Chronic Fatigue Syndrome: Always tired

Do you ever feel as if you cannot make it through the day? That the activities of daily life are an immense physical and mental burden? Are you riddled with sleep problems, pain, or dizziness? If so, you are not alone. Chronic fatigue syndrome, or myalgic encephalomyelitis, is more than being tired. The condition is a complex illness that impacts physical and mental health in people of all ages and ethnicities.

Chronic Fatigue Syndrome: Always tired
Photo by Pixabay from Pexels

What is Chronic Fatigue Syndrome?

Chronic fatigue syndrome (CFS) is a serious, but common health condition affecting approximately one million Americans with women four times more likely than males to develop the diagnosis. Also known as myalgic encephalomyelitis (M.E.), it is characterized by profound fatigue that lasts longer than six months and cannot be explained by another condition. People with it struggle to complete daily tasks such as work, school, personal care, and household chores. This leads to post-exertional malaise, which is the mental or physical decline after exertion. Although most appear healthy, the condition is debilitating.

Symptoms of Chronic Fatigue Syndrome

The central presence of fatigue is how chronic fatigue syndrome received its name, but symptoms of the condition can be widespread throughout the body. They may be severe or mild.

  • Fatigue
  • Poor concentration, attention, or memory
  • Sleep problems
  • Orthostatic hypotension (i.e. feeling dizzy or faint upon standing from a drop in blood pressure)
  • Headaches
  • Muscle pain
  • Joint pain without swelling or redness
  • Sore throat
  • Swollen, tender lymph nodes
  • Numbness and tingling in the hands or feet
  • Psychological symptoms—anxiety, depression, panic attacks
  • Sensitivity to light
  • Allergies

Causes of Chronic Fatigue Syndrome

The overall causes are unknown. Some individuals are genetically susceptible and the symptoms initiate when triggered. It is thought to be triggered by viral infections like the Epstein-Barr virus, human herpesvirus 6, rubella, or human immunodeficiency virus (HIV). Immune system problems from cytokine production and altered immune cells may also play a role. Researchers speculate that hormonal imbalances and stress are another potential cause. Glands in the hypothalamic-pituitary-adrenal axis stop releasing sufficient cortisol and stress hormones to reduce inflammation in the immune system. Cases of females in their 40s and 50s experiencing a stressful life event are most prevalent.

Chronic Fatigue Syndrome and the Brain

Brain changes in structure and function occur in chronic fatigue syndrome. Magnetic resonance imaging reveals (MRI) that in patients with it, there is a reduction in white matter which carries information to connected neurons in the brain. Sandford University studies found an abnormal right arcuate fasciculus (Goldmen, 2014). The right arcuate fasciculus runs through both the frontal and temporal lobes. These differences are connected to process such as attention, motivation, reward, emotional regulation, sensory processing, and memory. The extent of the brain changes is correlated with the severity of symptoms.

Chronic Fatigue Syndrome and Mental Health

It is not a psychological diagnosis. It is a physical illness that has the potential to cause psychiatric illness. Depression and generalized anxiety likely stem from dysregulation of pain mechanisms, the stress system regulated by the pituitary and adrenal glands, as well as the immune system. Some patients have psychiatric symptoms before the onset of their chronic fatigue syndrome symptoms, while others do not develop them until years after the diagnosis.

Chronic Fatigue Syndrome and Depression

Depression is a mood disorder affecting how a person thinks, feels, and behaves. It is characterized by a persistent, unexplained sadness that interferes with daily functioning. Hopelessness, apathy, a loss of interest, sleep disturbance, and fatigue go hand-in-hand with depression and chronic fatigue syndrome.

Those with it experience immense stress because of their illness. They cannot partake in all of the activities they once did. They may struggle to maintain a social life or hold down a steady job due to the interference of symptoms. If they do not cope with these challenges, depression can develop.

Chronic Fatigue Syndrome and Anxiety

Generalized anxiety disorder is defined as excessive worry about routine life factors: social interactions, health, finances, etc. It leads to sleep problems, irritability, difficulty concentrating, and fatigue. Anxiety is common in it because of the latter’s effect on the autonomic nervous system. The autonomic nervous system controls the fight-or-flight response, and when it becomes dysfunctional as it does in some chronic fatigue syndrome patients, a state of anxiety arises. Anxiety can also emerge from the fear of symptoms. Again, it is important to note that it is not a psychiatric illness. Mental health manifestations are only a consequence of the underlying physical illness. Addressing mental health issues can prove to be a valuable asset in treatment.

Chronic Fatigue Syndrome Diagnosis

Chronic fatigue syndrome is a diagnosis of elimination. There is no one standard test to diagnose the disorder. First, the doctor makes a thorough assessment of medical history. This includes previous illness of the patient and their family, a mental status evaluation, and questions regarding daily activities. Blood tests to check liver function, thyroid hormone levels, and inflammatory markers are used to rule out other conditions.

The diagnosis of chronic fatigue syndrome is only given when the patient:

  1. Has unrelenting fatigue after regular tasks that do not resolve with rest, exercise intolerance, pain, and sleep problems
  2. The fatigue lasts at least 6 months or longer
  3. There is no underlying mental or psychological reason for the symptoms

Comorbid Diagnoses To Chronic Fatigue Syndrome

A subset of chronic fatigue syndrome symptoms can be diagnosed as separate disorders. This is referred to as comorbidities. Possible comorbid diagnoses are:

  • Fibromyalgia
  • Irritable bowel syndrome
  • Postural Orthostatic Tachycardia Syndrome
  • Depression
  • Anxiety
  • Hashimoto’s thyroiditis
  • Endometriosis
  • Mast Cell Activation Syndrome
  • Multiple Chemical Sensitivities
  • Temporomandibular joint disorder

Is It Chronic Fatigue Syndrome or Fibromyalgia?

Fibromyalgia is a disorder characterized by widespread musculoskeletal pain. It shares symptoms with it, like pain, fatigue, sleep irregularities, and memory problems. With considerable symptom overlap, the two conditions are often confused. However, widespread pain is the predominant symptom in fibromyalgia, whereas fatigue is the central manifestation in chronic fatigue syndrome. Further, the chronic pain associated with fibromyalgia occurs in trigger point locations and is typically accompanied by stiffness. Although it is possible to have both conditions, only a physician can confirm or deny the diagnoses.

Treatment for Chronic Fatigue Syndrome

While it has no cure, a variety of treatments can lessen symptoms. Treatment is focused on exercise, pain management, and lifestyle adjustments. The combination of therapies is tailored to the predominant symptoms, so treatment differs from patient to patient.

Physical Therapy

Initially, it is advised patients decrease their activity level to allow their bodies time to recover. This is especially important for post-viral cases. Those with it must learn to conserve their energy. Pacing is key to completing essential activities while limiting the activities that are not absolutely necessary.  

Deconditioning, however, leads to an exacerbation of symptoms. Introducing exercise into the patient’s routine is crucial and can be accomplished with the assistance of a physical therapist. A physical therapist implements aerobic physical activity gradually, ensuring several days between sessions to recover from post-exertional malaise, which is the worsening of symptoms 24 to 72 hours after physical or mental exertion.

After 12 weeks of therapy, a patient-reported that their baseline pain level decreased from a 6 or 7 to a 3 or 4 on a 10 point scale (Ries, 2012). These studies reflect the capacity to treat chronic pain through the gradual pacing of a light exercise regimen.

Pain Management Medications

Most find physical therapy effective in combination with medications. Physicals prefer to prescribe non-opioid medications due to the chronic nature of the pain caused by chronic fatigue syndrome. These medications include nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen (Tylenol) for muscle pain, joint pain, and headaches. Low dose tricyclic antidepressants also treat pain and decrease sleep disturbance. Since chronic fatigue syndrome results in an increase in allergies, anti-histamines manage allergy symptoms.

Cognitive Behavioral Therapy

Cognitive-behavioral therapy (CBT) is a form of psychotherapy to alter distorted thinking patterns that contribute to unwanted behavior Even without a psychological diagnosis, patients with it can still advantage from CBT. Their fatigue and pain after activity precipitate to a fear of activity, which prompts them to engage in behaviors that contribute to their fatigue. The goal of CBT is to change this response to modify their behavior. The PACE study (Sharpe et al., 2019) which tests the effectiveness of non-pharmaceutical treatment options for it concluded that CBT is beneficial for targeting post-exertional malaise, fatigue, social adjustment, depression, and anxiety.

Lifestyle Adjustments

Living with it is not easy. Having to sacrifice activities is difficult to cope with, but lifestyle adjustments go a long way in restoring a sense of normalcy.


Eating healthy supports the body. Those with chronic fatigue syndrome often develop food sensitivities and gastrointestinal distress like nausea, gas, stomach pain, and diarrhea. Omit processed foods with preservatives that are difficult for the GI tract to process and contribute to food sensitivities. It is recommended to avoid artificial sugars, sweeteners, and stimulants (i.e. caffeine and alcohol). Consume animal fats in moderation, as they are not ideal for gallbladder and liver dysfunction common in chronic fatigue syndrome.

Photo by Ben Libby from Pexels

Vitamin Supplementation

Studies indicate those with it have lower ratios of omega-3 to omega-6 fatty acids. The fatty acids in fish oil are a prime example. Supplementation can reduce fatigue.

Vitamin B12 does not specifically treat it, but low levels contribute to fatigue. Injections restore B12 levels better than oral supplementation.

Time Management

Time management is an important part of pacing. During a flare, a lack of energy makes routine activities more difficult. Give extra time to shower, complete chores, and other tasks. Memory is also a struggle for people with chronic fatigue syndrome. They may forget important dates or work obligations. Keep a calendar and planner to stay on schedule.

Prognosis of Chronic Fatigue Syndrome

It is not terminal. 5 to 10 percent of adults diagnosed with it do not recover fully. However, many are able to work part-time and continue to lead productive lives with symptomatic treatment.

Children with it have a better prognosis with an 80 percent recovery rate (Bell, 2001). They experience additional struggles related to school, academic success, and maintaining a social life, but usually grow out of the disorder within four years.


Bell D.S., Jordan K., Robinson M. (2001). Thirteen-year follow-up of children and adolescents with chronic fatigue syndrome. Pediatrics, 107(5):994-8.

Goldmen, B. (2014). Study finds brain abnormalities in chronic fatigue patients. Retrieved from

Ries, E. (2017). The Real Story About Chronic Fatigue Syndrome. Retrieved from

Sharpe, M., Goldsmith, K., & Chalder, T. (2019). The PACE trial of treatments for chronic fatigue syndrome: a response to WILSHIRE et al. BMC Psychology, 7(15).

Leave a Reply