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Chronic fatigue syndrome

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Related Terms
  • Autoimmune disorder, chronic fatigue, chronic fatigue and immune dysfunction syndrome, dysfunctional immune system, enlarged lymph nodes, exhaustion, fatigue, hypoglycemia, hypotension, immune system, memory loss, muscle soreness, sleep disturbance.

Background
  • Chronic fatigue syndrome (CFS) is a disorder that causes extreme fatigue. The condition does not improve with bed rest. The flu-like symptoms associated with the disorder may last for years.
  • The U.S. Centers for Disease Control and Prevention (CDC) discovered the disease in 1988. However, the cause still remains unknown, and there is currently no method to measure the severity of the condition. Also, since little is known about the disease, there are few treatment options available.
  • CFS may occur after an infection. It may develop during or shortly after a period of high stress. It may also develop gradually with no clear starting point.
  • The illness may develop at any point in life. However, the CDC has found that it is most prevalent among individuals who are 40 to 59 years old. Occasionally, CFS is seen in members of the same family. However, there is no scientific evidence to suggest that CFS is contagious. Instead, researchers suspect that there may be a familial predisposition or genetic link to the disease. More research is needed to confirm these claims.
  • Women are diagnosed with CFS two to four times more often than men, according to researchers. However, it is unclear whether CFS affects more women or if women report the condition to their doctors more than men.
  • According to the CDC, about one million Americans have CFS. This disease affects more Americans than multiple sclerosis, lupus, lung cancer or ovarian cancer.

Author information
  • This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography
  1. Centers for Disease Control and Prevention. . Accessed March 10, 2009.
  2. Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS) Association of America. . Accessed March 10, 2009.
  3. National Institutes of Health (NIH). . Accessed March 10, 2009.
  4. Natural Standard: The Authority on Integrative Medicine. . Copyright © 2009. Accessed March 10, 2009.

Causes
  • The cause of chronic fatigue syndrome (CFS) remains unknown. However, researchers have suggested some possible causes, which include iron deficiency anemia, hypoglycemia (low blood sugar), history of allergies, viral infections (like Epstein-Barr virus), immune system dysfunction, hypotension, as well as changes in the levels of hormones produced in the hypothalamus, pituitary glands and adrenal glands.
  • The disease may be caused by inflammation in the nervous system pathways, which occurs in reaction to the autoimmune process. However, unlike other autoimmune diseases (like rheumatoid arthritis or lupus), CFS cannot be detected in the blood. Other researchers suggest that CFS occurs when a viral illness is complicated by a dysfunctional immune system.

Symptoms
  • Symptoms of chronic fatigue syndrome (CFS) are similar to common viral infections. However, CFS symptoms may last anywhere from months to years. Some individuals recover completely from the disorder while other patients' symptoms become progressively worse. Symptoms may also subside and then reappear later.
  • An individual meets the diagnostic criteria for CFS when they experience unexplained persistent fatigue for six months or longer with at least four of the eight primary symptoms, according to the International Chronic Fatigue Syndrome Study Group, which was brought together by the Centers for Disease Control and Prevention (CDC).
  • The eight primary symptoms of CFS include: loss of memory or concentration, sore throat, painful and enlarged lymph nodes, muscle soreness, joint pain (without swelling or redness), headache, sleep disturbance and extreme exhaustion.
  • Individuals with CFS may also experience a wide range of symptoms that are not part of the official diagnostic criteria. Additional symptoms may include: abdominal pain, alcohol intolerance, bloating, chest pain, chronic cough, diarrhea, dizziness, dry eyes/mouth, earache, irregular heartbeat, jaw pain, morning stiffness, nausea, night sweats, psychological problems (like depression and anxiety disorders), shortness of breath, tingling sensation and weight loss.
  • Some people with CFS may develop a low blood pressure (hypotensive) disorder that causes fainting.

Diagnosis
  • In general, it is often difficult to diagnose chronic fatigue syndrome (CFS) because it shares the symptoms of many other diseases, and there is currently no diagnostic or laboratory procedure that can confirm a diagnosis. In fact the U.S. Centers for Disease Control and Prevention (CDC) estimates that less than 20% of individuals who have CFS have been diagnosed.
  • The healthcare provider will first try to rule out other possible causes of fatigue, such as infections, immune disorders, tumors, muscle or nerve diseases (like multiple sclerosis), endocrine diseases (like hypothyroidism), drug dependence, heart disease, liver disease, kidney disease or psychiatric/psychological illnesses (like depression).
  • A diagnosis is confirmed if the patient has experienced unexplained persistent fatigue for six months or longer with at least four of the eight primary symptoms described by the International Chronic Fatigue Syndrome Study Group.

Treatment
  • Currently, there is no specific treatment available for chronic fatigue syndrome (CFS). However, some medical treatments may help alleviate symptoms of the disease.
  • Anti-anxiety medications: Lorazepam (Ativan®) or alprazolam (Xanax®) may be prescribed to relieve anxiety symptoms associated with CFS.
  • Antidepressants: Antidepressants may help improve sleep and relieve pain associated with CFS. Tricyclic antidepressants like amitriptyline (Limbitrol® or Triavil®) have been used. Selective serotonin reuptake inhibitors (SSRIs) like fluoxetine (Prozac® or Sarafem®), paroxetine (Paxil®), sertraline (Zoloft®) and bupropion (Wellbutrin®) have also been used.
  • Antihistamines: Antihistamines like fexofenadine (Allegra®) and cetirizine (Zyrtec®), as well as decongestants that contain pseudoephedrine (Sudafed® or Dimetapp®) may relieve allergy-like symptoms.
  • Clonazepam: Clonazepam (Klonopin®) may be used to treat dizziness and skin tenderness associated with CFS.
  • Exercise: CFS patients may be encouraged to begin an exercise program with the help of a physical therapist. The program should gradually increase in length and difficulty. Consistent exercise may help prevent or decrease muscle weakness, as well as increase the individual's energy level.
  • Hypotension medications: Fludrocortisone (Florinef®) and midodrine (ProAmatine®) have been used to treat CFS patients who experience hypotension (low blood pressure).
  • Lifestyle changes: Patients may be encouraged to avoid excessive physical and psychological stress. A change in lifestyle may help the individual save more energy for important activities.
  • NSAIDs: Nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen (Advil® or Motrin®) may be helpful to reduce pain and fever. Acetaminophen (Tylenol®) has also been used to reduce CFS symptoms.

Integrative therapies
  • Unclear or conflicting scientific evidence:
  • Aspartic acid: Evidence from clinical study suggests that potassium and magnesium salts of aspartate may have fatigue-reducing effects. However, the effects of aspartic acid alone are unclear. Secondary sources suggest that aspartates may be low in individuals with chronic fatigue syndrome. Additional clinical study is needed in this area.
  • Use cautiously in patients with high protein intakes, gastrointestinal concerns, liver damage, gout, kidney damage, or osteoporosis.
  • Coenzyme Q10: Early study indicates that CoQ10 may improve symptoms of chronic fatigue syndrome. High quality research is needed in this area before a decision can be made.
  • Allergy associated with Coenzyme Q10 supplements has not been reported in the available literature, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners), antiplatelet drugs (like aspirin, warfarin, clopidogrel (like Plavix®), or blood pressure, blood sugar, cholesterol, or thyroid drugs. Avoid if pregnant or breastfeeding.
  • DHEA: The scientific evidence remains unclear regarding the effects of DHEA (dehydroepiandrosterone) supplementation in patients with chronic fatigue syndrome. Better research is necessary before a clear conclusion can be drawn.
  • Avoid if allergic to DHEA products. Few side effects are reported when DHEA supplements are taken by mouth in recommended doses. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders, or in patients taking anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.
  • Evening primrose oil: Not enough information is currently available to advise the use of evening primrose oil for chronic fatigue syndrome or post-viral infection symptoms.
  • Avoid if allergic to plants in the Onagraceae family, gamma-linolenic acid, or other ingredients in evening primrose oil. Several reports describe seizures in individuals taking evening primrose oil. Avoid if pregnant or breastfeeding.
  • Folate (folic acid): Some patients with chronic fatigue syndrome have decreased folic acid levels. Daily injections of a combination of folic acid, bovine liver extract and vitamin B12 for three weeks were not beneficial for CFS in limited available study.
  • Avoid if allergic to folate. Folate appears to be well tolerated in recommended doses. The U.S. Recommended Dietary Allowance (RDA) for adults is 400 micrograms per day for males or females ages 14 years and older; 500 micrograms per day for breastfeeding adult women and 600 micrograms per day for pregnant adult women. The RDA for infants 0-6 months-old is 65 micrograms per day; for infants 7-12 months-old the RDA is 80 micrograms per day; for children 1-3 years-old the RDA is 150 micrograms per day; for children 4-8 years-old the RDA is 200 micrograms per day; for children 9-13 years-old the RDA is 300 micrograms per day. Stomatitis (mouth sores), alopecia (hair loss), myelosupression (blood marrow condition) and zinc depletion have been reported with folate use. It is recommended that all women capable of becoming pregnant consume folate in order to reduce the risk of the fetus developing a neural tube defect. Folic acid supplementation in recommended doses is FDA Pregnancy Category A. When taken in higher doses, it is categorized as FDA Pregnancy Category C. Folic acid is present in the breast milk and is likely safe to use during breastfeeding under the supervision of a qualified healthcare provider.
  • Ginseng: A few studies using ginseng extract G115® (with or without multivitamins) report improvements in patients with fatigue of various causes. However, these results are early, and studies have not been high-quality.
  • Avoid ginseng with a known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.
  • Iron: Ferrous sulfate may improve fatigue in women with low ferritin levels. Further research is needed to confirm these results.
  • Iron is a trace mineral, and hypersensitivity is unlikely. Avoid with a known allergy/hypersensitivity to products containing iron. Avoid excessive intake. Avoid with blood disorders that require frequent blood transfusions. Use cautiously with a history of kidney disease, intestinal disease, peptic ulcer disease, enteritis, colitis, pancreatitis, hepatitis, alcoholism, or in those who plan to become pregnant, or are over age 55 and have a family history of heart disease. Pregnant or breastfeeding women should consult a healthcare professional before beginning iron supplementation.
  • Jasmine: Jasmine is commonly used in aromatherapy as a relaxing, yet stimulating herb. However, preliminary study did not find a significant difference between the alertness levels of essential oil users and controls. More research is needed in this area.
  • Use cautiously during pregnancy or lactation. Use cautiously in patients allergic to jasmine, jasmine oil, or other fragrances. Avoid oral consumption of essential oils, including jasmine essential oil, as they are extremely potent and can be poisonous.
  • Kiwi: One study suggests that a kiwi-containing drink has beneficial effects on athletic performance. However, methodological weaknesses in this study preclude making any firm conclusions regarding kiwi's effectiveness for energy enhancement.
  • Avoid if allergic or hypersensitive to kiwi, latex, birch pollen, banana, chestnut, fig, flour, melon, poppy seeds, rye grain, sesame seeds and related substances. Kiwi is generally considered safe when taken in amounts naturally found in foods. Use cautiously with anti-platelet drugs like aspirin, cilostazol or clopidogrel. Use cautiously with hormone therapies or serotonergic drugs. Avoid if pregnant or breastfeeding. The amount found in foods appears to be safe in most people.
  • L-carnitine: There are several promising reports on the use of L-carnitine for fatigue. However, additional study is warranted in this area.
  • Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.
  • Liver extract: An injectable solution of bovine liver extract containing folic acid and cyanocobalamin has been studied as a potential treatment for chronic fatigue syndrome. Preliminary study indicates that patients with chronic fatigue syndrome reacted positively to intramuscular bovine liver extract. Additional study is needed to make a conclusion.
  • Use cautiously as raw liver may contain liver flukes or the bacterium, Vibrio fetus. Use cautiously if taking antacids or with acid reflux. Use cautiously with clotting disorders, compromised immune function, or abnormal iron levels. Use cautiously if taking antihypercholesterolemic drugs (drugs that affect blood cholesterol), antiviral agents, especially interferon, or any agents for cancer. Use cautiously in hepatopathic patients with reduced human growth hormone metabolic clearance rate. Avoid if allergic or hypersensitive to liver extract or its constituents. Avoid with iron metabolism disorders or iron shortage disorders, such as hemochromatosis. Avoid liver extract from countries where bovine spongiform encephalitis (BSE or "mad cow disease") has been reported. Avoid if pregnant or breastfeeding.
  • Meditation: Mindfulness meditation with Qi gong may contribute to improved overall health. However, not enough studies have examined the specific effects of meditation on chronic fatigue syndrome. More studies are needed in this area.
  • Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.
  • Physical therapy: There is inconclusive evidence on whether physical therapy may help reduce cancer-related fatigue. Additional study is needed in this area.
  • Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.
  • Reflexology: Reflexology may help relieve fatigue and stress. High quality clinical research is needed to make a conclusion.
  • Avoid with recent or healing foot fractures, unhealed wounds, or active gout flares affecting the foot. Use cautiously and seek prior medical consultation with osteoarthritis affecting the foot or ankle, or severe vascular disease of the legs or feet. Use cautiously with diabetes, heart disease, or the presence of a pacemaker, unstable blood pressure, cancer, active infections, past episodes of fainting (syncope), mental illness, gallstones, or kidney stones. Use cautiously if pregnant or breastfeeding. Reflexology should not delay diagnosis or treatment with more proven techniques or therapies.
  • Rolfing® Structural Integration: Rolfing® Structural Integration may benefit cardiovascular endurance in people with chronic fatigue syndrome. In preliminary study, patients showed improvement in overall well being. However, larger well-designed studies are needed to confirm these results.
  • Rolfing® Structural Integration should not be used as the sole therapeutic approach to disease, and it should not delay the time it takes to speak with a healthcare provider about a potentially severe condition. Rolfing® Structural Integration is generally believed to be safe in most people. Avoid in patients taking blood thinners and in patients with broken bones, severe osteoporosis, disease of the spine or vertebral disks, skin damage or wounds, bleeding disorders, blood clots, tooth abscesses, acute disc problems, aneurysm, fever, recent scar tissue, connective tissue disease, cancer, and in patients who have just received cortisone shots or who are on chronic cortisone therapy. Use cautiously in patients with varicose veins or phlebitis, joint diseases, psychosis or bipolar disorder, severe kidney, liver, or intestinal disease, diabetes, menstruation, infectious conditions, colostomies, high blood pressure, and stenoses or strictures.
  • Sandalwood: Preliminary study indicates that sandalwood oil may increase alertness; however, more research is needed in this area.
  • Avoid if allergic or hypersensitive to sandalwood (Santalum album), its constituents, or related members of the Santalaceae family. Avoid if pregnant or breastfeeding.
  • Selenium: Evidence of selenium's effectiveness for fatigue is currently inconclusive. Additional research is needed in this area.
  • Avoid if allergic or sensitive to products containing selenium. Avoid with a history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
  • Taurine: Energy drinks containing taurine, along with other ingredients such as caffeine and glucuronolactone, are widely available. Overall these drinks have been suggested to decrease sleepiness associated with driving, increase energy, concentration, and memory, and positively affect mood, well-being, and vitality. Further study is required to examine the effect of taurine alone.
  • Taurine is an amino acid and it is unlikely that there are allergies related to this constituent. However, allergies may occur from multi-ingredient products that contain taurine. Use cautiously in patients with high cholesterol, low blood pressure, coagulation disorders, potential for mania, or epilepsy. Avoid alcohol or exercise after consumption of energy drinks containing taurine, caffeine, glucuronolactone, B vitamins, and other ingredients. Use cautiously if pregnant or breastfeeding; taurine is a natural component of breast milk.
  • Vitamin B12: There is some evidence that intramuscular injections of vitamin B12 given twice per week may improve the general well-being and happiness of patients with symptoms of tiredness or fatigue. However, fatigue has many potential causes and well-designed clinical trials are needed before a recommendation can be made.
  • Avoid if allergic or hypersensitive to cobalamin, cobalt, or any other vitamin B12 product ingredients. Avoid with coronary stents (mesh tube that holds clogged arteries open) and Leber's disease. Use cautiously if undergoing angioplasty and with anemia. Vitamin B12 is generally considered safe when taken in amounts that are not higher than the Recommended Dietary Allowance (RDA). There is not enough scientific data available about the safety of larger amounts of vitamin B12 during pregnancy and/or breastfeeding.
  • Yoga: Preliminary studies in humans report that yoga may improve fatigue in adults. However, better-designed studies are needed before any conclusion can be made.
  • Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.
  • Fair negative scientific evidence:
  • Spirulina: There is currently inadequate evidence to recommend the use of spirulina in chronic fatigue syndrome.
  • Avoid if allergic or hypersensitive to spirulina or blue-green algae. Use cautiously with phenylketonuria (a genetic disorder of a liver enzyme that disrupts normal body functions), autoimmune diseases, bleeding disorders, diabetes, and osteoporosis. Use cautiously with products containing the blue-green algae species Anabaena spp., Aphanizomenon spp., and Microcystis spp.; in underweight patients or in those taking antiobesity agents or appetite suppressants; or if consuming a high-protein diet. Avoid in children and if pregnant or breastfeeding.

Prevention
  • Since the cause of chronic fatigue syndrome (CFS) remains unclear, there is no known method to prevent the disease. Individuals who experience CFS symptoms should consult their healthcare providers.

Support for cfs patients
  • The CFIDS (Chronic Fatigue and Immune Dysfunction Syndrome) Association of America is the largest charitable organization dedicated to conquering CFS. Since the organization was founded in 1987, the association has invested more than $18.4 million in initiatives to find a cure for CFS. The organization works to promote awareness of CFS and promotes high-quality scientific research.
  • For more information about the CFIDS Association of America, please visit www.cfids.org.

Copyright © 2011 Natural Standard (www.naturalstandard.com)


The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.

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