The Brief Fatigue Syndrome Scale: Validation and Utilization in Fatigue Recovery Studies

  • Bengt B. Arnetz
  • Lena Frenzel
  • Torbjörn Åkerstedt
  • Jan Lisspers


Medically, nonexplained fatigue is a significant clinical and public health concern. However, the construct fatigue is not easily defined, and this is reflected in the large number of different scales used to measure fatigue. In this chapter, we define fatigue using the sustained stress activation theory. It is proposed that sustained stress, with a lack of sufficient recovery periods, is characterized by a decline in the ability to concentrate, be energetic, and sleep. Based on this definition, the brief fatigue syndrome scale (BFSS) was created using visual analogue scales (VAS) to rate self-assessed energy, ability to concentrate, and quality of sleep. The BFSS consisted of one factor, with a Cronbach’s α of >0.70. The validity and sensitivity of the scale was assessed by following a group of fatigued patients undergoing a 1-year lifestyle recovery program. In addition, a reference group of healthy controls was followed over the same period. Both groups responded regularly to a survey containing the BFSS. Blood samples were also collected during the first 6 months. The BFSS scores decreased significantly as the clinical conditions of the fatigued participants improved. Furthermore, self-rated mental energy, assessed by a separate and validated five-item Likert-type scale, improved with decreasing fatigue. Participants scoring above the proposed cut-off point of 8 for depression on the hospital depression and anxiety scale had significantly higher BFSS scores. BFSS scores were also higher among subjects scoring in the burn-out range on the Shirom-Melamed scale. Decreased fatigue over time was related to improved/ increased serum levels of testosterone. It is suggested that the cut-off point for fatigue vs. nonfatigue should be set at 40%. The BFSS is suggested as a valid and quick instrument to assess fatigue.


Chronic Fatigue Syndrome Fatigue Severity Scale Chronic Fatigue Syndrome Patient Fatigue Scale Vital Exhaustion 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Fehnel SE, Bann CM, Hogue SL, Kwong WJ, Mahajan SS (2004) The development and psychometric evaluation of the motivation and energy inventory (MEI). Qual Life Res 13:1321–1336PubMedCrossRefGoogle Scholar
  2. 2.
    Masand PS, Gupta S (1999) Selective serotonin reuptake inhibitors: an update. Harvard Rev Psychiatr 7:69–84CrossRefGoogle Scholar
  3. 3.
    Stein KD, Martin SC, Hann DM, Jacobsen PB (1998) A multi-dimensional measure of fatigue for use with cancer patients. Cancer Pract 6:143–152PubMedCrossRefGoogle Scholar
  4. 4.
    Kent-Braun JA, Sharma KR, Weiner MW, Massie B, Miller RG (1993) Central basis of muscle fatigue in chronic fatigue syndrome. Neurology 43:125–131PubMedGoogle Scholar
  5. 5.
    Kroenke K, Wood DR, Mangelsdorff DA, Meirer NJ, Powell JB (1988) Chronic fatigue in primary care: prevalence, patient characteristics, and outcome. J Am Med Assoc 260:929–934CrossRefGoogle Scholar
  6. 6.
    Melillo N, Corrado A, Quarta L, D’Onofrio F, Trotta A, Cantatore FP (2005) Fibromialgic syndrome: new perspectives in rehabilitation and management. A review. Minerva Med 96:417–423Google Scholar
  7. 7.
    Appels A, de Vos Y, van Diest R, Höppner P, Mulder P, de Groen J (1987) Are sleep complaints predictive of future myocardial infarction? Activitas Nervosa Superior 29:147–151PubMedGoogle Scholar
  8. 8.
    Melamed S, Ugarten U, Shirom A, Kahana L, Lerman Y, Froom P (1999) Chronic burnout, somatic arousal and elevated salivary cortisol levels. J Psychosom Res 46:591–598PubMedCrossRefGoogle Scholar
  9. 9.
    Kalia M (2002) Assessing the economic impact of stress. The modern-day hidden epidemic. Metabolism 51 Suppl 1:49–53PubMedCrossRefGoogle Scholar
  10. 10.
    Uehata T (1991) Karoshi due to occupational stress-related cardiovascular injuries among middle-aged workers in Japan. J Sci Labour 67:20–28Google Scholar
  11. 11.
    Winwood PC, Winefield AH, Dawson D, Lushington K (2005) Development and validation of a scale to measure work-related fatigue and recovery: the occupational fatigue/recovery scale (OFER). J Occup Environ Med 47:594–606PubMedCrossRefGoogle Scholar
  12. 12.
    Anderzén I, Arnetz BB (2005) The impact of a prospective survey-based workplace intervention program on employee health, biological stress markers, and organizational productivity. J Occup Environ Med 47:671–682PubMedCrossRefGoogle Scholar
  13. 13.
    Heim C, Bierl C, Nisenbaum R, Waginer D, Reeves WC (2004) Regional prevalence of fatiguing illnesses in the United States before and after the terrorist attacks of September 11, 2001. Psychosom Med 66:672–678PubMedCrossRefGoogle Scholar
  14. 14.
    Lewis G, Wessely S (1992) The epidemiology of fatigue: more questions than answers. J Epid Com Health 46:92–97CrossRefGoogle Scholar
  15. 15.
    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
  16. 16.
    Arnetz BB, Ekman R (2006) Fatigue and recovery. In: Arnetz B, Ekman R (eds) Wiley-VCH, New York, pp 298–309Google Scholar
  17. 17.
    Shapiro CM (2004) Chronic fatigue: chronically confusing but growing information. Editorial. J Psychosom Res 56:153–155PubMedCrossRefGoogle Scholar
  18. 18.
    Felton JS (1998) Burnout as a clinical entity: its importance in health care workers. Occup Med 48:237–250CrossRefGoogle Scholar
  19. 19.
    Krupp LB, Alvarez LA, LaRocca NG, Scheinberg LC (1988) Fatigue in multiple sclerosis. Arch Neurol 45:435–437PubMedGoogle Scholar
  20. 20.
    Pearson PG, Byars GE (1956) The development and validation of a checklist measuring subjective fatigue. Report no. 56–115, School of Aviation, USAF, Randolf AFB, TexasGoogle Scholar
  21. 21.
    Brook RH, Ware JE, Davies-Avery A, Stewart AL, Donald CA, Rogers WH, Williams KN, Johnston SA (1979) Overview of adult health status measures fielded in Rand’s health insurance study. Med Care 17(Suppl):1–55Google Scholar
  22. 22.
    Montgomery GK (1983) Uncommon tiredness among college undergraduates. J Con Clin Psychol 51:517–525CrossRefGoogle Scholar
  23. 23.
    Krupp B, LaRocca NG, Muir-Nash J, Steinberg AD (1989) The fatigue severity scale. Application to patients with multiple sclerosis and systematic lupus erythematosus. Arch Neurol 46:1121–1123PubMedGoogle Scholar
  24. 24.
    Wessely S, Powell R (1989) Fatigue syndromes: a comparison of chronic postviral fatigue with neuromuscular and affective disorders. J Neurol Neurosurg Psychol 52:940–948CrossRefGoogle Scholar
  25. 25.
    Haylock PJ, Kart LK (1979) Fatigue in patients receiving localized radiation. Cancer Nursing 2:461–467PubMedCrossRefGoogle Scholar
  26. 26.
    Piper BF, Lindsey AM, Dodd MJ, Ferketich S, Paul SM, Weller S (1989) The development of an instrument to measure the subjective dimension of fatigue. In: Funk SG, Tornquist EM, Campagene MT, Archer Gropp LM, Wiese RA (eds) Key aspects of comfort: management of pain, fatigue and nausea. Springer, New York, pp 199–208Google Scholar
  27. 27.
    Stein KD, Martin Sc, Hann DM, Jacobsen PA (1998) A multidimensional measure of fatigue for use with cancer patients. Cancer Pract 6:143–152PubMedCrossRefGoogle Scholar
  28. 28.
    Fawzy FI, Cousin N, Fawzy NW, Kemeny ME, Elashoff R, Morton D (1990) a structured psychiatric intervention for cancer patients. Arch Gen Psychiatr 18:35–59Google Scholar
  29. 29.
    Salinsky MC, Storzbach D, Dodrill CB, Binder LM (2001) Test-retest bias, reliability, and regression equations for neuropsychological measures repeated over a 12–16-week period. J Int Neuropsychol Soc 7:597–605PubMedCrossRefGoogle Scholar
  30. 30.
    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
  31. 31.
    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
  32. 32.
    Raison CL, Miller AH (2003) When not enough is too much: the role of insufficient glucocorticoid signaling in the pathophysiology of stress-related disorders. Am J Psychiatr 160:1554–1565PubMedCrossRefGoogle Scholar
  33. 33.
    Svenningsson P, Chergui K, Rachleff I, Flajolet M, Zhang X, El Yacoubi M, Vaugeois J-M, Nomikos GG, Greengard P (2006) Alterations in 5-HT1b receptor function by p11 depressionlike states. Science 311:77–80PubMedCrossRefGoogle Scholar
  34. 34.
    Hasson D, Anderberg UM, Theorell T, Arnetz BB (2005) Psychophysiological effects of a web-based stress management system. A prospective, randomized controlled intervention study of IT and media workers. BMC Public Health 5:78 ( Scholar
  35. 35.
    Hasson D, Arnetz BB (2005) Validation and findings comparing VAS vs. Likert scales for psychosocial measurements. Int Electron J Health Educ 8:178–192Google Scholar
  36. 36.
    Arnetz BB (1996) Techno-stress. A prospective psychophysiological study of the impact of a controlled stress-reduction program in advanced telecommunication systems design work. JOEM 38:53–65PubMedCrossRefGoogle Scholar
  37. 37.
    Lisspers J, Sundin Ö, Öhman A, Hofman-Bang C, Rydén L, Nygren Å (2005) Long-term effects of lifestyle behavior change in coronary artery disease: effects on recurrent coronary events after percutaneous coronary intervention. Health Psychol 24:41–48PubMedCrossRefGoogle Scholar
  38. 38.
    Lisspers J, Hofman-Bang C, Nordlander R, Rydén L, Sundin Ö, Öhman A, Nygren Å (1999) Multifactorial evaluation of a program for lifestyle behavior change in rehabilitation and secondary prevention of coronary artery disease. Scand Cardiovasc J 33:9–16PubMedCrossRefGoogle Scholar
  39. 39.
    Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67:361–370PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2008

Authors and Affiliations

  • Bengt B. Arnetz
    • 1
    • 2
    • 3
  • Lena Frenzel
    • 3
  • Torbjörn Åkerstedt
    • 4
  • Jan Lisspers
    • 5
  1. 1.Section for Social Medicine, Department of Public HealthUppsala UniversityUppsalaSweden
  2. 2.Division of Occupational and Environmental Health, Department of Family Medicine and Public Health SciencesWayne State UniversityDetroitUSA
  3. 3.Center for Environmental Health and Stress Disorders (CEOS)Uppsala Academic HospitalUppsalaSweden
  4. 4.Department of Public Health Sciences, Division of Psychosocial Factors and Health, and Institute for Psychosocial Medicine (IPM)Karolinska InstitutetStockholmSweden
  5. 5.Research Group for Behavioral Medicine and Health Psychology, Department of Social Sciences (Psychology Section)Mid-Sweden University at ÖstersundÖstersundSweden

Personalised recommendations