Chronic fatigue syndrome

Definition

Chronic fatigue syndrome (CFS) is a complicated disorder characterized by extreme fatigue that doesn't improve with bed rest and may worsen with physical or mental activity.

Chronic fatigue syndrome may occur after an infection, such as a cold or viral illness. The onset can be during or shortly after a time of great stress, or chronic fatigue syndrome come on gradually without a clear starting point or obvious cause.

Women are diagnosed with chronic fatigue syndrome far more often than men are. However, it's unclear whether chronic fatigue syndrome affects women more frequently or if women report it more often than men do.

Treatment for chronic fatigue syndrome focuses on a combination of approaches to relieve signs and symptoms.

Symptoms

Chronic fatigue syndrome is a flu-like condition that can drain your energy and, sometimes, last for years. People previously healthy and full of energy may experience a variety of signs and symptoms.

People with chronic fatigue syndrome exhibit signs and symptoms similar to those of most common viral infections. Unlike flu (influenza) symptoms, which usually subside in a few days or weeks, the signs and symptoms of CFS can last much longer. They may come and go frequently with no identifiable pattern.

Primary signs and symptoms
In addition to persistent fatigue, not caused by other known medical conditions, chronic fatigue syndrome has eight possible primary signs and symptoms. Chronic fatigue syndrome symptoms include:

• Loss of memory or concentration
• Sore throat
• Painful and mildly enlarged lymph nodes in your neck or armpits
• Unexplained muscle soreness
• Pain that moves from one joint to another without swelling or redness
• Headache of a new type, pattern or severity
• Sleep disturbance
• Extreme exhaustion lasting more than 24 hours after physical or mental exercise

According to the International Chronic Fatigue Syndrome Study Group — a group of scientists, researchers and doctors brought together by the Centers for Disease Control and Prevention (CDC) to determine a standard method for defining and diagnosing chronic fatigue syndrome — a person meets the diagnostic criteria of chronic fatigue syndrome when unexplained persistent fatigue occurs for six months or more along with at least four of the eight primary signs and symptoms.

Additional signs and symptoms
In addition, people with chronic fatigue syndrome have reported other various signs and symptoms that aren't part of the official definition. These include:

• Abdominal pain
• Allergies or sensitivities to foods, alcohol, odors, chemicals, medications or noise
• Bloating
• Chest pain
• Chronic cough
• Diarrhea
• Dizziness, balance problems or fainting
• Dry mouth
• Earache
• Irregular heartbeat
• Jaw pain
• Morning stiffness
• Nausea
• Chills and night sweats
• Psychological problems, such as depression, irritability, anxiety disorders and panic attacks
• Shortness of breath
• Tingling sensations
• Visual disturbances, such as blurring, sensitivity to light, eye pain and dry eyes
• Weight loss or gain

If you have chronic fatigue syndrome, your symptoms may peak and become stable early on, and then come and go over time. Some people go on to recover completely, while others grow progressively worse.

Causes

Of all chronic illnesses, chronic fatigue syndrome is one of the most mysterious. Unlike definite infections, it has no clear cause. Several possible causes have been proposed, including:

• Depression
• Iron deficiency anemia
• Low blood sugar (hypoglycemia)
• History of allergies
• Virus infection, such as Epstein-Barr virus or human herpesvirus 6
• Dysfunction in the immune system
• Changes in the levels of hormones produced in the hypothalamus, pituitary glands or adrenal glands
• Mild, chronic low blood pressure (hypotension)

The cause of chronic fatigue syndrome may be an inflammation of the pathways of the nervous system as a response to an autoimmune process, but with nothing measurable in the blood as in other autoimmune diseases, such as rheumatoid arthritis and lupus. Chronic fatigue syndrome may also occur when a viral illness is complicated by a dysfunctional immune system. Some people with CFS may have a low blood pressure disorder that triggers the fainting reflex.

In many cases, however, no serious underlying infection or disease is proved to specifically cause chronic fatigue syndrome. Lack of medical knowledge and understanding of CFS has made determining and describing the characteristics of the condition difficult.

Risk factors

Women are diagnosed with chronic fatigue syndrome two to four times as often as men, but sex isn't a proven risk factor for this condition. It may be that women are simply more likely than men are to report their symptoms to their doctor.

The condition is most common in people in their 40s and 50s, but it can affect people of all ages.

Because the cause of the condition is unknown, doctors have yet to determine and confirm definite risk factors for the disease.

When to seek medical advice

Fatigue can be a symptom of many illnesses, such as infections or psychological disorders. In general, see your doctor if you have persistent or excessive fatigue. Severe fatigue that prevents you from fully participating in activities at home, work or school may be a symptom of an underlying medical problem.

Tests and diagnosis

A diagnosis of chronic fatigue syndrome is based on exclusion. This means that before arriving at a diagnosis, a doctor has ruled out any other disease or condition that may be causing your fatigue and related symptoms.

In general, doctors find it difficult to diagnose chronic fatigue syndrome because it has some of the same signs and symptoms as many other diseases. There's no diagnostic or laboratory procedure to confirm the presence of chronic fatigue syndrome.

Doctors exclude certain conditions before considering a diagnosis of chronic fatigue syndrome. These include:

• Having an active, identifiable medical condition that often results in fatigue, such as low levels of thyroid hormones (hypothyroidism) or sleep apnea
• Using medicines that may cause fatigue
• Having a relapse of a previously treated illness that can result in fatigue, such as cancer
• Having had a past or current diagnosis of a major depressive disorder or other psychiatric illness, such as schizophrenia or an eating disorder
• Abusing alcohol or another substance
• Being severely obese, as defined by a body mass index (BMI) of 45 or greater

Over time, be alert to any new cues that might indicate that the problem is caused by something other than chronic fatigue syndrome. When other diseases or conditions are excluded, your doctor may then determine if your illness meets the CFS-specific criteria.

Complications

Possible complications of chronic fatigue syndrome include:

• Depression, related both to symptoms and lack of diagnosis
• Side effects and adverse reactions related to medication treatments
• Side effects and adverse reactions associated with lack of activity (deconditioning)
• Social isolation caused by fatigue
• Lifestyle restrictions
• Missing work

Treatments and drugs

There's no specific chronic fatigue syndrome treatment. In general, doctors aim to relieve signs and symptoms by using a combination of treatments, which may include:

• Moderating daily activity. Your doctor may encourage you to slow down and to avoid excessive physical and psychological stress. However, too much rest can make you weaker, worsening your long-term symptoms. Your goal should be to maintain a moderate level of daily activity and gently increase your stamina over time.
• Gradual but steady exercise. Often with the help of a physical therapist, you may be advised to begin an exercise program that slowly becomes more challenging. Research has proved that gradually increasing exercise can improve the symptoms of chronic fatigue syndrome. In one study, 70 percent of participants with CFS reported feeling better after completing a supervised program of graduated exercise.
• Cognitive behavior therapy. This treatment, often used in combination with graduated exercise, also has been found to improve the symptoms of chronic fatigue syndrome. In cognitive behavior therapy, you work with a mental health professional to identify negative beliefs and behaviors that might be delaying your recovery and replace them with healthy, positive ones.
• Treatment of depression. If you're depressed, medications, such as tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs), may help. Antidepressants may also help improve sleep and relieve pain. Tricyclic antidepressants include amitriptyline (Limbitrol, a multi-ingredient drug that contains amitriptyline), desipramine (Norpramin) and nortriptyline (Aventyl, Pamelor). SSRIs include fluoxetine (Prozac, Sarafem), paroxetine (Paxil), sertraline (Zoloft) and bupropion (Wellbutrin).
• Treatment of existing pain. Acetaminophen (Tylenol, others) and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen (Advil, Motrin, others), may be helpful to reduce pain and fever.
• Treatment of allergy-like symptoms. Antihistamines, such as fexofenadine (Allegra) and cetirizine (Zyrtec), and decongestants that contain pseudoephedrine (Sudafed) may relieve allergy-like symptoms such as runny nose.
• Treatment of low blood pressure (hypotension). The drugs fludrocortisone (Florinef), atenolol (Tenormin) and midodrine (ProAmatine, Orvaten) may be useful for certain people with chronic fatigue syndrome.
• Treatment for problems of the nervous system. Symptoms such as dizziness and extreme skin tenderness can sometimes be relieved by clonazepam (Klonopin). Your doctor may prescribe medications such as lorazepam (Ativan) and alprazolam (Xanax) to relieve symptoms of anxiety.

Experimental therapies
Research aimed at finding new treatments for chronic fatigue syndrome has included studies of the following medications:

• Methylphenidate (Ritalin, Concerta). This psychostimulant appears to boost and balance levels of the brain chemicals called neurotransmitters. It's commonly used to treat attention-deficit/hyperactivity disorder (ADHD). One study found that methylphenidate improved fatigue and concentration in some people with chronic fatigue syndrome.
• D-ribose. Also called ribose, this form of sugar is an essential energy source for your cells. Scientists believe that impaired cellular metabolism — some kind of disorder in the way your cells do their work — may play a role in chronic fatigue syndrome. Some research has found that natural D-ribose supplements may significantly improve the symptoms of chronic fatigue syndrome, with particular benefit in study participants' energy level and overall well-being.
• Acupuncture. Acupuncture has been studied as a treatment for the symptoms of fibromyalgia, a disease that is considered similar to CFS and is also characterized by fatigue and muscle soreness. In one clinical trial, half the participants received acupuncture, while the other half received a placebo treatment. Those treated with acupuncture experienced a significant improvement in their symptoms — especially fatigue and anxiety — compared with the nonacupuncture group.
• Corticosteroids. Some studies have found that oral hydrocortisone may improve symptoms of chronic fatigue syndrome, while other studies have found no benefit.
• Immune globulins and interferons. These medications are used to boost your immune system's ability to fight infection. Studies have not found them to be consistently effective in treating chronic fatigue syndrome, and participants have experienced severe side effects.
• Antiviral drugs, such as acyclovir. The possible connection between chronic fatigue syndrome and Epstein-Barr virus led researchers to test whether powerful antiviral medications could improve the symptoms of chronic fatigue syndrome. This approach has not been found effective, and the connection between Epstein-Barr virus and chronic fatigue syndrome has since been disproved.
• Cholinesterase (ko-lin-ES-tur-ase) inhibitors, such as galantamine. These drugs improve the effectiveness of acetylcholine, a chemical messenger that is believed to be important for memory, thought and judgment. Galantamine is used in the treatment of Alzheimer's disease, but has not been found beneficial for chronic fatigue syndrome.

Prevention

Because the cause of chronic fatigue syndrome remains unknown, there's no known way to prevent the illness from occurring. Be aware of the symptoms and signs of chronic fatigue syndrome and seek the help of your doctor to manage them if they occur.

Lifestyle and home remedies

Learning how to manage fatigue can help you improve your level of functioning and your quality of life despite your symptoms. You may work with a rehabilitation medicine specialist who can teach you how to plan activities to take advantage of times when you usually feel better.

These important self-care steps can help you to maintain good general health:

• Reduce stress. Develop a plan to avoid or limit overexertion and emotional stress. Allow yourself time each day to relax. That may mean learning how to say no without guilt. If possible, don't change your routine totally. People who quit work or drop all activity tend to do worse than those who remain active.
• Get enough sleep. Getting sufficient sleep is essential. In addition to allotting enough time for sleep, practice good sleep habits, such as going to bed and getting up at the same time each day and limiting daytime napping.
• Exercise regularly. You may need to start slow and build up gradually. But exercising regularly often improves symptoms. Many people find exercises such as walking, swimming, biking and water aerobics to be helpful. A physical therapist may help you develop a home-exercise program. Stretching, good posture and relaxation exercises also can be helpful.
• Pace yourself. Keep your activity on an even level. If you do too much on your good days, you may have more bad days.
• Maintain a healthy lifestyle. Try to eat a balanced diet, drink plenty of fluids, limit your caffeine intake, stop smoking, get adequate rest and exercise regularly. Find a hobby or career that's enjoyable and fulfilling for you.

Coping and support

The experience of chronic fatigue syndrome varies from person to person. For many people, however, the symptoms are more bothersome early in the course of the illness and then gradually decrease. Some people recover completely with time. Emotional support and counseling may help you and your loved ones deal with the uncertainties and restrictions of chronic fatigue syndrome.

You may find it therapeutic to join a support group and meet other people with chronic fatigue syndrome. Support groups aren't for everyone, and you may find that a support group adds to your stress rather than relieves it. Experiment and use your own judgment to determine what's best for you.

Alternative medicine

Some makers of various dietary supplements and herbal remedies claim these substances have potential benefits for people with chronic fatigue syndrome, but the effectiveness of these substances for treating the condition hasn't been proved in controlled studies. Though a product may be of "natural" origin, that doesn't ensure its safety. Dietary supplements and herbal preparations can have potentially harmful side effects and may dangerously interfere or interact with prescription medications.

Some complementary therapies can benefit people with chronic fatigue syndrome by reducing anxiety and promoting a sense of well-being. These include deep-breathing and muscle-relaxation techniques, massage and healing touch, and movement therapies such as stretching, yoga and tai chi.

Talk to your doctor before using any unprescribed remedy or new complementary therapy.