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Chronic fatigue syndrome
By Mayo Clinic staffMayo Clinic Health Manager
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Definition
Chronic fatigue syndrome (CFS) is a complicated disorder characterized by extreme fatigue that may worsen with physical or mental activity, but doesn't improve with rest. Although there are many theories about what causes this condition — ranging from viral infections to psychological stress — in most cases the cause is still unknown.
Because its symptoms are difficult to measure, CFS wasn't widely accepted as a real medical condition for several years. Today, however, doctors and researchers agree that this chronic condition should be taken seriously.
Although an underlying cause often isn't found, effective treatments for the signs and symptoms of CFS are available. Many people recover from chronic fatigue syndrome over time.
Symptoms
People with chronic fatigue syndrome may experience a variety of signs and symptoms that come and go frequently with no identifiable pattern.
Primary signs and symptoms
Chronic fatigue syndrome has eight official symptoms, plus the central symptom that gives the condition its name:
- Fatigue
- Loss of memory or concentration
- Sore throat
- Painful and mildly enlarged lymph nodes in your neck or armpits
- Unexplained muscle pain
- Pain that moves from one joint to another without swelling or redness
- Headache of a new type, pattern or severity
- Unrefreshing sleep
- Extreme exhaustion lasting more than 24 hours after physical or mental exercise
Additional signs and symptoms
In addition, people with chronic fatigue syndrome have reported other various signs and symptoms that aren't part of the official definition. These include:
- Abdominal pain
- Allergies or sensitivities to foods, alcohol, odors, chemicals, medications or noise
- Bloating
- Chest pain
- Chronic cough
- Diarrhea
- Dizziness, balance problems or fainting
- Dry mouth
- Earache
- Irregular heartbeat
- Jaw pain
- Morning stiffness
- Nausea
- Chills and night sweats
- Psychological problems, such as depression, irritability, anxiety disorders and panic attacks
- Shortness of breath
- Tingling sensations
- Visual disturbances, such as blurring, sensitivity to light, eye pain and dry eyes
- Weight loss or gain
If you have chronic fatigue syndrome, your symptoms may peak and become stable early on, and then come and go over time. Some people go on to recover completely, while others grow progressively worse.
When to see a doctor
Fatigue can be a symptom of many illnesses, such as infections or psychological disorders. In general, see your doctor if you have persistent or excessive fatigue.
The earlier a person with CFS receives medical treatment the greater the likelihood that the illness will resolve. In addition, severe fatigue that prevents you from fully participating in activities at home, work or school may be a symptom of an underlying medical problem.
Causes
Of all chronic illnesses, chronic fatigue syndrome is one of the most mysterious. Several possible causes have been proposed, including:
- Depression
- Iron deficiency anemia
- Low blood sugar (hypoglycemia)
- History of allergies
- Virus infection, such as Epstein-Barr virus or human herpesvirus 6
- Dysfunction in the immune system
- Changes in the levels of hormones produced in the hypothalamus, pituitary glands or adrenal glands
- Mild, chronic low blood pressure (hypotension)
- An autoimmune process causing inflammation of certain nervous-system pathways
- A viral infection complicated by a dysfunctional immune response
- A low blood pressure disorder that triggers the fainting reflex
Symptoms similar to those of chronic fatigue syndrome sometimes have straightforward, correctable causes, such as:
- An active, identifiable medical condition that often results in fatigue
- Medication side-effects
Risk factors
Women are diagnosed with chronic fatigue syndrome at least four times as often, but sex isn't a proven risk factor for this condition. It may be that women are simply more likely to report their symptoms to a doctor.
The condition is most common in people in their 40s and 50s, but it can affect people of all ages.
Because the cause of the condition is unknown, doctors have yet to determine and confirm definite risk factors for the disease.
Complications
Possible complications of chronic fatigue syndrome include:
- Depression, related both to symptoms and lack of diagnosis
- Side effects and adverse reactions related to medication treatments
- Side effects and adverse reactions associated with lack of activity (deconditioning)
- Social isolation caused by fatigue
- Lifestyle restrictions
- Missing work
Preparing for your appointment
You're likely to start by first seeing your family doctor or primary care provider. Because the symptoms of chronic fatigue syndrome can mimic so many other health problems, you may need patience while waiting for a diagnosis. Your doctor must rule out a number of other illnesses before diagnosing chronic fatigue syndrome.
Here's some information to help you prepare for your first appointment, and what to expect from your doctor.
What you can do
- Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment. For example, while fatigue may be affecting you most, other symptoms, such as memory problems or headache, are important to share with your doctor.
- Write down key personal information, including any recent changes or major stressors in your life. These psychological challenges can play a very real role in your physical well-being.
- Make a list of your key medical information, including any other conditions for which you're being treated and the names of any medications, vitamins or supplements you're taking.
- Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.
For CFS, some basic questions to ask your doctor include:
- What are the possible causes of my symptoms or condition?
- What tests do you recommend?
- If these tests don't pinpoint the cause of my symptoms, what additional tests might I need?
- On what basis would you make a diagnosis of chronic fatigue syndrome?
- Are there any treatments or lifestyle changes that could help my symptoms now?
- What activity level should I aim for while we're seeking a diagnosis?
- Do you recommend that I also see a mental health provider?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:
- What are you symptoms? In what part of your body do they occur?
- When did you first notice these symptoms?
- Have your symptoms gotten worse over time?
- Does anything make your symptoms better or worse?
- Do your symptoms include any problems with memory or concentration?
- Do your symptoms include problems with sleep?
- How often do you feel down or depressed?
- How often do you feel stressed or anxious?
- How much do your symptoms limit your ability to function? For example, have you ever had to miss school or work because of your symptoms?
- Are your symptoms causing difficulty in your marriage or other important personal relationships?
- What treatments have you tried so far for this condition? How have they worked?
- Have you been diagnosed with any other medical conditions, including mental health problems?
- What do you think is causing your pain?
What you can do in the meantime
While you're waiting for your appointment, you may find some relief by using over-the-counter pain relievers such as aspirin, ibuprofen (Advil, Motrin, others) or acetaminophen (Tylenol, others).
To boost your chances of sleeping well at night, skip naps during the day and go to bed at a regular time each night. Other adjustments that may help you rest well at night include light exercise and stretching several hours or more before bedtime, as well as avoiding caffeine, alcohol and nicotine.
Tests and diagnosis
To meet the diagnostic criteria of chronic fatigue syndrome, you must have unexplained, persistent fatigue for six months or more, along with at least four of the eight primary signs and symptoms.
Primary signs and symptoms of CFS include:
- Loss of memory or concentration
- Sore throat
- Painful and mildly enlarged lymph nodes in your neck or armpits
- Unexplained muscle pain
- Pain that moves from one joint to another without swelling or redness
- Headache of a new type, pattern or severity
- Unrefreshing sleep
- Extreme exhaustion lasting more than 24 hours after physical or mental exercise
There's no diagnostic or laboratory procedure to confirm the presence of chronic fatigue syndrome. The diagnosis is based on exclusion. This means that before arriving at the diagnosis, your doctor has ruled out other well-defined diseases or conditions that may be causing your fatigue and related symptoms. Conditions your doctor may rule out or identify as contributing factors early on include:
- Low levels of thyroid hormone (hypothyroidism)
- Sleep apnea
- Depression
- Eating disorders
- Substance abuse
- A relapse of a previously treated illness, such as cancer
- Severe obesity, defined by a body mass index (BMI) of 40 or greater
Treatments and drugs
There's no specific chronic fatigue syndrome treatment. In general, doctors aim to relieve signs and symptoms by using a combination of treatments, which may include:
- Moderating daily activity. Your doctor may encourage you to slow down and to avoid excessive physical and psychological stress. However, too much rest can make you weaker, worsening your long-term symptoms. Your goal should be to maintain a moderate level of daily activity and gently increase your stamina over time.
- Gradual but steady exercise. With the help of a physical therapist, you may be advised to begin an exercise program that slowly becomes more challenging. Research has proved that gradually increasing exercise can improve the symptoms of chronic fatigue syndrome.
- Cognitive behavior therapy. This treatment, often used in combination with graduated exercise, also has been found to improve the symptoms of chronic fatigue syndrome. In cognitive behavior therapy, you work with a mental health provider to identify negative beliefs and behaviors that might be delaying your recovery and replace them with healthy, positive ones.
- Treatment of depression. If you're depressed, medications such as tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) may help. Antidepressants may also help improve sleep and relieve pain. Commonly prescribed antidepressants include amitriptyline (Amitid, Amitril), desipramine (Norpramin) and nortriptyline (Aventyl, Pamelor). SSRIs include fluoxetine (Prozac, Sarafem), paroxetine (Paxil) and sertraline (Zoloft).
- Treatment of existing pain. Acetaminophen (Tylenol, others) and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen (Advil, Motrin, others) may be helpful to reduce pain and fever.
- Treatment of sleep problems. Changing your sleep habits may be enough to help you start getting restorative nighttime sleep. But if techniques such as sticking with a regular bedtime, skipping daytime naps, and avoiding substances such as caffeine and alcohol don't help, your doctor may prescribe a short course of sleep medication.
- Treatment of allergy-like symptoms. Antihistamines such as fexofenadine (Allegra) and cetirizine (Zyrtec), and decongestants that contain pseudoephedrine (Sudafed) may relieve allergy-like symptoms such as runny nose.
- Treatment of low blood pressure (hypotension). The drugs fludrocortisone (Florinef) and atenolol (Tenormin) may be useful for certain people with chronic fatigue syndrome.
- Treatment for problems of the nervous system. Symptoms such as dizziness and extreme skin tenderness can sometimes be relieved by clonazepam (Klonopin). Your doctor may prescribe medications such as lorazepam (Ativan) and alprazolam (Xanax) to relieve symptoms of anxiety.
Experimental therapies
Research aimed at finding new treatments for chronic fatigue syndrome has included studies of the following medications:
- Methylphenidate (Ritalin, Concerta, others). This psychostimulant appears to boost and balance levels of the brain chemicals called neurotransmitters. It's commonly used to treat attention-deficit/hyperactivity disorder (ADHD). One study found that methylphenidate lessened fatigue and improved concentration in some people with chronic fatigue syndrome.
- Corticosteroids. Some studies have found that oral hydrocortisone may improve symptoms of chronic fatigue syndrome, while other studies have found no benefit.
- Immune globulins and interferons. These medications are used to boost your immune system's ability to fight infection. Studies have not found them to be consistently effective in treating chronic fatigue syndrome, and some participants have experienced severe side effects.
- Antiviral drugs, such as acyclovir. The possible connection between chronic fatigue syndrome and Epstein-Barr virus led researchers to test whether powerful antiviral medications could improve the symptoms of chronic fatigue syndrome. This approach has not been found effective, and the connection between Epstein-Barr virus and chronic fatigue syndrome has since been disproved.
- Cholinesterase (ko-lin-ES-tur-ase) inhibitors, such as galantamine. These drugs improve the effectiveness of acetylcholine, a chemical messenger that is believed to be important for memory, thought and judgment. Galantamine is used in the treatment of Alzheimer's disease, but it has not been found beneficial for chronic fatigue syndrome.
Lifestyle and home remedies
Learning how to manage fatigue can help you improve your level of functioning and your quality of life despite your symptoms. You may work with a rehabilitation medicine specialist who can teach you how to plan activities to take advantage of times when you usually feel better.
These important self-care steps can help you to maintain good general health:
- Reduce stress. Develop a plan to avoid or limit overexertion and emotional stress. Allow yourself time each day to relax. That may mean learning how to say no without guilt.
- Get enough sleep. Getting sufficient sleep is essential. In addition to allotting enough time for sleep, practice good sleep habits, such as going to bed and getting up at the same time each day and limiting daytime napping.
- Exercise regularly. You may need to start slowly and build up gradually. But exercising regularly often improves symptoms. Many people find exercises such as walking, swimming, biking and water aerobics to be helpful. A physical therapist may help you develop a home-exercise program. Stretching, good posture and relaxation exercises also can be helpful.
- Pace yourself. Keep your activity on an even level. If you do too much on your good days, you may have more bad days.
- Maintain a healthy lifestyle. Try to eat a balanced diet, drink plenty of fluids, limit your caffeine intake, stop smoking, get adequate rest, and exercise regularly. Find a hobby or career that's enjoyable and fulfilling for you.
Alternative medicine
Many alternative therapies have been promoted for chronic fatigue syndrome, but few have been evaluated in clinical trials. Among those that have been studied, two that may offer benefit for CFS include.
- D-ribose. Also called ribose, this form of sugar is an essential energy source for your cells. Scientists believe that impaired cellular metabolism — some kind of disorder in the way your cells do their work — may play a role in chronic fatigue syndrome. Some research has found that natural D-ribose supplements may significantly improve energy and decrease pain associated with chronic fatigue syndrome.
- Acupuncture. Acupuncture has been evaluated as a treatment for the symptoms of fibromyalgia, a disease that is considered similar to CFS and is also characterized by fatigue and muscle soreness. Studies suggest that acupuncture may decrease fatigue, pain, anxiety and other symptoms associated with CFS.
Other complementary therapies that may reduce anxiety and promote well-being in people with chronic fatigue syndrome include:
- Deep-breathing and muscle-relaxation techniques
- Meditation
- Massage and healing touch
- Movement therapies such as stretching, yoga and tai chi
Natural doesn't mean safe
Makers of various dietary supplements and herbal remedies claim these substances have potential benefits for people with CFS. However, in most cases the effectiveness of these therapies hasn't been proved in controlled studies.
Though a product may be of "natural" origin, that origin doesn't ensure its safety. Dietary supplements and herbal preparations can have potentially harmful side effects and may dangerously interfere or interact with prescription medications.
Talk to your doctor before using any unprescribed remedy or new complementary therapy.
Coping and support
The experience of chronic fatigue syndrome varies from person to person. For many people, however, the symptoms are more bothersome early in the course of the illness and then gradually decrease. Some people recover completely with time. Emotional support and counseling may help you and your loved ones deal with the uncertainties and restrictions of chronic fatigue syndrome.
You may find it therapeutic to join a support group and meet other people with chronic fatigue syndrome. Support groups aren't for everyone, and you may find that a support group adds to your stress rather than relieving it. Experiment and use your own judgment to determine what's best for you.
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