Chronic Fatigue Syndrome
Medicine has changed a great deal in my lifetime,
but it changed even more in the previous century. One hundred and fifty years ago, most
diseases were of unknown cause. Even so,
the physicians’ education and experience permitted them to give a more accurate
prognosis than the patient’s fears, a process frequently reassuring to the
patient. Doctors were also expected to
give common sense advice about lifestyle.
Such advice is still appropriate if it can be successfully imparted. Examples of diseases of unknown cause at the
present time include chronic fatigue syndrome, fibromyalgia and irritable bowed
syndrome. These three have at least some
overlapping symptoms in most cases and may not even be separate entities, or
there may be several causative agents producing the very same group of
symptoms. After all, fatigue, muscle
aches and bowel irregularities are commonplace symptoms and are a concern only
if they are persistent in the absence of obvious precipitating factors. For example, easy fatiguability occurs almost
universally after important infections such as infectious mononucleosis. When infectious mononucleosis was discovered
60 years ago and a viral cause isolated, for a few years, it was thought that
persistence of this virus might be a cause or the cause of chronic fatigue
syndrome, but infectious mononucleosis causes not very much more fatigue than
other infections and does not explain the chronic fatigue syndrome after all.
Stomach ulcers are an example of a disease recently
passing from the unknown cause group to that of known cause. We were taught that ulcers were due to excess
acidity, aggravated by irregular habits, alcohol, tobacco, caffeine and life
stresses such as overwork and the scapegoat mother-in-law. The tendency to ulcers was thought to be at
least partly inherited, seemingly confirmed by the fact that on skid row, less
than half the residents have ulcers.
Advice about regular habits and treatment with antacids did help most
sufferers temporarily.
Enter Barry Marshall, MD of
The Helicobacter pylori/stomach ulcer story
inspires hope of similar discoveries to account for at least some of the misery
of chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome… For convenience, I will refer to this group
as “these syndromes” (syndrome is defined as a combination of symptoms). As mentioned before,
many workers have considered these syndromes to be closely related. The term “hysteria” was coined because of an
old theory that these syndromes were due to the uterus out of place even though
many cases occur in males. Sigmund Freud
considered these syndromes to be psychogenic.
Psychotherapy, especially cognitive behavior therapy, does help these
patients, but only the fraction of them who accept the psychogenic explanation. The majority remain
convinced that their symptoms have a physical origin. Both groups are helped by antidepressant
medications to about an equal degree, more than half. This may suggest multiple causes for these
syndromes. So what to
do about those who reject psychiatric treatment, even antidepressants. Pragmatically, we are returning to the late
pre-Freudian point of view that these syndromes are due to a reversible
functional disturbance of the nervous system, including the involuntary nervous
system that controls the internal organs.
No microscopic abnormalities of the brain, voluntary or involuntary
muscles have ever been detected in these patients. Until more is known, we need to try to help
these people by the best means that can be confirmed effective by experience. The victims become discouraged when multiple
laboratory tests remain normal. The
doctor’s apparent anxiety in continuing to order tests tends to confirm the
patient’s fear that they have something serious which has not yet been
detected. They may end up in a no-man’s
land between medicine and psychiatry.
To avoid this impass, it is hard to improve on the
“rational persuasion” proposed in 1904 by Paul Dubois, a Swiss physician. “First, the physician should obtain the
patient’s confidence and demonstrate sympathy with the patient’s experience;
second, the physician should listen to the patient’s history without
impatience; third, the physician should use medical authority and the
therapeutic relationship to convey to patients the belief that they will
recover; and finally, the relationship between patient and physician should be
collaborative, and the treatment approach should be explained to family
members.”
Finally, some personal observations from dealing
with these patients: chronic fatigue
patients who are quite well conditioned by hard work may be briefly relieved by
rest, but the symptoms recur when they become accustomed to the new lower level
of activity. Conversely, those persuaded
to undertake a progressive exercise program to achieve aerobic conditioning may
end up no more fatigued at the higher level of physical functioning.
Those with irritable bowels are usually, if not
always, more conscientious than the rest of us.
I call it the jet mechanic personality because that is just the sort of
person we all hope is working on the jet aircraft that we use. If they can accept their problem as the
backside of a virtue, they may decide to accept some symptoms as preferable to
becoming sufficiently slovenly in their attitudes to overcome their symptoms
completely.
In summary:
when dealing with these puzzling symptoms, we modern physicians are
walking in the shoes of our colleagues of hundreds of years ago except that now
progress is so rapid that we must be alert to know about new advances
exemplified by H. pylori and stomach ulcers.
John A. Frantz, M.D.
Chairman,
(rural
because they already know about hybrid corn)
Suppose
that black people really are inferior. I
don’t really believe that, but just for a moment suppose. In
This
item is dedicated to Dick Gregory who, when asked what he thought about being
on President Nixon’s enemies list, replied without hesitation, I’m not worried
at all. I’m just the token black.”