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1988 CDC CFS/ME Diagnostic Criteria

Details: Last Updated: 30 November 2015 30 November 2015

The first U.S. Case Definition for the Chronic Fatigue Syndrome (CFS) was published by researchers under the auspices of the Centers for Disease Control & Prevention (CDC) in 1988 in the prestigious journal Annals of Internal Medicine. The case definition is as follows:

"A case of the chronic fatigue syndrome must fulfill major criteria 1 and 2, and the following minor criteria: (a) 6 (or more) of the 11 symptom criteria and 2 (or more) of the 3 physical criteria; or (b) 8 (or more) of the symptom criteria."

Major Criteria

"New onset of persistent or relapsing, debilitating fatigue or easy fatigability in a person who has no previous history of similar symptoms, that does not resolve with bed rest, and that is serious enough to reduce or impair average daily activity below 50% of the patient's premorbid activity level for a period of at least six months."
"Other clinical conditions that may produce similar symptoms must be excluded by thorough evaluation based on history, physical examination, and appropriate laboratory findings. These conditions include malignancies, autoimmune disease, localized infection (such as occult abscess); chronic or subacute bacterial disease (such as endocarditis, Lyme disease, or tuberculosis), fungal disease (such as histoplasmosis, blastomycosis, or coccidiodomycosis), and parasitic disease (such as toxoplasmosis, amebiasis, giardiasis, or helminthic infestation); disease related to human immunodeficiency virus (HIV) infection;"

"...chronic psychiatric disease, either newly diagnosed or by history (such as endogenous depression; hysterical personality disorder; anxiety neurosis, schizophrenia..."

[Comment: These psychiatric diagnoses as a basis for exclusion of a CFS diagnosis were substantially removed from the 1994 CDC definition, especially those not related to major mental illness. The 1994 Definition recognized that anxiety and secondary depression were likely to occur as a result of chronic physical illness. This is one of the few elements of the 1988 definition that was improved in the 1994 definition.]

"...or chronic use of major tranquilizers, lithium, or antidepressive medication); chronic inflammatory disease (such as sarcoidosis, Wegener granulomatosis, or chronic hepatitis); neuromuscular disease (such as multiple sclerosis or myasthenia gravis); endocrine disease (such as hypothyroidism, Addison's disease, Cushing Syndrome, or diabetes mellitus); drug dependency or abuse (such as alcohol; controlled prescription drugs, or illicit drugs); side effects of a chronic medication or other toxic agent (such as a chemical solvent, pesticide, or heavy metal); or other known or defined chronic pulmonary, cardiac, gastrointestinal, hepatic, renal, or hematologic disease."

Lab Tests:

"Specific lab tests or clinical measurements are not required to satisfy the definition of chronic fatigue syndrome, but the recommended evaluation includes serial weight measurements...serial morning and afternoon temperature measurements; complete blood count and differential; serum electrolytes; glucose; creatinine; blood urea nitrogen; calcium, phosphorous; total bilirubin; alkaline phosphatase; serum aspartate aminotransferase, serum alanine aminotransferase; creatine phosphokinase or aldolase; urinanalysis...personal and family psychiatric history ...erythrocyte sedimentation rate; antinuclear antibody; thyroid stimulating hormone level; HIV antibody measurement;...and PPD skin test with controls."

"If any of the above are abnormal, the physician should search for other conditions that may cause such a result. If no such conditions are detected by a reasonable evaluation, this criterion is satisfied."

Minor Criteria

Symptom Criteria

"To fulfill a symptom criterion, a symptom must have begun at or after the time of onset of increased fatigability, and must have persisted or recurred over a period of at least six months. (Individual symptoms may or may not have occurred simultaneously.) Symptoms include:

Mild fever—oral temperature between 37.5 C and 38.6 C if measured by the patient—or chills. (Note: oral temperatures of greater than 38.6 C. are less compatible with chronic fatigue syndrome and should prompt studies for other causes of illness.)

Sore throat
Painful lymph nodes in the anterior or posterior cervical or axillary distribution
Unexplained generalized muscle weakness
Muscle discomfort or myalgia
Prolonged (24 hours or greater) generalized fatigue after levels of exercise that would have been easily tolerated in the patient's premorbid state
Generalized headaches (of a type, severity, or pattern that is different from headaches the patient may have had in the premorbid state)
Migratory arthralgia without joint swelling or redness
Neuropsychologic complaints (one or more of the following: photophobia, transient visual scotomata, forgetfulness, excessive irritability, confusion, difficulty thinking, inability to concentrate, depression)
Sleep disturbance (hypersomnia or insomnia)
Description of the main symptom complex as initially developing over a few hours to a few days (this is not a true symptom, but may be considered as equivalent to the above symptoms in meeting the requirements of the case definition.)"

Physical Criteria

"Physical criteria must be documented by a physician on at least two occasions, at least one month apart.

Low grade fever—oral temperature between 37.6 degrees C and 38.6 degrees C or rectal temperature between 37.8 C and 38.8 C.
Nonexudative pharyngitis.
Palpable or tender anterior or posterior cervical or axillary lymph nodes. (Note: lymph nodes greater than 2 cm in diameter suggest other causes. Further evaluation is warranted)."

More resources

1994 CDC definition

2003 Canadian definition

Critique of the 1994 CDC definition

History of ME/CFS/CFIDS

1994 CDC Definition

Details: Last Updated: 30 November 2015 30 November 2015

The Primary U.S. Case Definition

The major case definitions and diagnostic criteria for the Chronic Fatigue Syndrome (CFS) were developed from clinical experience and medical research over the past two decades in the United States, Canada, Australia and Europe.

In the United States, the case definition in most widespread use in 2012 was developed in 1994 under the auspices of the U.S. Centers for Disease Control & Prevention (CDC), the primary federal public health agency.

The Criteria were published as an article, "The Chronic Fatigue Syndrome: A Comprehensive Approach to its Definition and Study" in 1994 in the Annals of Internal Medicine, a prestigious medical journal. This definition identified the illness as "Chronic Fatigue Syndrome"—the name the CDC gave to the illness in its first CFS definition in 1988. (Hence the 1994 criteria are termed the "revised" definition.)

This definition remains the "official" and "authoritative" definition of the U.S. public health and research agencies and is the one most widely distributed among and subscribed to by many researchers and clinicians in the U.S. and other countries.

The CDC diagnostic criteria are also the standard used by the U.S. Social Security Administration (SSA) in determining ME/CFS disability, although in 2014 it issued a ruling accepting the 2003 Canadian criteria as well as some of the 2011 International Consensus Criteria. (See the article "Major 2014 Social Security Ruling.")

To date, in our opinion the 2003 Canadian Definition is the most medically accurate and detailed case definition available to physicians and patients. A patient and his/her physician will best determine presence of the illness using the Canadian Diagnostic Criteria.

So we suggest the that the 1994 Case Definition and the subsequent 2006 CDC Guidelines (an abridgement of the 1994 case definition) not be used as the sole method of diagnosing a case of the Myalgic Encephalomyelitis/chronic Fatigue Syndrome (ME/CFS).

CDC Guidelines for the evaluation and study of CFS

The Centers for Disease Control website presents a summarized version of the 1994 definition (originally published in the 1994 Annals of Internal Medicine) at their site: http://www.cdc.gov/cfs/case-definition/1994.html .

As a reference guide, it is useful to print out the summarized version. Patients may also want to give a copy to their physicians.

In 2010 and 2012, the CDC substantially improved its website information on the CFS diagnostic process. Patients and Health Care Professionals should review the CDC website's most comprehensive explanation of the diagnostic process.

Diagnosis (http://www.cdc.gov/cfs/diagnosis/index.html)—this section of the CDC website covers the following topics: Diagnostic challenges, Exams and Screening Tests for CFS, and Criteria for Diagnosing CFS. It also includes information for patients who think they might have CFS.
Diagnostic Tests to Exclude Other Causes (http://www.cdc.gov/cfs/diagnosis/testing.html)—this section includes tests that will exclude other causes of fatiguing illness and diagnose illness other than CFS.

For the ease of our readers, we are making these sections available here; however, patients may wish to print-out the information at CDC web pages for their providers.

Diagnosis

Diagnostic Challenges

For doctors, diagnosing chronic fatigue syndrome (CFS) can be complicated by a number of factors:

There's no lab test or biomarker for CFS.
Fatigue and other symptoms of CFS are common to many illnesses.
For some CFS patients, it may not be obvious to doctors that they are ill.
The illness has a pattern of remission and relapse.
Symptoms vary from person to person in type, number, and severity.

These factors have contributed to a low diagnosis rate. Of the one to four million Americans who have CFS, less than 20% have been diagnosed.

Exams and Screening Tests for CFS

Because there is no blood test, brain scan, or other lab test to diagnose CFS, the doctor should first rule out other possible causes.

If a patient has had 6 or more consecutive months of severe fatigue that is reported to be unrelieved by sufficient bed rest and that is accompanied by nonspecific symptoms, including flu-like symptoms, generalized pain, and memory problems, the doctor should consider the possibility that the patient may have CFS. Further exams and tests are needed before a diagnosis can be made:

A detailed medical history will be needed and should include a review of medications that could be causing the fatigue and symptoms
A thorough physical and mental status examination will also be needed
A battery of laboratory screening tests will be needed to help identify or rule out other possible causes of the symptoms that could be treated
The doctor may also order additional tests to follow up on results of the initial screening tests

A CFS diagnosis requires that the patient has been fatigued for 6 months or more and has 4 of the 8 symptoms for CFS for 6 months or more. If, however, the patient has been fatigued for 6 months or more but does not have four of the eight symptoms, the diagnosis may be idiopathic fatigue.

For Doctors and Other Healthcare Professionals: Criteria for Diagnosing CFS

Consider a diagnosis of CFS if these three criteria are met:

1. The individual has severe chronic fatigue for 6 or more consecutive months that is not due to ongoing exertion or other medical conditions associated with fatigue (these other conditions need to be ruled out by a doctor after diagnostic tests have been conducted)
2. The fatigue significantly interferes with daily activities and work
3. The individual concurrently has 4 or more of the following 8 symptoms:

post-exertion malaise lasting more than 24 hours
unrefreshing sleep
significant impairment of short-term memory or concentration
muscle pain
multi-joint pain without swelling or redness
headaches of a new type, pattern, or severity
tender cervical or axillary lymph nodes
a sore throat that is frequent or recurring

For Patients Who Think They Might Have CFS

It can be difficult to talk to your doctor or other health care professional about the possibility that you may have CFS. A variety of health care professionals, including doctors, nurse practitioners, and physician assistants, can diagnose CFS and help develop an individualized treatment plan for you.

CFS can resemble many other illnesses, including mononucleosis, Lyme disease, lupus, multiple sclerosis, fibromyalgia, primary sleep disorders, and major depressive disorder. Medications can also cause side effects that mimic the symptoms of CFS.

Because CFS can resemble many other disorders, it's important not to self-diagnose CFS. It's not uncommon for people to mistakenly assume they have chronic fatigue syndrome when they have another illness that will respond to treatment. If you have CFS symptoms, consult a health care professional to determine if any other conditions are responsible for your symptoms. A CFS diagnosis can be made only after other conditions have been excluded.

It's also important not to delay seeking a diagnosis and medical care. CDC research suggests that early diagnosis and treatment of CFS can increase the likelihood of improvement.

Diagnostic tests to exclude other causes

Tests for Routine Diagnosis of CFS
While the number and type of tests performed may vary from doctor to doctor, the following tests constitute a typical standard battery to exclude other causes of fatiguing illness:

alanine aminotransferase (ALT)
albumin, alkaline phosphatase (ALP)
blood urea nitrogen (BUN)
calcium
complete blood count with differential
creatinine
electrolytes
erythrocyte sedimentation rate (ESR)
globulin
glucose
phosphorus
thyroid stimulating hormone (TSH)
total protein
transferrin saturation
urinalysis

Further testing may be required to confirm a diagnosis for illness other than CFS. For example,
• If a patient has low levels of serum albumin together with an above-normal result for the blood urea nitrogen test, kidney disease would be suspected. The doctor may choose to repeat the relevant tests and possibly add new ones aimed specifically at diagnosing kidney disease.
• If autoimmune disease is suspected on the basis of initial testing and physical examination, the doctor may request additional tests, such as for antinuclear antibodies.

Assessing the Impact of Fatigue on Cognition
For some patients, it may be beneficial to conduct tests to assess how fatigue is affecting their cognitive skills such as concentration, memory, and organization. This additional testing can be useful in the differential diagnosis process or in identifying specific areas in which therapy may help. This may be particularly helpful to children and adolescents with CFS. Academic attendance and performance are important in these patients, and their specific educational needs should be addressed.

Tests for Differential Diagnosis and Management
CFS remains a diagnosis based on medical history, illness symptoms, physical examination, and exclusion of certain illnesses using a standard group of laboratory tests (1994 case definition). Additional tests such as imaging and physiological assessments can also be used to diagnose underlying illnesses:
• specific cultures or serological tests if an ongoing infection is considered
• MRI or other neuroimaging procedures to test for diseases such as multiple sclerosis
• physiological testing such as sleep studies, exercise testing (including VO₂ max), or tilt table testing to address specific questions, often in consultation with a specialist

Be aware that a patient can have CFS as well as a co-existing illness that cause fatigue or other CFS symptoms—for example, depression or low blood pressure. If treatment of those other illnesses does not resolve the symptoms, then the person can still have CFS.

Assessment of the 1994 CDC Definition

Recently, the CDC has very substantially improved its guidelines for the application of the 1994 CFS Criteria, and the Agency has stated it is reviewing the efficacy of more recent Diagnostic Criteria.

The CDC Criteria had very substantial flaws at its inception, so it is helpful to review both (1) some supplemental lab tests available to physicians for diagnostic purposes, and (2) the substantial limitations of the Criteria in accurately diagnosing ME/CFS.

Other Laboratory testing: Given more recent research and clinical experience, as well as the Social Security Administration Ruling on CFS, 2014, other tests may be indicative of CFS. A number CFS expert researchers and clinicians have developed protocols of laboratory and other tests that are helpful in adding confirmatory weight to a ME/CFS diagnosis. These tests are not directly diagnostic; however, in a percentage of cases they can positively contribute to a diagnosis after all other steps are taken under various diagnostic criteria.

It should be noted that in other sections of this website are references to various recent papers which provide evidence of viral and other microbial involvement in ME/CFS. Experienced clinicians and researchers are beginning to make use of various tests to determine the presence of active virus, including EBV, CMV, HHV-6, as well as other microbes. Clinicians certainly can run the protocols below as part of their effort to diagnose ME/CFS.

Dr. Anthony Komaroff, a leading specialist in ME/CFS cites the following laboratory abnormalities as supportive of a ME/CFS diagnosis:

Laboratory Abnormalities and Chronic Viral Fatigue Syndrome (CFS)*:

Mild leukopenia (3000-5000/mm)
Moderate monocytosis (7%-15%)
Relative lymphocytosis (>40%)
Atypical lymphocytosis (1%-20%)
Slight elevation in SGOT and SGPT
Erythrocyte sedimentation rate unusually low (0-4mm)
Partial reduction in immunoglobulins
Circulating immune complexes (low levels)
Increased CD4/CD8 ratio
EBV antibodies:

Viral capsid antigen-IgG > 1:640
Viral capsid antigen-IgM-not detectable
Early antigen- 1:40
EB nuclear antigen <1:5

*It is unusual for more than one or two of these findings to be present in any single patient.

Flaws in the 1994 Case Definition

The 1994 CDC definition, unfortunately, has proven to be partially flawed. First, the Criteria was originally intended as a research definition and for that reason excluded CFS cases that might have certain dual diagnoses, for instance CFS and obesity and CFS and bi-polar disorder.

The CFS definition, however, had come into wide use clinically—that is to diagnose patients in normal medical settings. Hence, a number of research exclusions would prevent patients, with additional diagnoses, from properly receiving a CFS diagnosis. To its credit the CDC has currently recognized this problem.

The CDC definition refers to a "mental status examination". In the past, many physicians have been unclear as to how, and by whom, such an examination should be performed. The CDC now suggests this exam can be performed by the patient's examining physician.

The 1994 Criteria, itself, does not with acceptable accuracy, clinically identify and distinguish the actual illness. (This has been shown in convincing research studies. See some references mentioned in the Canadian Guidelines booklet). For this reason, research results that use the 1994 definition may also be flawed, as some subjects who do not have the illness are invariably included.

The 1994 definition puts too much emphasis on the existence of a major symptom—fatigue—while not taking into sufficient account other major symptom complexes or the peculiar characteristics of the fatigue (which include post-exertional malaise mimicking that found in mitochondrial disease occurring the day after minor exertion).

The definition clouds the now research-validated difference between psychiatric illnesses and the multi-systemic, physiological, and coherent disease entity which is ME/CFS—an illness with common immune, endocrine, cardiovascular, and neurological dysfunction.

More and more research is also identifying the involvement of viruses and other potential microbes, as well as involvement of the RNase-L system in cells. The 1994 definition is diagnostically not sufficiently rigorous as it permits the misdiagnosis of individuals with psychiatric illness as having ME/CFS, and conversely, permits individuals who actually have ME/CFS to be misdiagnosed as having psychiatric illness.

Moreover, the name itself, Chronic Fatigue Syndrome, is inaccurate and not only distorts the medical nature of the illness but also badly serves a real understanding of the illness by patients, physicians and the general public. Many of the U.S. and international researchers most knowledgeable about the illness clearly recognize the deficiencies of the case definition and the 1994 diagnostic criteria.

In an attempt to overcome the harm created by the name Chronic Fatigue Syndrome, patients in the United States, beginning in the early 1990s, have termed the illness Chronic Fatigue Immune Dysfunction Syndrome (CFIDS), since immune abnormalities in patients have been demonstrated by many definitive research studies. In 2012, the patient community in the United States has been advocating to the federal agencies the use of the name Myalgic Encephalomyelitis.

For a more detailed analysis of the flaws in the 1994 CDC Definition, see Critique of the CDC Case Definitions and Detailed explanation of the 1994 CFS Definition .

When the 1994 CDC Case Definition should be used

There are a number of situations in which the patient will clearly need a diagnosis that relies upon the 1994 CDC definition. This definition is the only one recognized by some long-term disability insurance companies, and other agencies providing financial, medical, housing and food assistance. In these cases, diagnosis according to both the 2003 Canadian definition and the 1994 CDC definition is preferable, and the doctor may rely on the 1994 definition in providing disability documentation.

2003 Canadian Definition

Details: Last Updated: 21 January 2016 21 January 2016

History

The lack of clarity and accuracy of the dominant, but somewhat amorphous 1994 Centers for Disease Control & Prevention (CDC) definition for the Chronic Fatigue Syndrome (CFS) led a number of the leading researchers and clinicians from the U.S. and other nations to develop and publish in 2003 a new and much more accurate case definition/diagnostic criteria for the illness:

"Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Definition, Diagnostic and Treatment Protocols"

As this definition was published partially under the auspices of the Canadian Ministry of Health, it is informally called the Canadian Definition. The Canadian government assisted in organizing a committee following "input from invited world leaders in the research and clinical management of ME/CFS patients." (The combined experience of the committee was with over 20,000 patients.)

The Canadian Definition and Diagnostic protocols draw together the most rigorous findings both from the CFS-CDC sponsored research and the ME European research. Authors include CFS/ME experts Dr. Kenny De Meirleir of Belgium and Drs. Martin Lerner, Daniel Peterson, and Nancy Klimas of the U.S., among others.

To date, in our opinion the Canadian Definition is the most medically accurate and detailed case definition for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) available to physicians and patients. A patient and his/her physician will best determine presence of the illness using the Canadian Diagnostic Criteria.

If necessary, a patient can print out the Canadian Definition and take it to his or her physician.

The Canadian Definition and Diagnostic Criteria

The Diagnostic Protocol includes the "Clinical Working Case Definition"; a section on "Applying the Case Definition to the Individual Patient"; a "Discussion of the Major Features of ME/CFS"; "Features of ME/CFS in Children"; a guide for the "Clinical Evaluation of ME/CFS", which includes procedures for taking a patient history and for conducting the physical examination; the "Laboratory and Investigative Protocol" (general and more specialized lab tests); sections on differential diagnoses; along with a section on prognosis and disability assessment.

The entire diagnostic and case protocol is an extensive 22 pages, and requires careful reading. We will present a brief summary here with the hope of making the full document more accessible.

The first section contains the actual signs and symptoms criteria by which a patient achieves a diagnosis after other excluding illnesses are eliminated. Throughout, the definition makes clear that this clustering of symptoms, symptom-complexes, and pathophysiological signs is not random or disorganized, but is a coherent and recognizable cluster pattern of a specific and identifiable disease syndrome. As an analogy—before the nature and possible causes of Multiple Sclerosis (MS) were discovered, medical science identified MS primarily through its (unfortunately) reproducible symptoms.

Required Canadian Diagnostic Criteria for ME/CFS (in summary)

To have ME/CFS, a patient must meet all four of these criteria:

"the criteria for fatigue, post-exertional malaise and/or fatigue, sleep dysfunction, and pain" explained below
"have two or more neurological/cognitive manifestations"
"one or more symptoms from the categories of autonomic, neuroendocrine and immune manifestations"
"the illness persists for at least six months usually having a distinct onset, although it may be gradual." A "preliminary diagnosis may be possible earlier."

The definition also makes clear that the symptom criteria cannot be used as a mere template for diagnosis, but must be applied according to stated guidelines (to be summarized shortly.)

Thus, to be diagnosed the person must qualify under each and all of the following symptom categories (as qualified in the further application categories):

"Fatigue: The patient must have a significant degree of new onset, unexplained, persistent, or recurrent physical and mental fatigue that reduces activity level. Three months is appropriate for children."
"Post-exertional malaise...There is an inappropriate loss of physical and mental stamina, rapid muscular and cognitive fatigability, post-exertional malaise...and/or pain and a tendency of other associated symptoms within the patient's cluster of symptoms to worsen. There is a pathologically slow recovery period—usually 24 hours or longer."
Sleep dysfunction: There is non-restorative sleep or decline in sleep quantity or dysregulation of normal sleep rhythms.
Pain. "There is a significant degree of myalgia." The word means muscle pain, and is often the type of deep muscle pain experienced during the flu. "Pain can be experienced in the muscles/joints, and is often widespread and migratory in nature." There are often headaches of a "new type, pattern or severity".
"Neurological/Cognitive Manifestations" To qualify in this category two or more of the listed symptoms must be present. Please see the specific list of symptoms in the actual document. They are grouped into a) cognitive deficits including problems with memory, information processing, difficulties with thinking, and perceptual disturbances; and b) more classical neurological symptoms, including difficulty walking and muscle weakness; sensory hypersensitivity, including lower threshold for emotional overload.
To qualify under this category, the patient must have at least one symptom from two of the following three subcategories. Often a patient will have multiple symptoms:

a) "Autonomic Manifestations: orthostatic intolerance, neurally-mediated hypotension; postural orthostatic tachycardia; light-headedness; extreme pallor; nausea and irritable bowel syndrome; urinary frequency and bladder dysfunction; difficulty breathing upon exertion; palpitations with or without cardiac arrhythmias."

b) "Neuroendocrine Manifestations: loss of thermostatic stability—subnormal body temperature...sweating episodes, recurrent feelings of feverishness and cold extremities; intolerance of heat and cold, marked weight change—anorexia or abnormal appetite; loss of adaptability and worsening symptoms with stress."

c) "Immune Manifestations: tender lymph nodes, recurrent sore throats, recurrent flu-like symptoms, general malaise, new sensitivities to food, medications and or chemicals."

Exclusionary Conditions

The Diagnostic Protocol next provides a list of active disease processes that may explain most of the major illness symptoms. If one of these diseases is diagnosed it would likely exclude a diagnosis of ME/CFS. However, "If a confounding medical condition is under control, then the diagnosis of ME/CFS can be entertained if patients meet the criteria otherwise."

See the protocol list in the actual document for these exclusionary illnesses. They include diseases of various endocrine organs, cancers, blood diseases, deficiency diseases, known sleep disorders, and known immune, infectious, and neurological disorders.

Non-exclusionary Conditions

The protocol then provides a list of co-morbid entities—that is, illnesses that may, and often do, accompany CFS/ME. Presence of these conditions does not exclude ME/CFS. Such illnesses include fibromyalgia (FM) (as a separate, coexisting condition); irritable bowel syndrome; depression; multiple chemical sensitivities, etc.

Guidelines for using the symptom listings

The protocol next provides Guidelines for the application of the symptom listings to the patient. For instance: "The widely distributed symptoms are connected as a coherent entity through the temporal and causal relationships revealed in the history. If this coherence of symptoms is absent, the diagnosis is in doubt."

The Case Definition then includes a detailed discussion section on each of the symptom groupings and its major features. It includes a short section on features of ME/CFS in children.

Clinical Evaluation and Laboratory Testing

The next major section describes the steps in the clinical evaluation of ME/CFS (that is, how the physician proceeds to assess the patient's illness):

"Assess the total illness burden, taking a thorough history, physical examination and investigations as indicated to confirm clinical findings and to rule out other active illness processes. The patient evaluation is to be used in conjunction with the clinical definition."

The section presents a detailed protocol for the patient history and physical examination.

Finally the definition lists the Laboratory and Investigative Protocol. First is a listing of routine lab tests for general diagnostic purposes. These tests are normally given to test for infections, various deficiencies, abnormal pathophysiological processes, organ function, autoimmune disease, etc. Abnormalities could indicate exclusionary conditions.

ME/CFS often shows near normal routine lab tests; although some tests may be somewhat abnormal and thereby be a sign of ME/CFS.

The protocol then lists further specialized laboratory and other testing. This testing falls into two categories:

(a) specialized testing for other exclusionary conditions

(b) testing for further exploration of specific ME/CFS symptom complexes and pathophysiology. This testing can also be used to identify co-morbid conditions.

Specialized tests are indicated when the routine lab tests, or history/examination, indicate that testing be undertaken for other exclusionary conditions such as: infectious diseases (HIV, hepatitis, western blot for Lyme disease, parasites, TB, etc.); neurological disease (MRI for MS and cervical stenosis); specific endocrine testing; autoimmune testing; sleep studies for sleep apnea and other possible exclusionary conditions.

Specialized testing may also be done for the further exploration of ME/CFS symptom complexes and pathophysiology; and also for co-morbid conditions. The tests may be indicated by the seriousness of the symptom-complex or for possible treatment. Such tests could include: immune testing (when available); brain scans; tilt table testing for orthostatic symptoms; sleep studies for ME/CFS sleep pathology; 24-hour Holter monitoring for cardiac symptoms; and neuropsychological testing for cognitive dysfunction.

Finally, the protocol discusses in some detail the differential diagnoses between ME/CFS and fibromyalgia; and ME/CFS and psychiatric disorders.

As there are, at the present time, no clear, readily available true diagnostic markers for the illness (which would constitute a diagnostic "gold standard"), we consider the Canadian Criteria to be a "silver standard" for ME/CFS diagnosis and currently provide the most accurate diagnostic tool for ME/CFS.

More resources

1988 CDC definition

1994 CDC definition

Canadian Expert Consensus Panel Clinical Case Definition for ME/CFS

Critique of the 1994 CDC definition

History of ME/CFS/CFIDS

The Physical Basis of CFS

History of ME/CFS/CFIDS

Details: Last Updated: 30 November 2015 30 November 2015

The Disease of a Thousand Names

Some of the many names for the illness Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) over more than 100 years are:

atypical poliomyelitis, Iceland disease, Akureyi disease, Coventry disease, Tapanui flu, Otago mystery disease, Royal Free disease, Lake Tahoe mystery disease, Lyndonville chronic mononucleosis, the English disease, neuromyasthenia, neurasthenia, epidemic neuromyasthenia, myalgic encephalomyelitis, muscular rheumatism, Da Costa's syndrome, Beard's disease, Ramsey's disease, chronic fatigue syndrome, La Spasmophilie, Raggedy Ann Syndrome, post-viral fatigue syndrome, persistent viral fatigue syndrome, chronic immune activation syndrome, chronic immune dysfunction syndrome, low natural killer cell syndrome, allergic fatigue syndrome, chronic fatigue and immune dysfunction syndrome, Naxalone-reversible monocyte dysfunction syndrome, chronic Epstein-Barr virus syndrome, chronic mononucleosis-like syndrome, Yuppie flu, Yuppie plague.

In early 2015 another name was suggested in the report by the Institue of Medicine of the National Academy of Sciences: Systemic Exertional Intolerance Disease (SEID).

Early History

Possibly the earliest "modern" mention of the illness was by Thomas Sydenham, the father of English medicine, in 1681. (Some people claim the first mention of the illness in the medical literature goes back to the time of Hammurabi in Ancient Babylon.) He called it Muscular Rheumatism. The earliest mentions of ME/CFS in the more modern medical literature were in the 19^th century under the names neurasthenia, neuromyasthenia and Beard's disease. While neurasthenia was commonly considered to be a psychosomatic disorder, some descriptions of it indicate real physical symptoms and an origin after a bacterial or viral illness that strongly resembles what is now known as ME/CFS.

Early 20th Century History

This organic syndrome has also had a recent epidemiological history in other parts of the world, often in epidemic form. The first modern reported U.S. outbreak occurred in 1934 in Los Angeles County General Hospital. Another major outbreak was investigated in 1958 by Dr. Donald A. Henderson of the U.S. Centers for Disease Control and Prevention (who was renowned for his work in polio and won a Medal of Freedom in 2002 for his long-term work directing the World Health Organization's smallpox eradication campaign).

In between 1934 and 1958, there were at least twenty-three epidemic outbreaks of what mimicked ME/CFS during polio outbreaks. A number of researchers and clinicians in other nations had direct clinical experience with these cluster outbreaks. Some of these investigators were able to identify an illness of multiple symptom-complexes across a number of physiological systems and to define the illness as a coherent medical syndrome. These outbreaks occurred in the U.S., England, Iceland, Denmark, Germany, Australia, Greece and South Africa.

Origin of the name M.E.

As a result of investigations from the 1950s to the present, particularly in Canada, European countries, Australia and New Zealand, the illness in these countries became known as Myalgic Encephalomyelitis or Myalgic Encephalopathy (ME) as well as benign epidemic neuromyasthenia, neuromyasthenia, or post-viral fatigue syndrome.

The first article attempting to clarify the various outbreaks was published in the Lancet in 1956 and was further discussed in an article in the American Journal of Medicine in 1959. This line of research came from observant clinicians, including the pioneer, Dr. Melvin Ramsay, who understood the development and proliferation of a coherent disease syndrome.

Hence, the definition of the illness and its name were more directly connected to the clear physical nature of the illness. In 1988, Ramsay stated, "ME is an endemic illness which is subject to periodic epidemics."

In 1994, Dr. Dowsett, a colleague of Ramsay in Britain, developed the London Criteria for ME, which was a summation of the extensive previous work.

Origin of the name CFS—1988 Case Definition

In 1984 there was an outbreak of ME in Tapanui, New Zealand.

This was followed by outbreaks in Lyndonville, NY amongst Dr. David Bell's patients (1984-1987) after a possible retrovirus infection, and in the Lake Tahoe, Nevada area (1984-1987) amongst Drs. Paul Cheney and David Peterson's patients of what was initially characterized as chronic Epstein-Barr virus.

The Centers for Disease Control & Prevention (CDC) investigated the latter outbreak. Eventually a committee was formed to come up with a case definition of the illness. This committee was headed by Dr. G.P. Holmes of the CDC and included many others, including Dr. Anthony Komaroff of Brigham and Women's Hospital Boston, a good friend of Massachusetts CFIDS/ME & FM Association.

Oxford and 1994 Definitions

In 1991 the British invented the Oxford definition of CFS, which essentially just says the patient is tired.

In 1994, the CDC revisited the 1988 definition. Development of both CDC definitions occurred in response to a number of epidemic outbreaks in the U.S. Moreover, a number of clinicians had experienced groups of endemic cases within their practices.

Despite the careful clinical reporting which demonstrated a very similar organic pathophysiolgy of the both epidemic and endemic cases, the CDC chose to place a partially psychiatric emphasis on the illness. This bias led to the 1994 definition which was less evidence-based and more of a compromise between those who wished to characterize the illness largely as fatigue and somatization, and those who understood the illness to be primarily physical in nature.

As a compromise definition, it gave something to both views—thereby allowing for the proper diagnosis of many patients, but also for egregious misdiagnosis. Patients with psychiatric illness could be misdiagnosed as having the physical syndrome, or patients having the physical syndrome could be falsely diagnosed with psychiatric illness.

The consequences for either group of patients in obtaining either ineffectual or harmful treatment are immediately obvious.

It was during the 1990s that patients began calling the illness the Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS)—pronounced SEE-fids.

2003 Canadian Definition

The lack of clarity and accuracy of the dominant, but somewhat amorphous 1994 CDC definition led a number of the leading researchers and clinicians from the U.S. and other nations to develop and publish in 2003 a new and much more accurate case definition for the illness: Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Definition, Diagnostic and Treatment Protocols.

It draws together the most rigorous findings both from the CFS CDC-sponsored research and the ME European research. Authors include ME/CFS experts Dr. Kenny De Meirleir of Belgium and Drs. Martin Lerner, Daniel Peterson, and Nancy Klimas of the U.S., among others.

In our opinion, to date the 2003 Canadian Definition is the most medically accurate and detailed case definition available to physicians and patients. A patient and his/her physician will best determine presence of the illness using the Canadian Diagnostic Criteria.

More resources

1988 CDC Definition

1994 CDC Definition

2003 Canadian definition

Critique of the CDC Definitions

Diagnosis of ME/CFS

Details: Last Updated: 23 January 2016 23 January 2016

Why an accurate diagnosis is important

To be sick and not know what the problem is makes it impossible to know what is happening. It is like being lost without a map.
By identifying the illness, the patient will know what treatments are available and how to obtain help in coping with ME/CFS.

Symptoms

The most immediate and ongoing experience with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is its symptoms. Unlike many other illnesses,it has different symptoms that may change from day to day, week to week, and month to month. Identification of an ongoing and coherent pattern and clustering of symptoms is an important element in making a diagnosis. As a patient, it is very helpful to see and understand that the number and types and symptoms that you have are, in fact, common to other patients with ME/CFS. It has been shown recently that which symptoms predominate in a patient is influenced by how long since the illness started. It appears that the illness changes it character somewhat after some years.

Here is an extensive list of ME/CFS symptoms which has been drawn up by several international experts on the illness.

Most common ME/CFS symptoms

Exhaustion, made worse by physical exercise (100%)
Low-grade fever in early stages (60-95%)
Recurrent flu-like illness (75%)
Frequent pharyngitis (sore throats) (50-75%)
Joint and muscle pain (65%)
Severe muscle weakness (40-70%)
Stiffness (50-60%)
Post-exertional fatigue & flu-like symptoms (50-60%)
Multiple sensitivities to medicines, foods, and chemicals (40-60%)
Severe nasal & other allergies (often with worsening of previous mild allergies) (40-60%)
Frequently recurring, difficult to treat respiratory infections (40-60%)
Dyspnea (labored breathing or hunger for air) on exertion
Painful lymph nodes (especially in the neck and under arms) (30-40%)

Neurological Symptoms

Sleep disorders & unrefreshing sleep (50-90%)
Headaches (35-85%)
Visual blurring (50-60%)
Intolerance of bright lights
Parasthesias (numbness or tingling feelings) (30-50%)
Dizziness/ Lightheadedness (30-50%)
Ringing in the ears
Impaired cognition (50-85%), which may include:
- Attentional difficulties
- Calculation difficulties
- Memory disturbance
- Spatial disorientation
- Saying the wrong word

Other Symptoms

Worsening of premenstrual symptoms (70% of women)
Nocturia (excessive urination during the night) (50-60%)
Tachycardia (abnormal rapid heart action) (40-50%)
Chest pain (25-40%)
Cough (30-40%)
Weight gain (50-70%)
Nausea, especially in earlier stages (50-60%)
Diarrhea, intestinal gas or irritable bowel (50%)
Intolerance of alcohol
Night sweats (30-50%)
Dry eyes (30-40%)
Dry mouth (30-40%)
Rash (30-40%)
Frequent canker sores (30-40%)
Herpes simplex or shingles (20%)
Symptoms worsened by extremes in temperature

(Statistics compiled from data on CFS patients by: Paul Cheney MD, Anthony Komaroff MD, Charles Lapp MD, Daniel Peterson MD)

What is a syndrome?

In medicine, a "syndrome" is a set of signs and symptoms that occur together in a medical condition. For instance, AIDS is Acquired Immunodeficiency Syndrome, and until infection by the HIV virus was discovered to be the cause, diagnosis of AIDS was made solely by a collection of signs and symptoms. (In medicine, a "sign" is something that can be objectively measured by a physician and a "symptom" is something subjective experienced by a patient, such as severity of pain.)

In the early 1980s, a number of U.S. physicians noticed what seemed to be an emerging syndrome. The Centers for Disease Control and Prevention (CDC) was called in to investigate an outbreak in the Lake Tahoe, Nevada area. The CDC later convened a committee to come up with a research definition of the syndrome using signs and symptoms. This is now known as the 1988 CDC definition and the illness was named the Chronic Fatigue Syndrome (CFS).

In 1994, the CDC came up with a new research case definition, which loosened the requirements for diagnosis with ME/CFS. This is known as the 1994 CDC definition. Both definitions were intended to be used by researchers, to make sure their research subjects all had the same illness.

Unfortunately, it has been shown that the 1994 requirements were loosened too much compared to the 1988 definition, and people with other illnesses (including depression) were being mistakenly diagnosed as having ME/CFS. This has created major problems for the ME/CFS research results of the last 20 years, since in studies some of the subjects didn't have ME/CFS, but were mixed in with those who did. (See " Critique of the 1994 CDC definition " and the discussion "Are the illnesses described by the 1988 and 1994 CDC definitions the same?")

Later a Canadian, Dr. Carruthers, led an international team of clinicians to come up with a definition of ME/CFS to be used by physicians who regularly see patients. This was published in 2003 under the auspices of the Canadian Ministry of Health. This 2003 Canadian definition is what the physician authors of ME/CFS: A Primer for Clinical Practitioners as well as many other internationally known ME/CFSD clinicians suggest be used for diagnosing ME/CFS.

Diagnostic criteria for ME/CFS

What is Necessary to Receive a Correct and Accurate Diagnosis of An Illness?

Before any illness can be diagnosed, medical science must provide an accurate "case definition" for the illness—a definition that correctly describes the signs, symptoms, illness progression, pathophysiology (deleterious effects of the illness on the body), laboratory abnormalities, and known causal agents. Second, this "case definition" must distinguish the specific illness from other known illnesses—otherwise a specific illness would not be distinguishable from other illnesses, and a diagnosis of it would be impossible.

The preceding discussion is necessary because there has been much confusion and disagreement as to what the illness ME/CFS actually is. Not only is the illness known by various names, but there are several different case definitions that describe the illness somewhat differently and provide different diagnostic criteria. Because the illness first became widely identified in the mid-1980s, a number of case definitions and diagnostic criteria were developed as physicians and researchers learned more about the illness.

Because it is a syndrome and thus only diagnosed by a collection of signs and symptoms in a case definition, receiving an accurate diagnosis of ME/CFS can be difficult. A diagnosis must be obtained from a physician who is knowledgeable about the illness, knows how to rule out other illnesses that can cause similar symptoms, and can apply a case definition accurately.

In early 2015, the United States Institute of Medicine proposed another new diagnostic criteria for ME/CFS. As yet this criteria is a proposal and has not been adopted by the Federal Health Agencies, clinical physicians, and researchers. They also proposed a new name, Systemic Exertional Intolerance Disease (SEID). So far this name has not been adopted by anyone else.

As of late 2015, there are two principal diagnostic criteria used to diagnosis ME/CFS: the 2003 Canadian Definition and the 1994 Centers for Disease Control definition. In our view and that of many ME/CFS experts, the Canadian Definition is superior in accurately diagnosing the illness.

Unfortunately, the 2003 Canadian definition of ME/CFS is complex. We will give a summary below. For more detail, see the article 2003 Canadian definition and pp. 43-44 of the ME/CFS: A Primer for Clinical Practitioners. All quotations below are from the original medical paper.¹

2003 Canadian case definition of ME/CFS

The definition first requires that other illnesses which could explain a patient's symptoms be ruled out.

To have ME/CFS, a patient must meet all four of these criteria:

"the criteria for fatigue, post-exertional malaise and/or fatigue, sleep dysfunction, and pain" explained below
"have two or more neurological/cognitive manifestations"
"one or more symptoms from the categories of autonomic, neuroendocrine and immune manifestations"
"the illness persists for at least six months usually having a distinct onset, although it may be gradual." A "preliminary diagnosis may be possible earlier."

Thus, to be diagnosed the person must qualify under each and all of the following symptom categories:

"Fatigue: The patient must have a significant degree of new onset, unexplained, persistent, or recurrent physical and mental fatigue that reduces activity level. Three months is appropriate for children."

"Post-exertional malaise...There is an inappropriate loss of physical and mental stamina, rapid muscular and cognitive fatigability, post-exertional malaise...and/or pain and a tendency of other associated symptoms within the patient's cluster of symptoms to worsen. There is a pathologically slow recovery period—usually 24 hours or longer."

Sleep dysfunction: There is non-restorative sleep or decline in sleep quantity or dysregulation of normal sleep rhythms.

Pain. "There is a significant degree of myalgia." The word means muscle pain, and is often the type of deep muscle pain experienced during the flu. "Pain can be experienced in the muscles/joints, and is often widespread and migratory in nature." There are often headaches of a "new type, pattern or severity."

"Neurological/Cognitive Manifestations"—To qualify in this category two or more of the listed symptoms must be present. Please see the specific list of symptoms in the actual document. They are grouped into:
a) cognitive deficits including problems with memory, information processing, difficulties with thinking, and perceptual disturbances

b) more classical neurological symptoms, including difficulty walking and muscle weakness; sensory hypersensitivity, including lower threshold for emotional overload.

"Autonomic, Neuroendocrine and Immune Manifestations"—To qualify under this category the patient must have at least one symptom from two of the following three subcategories. Often a patient will have multiple symptoms:

a) "Autonomic Manifestations: orthostatic intolerance, neurally-mediated hypotension; postural orthostatic tachycardia; light-headedness; extreme pallor; nausea and irritable bowel syndrome; urinary frequency and bladder dysfunction; difficulty breathing upon exertion; palpitations with or without cardiac arrhythmias."

b) "Neuroendocrine Manifestations: loss of thermostatic stability—subnormal body temperature...sweating episodes, recurrent feelings of feverishness and cold extremities; intolerance of heat and cold, marked weight change—anorexia or abnormal appetite; loss of adaptability and worsening symptoms with stress."

c) "Immune Manifestations: tender lymph nodes, recurrent sore throats, recurrent flu-like symptoms, general malaise, new sensitivities to food, medications and or chemicals

Reference

1. Carruthers et al. "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Definition, Diagnostic and Treatment Protocols," Journal of Chronic Fatigue Syndrome 11, No. 1 (2003): 18-126.

ME/CFS is a serious, usually chronic, multi-systemic, physical illness

Despite what you may have heard or been told, it is essential to know that ME/CFS is a real and serious physical illness.

The international medical researchers and clinicians who have done the best and most rigorous scientific work and treated thousands of patients are in full agreement that the illness is organic and not psychologically caused. Even the Centers for Disease Control and Prevention (CDC) has finally officially endorsed this view.

ME/CFS involves pathology in multiple systems of the body including: the immune system, the neurological system including the brain, the endocrine system, the cardiovascular system, as well as other systems and organs. A list of common ME/CFS symptoms makes this abundantly clear, as well as Dr. Anthony Komaroff's article The Physical Basis of CFS.

Please note: For those people who already have ME/CFS, if new symptoms develop during the course of the illness, don't just assume that they are new or variant symptoms of ME/CFS. People with this illness can develop new illnesses that require diagnosis and treatment. So, if new symptoms are present, err on the side of caution and see a physician to rule out another illness. If s/he seems unnecessarily casual about it, seek a second opinion. Dr. Rosalind Vallings of New Zealand has warned that late diagnosis of cancer is a problem and patients need to report new symptoms and attend to having regular cancer screenings.

What causes ME/CFS?

The cause of ME/CFS is not yet known, but current research shows strong evidence of immune, neuroendocrine, and circulatory system dysfunction. Research indicates that some parts of the immune system may be in an overactive state, while other parts of the system may be in an underactive state. There is convincing evidence that viruses or persistent viral fragments are associated with ME/CFS in many cases.

The authors of ME/CFS: A Primer for Clinical Practitioners (p. 43) have this to say about causality:

"ME/CFS usually occurs as sporadic (isolated) cases, but clusters of cases have occurred worldwide. Some outbreaks have affected large
numbers of individuals in a particular community, hospital, or school. In sporadic cases, 20% of patients have another family member with the illness. These facts suggest that both genetic and environmental factors may contribute to the illness.

"ME/CFS frequently starts with acute, 'flu-like' symptoms and immune system changes found in ME/CFS are similar to immune system changes found in some viral infections. A number of infectious agents have been found more frequently in patients with ME/CFS than in the general population, but no infectious agent has been proven to be the cause.

"To avoid any possible contamination of the blood supply, patients with ME/CFS should refrain from donating blood.

"Occasionally, ME/CFS has been triggered by environmental toxins, the receipt of an immunizing injection, or surviving a
major trauma.

"Although depression and anxiety may occur secondary to the illness, research studies have shown that ME/CFS and major depressive disorder
can be distinguished by behavioral, immunological and hormonal testing.

"The Centers for Disease Control and Prevention (CDC) recognizes CFS as an organic syndrome, not a psychiatric disorder."

What is the typical course of illness for ME/CFS?

ME/CFS may last many months or years. Symptoms may vary in severity and may wax and wane. A 25-year follow-up of his patients by Dr. David Bell found that some of his patients recovered, but some of those who didn't became increasingly incapacitated. The 10+ Long-term CFS Study found that the predominant symptoms became more neurological in patients ill more than fifteen years. More recent studies have found similar results.

Research has shown that there is no "typical" course of the illness. Both of the studies above found this. However, a 2014 New York multi-site study of ME/CFS patients ill more than five years found that temporary remissions, sometimes lengthy, were common.

While there is no known cure, many of the symptoms can be treated. Some patients show improvement over time, while others may show little improvement or a worsening of symptoms. The best strategy is for a patient to accept the fact of the illness and to develop coping skills that will make the situation as tolerable as possible. It is also important not to entirely give up on life, while waiting for the illness to resolve. It might not. See the section Living with ME/CFS for coping suggestions and the section on Treatment.

Finding a physician to make a proper and accurate diagnosis of ME/CFS

To obtain a proper and accurate diagnosis of ME/CFS, patients must have a physician who is sufficiently informed about the illness to make a proper and accurate diagnosis. Ideally s/he must be familiar enough with the 2003 Canadian and the current CDC definitions to apply them capably and correctly. So not only must the physician be able to diagnose ME/CFS, s/he must be a good diagnostician in terms of making differential diagnoses of neurological, endocrine, cardiovascular, and in some cases, psychiatric illness. Hence, a general practitioner may wish to consult one or more specialists.

Because ME/CFS is an illness about which physicians are still not sufficiently educated, patients must try to educate themselves to decrease the chances of misdiagnosis.

Occasionally the physician may be fairly well informed about ME/CFS and about how to diagnose the illness. In this case, the patient may be able to receive a proper diagnosis within a reasonable period of time. Unfortunately, experience shows that many doctors, both primary care physicians (PCPs) and specialists, are not yet well-informed about the illness, and so obtaining a diagnosis may take longer and be more difficult. The same is true about treatment and management; that is, the physician may be able to diagnose ME/CFS, yet not know how to manage it.

Many PCPs will be open-minded and will be willing to learn about the illness, especially if the physician knew the patient as a healthy person. In this case, the patient can give the doctor the 2003 Canadian and/or the current CDC definition (based on the 1994 definition), along with a few other medical or informational articles. The patient must be selective in the amount of material s/he gives to the doctor, since doctors are busy.

The doctor may consult with a colleague who knows more about the illness. If a PCP is confident in his or her ability to learn about the illness, s/he may make at least a tentative diagnosis of ME/CFS. If the doctor expresses uncertainty about knowing enough about ME/CFS for diagnosing, or seems unwilling to learn more about it, then request a referral to a physician more informed about the illness.

A specialist who is unfamiliar with ME/CFS can make a misdiagnosis as well as any other physician. Such misdiagnoses can often lead to many months of difficulty and, perhaps, improper treatment. To the extent possible, it is best to avoid these discouraging and painful detours that result from misdiagnosis. (Please see the section on Differential Diagnoses, and don't be shy in providing the linked articles or printouts to either a PCP or specialist, if appropriate.)

For more tips, see our section Working with your Health Care Provider . For assistance in finding a health care provider knowledgeable about ME/CFS, please contact us by phone or email.

What to do if a doctor insists "nothing" is wrong

Unfortunately, some patients have found that a previously concerned, friendly and helpful PCP may be less than helpful with an ME/CFS diagnostic process. The same can occur with any other doctor.

After an initial work-up, the PCP may say that s/he really can't find anything wrong, that the lab tests seem to be normal, and that the patient just really needs to rest, and then can resume a normal routine.

The patient may try this but finds it impossible because of the continuing symptoms, goes back to the doctor and reiterates the symptoms. The doctor begins to sound like a broken record while telling the patient "there is really nothing wrong." Both the patient and doctor can become very frustrated with this process. However, the patient must be persistent in reporting the symptoms to the physician.

What makes the situation especially difficult is that there are definitive, objective tests that show abnormalities in ME/CFS, but they are only done in a research setting—such as testing Natural Killer cell function or the RNase-L level in cells. Standard tests done in an illness work-up usually come back "normal" in ME/CFS, or just a little "off." (See Dr. Komaroff's article " The Physical Basis of CFS. ")

The doctor may become more distant and less friendly. S/he may imply the patient isn't physically ill; may state that the patient is under too much stress or have emotional problems and s/he may refer the patient to a psychiatrist. The doctor, rather than honestly expressing a lack of understanding, may begin to insist that as a doctor, s/he is in the best position to know what is going on.

Two things may be happening. First, when a doctor can't find anything physically wrong, the default clinical position is often that the illness might well be psychiatric.

Second, some doctors are overly concerned about being in control. So rather than admitting they cannot determine what is wrong, they need to feel they can make an actual diagnosis. Thus if the doctor can find no "objective" evidence (other than the sick patient in front of him/her), then s/he may conclude that the illness is psychiatric or due to "stress".

If this is the case, then the patient will clearly have to find another doctor who is informed and experienced enough to make a careful and objective diagnosis. If the patient is finally diagnosed properly—whether the diagnosis is ME/CFS or not—then the patient will have to decide whether s/he can still work with the PCP. Perhaps, after another, better-informed doctor makes the correct diagnosis, the PCP will accept the diagnosis and be willing to again engage in a genuinely helpful patient/doctor relationship.

Some patients find that their PCP is very good for routine and other medical issues, while at the same time they see a better-informed physician for ME/CFS treatment. However, this is not the best arrangement, since ME/CFS cannot be separated from the patient's overall health. Should another illness develop, only a doctor who is keeping up with the patient's entire clinical picture is in the best position to recognize a new and separate problem.

Is there a psychiatric disorder?

One of the thornier problems in the diagnosis of ME/CFS is whether the patient has ME/CFS or a psychiatric disorder. In some cases, there can be a genuine need to make a differential diagnosis between ME/CFS and a psychiatric disorder. Here the most important diagnostic step to differentiate primary from secondary (post-illness) onset is the patient's history. If not carefully and thoroughly done, the physician may miss what is a simple but very imporant differentiation. Taking an adequate history requires more than a few minutes!

In cases where ME/CFS is already established, there can be difficult, sometimes very difficult, emotional problems coping with and living with this illness. There can be definite secondary depression or anxiety secondary to having to deal with the very real problems caused by the illness.

A properly trained mental health professional who is knowledgeable about ME/CFS can be supportive and additionally help a patient figure out ways to cope with the illness. In cases in which the patient becomes severely depressed or even suicidal, then such mental health care becomes imperative, and a physician would be negligent in not making a referral.

However, there is all too often a psychiatric referral for differential diagnosis that is made out of ignorance or for biased reasons. If the PCP is making the referral because of some real question in his/her mind of whether the illness is ME/CFS or psychiatric, the patient must carefully consider the PCP's reasoning and explanation for the referral.

If there is some genuine doubt that the patient is not physically ill or that the primary cause for physical symptoms is psychological (a rarity of cases), then proper differential diagnosis would call for a psychiatric consult—but only to a psychiatrist or psychologist who is well informed about ME/CFS.

All too often referrals to psychiatrists and other mental health professionals result in blatant misdiagnoses that can become a harmful and counter-productive problem that will take much effort to rectify. If the patient finds a psychiatric consult to be unhelpful or "psychologically-biased" concerning physical symptoms, then the patient should leave.

Make sure to see a mental health professional who is properly informed about ME/CFS. An example of such an instance might be that a patient is applying for Social Security disability and the PCP has indicated some concern that the patient suffers from depression rather than ME/CFS. Then, a properly educated mental health professional would set the record straight that the patient does in fact have ME/CFS.

For more information about the differential diagnosis of ME/CFS vs. psychiatric disorder, see our Differential Diagnosis section.

Summary of elements necessary to obtain a proper and accurate diagnosis of ME/CFS

The patient should learn as much as possible about how a proper and accurate diagnosis of ME/CFS is made: what medical Diagnostic Criteria are most accurate and in current use. (We recommend the 2003 Canadian definition.) The patient, his/her family and significant others must be in a position to evaluate if the physician is properly diagnosing the illnesses, or if a misdiagnosis is occurring. A patient cannot be his or her own doctor—not only is this impossible, it is hazardous—but an educated patient can assist the physician and be, as much as possible, a partner with him or her. This is difficult when the patient is very sick, so perhaps a family member or friend can help with this. Unfortunately, with so much misinformation about these illnesses, even among many fine doctors, the patient must be able to evaluate what is going on. Moreover, by being informed, the patient can provide the physician, when appropriate, with copies of the Diagnostic Criteria and other information on the illnesses. Many doctors who are not fully informed about the illnesses will appreciate receiving scientific and medical information that will assist them in diagnosing and treating their patients.

The patient must be able to describe his/her illness as carefully and accurately as possible to the physician—the symptoms of the illness, how severe they are, do they come and go; how did the illness begin, how does it occur from day-to-day and week-to-week. The physician needs to be able to spend the necessary time evaluating the illness and eliciting from the patient the information needed to make a careful diagnosis. It is crucial that the patient is as succinct and well-organized as possible during the visit. This requires homework before the appointment, perhaps with the assistance of a family member or friend. Without that preparation on the part of the patient, the physician can't do his/her job.

The patient needs to have a doctor who is capable of making an accurate and proper diagnosis. The physician should be sufficiently informed as to the actual nature of the illness and how the proper diagnostic criteria are correctly applied.

The patient and doctors may find it helpful to use the Activity Log in Appendix D p. 39 and the Functional Capacity Scale in Appendix C p. 38 of ME/CFS: A Primer for Clinical Practitioners.