Anorexia and eating disorders: Difference between revisions

From MEpedia, a crowd-sourced encyclopedia of ME and CFS science and history
(→‎Anorexia and ME/CFS: move into to Anorexia appetite loss page)
(fix cat, c/e Byron Hyde, add links, add refs, exclusion)
Line 1: Line 1:
'''Anorexia nervosa''' is a [[:Category:Mental disorders|mental and behavioral disorder]] involving refusing or reducing food, distorted thoughts around eating or body weight for example fear of getting "fat" when underweight, and/or other thoughts and behaviors that lead to sufferer being significantly underweight.<ref name="neda-anorexia">{{Cite web|url=https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia|title=Anorexia Nervosa|date=2017-02-25|website=National Eating Disorders Association|language=en|access-date=2019-02-25}}</ref><ref name="mayo-anorexia">{{Cite web|url=https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-20353591|title=Anorexia nervosa - Symptoms and causes|website=Mayo Clinic|language=en|access-date=2019-02-25}}</ref><ref name="MosbyDictionary">{{Cite book|title=Mosby's Dictionary of Medicine, Nursing and Health Professions|pages=102|isbn=978-0-7295-8691-7|edition=Revised 3rd Anz|volume=|language=en|title-link=|url=https://books.google.co.uk/books?id=z46ADwAAQBAJ&newbks=0&lpg=PA102&dq=anorexia%20appetite%20loss%20intitle:dictionary&pg=PA102#v=onepage&q&f=true|access-date=|date=2018|publisher=Elsevier Health Sciences|editor-last=Harris|editor-first=Peter|editor-link=|editor-last2=Nagy|editor-first2=Sue|editor-link2=|editor-last3=Vardaxis|editor-first3=editor-Nicholas|editor-link3=|veditors=|others=|doi=|oclc=|quote=|archive-url=|archive-date=|publisher=Elsevier |location=Australia}}</ref>
'''Anorexia nervosa''' is a [[:Category:Mental disorders|mental and behavioral disorder]] involving refusing or reducing food, distorted thoughts around eating or body weight for example fear of getting "fat" when underweight, and/or other thoughts and behaviors that lead to sufferer being significantly underweight.<ref name="neda-anorexia">{{Cite web|url=https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia|title=Anorexia Nervosa|date=2017-02-25|website=National Eating Disorders Association|language=en|access-date=2019-02-25}}</ref><ref name="mayo-anorexia">{{Cite web|url=https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-20353591|title=Anorexia nervosa - Symptoms and causes|website=Mayo Clinic|language=en|access-date=2019-02-25}}</ref><ref name="MosbyDictionary">{{Cite book|title=Mosby's Dictionary of Medicine, Nursing and Health Professions|pages=102|isbn=978-0-7295-8691-7|edition=Revised 3rd Anz|volume=|language=en|title-link=|url=https://books.google.co.uk/books?id=z46ADwAAQBAJ&newbks=0&lpg=PA102&dq=anorexia%20appetite%20loss%20intitle:dictionary&pg=PA102#v=onepage&q&f=true|access-date=|date=2018|publisher=Elsevier Health Sciences|editor-last=Harris|editor-first=Peter|editor-link=|editor-last2=Nagy|editor-first2=Sue|editor-link2=|editor-last3=Vardaxis|editor-first3=editor-Nicholas|editor-link3=|veditors=|others=|doi=|oclc=|quote=|archive-url=|archive-date= |location=Australia}}</ref>


Other eating disorders include:
Other eating disorders include:
Line 9: Line 9:


{{See also description|1=appetite loss causing an inability to eat, caused by a physical illness|2=Anorexia (appetite loss)}}
{{See also description|1=appetite loss causing an inability to eat, caused by a physical illness|2=Anorexia (appetite loss)}}
==Signs and symptoms ==
==Treatment ==
==Exclusion in ME/CFS diagnostic criteria==
Eating disorders including anorexia nervosa can be extremely [[fatigue|fatiguing]], as can morbid obesity without an eating disorder. A pre-existing diagnosis of anorexia nervosa means that ME/CFS cannot be diagnosed, although an eating disorder could develop after onset of ME/CFS.<ref name="ICC2011primer">{{citation
| last1 = Carruthers | first1 = BM | authorlink1 = Bruce Carruthers
| last2 = van de Sande | first2 = MI | authorlink2 = Marjorie van de Sande
| last3 = De Meirleir | first3 = KL | authorlink3 = Kenny de Meirleir
| last4 = Klimas | first4 = NG | authorlink4 = Nancy Klimas
| last5 = Broderick | first5 = G | authorlink5 = Gordon Broderick
| last6 = Mitchell | first6 = T | authorlink6 = Terry Mitchell
| last7 = Staines | first7 = D | authorlink7 = Donald Staines
| last8 = Powles | first8 = ACP | authorlink8 = A C Peter Powles
| last9 = Speight | first9 = N | authorlink9 = Nigel Speight
| last10 = Vallings | first10= R | authorlink10= Rosamund Vallings
| last11 = Bateman | first11= L | authorlink11= Lucinda Bateman
| last12 = Bell | first12= DS | authorlink12= David Bell
| last13 = Carlo-Stella | first13= N | authorlink13= Nicoletta Carlo-Stella
| last14 = Chia | first14= J | authorlink14= John Chia
| last15 = Darragh | first15= A | authorlink15= Austin Darragh
| last16 = Gerken | first16= A | authorlink16= Anne Gerken
| last17 = Jo | first17= D | authorlink17= Daehyun Jo
| last18 = Lewis | first18= DP | authorlink18= Donald Lewis
| last19 = Light | first19= AR | authorlink19= Alan Light
| last20 = Light | first20= KC | authorlink20= Kathleen Light
| last21 = Marshall-Gradisnik | first21= S | authorlink21= Sonya Marshall-Gradisnik
| last22 = McLaren-Howard | first22= J | authorlink22= John McLaren-Howard
| last23 = Mena | first23= I | authorlink23= Ismael Mena
| last24 = Miwa | first24= K | authorlink24= Kunihisa Miwa
| last25 = Murovska | first25= M | authorlink25= Modra Murovska
| last26 = Stevens | first26= SR | authorlink26= Staci Stevens
| title = Myalgic encephalomyelitis: Adult & Paediatric: International Consensus Primer for Medical Practitioners
| date = 2012| isbn = 978-0-9739335-3-6
| url = http://www.investinme.org/Documents/Guidelines/Myalgic%20Encephalomyelitis%20International%20Consensus%20Primer%20-2012-11-26.pdf
}}</ref><ref name="canadianconsensus">{{Citation
| last1  = Carruthers    | first1 = Bruce M.      | authorlink1 = Bruce Carruthers
| last2  = Jain          | first2 = Anil Kumar    | authorlink2 = Anil Kumar Jain
| last3  = De Meirleir  | first3 = Kenny L.      | authorlink3 = Kenny De Meirleir
| last4  = Peterson      | first4 = Daniel L.    | authorlink4 = Daniel Peterson
| last5  = Klimas        | first5 = Nancy G.      | authorlink5 = Nancy Klimas
| last6  = Lerner        | first6 = A. Martin    | authorlink6 = Martin Lerner
| last7  = Bested        | first7 = Alison C.    | authorlink7 = Alison Bested
| last8  = Flor-Henry    | first8 = Pierre        | authorlink8 = Pierre Flor-Henry
| last9  = Joshi        | first9 = Pradip        | authorlink9 = Pradip Joshi
| last10  = Powles        | first10 = A C Peter    | authorlink10 = A C Peter Powles
| last11  = Sherkey      | first11 = Jeffrey A.  | authorlink11 = Jeffrey Sherkey
| last12  = van de Sande  | first12 = Marjorie I.  | authorlink12 = Marjorie van de Sande| title  = Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols
| journal = Journal of Chronic Fatigue Syndrome | volume = 11 | issue = 2 | page = 7-115| date    = 2003| pmid    = | doi    = 10.1300/J092v11n01_02
| url    = http://www.investinme.org/Documents/PDFdocuments/CanadianDefinitionME-CFS.pdf
}}</ref><ref name="fukuda1994">{{Cite journal|last=Fukuda|first=K.|author-link=Keiji Fukuda|last2=Straus|first2=S. E.|author-link2=Stephen Straus|last3=Hickie|first3=I.|author-link3=Ian Hickie|last4=Sharpe|first4=M. C.|author-link4=Michael Sharpe|last5=Dobbins|first5=J. G.|author-link5=James Dobbins|last6=Komaroff|first6=A.|author-link6=Anthony Komaroff|date=1994-12-15|title=The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group|url=https://www.researchgate.net/profile/Michael_Sharpe2/publication/247808895_The_Chronic_Fatigue_Syndrome_A_Comprehensive_Approach_to_Its_Definition_and_Study/links/0c96053201643bfc4b000000/The-Chronic-Fatigue-Syndrome-A-Comprehensive-Approach-to-Its-Definition-and-Study.pdf|journal=Annals of Internal Medicine|volume=121|issue=12|pages=953–959|issn=0003-4819|pmid=7978722|via=|publisher=American College of Physicians}}</ref><ref name="CDC-SEID">{{Cite web|url=https://www.cdc.gov/me-cfs/healthcare-providers/diagnosis/iom-2015-diagnostic-criteria.html|title=Systemic Exertional Intolerance Disease|website=[[Centers for Disease Control]]|last=Institute of Medicine|access-date =2021-02-24}}</ref>


==<span id="anorexianervosa">Anorexia and ME/CFS</span> ==
==<span id="anorexianervosa">Anorexia and ME/CFS</span> ==
Anorexia nervosa and eating disorders are not common in people with [[ME/CFS]].[[Anorexia (appetite loss)|Anorexia (appetite loss or abnormal appetite)]] is listed as a possible ''neuroendocrine'' symptom in the [[Canadian Consensus Criteria]] for [[ME/CFS]].<ref name="CCC"/>
Anorexia nervosa and eating disorders are not common in people with [[ME/CFS]]. The ''symptom'' [[Anorexia (appetite loss)|anorexia (appetite loss or abnormal appetite)]] is listed as a possible ''neuroendocrine'' of ME/CFS in the [[Canadian Consensus Criteria]] for [[ME/CFS]].<ref name="canadianconsensus"/>


==Children and "refusal" to eat ==
==Children and "refusal" to eat ==


Some parents have reported that their child’s swallowing difficulties or vomiting have resulted in medical professionals interpreting these ME/CFS as an indicator of a mental disorder, for example some children originally diagnosed with [[chronic fatigue syndrome]] have had their diagnosis changed to [[Pervasive Refusal Syndrome]] because they were wrongly judged as "refusing" to eat, wash, or increase their activity levels.<ref>https://www.dailykos.com/stories/2018/10/10/1803351/-Karina-Hansen-is-FREE</ref><ref name=":0" />
Some parents have reported that their child’s swallowing difficulties or vomiting have resulted in medical professionals interpreting these ME/CFS as an indicator of a mental disorder, for example some children originally diagnosed with [[chronic fatigue syndrome]] have had their diagnosis changed to [[Pervasive Refusal Syndrome]] because they were wrongly judged as "refusing" to eat, wash, or increase their activity levels.<ref name="kos">https://www.dailykos.com/stories/2018/10/10/1803351/-Karina-Hansen-is-FREE</ref>


{{Quote frame |text=Our son’s main symptom was dizziness / orthostatic intolerance and abnormal gait which he adopted because of his dizziness. We were told that as neurological examination was normal there must be a psychological element to his problems (this was from a very eminent Consultant Paediatric Neurologist).
{{Quote frame |text=Our son’s main symptom was dizziness / orthostatic intolerance and abnormal gait which he adopted because of his dizziness. We were told that as neurological examination was normal there must be a psychological element to his problems (this was from a very eminent Consultant Paediatric Neurologist).
When we finally had to give in and admit him to hospital he was too weak to swallow his own saliva and had lost 20% of his body weight. Within 24 hours of admission he developed myoclonic jerks. We were asked whether he had a negative body image (ie was he anorexic) and whether we thought he was ‘putting on’ the muscle jerks.
When we finally had to give in and admit him to hospital he was too weak to swallow his own saliva and had lost 20% of his body weight. Within 24 hours of admission he developed myoclonic jerks. We were asked whether he had a negative body image (ie was he anorexic) and whether we thought he was ‘putting on’ the [[myoclonus|muscle jerks]].
HELP! Please educate the Doctors and Nurses.|author =From a family outside Essex, [[UK]]|source=Our needs, our lives (2003)<ref name ="ourneedsourlives"/>}}
HELP! Please educate the Doctors and Nurses.|author =From a family outside Essex, [[UK]]|source=Our needs, our lives (2003)<ref name ="ourneedsourlives"/>}}


Line 30: Line 81:
[[Merryn Crofts]] was bedbound and unable to eat when she died of [[Severe and very severe ME|very severe ME]]. Merryn weighed six stone (84 lbs) at her death but did not have an eating disorder, she had severe [[digestive problems|gastrointestinal symptoms]] causing weight loss. Merryn's autopsy revealed [[Dorsal root ganglia|ganglia]] [[inflammation]]. It is suspected that in the later years of her illness Merryn also suffered from [[Ehlers-Danlos syndrome|EDS]] and [[Mast cell activation disorder|MCAD]]. Her death certificate is the second in the [[United Kingdom|UK]] publicly known to have been attributed to ME.{{Citation needed|date=February 2021}}
[[Merryn Crofts]] was bedbound and unable to eat when she died of [[Severe and very severe ME|very severe ME]]. Merryn weighed six stone (84 lbs) at her death but did not have an eating disorder, she had severe [[digestive problems|gastrointestinal symptoms]] causing weight loss. Merryn's autopsy revealed [[Dorsal root ganglia|ganglia]] [[inflammation]]. It is suspected that in the later years of her illness Merryn also suffered from [[Ehlers-Danlos syndrome|EDS]] and [[Mast cell activation disorder|MCAD]]. Her death certificate is the second in the [[United Kingdom|UK]] publicly known to have been attributed to ME.{{Citation needed|date=February 2021}}


Anorexia is recognized as a possible symptom in the [[Canadian Consensus Criteria]] for ME, but is not regarded as a diagnostic symptom.<ref name="canadianconsensus" /> A number of patient groups have raised concerns that anorexia may be a misdiagnosis in some patients with ME, particularly children or young people, and the [[Severe and very severe ME|severely ill]].<ref name=":0" />
Anorexia is recognized as a possible symptom in the [[Canadian Consensus Criteria]] for ME, but is not regarded as a diagnostic symptom.<ref name="canadianconsensus" /> A number of patient groups have raised concerns that anorexia may be a misdiagnosis in some patients with ME, particularly children or young people, and the [[Severe and very severe ME|severely ill]].<ref name="kos" />


[[Digestive problems|Digestive symptoms]] problems are well recognized, particularly [[irritable bowel syndrome]], and [[Food sensitivities|food intolerances]], and are optional diagnostic criteria. Common ME/CFS symptoms which may cause changes in eating or weight include:
[[Digestive problems|Digestive symptoms]] problems are well recognized, particularly [[irritable bowel syndrome]], and [[Food sensitivities|food intolerances]], and are optional diagnostic criteria. Common ME/CFS symptoms which may cause changes in eating or weight include:
Line 43: Line 94:
There do not appear to be any significant studies assessing swallowing or eating issues in patients with ME/CFS, or investigating the presence of comorbid eating disorders, or the potential misdiagnosing of eating disorders, although there are many different accounts from patients or their carers/parents.
There do not appear to be any significant studies assessing swallowing or eating issues in patients with ME/CFS, or investigating the presence of comorbid eating disorders, or the potential misdiagnosing of eating disorders, although there are many different accounts from patients or their carers/parents.


Byron and Hyde have started that enteroviruses may disrupt swallowing reflexes.<ref name="swallowing" />
[[Byron Hyde]] has started that enteroviruses may disrupt swallowing reflexes in ME/CFS.<ref name="swallowing" />
 
==Possible causes==


==See also==
==See also==
* [[Mental illness]]
* [[Ethical issues]]
* [[Ethical issues]]
* [[Psychologization]]
* [[Pervasive Refusal Syndrome]]
* [[Pervasive Refusal Syndrome]]
* [[dysphagia]] - swallowing difficulties
* [[Dysphagia]] - swallowing difficulties
* [[Anorexia (appetite loss)]] - symptom of a medical illness
* [[Digestive problems]]


==Learn more==
==Learn more==
Line 56: Line 109:


*[https://www.tymestrust.org/pdfs/metheillness.pdf ME - The Illness and Common Misconceptions: Abuse, Neglect, Mental Incapacity. A summary originally produced for the legal profession] - [[Tymes Trust]]  
*[https://www.tymestrust.org/pdfs/metheillness.pdf ME - The Illness and Common Misconceptions: Abuse, Neglect, Mental Incapacity. A summary originally produced for the legal profession] - [[Tymes Trust]]  
*Wikipedia


==References==
==References==
Line 65: Line 117:
[[Category:Diagnoses]]
[[Category:Diagnoses]]
[[Category:Potential comorbidities]]
[[Category:Potential comorbidities]]
[[Category:Psychological signs and symptoms]]
[[Category:Signs and symptoms]]
[[Category:Endocrine signs and symptoms]]

Revision as of 14:14, February 24, 2021

Anorexia nervosa is a mental and behavioral disorder involving refusing or reducing food, distorted thoughts around eating or body weight for example fear of getting "fat" when underweight, and/or other thoughts and behaviors that lead to sufferer being significantly underweight.[1][2][3]

Other eating disorders include:

  • bulimia nervosa, which involves intentional vomiting or purging food to avoid weight gain[4][5];
  • binge eating disorder,[6][7]
  • orthorexia: eating an extremely restricted diet based on fear of eating "unhealthy" foods),[8][9][10] and
  • other specified feeding or eating disorder (OSFED).[11]


Signs and symptoms[edit | edit source]

Treatment[edit | edit source]

Exclusion in ME/CFS diagnostic criteria[edit | edit source]

Eating disorders including anorexia nervosa can be extremely fatiguing, as can morbid obesity without an eating disorder. A pre-existing diagnosis of anorexia nervosa means that ME/CFS cannot be diagnosed, although an eating disorder could develop after onset of ME/CFS.[12][13][14][15]

Anorexia and ME/CFS[edit | edit source]

Anorexia nervosa and eating disorders are not common in people with ME/CFS. The symptom anorexia (appetite loss or abnormal appetite) is listed as a possible neuroendocrine of ME/CFS in the Canadian Consensus Criteria for ME/CFS.[13]

Children and "refusal" to eat[edit | edit source]

Some parents have reported that their child’s swallowing difficulties or vomiting have resulted in medical professionals interpreting these ME/CFS as an indicator of a mental disorder, for example some children originally diagnosed with chronic fatigue syndrome have had their diagnosis changed to Pervasive Refusal Syndrome because they were wrongly judged as "refusing" to eat, wash, or increase their activity levels.[16]

Our son’s main symptom was dizziness / orthostatic intolerance and abnormal gait which he adopted because of his dizziness. We were told that as neurological examination was normal there must be a psychological element to his problems (this was from a very eminent Consultant Paediatric Neurologist).

When we finally had to give in and admit him to hospital he was too weak to swallow his own saliva and had lost 20% of his body weight. Within 24 hours of admission he developed myoclonic jerks. We were asked whether he had a negative body image (ie was he anorexic) and whether we thought he was ‘putting on’ the muscle jerks. HELP! Please educate the Doctors and Nurses.

— From a family outside Essex, UK, Our needs, our lives (2003)[17]

Prevalence[edit | edit source]

Unknown.

Symptom recognition[edit | edit source]

Whitney Dafoe is an American photographer who has very severe ME, which causes him very severe gastrointestinal symptoms, because of this he is tube fed and remain severely underweight. Whitney can no longer speak, eat, or have contact with anyone but his parents due to visual dysfunction and very severe ME. Whitney was previously misdiagnosed with the eating disorder anorexia, which resulted in him being refused the surgery needing for a feeding tube and in-patient psychiatric care recommended instead. Whitney is now fed via a PEG, is still unable to even drink water, and he needs full time care.[citation needed]

Merryn Crofts was bedbound and unable to eat when she died of very severe ME. Merryn weighed six stone (84 lbs) at her death but did not have an eating disorder, she had severe gastrointestinal symptoms causing weight loss. Merryn's autopsy revealed ganglia inflammation. It is suspected that in the later years of her illness Merryn also suffered from EDS and MCAD. Her death certificate is the second in the UK publicly known to have been attributed to ME.[citation needed]

Anorexia is recognized as a possible symptom in the Canadian Consensus Criteria for ME, but is not regarded as a diagnostic symptom.[13] A number of patient groups have raised concerns that anorexia may be a misdiagnosis in some patients with ME, particularly children or young people, and the severely ill.[16]

Digestive symptoms problems are well recognized, particularly irritable bowel syndrome, and food intolerances, and are optional diagnostic criteria. Common ME/CFS symptoms which may cause changes in eating or weight include:

Notable studies[edit | edit source]

There do not appear to be any significant studies assessing swallowing or eating issues in patients with ME/CFS, or investigating the presence of comorbid eating disorders, or the potential misdiagnosing of eating disorders, although there are many different accounts from patients or their carers/parents.

Byron Hyde has started that enteroviruses may disrupt swallowing reflexes in ME/CFS.[18]

See also[edit | edit source]

Learn more[edit | edit source]

References[edit | edit source]

  1. "Anorexia Nervosa". National Eating Disorders Association. February 25, 2017. Retrieved February 25, 2019.
  2. "Anorexia nervosa - Symptoms and causes". Mayo Clinic. Retrieved February 25, 2019.
  3. Harris, Peter; Nagy, Sue; Vardaxis, editor-Nicholas, eds. (2018). Mosby's Dictionary of Medicine, Nursing and Health Professions (Revised 3rd Anz ed.). Australia: Elsevier Health Sciences. p. 102. ISBN 978-0-7295-8691-7.CS1 maint: extra text: editors list (link)
  4. "Bulimia Nervosa". National Eating Disorders Association. February 26, 2017. Retrieved February 25, 2019.
  5. "Bulimia nervosa - Symptoms and causes". Mayo Clinic. Retrieved February 25, 2019.
  6. "Binge Eating Disorder". National Eating Disorders Association. February 26, 2017. Retrieved February 25, 2019.
  7. "Mental Health and Binge Eating Disorder". WebMD. Retrieved February 25, 2019.
  8. webMD.com https://www.webmd.com/mental-health/eating-disorders/what-is-orthorexiao. Retrieved February 21, 2021. Missing or empty |title= (help)
  9. Hill, Amelia (August 15, 2009). "Pure food obsession is latest eating disorder". The Observer. ISSN 0029-7712. Retrieved February 25, 2019.
  10. Bratman, Steven (January 23, 2014). "What is Orthorexia? | Orthorexia". www.orthorexia.com. Retrieved February 25, 2019. Cite has empty unknown parameter: |dead-url= (help)
  11. "Other Specified Feeding or Eating Disorder". National Eating Disorders Association. March 21, 2017. Retrieved February 25, 2019.
  12. Carruthers, BM; van de Sande, MI; De Meirleir, KL; Klimas, NG; Broderick, G; Mitchell, T; Staines, D; Powles, ACP; Speight, N; Vallings, R; Bateman, L; Bell, DS; Carlo-Stella, N; Chia, J; Darragh, A; Gerken, A; Jo, D; Lewis, DP; Light, AR; Light, KC; Marshall-Gradisnik, S; McLaren-Howard, J; Mena, I; Miwa, K; Murovska, M; Stevens, SR (2012), Myalgic encephalomyelitis: Adult & Paediatric: International Consensus Primer for Medical Practitioners (PDF), ISBN 978-0-9739335-3-6
  13. 13.0 13.1 13.2 13.3 Carruthers, Bruce M.; Jain, Anil Kumar; De Meirleir, Kenny L.; Peterson, Daniel L.; Klimas, Nancy G.; Lerner, A. Martin; Bested, Alison C.; Flor-Henry, Pierre; Joshi, Pradip; Powles, A C Peter; Sherkey, Jeffrey A.; van de Sande, Marjorie I. (2003), "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols" (PDF), Journal of Chronic Fatigue Syndrome, 11 (2): 7-115, doi:10.1300/J092v11n01_02
  14. Fukuda, K.; Straus, S. E.; Hickie, I.; Sharpe, M. C.; Dobbins, J. G.; Komaroff, A. (December 15, 1994). "The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group" (PDF). Annals of Internal Medicine. American College of Physicians. 121 (12): 953–959. ISSN 0003-4819. PMID 7978722.
  15. Institute of Medicine. "Systemic Exertional Intolerance Disease". Centers for Disease Control. Retrieved February 24, 2021.
  16. 16.0 16.1 https://www.dailykos.com/stories/2018/10/10/1803351/-Karina-Hansen-is-FREE
  17. Tymes Trust (2003). "Our Needs Our Lives" (PDF).
  18. Cite error: Invalid <ref> tag; no text was provided for refs named swallowing