Volume 7 Issue 7 July, 2017
The mind and body have been viewed as two separate entities for millennia in the Eastern medical traditions, and at least for a few centuries in the Western medicine, since Rene Descartes proposed the idea (The Cartesian Dualism). Equally notable is the common sense and experience that both are not independent of the other, and it is a universal experience that when one of these is in imbalance the other too suffers. This is the interface field between Psychiatry and other branches of medicine, variously termed as psychosomatic medicine, consultation-liaison psychiatry and so on.
There are umpteen number of conditions which come under this rubric – many of them are quite common ones, e.g. asthma, diabetes, hypertension. But now let us look at one peculiar condition in this area – chronic fatigue syndrome.
It is also known as myalgic encephalomyelitis. In the 19th and early 20th centuries it was known as neurasthenia or neurocirculatory asthenia. A disorder of young adulthood (20-40yrs), its incidence can be as much as 2.8% in the general adult population, and it affects women twice as common as men.
Etiology
Etiology is unknown. It is a disorder of exclusion. Till date, there are no specific signs or diagnostic tests for this condition. A disruption of the hypothalamic-pituitary-adrenal (HPA) axis leading to mildly decreased cortisol level has been found. Elevated levels of cytokines like interferon – α and interleukin – 6 are seen in the brains of some of these patients. Correlation between identical twins for the disorder has been found to be 2.5 times more than that for fraternal twins suggesting a familial predisposition.
Clinical features
As the name itself suggests, fatigue is the central feature. This fatigue is chronic (at least of 6 months duration), is not secondary to exertion, not relieved by rest and renders the individual unable to carry out their daily functions. This is usually accompanied by other symptoms like inability to concentrate, sore throat, tender lymph nodes, multiple muscular and joint pains, headache, unrefreshing sleep and the like.
Differential diagnosis
Some of the most common differentials are endocrine disorders like hypothyroidism, neurological disorders like multiple sclerosis, infectious disorders like HIV-AIDS, infectious mononucleosis and psychiatric disorders like major depression. The major points differentiating it from depression are absence of feelings of guilt, suicidal ideation, anhedonia (lacking interest and pleasure in activities which the individual previously found pleasurable) and weight loss.
Treatment – Treatment is mainly supportive. It is important for the treating physician to acknowledge that the patient’s complaints are not imaginary and hence they shouldn’t dismiss their symptoms as without basis. Establishing rapport and a good therapeutic alliance helps. Amantadine has found to reduce the fatigue to some extent. Encouraging patients to continue their daily activities, a reduced workload and graded exercise therapy (GET) have been useful. Cognitive behavioral therapy helps by addressing faulty thinking the patient might have, like “any activity causing fatigue worsens the disorder”. The antidepressant Bupropion has shown some results. Methylphenidate may reduce the fatigue. Finally, the role of self-help groups cannot be overemphasized- they help in sharing their experiences, instilling hope and encouraging each other towards recovery.
Dr Tejus Murthy. A. G MD Assistant Professor of Psychiatry Pondicherry Institute of Medical Sciences, Pondicherry
