Chicken or the Egg

With regard to the article:

"Memory for fatigue in chronic fatigue syndrome: relationships to
fatigue variability, catastrophizing, and negative affect."
Journal: Behav Med. 2008 Spring;34(1):29-38.
Authors: Sohl SJ, Friedberg F.

and the abstract posted on Co-Cure:
http://listserv.nodak.edu/cgi-bin/wa.exe?A2=ind0804b&L=co-cure&T=0&P=4722

The authors suggested that "Recall discrepancy was significantly
related to the variability of momentary fatigue. In addition,
catastrophizing, depression, and momentary fatigue were all
significantly related to recall discrepancy. Catastrophizing,
depression, anxiety, and momentary negative affect were all
significantly associated with momentary fatigue.The findings
suggest that momentary fatigue in patients with CFS is
related to modifiable psychological factors."

I may have misread the authors' hypothesis, but as I understand
it, they are saying that if the psychological factors could be reduced
CFS patients would have fewer incidents of momentary fatigue.

Is it possible that the reverse is the case?  That is, could this again
be a situation where no conclusion can be drawn about the CAUSE
of what is an apparent CORRELATION, without first making a
statement about the nature of the disease itself.

Perhaps patients who experience [surprising, debilitating] episodes
of momentary fatigue are MORE LIKELY to feel "depression, anxiety,
and momentary negative affect," and also be MORE LIKELY to
"catastrophize."

When you cannot do something that you are used to doing in every day
life, it is very disconcerting.  The direction of causation should run
from the abnormal experience (caused by the illness) to the
psychological effects of having an abnormal experience.

As a simple example, an ambulatory patient could find it frightening
to be left alone in a large place because patients with ME/CFS often
have episodes of memory loss where they have no idea where they
are, how they got there, or why they are there at all.  Would this not
lead quite naturally to feeling anxious?

A person who was competent in various avenues of life - as a
parent, or a cook, or a driver, or a teacher, or a physician, or a
lawyer, or an executive - who suddenly was unable to recall
simple words or phrases, or what the conversation was about in
the first place, would be expected to feel all kinds of things -
fear, anxiety, depression being among them. 

What is it like to sink into Alzheimer's?  What is it like to have
Parkinson's?  What is it like to have M.S and suddenly find
yourself getting worse?

Sudden weakness - sudden loss of ability - suddenly loss of
memory in a highly verbal society - is disconcerting to
a functioning person, whether adult or child.  Momentary fatigue
and momentary loss of memory translates into momentary
inability to do something that normally you could do, that other
people around you do with ease.   It then seems perfectly
normal to experience:

Depression - because you have been rendered impotent, and
                         thus sad;
Anxiety - because you don't know what this means, or how
                long it will last, and the uncertainty is frightening;
Momentary negative affect - you have, in a very real sense,
               suddenly lost yourself - lost who you were;
and
Catastrophizing - fear of it this strange experience happening
               again, or worse - happening more often

The remedy would depend on the direction of causation, so it
is important to understand which comes first.

If the psychiatric experiences are the result of physical
and mental insufficiencies, however short, that the patient
cannot control and that render the patient "less" than he
or she was before, perhaps a better understanding
of the disease can relieve the psychiatric distress.

As I read the abstract, I understood the study to either be
neutral about causation, or to assign causation to the
physical abnormality - until I read the last line:

"The findings suggest that momentary fatigue in patients with
CFS is related to modifiable psychological factors."

That suggests the authors believe if the psychological
experiences are themselves altered (by some type of
psychological therapy), the patients will have fewer or
less intense experiences of momentary fatigue or
loss of recall. 

Surely an understanding of the psychological
impact of momentary memory lapses or weakness -
being able to explain to the patient that THIS is what
we call "depression," and it is normal; THIS is what
we call "anxiety," and it is normal; THIS is what we call
"catastrophizing," and it is normal - can help with
the psychic pain of having a debilitating disease.

But modifying psychological factors is NOT going to change
the disease process itself - any more than it will mend
a broken leg, cure cancer, alter the progression of
Alzheimer's, or reverse ALS.

Once again with this disease, we find it necessary to
warn that when working with correlations, one should
not make assumptions about causation without being
certain that the PHYSICAL problem isn't leading to the
PSYCHOLOGICAL distress - rather than the other way
around.

Mary Schweitzer, Ph.D.

* * *

As one of many patients with unwarranted psychiatric diagnoses made by MDs (and dismissed by psych evaluators), I think this is important to note.

When I say "I can't", I mean that I have tried and failed, not that I am depressed and afraid to try.

When I say that I have concerns about walking down a flight of stairs and crossing busy streets alone due to daily fainting spells that come without warning, that's a reasonable concern based in reality, not anxiety. 

And it's certainly not catastrophizing to think that on a street where people regularly drive at high speeds, someone might run me over if I've passed out in the middle of the street and they don't see me lying there in time to stop, or that I would become injured if I fell down a flight of stairs and landed on concrete.  Those are logical results of losing consciousness with no one around to catch me or direct traffic around me.

But it's easier for doctors to assign unwarranted psych diagnoses than to think outside the box to find the tests that will show something physically wrong.

Similarly, there are numerous instances in my medical records where the easy answer required the doctor to reverse the order of cause-and-effect.  If you believe the doctors, I didn't lose my job because I was sick, I got depressed because I lost my job; and I didn't stop exercising because I was sick, I got sick becauseI stopped exercising.  My version makes sense, too ... it just wasn't what they wanted to hear.