The following is an excerpt from Understanding Chronic Pain: A Doctor Talks to His Patients
By Robert T. Cochran, Jr., M.D.
About the author: A graduate of Vanderbilt University Medical School, Robert T. Cochran Jr., M.D. completed his residency in internal medicine and neurology at the University of Texas and Duke University. He established his private medical practice in Nashville in 1963, where he continues to work today.
Serving as the co-director of the Pain Center at Centennial Hospital in Nashville in the 1990s, he built a reputation as a leader in chronic pain management. Treating thousands of pain patients throughout his 40-year practice has enabled Dr. Cochran to explore the commonality in chronic pain sufferers, as well as understand the real scope of painfulness.
Chronic Fatigue: A Case Study
Darlene was new to the city. She was a stockbroker and an attractive, poised, and forceful young woman. She began our conversation by asking me, "Do you know anything about dysautonomia?"
"A little maybe. I am not sure anybody knows much about it."
"I have chronic fatigue and dysautonomia. The doctors in St. Louis finally got it worked out. They want to keep an eye on me, and I will go back there a couple of times a year, but I need a primary care physician."
"Tell me about it."
"About two years ago I developed fibromyalgia. I had constant dull pain in my neck and shoulders. I was tired all the time, and I couldn't sleep at night. My doctor gave me sleeping pills and told me to exercise."
"Did that help?"
"No, I was too tired to exercise. Whenever I did, I would feel faint. I would suddenly break out in a sweat, and when that happened, I felt like I was losing it, like I was passing out. Sometimes I would be so weak I could hardly walk. The doctor did some blood tests and told me I had mononucleosis and the chronic fatigue syndrome."
"What did he do then?"
"He told me to rest, and the symptoms would probably go away."
"No, they just got worse. I kept feeling like I was blacking out. It was so bad one time that I went to the emergency room. The doctors there told me that my pulse was thirty, and my blood pressure ninety over sixty. They called in a cardiologist, and after he checked me over, he told me I had dysautonomia. He put in a heart pacemaker."
Dysautonomia, as the name suggests, is a disorder of the neural system that regulates cardiac and visceral activity. It is, in a sense, a functional disease. A heart which is anatomically normal behaves in a dysfunctional manner just as the bowels behave dysfunctionally in the patient with the irritable bowel syndrome.
That disease is one of discomfort and inconvenience. Cardiac dysautonomia, however, is a much more threatening illness. A pulse rate of thirty is always taken seriously. A heart rate that slow can certainly cause faintness and fatigue. The insertion of a cardiac pacemaker was warranted. The procedure has been done countless times, usually in the elderly who suffer heart disease. Not many 32-year-olds require pacemakers, though.
"I am sure you felt better with a pacemaker."
"Not really. My heart rate stayed up, but I didn't get any better. I kept feeling like I was fainting. My fatigue was just terrible. I couldn't think right, and I had a bad problem with my memory. I was in a brain fog all the time. It was really hard to work."
Dysautonomia, and with it, chronic fatigue. Appropriately diagnosed and appropriately treated but without success. The heart rhythm was restored, but the patient did not improve – a failure to recover syndrome if there ever was one. I asked Darlene to continue.
"I decided to go to another cardiologist."
"That sounds like a good idea."
"He was expert in dysautonomia. He put me on a tilt table and measured my pulse and blood pressure in different positions and after exercise. I wore a heart monitor for 24 hours, and when it was all done, he gave me a drug called Norpace."
"Did that work? Did you feel better?"
"Yes, I did, but it took a long time. It was a couple of months before I started getting well, but I did finally. My energy came back, and my fibromyalgia improved. I felt well enough to start working again. I left St. Louis and relocated here to start over."
"And the pacemaker, it is still in there isn't it?"
"No, they took it out."
Wow! A 32-year-old woman subjected to a pacemaker in, then a pacemaker out – and then exquisite control of her complex symptoms with a cardiac drug, little-used now. I searched for information about Norpace and the treatment of fatigue, but I couldn't find any. No matter, the drug seemed to be working. Leave well enough alone. I told Darlene I would be happy to see her if problems arose. She could return to St. Louis periodically for follow-up.
I kept my real thoughts to myself. Was her disease in the heart or was it in the mind? A pacemaker restored the heart rhythm but didn't help the patient. Her slow heart rate and low blood pressure were, I suspected, not the cause of her illness. They were symptoms of it. Her response to Norpace was queer. It is a quick-acting drug. Within hours, days at most, its effect should be evident. In Darlene it took months to start working. I pushed a little harder.
"Do you have a problem with depression?"
"Yes, I'm on Prozac."
"Is it working?"
"Yes, very well. I need the Prozac. If I stop it for a few days, the depression comes back. When I take it, I do okay, but I still have trouble sleeping. Every time I get in bed at night, my legs start jerking. They told me it is called restless legs."
"How long have you had trouble sleeping?"
"As far back as I can remember. Everybody in my family has trouble sleeping. They all have restless legs."
"Do any of them have trouble with pain, fatigue, or depression?"
"No, they are all healthy. We are just a family of poor sleepers."
"I suppose you have taken many kinds of sleeping pills?"
"Yes, I have tried several of them, but none really worked. When I first got sick and was so fatigued and sleepy all the time, they did a sleep study and told me I had sleep apnea. It was a severe case, and the doctors advised an operation to open up the back of my throat so I could breathe better at night."
"Did it work?"
"Yes, at first I slept well, but when I developed dysautonomia a few months later, the insomnia came back."
Sleep apnea occurs in persons, usually males, with obesity and with thick, heavy necks. Darlene had the neck of a swan. Her disordered sleep notwithstanding, Darlene was almost well when I first saw her. Prozac and Norpace had cured her. A cardinal rule, in dealing with the human machine, is to leave it alone when it is working well. I told Darlene I would not suggest any change her medicines, but I had a few more questions if she was willing to talk about her personal life.
"Yes, ask me anything you want."
"Are you married? Do you have children?"
"No to both. I got married when I was 25 and divorced when I was 28. I enjoyed my career more than my marriage."
"When did your depression first appear?"
"About the time I developed fibromyalgia and fatigue."
"What was going on in your life at that time? Were you happy in your work, in your relationships?"
"Yes, I was very happy. I was doing well and making a good living, but I did have a problem with my boss. He had a thing for me, and he was pretty aggressive. He touched me a lot. It got very frustrating. I wish I had said something about it earlier."
"What do you mean?"
"One day, after work when everyone was gone, he tried to have sex with me. I fought him off, but it was pretty frightening."
"When did this occur?"
"Right before I got sick."
An assault on that most personal and private of our behaviors can be an event of catastrophic consequence. It is, however, perhaps too easy and too convenient to ascribe diseases such as chronic pain and chronic fatigue to unfortunate sexual encounters. We have to keep it in perspective.
Is it reasonable to relate the remarkable development of her illness to a single unsuccessful sexual assault? As is often the case in patients with chronic pain (and chronic fatigue), there is more going on than meets the eye. It wasn't just the assault that made Darlene ill. It was the harassment complaint that followed. It became public in short order. Lines were drawn, and Darlene found some new friends, but she lost a lot of old ones. Management circled the wagons, and Darlene became a pariah. The violated became the violator. In the end, after several months of negotiations and confrontations, her boss was reprimanded.
Darlene was given a financial settlement and advised to relocate to another city.
I thanked Darlene for sharing her story with me. She was to continue her Prozac and Norpace. I advised her to check back periodically. I had a suspicion, which I did not share with her, that her recovery represented more a spontaneous remission than a pharmacologic effect.
She returned a couple of months later. Her career was going nicely, but her sleeplessness was becoming more of a problem. I inquired if she had ever taken the drug Klonopin. She had not. It worked pretty well at first (most of the drugs work pretty well at first – sustaining their benefit is another matter). She began to experience sedation from the drug, and her depression worsened. I told her to discard the Klonopin and to increase the Prozac dosage. A few weeks later she awoke feeling very unwell and nauseated. She dressed and went out to her car and then collapsed. A neighbor found her and brought her to my office. She was drenched with sweat, unsteady on her feet, and disoriented. Her blood pressure was eighty over fifty, and her pulse forty beats per minute. The beautiful young stockbroker was a sick and frightened girl.
Her electrocardiogram, aside from the slow rate, was normal. She rested for a while and then took a Coke and gradually improved even though her blood pressure and pulse had changed not at all. When she came fully to her senses, I offered her hospital admission and consultation with a cardiologist, an electrophysiologist skillful in the treatment of dysautonomia. Perhaps he could solve the riddle that others had so clearly failed to do. Maybe Darlene recognized that this offering was less than enthusiastic. I didn't think we were going to solve her mind disease by attacking its target organ, the heart.
"No, no more heart stuff. I would like to just go home and rest."
"That's okay with me, Darlene. You are sick, but you are not dying. You have been like this many times before, and you have recovered. You can go home, but keep in touch with me and let's meet again next week to go over this thing again."
I looked forward to her next visit, perhaps selfishly. For the first time in my encounters with this woman, I did not have to be obedient to that which had gone before. The drugs were not working. I was going to get my chance.
She looked better when I saw her, but not a lot. Her fatigue had returned full force, and her movements were cautious. Standing up rapidly made her feel faint. Her blood pressure and her pulse were still low. I told her to discard the Norpace. She had already done it, she told me.
"It wasn't working. I don't think it ever worked."
Which drug to use? Many have been employed in the treatment of fatigue. The SSRIs can be helpful, but she was already on one of those. Ritalin can be used, but it is a controlled substance, and some authorities look askance at its use in the treatment of fatigue, a second class disorder in the minds of many. The tricyclics are frequently employed, but one of their major side effects is fatigue.
Nonetheless, she had never taken one before, so I gave her Nortriptyline. If it did nothing but help her sleep, that would be useful. It didn't work at all. Darlene felt worse after she took it.
I chose Topamax. It is a new drug, and its clinical indications are still uncertain, but it is potentially useful in a variety of disorders. It can relieve essential tremor. It is an antimanic drug and perhaps antidepressant. It is an impulse-controlling agent.
Explosive behavior can sometimes be managed with Topamax. It is often used in the treatment of chronic pain of all origins, and it can be very effective in preventing migraine. I had no certain knowledge that Topamax could be helpful in the treatment of chronic fatigue, but I knew that Darlene was off the diagnostic tables – way off. She was afflicted with a very complex illness, and it was destructive to the simplest acts of her existence. Just think about it – life-long insomnia, restless legs, sleep apnea, chronic fatigue, fibromyalgia, dysautonomia, depression, and migraine (she had that disease also) were all comorbid in a single young woman!
Within a week, Darlene was restored. Her fatigue, her pain, her faints, her insomnia, and her restless legs were gone. It was a clinical miracle – they do happen. There is a drug out there, as I have said before, for almost everybody. Darlene remains well four years later. Prozac and Topamax cured her.
For more information, visit www.understandingpain.com