Science / Medicine : Chronic Fatigue Debate Still Going Strong : Research: Thousands who suffer from the syndrome, and their doctors, claim it’s caused by a virus. But researchers say the syndrome is rare, if it exists at all, and psychological.
Years after it first grabbed headlines and became a popular talk-show subject, chronic fatigue syndrome continues to raise more questions than it answers.
Is it a new, media-made illness or is it 100 years old? Is it common or rare? In the search for its underpinnings, is medical technology on a witch hunt or is science closing in on a complex crippler?
Medical researchers at the University of Connecticut claim to have largely answered those questions and helped scores of CFS sufferers recover.
Their finding: chronic fatigue syndrome, formerly known as chronic Epstein-Barr virus syndrome, is rare if it exists at all. Most of the patient-reported symptoms attributed to the syndrome--exhaustion, fever, swollen glands, disturbed sleep and fogged thinking, all occurring or recurring for months or years on end--are the result of treatable psychiatric disorders, particularly depression.
Far from settling the matter, their reports and those by others with similar findings have further fueled a heated debate.
“To say this is psychological is bull,” snaps Dr. James Jones, a senior staff member at the National Jewish Center for Immunology and Respiratory Medicine in Denver. He says he has seen nearly 2,000 people suffering from CFS.
Jones has co-authored the CFS “working case definition,” arrived at in March, 1988, after elevated antibodies in response to the Epstein-Barr virus proved to be a false lead in the hunt for a cause and an agreed-upon diagnosis.
Some researchers argue that CFS sufferers first become physically sick from an as-yet-unidentified virus that causes chronic flu-like symptoms. Depression is a common symptom of CFS, they say.
Others, such as the University of Connecticut researchers, say people with CFS symptoms start with a history of recurrent mental illness, including depression, panic attacks and other disorders. Their physical symptoms then emerge from patients’ unspoken “psycho-emotional conflicts.”
Both sides in the CFS debate agree that most people who go to doctors complaining of persistent tiredness are probably suffering from a treatable mental illness, such as depression.
Both sides also agree that CFS, or the illness that people are now calling CFS, is probably not a new disease.
Reports of a similar plaguing fatigue, then labeled neurasthenia, first emerged in the United States in the mid-1800s, notes Dr. Peter Manu, lead author of the studies by the University of Connecticut researchers.
Similar symptoms have since been attributed to Iceland disease, chronic brucellosis and, in England, benign myalgic encephalomyelitis, he says.
But here the two sides of the debate part company.
Manu says that neurasthenia, still a common diagnosis in other countries, gave way to psychiatric diagnoses in the 20th-Century United States. He thinks it was wrongly revived as CFS in America in the 1980s.
In January, 1985, two articles in the Annals of Internal Medicine reported that patients suffering from chronic fatigue showed a persistent infection from the Epstein-Barr virus as measured by certain antibody levels in their blood.
In some people, the Epstein-Barr virus causes mononucleosis, with its weeks or months of fevers, swollen glands and exhaustion.
Subsequently, however, doctors found that some healthy people were walking around with the same antibody levels as those people chronically fatigued. Morever, many people suffering from what seemed like chronic mononucleosis did not show high antibody levels.
But by then it was too late, Manu says. Patients were rushing to doctors, newspaper clippings in hand, seeking a physical diagnosis for an illness that was probably psychological.
In Manu’s view, doctors were too pressed for time to do the extensive interviews necessary to make a psychiatric diagnosis. Or perhaps they were uncomfortable broaching the idea of mental illness with patients.
Since testing for certain Epstein-Barr antibodies had recently become commercially available, doctors were able to give patients the technological fix they sought.
Although those antibody counts proved imprecise and largely irrelevant, in this age of AIDS, both medical and popular thought focused on a viral cause for chronic fatigue.
“Here you had millions of people that for about two years, 1986 to 1987, believed they had chronic Epstein-Barr virus, and all of a sudden that was taken away from them,” Manu says.
“The evidence is that (CFS) need not be produced by a virus but is . . . associated with a high prevalence of psychiatric disorders,” says Manu, who says he has seen 200 patients with the syndrome’s symptoms since he and two other doctors set up the University of Connecticut’s Chronic Fatigue Clinic in late 1986.
Not everyone agrees that people catch CFS from magazine articles.
“I think the knee-jerk reaction is to call anything that we don’t understand, or that we can’t prove is organic by the definition of the day or the technology of the day, ‘psychiatric.’ And I don’t think that’s right,” Dr. Paul Cheney says.
As a senior staff physician at the Nolle Clinic in Charlotte, N.C., Cheney says he has seen 1,000 patients with chronic fatigue in the past three years. He is following 500 people from that group, analyzing them over time for immune system and neurological abnormalities.
“They have enough objective abnormalities that they could not manufacture through psychic means,” Cheney says of the majority of those patients.
And he adds, “Between the years 1980 and 1984, the only thing we could find in AIDS patients was disturbed immune function and a menagerie of other infections that didn’t make any sense.”
Both Cheney and Dr. Anthony Komaroff, chief of general medicine at Brigham and Women’s Hospital in Boston, say they will soon publish studies showing immune system dysfunction in CFS patients.
Measurable immune system abnormalities, which Cheney says have been reported in other countries’ medical journals, could provide a more clear-cut and readily accepted diagnosis.
But Cheney concedes, “There isn’t a single test within this immunologic profile that we do that is always abnormal in CFS patients.”
