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What is Chronic Fatigue?

Causes of CFS
Risk Factors


Chronic fatigue syndrome (CFS) is a complicated disorder characterized by extreme fatigue that doesn’t improve with bed rest and may worsen with physical or mental activity.

Chronic fatigue syndrome may occur after an infection, such as a cold or viral illness. The onset can be during or shortly after a time of great stress, or chronic fatigue syndrome come on gradually without a clear starting point or obvious cause.

Women are diagnosed with chronic fatigue syndrome far more often than men are. However, it’s unclear whether chronic fatigue syndrome affects women more frequently or if women report it more often than men do.

The Fact Sheet for CFS published by the National Institutes of Allergy and Infectious Diseases of the National Institutes of Health states that “Today, CFS is also known as myalgic encephalomyelitis (ME), post viral fatigue syndrome (PVFS), and chronic fatigue and immune dysfunction syndrome (CFIDS).” ME/CFS is now recognized as part of a range of illnesses that have fatigue as a major symptom.

Causes of CFS

Of all chronic illnesses, chronic fatigue syndrome is one of the most mysterious. Unlike definite infections, it has no clear cause. 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 herpes virus 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)

The cause of chronic fatigue syndrome may be an inflammation of the pathways of the nervous system as a response to an autoimmune process, but with nothing measurable in the blood as in other autoimmune diseases, such as rheumatoid arthritis and lupus. Chronic fatigue syndrome may also occur when a viral illness is complicated by a dysfunctional immune system. Some people with CFS may have a low blood pressure disorder that triggers the fainting reflex.

In many cases, however, no serious underlying infection or disease is proved to specifically cause chronic fatigue syndrome. Lack of medical knowledge and understanding of CFS has made determining and describing the characteristics of the condition difficult.


The main symptom of chronic fatigue syndrome (CFS) is a devastating tiredness or exhaustion that has lasted at least 6 months and does not improve much with rest. This fatigue also is so severe that it interferes with your work, your play, and your social activities. The fatigue and other symptoms described below may begin suddenly or they may develop gradually over weeks or months.

Primary signs and symptoms

In addition to persistent fatigue, not caused by other known medical conditions, chronic fatigue syndrome has eight possible primary signs and symptoms. Chronic fatigue syndrome symptoms include:

  • Loss of memory or concentration
  • Sore throat
  • Painful and mildly enlarged lymph nodes in your neck or armpits
  • Unexplained muscle soreness
  • Pain that moves from one joint to another without swelling or redness
  • Headache of a new type, pattern or severity
  • Sleep disturbance
  • Extreme exhaustion lasting more than 24 hours after physical or mental exercise

According to the International Chronic Fatigue Syndrome Study Group — a group of scientists, researchers and doctors brought together by the Centers for Disease Control and Prevention (CDC) to determine a standard method for defining and diagnosing chronic fatigue syndrome — a person meets the diagnostic criteria of chronic fatigue syndrome when unexplained persistent fatigue occurs for six months or more along with at least four of the eight primary signs and symptoms.

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.

Diagnosis of CFS

A diagnosis of chronic fatigue syndrome is based on exclusion. This means that before arriving at a diagnosis, a doctor has ruled out any other disease or condition that may be causing your fatigue and related symptoms.

In general, doctors find it difficult to diagnose chronic fatigue syndrome because it has some of the same signs and symptoms as many other diseases. There’s no diagnostic or laboratory procedure to confirm the presence of chronic fatigue syndrome.

Doctors exclude certain conditions before considering a diagnosis of chronic fatigue syndrome. These include:

  • Having an active, identifiable medical condition that often results in fatigue, such as Lupus, low levels of thyroid hormones (hypothyroidism) or sleep apnea
  • Using medicines that may cause fatigue
  • Having a relapse of a previously treated illness that can result in fatigue, such as cancer
  • Having had a past or current diagnosis of a major depressive disorder or other psychiatric illness, such as schizophrenia or an eating disorder
  • Abusing alcohol or another substance
  • Being severely obese, as defined by a body mass index (BMI) of 45 or greater

Over time, be alert to any new cues that might indicate that the problem is caused by something other than chronic fatigue syndrome. When other diseases or conditions are excluded, your doctor may then determine if your illness meets the CFS-specific criteria.

Treatment of CFS

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. Often 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. In one study, 70 percent of participants with CFS reported feeling better after completing a supervised program of graduated exercise.
  • 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 professional 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. Tricyclic antidepressants include amitriptyline (Limbitrol, a multi-ingredient drug that contains amitriptyline), desipramine (Norpramin) and nortriptyline (Aventyl, Pamelor). SSRIs include fluoxetine (Prozac, Sarafem), paroxetine (Paxil), sertraline (Zoloft) and bupropion (Wellbutrin).
  • 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 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), atenolol (Tenormin) and midodrine (ProAmatine, Orvaten) 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). 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 improved fatigue and concentration in some people with chronic fatigue syndrome.
  • 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 the symptoms of chronic fatigue syndrome, with particular benefit in study participants’ energy level and overall well-being.
  • Acupuncture. Acupuncture has been studied 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. In one clinical trial, half the participants received acupuncture, while the other half received a placebo treatment. Those treated with acupuncture experienced a significant improvement in their symptoms — especially fatigue and anxiety — compared with the nonacupuncture group.
  • 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 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 has not been found beneficial for chronic fatigue syndrome.
Risk Factors

Women are diagnosed with chronic fatigue syndrome two to four times as often as men, but sex isn’t a proven risk factor for this condition. It may be that women are simply more likely than men are to report their symptoms to their 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.


The long-term outlook for patients with C.F.S. is variable and difficult to predict at the initial onset. Some patients have been reported to completely recover after six months to a year. Others may take longer for a complete recovery.

Some patients report never returning to their pre-illness state. Most studies report that patients treated in an extensive rehabilitation program have a better prognosis of improving significantly than those patients who don’t seek treatment.


There are a number of complications arising from CFS, including:

• social isolation caused by fatigue
• lifestyle restrictions (some people are so fatigued that they are essentially disabled during the course of the illness)
• depression (related both to symptoms and lack of diagnosis)
• side effects and adverse reactions related to medication treatments


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 excluded. More information on C.F.S. is available from the Centers for Disease Control and Prevention and the CFIDS Association of America.


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