I was watching the Two Oceans running marathon in Cape Town yesterday on the square box, and marvelled not only at the aesthetic beauty of Cape Town, but also at how many folk of all ages ran the iconic race, and at their visible efforts to resist the sensations of fatigue they were clearly all feeling as the race reached its endpoint and as they laboured valiantly to reach the finish line in the fastest time possible for each of their abilities. Some recently published top-notch research articles on the mechanisms of fatigue by Roger Enoka, Romain Mueusen and Markus Amman, amongst others (surely with Simon Gandevia the scientists who have shaped our contemporary view of fatigue more than anyone else) have been doing the ’rounds’ amongst us science folk on research discussion groups the last while, and has ‘reignited’ an interest in the field in me. A large period of my research life was involved in trying to understand the mechanism behind the symptoms of fatigue, mainly in athletes, but also in those suffering from the clinical disorder known as chronic fatigue syndrome. As I come up quickly to the big age of 50 later this year, I notice that the daily physical and mental activity which I used to do with ease in my youth fatigue me more easily now. Because of this I have to ‘pace’ myself more carefully in all aspects of life to ‘preserve’ energy to ‘fight the good fight’ another day, in order to not run the risk of collapsing completely in the manner I witnessed in those folk with chronic fatigue syndrome I tried to assist both as a clinician and scientist during my earlier career, who pushed too hard and subsequently became moribund because of it. All of these recent observations have got me thinking of chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis (ME), what causes it, and why it manifests in some folk and not others.
Fatigue is a complex emotion which is felt by all folk on a daily basis, but paradoxically is very difficult to define. It has mental and physical symptoms and signs, and is often increased by and related to exertion of any kind. Fatigue can be either acute, where there is a direct correlation of the symptoms of fatigue to a specific task or activity and the symptoms attenuate when the activity ends, or can be chronic, when the symptoms of fatigue remain for a prolonged period and are not attenuated by a period of rest, and the reasons for these chronic symptoms remaining are very difficult to understand. In the sporting world, chronic fatigue is caused by pushing oneself too long and too hard in training and racing, and is known as over-training syndrome, and has a symptom complex which includes apart from the symptom of extreme fatigue also those of ‘heavy legs’, increased waking pulse rate, sleep disorders, weight loss (or weight gain), lack of motivation, depression and decreased libido, which do not improve unless there is a prolonged period of rest with no physical training. Working at the University of Cape Town with great scientists Mike Lambert, Liesl Grobler, Malcolm Collins, Karen Sharwood, Wayne Derman, and others, for my medical doctorate in the late 1990’s we examined athletes who were moribund from over-training, and found that a number of them had pushed themselves so hard and so long that they had developed skeletal muscle pathology (damaged mitochondria in particular) to go with all these chronic fatigue symptoms, and we called this symptom complex the fatigued athlete myopathic syndrome, and later acquired training intolerance. The words the athletes we examined used to describe their symptoms were classic and perhaps ‘explained’ the issues better than scientific or medical terms – with one sufferer declaring that they had ‘no spring in the legs’, another that ‘one kilometre now feels what equalled 100 km previously’, and another that ‘at its peak, the fatigue left me halfway between sleeping and waking most of the time’. Although there was perhaps a degree of hubris in these self-reported symptoms of fatigue, all these folk felt that the symptoms profoundly affected their exercise performance and lifestyle. Significantly, the majority of folk had evidence of suffering from depression, and also did not want to stop training and racing, and indeed found it almost impossible to stop training and racing despite these profound symptoms of chronic fatigue.
I carried on my interest in this field when moving to Northumbria University in the UK in 2006, and assisted Paula Robson Ansley and her PhD student Chris Toms, who did some great work examining causation, clinical testing of and exercise prescription for folk with classical chronic fatigue syndrome, as opposed to those with acquired training intolerance (though there is surely a relationship between these syndromes). Folk with CFS have symptoms of chronic and extreme fatigue which is persistent or relapsing, present for six months or longer, not resulting from ongoing exertion, not attenuated substantially by rest and causing impairment of activities which were previously easy to perform. They also have four or more ‘other’ diagnostic criteria, including impaired memory or concentration, sore throat, tender cervical / axillary lymph nodes, muscle pain, multi-joint pain, headaches, unrefreshing sleep or post-exercise malaise. It is importantly a diagnosis of exclusion of other medical causes of fatigue such as cancer, TB, endocrine or hormonal imbalances, or psychiatric or neurological disorders, and a clinician must always be careful to exclude these specific organic medical causes before diagnosing someone with CFS. The cause of CFS is unknown and hotly debated – it is usually precipitated by a viral infection such as Ebstein Barr Virus infection (glandular fever), and viral or infective causes, immune function issues, toxic pathogens or chemicals have all been suggested to be the cause of CFS, but not all folk who have CFS have any or all of these potential triggers or causal agents as part of their presenting history. It is notoriously difficult to treat, and some folk are left moribund and with significantly impaired lives for decades, although in some folk the syndrome seems to ‘burn out’ and they improve with time or learn to live with their symptoms by managing them carefully. Unfortunately there is a high level of suicide in folk suffering from CFS, though it is not clear if this is related to the underlying causation of the disorder or due to its long-term effect on lifestyle and physical capacity.
What is interesting (and of concern) for those folk studying CFS and trying to understand its aetiology and how to treat it, is the controversy and level of emotion attached to its diagnosis and treatment. Chronic fatigue syndrome used to be more well known as myalgic encephalomyelitis (ME), first diagnosed in the 1950’s after a group of doctors and nurses in a specific hospital developed post-viral syndrome with symptoms including chronic fatigue and with some neurological muscle and central nervous system related symptoms (hence the name ME) and it was first thought to be a neurological disorder. But with time, and as it was found that more folk who were diagnosed with ME did not have classic ‘organic’ neurological signs, it became thought of more as a psychiatric disorder and became more often described as CFS, due to the predominant symptomatology of fatigue as being the major ‘descriptor’ of the disorder. What is astonishing is that, as well described in a fascinating article by Wotjek Wojcic and colleagues at Kings College, London, in a survey of neurologist specialist members of the British Neurologist Association, 84% of respondents did not view CFS as a neurological disorder but rather as a psychiatric disorder. But, paradoxically, a number of patients with CFS would prefer it to be described as a neurological rather than a psychiatric disorder (and would prefer it to be still called ME), because of the social stigma of the label of having a psychiatric disorder. Somewhat astonishingly, as described by Michal Sharpe of the University of Edinburgh, there was even a negative response to a study of his which found that cognitive behavioural therapy and graded exercise therapy (the PACE trial) helped improved the symptoms of sufferers of CFS/ME, with several major patient organizations apparently dismissing the trial findings and being critical of them, because the findings could suggest that the syndrome was psychiatric in origin if cognitive behavioural therapy worked, rather than what would be the case if it was an organic neurological disorder, in which case such therapy should not work. As Sharpe concluded, in his own words it is a ‘funny old world’ when a study shows that a therapy works, but patients are angry because they didn’t want it to work, because of the stigma it would potentially create by it working.
Wojcic and colleagues also made the point that the majority of symptoms of CFS are almost identical to that of neurasthenia, a psychiatric disorder which was prominent in the 1800’s and early 1900’s, but has become almost unheard of as a diagnosis in contemporary times. Neurasthenia was described as a ‘weakness of nerves’ by George Beard in 1869, and as having symptoms of fatigue, anxiety, headache, heart palpitations, high blood pressure, neuralgia (pain along the course of a specific nerve) and depressed mood associated with it. The ICD-10 definition of neurasthenia is that of having fatigue or body weakness and exhaustion after minimal effort, which is persistent and distressing, along with depressive symptoms and two of the symptoms of either muscle aches and pains, dizziness, tension headaches, sleep disturbances, inability to relax, irritability and dyspepsia (indigestion). William James referred to neurasthenia as ‘Americanitis’ (he suffered from neurasthenia himself) as so many Americans in the 1800’s were diagnosed with it, particularly women, and it was a ‘popular’ diagnosis whose treatment was either a rest cure or electrotherapy. In world war one neurasthenia was a common diagnosis for and of ‘shell shock’, and folk with shell shock related neurasthenia were treated with prolonged rest. In the 20th century neurasthenia was increasingly thought of as a behavioural rather than a physical condition, and eventually it ‘fell out of favour’ and was ‘abandoned’ as a medical diagnosis. As Wojcic and colleagues suggest, not just the symptoms, but the ‘trajectory’ of the classification of the disorder have and follow a strikingly similar pattern to that of CFS/ME, which also started off as being diagnosed as an organic / neurological disorder and is now thought of a psychiatric disorder, which is (sadly) increasingly stigmatized by lay folk and indeed even some clinicians.
Neurasthenia was thought by Beard to being caused by ‘exhaustion’ of the central nervous system’s energy reserves, which he attributed to the (even in those days) stresses of urbanization, increasingly competitive business environment and social requirements – it was thought that neurasthenia was mostly associated with ‘upper class’ folk and with professionals working in stressful environments. Sigmund Freud thought there was a strong relationship to anxiety and to the basic ‘drives’, and as he almost always did, related neurasthenia to ‘insufficient libidinal discharge (ie not enough sex) that had a poisonous effect on the organism’. Both Freud and Carl Jung believed that drives were the result of the ‘ego’ state, and that disorders such as neurasthenia were a result of imbalances in this ego state. In their model, the ‘id’ was the basic component of the subconscious psyche which encompassed all our primitive needs and desires. The ‘ego’ was the portion of the psyche which maintains the sense of self, and recognizes and tests reality. A well-functioning ego perceives reality and differentiates the outer world from inner images and desires generated by the id, and ‘controls’ these. The ego develops in the first part of life, and is associated with a history of object cathexes. Cathexes are attachments of mental or emotional energy upon an idea or object. Object cathexes are generated by the id, which ‘feels’ erotic and other ‘trends’ as needs. The ego, which to begin with is feeble, becomes aware of these object cathexes, and either acquiesces or understands these needs and manages them (and thus becomes ‘strong’) or is disturbed by them and ‘fends’ them off by the process of repression (and becomes weak and ‘conflicted’). If weak, the ego deals with its inadequacy by either repressing unwanted thoughts (thrusting back by the ego from the conscious to the unconscious any ideas of a disagreeable nature) or developing a complex (a group of associated, partially or wholly represented ideas that can evoke emotional forces which influences an individual’s behaviour, usually ‘outside’ of their awareness). As a result of these complex developments, folk either use projection, which is a mental mechanism by which a repressed complex is disguised by being thought to be belonging to the external world or to someone else, or transference, which is the ‘shifting’ of an affect from one person to another or from one idea to another, either affection or hostility, based on unconscious identification, in order to deal with them at a subconscious level. Albert Adler described the inferiority complex as such – that a combination of emotionally charged feelings of inferiority operates in the unconscious to produce either timidity, or as a compensation, exaggerated aggression or paradoxical perception of superiority, and ones drives were a result of, or compensation for, feelings of inferiority derived from previous unpleasant experiences. For example, competing in extreme sport would be a compensation for being bullied in the past, or being abused as a child, or being ignored by a parent when young. Signs of such complexes included for Freud and Jung disturbing dreams and ‘slips of the tongue’, nervous tics and involuntary tremors, fanatical attachment to projects and goals, envy and dislike of individuals who are successful, falling apart when failing to successfully complete a challenge, desire for public acknowledgement and seeking of title and awards, compulsive exercising, and the development of neuroses and psychoses, all of which can be used to diagnosed the presence of ‘unsolved’ complexes, projections and transferences. Importantly for the development of neurasthenia (and chronic fatigue), Jung and Freud thought that there was an ‘energy cost’ to maintaining repressions and their associated complexes – Freud defined drives as the ‘psychical representative of the stimuli originating within the organism and reaching the mind, as a measure of the demand made for work in consequence of its connection to the body’ – and this energy cost eventually leads to the ‘breaking down of the will’ by the constant ‘fighting’ to maintain what was ‘hidden’ that was painful and not wanting to ‘come out’, and this breakdown of the will / ‘mental exhaustion’ lead to the signs and symptoms described above, which could in a circular way be used to diagnosed the presence of the underlying disorders. In a positive final observation, both Jung and Adler thought that the psyche was self-regulating, and that the development of these symptoms was purposive, and an attempt to ‘self-cure’ by compensation, and by bringing the destructive repressions, which exist at a subconscious level so are not directly perceived by the folk who have them, to their attention, or at least to that of their clinician or therapist, it would eventually lead to cure or at least ‘individuation’ and acknowledgement of the underlying issues, which to therapist of that era was the start of the cure.
Therefore, in this ‘id and ego’ model developed by Freud, Jung and their colleagues all those years ago, symptoms of chronic fatigue and burnout may be the psyche’s way of creating knowledge of and thereby attempting to cure latent psychic drives which lead to obsessive work or sporting goals and activity, created by past psychological trauma and a resultant ‘weak ego’, which results in chronic fatigue when the psyche cannot ‘cope’ with ‘fighting’ these often unperceived issues for a long period of time / for the life period up to the point when they collapse. Interestingly, while these theories have been mostly long forgotten or have fallen into disfavour, there has recently been an increase again in interest in the concept that mental and physical ‘energy’ is a finite commodity, with psychologist Roy Baumeister’s theory of ‘ego depletion’ gaining much traction recently, which suggests that a number of disorders of ‘self-regulation’, such as alcohol addiction, eating disorders and obesity, lack of exercise or excessive exercise, gambling problems and inability to save money and personal debt, may be related to one using up one’s ‘store of energy’ resisting the ‘deep’ urges which lead to these life imbalances, and eventually willpower decreases to a level where one cannot resist ‘doing’ them, or cannot raise the effort to continue resisting the desire to act out one’s wishes. In Baumeisters own words a tempting impulse may have some degree of strength, and so, to overcome it, the self must have a greater amount of strength, which can eventually be worn out or overcome, leading to adverse lifestyle choices in this ‘impaired mental energy state’. All lifestyle diseases and disorders may in his model therefore be related to an insufficiency of self-regulatory capacity, and there is an energy cost to resisting the ‘urges’ that lead to poor lifestyle choices, that may with time lead to either acute mental or physical fatigue, or in extreme cases to the development of chronic fatigue. Like with most contemporary psychology, the underlying reasons for such potential eventual failure of self-regulation were not deeply examined by Baumeister to the level that it was by Freud, Jung and colleagues, perhaps because so much of Freud, Jung and Adler’s theories are difficult to prove or disprove and therefore psychology and psychiatry have in the last few decades ‘turned against’ their theories and embraced neuroscience as having the best chance of understanding how the mechanisms underpinning self-regulation or the lack of it ‘work’, but neuroscience is currently far too ‘weak’ a discipline methodologically wise to be able to do such. Having said this, it is surely important that folk like Roy Baumeister are re-breaking such ground, and our understanding of such complex disorders such as CFS, and others such as fibromyalgia, which are also complex diagnostic dilemmas, is enhanced by the insight that mental energy ‘ego’ depletion may play a part in them. Sadly, there is evidence (described by Tracie Afifie and colleagues at Manitoba and MacMaster Universities) that folks who suffered physical or sexual abuse in childhood, or were exposed to between-parent physical violence at a young age, have an increased association with a number of chronic physical conditions (including arthritis, back problems, high blood pressure, migraine headaches, cancer, stroke, bowel disease, and significantly also CFS), and also a reduced self-perceived general health in adulthood, all of which would support the ‘ego and id’ psychopathology development theories of Freud and Jung to a degree, though of course surely not all folk who develop CFS have such childhood trauma issues.
Like the definition of neurasthenia and CFS, perhaps our understanding of their ‘deep causes’ is also moving in a ‘full circle’, and our knowledge of the underlying causes of CFS, if it does not have a specific organic or viral / toxic cause, needs to reconsider these basic concepts proposed by Jung, Freud and Adler more than one hundred years ago, and currently appears to be potentially re-occurring in a ‘repackaged’ version as suggested by Baumeister and his contemporaries theories in recent times. Perhaps the drive to keep on exercising that we found in all those athletes we examined in our studies at the University of Cape Town all those years ago was the key factor in the cause of their chronic fatigue, and was an ‘external’ manifestation of issues that they were not even aware of. We did not know enough about the subject back then to even ask them about it when we were trying to understand the causation of their symptoms. Perhaps a major component of CFS is mental exhaustion associated with continuously ‘fighting’ underlying past psychological trauma that the folk suffering from it are not even aware of, or at least this is part of the cause of the symptom complex along with other more organic or infective causes. Of course describing a disorder as either neurological or psychiatric is reductive, and indeed dualistic, and surely similar physical brain neural mechanisms underpin both ‘neurologic’ and ‘psychological’ disorders which we just cannot currently comprehend with the research techniques currently available. One has try to understand the reasons why one is ‘driven’ to do anything, particularly as one gets older and one’s physical (and perhaps mental) resources diminish and need to be ‘husbanded’ more carefully, though paradoxically CFS is a disorder which afflicts folk most often initially in their early twenties, and often ‘burns out’ / attenuates with increasing age, perhaps because part of growing older is often about understanding one’s issues to a greater degree, dealing with them, and living more ‘within one’s means’ all of materially, socially, physically, mentally and spiritually (although for some folk such learning never occurs). Aging may therefore be curative or protective from a CFS perspective (or one may die of ‘corollary damage’ such as heart attacks rather than developing CFS as a result of chronic stress related to unfulfilled drives).
Fatigue as a symptom is surely the body and mind ‘telling us’ that something is not ‘right’ and we need to rest – either acutely when we are doing sport, or chronically when we are ‘fighting’ something we do not understand or are aware of. The challenge is for us not just to rest, but to try and understand why we so often resist resting (well, those of us with complexes rather than those of us who are completely self-actuated and do not have stress or drives), and why life balance is so hard for many folk to find. The need (or unwanted requirement) for a prolonged rest / period of avoidance of one’s routine life / a ‘long sleep’ is often perhaps the last resort of those who are chronically fatigued and is nature’s way of ‘telling’ folk that they have ‘run out’ of responsive resources, and healing will not happen without it, though the healing may paradoxically be not of the fatigue itself, but of its underlying ‘deep’ causes. Now I am finished this its time to rest, and ponder what caused the need to write it in the first place, and why I have spent my holiday Easter period preparing for its writing, and ‘stoking the creative demon’ which never rests and which surely eventually damages one even as it creates, rather than just sitting in a coffee shop watching the world go by and thinking of nothing but how nice the next sip of coffee is sure to be. Demons of the past, away with you, before you lead to permanent mental and even physical damage, and tire folk out in the process!