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IS CHRONIC FATIGUE SYNDROME AND ITS SYMPTOMS?
syndrome (CFS), also sometimes called immune dysfunction syndrome
or myalgic encephalomyelitis (in Europe), is not a new disorder.
In the 19th century the term neurasthenia, or nervous exhaustion,
was applied to symptoms resembling CFS. 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.
Fatigue that lasts for more than six months, impairs normal activities,
and has no identifiable medical or psychological problems to account
for it is referred to as unexplained chronic fatigue. This condition,
however, is not considered to be chronic fatigue syndrome
unless it meets certain criteria [ see Box ]. If it does
not meet these criteria, then the condition is referred to as idiopathic
chronic fatigue . (Idiopathic simply means that the cause is
not known.) It should be noted that six million patient visits are
made each year because of fatigue, although only a very small percentage
of these can be attributed to actual chronic fatigue syndrome.
for Chronic Fatigue Syndrome
The Centers for Disease Control define CFS as a distinct disorder
with specific symptoms and physical signs after eliminating
other identifiable causes of these symptoms and signs.
1. Four or more of the following symptoms must have been present
for longer than six months:
fatigue must be severe as indicated by the following:
Short-term memory loss or a severe inability to concentrate
that affects work, school, or other normal activities.
Swollen lymph nodes in the neck or armpits.
Pain without redness or swelling in a number of joints.
Intense or changing patterns of headaches.
After any exertion, weariness that lasts for more than
fatigue must be a new, not lifelong, condition with a definite
time of onset. 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.
Sleep or rest does not relieve it.
The fatigue is not the result of excessive work or exercise.
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.
4. 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.
Note: Other symptoms reported with CFS but not part of the
criteria include intolerance to alcohol, irritable bowel syndrome,
dry eyes and mouth, impaired circulation in the hands and
feet, visual disturbances, and painful periods in women.
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 surveys,
chronic fatigue syndrome itself affects over four in every 1000
Americans (.4%) and is considered a serious health problem.
a large 1999 US study, the highest rates of CFS were found among
women in general, minority groups (African- and Hispanic-Americans),
and people with lower levels of education and occupational status.
Chronic fatigue is most often experienced by individuals 40 to 50
years old; it is least prevalent in people under 29 or over 60.
This disorder, however, occurs in both sexes and at all ages and
in all racial and ethnic groups.
Women. Although CFS occurs much more commonly in women, they
do not appear to have more severe symptoms than men with the disorder.
Ethnic Groups. Although previous research reports found that
Caucasian women have higher rates of CFS than women from other ethnic
groups, reports now indicate that such estimates most likely reflect
the greater socioeconomic ability of Caucasian women to receive
Stress-Related Occupations. 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 than those without
these experiences. This finding suggests, perhaps, that stressful
work puts people at higher risk for CFS.
Children. Children and adolescents are not immune to its
effects. Most studies indicate that girls are more apt to develop
CFS than boys, although one found the incidence of the syndrome
to be equal. According to a 1999 study, half of the children and
adolescents with CFS also suffer psychiatric disorders, primarily
anxiety, but also depression.
Personality and Psychologic Factors. Some researchers suggest
that people who are over-achievers may be more susceptible to chronic
fatigue because they set impossibly high standards for themselves
and CFS allows them to escape from them. Personality and psychological
factors do not appear to be a direct cause of CFS but may increase
a person's susceptibility to the syndrome after exposure to mental
or physical stresses, such as viral infections.
CAUSES CHRONIC FATIGUE SYNDROME?
Theories for Chronic Fatigue Causes
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, there are no
consistent biologic factors that would allow objective measures,
such as blood tests or brain scans, to definitively diagnose CFS.
Convergence of Factors. A number of experts believe that
CFS develops from a convergence of conditions that may include the
the majority of patients report some preceding moderate to serious
physical (eg, a chronic viral infection) or emotional event (eg,
episode of depression). Some experts theorize that such events alone
or in combination coupled in people with certain neurologic and
genetic abnormalities may trigger the event. Still, it is not clear
what sequence of events actually leads to the fatigue and other
prominent symptoms of this disorder. Nor is there any specific neurologic
abnormality that experts can point to with assurance.
- A hyper-reactive
or other infectious agents.
or emotional conditions.
Sudden- and Gradual-Onset CFS. One interesting theory is
that CFS can be categorized as either sudden- or gradual onset,
with each category having different causes. In little over half
of patients, the onset is sudden, while the remaining patients have
a slow onset. Some experts believe that sudden-onset CFS may be
triggered by a virus or neurologic abnormality, while gradual-onset
CFS might have a psychologic cause. Supporting this theory was a
study that observed that MRI scans of the brains of CFS patients
without an accompanying psychiatric problem showed small injuries
suggesting either a viral infection or neurologic problem.
Nervous System and Hormone 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.
Abnormalities in the Hypothalamus-Pituitary-Adrenal Axis. Of
particular interest to researchers are higher incidences of abnormalities
in the brain system known as the hypothalamus-pituitary-adrenal
axis. This system produces or regulates hormones and brain chemicals
that control important functions, including sleep, response to stress,
Stress Hormone Deficiencies. A number of studies on CFS
patients have observed deficiencies in cortisol levels, a stress
hormone produced in the hypothalamus. Deficiencies may be the reason
why CFS patients have an impaired and weaker response to psychologic
or physical stresses (such as infection or exercise).
Abnormalities in Neurotransmitters. Other research has reported
that some patients with CFS have abnormally high levels of serotonin,
a neurotransmitter (chemical messenger in the brain). Such elevated
levels in the brain are associated with fatigue. Yet another study
reported that deficiencies in dopamine, another important neurotransmitter,
may play a role in CFS.
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 some cases. There
are three basic theories for infection-related causes of CFS:
Still, not all
CFS patients show signs of infection.
- One 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.
theory posits that an abnormal immune response reactivates a
virus that had persisted in a latent (inactive) stage after
an initial infection.
- A psychologic
response to viral infections occurs in susceptible individuals.
Evidence that Supports a Viral Cause. The evidence for CFS
having a viral cause is not based on hard evidence but on various
observations that suggest an association, such as the following:
Does Not Support an Infectious Cause.
- In up
to 80% of cases, chronic fatigue syndrome starts suddenly with
a flu-like condition.
- In the
US, 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 found that previous infections
may play some role.
- Some researchers
are suggesting that changes in normally harmless bacteria found
in the intestine may play a role in the development of CFS symptoms.
no specific virus has been identified as a single cause, CFS
patients typically have elevated levels of antibodies
to many viruses that cause fatigue and other CFS symptoms, including
Lyme disease, candida ("yeast infection"), herpesvirus type
6 (HHV-6), human T cell lymphotropic virus (HTLV), Epstein-Barr,
measles, coxsackie B, cytomegalovirus, or parvovirus.
- Most cases
of CFS occur sporadically, cropping up individually without
appearing to be contagious.
is no evidence that CFS is spread through casual contact, such
as shaking hands or coughing, or by intimate sexual contact.
- No single
virus has been implicated in chronic fatigue syndrome. Well-designed
studies of patients who met strict criteria for chronic fatigue
syndrome and of patients with idiopathic chronic fatigue have
not found an increased incidence of any specific infections.
CFS has sometimes
been referred to as the "chronic fatigue immune dysfunction syndrome."
A number of studies have found many irregularities of the immune
system, although there is no consistent pattern. Some components
appear to be overreactive, whereas others appear to be underreactive.
Allergies. Some, although not all, studies have reported
that a majority of CFS patients have allergies to food, pollen,
metals (such as nickel or mercury), or other substances. (Most allergic
people, in any case, do not have CFS.) Some research indicates that
people with both allergies and emotional disorders, such as anxiety
or depression, may be more vulnerable to the effects of the inflammatory
response. This is a harmful overreaction of the immune response,
which triggers the release of a number of immune factors, that can
cause fatigue, joint aches, and fever, which can also affect the
hypothalamus-pituitary-adrenal system in the brain.
One theory that may help tie in some of the various factors common
to CFS suggests that allergies, stress, and infections may deplete
a chemical in the body called adenosine triphosphate (ATP). This
chemical stores energy in cells and studies have reported a deficiency
in many CFS patients. Supporting this theory was a study in which
patients reported reduced CFS symptoms after they took a coenzyme
called NADH, which increases ATP levels.
Autoimmune Abnormalities. The risk profile for chronic fatigue
syndrome is similar to the risk profiles for a number of autoimmune
diseases such as systemic lupus erythematosus, rheumatoid arthritis,
Sjögren's syndrome, and multiple sclerosis. These disorders
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, however, have found no evidence of an autoimmune
Overactive Immune System. In one study, some patients, particularly
those with severe CFS symptoms, had higher-than-normal numbers of
infection-fighting white blood cells known as CD8 killer T cells,
which launch attacks on invading viruses and other disease-causing
microorganisms. These same people had lower-than-normal levels of
another white blood cell known as the suppressor T cell, which helps
to shut down the immune response once the invading organisms have
been killed. In such cases, the immune system becomes persistently
overactive and produces fatigue, muscle aches, and other symptoms
Deficiencies in Natural Killer Cells. Other studies have
indicated lower amounts of so-called natural killer cells in many
CFS patients, which might make them more susceptible to viruses.
have observed that a subgroup of patients who fit the strict criteria
for chronic fatigue syndrome also have a condition known as neurally
mediated hypotension (NMH). 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. Its immediate effect can be light-headedness,
nausea, and fainting. Some experts posit that a virus or infection
may cause injury to the central nervous system that results in NMH.
One 1999 study suggested that patients with NHM-associated chronic
fatigue syndrome tend to be younger and to recover from CFS sooner
than patients whose symptoms are not related to NMH. A less severe
hypotension condition known as postural orthostatic tachycardia
syndrome (POTS) is also associated with CFS. Not all CFS patients
experience NMH and, in fact, one 2001 twin study found no higher
incidence of NMH in chronic fatigue patients. 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.
Deconditioning and Disturbed Circadian Rhythms
believe that CFS is a disorder of the sleep-wake cycle (the circadian
rhythm). Some argue that this disruption may be precipitated by
some mentally or physically stressful event, such as a virus. CFS
patients are unable to reset their natural rhythm, which then results
in a perpetual cycle of sleep disturbances. According to one theory,
this causes avoidance of activity that in turn leads to physical
debilitation, which is the primary cause of CFS symptoms. Nevertheless,
some studies, including one in 2001, observed that CFS patients
are no more physically unfit than sedentary non-CFS peers. The results
of these studies indicate then that CFS is not the result of physical
unfitness, but that the limited level of activity among CFS is due
to the fatigue and symptoms of disease itself.
personality, and social factors are strongly associated with chronic
fatigue in most, but not all patients. The complex relationship
between physical and emotional factor has yet to be fully understood,
however. Psychologic factors are unlikely to be a primary cause
of CFS, but they may play a role in increasing susceptibility to
onset or perpetuation of the disorder. In many cases, CFS also promotes
psychologic and social dysfunction.
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.
Hyperventilation. 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 can cause an imbalance in oxygen and carbon dioxide,
which may 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.
Abnormalities in the Vagus Nerve s. 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.)
Mutations in Mitochondria. One theory about the cause of
CFS, as well as fibromyalgia and other illnesses, concerns mutations
of the mitochondria, the part of each cell that supplies energy.
Inherited disorders involving mutations that affect mitochondria
are known to cause fatigue and muscle pain. One study reported that
a specific genetic mitochondrial mutation called cytochrome b was
associated with intolerance to exercise and aches and pains in a
group of patients who had no known family history of mitochondrial
genetic disease. In such cases, the mutation might have been due
to environmental assaults, such as viruses. More work is warranted
on this interesting observation to determine if such a mutation
may account for some cases of CFS.
Gulf War Syndrome and Chronic Fatigue
90,000 Gulf War veterans have reported symptoms resembling
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.
Symptoms of Gulf War Syndrome. Persian Gulf War veterans
have been intensively studied because of a high percentage
reporting symptoms that are similar to those in CFS. They
Causes of Gulf War Syndrome. Researchers in 2000 reported
evidence of injury to nerve clusters in the left side of the
brain in Gulf War Veterans with CFS symptoms, which support
chemical based injury. Among the theories for the cause of
such injuries or why certain veterans were susceptible to
it are the following:
confusion and lack of coordination,
joint and muscle pain,
fear of doing simple tasks,
weakness and incontinence.
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. Whether uncovering the causes of the syndrome in Gulf
War soldiers can be applied to civilian cases of CFS, however,
is not known.
During this period, many veterans were exposed to a number
of environmental toxins, including oil-well fires, pesticides,
insect repellents, pyridostigmine bromide (a drug used
to prevent injury from nerve gas), depleted uranium used
in tank armor and ammunition, and other harmful chemical
agents. A survey of 20,000 troops who were within 50 miles
of stockpiles of the nerve gas sarin reported no higher
incidence of serious nerve injury.
Some studies have heavily implicated multiple vaccinations
given to military personnel during the Gulf War (but not
those given before). In addition some specific vaccines,
such as anthrax or botlinum, may have adverse long-term
effects. 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.
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
from biological warfare.
Some experts suspect that post-traumatic stress syndrome
(PTSS) may be responsible for the symptoms in some cases.
Because PTSS may weaken the blood-brain barrier, some
experts believe this weakened barrier may allow agents,
such as small viruses, to pass into the brain causing
damage and triggering CFS symptoms.
IS CHRONIC FATIGUE SYNDROME DIAGNOSED?
and Medical History
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
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.
- 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?
including thyroid and liver function tests, blood count, and sedimentation
rate, are typically recommended to rule out specific conditions
causing persistent fatigue. No blood, urine, or other laboratory
test can specifically diagnose CFS. If any are abnormal, they are
not useful for diagnosing chronic fatigue syndrome specifically
and the physician should look for other causes of these abnormalities.
In academic centers
where CFS is studied, a series of tests may be performed to measure
immune factors or specific proteins or substances that may eventually
prove to be causes or markers of chronic fatigue syndrome. For example,
a urine test detecting high levels of 5-HIAA, a product of the neurotransmitter
serotonin, may prove to be a reliable diagnostic tool for CFS. Of
particular interest is an enzyme called RNase L, which is part of
the immune defense system and degrades genetic material in viruses.
In one study 88% of CFS patients had a specific form of this enzyme
that only 28% of non-patients had.
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).
Test for Neurally Mediated Hypotension
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.
Conditions That Rule Out Chronic Fatigue Syndrome
Among the many
other common conditions that can lead to feelings of temporary exhaustion
are the following:
In most of these
cases, fatigue can be relieved with adequate rest. It is important
to note that persistent fatigue can be the harbinger of a serious
medical or psychological problem. A number of more serious conditions
may cause persistent fatigue and other symptoms of CFS and should
be ruled out. Patients and physicians should not overlook these
diseases, even if they have been previously treated, but which may
not have completely resolved or may cause residual fatigue. Physicians
can usually distinguish these diseases from CFS after a clinical
evaluation and laboratory testing.
Infectious Mononucleosis and Epstein-Barr Virus. Infectious
mononucleosis is marked by fatigue and swollen glands. It primarily
affects adolescents and young adults. Some patients may have lingering
fatigue that last for many months and blood tests that indicate
a persistence of the Epstein-Barr virus (EBV), which causes mononucleosis.
At one time, based on these cases, some experts believed that EBV
would turn out to be the cause of chronic fatigue syndrome. However,
many healthy persons without CFS have the same signs of low-level
EBV infection, and, conversely, many patients with CFS show 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.
Autoimmune Diseases. Some diseases, including systemic lupus
erythematosus, multiple sclerosis, and rheumatoid arthritis, are
caused by autoimmunity, a condition in which the person's
immune system attacks the body's own tissues. The early symptoms
of these conditions may mimic some of those that appear in CFS,
such as muscle and joint pain and fatigue. These diseases, like
CFS, also occur more often in women than in men. Autoimmune 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. (It should
also be noted that some experts are concerned that many patients
who actually have CFS will be mistakenly diagnosed with these diseases,
particularly multiple sclerosis, and subjected to unnecessary treatments.)
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. If CFS patients
are mistakenly diagnosed and treated for Lyme disease, they may
take prolonged courses of antibiotics that induce resistance to
the antibiotics, ultimately doing more harm than good.
Psychosis and Severe Mental Disorders. The Centers for Disease
Control, which set up the definitions in the US 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. Certain sleep disorders may cause persistent
fatigue and be confused with CFS:
[For more information
on sleep disorders , see the Reports Insomnia,
Leg Disorders, and Narcolepsy .]
apnea is a common disorder that can cause daytime fatigue without
the patient being aware of the problem. This is actually 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.
is a peculiar and rare disorder in which a person suddenly falls
asleep without any previous signs of fatigue.
sleep disorders that cause daytime fatigue include insomnia
and restless legs syndrome.
Conditions that Cause Joint Pain, Muscle Aches, or Both. A
number of illnesses cause one or more of CFS symptoms including
arthritic symptoms, fever, and fatigue [ see Table, below].
Other Diseases that Cause Joint Pain, Muscle Aches, or Both
Rheumatic Autoimmune Diseases
Rheumatoid arthritis, systemic vasculitis, systemic lupus
erythematosus, scleroderma, Still's Disease (also called juvenile
rheumatoid arthritis) Behcet's disease
Lyme disease, septic arthritis, bacterial endocarditis, mycobacterial
and fungal arthritis, viral arthritis
Postinfectious or Reactive Arthritis
Reiter's syndrome (a disorder characterized by arthritis and
inflammation in the eye and urinary tract), rheumatic fever,
inflammatory bowel disease
Crystal Induced Arthritis
Gout and pseudogout
Fibromyalgia (Does not necessarily rule out accompanying CFS)
Hepatitis C, familial Mediterranean fever, cancers, AIDS,
leukemia, bunions, Whipple's disease, dermatomyositis, Henoch-Schonlein
purpura, Kawasaki's disease, erythema nodosum, erythema multiforme,
pyoderma gangrenosum, pustular psoriasis
Other Medical Conditions that Usually Rule out CFS. 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.
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.
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.
That Do Not Rule Out Chronic Fatigue Syndrome
conditions cause symptoms similar to CFS but they can overlap and
so their presence does not necessarily rule CFS out as a co-disorder.
In fact, CFS patients appear to be at high risk for developing additional
health problems, particularly those with similar symptoms (eg, fibromyalgia,
irritable bowel syndrome, chronic pelvic pain, chemical sensitivities,
and temporomandibular disorder). Some tests may be positive for
other diseases that cause CFS-like symptoms but if the results are
ambiguous or weak, CFS should not be ruled out. If a physician can
verify that another similar disease has been treated adequately
but symptoms of chronic fatigue still persist, then CFS may be present.
Fibromyalgia. Fibromyalgia causes prolonged fatigue and widespread
muscle aches and is the disease most often confused with CFS. In
fact, many experts believe fibromyalgia is simply another variant
of chronic fatigue syndrome. One researcher compared the relationship
of fibromyalgia to chronic fatigue as that of migraine to headache.
A characteristic feature of fibromyalgia is the existence of at
least 10 distinct sites of deep muscle tenderness that hurt when
touched firmly. The sites often include the following:
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.
[For more information,
- 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.
Depression and Anxiety. The link between psychological disorders
and chronic fatigue syndrome is problematic because so many of the
symptoms overlap. A number of physicians, in fact, believe that
chronic fatigue is not a physical illness but can be attributed
to emotional disorders, particularly depression. In any case, the
relationship between CFS and emotional disorders is highly interrelated.
Many patients who are diagnosed with CFS report having felt depressed
before the onset of chronic fatigue. Many other CFS patients, however,
felt alert and mentally healthy before the onset of CFS symptoms.
Many of these previously healthy patients become depressed and anxious
because they feel so exhausted all the time. CFS may also lead to
highly stressful socioeconomic situations, such as social isolation
and poverty, that can contribute to and even cause emotional disorders
in susceptible individuals, which in turn can worsen CFS.
Depression, in any case, is very common in the general population,
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 major depression include the following:
is likely to be the responsible condition in the presence of several
of these symptoms and in the absence of physical symptoms (such
as sore throat, aches and pains, or fever). And the longer fatigue
has continued without such physical symptoms, the more likely the
diagnosis is depression.
- a depressed
mood every day,
weight gain or loss (of 10% or more of an individual's typical
or excessive sleeping,
or a sense of being slowed down.
- low energy
or inappropriately guilty feelings.
- an inability
to concentrate or to make decisions,
A persistent form of minor depression called dysthymia, however,
may be more difficult to differentiate from CFS and may actually
account for a subset of CFS cases. Dysthymia is characterized by
many of the same symptoms that occur in major depression but they
are less intense and last much longer, at least two years. The symptoms
of dysthymia have been described as a "veil of sadness" that covers
most activities. [For more information,
Other Conditions that Do not Rule out CFS. A number of other
conditions also often co-exist with CFS and, in fact, occur at higher-than-average
rates among CFS patients:
conditions can also co-exist with CFS. For example, chronic fatigue
and pain can be caused by exposure to various chemicals and environmental
toxins, such as solvents, pesticides, or heavy metals (cadmium,
mercury, or lead, for example).
SERIOUS IS CHRONIC FATIGUE SYNDROME?
of Physical Symptoms
severity of chronic fatigue syndrome varies:
Studies may under-report
the severity of the condition because severely disabled patients
may have difficulty getting to and from sites where studies are
being conducted and so would not be able to participate. Some medical
centers, in fact, do not accommodate the disabled CFS patients with
the same consideration or resources (eg, wheelchairs, beds) that
would be given patients with more identifiable disorders, such as
- In extreme
cases, patients are bedridden and can do virtually nothing,
including even light housework.
- Most commonly,
patients with CFS report that they have trouble fulfilling both
home and work responsibilities. CFS sufferers typically work
say that while fatigue is the most incapacitating symptom, those
of mental impairment, such as an inability to concentrate, are the
most distressing. The effects of CFS on mental functioning are complex:
- 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. Some experts argue
that the perceived differences in mental functioning are due
to emotional problems. (Mental tests used in studies are usually
performed in a doctor's office or clinical setting, however.
Positive results then may 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.)
Outlook in Adults
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 studies have reported that between 58% and 72% of patients
who complain of chronic fatigue (whether CFS or idiopathic fatigue)
continue to experience it after a year and in one study nearly 60%
were still fatigued at two years. Even if patients get progressively
worse, however, the disorder is not fatal and patients can expect
a normal life span. The outlook for specific individuals my depend
on certain factors.
Sudden or Gradual Onset. Some studies 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.
Severity of CFS. Many patients with moderate chronic fatigue
have reported turning a corner after a year or two and slowly regaining
energy despite some setbacks along the way. One small 1999 study
observed that even after four years few patients with severe CFS
had returned to their pre-illness state. It should be noted, however,
that in another study, patients with severe CFS who were treated
with a multidisciplinary rehabilitation program, nearly all improved
significantly and the gains were maintained for at least a year
Signs of Positive Outlook. According to one study, CFS patients
who are more likely to experience improvement over time have the
following positive signs:
- Can think
clearly most of the time.
- Have no
other physical or emotional complaints beyond CFS symptoms.
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 between two-thirds
and 95% of cases.
LIFE STYLE MEASURES CAN HELP MANAGE CHRONIC FATIGUE SYNDROME?
One study found
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. Unfortunately, CFS patients have a lower
exercise capacity than healthy individuals, and in fact over-exercising
can intensify symptoms. Some patients experience profound fatigue
following even modest exercise. It is the primary factor in the
low-activity levels in these patients.
The following tips may be helpful when embarking on an exercise
slowly and incrementally, beginning with as little as three
to five minutes of moderate exercise a day. The goal is to increase
activity by about 20% every two to three weeks. (Capacity varies
greatly among CFS sufferers, however, and some may not be able
to achieve this.)
limits and keep within them in order to avoid overexertion and
with different forms of physical activity that suit available
energy levels. Some patients report great benefits from Yoga
or Tai chi, which combine exercise with meditation.
will occur, but patients should not become discouraged.
syndrome patients should be sure to maintain a healthy diet that
includes the following:
of fresh dark-colored fruits and vegetables, which are rich
- Some fats
may be beneficial, but avoid saturated fats (found in animal
products). A few studies reported some improved symptoms in
patients who consumed black currant and fish oils (sold in supplement
form as EPA-DHA omega 3). These oils contain a fatty acids that
help block certain immune factors responsible for damaging inflammation.
- For those
with demonstrated low blood pressure, increasing the amount
of salt in the diet may be helpful.
One panel of
experts concluded that 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. A number of relaxation techniques
[For more information,
- deep breathing
relationships with family and friends may be an important factor
in the overall improvement of CFS patients. It should be strongly
noted, however, that many CFS patients are overly dependent and
should not impose expectations that cannot be met on loved ones.
Ongoing support groups with fellow patients may very helpful. In
one 2001 study, sharing experiences in a group therapy setting proved
to be the most valuable component and one that improved patients'
sense of coherence and coping abilities.
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. No scientific
evidence exists that vitamin and mineral supplements will relieve
CFS, but taken in moderation, they are usually not harmful. A number
of herbal medicines have been used for chronic fatigue syndrome.
Most have not proven to be effective and some may even be harmful
[See Warning Box.] One positive study concerned St. John's Wort,
which is being investigated for mild depression. In the study, the
herbal agent improved fatigue in CFS patients, even in those who
did not consider themselves to be depressed.
Warnings on Alternative and So-Called Natural Remedies
be strongly noted that alternative or natural remedies are
not regulated and their quality is not publicly controlled.
In addition, any substance that can affect the body's chemistry
can, like any drug, produce side effects that may be harmful.
There have been a number of reported cases of serious and
even lethal side effects from herbal products. In addition,
some so-called natural remedies were found to contain standard
prescription medication. Most problems reported occur in herbal
remedies imported from Asia, with one study reporting a significant
percentage of such remedies containing toxic metals. Even
if studies report positive benefits, most, to date, are very
small. In addition, the substances used in such studies are,
in most cases, not what are being marketed to the public.
CFS patients should be wary of those that promise a cure or
urge the purchase of expensive but useless and sometimes potentially
dangerous treatments, such as the following:
website is building a database of natural remedy brands that
it tests and rates. Not all are available yet. https://www.ConsumerLab.com/
Hydrogen peroxide injections (which can cause blood clots
Megadoses of vitamins (which can be toxic). Supplements
of folic acid, vitamin B12, and vitamin B15 (also called
pangamic acid) have shown no benefit.
High colonic enemas.
Bee pollen (which can cause an allergic reaction).
Injections of liver extract, or superoxide dismutase (SOD).
Of particular note for CFS patients 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.
The Food and Drug Administration has a program called MEDWATCH
for people to report adverse reactions to untested substances,
such as herbal remedies and vitamins (call 800-332-1088).
IS CHRONIC FATIGUE SYNDROME TREATED?
The criteria used for studying CFS are very helpful, particularly
if the patient does not have any accompanying disorder, such as
depression or arthritis, that could complicate the diagnosis. They
are not used, however, on specific diagnosis of individuals. [See
Box Criteria for Studying CFS.]
There is no proven or reliable cure for CFS, and no drug has been
developed specifically for this disorder. 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. Little significant research, however, is being conducted
on treatments for CFS. For example, there were no major trials on
drug therapies on either CFS or fibromyalgia reported during 2000.
In one study,
CFS patients who reported the severest symptoms also believed they
had the least control over them. Cognitive behavioral therapy is
designed to help patients control symptoms and is proving to have
substantial benefits for these patients. In fact, some experts believe
that patients who are diagnosed with CFS should immediately be referred
to therapists trained in cognitive behavioral therapy. (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.)
The Goals of Cognitive-Behavioral Therapy. The primary goals
of cognitive-behavioral therapy are to change any distorted perceptions
that individuals have of the world and of themselves and to change
their behavior accordingly. For CFS patients, this means learning
to think differently about their fatigue and to improve their ability
to deal with stressful situations and manage their disorder. Cognitive
therapy is particularly helpful in defining and setting limits,
behaviors that are extremely important for these patients.
The Procedure . Cognitive therapy may be expensive and not
covered by insurance, although it is usually of short duration,
typically six to 20 one-hour sessions. Patients are also given homework,
which usually includes keeping a diary and attempting tasks that
they have avoided because of negative thinking.
A typical cognitive therapy program may involve the following measures:
Using both self-observation
and specific tasks, 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.
- Keep a
Diary. The patient is almost always asked to keep 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.
Schedule. The patient adjusts schedules to conform to energy
peaks and valleys recorded in the diary. 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.
Negative or Discouraging Thoughts. Patients are taught to challenge
and reverse negative beliefs ("eg, I'm not good enough to control
this disease, so I'm a total failure.") to using coping statements
("Where is the evidence that I can control this disease?")
- Be Flexible.
Energy levels will most likely never be entirely predictable.
Patients must also be prepared to adapt to energy variations.
Instead of a long nap, for instance, patients may need five
to 10 minutes rest periods every hour or more, during which
time relaxation or meditation methods are useful.
- Set Limits.
Limits are 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. For example, tasks are broken down into incremental
steps and patients focus on one at a time.
Patients learn to drop some of the less critical tasks or delegate
them to others.
Impaired Concentration. Patients seek out activities that are
appealing, focus attention, and help increase alertness. They
learn to request instructions given as concise simple statements.
External distractions, such as music or talking, are kept to
Relapses. Over-coping and accomplishing too much too soon can
often cause a relapse of symptoms. Patients should respect these
relapses and back off. They should not consider them a sign
of treatment- or self-failure.
Success Rates. The following are some studies reporting results
on the cognitive therapy approach:
Not all studies
support the benefits of cognitive therapy; the skill of the therapist
is very important in its success. 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
- 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 functioning
normally after a year, as opposed to only 27% of those who received
- In another
study, 70% of patients improved significantly after six months
of cognitive therapy, compared to 19% who used only relaxation
- A 2001
study found that patients' symptoms of fatigue and daily functioning
improved significantly more after cognitive therapy than with
guided support groups.
- Some experts
believe that this approach may be particularly important for
victims of Gulf War syndrome, whether or not the cause turns
out to be the same as for CFS or nerve gas toxins since there
are no other proven treatments for either condition.
Supported Graded Exercise
In one 2001 study, patients were provided with medical reports suggesting
that their disorder was due to a physiologic disruption of their
biologic rhythms, which led to inactivity and caused a cycle of
poor physical condition and CFS symptoms. They were then encouraged
to engage in a self-managed graded exercise program. Over 80% of
patients reported improvement in many symptoms. The benefits persisted
for at least a year, although 32% of patients still complained of
fatigue at the end of this period. In the study, this approach was
less expensive and as successful as cognitive behavior therapy.
It should be noted, however, that no proof exists that CFS is caused
by physical unfitness, and, in fact, a number of studies suggest
that CFS limits exercise and causes poor conditioning. Excessive
exercise can even exacerbate symptoms. Opponents of the study also
argue that the subjects were not selected according to the latest
criteria for CFS and many may simply have depression-related fatigue.
There were also other methodological problems. Still, the improvement
experienced by many patients warrants further study. [Also see Exercise
under What Life Style Measures Can Help Manage Chronic Fatigue Syndrome?]
Because of the
association between depression and CFS, antidepressants are often
tried with varying degrees of success, depending on the type:
Common side effects
of many antidepressants include dry mouth, restlessness, reduced
sexual drive, a slightly increased heart rate, and constipation.
Virtually all antidepressants have complicated interactions with
other drugs, some are very serious. [For more details on these agents,
Antidepressants. Antidepressants known as tricyclics may
be particularly helpful for CFS patients. For example, the tricyclic
amitriptyline (Elavil) is known to relieve many of the symptoms
of CFS, including sleeplessness and low energy levels. Improvement
in symptoms can take three to four weeks. Other tricyclics include
doxepin (Sinequan), desipramine (Norpramin), nortriptyline (Pamelor),
clomipramine (Anafranil), and imipramine (Tofranil, Janimine).
These agents can have severe side effects, although patients
with CFS normally respond to much lower doses than those used
to treat people with depression. In fact, many CFS patients
cannot tolerate the higher doses commonly used to treat the
psychiatric disorder. Like all medications, tricyclics must
be taken as directed; overdose can be life threatening.
Oxidase Inhibitors (MAOIs). Monoamine oxidase inhibitors
(MAOIs) block the enzyme monoamine oxidase, which has negative
effects on many of the neurotransmitters that are important
for well being. In one study moclobemide, a newer MAOI, was
associated with improved energy levels in CFS patients regardless
of whether they are depressed or not. Other MAOIs are likely
to have similar effects. The most serious side effect of MAOIs
is severe hypertension, which can be brought on by eating certain
foods having a high tyramine content. Such foods include aged
cheeses, most red wines, sauerkraut, vermouth, chicken livers,
dried meats and fish, canned figs, fava beans, and concentrated
yeast products. They also have serious interactions with a number
of medications and should not be taken by pregnant women.
The popular antidepressants known as selective serotonin-reuptake
inhibitors (SSRIs) appear to have little value for CFS beyond
treating any accompanying depression. They include fluoxetine
(Prozac), sertraline (Zoloft), and Paroxetine (Paxil).
Antidepressants. Newer, so-called designer SSRIs, including
nefazodone (Serzone) or mirtazapine (Remeron) affect combinations
of different neurotransmitters, and some may have moderate benefits
for CFS patients. For example in one study nefazodone improved
mood, fatigue, and sleep disturbances.
Anti-Inflammatory Drugs (NSAIDs)
anti-inflammatory drugs (NSAIDs) are common pain relievers that
reduce inflammation. They include, among many others, aspirin, ibuprofen
(Motrin, Advil, Nuprin, Rufen), and naproxen (Aleve, Naprosyn, Naprelan,
Anaprox). Although NSAIDs can work very effectively against symptoms,
long term use can trigger gastrointestinal problems such as upset
stomachs, ulcers, and internal bleeding. [ See Box Ulcer
Risk for Specific NSAIDs.]
NSAIDs can also increase blood pressure, particularly among people
already being treated for hypertension. About 12% to 15% of elderly
people take both an NSAID and an antihypertensive drug. Piroxicam,
naproxen, and indomethacin appear to pose the greatest risk of high
blood pressure. Sulindac has the smallest effect.
Other side effects of NSAIDs include dizziness, ringing in the ears,
headaches, skin rashes, and possibly depression. Studies have appeared
suggesting that high doses of NSAIDs can damage cartilage, and there
have also been reports that NSAIDs can cause kidney damage (which,
however, resolves once the patient stops using the drug). People
with high blood pressure, severe circulation disorders, or kidney
or liver problems, as well as people taking diuretics or oral hypoglycemics,
must be closely monitored if they need to use NSAIDs on a long-term
basis. Because NSAIDs reduce blood clotting, NSAID users scheduled
for surgery should stop taking those drugs a week before the operation.
to Protect Against NSAID-Induced Ulcers. Some agents available
to protect against NSAID-induced ulcers include the following:
Ulcer Risk for NSAIDs
at Risk? In the US the effects of NSAIDs are responsible
for more than 100,000 hospitalizations and 16,500 deaths each
year. Research has suggested that 7.3 of every 1000 osteoarthritic
patients who regularly take NSAIDs will suffer a major gastrointestinal
complication in the course of a year. The elderly, smokers,
and alcohol abusers are at particular risk for such complications.
The risk for bleeding is continuous for as long as a patient
is on these drugs and may even persist for about a year after
taking them. Although short courses of NSAIDs for temporary
pain relief should not cause major problems, of concern was
a 1998 study indicating that taking NSAIDs for only six months
posed a risk for symptomatic ulcers that was greater than
1%. Regular use of even over-the-counter NSAIDs may be hazardous
One study ranked the sixteen most commonly used NSAIDs according
to risk for ulcers and bleeding.
Lowest risk: nabumetone (Relafen), etodolac (Lodine),
salsalate, and sulindac (Clinoril).
Medium risk: diclofenac (Voltaren), ibuprofen (Motrin,
Advil, Nuprin, Rufen), aspirin, naproxen (Aleve, Naprosyn,
Naprelan, Anaprox), and tolmetin (Tolectin). Drugs within
this group vary in risk. Studies show, for example, that
short-term use of naproxen is twice as likely as ibuprofen
to be associated with hospitalization from GI bleeding.
Although ketoprofen (Actron, Orudis KT) was considered
a medium-risk drug, another study reported that even one
week of taking the drug at low doses causes significant
Highest risk: flurbiprofen (Ansaid), piroxicam (Feldene),
fenoprofen, indomethacin (Indocin), meclofenamate (Meclomen),
inhibitors are the first choice for preventing ulcers in high-risk
individuals. They are well tolerated and may even heal existing
ulcers. Such drugs include omeprazole (Prilosec), lansoprazole
(Prevacid), rabeprazole (Aciphex), and pantoprozole. They may
reduce NSAID-ulcer rates by as much as 80% compared with no
is a prostaglandin, the protective substance blocked by NSAID
use. It is used to prevent NSAID-induced ulcers, both duodenal
and gastric, but is not useful in healing existing ulcers. (Arthrotec
is a combination of misoprostol and the NSAID diclofenac. One
study found that patients taking Arthrotec had 65% to 80% fewer
ulcers than those who took NSAIDs alone.
rofecoxib (Vioxx), and meloxicam (Mobic) are known as COX-2 (cyclooxygenase-2)
inhibitors, the so-called super-aspirins. Standard NSAIDs block
two enzymes called cyclooxygenase 1 and 2 (COX-1 and -2). The new
drugs block COX-2 (responsible for most inflammatory effects) but
not COX-1 (which normally protects the stomach).
Short-term studies comparing them to a number of NSAIDs are indicating
that they may be as effective and less harmful to the GI tract than
NSAIDs. Theoretically, they may even have properties that produce
less adverse effects on cartilage than NSAIDs may have. Some studies
have found that patients taking COX-2 inhibitors have the same gastrointestinal
symptoms (eg, diarrhea, abdominal discomfort) as standard NSAIDs.
(Other side effects found with short-term use include headache and
dizziness.) Nevertheless, studies that have actually examined patients
for ulcers have found far fewer with the use of the COX-2 inhibitors.
Importantly, a 2000 well-controlled study of celecoxib reported
a lower incidence of ulcers and other toxic side effects than in
patients taking ibuprofen or diclofenac. One 1999 study even found
that the rate of GI problems with celecoxib was equal to that in
people who do not take NSAIDs at all.
Still, long-term side effects are unknown, and some researchers
theorize that inhibiting COX-2 may have some negative as well as
positive results. One 2000 study observed that the COX-2 inhibitors
had some adverse effects on kidney function, particularly in elderly
people, that were similar to the effects of standard NSAIDs. Patients
taking anticoagulant drugs may experience a higher risk for bleeding
with the use of these agents. A few cases of psychiatric side effects
(hallucinations), fluid build up, high blood pressure, and excess
potassium in the blood has been observed with higher doses of celecoxib
or rofecoxib. They may have negative effects on pregnancy and fertility;
more research is needed to determine this. They are currently more
expensive than traditional NSAIDs, and some insurers do not pay
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. 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
Life Style Changes. For treating NHM, the physician might
first recommend nonmedicinal measures:
If the condition does not improve, certain medications may be
tried in combination or alone. Midodrine (ProAmatine), for example,
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.
salt content in the diet may be warranted in patients with demonstrated
low blood pressure.
beverages may be helpful.
exercises before getting out of bed that flex the feet so that
the blood moves up toward the head.
excessive activity after meals.
support garments may help to prevent circulating blood from
pooling in the lower part of the body and to return it to the
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 the following:
or ibuprofen (nonsteroidal anti-inflammatory drugs or NSAIDs).
(an anti-arrhythmic drug).
(drugs normally used to prevent hypertension).
erythropoietin epoetin alfa (used to increase red blood cells).
(Florinef), an oral steroid used for low blood pressure, has
been tested on CFS subjects with NMH but studies in 2000 and
2001 reported no benefits.
exists that 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, increased appetite, weight gain,
and, more seriously, suppression of the adrenal gland, make this
therapy unacceptable. One 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.
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, many patients have
reported adverse effects, and longer studies are needed.
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,
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 awakening in the
A natural antioxidant
agent called nicotinamide adenine dinucleotide, or NADH (Enada),
is also in trials. This substance boosts serotonin and triggers
adenosine triphosphate (ATP), a molecule found in every cell and
which is necessary for conversion of food into energy. Small studies
are reporting improved symptoms in patients taking it even after
18 months. Although the studies are small, these results showed
ELSE CAN HELP BE FOUND FOR CHRONIC FATIGUE SYNDROME?
chronic fatigue syndrome are not only physically and emotionally
debilitated, but may feel humiliated by their inability to cope
with everyday activities. Family and friends are also affected.
Even loved ones may react with anger and suspicion instead of the
sympathy and support essential for people with this disorder. Fortunately,
excellent reputable support associations composed of others who
suffer CFS are now available that offer advice, solace, and current
information. Patients should be careful, however, of groups or organizations
that market products, unproved remedies, and misinformation. The
Internet offers invaluable help and support for people with many
disorders, but patients should beware of web sites that are sponsored
by self-interested groups or companies.
The Chronic Fatigue and Immune Dysfunction Syndrome Association
of America, PO Box 220398, Charlotte, NC 28222-0398. Call (800-44-CFIDS
or 3437) or on the Internet (https://www.cfids.org)
National Chronic Fatigue Syndrome and Fibromyalgia Association,
PO Box 18426, Kansas City, MO 64133. Call (816-313-2000)
This organization is a good source of accurate information on CFS.
Send self-address envelope for information. They will return phone
calls using a collect call.
American Association for Chronic Fatigue Syndrome, c/o Harborview
Medical Center, 325 Ninth Avenue, Box 359780, Seattle, WA 98104.
Call (206-521-1932) or on the Internet (https://www.AACFS.org/)
Formed by health professionals to promote dissemination of information
Journal of Chronic Fatigue Syndrome (https://www.cfs-news.org/)
Centers for Disease Control and Prevention, Division of Viral Diseases,
Building 6, Rm. 120, Atlanta, GA 30333. Call (404-332-4555) or on
the Internet (https://www.cdc.gov/ncidod/diseases/cfs/)
American Chronic Pain Association, P.O. Box 850, Rocklin, CA 95677.
Call (916) 632-0922 or on the Internet (https://www.theacpa.org/)
National Chronic Pain Outreach Association.
7979 Old Georgetown Road, Suite 100, Bethesda, MD 20814-2429. Call
(301) 652-4948, or on the internet at https://neurosurgery.mgh.harvard.edu/ncpainoa.htm
American Pain Society, 4700 W. Lake Avenue, Glenview, IL 60025.
Call (847-375-4715) or on the Internet (https://www.ampainsoc.org/)
International Association for the Study of Pain, 909 NE 43rd St.,
Suite 306, Seattle, WA 98105-6020. Call (206-547-6409) or on the
National Institute of Allergy and Infectious Diseases (NIAID), Office
of Communications, Building 31, Rm. 7A50, 31 Center Dr., MSC 2520,
Bethesda, MD 20892-2520. Write for the publication Chronic Fatigue
Syndrome, NIH Publication No. 96-484
or on the Internet (www.niaid.nih.gov).
Herb Research Foundation. 1007 Pearl St., Suite 200, Boulder, CO
80302. Call (303) 449-2265, or on the internet, (https://www.
herbs.org). A non-profit research institute that sells information
on the health effects of herbs.
ConsumerLab, on the internet at https://www.consumerlab.com.
Provides research on the quality of herbal products and dietary
MEDWATCH, a Food and Drug Administration program called for people
to report adverse reactions to medical products, including drugs,
herbal remedies and vitamins. Call 800-332-1088.
American Association of Medical Acupuncture, 5820 Wilshire Blvd.,
Suite 500, Los Angeles, CA 90036. On the internet, https://www.medicalacupuncture.org.
This organization will provide information about physician acupuncturists
in particular areas.
The following Internet site offers many links and many sources of
information for those who want a broad selection.