Abstract
The complexities of the chronic fatigue syndrome and the methodologic problems associated with its study indicate the need for a comprehensive, systematic, and integrated approach to the evaluation, classification, and study of persons with this condition and other fatiguing illnesses. We propose a conceptual framework and a set of guidelines that provide such an approach. Our guidelines include recommendations for the clinical evaluation of fatigued persons, a revised case definition of the chronic fatigue syndrome, and a strategy for subgrouping fatigued persons in formal investigations.
*For a listing of members of the Study Group, see Appendix.
References
- 1. Holmes GP, Kaplan JE, Gantz NM, Komaroff AL, Schonberger LB, Straus SE, et al. Chronic fatigue syndrome: a working case definition. Ann Intern Med. 1988; 108:387-9. Google Scholar
- 2. Lloyd AR, Wakefield D, Boughton C, Dwyer J. What is myalgic encephalomyelitis? (Letter). Lancet. 1988; 1:1286-7. Google Scholar
- 3. Lloyd AR, Hickie I, Boughton CR, Spencer O, Wakefield D. Prevalence of chronic fatigue syndrome in an Australian population. Med J Aust. 1990; 153:522-8. Google Scholar
- 4. Sharpe MC, Archard LC, Banatvala JE, Borysiewicz LK, Clare AW, David A, et al. A report-chronic fatigue syndrome: guidelines for research. J R Soc Med. 1991; 84:118-21. Google Scholar
- 5. Holmes GP. The chronic fatigue syndrome. In: Schlossberg D, ed. Infectious Mononucleosis. 2nd ed. New York: Springer-Verlag; 1989:172-93. Google Scholar
- 6. Klonoff DC. Chronic fatigue syndrome. Clin Infect Dis. 1992; 15:812-23. Google Scholar
- 7. Shafran SD. The chronic fatigue syndrome. Am J Med. 1991; 90:730-9. Google Scholar
- 8. Wilson A, Hickie I, Lloyd A, Wakefield D. The treatment of chronic fatigue syndrome: science and speculation. Am J Med. 1994; 96:544-50. Google Scholar
- 9. Wilson A, Hickie I, Lloyd A, Hadzi-Pavlovic D, Boughton C, Dwyer J, et al. Longitudinal study of outcome of chronic fatigue syndrome. BMJ. 1994; 308:756-9. Google Scholar
- 10. Peterson PK, Schenck CH, Sherman R. Chronic fatigue syndrome in Minnesota. Minn Med. 1991; 74:21-6. Google Scholar
- 11. Manu P, Matthews DA, Lane TJ. The mental health of patients with a chief complaint of chronic fatigue. A prospective evaluation and follow-up. Arch Intern Med. 1988; 148:2213-7. Google Scholar
- 12. Manu P, Matthews DA, Lane TJ. Panic disorder among patients with chronic fatigue. South Med J 1991; 84:451-6. Google Scholar
- 13. Manu P, Lane TJ, Matthews DA. Somatization disorder in patients with chronic fatigue. Psychosomatics. 1989; 30:388-95. Google Scholar
- 14. Kruesi MJ, Dale J, Straus SE. Psychiatric diagnoses in patients who have chronic fatigue syndrome. J Clin Psychiatry. 1989; 50:53-6. Google Scholar
- 15. Wessely S, Powell R. Fatigue syndromes: a comparison of chronic postviral fatigue with neuromuscular and affective disorders. J Neurol Neurosurg Psychiatry. 1989; 52:940-8. Google Scholar
- 16. Swartz MN. The chronic fatigue syndrome—one entity or many? N Engl J Med. 1988; 319:1726-8. Google Scholar
- 17. Pawlikowska T, Chalder T, Hirsch SR, Wallace P, Wright DJ, Wessely SC. Population based study of fatigue and psychological distress. BMJ. 1994; 308:763-6. Google Scholar
- 18. Price RK, North CS, Wessely S, Fraser VJ. Estimating the prevalence of chronic fatigue syndrome and associated symptoms in the community. Public Health Rep. 1992; 107:514-22. Google Scholar
- 19. Walker EA, Katon WJ, Jemelka RP. Psychiatric disorders and medical care utilization among people in the general population who report fatigue. J Gen Intern Med. 1993; 8:436-40. Google Scholar
- 20. Kroenke K, Wood DR, Mangelsdorff AD, Meier NJ, Powell JB. Chronic fatigue in primary care. Prevalence, patient characteristics, and outcome. JAMA. 1988; 206:929-34. Google Scholar
- 21. Sharpe M, Hawton K, Seagroatt V, Pasvol G. Follow up of patients presenting with fatigue to an infectious diseases clinic. BMJ. 1992; 305:147-52. Google Scholar
- 22. Bates DW, Schmitt W, Buchwald D, Ware NC, Lee J, Thoyer E, et al. Prevalence of fatigue and chronic fatigue syndrome in a primary care practice. Arch Intern Med. 1993; 153:2759-65. Google Scholar
- 23. Mawle AC, Reyes M, Schmid DS. Is chronic fatigue syndrome an infectious disease? Infect Agents Dis. 1994; 2:333-41. Google Scholar
- 24. Schluederberg A, Straus SE, Peterson P, Blumenthal S, Komaroff AL, Spring SB, et al. NIH conference. Chronic fatigue syndrome research. Definition and medical outcome assessment. Ann Intern Med. 1992; 117:325-31. Google Scholar
- 25. Straus SE. Defining the chronic fatigue syndrome (Editorial). Arch Intern Med. 1992; 152:1569-70. Google Scholar
- 26. Matthews DA, Lane TJ, Manu P. Definition of the chronic fatigue syndrome (Letter). Ann Intern Med. 1988; 109:511-2. Google Scholar
- 27. Holmes GP, Kaplan JE, Schonberger LB, Straus SE, Zegans LS, Gantz NM, et al. Definition of the chronic fatigue syndrome (Letter). Ann Intern Med. 1988; 109:512. Google Scholar
- 28. Hickie I, Lloyd A, Hadzi-Pavlovic D, Parker G, Bird K, Wakefield D. Can the chronic fatigue syndrome be defined by distinct clinical features? Psychol Med. (In press.) Google Scholar
- 29. Gunn WJ, Connell DB, Randall B. Epidemiology of chronic fatigue syndrome: the Centers for Disease Control study. In: Bock G, Whelan J, eds. Chronic Fatigue Syndrome. New York: Wiley; 1993:83-101. (Ciba Foundation symposium 173). Google Scholar
- 30. Lane TJ, Matthews DA, Manu P. The low yield of physical examinations and laboratory investigations of patients with chronic fatigue. Am J Med Sci. 1990; 299:313-8. Google Scholar
- 31. Kroenke K. Chronic fatigue: frequency, causes, evaluation, and management. Compr Ther. 1989; 15:3-7. Google Scholar
- 32. Kuczmarski RJ. Prevalence of overweight and weight gain in the United States. Am J Clin Nutr. 1992; 55(2 Suppl):495S-502S. Google Scholar
- 33. Bray GA. Pathophysiology of obesity. Am J Clin Nutr. 1992; 55(2 Suppl):488S-94S. Google Scholar
- 34. Robins LN, Wing J, Wittchen HU, Helzer JE, Babor TF, Burke J, et al. The Composite International Diagnostic Interview. An epidemiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen Psychiatry. 1988; 45:1069-77. Google Scholar
- 35. Robins LN, Helzer JE, Croughan J, Ratcliff KS. National Institute of Mental Health Diagnostic Interview Schedule. Its history, characteristics, and validity. Arch Gen Psychiatry. 1981; 38:381-9. Google Scholar
- 36. Spitzer RL, Williams JB, Gibbon M, First MB. The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry. 1992; 49:624-9. Google Scholar
- 37. Schwartz JE, Jandorf L, Krupp LB. The measurement of fatigue: a new instrument. J Psychosom Res. 1993; 37:753-62. Google Scholar
- 38. Piper BF, Lindsey AM, Dodd MJ, Perketich S, Paul SM, Weller S. The development of an instrument to measure the subjective dimension of fatigue. In: Funk SG, Tournquist PM, Campagne MT, Archer Gopp L, Wiese RA, eds. Key Aspects of Comfort. Management of Pain, Fatigue and Nausea. New York: Springer; 1989:199-208. Google Scholar
- 39. Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol. 1989; 46:1121-3. Google Scholar
- 40. Chalder T, Berelowitz G, Pawlikowska T, Watts L, Wessely S, Wright D, et al. Development of a fatigue scale. J Psychosom Res. 1993; 37:147-53. Google Scholar
- 41. Vercoulen JH, Swanink CM, Fennis JF, Galama JM, van der Meer JW, Bleijenberg G. Dimensional assessment of chronic fatigue syndrome. J Psychosom Res. 1994; 38:383-92. Google Scholar
- 42. Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992; 30:473-83. Google Scholar
- 43. Bergner M, Bobbitt RA, Carter WB, Gilson BS. The Sickness Impact Profile: development and final revision of a health status measure. Med Care. 1981; XIX:787-805. Google Scholar
- 44. Katon W, Russo J. Chronic fatigue syndrome criteria. A critique of the requirement for multiple physical complaints. Arch Intern Med. 1992; 152:1604-9. Google Scholar
- 45. Lewis G, Wessely S. The epidemiology of fatigue: more questions than answers. J Epidemiol Community Health. 1992; 46:92-7. Google Scholar
- 46. Barofsky I, Legro MW. Definition and measurement of fatigue. Rev Infect Dis. 1991; 13(Suppl 1):S94-7. Google Scholar
Author, Article, and Disclosure Information
Authors:
Keiji Fukuda,
From the Centers for Disease Control and Prevention, Atlanta, Georgia; the National Institutes of Health, Bethesda, Maryland; Prince Henry Hospital and University of New South Wales, Sydney, Australia; University of Oxford and Warneford Hospital, Oxford, United Kingdom; and Brigham and Women's Hospital and Harvard University, Boston, Massachusetts.
Corresponding Author: Keiji Fukuda, MD, MPH, Mailstop A15, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30333.
Acknowledgments: The authors thank Carla Arpino, Judy Basso, Lyria Boast, Janet K. Dale, Karen Ezrine, Marya Grambs, K. Kimberly Kenney, Teruo Kitani, David Klonoff, Dorothy Knight, Gerhard R.F. Krueger, Hirohiko Kuratsune, Gudrun Lindh, Lars Lindquist, Lisa Livens, Alison Mawle, David McCluskey, John O'Connor, Orvalene Prewitt, Bonnie Randall, Karen B. Schmaling, Scott Schmid, John Stewart, Lars Wahlstrom, Denis Wakefield, and Andrew Wilson.