Reframing Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Biological Basis of Disease and Recommendations for Supporting Patients
Abstract
1. Background
2. Introduction
3. Part 1: Challenging Psychological/Psychiatric Causation of Disease
3.1. Overview of Biological and Physiological Characteristics of Disease
3.2. Countering the Psychological Cause Theory
4. Part 2: Recommendations for Healthcare Providers to Reduce Stigma
4.1. Mental Health Burden of Disease
4.2. Recommendations for Providers
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A. Recent Studies Underscoring the Biological Basis of ME/CFS
Citation | Description of Research |
Walitt et al. [40] | Brain and Nervous System Abnormalities
|
Eaton-Fitch et al. [41] | Immune System Dysregulation
|
National Institutes of Health [42] | Metabolic and Mitochondrial Dysfunction
|
Xiong et al. [43] | Gut Microbiome Imbalances
|
Maksoud et al. [44] | An evaluation of studies of potential biomarkers for ME/CFS found consistent alterations of amino acid metabolism, mitochondrial function, and altered oxidative stress markers in patients, suggesting these could serve as potential diagnostic indicators. |
Rowe et al. [21] Hakim et al. [45] National Institutes of Health [42] | Study finds a higher occurrence of Ehlers-Danlos Syndrome (EDS), particularly joint hypermobility, with ME/CFS
|
Van Campen et al. [6] | Episodic Reduction in Cerebral Blood Flow With Head Tilt
|
References
- Lim, E.J.; Ahn, Y.C.; Jang, E.S.; Lee, S.W.; Lee, S.H.; Son, C.G. Systematic review and meta-analysis of the prevalence of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). J. Transl. Med. 2020, 18, 100. [Google Scholar] [CrossRef]
- Cullinan, J.; Pheby, D.F.H.; Araja, D.; Berkis, U.; Brenna, E.; de Korwin, J.D.; Gitto, L.; Hughes, D.A.; Hunter, R.M.; Trepel, D.; et al. Perceptions of European ME/CFS Experts Concerning Knowledge and Understanding of ME/CFS among Primary Care Physicians in Europe: A Report from the European ME/CFS Research Network (EUROMENE). Medicina 2021, 57, 208. [Google Scholar] [CrossRef]
- Graves, B.S.; Patel, M.; Newgent, H.; Parvathy, G.; Nasri, A.; Moxam, J.; Gill, G.S.; Sawhney, V.; Gupta, M. Chronic Fatigue Syndrome: Diagnosis, Treatment, and Future Direction. Cureus 2024, 16, e70616. [Google Scholar] [CrossRef] [PubMed]
- Sandler, C.X.; Lloyd, A.R. Chronic fatigue syndrome: Progress and possibilities. Med. J. Aust. 2020, 212, 428–433. [Google Scholar] [CrossRef] [PubMed]
- Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome; Board on the Health of Select Populations, Institute of Medicine. The National Academies Collection: Reports funded by National Institutes of Health. In Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness; National Academies Press (US): Washington, DC, USA, 2015. [Google Scholar] [CrossRef]
- van Campen, C.; Verheugt, F.W.A.; Rowe, P.C.; Visser, F.C. Cerebral blood flow is reduced in ME/CFS during head-up tilt testing even in the absence of hypotension or tachycardia: A quantitative, controlled study using Doppler echography. Clin. Neurophysiol. Pract. 2020, 5, 50–58. [Google Scholar] [CrossRef] [PubMed]
- Chu, L.; Elliott, M.; Stein, E.; Jason, L.A. Identifying and Managing Suicidality in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Healthcare 2021, 9, 629. [Google Scholar] [CrossRef]
- Bateman, L.; Darakjy, S.; Klimas, N.; Peterson, D.; Levine, S.M.; Allen, A.; Carlson, S.A.; Balbin, E.; Gottschalk, G.; March, D. Chronic fatigue syndrome and co-morbid and consequent conditions: Evidence from a multi-site clinical epidemiology study. Fatigue Biomed. Health Behav. 2015, 3, 1–15. [Google Scholar] [CrossRef]
- Strnad, M.; Rudenko, N.; Rego, R.O.M. Pathogenicity and virulence of Borrelia burgdorferi. Virulence 2023, 14, 2265015. [Google Scholar] [CrossRef]
- Greenhalgh, T.; Sivan, M.; Perlowski, A.; Nikolich, J. Long COVID: A clinical update. Lancet 2024, 404, 707–724. [Google Scholar] [CrossRef]
- Vahratian, A.; Lin, J.S.; Bertolli, J.; Unger, E.R. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome in Adults: United States, 2021–2022. NCHS Data Brief 2023, 488, 1–8. [Google Scholar]
- Jason, L.A.; Benton, M.C.; Valentine, L.; Johnson, A.; Torres-Harding, S. The economic impact of ME/CFS: Individual and societal costs. Dyn. Med. 2008, 7, 6. [Google Scholar] [CrossRef] [PubMed]
- Sweetman, E.; Noble, A.; Edgar, C.; Mackay, A.; Helliwell, A.; Vallings, R.; Ryan, M.; Tate, W. Current Research Provides Insight into the Biological Basis and Diagnostic Potential for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Diagnostics 2019, 9, 73. [Google Scholar] [CrossRef] [PubMed]
- Cairns, R.; Hotopf, M. A systematic review describing the prognosis of chronic fatigue syndrome. Occup. Med. 2005, 55, 20–31. [Google Scholar] [CrossRef] [PubMed]
- McManimen, S.; McClellan, D.; Stoothoff, J.; Gleason, K.; Jason, L.A. Dismissing chronic illness: A qualitative analysis of negative health care experiences. Health Care Women Int. 2019, 40, 241–258. [Google Scholar] [CrossRef]
- Buchwald, D.; Herrell, R.; Ashton, S.; Belcourt, M.; Schmaling, K.; Sullivan, P.; Neale, M.; Goldberg, J. A twin study of chronic fatigue. Psychosom. Med. 2001, 63, 936–943. [Google Scholar] [CrossRef]
- Sabath, D.E.; Barcy, S.; Koelle, D.M.; Zeh, J.; Ashton, S.; Buchwald, D. Cellular immunity in monozygotic twins discordant for chronic fatigue syndrome. J. Infect. Dis. 2002, 185, 828–832. [Google Scholar] [CrossRef] [PubMed]
- Sullivan, P.F.; Evengård, B.; Jacks, A.; Pedersen, N.L. Twin analyses of chronic fatigue in a Swedish national sample. Psychol. Med. 2005, 35, 1327–1336. [Google Scholar] [CrossRef] [PubMed]
- Sweetman, E.; Ryan, M.; Edgar, C.; MacKay, A.; Vallings, R.; Tate, W. Changes in the transcriptome of circulating immune cells of a New Zealand cohort with myalgic encephalomyelitis/chronic fatigue syndrome. Int. J. Immunopathol. Pharmacol. 2019, 33, 2058738418820402. [Google Scholar] [CrossRef]
- Castori, M.; Morlino, S.; Celletti, C.; Ghibellini, G.; Bruschini, M.; Grammatico, P.; Blundo, C.; Camerota, F. Re-writing the natural history of pain and related symptoms in the joint hypermobility syndrome/Ehlers-Danlos syndrome, hypermobility type. Am. J. Med. Genet. A 2013, 161, 2989–3004. [Google Scholar] [CrossRef]
- Rowe, P.C.; Barron, D.F.; Calkins, H.; Maumenee, I.H.; Tong, P.Y.; Geraghty, M.T. Orthostatic intolerance and chronic fatigue syndrome associated with Ehlers-Danlos syndrome. J. Pediatr. 1999, 135, 494–499. [Google Scholar] [CrossRef]
- Fischer, D.B.; William, A.H.; Strauss, A.C.; Unger, E.R.; Jason, L.; Marshall, G.D., Jr.; Dimitrakoff, J.D. Chronic Fatigue Syndrome: The Current Status and Future Potentials of Emerging Biomarkers. Fatigue 2014, 2, 93–109. [Google Scholar] [CrossRef] [PubMed]
- Broderick, G.; Fuite, J.; Kreitz, A.; Vernon, S.D.; Klimas, N.; Fletcher, M.A. A formal analysis of cytokine networks in chronic fatigue syndrome. Brain Behav. Immun. 2010, 24, 1209–1217. [Google Scholar] [CrossRef]
- Torres-Harding, S.; Sorenson, M.; Jason, L.A.; Maher, K.; Fletcher, M.A. Evidence for T-helper 2 shift and association with illness parameters in chronic fatigue syndrome (CFS). Bull. IACFS ME 2008, 16, 19–33. [Google Scholar] [PubMed]
- Okada, T.; Tanaka, M.; Kuratsune, H.; Watanabe, Y.; Sadato, N. Mechanisms underlying fatigue: A voxel-based morphometric study of chronic fatigue syndrome. BMC Neurol. 2004, 4, 14. [Google Scholar] [CrossRef]
- Barnden, L.R.; Crouch, B.; Kwiatek, R.; Burnet, R.; Mernone, A.; Chryssidis, S.; Scroop, G.; Del Fante, P. A brain MRI study of chronic fatigue syndrome: Evidence of brainstem dysfunction and altered homeostasis. NMR Biomed. 2011, 24, 1302–1312. [Google Scholar] [CrossRef]
- Costa, D.C.; Tannock, C.; Brostoff, J. Brainstem perfusion is impaired in chronic fatigue syndrome. QJM 1995, 88, 767–773. [Google Scholar]
- Cook, D.B.; O’Connor, P.J.; Lange, G.; Steffener, J. Functional neuroimaging correlates of mental fatigue induced by cognition among chronic fatigue syndrome patients and controls. Neuroimage 2007, 36, 108–122. [Google Scholar] [CrossRef]
- Flor-Henry, P.; Lind, J.C.; Koles, Z.J. EEG source analysis of chronic fatigue syndrome. Psychiatry Res. 2010, 181, 155–164. [Google Scholar] [CrossRef] [PubMed]
- Thoma, M.; Froehlich, L.; Hattesohl, D.B.R.; Quante, S.; Jason, L.A.; Scheibenbogen, C. Why the Psychosomatic View on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Is Inconsistent with Current Evidence and Harmful to Patients. Medicina 2023, 60, 83. [Google Scholar] [CrossRef]
- Jason, L.A.; Cotler, J.; Islam, M.F.; Sunnquist, M.; Katz, B.Z. Risks for Developing Myalgic Encephalomyelitis/Chronic Fatigue Syndrome in College Students Following Infectious Mononucleosis: A Prospective Cohort Study. Clin. Infect. Dis. 2021, 73, e3740–e3746. [Google Scholar] [CrossRef]
- König, R.S.; Paris, D.H.; Sollberger, M.; Tschopp, R. Identifying the mental health burden in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) patients in Switzerland: A pilot study. Heliyon 2024, 10, e27031. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
- Centers for Disease Control and Prevention. Resources for Medical Students. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Available online: https://www.cdc.gov/me-cfs/hcp/toolkit/resources-for-medical-students.html (accessed on 31 July 2025).
- Bae, J.; Lin, J.S. Healthcare Utilization in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Analysis of US Ambulatory Healthcare Data, 2000–2009. Front. Pediatr. 2019, 7, 185. [Google Scholar] [CrossRef] [PubMed] [PubMed Central]
- Centers for Disease Control and Prevention. ME/CFS Basics. Available online: https://www.cdc.gov/me-cfs/about/index.html (accessed on 31 July 2025).
- Sanal-Hayes, N.E.M.; McLaughlin, M.; Hayes, L.D.; Mair, J.L.; Ormerod, J.; Carless, D.; Hilliard, N.; Meach, R.; Ingram, J.; Sculthorpe, N.F. A scoping review of ‘Pacing’ for management of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Lessons learned for the long COVID pandemic. J. Transl. Med. 2023, 21, 720. [Google Scholar] [CrossRef] [PubMed]
- Visible. Available online: https://www.makevisible.com/ (accessed on 1 June 2025).
- Calm. Available online: https://www.calm.com/ (accessed on 1 June 2025).
- Headspace. Available online: https://www.headspace.com/ (accessed on 1 June 2025).
- Walitt, B.; Singh, K.; LaMunion, S.R.; Hallett, M.; Jacobson, S.; Chen, K.; Enose-Akahata, Y.; Apps, R.; Barb, J.J.; Bedard, P.; et al. Deep phenotyping of post-infectious myalgic encephalomyelitis/chronic fatigue syndrome. Nat.Commun. 2024, 15, 907. [Google Scholar] [CrossRef]
- Eaton-Fitch, N.; Rudd, P.; Er, T.; Hool, L.; Herrero, L.; Marshall-Gradisnik, S. Immune exhaustion in ME/CFS and long COVID. JCI Insight 2024, 9, e183810. [Google Scholar] [CrossRef]
- National Institutes of Health (NIH). Lesser Studied Pathologies—ME/CFS Research Roadmap Working Group. Available online: https://www.ninds.nih.gov/news-events/events/mecfs-research-roadmap-webinar-series-lesser-studied-pathologies (accessed on 1 June 2025).
- Xiong, R.; Gunter, C.; Fleming, E.; Vernon, S.D.; Bateman, L.; Unutmaz, D.; Oh, J. Multi-‘omics of gut microbiome-host interactions in short- and long-term myalgic encephalomyelitis/chronic fatigue syndrome patients. Cell Host Microbe 2023, 31, 273–287.e5. [Google Scholar] [CrossRef]
- Maksoud, R.; Magawa, C.; Eaton-Fitch, N.; Thapaliya, K.; Marshall-Gradisnik, S. Biomarkers for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS): A systematic review. BMC Med. 2023, 21, 189. [Google Scholar] [CrossRef]
- Hakim, A.; De Wandele, I.; O’Callaghan, C.; Pocinki, A.; Rowe, P. Chronic fatigue in Ehlers-Danlos syndrome-Hypermobile type. Am. J. Med. Genet. C. Semin. Med. Genet. 2017, 175, 175–180. [Google Scholar] [CrossRef]
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Agarwal, P.; Friedman, K.J. Reframing Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Biological Basis of Disease and Recommendations for Supporting Patients. Healthcare 2025, 13, 1917. https://doi.org/10.3390/healthcare13151917
Agarwal P, Friedman KJ. Reframing Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Biological Basis of Disease and Recommendations for Supporting Patients. Healthcare. 2025; 13(15):1917. https://doi.org/10.3390/healthcare13151917
Chicago/Turabian StyleAgarwal, Priya, and Kenneth J. Friedman. 2025. "Reframing Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Biological Basis of Disease and Recommendations for Supporting Patients" Healthcare 13, no. 15: 1917. https://doi.org/10.3390/healthcare13151917
APA StyleAgarwal, P., & Friedman, K. J. (2025). Reframing Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Biological Basis of Disease and Recommendations for Supporting Patients. Healthcare, 13(15), 1917. https://doi.org/10.3390/healthcare13151917