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CHAPTER 59: CHRONIC FATIGUE SYNDROME

Gijs Bleijenberg; Jos W. M. van der Meer

DEFINITION

Chronic fatigue syndrome (CFS) is a disorder characterized by persistent and unexplained fatigue resulting in severe impairment in daily functioning. Besides intense fatigue, most patients with CFS report concomitant symptoms such as pain, cognitive dysfunction, and unrefreshing sleep. Additional symptoms can include headache, sore throat, tender lymph nodes, muscle aches, joint aches, feverishness, difficulty sleeping, psychiatric problems, allergies, and abdominal cramps. Criteria for the diagnosis of CFS have been developed by the U.S. Centers for Disease Control and Prevention (Table 59-1).

TABLE 59-1DIAGNOSTIC CRITERIA FOR CHRONIC FATIGUE SYNDROME
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TABLE 59-1DIAGNOSTIC CRITERIA FOR CHRONIC FATIGUE SYNDROME
Characteristic Persistent or Relapsing Unexplained Chronic Fatigue
Fatigue lasts for at least 6 months.
Fatigue is of new or definite onset.
Fatigue is not the result of an organic disease or of continuing exertion.
Fatigue is not alleviated by rest.
Fatigue results in a substantial reduction in previous occupational, educational, social, and personal activities.
Four or more of 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.
Exclusion Criteria
Medical condition explaining fatigue
Major depressive disorder (psychotic features) or bipolar disorder
Schizophrenia, dementia, or delusional disorder
Anorexia nervosa, bulimia nervosa
Alcohol or substance abuse
Severe obesity (body mass index >40)

EPIDEMIOLOGY

image CFS is seen worldwide, with adult prevalence rates varying between 0.2% and 0.4%. In the United States, the prevalence is higher among women (–75% of cases), members of minority groups (African and Native Americans), and individuals with lower levels of education and occupational status. The mean age of onset is between 29 and 35 years. Many patients probably go undiagnosed and/or do not seek help.

ETIOLOGY

There are numerous hypotheses about the etiology of CFS; there is no definitively identified cause. Distinguishing between predisposing, precipitating, and perpetuating factors in CFS helps to provide a framework for understanding this complex condition (Table 59-2).

TABLE 59-2PREDISPOSING, PRECIPITATING, AND PERPETUATING FACTORS IN CHRONIC FATIGUE SYNDROME
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TABLE 59-2PREDISPOSING, PRECIPITATING, AND PERPETUATING FACTORS IN CHRONIC FATIGUE SYNDROME
Predisposing Factors
Childhood trauma (sexual, physical, emotional abuse; emotional and physical neglect)
Physical inactivity during childhood
Premorbid psychiatric illness or psychopathology
Premorbid hyperactivity
             ↓
Precipitating Factors
Somatic events: infection (e.g., mononucleosis, Q fever, Lyme disease), surgery, pregnancy
Psychosocial stress, life events
             ↓
Perpetuating Factors
Non-acknowledgment by physician
Negative self-efficacy
Strong physical attributions
Strong focus on bodily symptoms
Fear of fatigue
Lack of social support
Low physical activity pattern

Predisposing factors

Physical inactivity and trauma in childhood tend to increase the risk of CFS in adults. Neuroendocrine dysfunction may be ...

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