Dimensions and Assessment of Fatigue

  • Leonard A. Jason
  • Michelle Choi


In this chapter, we first review the sources of diagnostic unreliability, otherwise known as variance, which lead to disagreement among clinicians regarding diagnostic decisions. We then review issues related to the assessment of fatigue. We conclude that basic data on scale reliability are often missing, few studies provide information about the cut-off scores that identify clinical cases, and there are few direct comparisons of existing fatigue scales. Fatigue scales used in chronic fatigue syndrome (CFS) studies should have been diagnostically validated in CFS and depression samples, and should represent several factorally distinct dimensions of fatigue. In addition, fatigue scales need to give an accurate assessment of the severe fatigue that is characteristically observed among people with CFS.


Multiple Sclerosis Systemic Lupus Erythematosus Chronic Fatigue Syndrome Numerical Rating Scale Fatigue Severity Scale 
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  1. 1.
    Chaudhuri A, Behan PO (2004) Fatigue in neurological disorders. Lancet 363:978–988PubMedCrossRefGoogle Scholar
  2. 2.
    Torres-Harding S, Jason LA (2005) What is fatigue? History and epidemiology. In: DeLuca J (ed) Fatigue as a window to the brain. MIT Press, BostonGoogle Scholar
  3. 3.
    Bartsch HH, Weis J, Moser MT (2003) Cancer-related fatigue in patients attending oncological rehabilitation programs: prevalence, patterns, and predictors. Onkologie 26:51–57PubMedCrossRefGoogle Scholar
  4. 4.
    Smets EMA, Garssen B, Schuster-Uitterhoeve ALJ, de Haes JCJM (1993) Fatigue in cancer patients. Br J Cancer 68:220–224PubMedGoogle Scholar
  5. 5.
    Jacobson DL, Gange SJ, Rose NR, Graham NM (1997) Epidemiology and estimated population burden of selected autoimmune diseases in the United States. Clin Immunol Immunopathol 84:223–243PubMedCrossRefGoogle Scholar
  6. 6.
    Schwid SR, Covington M, Segal BM, Goodman AD (2002) Fatigue in multiple sclerosis: current understanding and future directions. J Rehabil Res Dev 39:211–224PubMedGoogle Scholar
  7. 7.
    Swain MG (2000) Fatigue in chronic disease. Clin Sci 99:1–8PubMedCrossRefGoogle Scholar
  8. 8.
    Jason LA, Fennell P, Taylor RR (eds) (2003) Handbook of chronic fatigue syndrome. Wiley, New YorkGoogle Scholar
  9. 9.
    Wang B, Gladman DD, Urowitz MB (1998) Fatigue in lupus is not correlated with disease activity. J Rheumatol 25:892–895PubMedGoogle Scholar
  10. 10.
    Omdal R, Waterloo K, Koldingsnes W, Husby G, Mellgren SI (2003) Fatigue in patients with systemic lupus erythematosus: the psychosocial aspects. J Rheumatol 30:283–287PubMedGoogle Scholar
  11. 11.
    Jason LA, King CP, Richman JA, Taylor RR, Torres SR, Song S (1999) US case definition of chronic fatigue syndrome: diagnostic and theoretical issues. J Chronic Fatigue Syndrome 5:3–33CrossRefGoogle Scholar
  12. 12.
    Spitzer R, Endicott J, Robins E (1975) Clinical criteria for psychiatric diagnosis and DSM-III. Am J Psychiatry 132:1187–1192PubMedGoogle Scholar
  13. 13.
    Leckliter IN, Matarazzo JD (1994) Diagnosis and classification. In: Van Hasselt VB, Hersen M (eds) Advanced Abnormal Psychology. Plenum, New York, pp 3–18Google Scholar
  14. 14.
    Garfield S (1993) Methodological problems in clinical diagnosis. In: Sutker PB, Adams HE (eds) Comprehensive handbook of psychopathology. Plenum, New YorkGoogle Scholar
  15. 15.
    American Psychiatric Association (1952) Diagnostic and statistical manual of mental disorders. American Psychiatric Association, Washington, DCGoogle Scholar
  16. 16.
    American Psychiatric Association (1968) Diagnostic and statistical manual of mental disorders, 2nd edn. American Psychiatric Association, Washington, DCGoogle Scholar
  17. 17.
    Matarazzo J (1983) The reliability of psychiatric and psychological diagnosis. In: Hooley J, Neale J, Davidson G (eds) Readings in abnormal psychology. Wiley, New York, pp 36–65Google Scholar
  18. 18.
    Helzer J, Robins L, Taibleson M, Woodruff R, Reich T, Wish E (1977) Reliability of psychiatric diagnosis. Arch Gen Psychiatry 34:129–133PubMedGoogle Scholar
  19. 19.
    Endicott J, Spitzer RL (1977) A diagnostic interview. The schedule for affective disorders and schizophrenia. Paper presented at the American Psychiatric Association, Toronto, CanadaGoogle Scholar
  20. 20.
    American Psychiatric Association. (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington, DCGoogle Scholar
  21. 21.
    First MB, Spitzer RL, Gibbon M, Williams JBW (1995) Structured clinical interview for DSM-IV axis disorders. Patient edition. Biometrics Research Department, New York State Psychiatric Institute, New YorkGoogle Scholar
  22. 22.
    Cantwell DP (1996) Classification of child and adolescent psychopathology. J Child Psychol Psychiatry 37:3–12PubMedCrossRefGoogle Scholar
  23. 23.
    Tucker G (1998) Putting DSM-IV in perspective. Am J Psychiatry 155:159–161PubMedGoogle Scholar
  24. 24.
    Kendler K, Gardner C (1998) Boundaries of major depression. An evaluation of DSM-IV criteria. Am J Psychiatry 155:172–177Google Scholar
  25. 25.
    Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A (1994) The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med 121:953–959PubMedGoogle Scholar
  26. 26.
    Hartz A, Kuhn EM, Levine PH (1998) Characteristics of fatigued persons associated with features of chronic fatigue syndrome. J Chronic Fatigue Syndrome 4:71–97CrossRefGoogle Scholar
  27. 27.
    Friedberg F, Dechene L, McKenzie M, Fontanetta R (2000) Symptom patterns in long-term chronic fatigue syndrome. J Psychosom Res 48:59–68PubMedCrossRefGoogle Scholar
  28. 28.
    Linder R, Dinser R, Wagner M, Krueger GRF, Hoffmann A (2002) Generation of classification criteria for chronic fatigue syndrome using an artificial neural network and traditional criteria set. In vivo 16:37–44PubMedGoogle Scholar
  29. 29.
    Nisenbaum R, Reyes M, Mawle AC, Reeves W (1998) Factor analysis of unexplained severe fatigue and interrelated symptoms. Am J Epidemiol 148:72–77PubMedGoogle Scholar
  30. 30.
    Haley RW, Kurt TL, Hom J (1997) Is there a Gulf War syndrome? Searching for syndromes by factor analysis of symptoms. J Am Med Assoc 277:215–222CrossRefGoogle Scholar
  31. 31.
    Hall DG, Sanders SD, Replogle WH (1994) Fatigue: a new approach to an old problem. J Miss State Med Assoc 35:155–160PubMedGoogle Scholar
  32. 32.
    Ray C, Weir RC, Cullen S, Phillips S (1992) Illness perception and symptom components in chronic fatigue syndrome. J Psychosom Res 36:243–256PubMedCrossRefGoogle Scholar
  33. 33.
    Jason LA, Taylor RR, Kennedy CL, Jordan K, Huang CF, Torres-Harding S, Song S, Johnson D (2002) A factor analysis of chronic fatigue symptoms in a community-based sample. Soc Psychiatry Psychiatric Epidemiol 37:183–189CrossRefGoogle Scholar
  34. 34.
    Reeves WC, Wagner D, Nisenbaum R, Jones JF, Gurbaxani B, Solomon L, Papanicolaou D, Unger ER, Vernon SD, Heim C (2005) Chronic fatigue syndrome: a clinical empirical approach to its definition and study. BMC Med 3: 19; doi:10.1186/1741-7015-3-19 (available at: )PubMedCrossRefGoogle Scholar
  35. 35.
    Friedberg F, Jason LA (1998) Understanding chronic fatigue syndrome: an empirical guide to assessment and treatment. American Psychological Association, Washington, DCCrossRefGoogle Scholar
  36. 36.
    Friedberg F, Jason LA (2002) Selecting a fatigue rating scale. CFS Res Rev 3:5–7, 11Google Scholar
  37. 37.
    Dittner AJ, Wessely SC, Brown RG (2004) The assessment of fatigue. A practical guide for clinicians and researchers. J Psychosom Res 56:157–170PubMedCrossRefGoogle Scholar
  38. 38.
    Miller M, Ferris D (1993) Measurement of subjective phenomena in primary care research: the visual analogue scale. Fam Pract Res J 13:15–24PubMedGoogle Scholar
  39. 39.
    Jensen M, Karoly P (1992) Self-report scales and procedures for assessing pain in adults. In: Turk D, Melzack R (eds) Handbook of Pain Assessment. Guildford Press, New YorkGoogle Scholar
  40. 40.
    Chalder T, Berelowitz G, Pawlikowsy J, Watts L, Wessely D (1993) Development of a fatigue scale. J Psychosom Res 37:147–153PubMedCrossRefGoogle Scholar
  41. 41.
    Wessely S, Powell R (1989) Fatigue syndromes: a comparison of chronic “postviral” fatigue with neuromuscular and affective disorders. J Neurol Neurosurg Psychiatry 52:940–948PubMedCrossRefGoogle Scholar
  42. 42.
    Butler S, Chalder T, Ron M, Wessely S (1991) Cognitive behavior therapy in chronic fatigue syndrome. J Neurol Neurosurg Psychiatry 54:153–158PubMedCrossRefGoogle Scholar
  43. 43.
    David AS, Pelosi A, McDonald E, Stephens D, Ledger D, Rathbone R, Mann A (1990) Tired, weak, or in need of rest: fatigue among general practice attenders. Br Med J 301:1199–1202CrossRefGoogle Scholar
  44. 44.
    Pawlikowska T, Chalder T, Hirsch SR, Wallace P, Wright DJM, Wessely SC (1994) Population-based study of fatigue and psychological distress. Br Med J 308:763–766Google Scholar
  45. 45.
    Loge JH, Ekeberg O, Kaasa S (1998) Fatigue in the general Norwegian population: normative data and associations. J Psychosom Res 45:53–65PubMedCrossRefGoogle Scholar
  46. 46.
    Jason LA, Ropacki MT, Santoro NB, Richman JA, Heatherly W, Taylor RR, Ferrari JR, Haney-Davis TM, Rademaker A, Dupuis J, Golding J, Plioplys AV, Plioplys S (1997) A screening scale for chronic fatigue syndrome: reliability and validity. J Chronic Fatigue Syndrome 3:39–59CrossRefGoogle Scholar
  47. 47.
    Morriss RK, Wearden AJ, Mullis R (1998) Exploring the validity of the Chalder fatigue scale in chronic fatigue syndrome. J Psychosom Res 45:411–417PubMedCrossRefGoogle Scholar
  48. 48.
    Ware JE, Sherbourne CD (1992) The MOS 36-item short form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30:473–483PubMedCrossRefGoogle Scholar
  49. 49.
    Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD (1989) The fatigue severity scale: application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol 46:1121–1123PubMedGoogle Scholar
  50. 50.
    Pepper CM, Krupp LB, Friedberg F, Doscher C, Coyle PK (1993) A comparison of neuropsychiatric characteristics in chronic fatigue syndrome, multiple sclerosis, and major depression. J Neuropsychiatry Clin Neurosci 5:200–205PubMedGoogle Scholar
  51. 51.
    Taylor RR, Jason LA, Torres A (2000) Fatigue rating scales: an empirical comparison. Psychol Med 30:849–856PubMedCrossRefGoogle Scholar
  52. 52.
    Vercoulen JHMM, Hommes OR, Swanink CMA, Jongen PJ, Fennis JF, Galama JM, van der Meer JW, Bleijenberg G (1996) The measurement of fatigue in patients with multiple sclerosis: a multidimensional comparison with chronic fatigue syndrome and healthy subjects. Arch Neurol 53:642–649PubMedGoogle Scholar
  53. 53.
    Beursken AJHM, Bultmann U, Kant I, Vercoulen JHMM, Bleijenberg G, Swaen GMH (2000) Fatigue among working people: validity of a questionnaire measure. Occup Environ Med 57:353–357CrossRefGoogle Scholar
  54. 54.
    Prins JB, Bleijenberg G, Bazelmans E, Elving LD, de Boo TM, Severens JL, van der Wilt GJ, Spinhoven P, van der Meer JWM, Prins JWM (2001) Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre randomised controlled trial. Lancet 357:841–847PubMedCrossRefGoogle Scholar
  55. 55.
    Koschera A, Hickie I, Hadzi-Pavlovic D, Wilson A, Lloyd A (1999) Prolonged fatigue, anxiety and depression: exploring relationships in a primary care sample. Aust N Z J Psychiatry 33:545–552PubMedCrossRefGoogle Scholar
  56. 56.
    Hickie IB, Davenport T, Hadzi-Pavlovic D, Koschera A, Naismith S, Scott EM, Wilhelm K (2001) Development of a simple screening tool for common mental disorders in general practice. Med J Aust 175:S10–S17PubMedGoogle Scholar
  57. 57.
    Bennett BK, Hickie IB, Vollmer-Conna US, Quigley B, Brennan CM, Wakefield D, Douglas MP, Hansen GR, Tahmindjis AJ, Lloyd AR (1998) The relationship between fatigue, and psychological and immunological variables in acute infectious illness. Aust N Z J Psychiatry 32:180–186PubMedCrossRefGoogle Scholar
  58. 58.
    Reeves WC, Lloyd A, Vernon SD, Klimas N, Jason L, Bleijenberg G, Evengard B, White PD, Nisenbaum R, Unger ER (2003) Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution. BMC Health Serv Res 3: 25 ( Scholar
  59. 59.
    Cartmel B, Moon T (1992) Comparison of two physical activity questionnaires, with diary for assessing physical activity in an elderly population. Clin Epidemiol 45:877–883CrossRefGoogle Scholar
  60. 60.
    Paffenbarger R, Blair S, Lee I, Hyde R (1993) Measurement of physical activity to assess health effects in free-living populations. Med Sci Sports Exercise 25:60–70CrossRefGoogle Scholar
  61. 61.
    Gerber LH, Furst G (1992) Validation of the NIH activity record. A quantitative measure of life activities. Arthritis Care Res 5:81–86PubMedCrossRefGoogle Scholar
  62. 62.
    King CP (2001) The development of a diagnostic instrument for chronic fatigue syndrome. Unpublished doctoral dissertation, DePaul University, ChicagoGoogle Scholar
  63. 63.
    Tryon WW, Williams R (1996) Fully proportional actigraphy: a new instrument. Behav Res Methods Instrum Comput 28:392–403Google Scholar
  64. 64.
    Jason LA, King CP, Frankenberry EL, Jordan KM, Tryon WW, Rademaker F, Huang C-F (1999) Chronic fatigue syndrome: assessing symptoms and activity level. J Clin Psychol 55:411–424PubMedCrossRefGoogle Scholar
  65. 65.
    Tryon WW, Jason LA, Frankenberry E, Torres-Harding S (2004) Chronic fatigue syndrome impairs circadian rhythm of activity level. Physiol Behav 82:849–853PubMedGoogle Scholar
  66. 66.
    Ohashi K, Bleijenberg G, van der Werf S, Prins J, Amaral LAN, Natelson BH, Yamamoto Y (2004) Decreased fractal correlation in diurnal physical activity in chronic fatigue syndrome. Methods Inf Med 43:26–29PubMedGoogle Scholar
  67. 67.
    Barofsky I, West Legro M (1991) Definition and measurement of fatigue. Rev Infect Dis 13: S94–S97PubMedGoogle Scholar
  68. 68.
    Cope H (1992) Fatigue: a non-specific complaint? Int Rev Psychiatry 4:273–280CrossRefGoogle Scholar
  69. 69.
    Stouten B (2005) Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution. BMC Health Serv Res 5: 37 (doi:10.1186/1472-6963-5-37)PubMedCrossRefGoogle Scholar
  70. 70.
    Ray C, Weir WRC, Phillips S, Cullen S (1992) Development of a measure of symptoms in chronic fatigue syndrome: the profile of fatigue-related symptoms (PFRS). Psychol Health 7:27–43CrossRefGoogle Scholar
  71. 71.
    Wessely S (1998) The epidemiology of chronic fatigue syndrome. Epidemiol Psychiatr Soc 7:10–24Google Scholar
  72. 72.
    Piper B, Lindsey A, Dodd M, Ferketich S, Paul S (1989) The development of an instrument to measure the subjective dimension of fatigue. In: Funk S, Tornquist E, Champagne M, Copp L, Wiese R (eds) Key aspects of comfort: management of pain, fatigue, and nausea. Springer, New York, pp 199–207Google Scholar
  73. 73.
    Lee KA, Hicks G, Nino-Murcia G (1991) Validity and reliability of a scale to assess fatigue. Psychiatry Res 36:291–298PubMedCrossRefGoogle Scholar
  74. 74.
    Rhoten D (1982) Fatigue and the post-surgical patient. In: Norris DM (ed) Concept clarification in nursing. Aspen, Rockville, pp 277–300Google Scholar
  75. 75.
    Vercoulen JHMM, Swanink CMA, Fennis JFM, Galama JMD, van der Meer JWM, Bleijenberg G (1994) Dimensional assessment of chronic fatigue syndrome. J Psychosom Res 38:383–392PubMedCrossRefGoogle Scholar
  76. 76.
    Schwartz JE, Jandorf L, Krupp LB (1993) The measurement of fatigue: a new instrument. J Psychosom Res 37:753–762PubMedCrossRefGoogle Scholar
  77. 77.
    Belza B, Henke C, Yelin E, Epstein W, Gillis C (1993) Correlates of fatigue in older adults with rheumatoid arthritis. Nurs Res 42:93–99PubMedCrossRefGoogle Scholar
  78. 78.
    Fisk JD, Ritvo PG, Ross L, Haase DA, Marrie TJ, Schlech WF (1994) Measuring the functional impact of fatigue: initial validation of the fatigue impact scale. Clin Infect Dis 18(Suppl 1):S79–83PubMedGoogle Scholar
  79. 79.
    Smets EMA, Garssen B, Bonk B, Haes JCJM (1995) The multi-dimensional fatigue inventory (MFI): psychometric qualities of an instrument to assess fatigue. J Psychosom Res 39:315–325PubMedCrossRefGoogle Scholar
  80. 80.
    McNair D, Lorr R, Droppleman L (1992) Edits manual for the Profile of Mood States. Educational and Industrial Testing Services, San DiegoGoogle Scholar

Copyright information

© Springer 2008

Authors and Affiliations

  • Leonard A. Jason
    • 1
  • Michelle Choi
    • 1
  1. 1.Center for Community ResearchDePaul UniversityChicagoUSA

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