Myalgic encephalomyelitis/chronic fatigue syndrome: Difference between revisions

Myalgic encephalomyelitis/chronic fatigue syndrome
Myalgic encephalomyelitis/chronic fatigue syndrome
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Chronic fatigue syndrome (CFS) is the most common name^[1] given to a variably debilitating disorder or disorders generally defined by persistent fatigue unrelated to exertion and not substantially relieved by rest, and accompanied by the presence of other specific symptoms for a minimum of six months.^[2] The disorder may also be referred to as post-viral fatigue syndrome (PVFS, when the condition arises following a flu-like illness), myalgic encephalomyelitis (ME), or several other terms. The etiology (cause or origin) of CFS is currently unknown and there is no diagnostic laboratory test or biomarker.^[2]

Fatigue is a common symptom in many illnesses, but CFS is a multi-systemic disease and is relatively rare by comparison.^[3] Symptoms of CFS include widespread muscle and joint pain; cognitive difficulties; chronic, often severe, mental and physical exhaustion; and other characteristic symptoms in a previously healthy and active person. CFS patients may report additional symptoms including muscle weakness, hypersensitivity, orthostatic intolerance, digestive disturbances, depression, poor immune response, and cardiac and respiratory problems.^[4] It is unclear if these symptoms represent co-morbid conditions or are produced by an underlying etiology of CFS.^[5] All diagnostic criteria require that the symptoms must not be caused by other medical conditions.

CFS is thought to have an incidence of 4 adults per 1,000 in the United States.^[6] According to the ME Association ^[7] it affects an estimated 250,000 people in the UK. For unknown reasons CFS occurs most often in people in their 40s and 50s, more often in women than men,^[8]^[9] and is less prevalent among children and adolescents.^[10] Full recovery from the condition occurs in only 5-10% of cases.^[10]

Whereas there is agreement on the genuine threat to health, happiness and productivity posed by CFS, various physicians' groups, researchers and patient advocates promote different nomenclature, diagnostic criteria, etiologic hypotheses and treatments, resulting in controversy about many aspects of the disorder. The name CFS itself is controversial as many patients and advocacy groups, as well as some experts, believe the name chronic fatigue syndrome stigmatizes, by not conveying the seriousness of the illness, and want the name changed.^[11]

Classification

Notable definitions include:^[4]

CDC definition (1994)^[12]—the most widely used clinical and research description of CFS,^[5] it is also called the Fukuda definition and was based on the Holmes or CDC 1988 scoring system.^[13] The 1994 criteria require the presence of four or more symptoms beyond fatigue, where the 1988 criteria require six to eight.^[14]

The Oxford criteria (1991)^[15]—includes CFS of unknown etiology and a subtype called post-infectious fatigue syndrome (PIFS). Important differences are that the presence of mental fatigue is necessary to fulfill the critera and symptoms are accepted that may suggest a psychiatric disorder.^[4]

The 2003 Canadian Clinical working definition^[16]—this definition requires the presence of symptoms from at least two categories of autonomic, neuroendocrine, or immune manifestations.

Using different case definitions may influence the types of patients selected^[17] and there is research to suggest subtypes of patients or disease exist.^[18]^[19]^[20]^[21] Clinical practice guidelines—with the aim of improving diagnosis, management, and treatment—are generally based on case descriptions. An example is the CFS/ME guideline for the National Health Service in England and Wales, produced in 2007 by the National Institute for Health and Clinical Excellence (NICE).^[14]

Naming

Selecting a name for CFS has been challenging, since consensus is lacking within the clinical, research, and patient communities regarding its defining features and causes. Different authorities on the illness view CFS as a central nervous system, metabolic, infectious or post-infectious, cardiovascular, immune system or psychiatric disorder, and also consider the possibility that it is not a single homogenous disorder.

Over time and in different countries many names have been associated with the condition(s). Aside from CFS, some other names used include Akureyri disease, benign myalgic encephalomyelitis, chronic fatigue immune dysfunction syndrome, chronic infectious mononucleosis, epidemic myalgic encephalomyelitis, epidemic neuromyasthenia, Iceland disease, myalgic encephalomyelitis, myalgic encephalitis, myalgic encephalopathy, post-viral fatigue syndrome, raphe nucleus encephalopathy, Royal Free disease, Tapanui flu and yuppie flu (now considered pejorative).^[22]^[23] Many patients would prefer a different name such as "myalgic encephalomyelitis", believing the name "chronic fatigue syndrome" trivializes the condition, prevents it from being seen as a serious health problem, and discourages research.^[11]^[24]^[25]

A 2001 review referenced myalgic encephalomyelitis symptoms in a 1959 article by Acheson, stating ME could be a distinct syndrome from CFS, but in literature the two terms are generally seen as synonymous for the same illness.^[26] A 1999 review explained the Royal Colleges of Physicians, Psychiatrists, and General Practitioners in 1996 advocated the use of chronic fatigue syndrome instead of myalgic encephalomyelitis or ME which was in wide use in the United Kingdom, "because there is, so far, no recognized pathology in muscles and in the central nervous system as is implied by the term ME."^[1]^[27] The 1996 report received some acceptance, but also harsh criticism that patients' views had been excluded. In 2002, a Lancet commentary noted the recent report by the "Working Group on CFS/ME"^[28] used the compromise name CFS/ME stating, "The fact that both names for the illness were used symbolises respect for different viewpoints whilst acknowledging the continuing lack of consensus on a universally acceptable name."^[29]

Signs and symptoms

Onset

The majority of CFS cases start suddenly,^[30] usually accompanied by a "flu-like illness"^[5] while a significant proportion of cases begin within several months of severe adverse stress.^[30]^[31]^[32] An Australian prospective study found that after infection by viral and non-viral pathogens, a sub-set of individuals met the criteria for CFS, with the researchers concluding that "post-infective fatigue syndrome is a valid illness model for investigating one pathophysiological pathway to CFS".^[33] However, accurate prevalence and exact roles of infection and stress in the development of CFS are currently unknown. Many significant risk factors for developing CFS are known, but "definitive evidence that would be meaningful for clinicians is lacking".^[34]

Symptoms

The most commonly used diagnostic criteria and definition of CFS for research and clinical purposes were published by the United States Centers for Disease Control and Prevention (CDC).^[5] The CDC definition of CFS requires the following two criteria be fulfilled:^[2]

A new onset (not lifelong) of unexplained, persistent fatigue unrelated to exertion and not substantially relieved by rest, that causes a significant reduction in previous activity levels.
Four or more of the following symptoms that last six months or longer:

Impaired memory or concentration
Post-exertional malaise, where physical or mental exertions bring on "extreme, prolonged exhaustion and sickness"
Unrefreshing sleep
Muscle pain (myalgia)
Pain in multiple joints (arthralgia)
Headaches of a new kind or greater severity
Sore throat, frequent or recurring
Tender lymph nodes (cervical or axillary)

There are no medical tests or physical signs to diagnose CFS,^[10] so testing is used to rule out other potential causes for symptoms.^[12] When symptoms are attributable to other conditions, the diagnosis of CFS is excluded. The CDC specifically refers to several illnesses with symptoms resembling those of CFS: "mononucleosis, Lyme disease, lupus, multiple sclerosis, fibromyalgia, primary sleep disorders, severe obesity and major depressive disorders. Medications can also cause side effects that mimic the symptoms of CFS."^[2]

Activity levels

Patients report critical reductions in levels of physical activity^[35] and a reduction in the complexity of activity has been observed,^[36] with reported impairment comparable to other fatiguing medical conditions^[37] such as late-stage AIDS,^[38] lupus, rheumatoid arthritis, chronic obstructive pulmonary disease (COPD), and the effects of chemotherapy.^[39] CFS affects a person's functional status and well-being more than major medical conditions such as multiple sclerosis, congestive heart failure, or type II diabetes mellitus^[40]^[41] The severity of symptoms and disability is the same in both genders^[42] with strongly disabling chronic pain,^[43] but despite a common diagnosis the functional capacity of individuals with CFS varies greatly.^[44] While some lead relatively normal lives, others are totally bed-ridden and unable to care for themselves. Employment rates vary with over half unable to work and nearly two-thirds limited in their work because of their illness. More than half were on disability benefits or temporary sick leave, and less than a fifth worked full-time.^[45]

Pathophysiology

The mechanisms and pathogenesis of chronic fatigue syndrome are unknown.^[10] Research studies have examined and hypothesized about the possible biomedical and epidemiological characteristics of the disease, including oxidative stress, genetic predisposition,^[46] infection by viruses and pathogenic bacteria, hypothalamic-pituitary-adrenal axis abnormalities , immune dysfunction as well as psychological and psychosocial factors. Although it is unclear which factors are a cause, or consequence, of CFS, various models are proposed.^[47]^[48]^[49]

A 2009 study in Science suggested a link between the retrovirus xenotropic murine leukemia virus-related virus (XMRV) and chronic fatigue syndrome in the United States.^[50] Two follow-up studies in the United Kingdom, published in PLoS ONE and Retrovirology respectively, detected no XMRV in CFS patients.^[51]^[52]

Treatment

Many patients do not fully recover from CFS even with treatment, and there is no universally effective curative option.^[53] Diets, physiotherapy, dietary supplements, antidepressants, pain killers, pacing, and complementary and alternative medicine have been suggested as ways of managing CFS. Cognitive behavioural therapy (CBT) and graded exercise therapy (GET) have shown moderate effectiveness for many patients in multiple randomized controlled trials.^[26]^[54]^[55]^[56] As many of the CBT and GET studies required patients to visit a clinic, severely affected patients may have been excluded.^[54]

Patient surveys have found that pacing is reported to be the most helpful intervention.^[57]^[58]

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT), a form of psychological therapy often used to treat chronically ill patients,^[59] is a moderately effective treatment for CFS^[60] that is "useful in treating some CFS patients."^[59] Since the cause or causes of CFS are unknown, CBT tries to help patients understand their individual symptoms and beliefs and develop strategies to improve day-to-day functioning.^[61]

A Cochrane Review meta-analysis of 15 randomized, controlled cognitive behavioral therapy trials with 1043 participants concluded that CBT was an effective treatment to reduce symptoms of fatigue. Comparing CBT with "usual care," four reviewed studies showed that CBT was more effective (40% vs 26%). In three studies, CBT worked better than other types of psychological therapies (48% vs 27%). The effects may diminish after a course of therapy is completed; the reviewers write that "the evidence base at follow-up is limited to a small group of studies with inconsistent findings" and encourage further studies.^[62] A 2007 meta-analysis of 5 CBT randomized controlled trials of chronic fatigue and chronic fatigue syndrome reported 33-73% of the patients improved to the point of no longer being clinically fatigued.^[60] A 2010 meta-analysis of trials that measured physical activity before and after CBT showed that although CBT effectively reduced fatigue, activity levels were not affected by CBT and changes in physical activity were not related to changes in fatigue. They conclude that the effect of CBT on fatigue is not mediated by a change in physical activity.^[63]

CBT has been criticised by patients' organisations because of negative reports from some of their members,^[29] which have indicated that CBT can sometimes make people worse.^[64] One such survey conducted by Action for ME found that out of the 285 participants who reported using CBT, 7% reported it to be helpful, 67% reported no change, and 26% reported that it made their condition worse.^[65] A subsequent survey in 2008 reported that 50% of patients found CBT helpful, 38% reported no change, and 12% felt that it made their illness worse, though it remained among the lowest-rated treatments in the survey despite the significant increase.^[57]

Graded exercise therapy

Graded exercise therapy (GET) is a form of physical therapy. A meta-analysis of five randomized trials found that patients who received exercise therapy were less fatigued after 12 weeks than the control participants, and the authors cautiously conclude that GET shows promise as a treatment.^[66] A systematic review published in 2006 included the same five RCTs, noting that "no severely affected patients were included in the studies of GET".^[54] Surveys conducted on behalf of patient organizations commonly report adverse effects.^[29]^[64]^[65]^[58]

Pacing

Pacing is an energy management strategy which encourages behavioral change while acknowledging patient fluctuations in symptom severity and delayed exercise recovery. Patients are advised to set manageable daily activity/exercise goals and balance activity and rest to avoid over-exertion which may worsen symptoms. Those able to function within their individual limits are encouraged to gradually increase activity and exercise levels while maintaining established energy management techniques. The goal is to gradually increase the level of routine functioning of the individual.^[67] A small randomised controlled trial concluded that pacing had statistically better results than relaxation/flexibility therapy.^[68]^[69] A 2009 survey of 828 Norwegian CFS patients found that pacing was evaluated as useful by 96% of the participants.^[58] A 2008 survey of 2763 CFS patients by Action for ME found that pacing was the most helpful treatment, with 84% of patients finding it beneficial.^[57]

Other

Other treatments of CFS have been proposed but their effectiveness has not been confirmed.^[70] Medications thought to have promise in alleviating stress-related disorders include antidepressant and immunomodulatory agents.^[71] Many CFS patients are sensitive to medications, particularly sedatives, and some patients report chemical and food sensitivities.^[59] CFS patients have a low placebo response compared to patients with other diseases.^[72]

Prognosis

Recovery

A systematic review of 14 studies of the outcome of untreated people with CFS found that "the median full recovery rate was 5% (range 0–31%) and the median proportion of patients who improved during follow-up was 39.5% (range 8–63%). Return to work at follow-up ranged from 8 to 30% in the three studies that considered this outcome." .... "In five studies, a worsening of symptoms during the period of follow-up was reported in between 5 and 20% of patients." A good outcome was associated with less fatigue severity at baseline, a sense of control over symptoms and not attributing illness to a physical cause.^[73] Another review found that children have a better prognosis than adults, with 54–94% having recovered by follow-up compared to less than 10% of adults returning to pre-morbid levels of functioning.^[74] According to the CDC, delays in diagnosis and treatment can reduce the chance of improvement.^[75]

Mortality

Two studies were published in 2006 that directly addressed mortality in CFS. One retrospective study of deaths in individuals chronicled on a memorial list from a national CFS support group reported a greater likelihood of death from heart failure, suicide, and cancer. The ages of death for these three conditions were significantly younger than in the general population respectively. Significant limitations of the study were the inability to check the accuracy of the cause of death, or CFS diagnosis of the individuals.^[76] A separate 14 year follow up study of persons with CFS reported that all-cause mortality or suicide rates of individuals were not significantly different from standardized mortality rates (SMRs).^[77]

Epidemiology

Due to the multiple definitions of CFS, estimates of its prevalence vary widely. Studies in the United States have previously found between 4 and 2500 cases of CFS for every 100,000 adults.^[78] The CDC states that more than 1 million Americans have CFS and approximately 80% of the cases are undiagnosed.^[10] All ethnic and racial groups appear susceptible to the illness, and lower income groups are slightly more likely to develop CFS.^[9] A 2009 meta-analysis showed that compared with the White American majority, African Americans and Native Americans have a significantly higher risk of CFS.^[79] More women than men get CFS — between 60 and 85% of cases are women; however, there is some indication that the prevalence among men is underreported. The illness is reported to occur more frequently in people between the ages of 40 and 59.^[8] CFS is less prevalent among children and adolescents than adults.^[10] Blood relatives of people who have CFS appear to be more predisposed.^[9]^[80] There is no direct evidence that CFS is contagious, though it is seen in members of the same family; this is believed to be a familial or genetic link but more research is required for a definite answer.^[81]

Risk factors

A recent systematic review included 11 primary studies that had assessed various demographic, medical, psychological, social and environmental factors to predict the development of CFS/ME, and found many had reported significant associations to CFS.^[34] The reviewers concluded that the lack of generalizability and replication between studies meant that "none of the identified factors appear suitable for the timely identification of patients at risk of developing CFS/ME within clinical practice."

Associated diseases

Some diseases show a considerable overlap with CFS. Thyroid disorders, anemia, and diabetes are a few of the diseases that must be ruled out if the patient presents with appropriate symptoms.^[12]^[14]^[82]

People with fibromyalgia (FM, or fibromyalgia syndrome, FMS) have muscle pain and sleep disturbances. Fatigue and muscle pain occurs frequently in the initial phase of various hereditary muscle disorders and in several autoimmune, endocrine and metabolic syndromes; and are frequently labelled as CFS or fibromyalgia in the absence of obvious biochemical/metabolic abnormalities and neurological symptoms.^{[citation needed]} Multiple chemical sensitivity, Gulf War syndrome and post-polio syndrome have symptoms similar to those of CFS,^[83]^[84] and the latter is also theorized to have a common pathophysiology.^[84]

Although post-Lyme syndrome and CFS share many features/symptoms, a study found that patients of the former experience more cognitive impairment and the patients of the latter experience more flu-like symptoms.^[85]

A 2006 review found that there was a lack of literature to establish the discriminant validity of undifferentiated somatoform disorder from CFS. The author stated that there is a need for proponents of chronic fatigue syndrome to distinguish it from undifferentiated somatoform disorder. The author also mentioned that the experience of fatigue as exclusively physical and not mental is captured by the definition of somatoform disorder but not CFS.^[86] Hysterical diagnoses are not merely diagnoses of exclusion but require criteria to be met on the positive grounds of both primary and secondary gain.^[87] Primary depression can be excluded in the differential diagnosis due to the absence of anhedonia and la belle indifference, the variability (lability) of mood, and the presence of sensory phenomena and somatic signs such as ataxia, myoclonus and most importantly, exercise intolerance with paresis, malaise and general deterioration.^{[citation needed]} Feeling depressed is also a commonplace reaction to the losses caused by chronic illness^[88] which can in some cases become a comorbid situational depression.

Co-morbidity

Many CFS patients will also have, or appear to have, other medical problems or related diagnoses. Co-morbid fibromyalgia is common, where only patients with fibromyalgia show abnormal pain responses.^[89] Fibromyalgia occurs in a large percentage of CFS patients between onset and the second year, and some researchers suggest fibromyalgia and CFS are related.^[90] As previously mentioned, many CFS sufferers also experience symptoms of irritable bowel syndrome, temporomandibular joint pain, headache including migraines, and other forms of myalgia. CFS patients have significantly higher rates of current mood disorders than the general population.^[91] Compared with the non-fatigued population, male CFS patients are more likely to experience chronic pelvic pain syndrome (CP/CPPS), and female CFS patients are also more likely to experience chronic pelvic pain.^[92] CFS is significantly more common in women with endometriosis compared with women in the general USA population.^[93]

History

In 1934 an outbreak then referred to as atypical poliomyelitis (at the time it was considered a form of polio) occurred at the Los Angeles County Hospital. It strongly resembled what is now called chronic fatigue syndrome and affected a large number of nurses and doctors.^[94] In 1955 at the Royal Free Hospital in London, United Kingdom, another outbreak occurred that also affected mostly the hospital staff. Also resembling CFS, it was called both Royal Free disease and benign myalgic encephalomyelitis and formed the basis of descriptions by Acheson, Ramsay, and others.^[95] In 1969 benign myalgic encephalomyelitis was first classified into the International Classification of Diseases under Diseases of the nervous system.^[96]

The name chronic fatigue syndrome was proposed in the 1988 article, "Chronic fatigue syndrome: a working case definition", (the Holmes definition), to replace chronic Epstein-Barr virus syndrome. This research case definition was published after US Centers for Disease Control and Prevention epidemiologists examined patients at the Lake Tahoe outbreak.^[13]^[97]^[98] In 2006 the CDC commenced a national program to educate the American public and health care professionals about CFS.^[99]

Society and culture

Economic impact

Reynolds et al (2004), estimated that the illness caused about $20,000 per person with CFS in lost productivity which totals to $9.1 billion per year in the United States.^[18]^[100]

Social issues

A study found that CFS patients report a heavy psychosocial burden.^[101] A survey by the Tymes Trust reported that children with CFS often state that they struggle for recognition of their needs and/or they feel bullied by medical and educational professionals.^[102] The ambiguity of the status of CFS as a medical condition may cause higher perceived stigma.^[103]

Support groups

A study found that CFS patients in support groups reported no change in negative interactions compared to an improvement in negative interactions reported by those treated with Cognitive Behavioural Therapy.^[104] Patients with greater amounts of negative interactions received worse social support on average than disease-free cancer patients or healthy controls which, in turn, led to greater fatigue severity and functional impairment than CBT-treated patients.^[104]

Doctor-patient relations

Some in the medical community did not at first recognize CFS as a real condition, nor was there agreement on its prevalence.^[105]^[106] There has been much disagreement over proposed causes, diagnosis, and treatment of the illness.^[107]^[108]^[109]^[110]^[111] The context of contested causation may affect the lives of the individuals diagnosed with CFS, affecting the patient-doctor relationship, the doctor's confidence in their ability to diagnose and treat, ability to share issues and control in diagnosis with the patient, and raise problematic issues of reparation, compensation, and blame.^[112] A major divide exists over whether funding for research and treatment should focus on physiological, psychological or psychosocial aspects of CFS. This division is especially great between patient groups and psychological and psychosocial treatment advocates in Great Britain.^[111] Sufferers describe the struggle for healthcare and legitimacy due to bureaucratic denial of the condition because of its lack of a known etiology. Disagreements over how the condition is dealt with by health care systems has resulted in an expensive and prolonged conflict for all involved.^[106]^[113]

Controversy

References

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External links

[pmid_10583715-1] Evangard B, Schacterie R.S., Komaroff A. L. (1999). "Chronic fatigue syndrome: new insights and old ignorance". Journal of Internal Medicine. Nov, 246 (5): 455–469. doi:10.1046/j.1365-2796.1999.00513.x. PMID 10583715. Retrieved 2009-10-21.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[CDCdefinition-2] "Chronic Fatigue Syndrome: Diagnosing CFS". CDC. 2006-05-03. Retrieved 2009-01-22. Cite error: The named reference "CDCdefinition" was defined multiple times with different content (see the help page).

[PMID_15699086-3] Ranjith G (2005). "Epidemiology of chronic fatigue syndrome". Occup Med (Lond). 55 (1): 13–29. doi:10.1093/occmed/kqi012. PMID 15699086.

[Wyller-4] Wyller VB (2007). "The chronic fatigue syndrome--an update". Acta neurologica Scandinavica. Supplementum. 187: 7–14. doi:10.1111/j.1600-0404.2007.00840.x. PMID 17419822.

[pmid:12562565-5] Afari N, Buchwald D (2003). "Chronic fatigue syndrome: a review". Am J Psychiatr. 160 (2): 221–36. doi:10.1176/appi.ajp.160.2.221. PMID 12562565.

[pmid10527290-6] Jason LA; et al. (1999). "A community-based study of chronic fatigue syndrome". Arch. Intern. Med. 159 (18): 2129–37. doi:10.1001/archinte.159.18.2129. PMID 10527290. {{cite journal}}: Explicit use of et al. in: |author= (help)

[7] ttp://www.meassociation.org.uk

[PMID_15574853-8] Gallagher AM, Thomas JM, Hamilton WT, White PD (2004). "Incidence of fatigue symptoms and diagnoses presenting in UK primary care from 1990 to 2001". J R Soc Med. 97 (12): 571–5. doi:10.1258/jrsm.97.12.571. PMC 1079668. PMID 15574853.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[CDCRisk-9] "Chronic Fatigue Syndrome Who's at risk?". Centers for Disease Control and Prevention. March 10, 2006. Retrieved 2008-02-07.

[CDCBasic-10] ^ ^a ^b ^c ^d ^e ^f "Chronic Fatigue Syndrome Basic Facts". Centers for Disease Control and Prevention. May 9, 2006. Retrieved 2008-02-07.

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[Holmes1988-13] Holmes G, Kaplan J, Gantz N, Komaroff A, Schonberger L, Straus S, Jones J, Dubois R, Cunningham-Rundles C, Pahwa S (1988). "Chronic fatigue syndrome: a working case definition,". Ann Intern Med. 108 (3): 387–9. PMID 2829679.{{cite journal}}: CS1 maint: multiple names: authors list (link) Details Cite error: The named reference "Holmes1988" was defined multiple times with different content (see the help page).

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[103] Looper KJ, Kirmayer LJ (2004). "Perceived stigma in functional somatic syndromes and comparable medical conditions". J Psychosom Res. 57 (4): 373–8. doi:10.1016/j.jpsychores.2004.03.005. PMID 15518673.

[nosupport-104] Prins JB, Bos E, Huibers MJ, Servaes P, van der Werf SP, van der Meer JW, Bleijenberg G (2004). "Social support and the persistence of complaints in chronic fatigue syndrome". Psychother Psychosom. 73 (3): 174–82. doi:10.1159/000076455. PMID 15031590.{{cite journal}}: CS1 maint: multiple names: authors list (link)

[pmid1794092-105] Wallace, PG (1991). "Post-viral fatigue syndrome. Epidemiology: a critical review". Br Med Bull. 47 (4): 942–951. PMID 1794092. {{cite journal}}: Unknown parameter |month= ignored (help)

[pmid9231495-106] Mounstephen, A, (1997). "Chronic fatigue syndrome and occupational health". Occup Med (Lond). May;47(4):. 47 (4): 217–227. doi:10.1093/occmed/47.4.217. PMID 1794092. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |month= ignored (help)CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link)

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@@ Line 20: / Line 20: @@
 [[Fatigue (medical)|Fatigue]] is a common symptom in many illnesses, but CFS is a multi-systemic disease and is relatively rare by comparison.<ref name="PMID_15699086">{{cite journal | author = Ranjith G | title = Epidemiology of chronic fatigue syndrome. | journal = Occup Med (Lond) | volume = 55 | issue = 1 | pages = 13–29 | year = 2005 | pmid = 15699086 | doi = 10.1093/occmed/kqi012}}</ref> Symptoms of CFS include widespread [[myalgia|muscle]] and [[arthralgia|joint pain]]; [[cognitive]] difficulties; chronic, often severe, mental and physical [[exhaustion]]; and other characteristic symptoms in a previously healthy and active person. CFS patients may report additional symptoms including [[muscle weakness]], [[hypersensitivity]], [[orthostatic intolerance]], digestive disturbances, [[Depression (mood)|depression]], poor [[immune response]], and [[cardiac]] and [[Respiratory system|respiratory]] problems.<ref name = Wyller>{{cite journal |author=Wyller VB |title=The chronic fatigue syndrome--an update |journal=Acta neurologica Scandinavica. Supplementum |volume=187 |issue= |pages=7–14 |year=2007 |pmid=17419822 |doi=10.1111/j.1600-0404.2007.00840.x |url=}}</ref> It is unclear if these symptoms represent co-morbid conditions or are produced by an underlying etiology of CFS.<ref name="pmid:12562565">{{cite journal |author=Afari N, Buchwald D |title=Chronic fatigue syndrome: a review |journal=Am J Psychiatr |volume=160 |issue=2 |pages=221–36 |year=2003 |pmid=12562565 |url=http://ajp.psychiatryonline.org/cgi/content/full/160/2/221 | doi = 10.1176/appi.ajp.160.2.221}}</ref>  All diagnostic criteria require that the symptoms must not be caused by other medical conditions.
-CFS is thought to have an incidence of 4 adults per 1,000 in the [[United States]].<ref name=pmid10527290>{{cite journal |author=Jason LA et al. |title=A community-based study of chronic fatigue syndrome |journal=Arch. Intern. Med. |volume=159 |issue=18 |pages=2129–37 |year=1999 | url = http://archinte.ama-assn.org/cgi/content/full/159/18/2129 |pmid=10527290 | doi = 10.1001/archinte.159.18.2129}}</ref> For unknown reasons CFS occurs most often in people in their 40s and 50s, more often in women than men,<ref name="PMID_15574853">{{cite journal |author=Gallagher AM, Thomas JM, Hamilton WT, White PD |title=Incidence of fatigue symptoms and diagnoses presenting in UK primary care from 1990 to 2001 |journal=J R Soc Med |volume=97 |issue=12 |pages=571–5 |year=2004 |pmid=15574853 |doi=10.1258/jrsm.97.12.571 |pmc=1079668}}</ref><ref name="CDCRisk">{{cite web | title = Chronic Fatigue Syndrome Who's at risk? | publisher = Centers for Disease Control and Prevention | date = March 10, 2006 | url = http://www.cdc.gov/cfs/cfscausesHCP.htm | accessdate = 2008-02-07}}</ref> and is less prevalent among children and adolescents.<ref name="CDCBasic"/> Full recovery from the condition occurs in only 5-10% of cases.<ref name="CDCBasic">{{cite web | title = Chronic Fatigue Syndrome Basic Facts | publisher = Centers for Disease Control and Prevention | date = May 9, 2006 | url = http://www.cdc.gov/cfs/cfsbasicfacts.htm | accessdate = 2008-02-07}}</ref>
+CFS is thought to have an incidence of 4 adults per 1,000 in the [[United States]].<ref name=pmid10527290>{{cite journal |author=Jason LA et al. |title=A community-based study of chronic fatigue syndrome |journal=Arch. Intern. Med. |volume=159 |issue=18 |pages=2129–37 |year=1999 | url = http://archinte.ama-assn.org/cgi/content/full/159/18/2129 |pmid=10527290 | doi = 10.1001/archinte.159.18.2129}}</ref> According to the ME Association <ref>http://www.meassociation.org.uk</ref> it affects an estimated 250,000 people in the UK. For unknown reasons CFS occurs most often in people in their 40s and 50s, more often in women than men,<ref name="PMID_15574853">{{cite journal |author=Gallagher AM, Thomas JM, Hamilton WT, White PD |title=Incidence of fatigue symptoms and diagnoses presenting in UK primary care from 1990 to 2001 |journal=J R Soc Med |volume=97 |issue=12 |pages=571–5 |year=2004 |pmid=15574853 |doi=10.1258/jrsm.97.12.571 |pmc=1079668}}</ref><ref name="CDCRisk">{{cite web | title = Chronic Fatigue Syndrome Who's at risk? | publisher = Centers for Disease Control and Prevention | date = March 10, 2006 | url = http://www.cdc.gov/cfs/cfscausesHCP.htm | accessdate = 2008-02-07}}</ref> and is less prevalent among children and adolescents.<ref name="CDCBasic"/> Full recovery from the condition occurs in only 5-10% of cases.<ref name="CDCBasic">{{cite web | title = Chronic Fatigue Syndrome Basic Facts | publisher = Centers for Disease Control and Prevention | date = May 9, 2006 | url = http://www.cdc.gov/cfs/cfsbasicfacts.htm | accessdate = 2008-02-07}}</ref>
 Whereas there is agreement on the genuine threat to health, happiness and productivity posed by CFS, various physicians' groups, researchers and patient advocates promote different nomenclature, diagnostic criteria, etiologic hypotheses and treatments, resulting in [[Controversies related to chronic fatigue syndrome|controversy about many aspects]] of the disorder. The name CFS itself is controversial as many patients and advocacy groups, as well as some experts, believe the name chronic fatigue syndrome stigmatizes,  by not conveying the seriousness of the illness, and want the name changed.<ref name=Ottati>{{cite book |author=Ottati, Victor C. |title=The social psychology of politics |publisher=Kluwer Academic/Plenum |location=New York |year=2002 |pages=159–160 |isbn=0-306-46723-2 |oclc= |doi= |accessdate= 2009 08 11 | url = http://books.google.com/books?id=OYrErhPFFLwC&dq=+The+social+psychology+of+politics+By+Victor+C.+Ottati&printsec=frontcover&source=bl&ots=FatAIPCjQh&sig=Wb4avDc9dfc1v-GJEPUxbxYcEqw&hl=en&ei=WNKASoeTMJOKswOos5TvCA&sa=X&oi=book_result&ct=result&resnum=1#v=onepage&q=name%20change%20survey%20results&f=false}}</ref>
@@ Line 47: / Line 47: @@
 == Signs and symptoms ==
 === Onset ===
-The majority of CFS cases start suddenly,<ref name="PMID_9201648"/> usually accompanied by a "[[flu-like illness]]"<ref name="pmid:12562565"/> while a significant proportion of cases begin within several months of severe adverse stress.<ref name="PMID_9201648">{{cite journal | author = Salit IE | title = Precipitating factors for the chronic fatigue syndrome. | journal = J Psychiatr Res | volume = 31 | issue = 1 | pages = 59–65 | year = 1997 | pmid= 9201648 | doi = 10.1016/S0022-3956(96)00050-7}}</ref><ref>{{cite journal | author = Hatcher S, House A | title = Life events, difficulties and dilemmas in the onset of chronic fatigue syndrome: a case-control study. | journal = Psychol Med | volume = 33 | issue = 7 | pages = 1185–92 | year = 2003 | pmid= 14580073 | doi = 10.1017/S0033291703008274 | format =PDF |url= http://eprints.whiterose.ac.uk/1226/1/house3.pdf}}</ref><ref name="PMID_10367610">{{cite journal | author = Theorell T, Blomkvist V, Lindh G, Evengard B | title = Critical life events, infections, and symptoms during the year preceding chronic fatigue syndrome (CFS): an examination of CFS patients and subjects with a nonspecific life crisis. | journal = Psychosom Med. | volume = 61 | issue = 3 | pages = 304–10 | pmid= 10367610 | year = 1999}}</ref> An Australian prospective study found that after infection by viral and non-viral [[pathogen]]s, a sub-set of individuals met the criteria for CFS, with the researchers concluding that "post-infective fatigue syndrome is a valid illness model for investigating one pathophysiological pathway to CFS."<ref name="pmid16950834">{{cite journal |author=Hickie I, Davenport T, Wakefield D, ''et al'' |title=Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study |journal=BMJ |volume=333 |issue=7568 |pages=575 |year=2006 |pmid=16950834 |doi=10.1136/bmj.38933.585764.AE |pmc=1569956}}</ref> However, accurate prevalence and exact roles of infection and stress in the development of CFS are currently unknown. Many significant risk factors for developing CFS are known, but "definitive evidence that would be meaningful for clinicians is lacking."<ref name="PMID_17892624">{{cite journal | author = Hempel S, Chambers D, Bagnall AM, Forbes C | title = Risk factors for chronic fatigue syndrome/myalgic encephalomyelitis: a systematic scoping review of multiple predictor studies. | journal = Psychol Med | volume = 38 | issue = 7 | pages = 915–26 | year = 2008 | month = July | pmid = 17892624 | doi = 10.1017/S0033291707001602}}</ref>
+The majority of CFS cases start suddenly,<ref name="PMID_9201648"/> usually accompanied by a "[[flu-like illness]]"<ref name="pmid:12562565"/> while a significant proportion of cases begin within several months of severe adverse stress.<ref name="PMID_9201648">{{cite journal | author = Salit IE | title = Precipitating factors for the chronic fatigue syndrome. | journal = J Psychiatr Res | volume = 31 | issue = 1 | pages = 59–65 | year = 1997 | pmid= 9201648 | doi = 10.1016/S0022-3956(96)00050-7}}</ref><ref>{{cite journal | author = Hatcher S, House A | title = Life events, difficulties and dilemmas in the onset of chronic fatigue syndrome: a case-control study. | journal = Psychol Med | volume = 33 | issue = 7 | pages = 1185–92 | year = 2003 | pmid= 14580073 | doi = 10.1017/S0033291703008274 | format =PDF |url= http://eprints.whiterose.ac.uk/1226/1/house3.pdf}}</ref><ref name="PMID_10367610">{{cite journal | author = Theorell T, Blomkvist V, Lindh G, Evengard B | title = Critical life events, infections, and symptoms during the year preceding chronic fatigue syndrome (CFS): an examination of CFS patients and subjects with a nonspecific life crisis. | journal = Psychosom Med. | volume = 61 | issue = 3 | pages = 304–10 | pmid= 10367610 | year = 1999}}</ref> An Australian prospective study found that after infection by viral and non-viral [[pathogen]]s, a sub-set of individuals met the criteria for CFS, with the researchers concluding that "post-infective fatigue syndrome is a valid illness model for investigating one pathophysiological pathway to CFS".<ref name="pmid16950834">{{cite journal |author=Hickie I, Davenport T, Wakefield D, ''et al'' |title=Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study |journal=BMJ |volume=333 |issue=7568 |pages=575 |year=2006 |pmid=16950834 |doi=10.1136/bmj.38933.585764.AE |pmc=1569956}}</ref> However, accurate prevalence and exact roles of infection and stress in the development of CFS are currently unknown. Many significant risk factors for developing CFS are known, but "definitive evidence that would be meaningful for clinicians is lacking".<ref name="PMID_17892624">{{cite journal | author = Hempel S, Chambers D, Bagnall AM, Forbes C | title = Risk factors for chronic fatigue syndrome/myalgic encephalomyelitis: a systematic scoping review of multiple predictor studies. | journal = Psychol Med | volume = 38 | issue = 7 | pages = 915–26 | year = 2008 | month = July | pmid = 17892624 | doi = 10.1017/S0033291707001602}}</ref>
 === Symptoms ===
@@ Line 71: / Line 71: @@
 The mechanisms and [[pathogenesis]] of chronic fatigue syndrome are unknown.<ref name=CDCBasic/> Research studies have examined and hypothesized about the possible [[biomedical]] and [[epidemiological]] characteristics of the disease, including [[oxidative stress]], [[genetic predisposition]],<ref name="pmid17853290">{{cite journal |author=Sanders P, Korf J |title=Neuroaetiology of chronic fatigue syndrome: An overview |journal=World J Biol Psychiatry |volume= 9|issue= 3|pages=1–7 |year=2007 |pmid=17853290 |doi=10.1080/15622970701310971 |url=http://www.informaworld.com/openurl?genre=article&doi=10.1080/15622970701310971&magic=pubmed |unused_data=|1B69BA326FFE69C3F0A8F227DF8201D0}}</ref> [[infection]] by [[virus]]es and  [[pathogenic bacteria]], [[hypothalamic-pituitary-adrenal axis]] abnormalities , [[autoimmunity|immune dysfunction]] as well as psychological and [[psychosocial]] factors.  Although it is unclear which factors are a cause, or consequence, of CFS, various models are proposed.<ref name="pmid11388124">{{cite journal |author=Patarca-Montero R, Antoni M, Fletcher MA, Klimas NG |title=Cytokine and other immunologic markers in chronic fatigue syndrome and their relation to neuropsychological factors |journal=Appl Neuropsychol |volume=8 |issue=1 |pages=51–64 |year=2001 |pmid=11388124 |doi= 10.1207/S15324826AN0801_7|url=}}</ref><ref name="pmid17561686">{{cite journal |author=Kuratsune H |title=[Overview of chronic fatigue syndrome focusing on prevalence and diagnostic criteria] |language=Japanese |journal=Nippon Rinsho |volume=65 |issue=6 |pages=983–90 |year=2007 |month=June |pmid=17561686 |doi= |url=}}</ref><ref name="pmid9859853">{{cite journal |author=Vercoulen JH, Swanink CM, Galama JM, ''et al'' |title=The persistence of fatigue in chronic fatigue syndrome and multiple sclerosis: development of a model |journal=J Psychosom Res |volume=45 |issue=6 |pages=507–17 |year=1998 |pmid=9859853| doi = 10.1016/S0022-3999(98)00023-3 }}</ref>
+A 2009 study in [[Science (journal)|''Science'']] suggested a link between the retrovirus [[xenotropic murine leukemia virus-related virus]] (XMRV) and chronic fatigue syndrome in the United States.<ref name="pmid19815723">{{Cite journal | author= Lombardi VC, Ruscetti FW, Das Gupta J, Pfost MA, Hagen KS, Peterson DL, Ruscetti SK, Bagni RK, Petrow-Sadowski C, Gold B, Dean M, Silverman RH, Mikovits JA | year= 2009 | title= Detection of an Infectious Retrovirus, XMRV, in Blood Cells of Patients with Chronic Fatigue Syndrome | journal= Science | volume= 326 | issue= 5952 | pages= 585–9 | doi= 10.1126/science.1179052 | pmid=19815723}}</ref> Two follow-up studies in the United Kingdom, published in ''[[PLoS ONE]]'' and ''Retrovirology'' respectively, detected no XMRV in CFS patients.<ref name=PLoSOne>{{cite journal |author=Erlwein, O, ''et al.'' |title=Failure to Detect the Novel Retrovirus XMRV in Chronic Fatigue Syndrome |journal=PLoS ONE |volume= |issue= |pages= |year=2010 |pmid= |pmc= |doi=10.1371/journal.pone.0008519 |url=http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0008519}}</ref><ref>{{cite journal |author=Harriet C T Groom, Virginie C Boucherit, Kerry Makinson, Edward Randal, Sarah Baptista, Suzanne Hagan, John W Gow, Frank M Mattes, Judith Breuer, Jonathan R Kerr, Jonathan P Stoye, Kate N Bishop |title=Absence of xenotropic murine leukaemia virus-related virus in UK patients with chronic fatigue syndrome |journal=Retrovirology |volume= |issue= |year=2010 |pmid= |doi=10.1186/1742-4690-7-10 |url=http://www.retrovirology.com/content/7/1/10/abstract}}</ref>
 == Treatment ==
@@ Line 84: / Line 86: @@
 A ''[[Cochrane Library|Cochrane Review]]'' meta-analysis of 15 randomized, controlled cognitive behavioral therapy trials with 1043 participants concluded that CBT was an effective treatment to reduce symptoms of fatigue. Comparing CBT with "usual care," four reviewed studies showed that CBT was more effective (40% vs 26%). In three studies, CBT worked better than other types of psychological therapies (48% vs 27%). The effects may diminish after a course of therapy is completed; the reviewers write that "the evidence base at follow-up is limited to a small group of studies with inconsistent findings" and encourage further studies.<ref name="CochraneCBT">{{cite journal |author=Price JR, Mitchell E, Tidy E, Hunot V |title=Cognitive behaviour therapy for chronic fatigue syndrome in adults |journal=Cochrane Database Syst Rev |volume= |issue=3 |pages=CD001027 |year=2008 |pmid=18646067 |doi=10.1002/14651858.CD001027.pub2 |url=}}</ref>  A 2007 meta-analysis of 5 CBT randomized controlled trials of chronic fatigue and chronic fatigue syndrome reported 33-73% of the patients improved to the point of no longer being clinically fatigued.<ref name=pmid_18060672/> A 2010 meta-analysis of trials that measured physical activity before and after CBT showed that although CBT effectively reduced fatigue, activity levels were not affected by CBT and changes in physical activity were not related to changes in fatigue. They conclude that the effect of CBT on fatigue is not mediated by a change in physical activity.<ref>{{cite journal |author=Wiborg JF, Knoop H, Stulemeijer M, Prins JB, Bleijenberg G |title=How does cognitive behaviour therapy reduce fatigue in patients with chronic fatigue syndrome? The role of physical activity |journal=Psychol Med |volume= |issue= |pages=1–7 |year=2010 |month=January |pmid=20047707 |doi=10.1017/S0033291709992212}}</ref>
+CBT has been criticised by patients' organisations because of negative reports from some of their members,<ref name="PMID_11809249"/> which have indicated that CBT can sometimes make people worse.<ref name="PMID_17397525"/> One such survey conducted by Action for ME found that out of the 285 participants who reported using CBT, 7% reported it to be helpful, 67% reported no change, and 26% reported that it made their condition worse.<ref name="CMO_report"/> A subsequent survey in 2008 reported that 50% of patients found CBT helpful, 38% reported no change, and 12% felt that it made their illness worse, though it remained among the lowest-rated treatments in the survey despite the significant increase.<ref name="afme_2008_survey">http://www.afme.org.uk/res/img/resources/Survey%20Summary%20Report%202008.pdf</ref>
-CBT has been criticised by some patients' organisations<ref name="PMID_11809249"/> that believe CBT can sometimes make symptoms worse.<ref name="PMID_17397525"/>
 === Graded exercise therapy ===
@@ Line 101: / Line 103: @@
 === Mortality ===
-A 14 year follow up study of 1201 persons with CFS reported that all-cause mortality or suicide rates of individuals were not significantly different from [[standardized mortality ratio|standardized mortality rates]] (SMRs).<ref>{{cite journal |author=Smith WR, Noonan C, Buchwald D |title=Mortality in a cohort of chronically fatigued patients |journal=Psychological medicine |volume=36 |issue=9 |pages=1301–6 |year=2006 |pmid=16893495 |doi=10.1017/S0033291706007975}}</ref>
+Two studies were published in 2006 that directly addressed mortality in CFS. One retrospective study of deaths in individuals chronicled on a memorial list from a national CFS [[support group]] reported a greater likelihood of death from heart failure, suicide, and cancer. The ages of death for these three conditions were significantly younger than in the general population respectively. Significant limitations of the study were the inability to check the accuracy of the cause of death, or CFS diagnosis of the individuals.<ref name = HCWI>{{cite journal |author=Jason LA, Corradi K, Gress S, Williams S, Torres-Harding S |title=Causes of death among patients with chronic fatigue syndrome |journal=Health care for women international |volume=27 |issue=7 |pages=615–26 |year=2006 |pmid=16844674 |doi=10.1080/07399330600803766}}</ref> A separate 14 year follow up study of persons with CFS reported that all-cause mortality or suicide rates of individuals were not significantly different from [[standardized mortality ratio|standardized mortality rates]] (SMRs).<ref>{{cite journal |author=Smith WR, Noonan C, Buchwald D |title=Mortality in a cohort of chronically fatigued patients |journal=Psychological medicine |volume=36 |issue=9 |pages=1301–6 |year=2006 |pmid=16893495 |doi=10.1017/S0033291706007975}}</ref>
 == Epidemiology ==

v t e Myalgic encephalomyelitis/chronic fatigue syndrome
Medical issues	Clinical descriptions Treatment Post-exertional malaise 2-day CPET
Research	DecodeME
Society and history	History Controversies Notable patients
Organizations	Action for ME ME Association ME Research UK Open Medicine Foundation Solve ME/CFS Initiative Whittemore Peterson Institute