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Chronic Fatigue Syndrome

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by Stephen Gluckman, MD

Chronic fatigue syndrome refers to long-standing severe and disabling fatigue without a proven physical or psychologic cause.

  • Unexplained fatigue lasts for 6 months or longer.

  • Sometimes symptoms begin during or after an illness that resembles a viral infection.

  • Treatments include relieving symptoms, cognitive-behavioral therapy, and graded exercise.

Although as many as 25% of people report being chronically fatigued (see Fatigue), only 0.5% of people (1 in 200) have chronic fatigue syndrome (CFS). Chronic fatigue syndrome affects people primarily between the ages of 20 and 50 and is more common among young and middle-aged women than men, although it occurs in people of all ages, including children. People with chronic fatigue syndrome have real and often disabling symptoms. Chronic fatigue syndrome is not the same as pretending to have symptoms (a disorder known as malingering).

Causes

Despite considerable research, the cause of chronic fatigue syndrome remains unknown. Controversy exists as to whether there is a single cause or many causes and whether the cause is physical or mental, but either way the symptoms are very real to the person.

Some studies have suggested infection with the Epstein-Barr virus, Lyme disease, cytomegalovirus, or candida (a yeast) as a possible cause of chronic fatigue syndrome. However, current research indicates that these infections do not cause this syndrome. In addition, no evidence indicates that other infections (such as infections due to rubella virus, herpesvirus, or human immunodeficiency virus ([HIV]) are related to the syndrome.

Some minor abnormalities of the immune system are possible. They can collectively be called immune system dysregulation. However, no abnormalities are specifically characteristic of the disorder. People with chronic fatigue syndrome do not have a medically serious problem with their immune system. No evidence indicates that allergies are the cause, although about 65% of people with chronic fatigue syndrome report previous allergies. No hormonal abnormalities or mental health disorders have been shown to cause chronic fatigue syndrome.

Chronic fatigue syndrome seems to run in families, possibly supporting a genetic component or an environmental trigger. Alternatively, members of the same family may respond similarly to physical and psychosocial stress and/or may have been exposed to the same substances.

Some researchers believe the syndrome ultimately will prove to have several causes, including genetic predisposition and exposure to microbes, toxins, and other physical and emotional factors.

Symptoms

Most people who have chronic fatigue syndrome are successful and function at a high level until the disorder begins. The main symptom is fatigue that usually lasts at least 6 months and is severe enough to interfere with daily activities. Severe fatigue is present even on awakening and persists throughout the day. The fatigue often worsens with physical exertion or during periods of psychologic stress. However, physical evidence of muscle weakness or of joint or nerve abnormalities is rare. Extreme fatigue may begin during or after recovery from an illness that resembles a viral infection, with a fever, runny nose, and tender or painful lymph nodes. However, in many people, fatigue begins without any such preceding illness. Other symptoms that may occur are difficulty concentrating and sleeping, sore throat, headache, joint pains, muscle pains, and abdominal pain. Depression is common, particularly when symptoms are severe or worsening. Symptoms often overlap with those of fibromyalgia, a related disorder (see Fibromyalgia).

Diagnosis

No laboratory tests are available to confirm a diagnosis of chronic fatigue syndrome. Doctors therefore must rule out other diseases that may cause similar symptoms. Sometimes doctors do tests to rule out disorders such as anemia, electrolyte abnormalities, kidney failure, inflammatory disorders (such as rheumatoid arthritis), or thyroid or adrenal gland disorders. The diagnosis of chronic fatigue syndrome is made only if no other cause, including side effects of drugs, is found to explain the fatigue and other symptoms.

Treatment

In most cases, symptoms of chronic fatigue syndrome lessen over time. However, it often takes years for symptoms to subside, and not all symptoms disappear. People may recover more fully if they focus more on what function they can recover than on how much function they have lost.

Specific symptoms such as pain, depression, and poor sleep are treated. The only treatments proven effective for chronic fatigue syndrome itself are cognitive-behavioral therapy and graded exercise.

Cognitive-behavioral therapy is usually a brief course of psychotherapy aimed at redirecting hidden thoughts that could discourage people and prevent positive outlook and recovery.

Excessive periods of prolonged rest cause deconditioning and may actually worsen symptoms of chronic fatigue syndrome. Gradual introduction of regular aerobic exercise, such as walking, swimming, cycling, or jogging, under close medical supervision (called a graded exercise program) may reduce fatigue and improve physical function. Formal, structured physical rehabilitation programs may be best.

Many different drugs and alternative therapies have been tried. Although many treatments, such as antidepressants and corticosteroids, seem to make a few people feel better, none are clearly effective for all. It can be hard for people and doctors to tell what treatments work because symptoms are different in different people and because symptoms may come and go on their own.

Controlled clinical trials (see The Science of Medicine), which compare the benefits of a drug to those of a placebo (a substance that is made to resemble a drug but that does not contain an active drug), are the best way to test therapies, and no drug therapy has been shown to be effective in controlled trials. A number of treatments directed at possible causes, including use of interferons, intravenous injections of immune globulin, and antiviral drugs, have been mostly disappointing. Dietary supplements, such as evening primrose oil, fish oil supplements, and high-dose vitamins, are commonly used, but their benefits remain unproved. Other alternative treatments (for example, essential fatty acids, animal liver extracts, exclusion diets, and removal of dental fillings) have also been ineffective. Treatments that have no proven benefits are best avoided because they can have side effects.

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