Neurasthenia and chronic fatigue syndrome: the role of culture in the making of a diagnosis

Abstract:

Chronic fatigue syndrome is an increasingly popular diagnosis consisting of multiple psychiatric and somatic symptoms. It bears a striking resemblance to the nineteenth-century diagnosis of . Both disorders arose during periods characterized by a preoccupation with commerce and material success and major changes in the role of women. They illustrate the role of culture in the development of a new diagnosis that emphasizes a “medical” rather than “psychiatric” etiology. The authors argue that chronic fatigue syndrome will meet the same fate as neurasthenia–a decline in social value as it is demonstrated that the majority of its sufferers are experiencing primary psychiatric disorders or psychophysiological reactions and that the disorder is often a culturally sanctioned form of illness behavior.

Comment in:

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

Taking chronic fatigue syndrome seriously. [Am J Psychiatry. 1992]

 

Source: Abbey SE, Garfinkel PE. Neurasthenia and chronic fatigue syndrome: the role of culture in the making of a diagnosis. Am J Psychiatry. 1991 Dec;148(12):1638-46. http://www.ncbi.nlm.nih.gov/pubmed/1957925

 

Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome

Abstract:

Chronic fatigue syndrome is characterized by persistent or relapsing debilitating fatigue for at least 6 months in the absence of a medical diagnosis that would explain the clinical presentation. Because primary glucocorticoid deficiency states and affective disorders putatively associated with a deficiency of the arousal-producing neuropeptide CRH can be associated with similar symptoms, we report here a study of the functional integrity of the various components of the hypothalamic-pituitary-adrenal axis in patients meeting research case criteria for chronic fatigue syndrome.

Thirty patients and 72 normal volunteers were studied. Basal activity of the hypothalamic-pituitary-adrenal axis was estimated by determinations of 24-h urinary free cortisol-excretion, evening basal plasma total and free cortisol concentrations, and the cortisol binding globulin-binding capacity. The adrenal cortex was evaluated indirectly by cortisol responses during ovine CRH (oCRH) stimulation testing and directly by cortisol responses to graded submaximal doses of ACTH. Plasma ACTH and cortisol responses to oCRH were employed as a direct measure of the functional integrity of the pituitary corticotroph cell. Central CRH secretion was assessed by measuring its level in cerebrospinal fluid.

Compared to normal subjects, patients demonstrated significantly reduced basal evening glucocorticoid levels (89.0 +/- 8.7 vs. 148.4 +/- 20.3 nmol/L; P less than 0.01) and low 24-h urinary free cortisol excretion (122.7 +/- 8.9 vs. 203.1 +/- 10.7 nmol/24 h; P less than 0.0002), but elevated basal evening ACTH concentrations.

There was increased adrenocortical sensitivity to ACTH, but a reduced maximal response [F(3.26, 65.16) = 5.50; P = 0.0015). Patients showed attenuated net integrated ACTH responses to oCRH (128.0 +/- 26.4 vs. 225.4 +/- 34.5 pmol/L.min, P less than 0.04). Cerebrospinal fluid CRH levels in patients were no different from control values (8.4 +/- 0.6 vs. 7.7 +/- 0.5 pmol/L; P = NS).

Although we cannot definitively account for the etiology of the mild glucocorticoid deficiency seen in chronic fatigue syndrome patients, the enhanced adrenocortical sensitivity to exogenous ACTH and blunted ACTH responses to oCRH are incompatible with a primary adrenal insufficiency. A pituitary source is also unlikely, since basal evening plasma ACTH concentrations were elevated.

Hence, the data are most compatible with a mild central adrenal insufficiency secondary to either a deficiency of CRH or some other central stimulus to the pituitary-adrenal axis. Whether a mild glucocorticoid deficiency or a putative deficiency of an arousal-producing neuropeptide such as CRH is related to the clinical symptomatology of the chronic fatigue syndrome remains to be determined.

 

Source: Demitrack MA, Dale JK, Straus SE, Laue L, Listwak SJ, Kruesi MJ, Chrousos GP, Gold PW. Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome. J Clin Endocrinol Metab. 1991 Dec;73(6):1224-34. http://www.ncbi.nlm.nih.gov/pubmed/1659582

 

Chronic fatigue syndrome

Comment in: Chronic fatigue syndrome. [Br J Gen Pract. 1992]

Comment on: Antidepressant therapy in the chronic fatigue syndrome. [Br J Gen Pract. 1991]

 

Sir, The adoption of the term chronic fatigue syndrome for conditions like myalgic encephalomyelitis and effort syndrome in the paper by Lynch and colleagues (August Journal, p.339) is difficult to understand. The differences between these disorders are so marked, that an umbrella term is destined to be both confusing and misleading.

The emphasis on the term fatigue is unfortunate for many reasons. First; research has shown that only a tiny proportion of people with unexplained fatigue fulfil the standard diagnostic criteria for myalgic encephalomyelitis. (1) Secondly, Lynch and colleagues’ definition of chronic fatigue syndrome is too broad to distinguish people with myalgic encephalomyelitis from those who are feeling run down or depressed or suffering from the more common and less severe post-viral syndrome. Thirdly, the term trivializes the illness. Everyone gets tired now and then and most people find it hard to understand how some may be disabled by it. In our view, the name suggests something which is tolerable and volitional, requiring little more than adequate rest and a positive attitude. What the term fails to communicate is that the fatigue reported by people with myalgic encephalomyelitis is severe and debilitating; that it is unlike anything most of them have experienced before and that it is often associated with an intense influenza-like malaise. (2’3) We therefore agree with English that as far as myalgic encephalomyelitis is concerned, ‘fatigue is the most pathetically inadequate term’. (2)

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371802/pdf/brjgenprac00062-0041.pdf

 

Source: Goudsmit EM, Macintyre A, Sullivan M. Chronic fatigue syndrome. Br J Gen Pract. 1991 Nov;41(352):479-80. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371802/

 

Chronic fatigue syndrome

Comment on:

Antidepressant therapy in the chronic fatigue syndrome. [Br J Gen Pract. 1991]

General practitioners’ experience of the chronic fatigue syndrome. [Br J Gen Pract. 1991]

 

Sir, I read with interest the papers on the chronic fatigue syndrome (August Journal, p.324, 339). This syndrome has become an important diagnosis in both general practice and psychiatry. With the awareness of such a diagnostic entity, more patients are being recognized and managed (although the aetiology still remains unknown).

Depression as an inherent feature of chronic fatigue syndrome remains a controversial issue and great care is needed in treating these patients as ‘depressed’. Subjectively, many patients with the chronic fatigue syndrome describe their mood state as depressed, probably because of lack of any other socially approved metaphor. For a practitioner, however, it is important to make an objective assessment about the significance of this expression in terms of the range and reactivity of affect and the disproportion of depressive presentation in the context of the patient’s life situation and experiences. If depression is significant, the diagnosis of chronic fatigue syndrome becomes secondary to that of depressive disorder as fatigue may be a feature of depression. However, if chronic fatigue syndrome remains the primary diagnosis, one must remember that antidepressant drugs are neither euphoriants nor stimulants and that there is no empirical evidence for the benefit of antidepressant treatment in this syndrome, although there is a recommendation for it to be tried as an alternatp mode of treatment.

 

Source: Arya DK. Chronic fatigue syndrome. Br J Gen Pract. 1991 Nov;41(352):480. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371803/

 

Chronic fatigue syndrome

Comment on: General practitioners’ experience of the chronic fatigue syndrome. [Br J Gen Pract. 1991]

 

Sir, Ho-Yen and McNamara give an interesting account of general practitioners’ experience of the chronic fatigue syndrome (August Journal, p.324). However, many of the conclusions which they draw are not supported by their study.

The problem lies in the method by which cases were identified. It seems unlikely that the doctors who responded to the questionnaire would have screened every patient on their practice lists for the condition. Even to screen only those patients who attended the surgery would have been a massive undertaking. There is no evidence that the practices involved kept a case register for this illness. I presume therefore that the cases reported were identified from memory by the doctors who responded to the survey. Thus, for patients who meet the criteria for this illness to be identified as a ‘case’ they must: decide that they are ill, decide to visit the doctor, be correctly identified as a case by the general practitioner and leave such an impression on the doctor’s mind as to be easily recalled later. It is very unlikely that, having passed through such a selection procedure, the cases identified would represent either the true number or display the typical characteristics of patients with this condition in the general population.

You can read the rest of this comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371804/pdf/brjgenprac00062-0042b.pdf

 

Source: Plummer WP. Chronic fatigue syndrome. Br J Gen Pract. 1991 Nov;41(352):480. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1371804/

 

Human quadriceps strength and fatiguability in patients with post viral fatigue

Abstract:

Quadriceps isometric strength, activation and fatiguability were measured in 11 patients with symptoms of fatigue three months after glandular fever or a glandular fever-like illness.

Predicted normal and lower limits of normal muscle strength were calculated from height and age. These measures and the fatigue index were compared with a group of healthy students of similar age.

Two of the patients were unable to activate fully their muscles. After allowing for this inhibition the group mean (SD) strength was 104 (22%) of predicted. Although there was no significant difference in the fatigue index between the patients and the control group, there was a trend for the patients to show less fatigue than controls.

There was no difference in the muscle results for those patients who were found to have Epstein-Barr virus infections and those who did not. The feelings of weakness and fatigue experienced by the patients could not be explained by either physiological muscle fatigue or lack of effort.

 

Source: Rutherford OM, White PD. Human quadriceps strength and fatiguability in patients with post viral fatigue. J Neurol Neurosurg Psychiatry. 1991 Nov;54(11):961-4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1014616/ (Full article)

 

Seasonal affective disorder presenting as chronic fatigue syndrome

Abstract:

Although operational criteria have been recently proposed to better define chronic fatigue syndrome (CFS), it remains a controversial diagnosis. There are many overlapping symptoms between CFS and major depression. The author presents two patients with seasonal affective disorder, who responded to phototherapy and had previously been diagnosed as CFS. Because of the consequences of treatment, seasonal and non seasonal depression need to be ruled out in patients with chronic fatigue symptoms.

 

Source: Lam RW. Seasonal affective disorder presenting as chronic fatigue syndrome. Can J Psychiatry. 1991 Nov;36(9):680-2. http://www.ncbi.nlm.nih.gov/pubmed/1773405

 

Intense fatigue in humans. Psychosocial and cultural aspects

Abstract:

A differentiation between the normal sensation of tiredness and the symptom “fatigue” is often difficult. Both are influenced by cultural, social, psychological and biological factors, which can lead–interactively–to symptom formation. Psychiatric disorders frequently associated with fatigue are all forms of depression, somatization and anxiety disorders, chronic pain states and drug abuse among many others. In at least 2/3 of patients with the fashionable chronic fatigue syndrome–formerly called neurasthenia–a psychiatric diagnosis can be made, most of them also suffer from many symptoms attributes to the autonomous nervous system. The clinical approach should be cautious avoiding diagnostic and therapeutic overaction and therapy should emerge from a diagnosis properly assessed.

 

Source: Radvila A. Intense fatigue in humans. Psychosocial and cultural aspects. Ther Umsch. 1991 Nov;48(11):756-61. [Article in German] http://www.ncbi.nlm.nih.gov/pubmed/1754973

 

Biopsychosocial aspects of chronic fatigue syndrome (myalgic encephalomyelitis)

Abstract:

Fifteen patients, with a primary complaint of chronic fatigue, were referred to a physician by their general practitioners. Psychological distress, measured by simple psychiatric rating scales was common, but specific psychiatric diagnoses, derived from a comprehensive diagnostic interview, occurred less frequently.

One questionnaire (Montgomery-Asberg depression rating scale) found emotional distress in 93%, but the diagnostic instrument (Present State Examination) suggested depressive syndromes in only two patients (13%). There were significant occupational difficulties in 87%. No consistently abnormal indices of biochemical or immunological function were found, nor evidence of acute or chronic infection.

Chronic fatigue syndrome (CFS) is associated with physical, psychological and social distress. The illness cannot be defined using just one of these dimensions. Such a unilateral approach has resulted in unnecessary controversy over the nature of the ‘real’ core of CFS. A problem-oriented approach, recognising the multi-factorial and overlapping cause and effect issues in CFS, may be of more benefit to patients.

 

Source: Yeomans JD, Conway SP. Biopsychosocial aspects of chronic fatigue syndrome (myalgic encephalomyelitis). J Infect. 1991 Nov;23(3):263-9. http://www.ncbi.nlm.nih.gov/pubmed/1753134

 

Evaluation and management of patients with chronic fatigue

Abstract:

Chronic fatigue is a common and disabling problem in primary care practice. The differential diagnosis of chronic fatigue is extensive and includes medical disorders, altered physiologic states (eg, pregnancy, exertion), psychiatric disorders, lifestyle derangements, drugs, and controversial entities (eg, chronic candidiasis, food allergies, environmental illness, and chronic fatigue syndrome). The most common diagnoses are psychiatric disorders, including mood, anxiety, and somatoform disorders.

A comprehensive approach to diagnosis and management is necessary, including structured psychiatric interviewing, functional assessment, and elicitation of the patient’s diagnostic beliefs. Patients often believe they are suffering from an organic medical disorder (eg, viral or immunologic) and resist psychiatric labelling of their symptoms and referral to mental health practitioners. Establishing and maintaining rapport, having a flexible approach, and demonstrating a personal concern for the patient is essential. Drug therapy for specific psychiatric and medical illnesses and cognitive-behavioral approaches for enhancing coping mechanisms are effective.

 

Source: Matthews DA, Manu P, Lane TJ. Evaluation and management of patients with chronic fatigue. Am J Med Sci. 1991 Nov;302(5):269-77. http://www.ncbi.nlm.nih.gov/pubmed/1750445