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Fatigue with Medical Disease
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Myopathic Fatigue Not unexpectedly, fatigue and intolerance of exercise (ie, fatigue with mild exertion) are prominent manifestations of myopathic disease, in which muscles are weak to begin with Even in a disease such as myasthenia gravis, the muscles exhibiting fatigue are usually weak even in the resting state The classes of myopathic disease in which weakness, inability to sustain effort, and excessive fatigue are notable features include the following: the muscular dystrophies, congenital myopathies, disorders of neuromuscular transmission (myasthenia gravis, Lambert-Eaton syndrome), toxic myopathies (eg, due to cholesterol-lowering drugs), some of the glycogen storage myopathies, and mitochondrial myopathies One type of glycogen storage disease McArdle phosphorylase de ciency is exceptional in that fatigue and weakness are accompanied by pain and sometimes by cramps and contracture The rst contractions after rest are of near normal strength, but after 20 to 30 contractions, there occurs a deep ache and an increasing rmness and shortening of the contracting muscles The characteristics of these diseases are presented in the chapters on muscle disease Another such process acid maltase de ciency is at times associated with disproportionate weakness and fatigue of respiratory muscles, which leads to dyspnea and retention of carbon dioxide Fatigue in Neurologic Diseases Fatigue of varying degree is a regular feature of all diseases that are marked by denervation of muscle and loss of muscle ber Fatigue in these cases is due to the excessive work imposed on the intact muscle bers (overwork fatigue) This is most characteristic of amyotrophic lateral sclerosis and the postpolio syndrome, but it also occurs in patients who are recovering from Guillain-Barre syndrome and in those with chronic polyneuropathy Not surprisingly, many neurologic diseases that are characterized by incessant muscular activity (Parkinson disease, double athetosis, Huntington disease, hemiballismus) induce fatigue Also, muscles partially paralyzed by a stroke feel tired and may cause overall fatigue state (the distinguished neuroanatomist A Brodal has given an interesting account of his own stroke and its effects on muscle power) Fatigue is often a major complaint of patients with multiple sclerosis; its cause is unknown, although the effect of interleukins circulating in the cerebrospinal uid has been pos-
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Lassitude and Fatigue as Symptoms of Psychiatric Illness
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The great majority of patients who seek medical help for unexplained chronic fatigue and lassitude are found to have some type of psychiatric illness Formerly this state was called neurasthenia, but since lassitude and fatigue rarely exist as isolated phenomena, the current practice is to label such cases according to the total clinical picture The usual associated symptoms are nervousness, irritability, anxiety, depression, insomnia, headaches, dizziness, dif culty in concentrating, reduced sexual impulse, and loss (or sometimes increase) of appetite In one series, 85 percent of persons admitted to a general hospital and seen in consultation by a psychiatrist for the chief complaint of chronic fatigue were diagnosed, nally, as having anxious depression or anxiety neurosis In a subsequent study, Wessely and Powell found similarly that 72 percent of patients who presented to a neurologic center with unexplained chronic fatigue proved to have a psychiatric disorder, most often a depressive illness Several features are common to the psychiatric group with fatigue Tests of peak muscle power on command, with the patient exerting full effort, reveal no weakness The muscles retain their normal bulk and tendon re ex activity The fatigue may be worse in the morning There is an inclination to lie down and rest, but sleep does not follow The fatigue is worsened by mild exertion and relates more to some activities than to others Inquiry may disclose that the fatigue was rst experienced in temporal relation to a grief reaction, a surgical operation, physical trauma such as an automobile accident, or a medical illness such as myocardial infarction The feeling of fatigue interferes with mental as well as physical activities; the patient is easily worried, is mentally inactive, is full of complaints, and nds it dif cult to concentrate in attempting to solve a problem or to read a book, or in carrying on a complicated conversation Also, sleep is disturbed, with a tendency to early-morning waking, so that such persons are at their worst in the morning, both in spirit and in energy output Their
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