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(ME/CFS) and Sickness Behavior Gerwyn Morris1, George Anderson2, Piotr Galecki3, Michael Berk4,5,6,7,8 and Michael Maes4,9*

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(ME/CFS) and Sickness Behavior Gerwyn Morris1, George Anderson2, Piotr Galecki3, Michael Berk4,5,6,7,8 and Michael Maes4,9* Morris et al. BMC Medicine 2013, 11:64 http://www.biomedcentral.com/1741-7015/11/64 REVIEW Open Access A narrative review on the similarities and dissimilarities between myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and sickness behavior Gerwyn Morris1, George Anderson2, Piotr Galecki3, Michael Berk4,5,6,7,8 and Michael Maes4,9* Introduction Abstract Humans and animals use a range of autonomic, meta- It is of importance whether myalgic bolic and behavioral responses to combat acute infections encephalomyelitis/chronic fatigue syndrome (ME/CFS) or injuries. Sickness behavior is a physiological behavioral is a variant of sickness behavior. The latter is induced response principally induced and regulated by proinflam- by acute infections/injury being principally mediated matory cytokines, including interleukin 1b (IL-1b), IL-6 through proinflammatory cytokines. Sickness is a and tumor necrosis factor (TNF)a, which act centrally to beneficial behavioral response that serves to enhance induce sickness behaviors, including pyrexia. Proinflam- recovery, conserves energy and plays a role in the matory cytokines modify the activity of hypothalamic resolution of inflammation. There are behavioral/ neurons causing an increase of the thermoregulatory set symptomatic similarities (for example, fatigue, malaise, point [1]. In addition, animals and humans display symp- hyperalgesia) and dissimilarities (gastrointestinal toms such as fatigue, malaise, hyperalgesia, neurocogni- symptoms, anorexia and weight loss) between tive disorders, sleepiness, anhedonia, anorexia and weight sickness and ME/CFS. While sickness is an adaptive loss, as well as diminished food intake, social activities, response induced by proinflammatory cytokines, ME/ locomotor activity, grooming and exploration [2,3]. Sick- CFS is a chronic, disabling disorder, where the ness behaviors are viewed as adaptive responses, which pathophysiology is related to activation of facilitate recovery from acute infections or injuries [2,3]. immunoinflammatory and oxidative pathways and Sickness behaviors, including fever, are postulated to autoimmune responses. While sickness behavior is a offer a survival benefit in endothermic and ectothermic state of energy conservation, which plays a role in vertebrates [4]. The sickness response is conserved by combating pathogens, ME/CFS is a chronic disease evolution and has an adaptive function in enabling survi- underpinned by a state of energy depletion. While val of individuals and species in the face of assault by a sickness is an acute response to infection/injury, the myriad of microbial pathogens and injuries [5]. Stereoty- trigger factors in ME/CFS are less well defined and pical patterns of sickness are displayed by mammals, encompass acute and chronic infections, as well as birds, reptiles and even invertebrates [6]. In summary, inflammatory or autoimmune diseases. It is concluded (a) this proinflammatory cytokine-induced sickness that sickness behavior and ME/CFS are two different response is short lasting, evolutionarily conserved, and conditions. beneficial to the organism; and (b) many of the sickness Keywords: CFS, chronic fatigue, depression, inflam- behaviors are valuable in conserving energy and therefore mation, ME, oxidative stress, sickness behavior to combat and attenuate the inflammatory response caused by infections or inflammatory trauma [3,7]. Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a disabling disorder that can have a greater * Correspondence: [email protected] impact on functional status and well-being than many 4Barwon Health, School of Medicine, Deakin University, PO Box 291, Geelong, other chronic, life-threatening diseases [8,9]. ME/CFS 3220, Australia is associated with a dramatic decrement in physical Full list of author information is available at the end of the article © 2013 Morris et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Morris et al. BMC Medicine 2013, 11:64 Page 2 of 19 http://www.biomedcentral.com/1741-7015/11/64 functioning [10] with patients scoring significantly lower and themselves being driven by, inflammatory and related on most of the eight Medical Outcome Study (MOS) pathways, providing a more parsimonious explanation 36-item Short-Form (SF-36) health survey subscales based on biological underpinnings [17]. when compared with patients with cardiovascular and In the present work, we review: (a) the phenomenologi- neurological disorders, as well as higher on depression cal similarities and dissimilarities between sickness beha- measures [8]. Typical symptoms of ME/CFS are: physi- vior and ME/CFS, (b) the course of sickness behavior cal and mental fatigue, pain, muscle weakness, neuro- versus ME/CFS, (c) the immunoinflammatory-related cognitive impairment, sleep disturbances, depression, pathways that underpin or may discriminate both sickness gastrointestinal symptoms, a subjective feeling of infec- and ME/CFS, and (d) the differences in etiologic factors tion or a flu-like malaise and post-exertion fatigue or that trigger both conditions. malaise [11,12]. Thus, there are important behavioral/symptomatic Phenomenological similarities between sickness similarities between both ME/CFS and sickness behavior. behavior and ME/CFS Moreover, activated immunoinflammatory pathways play Symptoms typical of sickness behavior are described a role in the pathophysiology of ME/CFS, for example, above. The phenomenological experience of acute viral or increased proinflammatory cytokine levels [13]. As such, bacterial infection involves malaise, a lack of motivation or both sickness behavior and ME/CFS share common phe- lassitude, with accompanying fatigue bordering on exha- nomenological and biochemical aspects. These findings ustion. Other responses include numbness, shivering, led some authors to conclude that ME/CFS and sickness impaired appetite and weight loss, as well as aches and behaviors are a manifestation of a common pathophysiol- pains in muscles and joints [3]. ogy with other neurophysiological mechanisms of sick- Table 1 summarizes the similarities and dissimilarities ness behavior being similarly extrapolated to ME/CFS between sickness behavior and ME/CFS. People with and related conditions [14]. Other authors maintain that ME/CFS have a wide range of classically conceptualized ME/CFS is fundamentally a more chronic version of psychosomatic, but recently reframed physiosomatic, acute sickness behavior [15]. The latter authors in fact symptoms [11-13]. Typical symptoms include fatigue and change the meaning of the term sickness behavior and chronic exhaustion. These symptoms include unrelenting usethetermtodescribeasituationwherethesickness severe disabling mental and physical fatigue combined behavioral complex and the inflammatory condition per- with disabling levels of muscle fatiguability. Hyperalgesia, sist. This situation should then be recognized as persis- muscle pain and tension, migraine type headaches, tent sickness behavior or ME/CFS. insomnia, hypersomnia, non-refreshing sleep or sleep A further confounding factor is the diagnosis and sub- wake cycle reversal are typical symptoms of ME/CFS. typing of ME/CFS. There are different diagnostic criteria Problems with memory retrieval can manifest as an used to make the diagnosis of ME/CFS, generating consid- inability to finish sentences, negatively feeding back on erable controversy. According to a commonly used diag- self-esteem and subjective wellbeing. These symptoms nostic classification for ME/CFS, Fukuda’s criteria [16], are exacerbated by cognitive and or physical activity. ME/CFS is accompanied by chronic fatigue lasting for Intolerance to even trivial increases in physical or mental more than 6 months and at least four additional symptoms activity above individual norms is the hallmark symptom (sore throat, tender lymph nodes, neurocognitive disor- of ME [10-12,17,18]. This intolerance manifests itself as ders, multiple joint pain, muscle pain, headache, non- marked worsening of symptoms that may be short lived refreshing sleep or post-exertion malaise (PEM) lasting or prolonged (sometimes weeks) but only rarely resulting more than 24 h). The diagnosis of ME/CFS according to in permanent disability [10,11]. Post-exertion malaise Fukuda’s criteria, however, defines a heterogeneous group indicates the intense malaise, exhaustion or neurocogni- of patients [11]. Recently, we have provided evidence sug- tive symptoms following physical or mental activities and gesting that ME/CFS patients should be divided into those lasting for more than 24 h. This typical symptom in ME with and without post-exertion malaise into ME and CFS, corresponds with the fatigue and exhaustion behaviors respectively. Doing so, it was defined that ME and CFS are expressed during sickness behavior. qualitatively distinct diagnostic classes [11]. Malaise, a key aspect of sickness behavior, is also a Another major confound is the common perspective major feature of ME/CFS. Many individuals with ME/CFS within psychosocial psychiatry to consider ME/CFS as a display symptoms normally associated with severe influ- condition triggered by excessive rest in predisposed indivi- enza, for example, including a flu-like malaise or the sub- duals following acute
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