Fashions In Disease Names And Patterns

Cheryl Farley Combat Diabetes In 10 Days Or Less

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If fashions in treatment are slow to change, this is equally true of the way illness patterns are conceptualized by doctors as well as patients.

As an intern more than 50 years ago, I worked up a 38-year-old man for complaints of weakness, fatigue, low grade fever, migrating aches and pains, and an inconstant rash. By a careful history, I found that he had worked 10 years earlier in a rendering plant where he experienced an acute infection with fever, chills, and myalgia. He recovered after several weeks, but had never felt completely well thereafter. When agglutinin titers came back positive from the laboratory and his skin test for the Brucella antigen puffed up, my colleagues and I confidently made the diagnosis of chronic brucellosis from the history and the serology. The patient was pleased to have a name for what was wrong even though we had no specific treatment to offer.

What was wrong with this diagnosis? Serology (and skin tests) remain positive for years after Brucella infection, whether or not the patient is symptomatic. Later studies were to show [26] that what distinguishes those with persisting symptoms from those without them is not the agglu-tinin titer but a depressive disorder which correlates with pre-illness personality and life circumstances. Chronic brucellosis is not a disease, but a pattern of illness behavior, triggered by an acute infection in a psychologically predisposed individual, an illness pattern reinforced by medical labeling that crystallizes distress by sanctioning it as a biological entity.

With chronic brucellosis largely controlled by public health measures, it disappeared from the medical scene in the USA. But it was soon replaced by new idioms of distress: chronic fatigue syndrome [27, 28], fibromyalgia [29, 30], and chronic Lyme disease [31, 32].

Chronic fatigue syndrome (CFS) was initially ascribed to infection with the Epstein-Barr (E-B) virus [33]. Patients did (and do) have high virus titers, but so do most Americans; the virus is ubiquitous! After the E-B virus was abandoned, other causal agents have been proposed; thus far, each has failed of proof [34]. CFS patients suffer an illness as real as any other. What is at issue is its causation and its significance. Despite the overlap in symptoms, CFS is not simply a somatized form of depression [35]; a randomized trial of fluoxetine for CFS did not show benefit—even for those patients with comorbid depression [36]. CFS patients failed to respond to a trial of fludrocortisone acetate [37], a treatment proposed to correct the neurally mediated hypotension common in CFS. Negative trials have left CFS patients in limbo; not only has the treatment failed, but the cause of their illness remains ambiguous. Patients are aggrieved when doctors dismiss their complaints as "mental" (i.e., not "real") because they can't find a bug or a toxin [38]. Patients have taken the lead in organizing a Chronic Fatigue Syndrome and Immune Deficiency Society to lobby for the legitimacy of their disease. They visit doctors who purvey illusory theories and "cures" and profit from their patronage.

Chronic brucellosis and CFS were preceded in the 19th century by neurasthenia [39] and early in the 20th century by effort syndrome and myalgic encephalomyelitis. "Chronic Lyme disease'' is a new entry on the scene. Like chronic brucellosis, it is an illness syndrome that appears months or years after an episode of acute disease caused, in this case, by infection with the spirochete Borrelia burgdorferi. Sufferers attribute the symptoms to the earlier infection; the evidence for this claim is at best equivocal. Seltzer et al. [32] reported a long-term study comparing several hundred patients who had suffered an episode of acute Lyme disease and age-matched controls with no history of Lyme disease. Although many former Lyme patients reported increases in symptoms and increased difficulties with daily activities of living during a follow-up of 1-11 years after the diagnosis of Lyme disease, the frequency of symptoms and problems did not differ significantly from those reported by the controls over the same interval. Allen Steere [40], a leading investigator of acute Lyme disease, evaluated 788 patients referred to his clinic for "chronic Lyme disease'' [41]. Twenty-three percent appeared to be suffering from acute Lyme disease; 20% had Lyme disease plus a concurrent illness (most commonly chronic fatigue syndrome or fibromyalgia); 57% had no Lyme disease at all, but suffered from other fatigue or pain syndromes.

With time, these syndromes will be sorted out in new constellations and will be renamed to fit new explanatory models. One can be certain of two things: that "new" somatization syndromes will arise and that new names will be given to them.

A Psychiatric Folie a Deux

In the last two decades, in the USA and the UK, there has been a virtual epidemic of "multiple personality disorder'' attributed to "repressed memories'' of sexual abuse in childhood. More accurately, there has been an epidemic of the diagnosis without any reliable evidence of an epidemic of the disorder. Pierre Janet reported dual consciousness as early as in the 1880s, but the clinical diagnosis of multiple personality disorder remained relatively rare until a case history was described at book length by Thigpen and Cleckley [42]. In the 1970s and 1980s, cases multiplied rapidly; even more strikingly, the number of different "personalities" found in individual patients multiplied just as rapidly [43]. By the end of the 1980s, claims reached the hundreds.

The dissociation was attributed to repressed memory of sexual abuse in childhood. "Therapists" were able to generate "memories" of abuse in the very first year of life despite the impossibility of an infant encoding memory in words before the development of language. With the "help" of psychotherapists, patients "recovered" memories of having been involved in Satanic sexual orgies and in breeding infants they subsequently cannibalized. Others reported having been abducted by Martian aliens for sexual manipulation. Quite apart from the absence of any confirmatory evidence, it is no less remarkable that many "memories" were of patently impossible events (e.g., giving birth at age six). The movement metastasized into the law courts. Patients sued their parents and obtained sizeable settlements in some cases. It was not long before parents began to retaliate by suing the "therapists" who had entrapped their children. The damage to families was incalculable [44]. What went on in the USA was repeated in the UK [45].

The repressed memories jointly fabricated by therapists and patients recall an era in 19th century Paris: the flamboyant symptoms displayed by hysterics who were presented by the eminent neurologist Jean-Martin Char-cot to packed amphitheaters at the Salpetriere. On command, patients would display arc en cercle (opisthotonos), pseudoseizures, anesthesias and paralyses [46]. The epidemic of grand hysteria gradually subsided and is no longer seen in Paris or elsewhere. Yet, Charcot was no charlatan, but one of the most highly regarded physicians of his time. He led his patients unwittingly into behaving as he expected; their performance met their needs as well as his. Thus, it is less surprising that it was not only unqualified "therapists" who participated in the generation of a non-disease; reputable psychiatry departments gave credence to the same ideologic baggage. The farce seems finally to be playing itself out, hoist with its own petard by the need to multiply personalities and to fabricate ever more outlandish "memories''. The history of this episode should be an embarrassment to psychiatry [47, 48]. It is a "memory" we dare not forget.

DOES PROSPERITY IMPLY THE END OF DISEASE?

The recognition that poverty is associated with disease is ancient. As living conditions in the industrialized nations have improved, so has life expectancy at birth—from less than 50 years at the beginning of the 20th century to well over 70 years by its end. Nonetheless, socioeconomic status and health status remain closely correlated. The extent of income inequality within a given population is an even more significant predictor of health status. In a study of the associations between income inequality and mortality in 282 US metropolitan areas, those areas with the greatest income inequalities were found to have death rates far higher than those with narrower extremes. Excess mortality ranged from 64.7 to 95.8 per hundred thousand. Effects were most evident for infant mortality and mortality in the adult years from 15 to 64. To put the magnitude of this mortality difference into perspective, it is comparable to the combined loss of life from lung cancer, diabetes, motor vehicle crashes, human immunodeficiency virus (HIV) infection, suicide and homicide in the USA [49].

Modernization, however, is not a royal road to better health. "Epidemics" of diabetes have appeared among Polynesians, American Indians, and Aboriginal Australians as traditional lifestyles have been altered. Consider the population of Nauru, a small Pacific island inhabited by about 5000 Micronesians. Until World War II, high energy expenditure was required for sheer survival through fishing and hardscrabble subsistence farming. After the war, foreign companies began large-scale phosphate mining and paid rental income to the Nauruans, rapidly transforming them into one of the world's wealthiest and most sedentary peoples. Today, virtually all foodstuffs are imported; most have a high caloric content; obesity is ubiquitous.

Non-insulin-dependent diabetes mellitus (NIDDM), previously minimal, reached epidemic proportions in the 1950s and afflicted almost two-thirds of 55-64-year-olds. Paradoxically, wealthy Nauru now has one of the world's shortest life spans because of diabetes and its complications [50]. The Nauru epidemic has ominous implications for Southeast Asia. Rates of diabetes among Chinese and Indian expatriates living in the West (in contrast to low rates in China and India) make it virtually certain that the improved living standards anticipated for India and China in the next century will lead to epidemics of NIDDM [51].

Social Class and Mental Disorder

Is there a relationship between mental disorder and poverty? Faris and Dunham [52] demonstrated that rates for mental disorder are higher in lower-class than in middle-class and upper-class neighborhoods. They reported that high rates of psychosis "cluster in the deteriorated regions in and surrounding the center of the city, no matter what race or nationality inhabits that region''. They hypothesized that "extended isolation of the person (a product of the disorganized neighborhood) produces the abnormal traits of behavior and mentality''. However, 30 years later, Dunham [53] undertook a new study which led him to conclude that "type of community and social class'' have no effect on the incidence of schizophrenia. Rather, the differential rates observed reflect residential mobility arising from social sorting and selection.

The association between disease rate and social class has been repeatedly confirmed. The question remains: to what extent does poverty account for increased rates in low-income areas and to what extent do those increases reflect downward social drift arising from economic and interpersonal incompetence? Conclusive answers are not in. The two hypotheses need not be dichotomous. Further, what is true for one mental disorder may not be true for another. Dohrenwend et al. [54] have provided evidence from a careful epidemiologic study in Israel that the aggregation of schizophrenia in poor areas reflects downward drift, whereas the high rates for depression in women, and antisocial personality and substance abuse disorders in men arise from the social stress associated with low socioeconomic status. For both schizophrenia and depression, the course and outcome of the illness are influenced by socioeconomic status, as it affects the likelihood of getting care and the quality of care that is provided.

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