Post-exertional malaise is associated with greater symptom burden and psychological distress in patients diagnosed with Chronic Fatigue Syndrome

Marcella May, Sara F. Milrad, Dolores M. Perdomo, Sara J. Czaja, Mary Ann Fletcher, Devika R. Jutagir, Daniel L. Hall, Nancy Klimas, Michael H. Antoni

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Objective: Post-exertional malaise (PEM) is often considered a cardinal symptom of Chronic Fatigue Syndrome (CFS). There is no gold standard diagnostic method for CFS, however, and the Centers for Disease Control (CDC) Fukuda case definition does not require PEM. Research has identified differences in symptom burden between patients according to PEM, but whether it is associated with psychological distress has not been investigated. Methods: The CDC CFS Inventory, Fatigue Symptom Inventory, Profile of Mood States, Center for Epidemiologic Studies Depression Scale, Perceived Stress Scale, and subscales of the Sickness Impact Profile were administered to 261 patients diagnosed with the Fukuda criteria. PEM status (loPEM/hiPEM) was determined via self-reported post-exertional fatigue severity. Analyses of covariance (ANCOVA), controlling for age and gender, assessed cross-sectional group differences, and cross-sectional linear regressions using the continuous PEM severity predictor paralleled these analyses. Results: hiPEM patients reported greater symptom intensity, frequency, and interference than loPEM counterparts (p's < .001). hiPEM patients also reported greater social disruption, depressive symptoms, and mood disturbance (p's ≤ .011). Groups did not differ in recent negative life experiences, perceived stress, or demographic variables. The results of regression analyses mirrored those of ANCOVAs. Conclusion: This study replicates the association between PEM and symptom burden and additionally associates PEM with psychological distress; psychological distress could, however, be a consequence of symptom burden. Differences between hiPEM and loPEM CFS patients highlight the heterogeneity of diagnoses resulting from the Fukuda criteria. It is also possible that PEM identifies particularly distressed patients for whom psychological intervention would be most beneficial.

Original languageEnglish (US)
Article number109893
JournalJournal of Psychosomatic Research
StatePublished - Feb 2020


  • CDC Fukuda case definition for CFS
  • Fatigue
  • Myalgic Encephalomyelitis/Chronic Fatigue Syndrome
  • Post-exertional malaise
  • Psychological distress
  • Symptom burden

ASJC Scopus subject areas

  • Clinical Psychology
  • Psychiatry and Mental health


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