1. Chronic Fatigue Syndrome Epidemiology and Treatment Considerations
Renee R. Taylor, Ph.D.
University of Illinois at Chicago

2. Chronic Fatigue Syndrome
Current US Case Criteria
(Fukuda et al., 1994)
Development sponsored by the Centers for Disease Control
There have been a number of approaches to defining chronic fatigue syndrome (CFS). Three sets of diagnostic criteria currently exist: the British definition (Sharpe et al., 1989), the Australian definition (Lloyd et al., 1990), and the current US definition, developed in collaboration with the CDC (Fukuda et al., 1994). Within the US, the diagnostic criteria have undergone considerable revision and continue to undergo revision. The first US case criteria for CFS were developed in collaboration with the CDC in 1988 (Holmes et al., 1988). A central problem with CFS case criteria in general is that they have been developed based on expert consensus. Current definitions have not been supported empirically.

3. CFS Criteria
Persistent or relapsing fatigue of 6 months or longer duration with other known medical and primary psychiatric conditions excluded by clinical diagnosis

4. CFS Criteria (Continued)
clinically evaluated, unexplained, persistent or relapsing chronic fatigue that is of new or definite onset (i.e., not life-long)
fatigue is not the result of ongoing exertion

5. CFS Criteria (Continued)
Concurrent occurrence of four
or more of the following:
1. Short term memory/concentration Persistent or recurring impairment in short term memory or concentration severe enough to cause substantial reductions in previous levels of occupational , educational, social, or personal activities

6. CFS Criteria (Continued)
2. sore throat
3. tender cervical or axillary lymph nodes
4. muscle pain
5. joint pain in multiple joints without joint swelling or redness

7. CFS Criteria (Continued)
6. headaches of a new type, pattern or severity
7. unrefreshing sleep
8. post exertional malaise lasting more than 24 hrs

8. History of CFS Neurasthenia coined in 1869 by George Beard.
One of the most prevalent diagnoses in the late 1800’s.
Herbert James Hall (a physician and one of the founders of occupational therapy) treated patients with neurasthenia.
By the early 1900’s the diagnosis was used less frequently and it is possible that those with severe fatigue were considered to have depression or another psychiatric condition.

9. History of CFS
Cluster outbreaks of unexplained fatiguing illnesses have been documented throughout the world for the past 45 years (e.g., icelandic disease, epidemic neuromyalsthenia, chronic encephalomyelitis).
Patterns of associated symptoms have differed and differed from modern case criteria.
Further controlled investigations of so-called cluster outbreaks were not confirmed (Fukuda et al., 1997).
Anecdotally, some argue that the reason cluster outbreaks reported within the US have not been confirmed empirically is due to methodological limitations.

10. Conditions That Can Explain Chronic Fatigue
Cancer
Narcolepsy
Sleep apnea
Severe obesity
Hypothyroidism
Alcohol or substance abuse
Unresolved hepatitis B or C

11. Conditions That Can Explain Chronic Fatigue (Continued)
Lupus
Tuberculosis
Lyme disease
Multiple sclerosis
Rheumatoid arthritis
Iatrogenic, e.g., medication side effects
HIV/AIDS

12. Conditions That Can Explain Chronic Fatigue (Continued)
Dementia
Schizophrenia
Bipolar disorder
Bulimia nervosa
Anorexia nervosa
Major Depression with Melancholia

13. Possible Causes of CFS Infectious agents Immunological defects
Hypothalamic-pituitary-adrenal axis dysfunction (cortisol dysregulation, hypocortisolism, dysfunction in neuroendocrine-immune communication).
Orthostatic intolerance/Neurally Mediated Hypotension
Biopsychosical

14. Findings from the Jason et al. (1999) Chicago Prevalence study
Epidemiology
Findings from the Jason et al. (1999) Chicago Prevalence study
Jason, L.A., Richman, J.A., Rademaker, A.W., Jordan, K.M., Plioplys, A.V., Taylor, R.R., McCreedy, W., Huang, C., & Plioplys, S. (1999) A community-based study of chronic fatigue syndrome Archives of Internal Medicine, 159,

15. Myths about CFS Late 1980s and early 1990s
Patients were thought to have “Yuppie Flu”
Few minority group members
Mostly women
Well educated

16. Myths vs. Facts
Myth: CFS is a relatively rare disorder
Fact: CFS affects over 800,000 adults and adolescents in the United States
(Jason et al., 1999)

17. Myths vs. Facts
Myth: The highest prevalence of CFS is among young, affluent, white professionals
Fact: Latinos have the highest prevalence; African Americans have the second highest

18. Race
Latinos: 726 per 100,000
(twice that of Whites/non-Latino EuroAmericans)
Whites: per 100,000
African Americans: 337 per 100,000

19. Gender Women have a much higher rate of CFS than men
522 women per 100,000 compared to
291 men per 100,000

20. CFS CFS in Context Social Loss Job/Income Loss 100% report
disruption in
relationships
Job/Income
Loss
76%
Unemployment
Median
Income Loss:
$13,000
CFS in Context
CFS
Immunological
Neurological
Gastrointestinal
Musculoskeletal
Endocrinological
Psychiatric
Socio-
political
Stigma
Mass Media
CDC
Misappropriating
Research Funds
Health Care
Stigma
77% report
negative
interactions with
health care
providers

21. Four Models of Chronic Fatigue Syndrome Etiology
PSYCHIATRIC
BIOLOGIC
SOCIAL -
BIO-
CFS is a form of
Currently, no single causal agent has been identified as responsible for CFS consistently across studies. Four general models exist in the literature. The biologic and biopsychosocial models may hold the most promise in future investigations of etiology.
The validity of CFS is
ENVIRONMENT
PSYCHOSOCIAL
Relational synergy
Negative contacts,
somatic depression
supported by
Patho
physiology
multiple roles
between all factors
or hypo
chondriasis

22. Is CFS a Distinct Entity?
Findings from the Taylor et al. (2001) study
Taylor, R.R., Jason, L.A., & Schoeny, M. (2001). Latent variable models of functional somatic distress in a community-based sample. Journal of Mental Health, 10,

23. CFS: A Distinct Diagnostic Entity?
QUESTION:
Debate regarding whether CFS differs from somatic depression, somatic anxiety, fibromyalgia, and irritable bowel syndrome.
Are these disorders better explained as a single unitary construct of functional somatic distress (somatoform disorders)?
METHOD:
Tested one-, two- and five-factor solutions using confirmatory factor analysis
Used factor scores to predict actual diagnostic outcomes in logistic regression

24. Findings
Taylor, R.R., Jason, L.A., & Schoeny, M. (2001). Latent variable models of functional somatic distress in a community-based sample. Journal of Mental Health, 10,
FINDINGS

25. CFS and Child Abuse?

26. The Current Status of Trauma Research
While many have speculated that histories of childhood sexual, physical, or emotional abuse may play a role in the etiology or course of CFS, few rigorous empirical studies have been conducted.

27. Prior Studies
Rosenthal (1996). 27 physician-diagnosed participants with CFS responded to a survey query in The CFIDS Chronicle.
100% reported a history of severe or prolonged stress or repeated traumatic events.
67% reported comorbid diagnosis of PTSD
74% felt that stress or trauma contributed to the development of CFS

28. Prior Studies
Tiersky et al. (1998) compared the occurrence of childhood trauma in individuals with CFS and healthy controls.
Individuals with CFS demonstrated a higher incidence of extreme illness or injury prior to age 17.
No other significant group differences related to abuse history were found.

29. Prior Studies
Doyle et al. (1999) conducted a large-scale study of domestic violence and sexual abuse history among women physicians.
There was a significantly higher rate of CFS among physicians reporting a history of domestic violence (16.1%) as compared with physicians not reporting such history (3.5%).

30. Prior Studies
Doyle et al. (1999) did not detect significant differences in rates of CFS among physicians reporting a lifetime history of sexual abuse.