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.
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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.”