Chronic fatigue syndrome

By Belinda Rowland

Definition

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

Description

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

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

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

Causes & symptoms

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

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

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

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

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

Other symptoms of CFS include:

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

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

Diagnosis

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

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

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

Treatment

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

Diet

Drinking 8 to 12 glasses of water daily helps fight fatigue. Food allergies can worsen CFS symptoms. Common food allergies include milk, wheat, eggs, citrus, alcohol, chocolate, and coffee. An extract from shiitake mushrooms (LEM) has been shown in Japanese studies to benefit CFS patients.

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

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

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

Supplements

The following supplements have been used in treating CFS.

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

Fluoride is a potentially toxic substance and should be avoided.

Other treatment options

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


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

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

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

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

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

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

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


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

Allopathic treatment

Drugs

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

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

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

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

Expected results

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

Prevention

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

Key Terms

Alexander technique
A movement therapy that identifies and changes poor physical habits that may cause fatigue. The body is put into a state of relaxation and balance through the use of simple movements.

Arthralgia
Joint pain.

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

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

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

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

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

Muscle balance and function development (MBF)
A movement therapy that strives to realign body posture through a series of exercises.

Myalgia
Muscle pain.

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

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

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

Symptoms of chronic fatigue syndrome
Symptoms of chronic fatigue syndrome Unexplained fatigue
Persistent low-grade fever
Muscle aches and weakness
Insomnia or oversleeping
Swollen lymph nodes
Forgetfulness, confusion
Lack of concentration
Recurrent sore throat
Headaches
Joint pain
Long-lasting symptoms that continue for six months or longer
Further Reading
For Your Information
Books

* Chopra, Deepak. Boundless Energy: the Complete Mind/Body Program for Overcoming Chronic Fatigue. New York: Harmony Books, 1995.
* Demitrack, Mark A., and Susan E. Abbey. Chronic Fatigue Syndrome: An Integrative Approach to Evaluation and Treatment. New York: The Guilford Press, 1996.
* Fisher, Gregg Charles. Chronic Fatigue Syndrome: A Comprehensive Guide to Symptoms, Treatments, and Solving the Practical Problems of CFS. New York: Warner Books, 1997.
* Skelly, Mari and Andrea Helm. Alternative Treatments for Fibromyalgia & Chronic Fatigue Syndrome: Insights from Practitioners and Patients. Alameda, CA: Hunter House, Inc., 1999.

Periodicals

* Gibson, Sheila L.M. and Robin G. Gibson. "A Multidimensional Treatment Plan for Chronic Fatigue Syndrome." Journal of Nutritional & Environmental Medicine 9 (March 1999): 47+.
* Johnson, Susan K., John DeLuca, and Benjamin H. Natelson. "Chronic Fatigue Syndrome: Reviewing the Research Findings." Annals of Behavioral Medicine 21 (1999): 258-271.
* "New Treatment for Chronic Fatigue Syndrome." Tufts University Diet & Nutrition Letter 13 (February 1996): 1-2.
* Weiss, Rick. "A Cure for Chronic Fatigue? If New Research Proves Right, Some Sufferers Have Nothing More than an Easy-to-Fix Blood Pressure Problem." The Nurse Practitioner 22 (July 1997): 30-40.

Organizations

* American Association for Chronic Fatigue Syndrome. 7 Van Buren Street, Albany, NY 12206. (518) 435-1765. http://weber.u.washington.edu/~dedra/aacfs1.html.
* The CFIDS Association. Community Health Services, P.O. Box 220398, Charlotte, NC 28222-0398. (704) 362-2343.
* The National CFIDS Foundation. 103 Aletha Road, Needham, MA 02192. (781) 449-3535. http://www.cfidsfoundation.org/.
* The National CFS Association. 919 Scott Avenue, Kansas City, KS 66105. (913) 321-2278.

Other

* Centers for Disease Control and Prevention "The Facts about Chronic Fatigue Syndrome." CFS Research group, Mailstop A15, Centers for Disease Control and Prevention, Atlanta, GA 30333. (404) 639-1338. http://www.cdc.gov/ncidod/diseases/cfs/facts1.htm.
* National Institutes of Health, Public Service Resources "Chronic Fatigue Syndrome." http://www.niaid.hih.gov/publications/cfs/complete.htm.

Gale Encyclopedia of Alternative Medicine. Gale Group, 2001.