Note: This letter was written in response to a letter published in the Canadian Medical Association Journal on May 1, 1989. You can read Holland’s letter here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1268972/pdf/cmaj00190-0022b.pdf
It is regrettable that the publication of an earlier letter from one of us (G.H.R.) and Dr. Jean A. Monro (Can Med Assocj 1989; 140: 361) generated surprise (and apparent disapproval of CMAJ’s action) on the part of Dr. Ray Holland (ibid 1016).
In expressing his disagreement with the use of the term “chronic fatigue syndrome” Holland also appears to be at odds with the US Centers for Disease Control (CDC), whose case definition for this condition (1) was the main point of the earlier letter. We have no disagreement with Holland that “there are also primary psychologic causes of chronic fatigue”. However, the CDC case definition specifically calls for the exclusion of clinical conditions, including psychiatric disease, that may produce similar symptoms.
The whole issue of what triggers psychologic symptoms or illness, however, is an important related matter. Holland reports, quite rightly, that panic disorder appears to be increasingly common. As physicians we have been led to assume that panic disorder has a psychologic origin rather than identifiable extrinsic causes. At the Environmental Health Center – Dallas we have confirmed that panic attacks and other emotional responses may be reproducibly triggered by double-blind testing for sensitivities to foods, inhalants and chemicals. (2)
Similar behavioural effects have been seen in pesticide poisoning (3) and with exposure to other environmental toxins. (4) Specifically, panic attacks have been cited in the psychiatric literature as being triggered by solvent exposure. (5’6)
Being unable to find physical diagnoses for chronic fatigue does not necessarily mean that psychologic illness is the cause. It may simply be that our understanding of the factors precipitating the illness is far from complete. Medical history teaches us that once physical causes for “psychologic” symptoms are discovered the condition moves, as if by magic, from the psychiatric to the medical realm. A good example of this is the relief of behavioural symptoms by correction of thiamin (7) or cobalamin (8) deficiency.
It is our experience that a substantial percentage of chronic fatigue cases (not a minuscule percentage, as Holland suggests) may arise from or be worsened by adverse reactions to components of the patient’s total environment, such as food, inhalants and chemicals.
~Gerald H. Ross, MD, CCFP Fellow in environmental medicine
~William J. Rea, MD, FACS, FAAEM Medical director
~Alfred R. Johnson, DO, FAAEM Environmental Health Center – Dallas; Dallas, Texas
References
1. Holmes GP, Kaplan JE, Gantz NM et al: Chronic fatigue syndrome: a working case definition. Ann Intern Med 1988; 108: 387-389
2. King DS: Can allergic exposure provoke psychological symptoms? A double-blind test. Biol Psychiatry 1981; 16:3-19
3. Rea Wl, Butler JR, Laseter JL et al: Pesticides and brain function changes in a controlled environment. Clin Ecol 1984; 2:145-150
4. Fein GG, Schwartz PM, Jacobson SW et al: Environmental toxins and behavioral development: a new role for psychological research. Am Psychologist 1983; 38: 1188-1197
5. Dager SR, Holland JP, Cowley DS et al: Panic disorder precipitated by exposure to organic solvents in the work place. Am I Psychiatry 1987; 144:1056-1058
6. Lindstrom K, Ruhimake H, Hamminen K: Occupational solvent exposure and neuropsychiatric disorders. Scand J Work Environ Health 1984; 10: 321-323
7. McLaren DS: Clinical manifestations of nutritional disorders. In Shils ME, Young VR (eds): Modem Nutrition in Health and Disease, Lea and Febiger, Philadelphia, 1988: 733-745
8. Lindenbaum J, Healton EB, Savage DG, et al: Neuropsychiatric disorders caused by cobalamin deficiency in the absence of anemia or macrocytosis. N EnglJ Med 1988; 318: 1720-1729
Source: G H Ross, W J Rea, and A R Johnson. Chronic fatigue syndrome. CMAJ. 1989 Jul 1; 141(1): 11–12. PMCID: PMC1269261 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1269261/