. 919 Scott Avenue, Kansas City, KS 66105. (913) 321–2278.

The National CFIDS Foundation. 103 Aletha Road, Needham, MA 02192. (781) 449–3535. http://www.cfidsfoundation.org.

Web sites

Centers for Disease Control and Prevention. "The Facts about Chronic Fatigue Syndrome." [Online] http://www.cdc.gov/ncidod/diseases. (accessed on October 15, 1999).

National Institutes of Health, Public Service Resources. "Chronic Fatigue Syndrome." [Online] http://www.niaid.nih.gov/publications. (accessed on October 15, 1999).

Chronic Fatigue Syndrome

What Is Chronic Fatigue Syndrome?

What Are the Symptoms of CFS?

What Causes CFS?

Diagnosis and Treatment of CFS

Resources

Chronic fatigue syndrome (KRAH-nik fuh-TEEG SIN-drome), or CFS, is a condition that makes people feel extremely exhausted and affects their participation in normal activities, such as work or school. Although the cause of the syndrome is still not known, researchers are investigating the possibility that an infection might trigger the condition in some cases.

KEYWORDS

for searching the Internet and other reference sources

Exhaustion

Fatigue

Neurasthenia

What Is Chronic Fatigue Syndrome?

Chronic fatigue syndrome is a condition that causes almost constant exhaustion. People with CFS cannot just get more sleep to feel better, because their fatigue does not improve with rest. In addition, physical or mental work may make the fatigue worse. Doctors and scientists do not know what causes CFS. In the past, people with CFS often were told their symptoms were psychological, or “all in their heads.” It was not until the 1980s that CFS began to be recognized as a medical condition associated with the physical symptoms of severe fatigue and weakness. CFS affects all racial groups, and the condition occurs in teens as well as adults. According to the National Institutes of Health, a woman is at least two to four times more likely than a man to develop CFS. Some studies have estimated that as many as 800,000 people in the United States have the syndrome.

What Are the Symptoms of CFS?

For a diagnosis of CFS, a person must have a sudden onset of exhaustion that continues for 6 months or recurs during that period of time. In addition, the person must have four of the following symptoms, and the symptoms must have started after the fatigue began:

• joint pain in several places in the body (without redness or swelling)
• muscle pain
• sore throat
• tender lymph nodes*

*lymph

(LIMF) nodes are small, bean-shaped masses of tissue that contain immune system cells that fight harmful microorganisms. Lymph nodes may swell during infections.

• difficulty in concentrating or short-term memory problems
• headaches different from those previously experienced
• general exhaustion that lasts for more than 24 hours after exercise or exertion
• a feeling of tiredness despite having slept

Some people with CFS also experience:

• dizziness
• abdominal* pain

*abdominal

(ab-DAH-mih-nul) refers to the area of the body below the ribs and above the hips that contains the stomach, intestines, and other organs.

• weight loss
• nausea
• night sweats
• chest pain
• continuing cough
• shortness of breath
• anxiety
• depression
• irregular heartbeat
• abnormal skin sensations

People diagnosed with CFS are not just a little sleepy. The fatigue they experience is so great that it significantly interferes with work or school.

What Causes CFS?

Doctors do not know what causes CFS. Because many people first experience the symptoms of CFS after an illness caused by a virus (such as mononucleosis or hepatitis), some scientists think that a viral illness can trigger the condition. Toxins, stress, and physical or emotional injury also have been suggested as possible causes of CFS. Some researchers think that CFS stems from a problem in the immune system, which helps the body fight disease. Because many people with CFS experience depression, other doctors believe that a psychological condition produces the physical symptoms of CFS. In the past, CFS has been blamed on many other conditions, such as allergies, hypoglycemia*, infection with Epstein-Barr virus (the virus that causes mononucleosis), candidiasis*, neurasthenia*, and Lyme disease.

*hypoglycemia

(hi-po-gly-SEEmee-uh) is a condition that occurs when the amount of glucose, or sugar, in the blood becomes too low. Symptoms can include dizziness, trembling, sweating, and confusion.

*candidiasis

(kan-dih-DYE-uh-sis) is an overgrowth of Candida, a type of yeast, in or on the body.

*neurasthenia

(nur-us-THEE-neeuh) is a disorder of the nervous system causing weakness and fatigue.

Diagnosis and Treatment of CFS

CFS is diagnosed if a person has the symptoms listed earlier. There are no specific laboratory tests that can confirm the diagnosis of CFS, although a person may have to undergo blood tests and physical examinations to rule out other possible causes of symptoms, such as multiple sclerosis*, hypothyroidism*, or heart or kidney disease. A diagnosis of CFS often is made when nothing else is found to account for the symptoms.

*multiple sclerosis

(skluh-RO-sis) (MS) is an inflammatory disease of the nervous system that disrupts communication between the brain and other parts of the body. MS can result in paralysis, loss of vision, and other symptoms.

*hypothyroidism

(hi-po-THY-roydih-zum) is an impairment of the functioning of the thyroid gland that causes too little thyroid hormone to be produced by the body. Symptoms of hypothyroidism can include tiredness, paleness, dry skin, and in children, delayed growth and mental and sexual development.

Because the cause of CFS is unknown, treatment for CFS involves relieving the symptoms. Although there is no specific treatment for CFS, moderate exercise, such as yoga or tai chi; antidepressants (medications that can ease depression); and nonsteroidal anti-inflammatory drugs, such as ibuprofen, can help minimize the severity of many of the symptoms. It is also important for people with CFS to watch their stress levels, because mental, physical, or emotional overexertion can aggravate CFS symptoms. A few patients with CFS may respond to drinking extra fluids and eating extra salt. Some people also find cognitive behavioral therapy* and rehabilitative therapy* helpful in decreasing or coping with their symptoms. For most patients, the symptoms of CFS are most severe in the beginning, and later they may come and go. Some people recover completely from CFS, although it is not clear why this happens. Most CFS patients recover gradually within 5 years after symptoms begin.

*cognitive behavioral therapy

(KOG-nih-tiv be-HAY-vyuh-rul THAIR-uh-pee) is treatment that helps people identify negative ways of thinking and behaving and change them to more positive approaches.

*rehabilitative therapy

helps people return to more normal physical, mental, or emotional function following an illness or injury. Rehabilitative therapy also helps people find ways to better cope with conditions that interfere with their lives.

See also

Lyme Disease

Mononucleosis, Infectious

Resources

Organizations

American Association for Chronic Fatigue Syndrome, 515 Minor Avenue, Suite 18, Seattle, WA 98104. People with CFS can find information about how to manage the symptoms of the disease at the American Association for Chronic Fatigue Syndrome website. Telephone 206-781-3544 http://www.aacfs.org

U.S. Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA 30333. The CDC offers information about chronic fatigue syndrome and its diagnosis and treatment on its website.

Telephone 800-311-3435 http://www.cdc.gov

U.S. National Institute of Allergy and Infectious Diseases (NIAID), Building 31, Room 7A-50, 31 Center Drive MSC 2520, Bethesda, MD 20892-2520. NIAID, part of the National Institutes of Health, posts fact sheets about chronic fatigue syndrome on its website.

Telephone 301-496-5717 http://www.niaid.nih.gov

CHRONIC FATIGUE SYNDROME

CHRONIC FATIGUE SYNDROME. As many as one out of four people who consult primary health care providers in the United States complain that they have major problems with fatigue. In the 1980s some researchers claimed that chronic infection with the Epstein-Barr virus, also thought to cause chronic mononucleosis, was the source of such fatigue. Later studies, however, showed chronic infection with the virus in patients who did not demonstrate fatigue symptoms, casting doubt on the virus as the source of the symptoms. Other researchers uncovered evidence of infection with other organisms, along with perturbations in the body's immune system, but could not pinpoint a specific cause of the symptoms. Eventually they labeled disabling fatigue lasting at least six months and of uncertain etiology as chronic fatigue syndrome. Doctors diagnosed the disease more often in women than in men and far less often in the lowest socioeconomic groups.

The media began a public discussion of the syndrome during the late 1980s, followed by the formation of patient support groups. By the late 1990s no consistently effective treatment had been discovered, and medical and lay authorities displayed open public disagreement over the nature and definition of the disease. Patient groups lobbied for recognition of chronic fatigue syndrome as a specific disease, while many physicians were reluctant to create an umbrella term for what they regarded as a set of common symptoms rather than a specific disease.

BIBLIOGRAPHY

Aronowitz, Robert A. "From Myalgic Encephalitis to Yuppie Flu: A History of Chronic Fatigue Syndromes." In Framing Disease: Studies in Cultural History. Edited by Charles E. Rosenberg and Janet Golden. New Brunswick, N.J.: Rutgers University Press, 1992.

Duff, Kat. The Alchemy of Illness. New York: Pantheon Books, 1993.

Joel D.Howell/c. w.

See alsoMedical Profession ; Medical Research ; Microbiology .