Hokum Locum

Myalgic encephalomyelitis (ME) has been described as epidemic neuromyasthenia, Iceland disease, Royal Free disease and post-infective fatigue syndrome. I will refer to it as chronic fatigue syndrome (CFS), a good neutral description free of unproven association with infective illnesses.

By definition, chronic fatigue is a key feature of the condition, yet up to 25% of patients in US and UK community surveys complained of persistent fatigue or generalised muscle weakness.1,2

These complaints are not new and, 100 years ago, would have been labelled "neurasthenia". Affective disorders, such as depression, characteristically cause a profound reduction in energy, along with other features such as sleep disturbance and weight loss. Up to 80% of patients with CFS manifest depression, anxiety and somatisation disorders (preoccupation with bodily sensations). Despite this, "they are unshakably convinced that their symptoms are due to organic illness and refuse antidepressive therapy."1

CFS commonly follows a viral infection, however there is no evidence of persistent viral infection. This illusory preoccupation with an "organic" cause demonstrates in both patients and some doctors a fundamental ignorance of the close association between mind and body.

As Kendell puts it, depressions have the great merit of being eminently treatable, unlike the chronic viral infections thought to underlie CFS. Cognitive behavioural therapy has proved successful in the treatment of CFS, but not where patients persisted in their belief that CFS was essentially physical.4

Numerous studies1,5,6,7 have failed to provide any evidence of an infection underlying CFS. This has not prevented new theories and the latest claim is of a link between CFS and giardiasis8, a diarrhoea caused by the giardia parasite. Alternative practitioners and some doctors have used electroacupuncture according to Voll (EAV)9 to diagnose and treat CFS. EAV is a delusion in the mind of the operator. Former patients, dissatisfied with the methods of one doctor, went so far as to complain publicly in Metro (October 1988).

CFS may be linked with hyperventilation syndrome, overbreathing producing a feeling of panic with numbness and tingling in the extremities. However, such links are hardly likely to be established while doctors and patients refuse to consider psychological factors. A study of patients thought to have CFS showed that all were made worse by hyperventilation, and such symptoms predated any viral infection by an average of 2 years.!°

Studies of CFS have been hampered by inadequate controls. One study11 claimed to find virus material in the muscles of CFS patients, but more than half of the cases were from the professional classes which would tend to confirm that CFS is a stress-related psychological disorder. There was no control group who had experienced recent viral infection but who had not developed CFS.

A series of 770 cases, reported by Dr Maros in the Australian Medical Journal and quoted in the Dominion (15/7/91), confirms the preponderance of cases in "do-ers". I presume, by this, they mean the active professional classes.

Dr Maros correctly says that CFS "sits on the very margin of the body and the mind" and quotes two patients: "One man says that his visual fields bounce with his pulse, and a young woman with long hair watches her hair beating during relapses." These are classic descriptions of the subjective experiences occurring through hyperventilation.

CFS is not a new syndrome. What is fascinating is the dogged insistence of both patients and some doctors that the disorder has some hitherto unexplained purely physical cause; the determined pursuit of which is the scientific equivalent of the search for the emperor's "new clothes".

In an article in The Press (31/7/91), James Le Fanu wrote "The commonest source of fashionable diseases lies in the need for the depressed and unhappy to explain their misery with its many associated physical symptoms — tiredness, lethargy and aches and pains — in terms of a genuine physical disease."

The term "genuine" deserves some scrutiny. Patients seem to reject any suggestion of a psychological cause for CFS. This suggests to me that we, as doctors, do not perform well in dealing with psychological ailments. This could explain the presentation of CFS as a purely "physical" disorder which, paradoxically, delays correct diagnosis and the application of effective cognitive therapy and antidepressant treatment.

A sensible strategy for dealing with CFS is needed. Patients should not be allowed to go onto DSW benefits unless they have been evaluated by a team which includes both a psychologist and a psychiatrist. A prospective study of 300 patients with CFS" found psychological diagnoses in 84% of the patients. The most common diagnosis was depression in 61%.

Doctors who use unscientific methods such as EAV or who consistently demonstrate an inability to understand basic science should be professionally disciplined. Patients who refuse to be evaluated properly should be refused DSW benefits. Of particular concern is the diagnosis of CFS in children.13,14

  1. Kendell R. E. Chronic fatigue, viruses, and depression. Lancet Vol 337: p160-161.
  2. David A, Pelosi A, McDonald E, et al. Tired, weak or in need of rest: fatigue among general practice attenders. Br Med J 1990; 301: 1192-202
  3. Gold D, Bowden R Sixbey J, et al. Chronic fatigue: a prospective clinical and virological study. JAMA 1990; 264: 48-53
  4. Butler S, Chalder T, Ron M, Wessely S. Cognitive behaviour therapy in CFS. J Neurol Neurosurg Psychiatry 1991; 54: 153-8
  5. Leading Article: Immune function and the chronic fatigue syndrome. Medical Journal of Australia vol 151 p117-8, August 7, 1989
  6. Bennet JE, NEJM 323: 1766-1767, 20 Dec 1990.
  7. Leading Article: Chronic fatigue syndrome-false avenues and dead ends. The Lancet vol 337 p331-2, Feb 9, 1991
  8. ME and giardiasis link investigated. NZ Doctor 17/6/91.
  9. Letter, NZ Med J 1986 vol 99 p513
  10. Rosen SD, King JC, Wilkinson JB, Nixon PGE. Is CFS synonymous with effort syndrome? J R Soc Med (in press)
  11. Clinical Research 38:(2): 1990 (Abstract)
  12. Damaging diagnoses of myalgic encephalitis in children. BMJ vol 299 p790
  13. Myalgic encephalomyelitis by proxy. BMJ vol 299 p1030

An article entitled "Journey For Life" appeared recently in the Listener (also known to skeptics as the NZ Journal of Alternative Medicine).

The article describes the efforts of Bill Hall (chairman Hallmark International) to obtain treatment for a malignant brain tumour. A doctor told him that his chances of surviving 5 years were 20%. Hall says "Who was he to play God? Didn't he understand just how powerful the healing properties of mind can be, given the right inputs?"

To be fair, the doctor would have been communicating cold hard facts in his knowledge that cases of spontaneous remission for cancer are very rare, but do occur. It is normal for people to become angry when confronted with their own mortality.

Hall then spent some time at the Bristol Cancer Centre, but there is no mention of the Lancet study which showed that patients attending the BCHC fared worse than those receiving conventional treatment (Skeptic No 19). It is highly probable that he would have been unaware of its existence. The healing program included "prayer, meditation, relaxation, affirmation and visualisation." These are all treatment modalities which could be adopted by conventional cancer treatment centres, and could be provided by _ clinical psychologists. This would fulfill a need which is at present being provided by alternative "healers".

The story is taken up by climber Graeme Dingle. They set out to locate Yeshi Dhonden, former personal physician to the Dalai Lama. Dingle is impressed because "without benefit of instruments or textbooks, the maroon-robed, shaven headed physician correctly diagnosed acute arthritis of the neck and back, simply by concentration and a little physical manipulation" and "in front of 500 medical practitioners" Dhonden had touched a patient's wrist briefly and diagnosed three rare diseases that only the patient knew he had.

What is it about Eastern gurus that elicits such gushing naivety from otherwise intelligent people?

After a 15-second examination, Dhonden proclaims "I can cure you." Imagine the power of such a positive, but manifestly impossible, statement to a desperate person. The guru then banned Hall from eating meat, fish and alcohol, and followed up with an examination of Hall's urine which involved sniffing it and beating the bottle with a stick. This medieval uroscopy (Skeptic No 17) is complete and utter nonsense.

Hall left with a five-month supply of Tibetan drugs "that would make a customs officer's hair stand on end." If the drugs included pills made from lama's faeces, a traditional Tibetan remedy, I can understand the concern.

Naturally, I wish Hall well with his struggle to beat cancer. Clearly, cancer patients have important emotional needs which are not being met by conventional medicine. As Hall says of Western medicine, it is "very advanced technologically, but that's where it seems to finish".

In Skeptic No 20, I outlined the latest obsession over alleged mercury toxicity from dental amalgam. The US National Council Against Health Fraud newsletter recently carried an article about dental amalgameters. If any of these machines are in use here, why haven't our own regulatory authorities taken action? I would appreciate hearing from any readers who know of the existence or use of these.

FDA Consumer 10/89, quoted in NCAHF

The FDA also moved swiftly against commercial organisations offering transillumination of the breasts as "non-x-ray, painless and rapid breast screening technique."

Transillumination is an accepted clinical method of determining if a lump is solid or cystic. This technique has no place in breast screening.

The US FDA seems to act much more responsibly than our own regulatory bodies. It is time there was some action against the use of unproven technology in NZ, such as in the case of EAV machines and dental amalgameters.

Morbidity and Mortality Weekly Report 1991; 40:293-6 quoted in Minerva BMJ Vol 302 8 June 91 p1412

Dr John Welch is a medical officer with the RNZAF.