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Chronic Fatigue Syndrome, Page 2 of the Clinical practice guidelines - 2002 - Royal Australasian College of Physicians. This supplement to the MJA was funded by a grant from the Commonwealth Department of Health and Ageing. Among 2075 people followed up in 19 published studies of the outcome of prolonged fatigue and CFS, there was one death by suicide and two unrelated deaths.[139] These studies included mean follow-up periods ranging from six months to four years, suggesting that suicide rates and overall mortality are not increased in people with CFS.
In studies of children and adolescents with CFS the outcome is significantly better than in adults. Immunological alterations are common in people with CFS (Level III-4), but are of uncertain pathophysiological significance. Neuroendocrine changes indicating hypothalamic-pituitary-axis disturbance are common in people with CFS (Level III-4), but are of uncertain pathophysiological significance.
Sleep disturbance is very common in people with CFS (Level I), but is of uncertain pathophysiological significance. Neuromuscular performance in people with CFS is normal, implicating the central nervous system as the likely site of pathophysiological disturbance (Level I). Diagnosis relies on the presence of characteristic symptoms and exclusion of alternative medical and psychiatric disorders (Level IV). People with CFS commonly have concurrent depression (Level I), which does not necessarily represent an alternative primary diagnosis.
CFS frequently overlaps with other common syndromes such as fibromyalgia and irritable bowel syndrome (Level III-2). The purpose of laboratory investigation is to exclude other conditions that may cause fatigue (Level IV).
For most patients the following investigations are sufficient: blood count and ESR, serum levels of electrolytes (including calcium and phosphate), standard biochemical tests of liver and kidney function, thyroid function tests (TSH) and urinalysis for protein, blood and glucose (Level I). Symptoms or signs that are not typical of CFS (eg, fever, weight loss, enlargement of liver, spleen or lymph nodes) should be investigated separately, as indicated clinically (Level IV). An experienced general practitioner should be able to make a diagnosis of CFS in most patients.
Patients who complain of persisting "fatigue" or "tiredness" may be describing any one of a diverse range of clinical phenomena, ranging from muscle weakness to dyspnoea or depressed mood. To differentiate the various causes of mental and physical fatigue, doctors should focus on the description of the complaint (Box 2.1).
In most instances the symptoms of chronic fatigue syndrome can be distinguished from the closely related phenomena of somnolence, muscle weakness, neuromuscular fatigability, depressed mood or anhedonia.
CFS is distinguished from similar fatigue-related illnesses not only by carefully characterising the fatigue itself, but also by evaluating associated symptoms and signs.
Although these symptoms are common in people with CFS, they are not specific and may occur in a range of other medical and neuropsychiatric disorders. Similarly, physical examination should be directed towards elucidating alternative diagnoses. When patients have been definitively diagnosed with a medical or psychiatric condition known to be associated with marked fatigue, a separate diagnosis of CFS is generally not justified. A formal diagnosis of CFS should not be made without an appropriate psychological evaluation of the patient.[6] Although this need not be done by a specialist psychiatrist or psychologist, referral can be useful in selected cases for both diagnostic and treatment purposes.
Many people with depressive disorders complain of fatigue or pain, rather than overt psychological symptoms such as tearfulness or sadness. The characteristic mood state of people with CFS is irritation, frustration and transient depression, rather than persistent and profound sadness. A careful review of the history of ill-health before the onset of CFS is the key to resolving the differential diagnosis of somatoform and somatisation disorders. The mental state examination of people with prolonged fatigue should focus on the observed behavioural features rather than simply those reported by the person. As in the management of other chronic medical conditions, assessing the social circumstances and interpersonal relationships of the patient with CFS is a key component of the medical evaluation. The functional impairment of people with CFS has been shown to be similar to or greater than that of people with other chronic disabling medical conditions (eg, multiple sclerosis)[440] and psychological conditions (eg, major depression).[20,21] Accordingly, the patient's current level of disability should be carefully assessed, with a review of the duration and intensity of physical activity that can be undertaken without precipitating prolonged fatigue. The only laboratory tests currently recommended for the routine evaluation of people with fatigue states (Box 2.4) are aimed at detecting alternative medical conditions. Many other laboratory procedures have been proposed as "diagnostic tests" by non-medical or alternative practitioners, but have not been subjected to rigorous evaluation.
A?a‚¬ Available evidence indicates that these tests have no role in standard laboratory evaluation of people with CFS. Given the lack of diagnostic certainty in people with CFS and the reliance on clinical history and examination, it may be appropriate to seek another medical opinion during evaluation or treatment.
For example, a history of snoring and daytime somnolence is an appropriate indication for assessment by a sleep physician, which may be followed by overnight sleep study. No single pharmacological treatment has been shown to be effective for people with CFS (Level I). Physical and intellectual activities should be "paced" according to the individual's functional capacity (Level IV). Antidepressant drugs may provide symptomatic relief of pain, sleep disturbance, and depressed mood in people with CFS (Level IV). Once the diagnosis of CFS is made, the doctor should establish an individualised management plan through a process of active discussion with the patient. The goal of treatment should be improvement towards and maintenance of maximal achievable functional capacity. It is important to give the patient a clear expectation that sustained improvements are rarely achieved in short time frames (days to weeks), but many patients can return to acceptable levels of functioning over longer periods (eg, three to six months). Sustained improvements are rarely achieved without some setbacks and exacerbations of symptoms along the way. To facilitate the reduction of disability, active control of key symptoms (eg, pain, sleep disturbance and depressed mood) with standard treatments should be explored. As with other chronic disorders, the patient's attitude to his or her illness experience, understanding of the nature of the disorder and its likely course over time, and the relationship between doctor and patient, are all likely to have a significant impact on long-term outcome.[451] Doctors who take an active approach to providing accurate information and to discussing key issues with their patients on an ongoing basis are likely to achieve the best results. When people with CFS develop significant new symptoms, or experience a marked change in symptoms, they should be carefully reassessed.
A range of antiviral, immunoregulatory, antidepressant and metabolic drug regimens have been evaluated in double-blind, placebo-controlled trials in people with CFS. Antidepressants and other CNS agents: Given the high rate of depression, and depression-related symptoms such as fatigue, sleep disturbance, poor concentration and irritability in people with CFS, antidepressant therapies have received considerable attention.
While the new serotonergic agents are particularly popular for treating major depression, there has been little evidence of their overall usefulness in patients with CFS. Rehabilitation, behavioural and cognitive approaches link the principles of good clinical management with varying degrees of graded physical activity and psychological intervention.[153,465,466] They have been evaluated not only in patients with CFS, but in a wide variety of other closely related and often chronically debilitating medical and psychological disorders (eg, chronic pain, chronic daily headache, irritable bowel syndrome and chronic depression). The behavioural component encourages planned and supervised resumption of appropriate physical and mental tasks. As simplistic illness attributions may be associated with poor outcomes,[470] people with CFS should be encouraged to adopt the widest possible view of the medical, physical, and psychosocial management strategies to assist in coping with the illness.[472,473] The doctor and patient should work cooperatively to improve understanding, attitudes and behaviours that can help maximise long-term function. In general, trials with more substantial differences between the intervention and the control treatment arms show the greatest benefits.[474] Active treatment programs that emphasise strong behavioural components (physical activity, rehabilitation) achieve good short-term results, but studies that incorporate a cognitive component produce more sustained long-term improvements. There have now been a number of controlled or partially controlled studies of the various components of cognitive behavioural management approaches. It is important to note that studies differ substantially in patient selection, intensity and duration of treatment provided, and suitability of the "control" interventions used for comparison.
Chronic Fatigue Syndrome (CFC) is a state of feeling tired for a long time that cannot be recovered soon after rest.
It is difficult to specifically confirm the symptoms of CFS as there are similarities with symptoms of other viral infections.
Chronic fatigue syndrome can in no way diagnosed as there are no specific reasons for the cause of the disease.


Complications like developing depression, loneliness and isolation, restrictions in lifestyle and less action in the work place may quite possibly occur with the syndrome.
The first step to cure fatigue syndrome is to reduce stress both physically and emotionally. The chronic stage of fatigue syndrome is seen in stressed conditions, too much of exercise and lack of sleep. Nevertheless, emotional support from family and friends and good counseling would increase the energy levels in a positive manner among patients with severe fatigue syndrome.
During follow-up, patients were very unlikely to develop other medical disorders (2%), but a significant number did develop other psychological disorders (19%), notably major depression and anxiety. The probable heterogeneity within patient groups labelled as having CFS[18,28,82,83,113] makes it highly likely that there are multiple contributing factors in the disorder. Specialist medical or psychiatric referral is only required if the diagnosis remains in doubt (Level IV).
Fatigue in people with CFS is typically exacerbated by physical tasks previously achieved with ease, and recovery from periods of worsened fatigue can take hours or even days.
Fatigue accompanied by fever, malaise and weight loss suggests an inflammatory or infective process, and fatigue accompanied by weight gain and cold intolerance may indicate hypothyroidism. Like the medical evaluation, the psychiatric assessment consists of two distinct parts: the history and the mental state examination. The family history should be reviewed for depressive disorder, self-destructive behaviour or substance misuse.
These include psychomotor slowing (which may suggest a serious depressive disorder),(433,434) demonstrable cognitive impairment (suggesting intoxication, delirium or a dementia syndrome), odd or bizarre interpersonal behaviour (suggesting a psychosis), and hostile, angry or excessively irritable responses (suggesting a personality disorder). For example, it may be evident that an adolescent's 45-minute walk to school produces fatigue and other symptoms that last all day. By this time, people with CFS are commonly in crisis with their school or workplace because of the accumulated time lost as a result of the illness.
In fact, as the diagnosis of CFS currently identifies a heterogeneous group of people,[16,113] it is unlikely that a single, reliable diagnostic test will emerge. The diagnostic yield of investigations beyond this restricted list is very low.[444-447] If specific alternative diagnoses are suggested by the clinical history or examination (eg, sleep apnoea or multiple sclerosis), further investigations may be warranted. Another opinion by an experienced primary care practitioner may be sufficient, but specific issues in diagnostic assessment or treatment planning sometimes require consultation with the specialist most relevant to the individual's needs.
People with severe or prolonged depression, severe anxiety symptoms, or those assessed as being at risk of self-harm may require psychiatric evaluation. The available pharmacological and non-pharmacological approaches should first be outlined, along with the role of continuing medical care and the place for physical, social and workplace (or school) rehabilitation programs.
While it is very unlikely that any single treatment will provide a "cure", current treatment approaches can result in significant reduction in disability over time.
Frequent switching from one form of treatment to another in search of an elusive "cure" should be discouraged, as it is likely to result only in frustration and continuing disability. These may include the use of analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants or hypnosedatives. This does not mean that the patient and doctor need necessarily agree about all treatment decisions (eg, the use of alternative therapies). To date, there has been no evidence that patients respond in the way that would be expected if CFS were simply misdiagnosed or "masked" major depression.
In one of the first large trials, fluoxetine (a selective serotonin reuptake inhibitor [SSRI]) showed no more benefit than placebo.[457] However, SSRIs may have a place in patients with concurrent major depression or a strong personal or family vulnerability to anxiety or depression.
A physical activity program is individually designed to take account of the patient's current level of disability.[467,468] After a prolonged period of illness and inactivity, new activities are introduced gradually and, most importantly, are "paced" (ie, scheduled to stop before they produce a significant exacerbation of symptoms).
The existence of such beliefs is ascertained by exploring the person's causal attributions and his or her understanding of the illness. As with many other chronic medical disorders, it is better for patients with CFS to be empowered through appropriate self-management and self-monitoring techniques[482] rather than passively submitting to fruitless investigations and marginally effective medical interventions.
In most studies patients were only included if they were physically well enough to attend clinics for assessment, treatment and follow-up.
This chronic condition may continue for almost 6 months tend to disturb the normal activity. However, tests conducted to treat other illnesses might prove successful in identifying the syndrome. So treating depression would reduce the problems associated with chronic fatigue syndrome to the maximum extent. Problems in the digestive system, hormones and immune problems might be created due to infections in the body and sleeplessness. Similar outcomes were confirmed in several other retrospective studies from tertiary referral centres.
Fatigue commonly accompanies many other medical conditions, particularly those directly involving the central nervous system and affecting information processing, the sleep-wake cycle, or arousal mechanisms (eg, multiple sclerosis).
The relationship between the onset of the fatigue state and relevant psychosocial stressors should be noted. At the severe end of the spectrum of CFS, people may be housebound and experience profound fatigue simply from the necessities of self-care, such as showering or dressing.
Similarly, by the time of diagnosis, parents, friends and partners of people with CFS are often questioning the nature of the unexplained illness.
Adolescents who are absent from school or occupational training for prolonged periods may benefit from assessment by a paediatrician. If patients are made aware of these possibilities at the outset, they will be less likely to abandon useful treatments prematurely.
If these pharmacological agents prove helpful for the patient, their ongoing use should be reviewed regularly and coordinated with appropriate non-pharmacological forms of care.
It does, however, mean that they should agree on realistic goals for the outcomes of conventional medical treatments. However, certain agents have been found to be beneficial for patients with CFS, particularly those with significant mood or sleep disturbances. SSRI therapy needs to be closely monitored for adverse side effects such as nausea, agitation and gastrointestinal disturbances in the early stages of treatment. Over time the level of activity attempted is slowly increased at a rate determined by the patient's response. Doctors should ensure that patients are informed of the dangers of prolonged rest[480] and the psychological risks of social isolation. Skilled practitioners who are able to explain the role of behavioural and psychological factors in a wide range of medical disorders can often overcome a patient's initial reservations and gain his or her confidence. It is therefore difficult to extrapolate the results to patients with more severe disability.
Epstein-Barr, human herpesvirus6 and mouse leukemia viruses may seem to spread virus that cause extreme tiredness but a fair judgment on the above point cannot be concluded. Swelling in the lymph nodes, redness in the throat, fever are some of the symptoms checked as a part of physical examination.
Antidepressants as suggested by the physician may improve sleep and reduce pain in such patients.
Avoiding the consumption of alcohol and caffeine can be a possible home tip to reduce the syndrome.
The immune systems of people CFS have been shown to be slightly impaired.Hormonal imbalances. As with pain, most people report that the fatigue is experienced as a peripheral phenomenon, apparently occurring in musculoskeletal regions. Many commonly prescribed medications (such as antihistamines and sedatives) and other substances (such as alcohol, marijuana and amphetamines) cause fatigue directly, or indirectly by disturbing the sleep-wake cycle. Whenever possible, an independent, corroborating history should be sought from a spouse, partner or other family member.


The effect of the illness upon the patient's key interpersonal relationships,[441-443] work or educational activities should be specifically evaluated. People who are persistently housebound with severe disability arising from CFS may require the assessment and advice of a team, including specialists in rehabilitation medicine, pain management, physiotherapy, occupational therapy, and social work. For example, short-term use of hypnosedatives may assist at the beginning of a structured sleep-wake cycle modification program.[449] Similarly, use of analgesics, NSAIDs or both may be necessary during the early phase of a physical rehabilitation approach. The significant non-specific (placebo) response rate in some controlled treatment trials for people with CFS is likely to be a reflection of these essential components of good clinical practice.[452,453]As a general principle of good management of patients with CFS, it can be useful to introduce the concept of self-monitoring of key symptoms and associated disability.
Moclobemide (a reversible monoamine oxidase inhibitor) has been evaluated in a large double-blind, placebo-controlled trial.[450] Limited evidence of benefit was observed, with an improvement in the subjective sense of vigour and energy that was not associated with any alteration in mood. As SSRIs may disturb sleep-wake architecture during the first few weeks of treatment, patients should also be closely monitored for any exacerbation of the CFS symptom complex. For clinical trial purposes, a specific number of structured treatments are packaged over a set time period. When properly used, a cognitive behavioural management approach promotes active patient participation with self-monitoring, and takes account of previous experiences, both beneficial and adverse. Moreover, many studies have significant refusal and drop-out rates, which may reflect on the acceptability of the treatment regimens. The disease might appear to be accompanied by problems in concentration leading to short term memory. People with weak immune system may fall at the risk of developing the disease to some extent. A careful observation of testing mononucleosis, lyme disease, thyroid, diabetes, cancers, bipolar disorder, depression and other psychological disorders might rule out the condition of fatigue syndrome. Gentle exercises particularly stretching movements may be prescribed to reduce pain in the muscles. Improving sleeping habits and balancing work evenly would also help in improving the condition. This will enable doctors to act as advocates for their patients by providing appropriate information to relevant individuals and institutions. Or, if an antidepressant agent (eg, moclobemide) improves a patient's subjective sense of energy and wakefulness,[450] this can provide an opportunity to embark on a return to school or work, or a social activity program. This can be achieved through a variety of standardised instruments (eg, SPHERE,431 Brief Disability Questionnaire) and activity, sleep-wake cycle or pain diaries. Similarly, selegiline (a specific monoamine oxidase inhibitor) has been reported to relieve tension and anxiety, and improve vigour and sexual relations.[456] All of these agents are somewhat "amphetamine-like" in their actions.
From this perspective, the older tricyclic agents and some of the new antidepressants with more sedative properties (eg, nefazodone) may be more suitable for some patients.
In routine clinical practice, however, the initial treatment strategy is usually individualised according to the patient's level of disability and personal preferences, and subsequently modified according to the response. Contrary to popular myths, this approach does not simplistically impose a psychological model of causation.
It is often difficult to diagnose the symptoms of the syndrome as it corresponds itself with other psychological diseases. Hormonal imbalance particularly in women might result in causing the syndrome but the factual information is still unclear. Blood test, antibody test, CT scan or MRI, computed tomography to test the decreased flow of blood might be the most suitable diagnosis for fatigue. A psychological counseling would also be helpful to improve the mental condition of the patient.
Acupuncture, yogic exercises and massages might transform the mental attitude of the patient. Chronic fatigue can be caused by sleep disorders such as obstructive sleep apnea, restless leg syndrome or insomnia which can be indentified by a sleep study.Medical problems. These allow both the doctor and patient to develop an accurate picture of whether progress is being made with a particular treatment, or whether there has been spontaneous improvement over time.
While this may assist with key symptoms like fatigue, wakefulness and concentration, they should be used cautiously and closely monitored for side effects such as agitation and insomnia. Rather, it encourages patients to adopt a wider view of the range of medical and psychological approaches that can promote optimal long-term functioning. However, serious illness or excessive stress and weakness in the immune system can cause this condition which might last for years if left untreated.
However, age, stress levels, work environment and hereditary reasons might lead to its development. Making necessary changes in the lifestyle like taking balanced diet, reducing stress, increasing the intake of nutrients in food and physical exertion might also reduce this syndrome.
Borage seed oil, garlic, biloba, primrose oil, astragalus and bromelain are some of the herbal supplements given to patients with the syndrome.
Fatigue is a common symptom in several medical conditions, such as anemia, diabetes and underactive thyroid (hypothyroidism). Such monitoring may also alert the doctor to the emergence of a change in key symptoms or disability. People with this syndrome become sick and weary both physically and mentally where the quality of life is completely disturbed.
In some cases muscle diseases, endocrine diseases and other diseases in heart, kidney or liver might possibly be the other causes of fatigue. Lab tests can check your blood for evidence of some of the top suspects.Mental health issues. Fatigue is also a symptom of a variety of mental health problems, such as depression, anxiety, bipolar disorder and schizophrenia.
A psychiatrist can help determine if one of these problems is causing your fatigue.?Treatment of  CFS can be  complex. There are no specific medicines for treatment is CFS especially as symptoms can vary a lot over time. Close monitoring and treatment of symptoms with strategies that change as the pattern of the disorder pattern changes.A team approach that involves doctors and patients is one key to managing CFS.
Patients benefit when they can work in collaboration with a team of doctors who might include a psychiatrist, a rehabilitation ?specialist, and physical or exercise therapists. Together, they can create an individualized treatment program that best meets the needs of the patient with CFS.
This program should be based on a combination of therapies that address symptoms, coping techniques, and managing normal daily activities.Psychological counseling. Talking with a counselor can help you figure out options to work around some of the limitations that chronic fatigue syndrome imposes on you. A detailed patient history is followed by  a thorough physical and mental health exam and a series of laboratory screening tests to help identify or rule out other possible causes of symptoms. Treating  depression can make it easier for the person to cope with the problems associated with chronic fatigue syndrome. And low doses of some antidepressants also can help improve sleep and relieve pain.Sleeping pills.
Inactive people often begin with range-of-motion and stretching exercises for just a few minutes a day. Nothing contained in this site is or should be considered or used as a substitute for professional medical or mental health advice, diagnosis, or treatment.
Never disregard medical advice from your doctor or delay seeking it because of something you have read on the Internet.



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