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FATIGUE, ASTHENIA, ANXIETY, AND DEPRESSIVE REACTIONS
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In this chapter, we consider the clinically related phenomena of lassitude, fatigue, nervousness, irritability, anxiety, and depression These complaints, though more abstruse than paralysis, sensory loss, seizures, or aphasia, are no less important, if for no other reason than their frequency in neurologic and general practice In an audit of one neurologic outpatient department, anxiety and depressive reactions were the main preliminary diagnosis in 20 percent of the patients second only to the symptom of headache (Digon et al) And in two primary care clinics in Boston and Houston, fatigue was the prominent complaint in 21 and 24 percent, respectively Some of these symptoms, acting through the autonomic nervous system, represent only slight aberrations of function or only a heightening or exaggeration of normal reactions to all manner of medical and neurologic diseases; others are integral features of the diseases themselves; and still others represent subtle and inchoate disturbances of neuropsychiatric function, which are not yet suf ciently advanced to be readily identi ed as one of the diseases described in the section on psychiatry It is because of their frequency and clinical signi cance that we have accorded them a chapter of their own among the cardinal manifestations of neurologic disease
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Of the symptoms to be considered in this chapter, lassitude and fatigue are the most frequent and often the most vague Fatigue refers to the universally familiar state of weariness or exhaustion resulting from physical or mental exertion Lassitude has much the same meaning, although more strictly it connotes an inability or disinclination to be active, physically or mentally More than half of all patients entering a general hospital register a complaint of fatigability or admit to it when questioned During World War I, fatigue was such a prominent symptom in combat personnel as to be given a separate place in medical nosology, namely combat fatigue, a term that came to be applied to practically all acute psychiatric disorders occurring on the battle eld In subsequent wars it was a key element in the posttraumatic stress and Gulf War syndromes In civilian life, fatigue is, of course, the central feature of the chronic fatigue syndrome The common clinical antecedents and accompaniments of fatigue, its signi cance, and its physiologic and psychologic bases should, therefore, be matters of interest to all physicians These aspects of the subject will be better understood if we rst consider the effects of fatigue on the normal individual
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duced output of work (work decrement) or a lack of endurance; and (3) a subjective feeling of tiredness and discomfort As to the biochemical and physiologic changes, continuous muscular work leads to depletion of muscle adenosine triphosphate (ATP), the supply of which is derived from creatine phosphate via phosphorylation of adenosine diphosphate (ADP) With continued and more intense exercise, a further supply of ATP becomes available as a result of the anaerobic breakdown of glycogen When all the muscle glycogen has been consumed, exercise at a maximal level cannot be continued However, mild to moderate exercise is still possible, since fatty acids provide an increasing share of muscle fuel Gradually there is an accumulation of lactic acid and other metabolites, which in themselves reduce the power of muscular contraction and delay the recovery of muscle strength Even in normal persons, extreme degrees of muscular effort, in which activity exceeds the provision of substrates, may result in necrosis of bers and a rise in serum concentrations of creatine kinase (CK) (this effect is much more evident in individuals with one of the hereditary metabolic diseases of muscle described in Chap 51) The decreased productivity and capacity for work, which is a direct consequence of fatigue, has been investigated by industrial psychologists Their ndings clearly demonstrate the importance of motivational factors on work output, whether the work be of physical or mental type More striking are individual constitutional differences in energy, which vary greatly, just as do differences in physique, intelligence, and temperament It should be emphasized that in the majority of persons complaining of fatigue, one does not nd true muscle weakness This may be dif cult to prove, for many such individuals are disinclined to exert full effort in tests of peak power of muscle contraction or in endurance of muscular activity A disinclination to make an effort is also an essential characteristic of the fatigued mind
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