Chronic fatigue syndrome

Chronic Fatigue Syndrome

What is chronic fatigue syndrome?

Chronic Fatigue Syndrome also known as Myalgic Encephalomyelitis (ME) or Systemic Exertional Intolerance Disease (SEID) is a complicated disorder. It presents as extreme fatigue that lasts for at least six months, but there is no underlying medical condition that can be explained as the cause of the disease.

The typical feature of this fatigue is that it becomes worse with physical or mental activity and it is not improved by taking rest.

Chronic fatigue syndrome statistics:

Chronic fatigue syndrome is seen all over the world. Adults are affected at a varying rate between 0.2 to 0.4 percent. In the United States, women are more affected than men, approx. 75 percent of the total cases in the United States are women.

Also, persons with lower levels of health awareness are more affected. Sadly, chronic fatigue syndrome is associated with an increased rate of death from suicide.

Commonly occurs in people with a mean age in between 29 and 35 years. But many sufferers do not seek medical help, so it is probably not diagnosed at an early stage in many cases.

Chronic fatigue syndrome risk factors:

There are several risk factors (predisposing factors) of chronic fatigue syndrome. These are the following 

  1. Childhood trauma (sexual, physical, emotional abuse, emotional and physical neglect)
  2. Physical inactivity during childhood 
  3. Psychiatric illness or psychopathology before the occurrence of the disease
  4. Hyperactivity before the occurrence of disease

Chronic fatigue syndrome triggering factors:

Several triggers lead to the development of chronic fatigue syndrome. These are the following triggering factors (precipitating factors) that causes the disease

  1. Infection (example- Mononucleosis, Q fever, Lyme disease)
  2. Surgery
  3. Pregnancy
  4. Psychological stress, life events

Factors that worsen the symptoms of chronic fatigue syndrome:

Several factors are responsible for worsening of the symptoms in chronic fatigue syndrome. The symptoms continue and progressively may worsen due to these factors. These factors are the following

  1. Negative self efficacy or better to say the negative set of self beliefs that how well we can execute an action in a given situation.
  2. Strong physical attributions or strong physical qualities
  3. Strong focus on bodily symptoms 
  4. Fear of fatigue 
  5. Lack of social support 
  6. Low physical activity pattern
  7. When it is not diagnosed due to different reasons. Many times patient denies the condition and left untreated.

Chronic fatigue syndrome symptoms:

The following symptoms may vary from person to person. All symptoms may not be present in a person. Also, the severity of symptoms can fluctuate day to day basis.

  1. Fatigue, mostly unexplained
  2. Headache that can be new or daily persisting headache with worsening situation day to day
  3. Sleep is not refreshing and there is difficulty in sleeping 
  4. Lack of concentration and focus
  5. Poor memory that you face with difficulty in remembering daily things
  6. Unexplained muscle pain or joint pain without swelling and redness.
  7. Extreme exhaustion after physical or mental exercise that does not go away with rest (this situation is known as post exertional malaise)
  8. Sore throat
  9. Enlarged lymph node in neck or armpit, the lymph node may be tender
  10. Chills and night sweats
  11. Muscle weakness
  12. Allergies and sensitivities to foods, chemicals, odors, light, noise, etc.
  13. Shortness of breath
  14. Irregular heartbeat
  15. Dizziness becomes worse after changing the position from lying down or sitting to standing ( known as orthostatic intolerance)
  16. Feverishness
  17. Belly cramps 

Chronic fatigue syndrome causes:

The exact cause of chronic fatigue syndrome is not known yet. Research indicates that some triggers may play an important role. These triggers are

Immune system dysfunction

It is seen that many sufferers of chronic fatigue syndrome have modest elevations in titres of antinuclear antibodies, reduction of different immunoglobulins, deficiencies in mitogen-driven lymphocyte proliferation, reductions in natural killer cell activity, disturbances in cytokines production, etc.

Though more research is needed to confirm that immune system dysfunction is associated with chronic fatigue syndrome. Because not all cases of chronic fatigue syndrome show similar changes in the above mentioned immune findings.

Excessive production of a cytokine such as an interleukin 1 may be associated with the development of symptoms in chronic fatigue syndrome.

Viral Infections

Suspicious viruses that may trigger chronic fatigue syndrome are Epstein Barr virus (EBV), Human Herpes virus 6, Rubella virus. It is observed that after viral infection, people have fatigue problems, so researchers believe that virus may play a role in chronic fatigue syndrome.

Also, it is seen that a high percentage of chronic fatigue syndrome cases are seen after one gets Q fever or Lyme disease.

Hormonal imbalance

Imbalance of the hormones produced by hypothalamus, pituitary, adrenal glands. More research is needed to confirm that whether hormonal imbalances are solely responsible for chronic fatigue syndrome.

Emotional trauma or Physical trauma

Research shows few people experience chronic fatigue syndrome after surgery, any injury, or significant emotional stress.

 Serious life events such as the loss of a loved one or job loss, military combat, or any other stressful situation may increase the chance to get chronic fatigue syndrome.


Some people may be genetically more prone to get chronic fatigue syndrome. So it is seen that there are many cases with the familial association. No particular gene is identified to date that causes chronic fatigue syndrome, but there is some association.


Allergy from different substances ( like food, chemical, etc.) may increase the chances to get chronic fatigue syndrome.

Psychiatric illness

Psychiatric illness and physical hyperactivity in adulthood increase the risk of getting chronic fatigue syndrome in later life.

Environmental factors

There are many environmental conditions that may increase the chances to get chronic fatigue syndrome. Such as, living with very high working pressures for years, toxic exposure to different chemical substances, stressed lifestyle or factors that can affect your wellness increases the chances of getting chronic fatigue syndrome.

It is important to mention that one third of all chronic fatigue syndrome sufferers can not recall a trigger.

Chronic fatigue syndrome may be the end stage of multiple different conditions not associated with any specific condition.

Chronic fatigue syndrome risk group:

It most commonly occurs in young to middle aged people but can occur at any age. Women in their 40s and 50s are more prone to develop chronic fatigue syndrome than men.

Women are 2 to 4 times more likely to develop chronic fatigue syndrome than men.

Chronic fatigue syndrome recovery factors:

Once chronic fatigue syndrome develops, many factors prevent to recover from this syndrome. Recovery from chronic fatigue syndrome are hampered by

  1. The patient’s focus on symptoms, avoidance of activities may also worsen symptoms of chronic fatigue syndrome.
  2. The patient has a firm belief in a physical cause, a strong focus on bodily sensations, and a poor sense of control over symptoms may also prolong or exacerbate the fatigue and also functional impairment.
  3. In many cases, it is seen that inactivity is the result of negative illness perceptions rather than poor physical fitness. Solicitous behavior of others may reinforce a patient’s illness related perceptions and behavior.
  4. A lack of social support.
  5. Many times, the cause for its chronicity may be due to unnecessary diagnostic tests.
  6. Many times, persistently assuming psychological issues as potential cause hampers delay in treatment
  7. Not acknowledging chronic fatigue syndrome as a diagnosis in timely manner leads to chronic stage.

Staying calm and peaceful from inside can help in many earlier cases of this disease.

Chronic fatigue syndrome complications:

There are many complications of chronic fatigue syndrome. Complications of chronic fatigue syndrome are the following

  1. Lifestyle restrictions- Due to extreme fatigue and other associated symptoms persons with chronic fatigue syndrome are not able to maintain the normal regular activities that they used to do previously. The incapability of doing regular activities (like walking, household chores etc.) becomes more difficult to finish by passing days.
  2. Depression- Mostly due to the effects of chronic fatigue syndrome, the regular lifestyle hampers. This leads to depression development within the sufferer after a certain period of time. This depression once appear can not easily go due to the already persisting messed up situation. The right handling of the situation is possible that also controls the depression.
  3. Increased work absence- Due to the extreme fatigue and other associated symptoms of chronic fatigue syndrome, the sufferer mostly unable to continue their work with stability. This syndrome if not controlled hampers work life.
  4. Social isolation- Due to the symptoms of chronic fatigue syndrome, sufferer isolates themselves from all kinds of social interactions. Actually, chronic fatigue syndrome gives so much of fatigue that one can not maintain any social engagement. Only the controlled chronic fatigue syndrome can make the situation better.
  5. Economic instability- With chronic fatigue syndrome, the sufferer loses the energy to do anything. So it ends up losing work life that leads to economic instability.

Chronic fatigue syndrome diagnosis:

There is no single test to confirm the diagnosis of chronic fatigue syndrome. As the symptoms are very similar to other medical conditions, so it is a challenge for the doctor to diagnose the chronic fatigue syndrome.

Health problems such as sleep disorders ( obstructive sleep apnoea, insomnia, restless leg syndrome, etc.) can lead to chronic fatigue. Moreover, fatigue is a very common symptom of various medical conditions such as Anaemia, Thyroid disorders, Diabetes, Heart problems, Cancer, etc.

Lab tests can be helpful to determine if any medical condition is the cause of this fatigue. Also, mental health related problems such as depression, anxiety, etc. may lead to fatigue. So mental health problems need to be ruled out by a counselor.

So a thorough medical history, systematic physical examination is very important to exclude other conditions as a potential cause of fatigue.

Laboratory tests help to exclude other conditions. Following laboratory tests may be needed

  1. Complete blood count
  2. Erythrocyte sedimentation rate ( ESR )
  3. C-reactive protein
  4. Serum creatinine
  5. Electrolytes
  6. Calcium 
  7. Iron
  8. Blood glucose (FPG, PP, HbA1c tests)
  9. Creatine kinase
  10. Liver function tests
  11. Thyroid stimulating hormone
  12. Anti-gliadin antibodies 
  13. Urinalysis

Serology for viral or bacterial infections is not usually helpful. No abnormalities are detected on MRI or CT scans.

It is important to mention that there are so many common symptoms between Fibromyalgia and chronic fatigue syndrome so sometimes researchers consider these two conditions are different aspects of the same disease.

Chronic fatigue syndrome diagnostic criteria

Characteristic persistent or relapsing unexplained chronic fatigue 

  • Fatigue lasts for at least six months.
  • Fatigue is new or just getting started
  • Fatigue is not the result of any prominent underlying medical condition
  • Fatigue does not become less even when taking sufficient rest
  • Fatigue results a significant reduction of previous occupational, educational, social, and personal activities.
  • If the following symptoms are concurrently present for 6 months: Impaired memory or concentration, sore throat, tender cervical or axillary lymph nodes, muscle pain, pain in several joints, new headaches, unrefreshing sleep, or malaise after exertion.

It is not a chronic fatigue syndrome when

There are many other conditions that must be confirmed before diagnosing the situation as chronic fatigue syndrome. When the following conditions are present then it is not a chronic fatigue syndrome

  • Medical condition explaining fatigue.
  • Major depressive disorder or bipolar disorder 
  • Schizophrenia, dementia, or delusional disorder
  • Anorexia nervosa, bulimia nervosa
  • Alcohol or substance abuse
  • Severe obesity ( body mass index greater than 40)

Proposed diagnostic guideline

United States Institute of Medicine proposed a guideline that defines fatigue associated with chronic fatigue syndrome as being

  1. It is so severe that it interferes with the ability to engage in pre illness activities
  2. It is of new-onset or definite onset (not lifelong)
  3. It is not substantially alleviated by rest.
  4. It is worsened by physical, mental, or emotional exertion.

With this above mentioned criteria, a person also need to experience at least one of these two symptoms

  • Problem with memory, lack of concentration or focus
  • Dizziness that becomes worse by changing the position from lying down or sitting to standing.

These above mentioned symptoms need to last for at least six months and must occur at least half the time at moderate, substantial, or severe intensity.

Chronic fatigue syndrome treatment:

Based on the symptoms such as fatigue or other accompanying symptoms, the duration of symptoms, and the impact of these symptoms on daily activities, the treatment differs from person to person.

It is important to identify potential risk factors that are causing chronic fatigue syndrome if possible.

A brief questionnaire is sometimes helpful such as ———-

How have you felt during the last two weeks?

Check below and rate all four statements and per statement check the box that reflects your situation best. Check the first question below, if that is yes, then you do not need to check the rest questions. But if the first question gives a NO reply then proceed for the rest questionnaire.

Scale of Rating: For maximum tiredness you score it as 7 and for minimum or no tiredness the value should be 1.

Fatigue Measurement Chart

Now, if your Sum scores greater than 18 then it indicates severe fatigue. Depending upon the severity the treatment differs.

If CBT (Cognitive Behavioural Therapy) for chronic fatigue syndrome is not available as an initial option and depression or anxiety is present, then these symptoms should be treated.

In case of headache, diffuse pain, feverishness- nonsteroidal anti-inflammatory drugs may be given. Modest symptoms improvement gives the sufferer confidence and makes a huge difference in respect to the patient’s self-esteem, self-sufficiency, and to get or appreciate pleasures of life.

Chronic fatigue syndrome relief

Study shows that medicines like acyclovir, fludrocortisone, galantamine, modafinil, IV immunoglobulin gives no significant benefit in chronic fatigue syndrome.

The sufferer is encouraged to maintain regular sleep patterns, to remain as active as possible. The sufferer is also encouraged to gradually return to previous levels of exercise and other activities.

There is no cure for chronic fatigue syndrome. Treatment is provided to give symptomatic relief. Treating these symptoms may give relief to some patients, but not all. Patients need to learn new ways to manage daily activities.

The symptoms that give the highest problem are treated first.

  1. Managing post exertional malaise
  2. The doctor advises the patient to develop healthy sleeping habits. Improved sleep always gives better outcome in chronic fatigue syndrome.
  3. To give relief from pain, Over-the-counter drugs ( OTC) are used for headaches and other types of pain. Sometimes the intensity of pain is so severe that stronger medication may be needed.
  4. To control anxiety and depression, sometimes low dose antidepressant drugs the doctor may prescribe.
  5. Lifestyle modifications-
    • A balanced and nutritious diet
    • Positive approach towards life
  6. Also consultation with the counselor to manage emotional, mental problems.
  7. Support from the family is utmost important to cope with all the challenges.

There are some non-drug therapies such as – gentle stretching, toning exercise, heat therapy, water therapy, gentle massage, etc. There are also some lifestyle remedies such as relaxation techniques, deep breathing, massage, tai chi, or yoga-like gentle exercise.


It is rare to get full recovery from untreated chronic fatigue syndrome. The median annual recovery rate is 5 percent (range is 0 to 31 percent), the median improvement rate is 39 percent (range is 8 to 63 percent ).

Patients who have an underlying psychiatric disorder and those who continue to think of their symptoms as an undiagnosed medical condition have poorer outcomes.

So it is best to hold the positive approach towards life and also regarding the disease. Wait for a while and think you are not suffering from a deadly disease! It is still under your control! Lifestyle modifications, growing some new habits to cope up the challenges you face can turn the situation in a much better way. Stay happy and healthy.


  1. Harrison’s Principles of Internal Medicine 20th edition, (pg. 3254 to pg. 3256)
  2. Research Report from National Library of Medicine
  3. NHS, UK
  4. Centers for Disease Control and Prevention
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