Chronic Fatigue No Longer Seen as 'Yuppie Flu'

By DAVID TULLER Published: July 17, 2007

Correction Appended For decades, people suffering from chronic fatigue syndrome have struggled to convince doctors, employers, friends and even family members that they were not imagining their debilitating symptoms. Skeptics called the illness yuppie flu and shirker syndrome.

Heidi Schumann for The New York Times

Donna Flowers, who became ill with chronic fatigue syndrome several years ago after a bout of mononucleosis, working out in her home in Los Gatos, Calif., while taking care of her twins.

But the syndrome is now finally gaining some official respect. The Centers for Disease Control and Prevention, which in 1999 acknowledged that it had diverted millions of dollars allocated by Congress for chronic fatigue syndrome research to other programs, has released studies that linked the condition to genetic mutations and abnormalities in gene expression involved in key physiological processes. The centers have also sponsored a $6 million public awareness campaign about the illness. And last month, the C.D.C. released survey data suggesting that the prevalence of the syndrome is far higher than previously thought, although these findings have stirred controversy among patients and scientists. Some scientists and many patients remain highly critical of the C.D.C.s record on chronic fatigue syndrome, or C.F.S. But nearly everyone now agrees that the syndrome is real. People with C.F.S. are as sick and as functionally impaired as someone with AIDS, with breast cancer, with chronic obstructive pulmonary disease, said Dr. William Reeves, the lead expert on the illness at the C.D.C., who helped expose the centers misuse of chronic fatigue financing. Chronic fatigue syndrome was first identified as a distinct entity in the 1980s. (A virtually identical illness had been identified in Britain three decades earlier and called myalgic encephalomyelitis.) The illness causes overwhelming fatigue, sleep disorders and other severe symptoms and afflicts more

women than men. No consistent biomarkers have been identified and no treatments have been approved for addressing the underlying causes, although some medications provide symptomatic relief. Patients say the word fatigue does not begin to describe their condition. Donna Flowers of Los Gatos, Calif., a physical therapist and former professional figure skater, said the profound exhaustion was unlike anything she had ever experienced. I slept for 12 to 14 hours a day but still felt sleep-deprived, said Ms. Flowers, 51, who fell ill several years ago after a bout of mononucleosis. I had what we call brain fog. I couldnt think straight, and I could barely read. I couldnt get the energy to go out of the door. I thought I was doomed. I wanted to die. Studies have shown that people with the syndrome experience abnormalities in the central and autonomic nervous systems, the immune system, cognitive functions, the stress response pathways and other major biological functions. Researchers believe the illness will ultimately prove to have multiple causes, including genetic predisposition and exposure to microbial agents, toxins and other physical and emotional traumas. Studies have linked the onset of chronic fatigue syndrome with an acute bout of Lyme disease, Q fever, Ross River virus, parvovirus, mononucleosis and other infectious diseases. Its unlikely that this big cluster of people who fit the symptoms all have the same triggers, said Kimberly McCleary, president of the Chronic Fatigue and Immune Dysfunction Syndrome Association of America, the advocacy group in charge of the C.D.C.-sponsored awareness campaign. Youre looking not just at apples and oranges but pineapples, hot dogs and skateboards, too. Under the most widely used case definition, a diagnosis of chronic fatigue syndrome requires six months of unexplained fatigue as well as four of eight other persistent symptoms: impaired memory and concentration, sore throat, tender lymph nodes, muscle pain, joint pain, headaches, disturbed sleeping patterns and post-exercise malaise. The broadness of the definition has led to varying estimates of the syndromes prevalence. Based on previous surveys, the C.D.C. has estimated that more than a million Americans have the illness. Last month, however, the disease control centers reported that a randomized telephone survey in Georgia, using a less restrictive methodology to identify cases, found that about 1 in 40 adults ages 18 to 59 met the diagnostic criteria an estimate 6 to 10 times higher than previously reported rates. However, many patients and researchers fear that the expanded prevalence rate could complicate the search for consistent findings across patient cohorts. These critics say the new figures are greatly

inflated and include many people who are likely to be suffering not from chronic fatigue syndrome but from psychiatric illnesses. There are many, many conditions that are psychological in nature that share symptoms with this illness but do not share much of the underlying biology, said John Herd, 55, a former medical illustrator and a C.F.S. patient for two decades. Researchers and patient advocates have faulted other aspects of the C.D.C.s research. Dr. Jonathan Kerr, a microbiologist and chronic fatigue expert at St. Georges University of London, said the C.D.C.s gene expression findings last year were rather meaningless because they were not confirmed through more advanced laboratory techniques. Kristin Loomis, executive director of the HHV-6 Foundation, a research advocacy group for a form of herpes virus that has been linked to C.F.S., said studying subsets of patients with similar profiles was more likely to generate useful findings than Dr. Reevess population-based approach. Dr. Reeves responded that understanding of the disease and of some newer research technologies is still in its infancy, so methodological disagreements were to be expected. He defended the populationbased approach as necessary for obtaining a broad picture and replicable results. To me, this is the usual scientific dialogue, he said. Dr. Jose G. Montoya, a Stanford infectious disease specialist pursuing the kind of research favored by Ms. Loomis, caused a buzz last December when he reported remarkable improvement in 9 out of 12 patients given a powerful antiviral medication, valganciclovir. Dr. Montoya has just begun a randomized controlled trial of the drug, which is approved for other uses. Dr. Montoya said some cases of the syndrome were caused when an acute infection set off a recurrence of latent infections of Epstein Barr virus and HHV-6, two pathogens that most people are exposed to in childhood. Ms. Flowers, the former figure skater, had high levels of antibodies to both viruses and was one of Dr. Montoyas initial C.F.S. patients. Six months after starting treatment, Ms. Flowers said, she was able to go snowboarding and take yoga and ballet classes. Now I pace myself, but Im probably 75 percent of normal, she said. Many patients point to another problem with chronic fatigue syndrome: the name itself, which they say trivializes their condition and has discouraged researchers, drug companies and government agencies from taking it seriously. Many patients prefer the older British term, myalgic encephalomyelitis, which means muscle pain with inflammation of the brain and spinal chord, or a more generic term, myalgic encephalopathy.

You can change peoples attributions of the seriousness of the illness if you have a more medicalsounding name, said Dr. Leonard Jason, a professor of community psychology at DePaul University in Chicago.

Chronic Fatigue Syndrome

Chronic fatigue syndrome refers to severe, continued tiredness that is not relieved by rest and is not directly caused by other medical conditions.

REFERENCE FROM A.D.A.M.

Alternative Names
CFS; Fatigue - chronic; Immune dysfunction syndrome; Myalgic encephalomyelitis (ME)

Causes
The exact cause of chronic fatigue syndrome (CFS) is unknown. Some theories suggest CFS may be due to:

Epstein-Barr virus or human herpes virus-6 (HHV-6); however, no specific virus has been identified as the cause Inflammation in the nervous system, because of a faulty immune system response The following may also play a role in the development of CFS:

Your age Previous illnesses Stress Genetics Environmental factors CFS most commonly occurs in women ages 30 to 50.

In-Depth Causes
Theories abound about the causes of chronic fatigue syndrome. No primary cause has been found that explains all cases of CFS, and no blood tests or brain scans can definitively diagnose the condition. Convergence of Factors. A number of experts believe that CFS develops from a convergence of conditions that may include the following:

Genetic factors Brain abnormalities A hyper-reactive immune system Viral or other infectious agents Psychiatric or emotional conditions

For example, most patients report some moderate-to-serious physical illness (such as a chronic viral infection) or emotional event (like an episode of depression) before CFS. Some experts theorize that such events, alone or in combination, may interact with certain neurologic and genetic abnormalities to trigger CFS. 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 brain or nervous system problem that experts can point to with assurance.

GENETIC DEFECTS CFS has been linked with genes involved in the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system. These genes control response to trauma, injury, and other stressful events. Nevertheless, researchers have been unable to determine how the genetic variations influence symptoms.

A number of studies have found alterations in genes involved with immune function, communication between cells, and transfer of energy to cells. Researchers have identified many different genes in patients with CFS related to blood disease, immune system function, and infection. However, no clear pattern has been found. CENTRAL NERVOUS SYSTEM AND HORMONE ABNORMALITIES Abnormal levels of certain chemicals regulated in the brain system known as the hypothalamus-pituitary-adrenal (HPA) axis have been proposed as a cause of CFS. This system controls important functions, including sleep, stress response, and depression. Of particular interest to researchers are the following chemicals and other factors controlled by the HPA axis:

Changes in Important Neurotransmitters. Some patients with CFS have abnormally high levels of serotonin -- a neurotransmitter (chemical messenger in the brain), deficiencies of dopamine -- an important neurotransmitter associated with feelings of reward, or imbalances between norepinephrine and dopamine. However, routine clinical testing for such chemical imbalances is cost-prohibitive.

Stress Hormone Deficiencies. A number of studies on CFS patients have observed lower levels of cortisol, a stress hormone produced in the adrenal glands. Deficiencies of cortisol have been suggested as the reason why CFS patients have an impaired and weaker response to psychological or physical stresses, such as infection or exercise. However, administering replacement cortisol improves symptoms only in some patients.

Disturbed Circadian Rhythms. Evidence suggests that, in certain patients, CFS is a disorder of the sleep-wake cycle, which is regulated by the so-called circadian clock, a nerve cluster in the HPA axis. Some mentally or physically stressful event, such as a viral infection, may disrupt natural circadian rhythms. An inability to reset these rhythms results in a perpetual cycle of sleep disturbances. Medications that improve sleep can be very helpful for certain patients with CFS.

It is still not clear whether any of these changes are causes of chronic fatigue syndrome, or merely findings in some patients. INFECTIONS Because most of the features of CFS resemble those of a lingering viral illness, many researchers have focused on the possibility that a virus or some other infectious agent causes the syndrome in some cases. Still, not all CFS patients show signs of infection. Although experts have long been divided on whether infections play any role in this disorder, subtypes of viral-related and non-viral CFS may both exist. Viruses. The theory that CFS has a viral cause is not based on hard evidence, but on various observations that suggest an association, such as the following:

CFS patients may be found to have elevated levels of antibodies to many organisms that cause fatigue and other CFS symptoms. Such organisms include those that cause Lyme disease, candida ("yeast infection"), herpesvirus type 6 (HHV6), human T cell lymphotropic virus (HTLV), Epstein-Barr, measles, coxsackie B, cytomegalovirus, or parvovirus. Many of these infectious agents are very common, however, and none has emerged as a significant cause of CFS. Well-designed studies of patients who met strict criteria for chronic fatigue syndrome and of patients with chronic fatigue without any known cause have not found an increased incidence of any specific infections.

In up to 80% of cases, chronic fatigue syndrome starts suddenly with a flu-like condition. However, there is no evidence that CFS is spread through casual contact, such as shaking hands or coughing, or by intimate sexual contact. In the U.S., there have been reports of cluster outbreaks of CFS occurring within the same household, workplace, and community (but most have not been confirmed by the Centers for Disease Control and Prevention). However, most cases of CFS occur sporadically in individuals, and do not appear to be contagious.

IMMUNE SYSTEM ABNORMALITIES 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. Some components appear to be over-reactive, while others appear to be underreactive, but no consistent picture has emerged to explain CFS as a disease of the immune system. Allergies. Some studies have reported that a majority of CFS patients have allergies to foods, pollen, metals (such as nickel or mercury), or other substances. One theory is that allergens, like viral infections, may trigger a cascade of immune abnormalities leading to CFS. However, most allergic people do not have CFS.

Autoimmune Abnormalities. The risk profile for chronic fatigue syndrome is similar to the risk profiles for a number of autoimmune diseases. Studies are inconsistent, however, in reporting the presence of autoantibodies (antibodies that attack the body's own tissues) in CFS, and the disease is unlikely to be due to autoimmunity. LOW BLOOD PRESSURE Studies have observed that some patients who fit the strict criteria for chronic fatigue syndrome also have symptoms of a condition known as neurally mediated hypotension (NMH). NMH causes a dramatic drop in blood pressure when a person stands up, even for as little as 10 minutes. Its immediate effects can be lightheadedness, nausea, and fainting. However, studies have reported no higher incidence of NMH in chronic fatigue patients. PSYCHOLOGICAL FACTORS Psychological, personality, and social factors are strongly associated with chronic fatigue in most patients. The complex relationship between physical and emotional factors has yet to be fully understood, however. Studies have not found any consistent association between emotional or personality disorders and CFS to explain a causal role. Psychological factors, then, are unlikely to be a primary cause of CFS. However, they may play a role in increasing susceptibility to the disorder. In many cases, CFS promotes psychological and social dysfunction.

Symptoms
Symptoms of CFS are similar to those of the flu and other common viral infections, and include muscle aches, headache, and extreme fatigue. However, symptoms of CFS last for 6 months or more. The main symptom of CFS is extreme tiredness (fatigue), which is:

New Lasts at least 6 months Not relieved by bed rest Severe enough to keep you from participating in certain activities Other symptoms include:

Feeling extremely tired for more than 24 hours after exercise that would normally be considered easy Feeling unrefreshed after sleeping for a proper amount of time Forgetfulness Concentration problems Confusion Joint pain but no swelling or redness Headaches that differ from those you have had in the past Irritability Mild fever (101 degrees F or less) Muscle aches [myalgias] Muscle weakness, all over or multiple locations, not explained by any known disorder Sore throat Sore lymph nodes in the neck or under the arms

Exams and Tests

The Centers for Disease Control (CDC) describes CFS as a distinct disorder with specific symptoms and physical signs, based on ruling out other possible causes. CFS is diagnosed after your health care provider rules out other possible causes of fatigue, including:

Drug dependence

Immune or autoimmune disorders Infections Muscle or nerve diseases (such as multiple sclerosis) Endocrine diseases (such as hypothyroidism) Other illnesses (such as heart, kidney, or liver diseases) Psychiatric or psychological illnesses, particularly depression Tumors A diagnosis of CFS must include:

Absence of other causes of chronic fatigue At least four CFS-specific symptoms Extreme, long-term fatigue There are no specific tests to confirm the diagnosis of CFS. However, there have been reports of CFS patients having abnormal results on the following tests:

Brain MRI White blood cell count

In-Depth Diagnosis
It is very difficult to diagnose chronic fatigue syndrome. Even experts do not have a clear definition of what chronic fatigue actually is, or what mechanisms in the brain or nervous system are responsible for it. The best diagnostic approach is to determine whether the patient matches the criteria for CFS and to rule out other possible causes of symptoms. CRITERIA FOR CHRONIC FATIGUE SYNDROME In May 2006, the Centers for Disease Control and Prevention (CDC) released a revised definition for Chronic Fatigue Syndrome based on a consensus of many of the leading CFS researchers and doctors (including input from patient group representatives). In the revised definition, chronic fatigue syndrome is considered a subset of chronic fatigue, a broader category defined as unexplained fatigue that lasts for 6 months or longer. Chronic fatigue is considered a subset of prolonged fatigue, which is defined as fatigue that lasts for 1 month or more. Unexplained chronic fatigue can be classified as CFS if the patient meets the following criteria:

Unexplained persistent or relapsing chronic fatigue that is either new or that started at a definite period of time; is not the result of ongoing exertion; is not substantially relieved by rest; and significantly reduces activities such as work, education, and social life.

Also, four or more of the following symptoms, which must have continued or recurred during 6 or more consecutive months of illness and must not have started before the fatigue:

o o o o o o o o

Significant impairment in short-term memory or concentration Sore throat Tender lymph nodes Muscle pain Joint pain without swelling or redness Headaches of a new type, pattern, or severity Unrefreshing sleep Malaise that lasts for more than 24 hours after exertion

CONDITIONS THAT CAN RULE OUT A CFS DIAGNOSIS

Any active medical condition that may explain the presence of chronic fatigue, such as:

o o

Untreated hypothyroidism (underactive thyroid gland) Sleep apnea and narcolepsy (common sleep disorders)

Side effects of medication

An illness (such as cancer, or hepatitis B or C virus infection) that relapsed or did not completely get better during treatment, that could explain the presence of chronic fatigue. A past or current major depressive disorder, such as:

o o o o o

Bipolar affective disorder Schizophrenia Delusional disorder Dementia Anorexia nervosa or bulimia nervosa

Alcohol or other substance abuse that occurs within 2 years of the onset of chronic fatigue and at any time afterward. Severe obesity, as defined by a body mass index (BMI) equal to or greater than 45. (Note: Body mass index values vary considerably among different age groups and populations. No "normal" or "average" range of values can be suggested. The range of 45 BMI or higher was selected because it falls within the range of severe obesity.)

Any other abnormality found during an exam or other tests that could explain CFS symptoms must be resolved before further attempting to classify the condition. In 2007, the National Institute for Health and Clinical Excellence (NICE) released new guidelines for the diagnosis and management of CFS in adults and children. According to these guidelines, CFS may be diagnosed if the person has disabling fatigue that starts suddenly, lasts a long time, keeps coming back, and can't be explained by another condition. People with CFS also can have the following symptoms:

Difficulty thinking, concentrating, remembering, finding the right words, planning, and organizing Difficulty sleeping Dizziness or nausea General malaise or flu-like symptoms Headaches Muscle or joint pain in many areas of the body without inflammation Painful lymph nodes without disease Fast heartbeat (palpitations) without heart problems Sore throat Worsening of symptoms with physical exertion

After ruling out other possible causes, the doctor should consider a diagnosis of CFS if symptoms have lasted for 4 months in adults or 3 months in children. Children should be diagnosed by a pediatrician. PERSONAL AND MEDICAL HISTORY A doctor 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 questions such as:

When did the fatigue first begin? Does anything make it worse or better? Is it better at certain times of the day? Does physical activity make it worse? Are there any other symptoms? Has anyone else in the family ever complained of fatigue? Is your personal and professional life stressful?

The doctor may also ask about any changes in weight, or request that a patient monitor his or her morning and afternoon body temperatures. Patients should report any drugs they are taking, including vitamins and over-the-counter or herbal medications. LABORATORY TESTS Standard tests are typically recommended to rule out specific conditions that can cause persistent fatigue. These tests include:

Blood count Blood tests for gluten sensitivity C-reactive protein Creatine kinase Erythrocyte sedimentation rate or plasma viscosity Liver function Random blood sugar (glucose) Serum calcium Serum creatinine Serum ferritin levels (only in children) Thyroid function Urea and electrolytes Urine test for protein, blood, and glucose

No blood, urine, or other laboratory test can specifically diagnose CFS. If any test is abnormal, it is not useful for diagnosing CFS specifically, and the doctor should look for other causes of these abnormalities. That said, research has found that certain components in urine are unique in people with CFS, and may someday be considered biomarkers of the disease. Additionally, antibodies to Epstein-Barr virus, increased levels of isoprostanes, and decreased levels of alpha-tocopherol (vitamin E) -- markers of oxidative stress -- have been found in the blood of people with CFS. IDENTIFYING OTHER CAUSES OF CHRONIC FATIGUE SYNDROME Among the many other common conditions that can lead to feelings of temporary exhaustion are the following:

Depression Infections Pregnancy Extreme exercise Excessive stress

In most of these cases, fatigue can be relieved with adequate rest. It is important to note that longstanding fatigue can be a sign 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 doctors should not overlook these diseases, even if the conditions have been previously treated, because they may not have completely resolved or they may cause residual fatigue. Doctors 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 fatigue that lasts for many months. Blood tests will indicate the Epstein-Barr virus (EBV), which causes mononucleosis. 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. Most of these conditions can be confirmed with laboratory or x-ray/radiologic findings. However, some autoimmune diseases may evolve slowly. Even if a diagnosis of chronic fatigue syndrome is considered, doctors should keep track of any changes in symptoms over time to rule out these serious illnesses. Post-Lyme Disease Syndrome. Rarely, patients treated for Lyme disease continue to have nonspecific symptoms, which can last for years after antibiotic treatment and that resemble symptoms of chronic fatigue syndrome. Depression and Severe Mental Disorders. The Centers for Disease Control (CDC), which established the definitions for chronic fatigue syndrome, recognizes depression as one of the symptoms of CFS. In one study, 36% of CFS patients were depressed. Depression in these patients was associated with lower self-esteem and an increased likelihood of suicidal thoughts. However,

according to the CDC, anyone with a history of major depression or other severe psychiatric disorders, including bipolar disorder and schizophrenia, does not meet the criteria for chronic fatigue syndrome. Symptoms of major depression include the following:

A depressed mood every day Significant weight gain or loss (10% or more of an individual's usual body weight) Insomnia or excessive sleeping Restlessness or a sense of being slowed down Low energy every day Worthless or inappropriately guilty feelings An inability to concentrate or make decisions Suicidal thoughts Loss of interest and enjoyment

Major depression is likely if a person has several of these symptoms and no physical symptoms (such as sore throat, aches and pains, or fever). The longer fatigue has continued without physical symptoms, the more likely that the diagnosis is depression. A persistent form of minor depression called dysthymia 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 2 years. The symptoms of dysthymia have been described as a "veil of sadness" that covers most activities. Patients with depression generally perceive their illnesses differently than people with CFS:

Patients with depression have significantly lower self-esteem, more thought distortions (for instance, focusing on the negative or personalizing their situations), and believe their condition stemmed from psychological factors. CFS patients, even those who also have depression or dysthymia, tend to identify medical causes as the source of their problems and to focus on physical symptoms.

Many previously healthy patients with CFS 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. These situations can contribute to, and even cause emotional disorders in susceptible individuals, which can worsen CFS. Sleep Disturbances. Certain sleep disorders may cause persistent fatigue and can be confused with CFS:

Sleep apnea is a common disorder that can cause daytime fatigue without the patient being aware of the problem. Apnea is actually a breathing disorder that is 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.

Narcolepsy is a peculiar and rare disorder in which a person suddenly falls asleep without any previous signs of fatigue. Other sleep disorders that cause daytime fatigue include insomnia and restless legs syndrome.

Researchers have found that people with CFS have altered amounts of slow wave sleep, which could indicate a problem with sleep regulation. Non-restorative sleep and nighttime restlessness are the most common complaints of people with CFS. Conditions that Cause Joint Pain, Muscle Aches, or Both. A number of illnesses cause one or more CFS symptoms, including arthritic symptoms, fever, and fatigue. Severe Obesity. People who are severely obese often have symptoms of chronic fatigue because of the stress imposed by their weight. People who are obese are also at higher risk for sleep apnea, which can confuse the diagnosis. Other Medical Conditions that Usually Rule Out CFS. Many diseases, both benign and serious, can fully explain prolonged or chronic fatigue, including:

Hepatitis Anemia Hemochromatosis (a hereditary disease caused by iron overload)

Various forms of cancer Neuromuscular diseases (such as myasthenia gravis) Hypothyroidism Diabetes

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 medicines. Withdrawal from caffeine can produce depression, fatigue, and headache.

Treatment
There is currently no cure for CFS. The goal of treatment is to relieve symptoms. Many people with CFS have depression and other psychological disorders that may improve with treatment. Treatment includes a combination of the following:

Cognitive-behavioral therapy (CBT) and graded exercise for certain patients Healthy diet Sleep management techniques Medications to reduce pain, discomfort, and fever Medications to treat anxiety (anti-anxiety drugs) Medications to treat depression (antidepressant drugs) Some medications can cause reactions or side effects that are worse than the original symptoms of the disease. Patients with CFS are encouraged to maintain active social lives. Mild physical exercise may also be helpful. Your health care team will help you figure out how much activity you can do, and how to slowly increase your activity. Tips include:

Avoiding doing too much on days when you feel tired Balancing your time between activity, rest, and sleep Breaking big tasks into smaller, more manageable ones Spreading out more challenging tasks throughout the week Relaxation and stress-reduction techniques can help manage chronic pain and fatigue. They are not used as the primary treatment for CFS. Relaxation techniques include:

Biofeedback Deep breathing exercises Hypnosis Massage therapy Meditation Muscle relaxation techniques Yoga

In-Depth Treatment
There is no proven or reliable cure for CFS, and no drug has been developed specifically for this disorder. Because CFS remains poorly understood, many patients have problems finding good care. Overall, the recommended strategy for treatment includes a combination of the following:

A healthy diet

Antidepressant drugs in some cases, usually low-dose tricyclics Cognitive-behavioral therapy (CBT) and graded exercise for certain patients Medication Sleep management techniques

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 choose 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. Cognitive-Behavioral Therapy CBT is designed to help CFS patients regain a sense of control, and is proving to have substantial benefits for some patients. Some experts believe that patients who are diagnosed with CFS should 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 CFS patients.) The Goals of Cognitive-Behavioral Therapy. The primary goals of cognitive-behavioral therapy (referred to below as just cognitive 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, improving their ability to deal with stressful situations, and managing their disorder. CBT can also help people manage their sleep problems and find the appropriate activity levels for them. Cognitive therapy is particularly helpful for defining and setting limits, behaviors that are extremely important for these patients. The Procedure. CBT is usually performed over 6 - 20 sessions, each lasting about an hour. Patients are also given homework, which usually includes keeping a diary and attempting tasks that they have avoided because of previous negative attitudes. A typical cognitive therapy program may involve the following measures:

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 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.

Adjust Schedule. The patient adjusts schedules to conform to energy peaks and valleys recorded in the diary. For instance, the patient may take a nap during low-energy times and plan important activities during high-energy times. Developing regular daily routines around probable energy spurts or drops may help establish a more predictable pattern.

Confront Negative or Discouraging Thoughts. Patients are taught to challenge and reverse negative beliefs (such as "I'm not good enough to control this disease, so I'm a total failure."), and to use 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 be prepared to adapt to energy variations. Instead of taking a long nap, for instance, patients may need 5- to 10-minute rest periods every hour or more, possibly involving relaxation or meditation.

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 step at a time.

Prioritize. Patients learn to drop some of the less critical tasks or delegate them to others. Manage 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 a minimum.

Accept 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 failure or personal failure.

Using both self-observation and specific tasks, patients gradually shift their fixed ideas that they are helpless against the fatigue that dominates their lives. They move to the perception that fatigue is only one negative experience among many positive ones. Success Rates. One review of CFS trials reported that, of all therapies available to CFS patients, only cognitive behavioral therapy (CBT) and graded exercise showed conclusive benefits. CBT is effective at reducing the symptoms of fatigue compared with usual care, and it appears to be more effective than other psychological therapies. Although CBT doesn't bring patients completely back to normal, research has found that people who use the therapy have higher mental health scores, and are able to walk faster and with less fatigue than those who did not use CBT. Cognitive therapy may also be an effective treatment for adolescents with CFS. Young patients who received CBT have reported improvements in fatigue, functional status, and school attendance. Not all studies support the benefits of cognitive therapy for CFS. It is important to note that different therapists may have different fundamental assumptions about CBT and may use different techniques. For instance, some therapists believe that CFS is a purely psychological problem and that patients must reject the notion of physical causes, abandon all reliance on assistive devices, and participate in challenging exercise programs. Other therapists do not attempt to change patients' underlying beliefs, but instead focus on helping patients conserve energy and better cope with the limitations of their illness. When considering CBT, patients and their families must be aware of such important differences in therapists. The power of the mind to improve or oppose health problems is significant, and treatments that promote a positive outlook are beneficial for any disease. GRADED EXERCISE A number of studies have suggested that a graded exercise program, in which patients perform increasingly more intense levels of exercise tailored to their individual abilities, has benefits for many patients with CFS. Exercise is best performed in combination with cognitive behavioral therapy. Reports have found that 75% of CFS patients who were able to engage in exercise, particularly aerobic exercise, reported less fatigue and better daily functioning and fitness after a year. A review of clinical trials found that exercise therapy is beneficial for CFS, particularly when combined with patient education. Some patient groups and experts contend that such studies use only patients with less severe conditions, and therefore the results do not apply to many CFS patients. Many patients have severe conditions, and some are very incapacitated (such as being wheelchair bound). These patients are unlikely to be able to do graded exercise. All CFS patients, in fact, have a lower exercise capacity than healthy individuals, and over-exercising can intensify symptoms. Some patients experience profound fatigue following even modest exercise. It is the primary reason for the low activity levels in these patients. The following tips may be helpful for CFS patients when embarking on an exercise program:

Work with your health care provider to determine a good starting level of activity for you. Start slowly and incrementally, beginning with as few as 3 - 5 minutes of moderate exercise a day. The goal is to increase activity by about 20% every 2 3 weeks, until you can handle about 30 minutes a day. Once you reach 30 minutes a day, start to increase the aerobic intensity of your workouts. (Capacity varies greatly among CFS sufferers, however, and some people may not be able to increase their aerobic intensity.)

Establish limits and keep within them to avoid overexertion and relapse. Experiment with different forms of physical activity that suit your available energy levels. Some patients report great benefits from yoga or tai chi, which combine exercise with meditation. Setbacks will occur, but do not become discouraged.

ACTIVITY MANAGEMENT Work with your health care provider to find a level of activity you can handle. Then gradually increase your activity level. Activity management should involve:

Balancing your time between activity, rest, and sleep Spreading out more challenging tasks throughout the week

Breaking big tasks into smaller, more manageable ones Avoiding doing too much on days when you feel tired

HEALTHY DIET Although there is no evidence to support any specific dietary factors in CFS, patients should be sure to maintain a healthy diet that includes:

Plenty of fresh, dark-colored fruits and vegetables, which are rich in antioxidants Fiber-rich foods Limited saturated fats (found in animal products) Omega-3 essential fatty acids, found in certain fish and oils Increased salt (only for those with low blood pressure) Starchy foods, particularly for nausea

OTHER APPROACHES FOR MANAGING CHRONIC FATIGUE SYNDROME Stress Reduction Techniques. One panel of experts concluded that relaxation and stress-reduction techniques were helpful in managing chronic pain. These techniques 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 are available, including:

Biofeedback Deep breathing exercises Hypnosis Massage therapy Meditation Muscle relaxation techniques Yoga

Light Therapy. Patients with seasonal affective disorder (SAD) experience more depression during the winter, when the hours of sunlight decrease. With light therapy (phototherapy), the patient sits for about 30 minutes each day a few feet away from a box-like device that emits very bright fluorescent light (4,000 lux). Light therapy is best performed immediately after awakening in the morning. Some CFS patients don't have much improvement from light therapy. However, the treatment may still help some patients with CFS whose symptoms are similar to those of patients with SAD. Supportive Family and Groups. Having strong, supportive relationships with family and friends can help CFS patients get better. However, CFS patients should try not to impose unreasonable expectations on loved ones. Attending support groups with fellow patients may be very helpful. In one study, sharing experiences in a group therapy setting proved to be the most valuable component in treatment, and it improved patients' coping abilities.

Outlook (Prognosis)
The long-term outlook for patients with CFS varies and is difficult to predict when symptoms first start. Some patients completely recover after 6 months to a year. Some patients never feel like they did before they developed CFS. Studies suggest that you are more likely to get better if you receive extensive rehabilitation.

Possible Complications

Depression Inability to participate in work and social activities, which can lead to isolation Side effects to medication or treatments

When to Contact a Medical Professional

Call for an appointment with your health care provider if you experience persistent, severe fatigue, with or without other symptoms of this disorder. Other more serious disorders can cause similar symptoms and should be ruled out. See also:Chronic fatigue syndrome - resources

References
Firestein GS, Budd RC, Harris ED Jr., et al., eds. Kelley's Textbook of Rheumatology . 8th ed. Philadelphia, Pa: Saunders Elsevier; 2008. Engleberg NC. Chronic fatigue syndrome. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases . 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2009:chap 131. Santhouse A, Hotopf M, David AS. Chronic fatigue syndrome. BMJ . 2010;340:c738.

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