Division in the medical camp

The medical profession is divided into two major camps: those who believe Chronic Fatigue Syndrome and its cousins (such as fibromyalgia) are legitimate diseases and those who believe they are merely bodily responses to stress.

On one hand you have a person who appears to be suffering from disabling fatigue or pain, and on the other, a divided medical profession, who say it’s a legitimate disease, a non-disease response to stress, or (a few) that it’s all in the person’s head.

Our purpose is not to resolve the medical debate. But we do need to help this person (and his or her family and friends) deal with the situation in a way that honours God.

Definitions

Chronic Fatigue

Chronic fatigue syndrome (CFS) is a debilitating and complex disorder characterized by intense fatigue that is not improved by bed rest and that may be worsened by physical or mental activity. People with CFS most often function at a substantially lower level of activity than they were capable of before the onset of illness. The cause or causes of CFS have not been identified and no specific diagnostic tests are available. (from the Center for Disease Control)

Common names:

• Chronic Fatigue and Immune Dysfunction Syndrome
• Yuppie Flu
• ME (myalgic encephalomyelitis)
• Chronic Candida
• Post Viral Fatigue Syndrome
• Historically it has been known by many names, including “the vapours.”

Common victims: The female-male ratio is 3:1. The mean time to recovery is about two years.

Suggested causes of Chronic Fatigue Syndrome:

• Epstein-Barr virus
• Immune system problems
• Allergies
• Hormone and cortisol problems (leading to increased inflammation and irregular immune cell activities)
• Blood pressure and pulse irregularities

Conclusion: While one or more of these factors appear to contribute in the case of one person or another, none contributes in every occurrence of chronic fatigue.

Restated: There may not be one source of chronic fatigue. It appears that a lot of different roads can lead to the final destination of chronic exhaustion.

Fibromyalgia

Connections with depression: About two-thirds of those diagnosed with fibromyalgia have “a lifetime history of major depression.” (Smith, The Christian Counselor’s Medical Desk Reference, 258)

The chicken-or-the-egg dilemma: Opinion is divided over whether the person’s unrelenting body pains are the cause of their depression or if the bodily aches and pains are physical consequences of their severe depression.

Divided medical opinion: The scientific literature presents a contradictory picture. Many consider it a definite disease of the body. Others believe that all these people are simply responding to stress in their lives.

[Image of fibromyalgia tender points map]

Three categories of people with Medically Unexplained Symptoms

Fakers

There can be no doubt that a small percentage of people who claim chronic fatigue or chronic body pain are proverbial sluggards, hoping to avoid work and life responsibilities by means of their self-professed medical condition.

The sluggard buries his hand in the dish, but will not even bring it back to his mouth. (Proverbs 19:24)

The desire of the sluggard puts him to death, for his hands refuse to work. (Proverbs 21:25)

The sluggard is wiser in his own eyes than seven men who can give a discreet answer. (Proverbs 26:16)

A real but undiagnosed physical disease

The person may have a real, but as-of-yet unidentified physical disease that is causing the fatigue or muscular pain. It may be undiagnosed because the person has not been to the doctor or the doctors have not yet run the correct tests to identify the problem. Less likely, but also possible (since medical knowledge is still advancing), is the possibility that the person’s disease has not yet been identified by medical science.

Spiritual problems with physical consequences

In this case, the person’s pain or fatigue is real, but its source is primarily spiritual, not physical. Their unwise or sinful responses to life situations such as stress and sickness have led to physical consequences.

Note: It might be important to help the counselee who is in category 3 to understand the difference between the following two words:

• Hypochondria: The practice of imagining symptoms or sickness that one doesn’t have.
• Psychosomatic: Having real physical symptoms that stem from one’s mental and emotional state rather than an organic disease.

Point: Hypochondriacs imagine symptoms. In contrast, psychosomatic conditions are not imaginary; they just can’t be traced to a demonstrable physical source. The difference is significant, and might help the person find relief from the fear that the pain or fatigue is “all in my head.”

Her genuine physiological pain or fatigue might have its initial source in bad choices rather than organic malfunction, but the symptoms are very real, whatever their source.

Different approaches required

Fakers

Fakers need a good dose of Proverbs on the sluggard, identifying what idol they are serving by falsifying or exaggerating their symptoms.

The genuine

To back up the proverbial dump truck and unload Proverbs on the sluggard on someone who very much wants to work and to be active but can’t muster the strength to do so would be unfair and cruel. Therefore, a counsellor needs to distinguish those who, over time, are obviously languishing in the sluggard category from those who are in the second and third categories.

Three questions that expose fakers

1. What does the counselee hope to gain by his or her professed fatigue or pain? Does he like lying on the couch and watching rugby re-runs while his wife goes out to work five days a week? Is she escaping painful emotional family situations by using her symptoms as a shield to hide behind?
2. What is he or she losing? If the counselee is unable to do things he or she really enjoys, it is unlikely that the symptoms are faked.
3. How much effort is the counselee willing to exert to carry out life responsibilities that are within the limitations of his or her symptoms? There is a categorical difference between a person who tries her best within the limits of her physical condition, and the person who refuses to or is openly reluctant to do what she is capable of doing (however limited that activity may be). If all she can do in the house is wash the dishes once a day, but she does so willingly, then she is probably not faking.

Summary: Fakers are usually exposed by their selfish motives and their unwillingness to cheerfully do what they can.

A side note on helping a counselee interact with his or her doctors

It is not unusual for a person with chronic fatigue or pain to have seen a dozen doctors or more in her pursuit of a solution. The following might help you counsel her on how to make her medical consultations more helpful.

1. Accept that vague symptoms tend to lead to vague diagnoses. This doesn’t mean the symptoms aren’t real; they just aren’t specific enough to allow the doctor to pinpoint a source. In light of this, realise that a good doctor might ask you to wait until more symptoms or more specific symptoms develop.
2. In spite of amazing technology such as MRI scans, most people have a thousand unexplained (and at this point unexplainable) symptoms every day. We must accept this especially in cases of chronic fatigue and pain, without in any way doubting the concern or skill of our doctors.
3. Avoid pressuring doctors to run tests they believe are unnecessary. Don’t be the patient for whom the doctor orders a test just to get rid of you so he can move on to his next patient.
4. Don’t give in or be offended when a doctor, having exhausted the obvious possible physiological diagnoses, defaults to prescribing anti-depressants, even though you aren’t depressed and don’t believe anti-depressants are the solution even if you were.
5. Don’t be angry or despondent when a doctor (most likely unintentionally) makes you feel as if you are imagining your symptoms because nothing has shown up in the blood tests.
6. Ask the doctor, “What would you be doing if you were in my situation?” Personal opinion mingled with professional opinion can be very helpful in making decisions about what further investigation or treatment options are worth pursuing.

What kind of doctor to look for

Usually patients with chronic syndromes appreciate the following in a doctor:

• A doctor who patiently listens to their story and symptoms.
• A doctor who gives explanations of the known medical options, even when he or she can’t pinpoint the problem. Such explanations assure the patient that the doctor cares, and that he knows his field well enough that some obvious problem isn’t slipping by unnoticed.
• A doctor who draws them into the evaluation process in an interactive way.
• A doctor who exhibits a bit of a “detective” attitude, willing to think a bit more deeply once the obvious, standard problems have been excluded.
• A doctor who is willing to give attention to the management of the symptoms.

Medically unexplained, chronic, disabling physical exhaustion and/or bodily pain

The spiritual physical connection

Human beings are spiritual-physical creatures, so both the physical aspects and the spiritual aspects of medically unexplained symptoms need to be addressed. As biblical counsellors, we will focus primarily on the spiritual.

My son, give attention to my words; Incline your ear to my sayings. Do not let them depart from your sight; keep them in the midst of your heart. For they are life to those who find them and health to all their body. (Proverbs 4:20-22)

Do not be wise in your own eyes; fear the LORD and turn away from evil. It will be healing to your body and refreshment to your bones. (Proverbs 3:7-8)

A tranquil heart is life to the body, but passion [zeal or jealousy] is rottenness to the bones. (Proverbs 14:30)

Bright eyes gladden the heart; good news puts fat on the bones. (Proverbs 15:30)

A joyful heart is good medicine, but a broken spirit dries up the bones. (Proverbs 17:22)

Point: Turning away from evil, keeping God’s word, humility, godly tranquility, and a joyful disposition strongly influence physical health. In other words, whatever the person’s physical symptoms, in these cases there will almost certainly be a spiritual component as well.

Physical aspects

Guiding principle: Unless your data gathering clearly suggests that the person is just a sluggard, assume the person’s symptoms are real, discouraging, and to some degree, disabling.

While biblical counsellors are (in most cases) not medical doctors, there is some general advice that can be given on the physical side of things.

General common sense advice

• If he or she has not done so, encourage the counselee to get a full medical check-up. A check-up might uncover a readily identifiable and treatable physical condition. If the problem is fatigue and headaches, encourage them to get an eye exam as well.
• Encourage the counselee to read reputable material that will calm her fears about some underlying, life-threatening condition. Point: Information like this might keep your counselee from pursuing unnecessary medical treatments and from worrying (which will only exacerbate his or her symptoms).
• Consider possible allergens or toxins in the home or workplace.
• Assuming it does not violate the doctors’ advice, encourage sensible sleep patterns, eating habits, and mild exercise.
• Warn against the danger of seeking medical treatments beyond their financial means.
• Help the person establish a schedule that will allow for and encourage recovery.

The need for a realistic schedule

In most cases of chronic fatigue, the pre-onset condition includes high levels of physical or emotional stress. You might need to help the counselee (and her family) rework her schedule and life responsibilities, exercising the discipline of rest so that her body can recover.

Significant or full recovery is possible in most cases of Chronic Fatigue Syndrome, but recovery time is usually between eighteen months and three years. During that period the counselee will need to regulate her schedule carefully so as not to exacerbate the problem or experience a relapse. Having pushed too hard and paying the consequences for it, like an athlete who has over trained, she must allow her body time to recover.

Note: On occasion, you might also need to warn a person who is headed toward this situation to take his or her foot off the accelerator pedal of life. The well is deep—a two-year recovery period on average. Don’t fall into it.