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A psychodynamic view of the chronic fatigue syndrome
A Psychodynamic View of the Chronic Fatigue Syndrome The Role of Object Relations in Etiology and Treatment Gary Taerk, M.D., and William Gnam, M.D.
Abstract: The chronic fatigue syndrome (CF.9 is a consfeflafion of physical and psychological symptoms including incapucifufingfafigue associated with a marked reduction in acfivify. Although the etiology of CFS is unclear, reports in the literature suggest the presence of both physical and psyckological dysfunction in this patient population. Thesefindings have led to a debate between those who consider CFS to be primarily organic in origin and those who view CFS as a primary psychiatric disorder characterized by somatic preoccupations. This debate led the authors to develop a workingmodel for CFS designed to integrate the psychological and physiological findings, based on the hypothesis that early object relations have an etiologic relationship to CFS. This hypothesis then formed the rationale for a psychoanalytic treatment approach which will be described. There are no published case reports describing psychoanalytic psychotherapy as a primary treatment modality for this patient population. The current paper attempts to fill a void. Two case reports of long-term (>28 months,), intensive (2-3 times per week) psychoanalytic psychotherapy with CFS patients referred by infectious disease specialists at a university teaching hospital will be presented. The following aspects of the treatment will be highlighted: 1) the unique opportunity afforded by this treatment to view the nature of CFS, namely, the intimate relationship over time of fatigue symptoms to disturbances in object relationships, particularly within the transference; (2) the improvement in symptoms when this relationship is seen and understood by the patient; (3) the importance of the patient-therapist bond as a facilitating medium for clinical improvement; (4) the chalienges involved in treating CFS patients with psychotherapy.
Department of Psychiatry, The Toronto Hospital and University of Toronto, Toronto, Ontario, Canada Address reprint requests to: Dr. Gary Taerk, Department of Psychiatry, The Toronto Hospital, General Division, 200 Elizabeth Street, EN-8, Toronto, Ont. M5G 2C4, Canada.
General Hospital Psychizty 16, 319-325, 1994 0 1994 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Introduction The chronic fatigue syndrome (CFS) is a term applied to a variety of nonspecific symptoms including incapacitating exhaustion, fatigue, malaise, myalgia, weakness, subjective feverishness, sore throat, painful lymph nodes, headaches, dizziness, lightheadedness, depression, impaired memory, confusion, and difficulties with concentration [ 11.
The etiology and pathophysiology remain unclear. Research has revealed alterations in immune functioning [Z-5], muscle metabolism [6], cognitive functioning [7], hypothalamic-pituitary-adrenal (HPA) axis functioning [8], and psychiatric status [9-111. Although the results of these studies have been challenged on methodological grounds [12,13], the findings have fueled an anachronistic mind-vs-body debate over whether CFS is a psychological or an organic disorder. Most of the hypotheses concerning CFS assume a simple cause and effect model in which an external agent, usually a virus, causes a fatiguing illness by persistent viral infection, immune dysfunction, or a mixture of the two. Alternatively, it has been suggested that CFS is primarily a psychiatric disorder, a form of depressive disorder associated with somatization [ll]. Some authors have attempted to integrate the psychiatric and organic aspects of the illness. Taerk et al. [9] and Salit [14,15] argued that neuromyasthenia reflects the interplay between organic and psychological factors in psychologically vulnerable individuals with a depressive diathesis.
319 ISSN 0163~6343/94/$7.00
G. Taerk and W. Gnam
Misattunement $*
Virus
Child - Caregiver
3( Failurew of Self-Consolidation
Affective and Physiological Instability Defective Capacity for Self-Regulation
Symptoms Dependence on Others for SelCRegulating Functions
2” Depression
Pituitary -Adrenal Depressive
Figure 1. Explanatory model for disease susceptibility applied to CFS.
In response to a viral illness, an individual becomes depressed either as a result of a disturbance in neural functioning or a reaction to the associated disability. Evidence for the depressive diathesis or vulnerability is evidenced by personal and family histories of affective disorder. Taylor [16-M] conceptualizes this vulnerability not specifically as a depressive diathesis but as an increased susceptibility to disease, which he attributes to a defect in the capacity of an individual to regulate his internal psychological and physiological environment. He believes this inability to selfregulate is a result of severe misattunements in the mother-child relationship. As a result, the child fails to internalize the tension-regulating functions of the mother. These individuals compensate for this “self” defect by becoming overly dependent on idealized others, only to fall ill when disruptions in the dependency relationships occur. The resulting illness (probably determined by genetic factors as well) could take the form of a psychiatric disorder, an organic disorder, or a combination of the two. There are several lines of research that lend support to the proposition that early object relations can effect an infant’s physiology and subsequent susceptibility to illness. Hofer [19] examined ways in which the mother rat regulates heart rate, levels of tissue enzyme, brain chemistry, and the sleepwake cycle in her rat pups by the level of milk she supplies, the level of actual stimulation she provides, and the rhythm and timing of her nursing interaction. Hofer believes that the mother-infant interaction can modify the physiological develop320
Illness
ment of the offspring. He suggests that motherinfant symbiosis may have effect on susceptibility to bodily disease that works directly through early alteration of the organ systems responsible for diseases later in life. Other researchers have reported on the negative impact that traumatic early events such as separation have on the hypothalamicpituitary-adrenal axis [20] and on later immune system functioning [21,22]. Given the evidence that immune system and HPA system abnormalities have been detected in CFS, these findings are of particular relevance to the concept of CFS as proposed in this paper. Figure 1 is the authors’ attempt to apply the foregoing ideas of disease susceptibility to current theories of the CFS. The authors propose that both a psychological and physiological vulnerability exists in CFS patients as a result of problems in early object relations which contribute to the clinical expression of the syndrome. Furthermore, it is proposed that this vulnerability results from a poorly developed capacity for regulating internal states in response to certain types of stressors, namely, disturbances in object relations. The paper then describes a psychotherapeutic technique based on the psychology of the self and object relations theory which attempts to diminish this vulnerability through an internalization of the tension-regulating components of the therapeutic relationship, thereby positively affecting the course of the illness. To illustrate this hypothesis, two cases of long-term (>18 months), intensive (2-3 x per week) psychoanalytic psychotherapy will be presented. The following aspects of the treatment will be highlighted: 1) the unique opportunity afforded by this treatment to view the nature of CFS, namely, the intimate relationship over time of fatigue symptoms to dis-
Psychodynamics of Chronic Fatigue Syndrome turbances in object relationships, particularly within the transference; 2) the improvement in symptoms when this relationship is seen and understood by the patient; 3) the importance of the patient-therapist bond as a facilitating medium for clinical improvement; and 4) the challenges involved in treating CFS patients with psychotherapy*
Case 1 Mr. 8, a 36-year-old account manager with an advertising agency, was referred by the infectious disease service of a university-affiliated. hospital because of recurrent episodes of fatigue, weakness, and difficulty concentrating. An exhaustive organic workup had been completed with no significant findings. Mr. B was a strikingly well-groomed, fashionably dressed man who was quite eager to talk about the limitations imposed upon him by his fatigue, particularly how he had trouble concentrating and applying himself at work. He believed that he had an illness that had been undetected for the previous ten years. He felt that no one believed him or understood how difficult it had been for him. He believed that if he could overcome the illness he would finally be able to make a success of his life. Mr. B was born in Germany. He and his mother emigrated to Canada when Mr. B was 5 years old. They joined Mr B’s father, who had come to Canada 2 years earlier. Not being fluent in English, Mr B struggled in grade school both academically and socially. He felt ridiculed by his teachers, ostracized by his peers, and unsupported by his parents, who saw him as a failure and a disappointment. As a male first-born child, much was expected of him. When he failed to live up to these expectations, he was made to feel ashamed of himself by his harshly critical parents. Mr. B was particularly frightened of his mother, whom he saw as critical and belittling in her treatment of both himself and his father. During his teenage years Mr. B had developed an idealizing relationship with an uncle. He experienced this relationship as comforting and sustaining. However, this relationship ended in disillusionment as his uncle, a reformed drug abuser, began using drugs again and eventually ended up in jail. After college Mr. B held a variety of jobs in the advertising business. However, things had never quite worked out the way he had hoped. Owing to
his considerable skills, he easily found management-level jobs but never could advance. He had worked for five different employers in a span of 8 years. In each job Mr. B would feel extremely enthusiastic at the start, especially if he was working with a boss whom he idealized and who seemed to take a special interest in him. However, at some point, Mr. B would feel that his employer did not truly value him and that he was being exploited. Eventually he would begin to feel lethargic, fatigued, and drained of his enthusiasm. His work would deteriorate and he would begin looking elsewhere for employment. The cycle of enthusiasm and promise followed by disappointment, despair, and fatigue would be repeated often in his work. In his love life, a similar pattern emerged. He would become involved with beautiful women with whom he would have intense physical relationships. But following what would appear to be a minor disappointment or a mildly critical comment, he would find himself becoming bored and disinterested. Mr. B seemed quite unable to identify and label his feelings when he entered therapy. He could not recognize the enthusiasm and hope he felt when beginning a relationship, nor did he seem aware of the disappointment and despair that followed any failures on the part of his objects to meet his needs. Therefore, it proved to be particularly useful for the psychotherapist to encourage a detailed examination of the context in which the fatigue symptoms evolved so that Mr. B could begin to experience and label disavowed affects. After 8 months of twice-weekly sessions, Mr. B asked about increasing the number of meetings per week because he felt he was learning so much new about himself. It was agreed to meet three times per week and at the therapist’s request to switch to the use of the couch. Over the next 2 months there was a noticeable change. Mr. B seemed more inhibited, frightened, and mistrustful. The context of his associations shifted back to his physical symptoms and his newly returned fatigue, a theme that had not been manifested for several months. He began to consult holistic practitioners about further tests and medications. He spoke caustically about the medical establishment and their insensitivity to people like himself who had unusual problems. An air of hopelessness and discouragement developed as he droned on about his physical symptoms. It seemed inevitable that the psychotherapeutic relationship, which had begun with so 321
G. Taerk and W. Gnam much promise, was going to end in frustration and disappointment just like Mr. B’s other endeavors. During one particularly difficult session marked by long silences, Mr. B related a dream, the theme of which related to being exploited and humiliated. His associations to the dream related to a memory of his mother discovering hidden pictures of naked women in his room and humiliating him by pasting them on his wall. He also remembered a high school experience in which he felt humiliated by a girl who told his friends that he was afraid to have sex with her and that she thought he must be a homosexual. According to Mr. B, this experience ruined high school for him. He felt exposed, or in his words “sussed out.” He never felt comfortable being with his friends after that. Noting the concurrent discomfort in the transference relationship, the therapist suggested to Mr. B that the shift to the couch and the more frequent meetings had aroused fears that the therapist, like Mr. B’s mother and his high school girlfriend, would now be better able to “suss him out” and use the information to belittle him. He would be exposed as the incompetent man he felt himself to be. In other words, the therapist had shifted from being a source of comfort and support to being a potential source of humiliation. Mr. B then spoke about his concern that he would prove to be a disappointment to the therapist, who he was sure would no longer have an interest in treating him. Therefore the only available course of action to protect his fragile self from humiliation was to quit therapy. This examination of the transference appeared to have a profound effect on Mr. B. A new vitality seemed to infuse his attitude with regard to his career and to the analytic work. His activity level increased and his reports of fatigue diminished as well. He once again expressed positive feelings towards the therapist who apparently was restored as an idealized figure in the transference. This scenario occurred repeatedly in Mr. B’s life and throughout treatment. When fears associated with the shame and humiliation of his earliest object relations were aroused, he withdrew in order to protect his fragile sense of self. This further alienated him from required sources of comfort and soothing. He seemed unable to hold onto the object as a source of comfort, strength, security, and affirmation. His state of withdrawal appeared to lead to a reemergence of his CFS symptoms. However, as this scenario was repeatedly observed, interpreted, and understood, clinical im-
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provement occurred. His reports of fatigue diminished, his work performance improved, and his object relationships appeared to stabilize. Case
2
Ms. M was a 29-year-old single woman who lived alone and worked as a social worker at a major pediatric hospital. At her request she was referred by the Family Medicine Service of a university teaching hospital, after extensive medical evaluations failed to reveal organic factors contributing to her incapacitating fatigue and multiple somatic symptoms. Her family physician suggested that she might benefit from an antidepressant, which she grudgingly accepted but discontinued within 1 week due to intolerable side effects. She was so angered by the implicit suggestion that she was depressed that she relied exclusively thereafter on the prescriptions of unconventional, alternative “practitioners,” which involved stringent diets and high-dose vitamins. She became desperate when she only partially improved, and with embarrassment, arranged for psychiatric evaluation after reading an article relating cancer patients’ recovery to psychological factors. Ms. M frequently stressed that she had doubts about psychiatry and wondered whether the therapist was “just another doctor who thinks the problem is all in my head.” In early sessions she repeatedly apologized for complaining about her life. She suspected that the therapist was skeptical about the legitimacy of her need for therapy. Over several sessions it emerged that this suspicion reflected the general lack of supportive, validating relationships in her life and the resulting failure to develop a genuine sense of entitlement to empathic responsiveness from those around her. Her mother had been depressed throughout Ms. M’s childhood because of her father’s frequent business trips and had relied on Ms. M for comfort and support. Her relationship with her current boyfriend also left her feeling exploited and unfulfilled. Ms. M’s identity was consolidated by her function as a caretaker for her mother, a role that enabled her to maintain vital ties to the family and gave her a sense of self-worth. She therefore had difficulty trusting that the therapist would be genuinely interested in her. Much of the early therapeutic work focused on allowing Ms. M to freely express her worries. These were initially related to her physical condition but gradually shifted to her
Psychodynamics
life, particularly her feelings related to two catastrophic events in the life of the family 10 years ago, namely, the car accident that rendered her sister paraplegic, and the death of her older brother from cancer 18 months ago. In both instances Ms. M recalled having to comfort her mother and having no one with whom to share her grief. She remembers feeling tremendous resentment when forced to catheterize her newly disabled sister, because her mother’s hand shook with anxiety. Her brother was a particularly significant figure in her life.. He was the only person who listened to her and accepted her. She intensely idealized his accomplishments. She remarked that she knew who she was when she was with her brot.her, and in his presence, felt good about herself. Following his death she fell ill with CFS. She revealed that she had rarely spoken about her brother since his death and had not had the opportunity to grieve for him. Over the initial 9 months of treatment there was a gradual improvement in her fatigue symptoms. She reported an increase in energy and a reduction in muscle pain. However, there was a noticeable deterioration at the time of the therapist’s first vacation. Although Ms. M claimed to be unperturbed by the announced 2-week break, she began experiencing increasing fatigue as the vacation approached. When the therapist returned, Ms. M related how she had been unable to work for several of the days the therapist was absent. This pattern repeated itself several times but was gradually recognized and understood as a reawakening of the loss of the self-regulatory function of the brother. Ms. M became aware that the therapist wa,s able to accept her dependency needs and consequently she became more tolerant of herself. The process of validating the patient’s experience and encouraging the tolerance of affects led to major changes over the first 18 months of treatment. Ms. M’s, relationship with her male partner deepened as she was able to clarify her own desire for intimacy and to confront him over his avoidance. Moreover, she felt better able to rely on him for comforting and understanding of her affective experience. She also developed a trusting relationship with the therapist and displayed much freer access to dreams and fantasy. As her somatic preoccupation diminished, she was able to resume a more active work schedule and abandoned her severe dietary restrictions.
emotional
of Chronic
Fatigue
Syndrome
Discussion Disturbances in object relations appeared to initiate the onset of illness in both cases presented. Ms. M fell ill following the death of her brother and Mr. B fell ill following disappointments in key relationships such as those within his family, his work, and his love life. The relationship of object loss to illness onset has been widely reported but poorly understood [23,24]. Taylor 1171 suggests that what is lost is not so much the object itself but the vital regulatory functions the object provides for the nascent self. Relationships with idealized objects had helped both patients to compensate for self defects that had arisen from early child-caregiver misattunements. It is hypothesized that when these compensatory relationships were disrupted there was a concurrent loss of the regulatory functions provided by these selfobjects.* In other words, there was a disregulation of the psychological and physiological systems which heralded the onset of the CFS. The transference relationship helped stabilize these patients and provided a new opportunity for the internalization of self-regulatory structures which had failed to develop in early life. Conversely, disruptions in the transference preceded the exacerbation of CFS symptoms. These disruptions were often difficult to detect and were often only discovered during a retrospective analysis of the events leading up to the deterioration in the patients’ condition. The establishment and maintenance of a stable self-selfobject tie between patient and therapist provides a facilitating medium through which the self-regulating capacities of the patient can be reinstated. The capacity for self-regulation is enhanced through an internalization of the tensionregulating functions of the selfobject. Bacall and Newman [25] believe that this occurs through the “sustained empathic attentiveness” of the therapist to the patients’ subjective psychological states. This allows the analyst to be optimally responsive to the patient’s selfobject needs. Bacall and Newman go on to say that there is no analyst whose
* A selfobject is an important figure who is perceived as part of the self and who performs vital functions in a relationship that evokes, maintains, or positively affects the sense of self. These functions include attunement to affective states; validation of subjective experience, affect containment, tension regulation, and soothing sustaining and organizing, and recognition of uniqueness and creative potential [25].
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G. Taerk and W. Gnam responses are so optimal as to preclude the patient’s experiencing frustrating and hurtful discrepancies between what is sought and what is obtained. The establishment and reestablishment of the self-selfobject relationship following disruptions associated with inevitable frustrations (as occurred in Case 1, where the patient felt humiliated or shamed by the therapist, or in Case 2 when the patient’s CFS would worsen following the therapist’s announcement of his vacation) strengthens the self. Gradually over time, this repeated working through leads to less dependency on the selfobject and greater capacity to sustain empathic failures in the transference and in outside object relations. Interpretations or explanations offered by the therapist could be considered to create meaning and coherence for the “child’ in the patient, a function similar to that provided by the mother when she names experience and thereby meets the child’s innate need and striving for organization. The naming of affective experience was especially important for the CFS patients who had difficulty identifying and labeling inner states. Doing psychotherapy with CFS patients presents formidable challenges. Severe misattunements in the early child-caregiver relationship, which give rise to psychic deficits, can have a negative impact on the course of therapy. These deficits include a decreased capacity to identify, label, and regulate affects; a decreased capacity for symbolization; and a tendency to express distress in physical rather than psychological terms. Also, patients are often mistrustful of physicians who in the past have failed to relieve their suffering and who seem to dismiss the severity of their symptoms. Therefore, care must be taken to establish a trusting relationship. Becoming embroiled in arguments with the patient over whether symptoms originate in the mind or body will further alienate the patient. The model of disease susceptibility shown in Figure 1 avoids the mind-vs-body argument that develops in the course of treating CFS patients. The therapist considers symptoms as a sign of a failure of self-regulating capacities which can potentially lead to psychological and physiological disregulation. Thus the therapist is free to listen to the patient’s symptoms empathically without trying to convince the patient that his disease is strictly psychological. A number of factors including cost makes psychoanalytic treatment impractical for most CFS patients. However, using the model of disease susceptibility described above, treatment interventions can be instituted at
324
various points in the system depending on the psychological makeup of the patient, the presenting complaint, the goals of treatment, and the patient’s understanding of the illness. These interventions might include cognitive-behavioral therapy, antidepressants, anxiolytics, antiviral agents, and so forth. Psychoanalytic treatment, while providing an important source of data about the nature of CFS, would likely be appropriate for a subgroup of CFS patients who are verbal, introspective, and whose goals include self-knowledge and personality change, in addition to symptom relief. This treatment approach and the model of disease susceptibility it is based upon are attempts to understand the interplay between psychological and biological factors in the pathogenesis of CFS. The psychoanalytic approach provides a unique viewpoint from which to observe the psychological vulnerability purported to exist in these patients, and enhances the patient’s capacity to better deal with previous disruptive, emotional experiences. This in turn may increase the self-regulating capacity of the patient and appears to prevent prolonged states of fatigue. However, definitive conclusions cannot be drawn from single case studies such as those presented in this paper. Future research could attempt to correlate clinical improvement with physiological or immunological evidence of change. In addition, comparison studies between groups receiving different treatment modalities such as antiviral agents, antidepressants, psychotherapy, rest, and so forth need to be conducted in order to get a truer sense of the clinical value of the psychoanalytic treatment approach.
References 1. Holmes GP, Kaplan JE, Gantz NM, et al: Chronic
2. 3. 4.
5.
6.
fatigue syndrome: a working case definition. Ann Int Med 108387-389, 1988 Klimas NG, Salvato FR, Morgan R, et al: Immunologic abnormalities in the chronic fatigue syndrome. J Clin Microbial 28:140%1410, 1990 Landay AL, Jessop C, Lennette ET, et al: Chronic fatigue syndrome: a clinical condition associated with immune activation. Lancet 338:707-712, 1991 Lloyd A, Hickie I, Brockman A, et al: Cytokine levels in serum and cerebrospinal fluid in patients with chronic fatigue syndrome and control subjects. J Infect Dis 164:102%1024, 1991 DeFreitas E, Hilliard B, Cheney PR, et al: Retroviral sequences related to human T-lymphotropic virus type II in patients with chronic fatigue immune dysfunction syndrome. Proc Nat1 Acad Sci USA 88: 2922-2926, 1991 Bryne E, Trounce I: Chronic fatigue and myalgia
Psychodynamics
7.
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9.
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14.
syndrome mitochondrial and glycolytic studies in skeletal muscle. J Neurol Neurosurg Psychiatry 50: 743-746, 1987 Wessely W, Butler S, Chalder T, David A: The cognitive behavioural management of the post-viral fatigue syndrome. In Jenkins R, Mowbray J (eds), Post-viral Fatigue Syndrome. John Wiley & Sons Ltd., 1991 Demitrack MA, Dale JK, Straus SE, et al: Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome. J Clin Endocrinol Metab 73:1224-1233, 1991 Taerk GS, Toner BB, Salit IE, et al: Depression in patients with neuromyasthenia (benign myalgic encephalomyelitis). Int J Psychiatry Med 17:49-56, 1987 Kruesi MJP, Dale J, Straus SE: Psychiatric diagnosis in patients who have chronic fatigue syndrome. J Clin Psychiatry 50:53-56, 1989 Manu P, Matthew DA, Lane TJ: The mental health of patients with a chief complaint of chronic fatigue: a prospective evaluation and follow-up. Arch Intern Med 148:221&2217, 1988 Abbey SE, Garfinkel PE: Chronic fatigue syndrome and depression: cause, effect or covariate. Rev Infect Dis 13(Suppl 1):573-583, 1991 Abbey SE, Garfinkel PE: Neurasthenia and the chronic fatigue syndrome: the role of culture in the making of a diagnosis. Am J Psychiatry 148:16381646, 1991 Salit IE: Sporadic post-infectious neuromyasthenia. Can Med Assoc J 133:659-663, 1985
of Chronic Fatigue Syndrome
15. Salit IE: Chronic EBV infection (post-infectious neuromyasthenia) Med North AM 10:1944,1950, 1987 16. Taylor GJ: Psychosomatics and self-regulation. In Barron JW, Eagle MN, Wolitsky DL (eds), The Interface of Psychoanalysis and Psychology. Am Psych Assoc, Washington DC, 1992 17. Taylor GJ: Psychoanalysis and psychosomatics: a new synthesis. J Am Acad of Psychoanalysis 20(2): 251-275, 1992 18. Taylor GJ: Psychosomatic Medicine and Contemporary Analysis. International Universities Press Inc, 1987 19. Hofer MA: The mother-infant interaction as a regulator of infant physiology and behavior. In: L Rosenblum, Moltz H (ed), Symbiosis in Parent-Offspring Interactions. New York, Plenum, 1983 20. Gunnar R: Reactivity of the hypothalamic-pituitaryadrenocortical system to stressors in normal infants and children. Pediatrics 90:491497, 1992 21. Coe L, Lubach G, Schneider M, et al: Early rearing conditions alter immune responses in the developing infant primate. Pediatrics 90:50>509, 1992 22. Laudenslager M, Capitanio J, Reite M: Possible effects of early separation experiences on subsequent immune function in adult macaque monkeys. Am J Psychiatry 142:862-866, 1985 23. Holmes TH, Rahe RH: The social readjustment rating scale V. Psychosomatic Res II:213218, 1967 24. Engel G: A life setting conducive to illness: the giving up-given up complex. Ann Int Med 69:293-300, 1968 25. Bacall HA, Newman MK: Theories of Object Relations: Bridges to Self-Psychology. Columbia University Press, 1990
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Abstract: The chronic fatigue syndrome (CF.9 is a consfeflafion of physical and psychological symptoms including incapucifufingfafigue associated with a marked reduction in acfivify. Although the etiology of CFS is unclear, reports in the literature suggest the presence of both physical and psyckological dysfunction in this patient population. Thesefindings have led to a debate between those who consider CFS to be primarily organic in origin and those who view CFS as a primary psychiatric disorder characterized by somatic preoccupations. This debate led the authors to develop a workingmodel for CFS designed to integrate the psychological and physiological findings, based on the hypothesis that early object relations have an etiologic relationship to CFS. This hypothesis then formed the rationale for a psychoanalytic treatment approach which will be described. There are no published case reports describing psychoanalytic psychotherapy as a primary treatment modality for this patient population. The current paper attempts to fill a void. Two case reports of long-term (>28 months,), intensive (2-3 times per week) psychoanalytic psychotherapy with CFS patients referred by infectious disease specialists at a university teaching hospital will be presented. The following aspects of the treatment will be highlighted: 1) the unique opportunity afforded by this treatment to view the nature of CFS, namely, the intimate relationship over time of fatigue symptoms to disturbances in object relationships, particularly within the transference; (2) the improvement in symptoms when this relationship is seen and understood by the patient; (3) the importance of the patient-therapist bond as a facilitating medium for clinical improvement; (4) the chalienges involved in treating CFS patients with psychotherapy.
Department of Psychiatry, The Toronto Hospital and University of Toronto, Toronto, Ontario, Canada Address reprint requests to: Dr. Gary Taerk, Department of Psychiatry, The Toronto Hospital, General Division, 200 Elizabeth Street, EN-8, Toronto, Ont. M5G 2C4, Canada.
General Hospital Psychizty 16, 319-325, 1994 0 1994 Elsevier Science Inc. 655 Avenue of the Americas, New York, NY 10010
Introduction The chronic fatigue syndrome (CFS) is a term applied to a variety of nonspecific symptoms including incapacitating exhaustion, fatigue, malaise, myalgia, weakness, subjective feverishness, sore throat, painful lymph nodes, headaches, dizziness, lightheadedness, depression, impaired memory, confusion, and difficulties with concentration [ 11.
The etiology and pathophysiology remain unclear. Research has revealed alterations in immune functioning [Z-5], muscle metabolism [6], cognitive functioning [7], hypothalamic-pituitary-adrenal (HPA) axis functioning [8], and psychiatric status [9-111. Although the results of these studies have been challenged on methodological grounds [12,13], the findings have fueled an anachronistic mind-vs-body debate over whether CFS is a psychological or an organic disorder. Most of the hypotheses concerning CFS assume a simple cause and effect model in which an external agent, usually a virus, causes a fatiguing illness by persistent viral infection, immune dysfunction, or a mixture of the two. Alternatively, it has been suggested that CFS is primarily a psychiatric disorder, a form of depressive disorder associated with somatization [ll]. Some authors have attempted to integrate the psychiatric and organic aspects of the illness. Taerk et al. [9] and Salit [14,15] argued that neuromyasthenia reflects the interplay between organic and psychological factors in psychologically vulnerable individuals with a depressive diathesis.
319 ISSN 0163~6343/94/$7.00
G. Taerk and W. Gnam
Misattunement $*
Virus
Child - Caregiver
3( Failurew of Self-Consolidation
Affective and Physiological Instability Defective Capacity for Self-Regulation
Symptoms Dependence on Others for SelCRegulating Functions
2” Depression
Pituitary -Adrenal Depressive
Figure 1. Explanatory model for disease susceptibility applied to CFS.
In response to a viral illness, an individual becomes depressed either as a result of a disturbance in neural functioning or a reaction to the associated disability. Evidence for the depressive diathesis or vulnerability is evidenced by personal and family histories of affective disorder. Taylor [16-M] conceptualizes this vulnerability not specifically as a depressive diathesis but as an increased susceptibility to disease, which he attributes to a defect in the capacity of an individual to regulate his internal psychological and physiological environment. He believes this inability to selfregulate is a result of severe misattunements in the mother-child relationship. As a result, the child fails to internalize the tension-regulating functions of the mother. These individuals compensate for this “self” defect by becoming overly dependent on idealized others, only to fall ill when disruptions in the dependency relationships occur. The resulting illness (probably determined by genetic factors as well) could take the form of a psychiatric disorder, an organic disorder, or a combination of the two. There are several lines of research that lend support to the proposition that early object relations can effect an infant’s physiology and subsequent susceptibility to illness. Hofer [19] examined ways in which the mother rat regulates heart rate, levels of tissue enzyme, brain chemistry, and the sleepwake cycle in her rat pups by the level of milk she supplies, the level of actual stimulation she provides, and the rhythm and timing of her nursing interaction. Hofer believes that the mother-infant interaction can modify the physiological develop320
Illness
ment of the offspring. He suggests that motherinfant symbiosis may have effect on susceptibility to bodily disease that works directly through early alteration of the organ systems responsible for diseases later in life. Other researchers have reported on the negative impact that traumatic early events such as separation have on the hypothalamicpituitary-adrenal axis [20] and on later immune system functioning [21,22]. Given the evidence that immune system and HPA system abnormalities have been detected in CFS, these findings are of particular relevance to the concept of CFS as proposed in this paper. Figure 1 is the authors’ attempt to apply the foregoing ideas of disease susceptibility to current theories of the CFS. The authors propose that both a psychological and physiological vulnerability exists in CFS patients as a result of problems in early object relations which contribute to the clinical expression of the syndrome. Furthermore, it is proposed that this vulnerability results from a poorly developed capacity for regulating internal states in response to certain types of stressors, namely, disturbances in object relations. The paper then describes a psychotherapeutic technique based on the psychology of the self and object relations theory which attempts to diminish this vulnerability through an internalization of the tension-regulating components of the therapeutic relationship, thereby positively affecting the course of the illness. To illustrate this hypothesis, two cases of long-term (>18 months), intensive (2-3 x per week) psychoanalytic psychotherapy will be presented. The following aspects of the treatment will be highlighted: 1) the unique opportunity afforded by this treatment to view the nature of CFS, namely, the intimate relationship over time of fatigue symptoms to dis-
Psychodynamics of Chronic Fatigue Syndrome turbances in object relationships, particularly within the transference; 2) the improvement in symptoms when this relationship is seen and understood by the patient; 3) the importance of the patient-therapist bond as a facilitating medium for clinical improvement; and 4) the challenges involved in treating CFS patients with psychotherapy*
Case 1 Mr. 8, a 36-year-old account manager with an advertising agency, was referred by the infectious disease service of a university-affiliated. hospital because of recurrent episodes of fatigue, weakness, and difficulty concentrating. An exhaustive organic workup had been completed with no significant findings. Mr. B was a strikingly well-groomed, fashionably dressed man who was quite eager to talk about the limitations imposed upon him by his fatigue, particularly how he had trouble concentrating and applying himself at work. He believed that he had an illness that had been undetected for the previous ten years. He felt that no one believed him or understood how difficult it had been for him. He believed that if he could overcome the illness he would finally be able to make a success of his life. Mr. B was born in Germany. He and his mother emigrated to Canada when Mr. B was 5 years old. They joined Mr B’s father, who had come to Canada 2 years earlier. Not being fluent in English, Mr B struggled in grade school both academically and socially. He felt ridiculed by his teachers, ostracized by his peers, and unsupported by his parents, who saw him as a failure and a disappointment. As a male first-born child, much was expected of him. When he failed to live up to these expectations, he was made to feel ashamed of himself by his harshly critical parents. Mr. B was particularly frightened of his mother, whom he saw as critical and belittling in her treatment of both himself and his father. During his teenage years Mr. B had developed an idealizing relationship with an uncle. He experienced this relationship as comforting and sustaining. However, this relationship ended in disillusionment as his uncle, a reformed drug abuser, began using drugs again and eventually ended up in jail. After college Mr. B held a variety of jobs in the advertising business. However, things had never quite worked out the way he had hoped. Owing to
his considerable skills, he easily found management-level jobs but never could advance. He had worked for five different employers in a span of 8 years. In each job Mr. B would feel extremely enthusiastic at the start, especially if he was working with a boss whom he idealized and who seemed to take a special interest in him. However, at some point, Mr. B would feel that his employer did not truly value him and that he was being exploited. Eventually he would begin to feel lethargic, fatigued, and drained of his enthusiasm. His work would deteriorate and he would begin looking elsewhere for employment. The cycle of enthusiasm and promise followed by disappointment, despair, and fatigue would be repeated often in his work. In his love life, a similar pattern emerged. He would become involved with beautiful women with whom he would have intense physical relationships. But following what would appear to be a minor disappointment or a mildly critical comment, he would find himself becoming bored and disinterested. Mr. B seemed quite unable to identify and label his feelings when he entered therapy. He could not recognize the enthusiasm and hope he felt when beginning a relationship, nor did he seem aware of the disappointment and despair that followed any failures on the part of his objects to meet his needs. Therefore, it proved to be particularly useful for the psychotherapist to encourage a detailed examination of the context in which the fatigue symptoms evolved so that Mr. B could begin to experience and label disavowed affects. After 8 months of twice-weekly sessions, Mr. B asked about increasing the number of meetings per week because he felt he was learning so much new about himself. It was agreed to meet three times per week and at the therapist’s request to switch to the use of the couch. Over the next 2 months there was a noticeable change. Mr. B seemed more inhibited, frightened, and mistrustful. The context of his associations shifted back to his physical symptoms and his newly returned fatigue, a theme that had not been manifested for several months. He began to consult holistic practitioners about further tests and medications. He spoke caustically about the medical establishment and their insensitivity to people like himself who had unusual problems. An air of hopelessness and discouragement developed as he droned on about his physical symptoms. It seemed inevitable that the psychotherapeutic relationship, which had begun with so 321
G. Taerk and W. Gnam much promise, was going to end in frustration and disappointment just like Mr. B’s other endeavors. During one particularly difficult session marked by long silences, Mr. B related a dream, the theme of which related to being exploited and humiliated. His associations to the dream related to a memory of his mother discovering hidden pictures of naked women in his room and humiliating him by pasting them on his wall. He also remembered a high school experience in which he felt humiliated by a girl who told his friends that he was afraid to have sex with her and that she thought he must be a homosexual. According to Mr. B, this experience ruined high school for him. He felt exposed, or in his words “sussed out.” He never felt comfortable being with his friends after that. Noting the concurrent discomfort in the transference relationship, the therapist suggested to Mr. B that the shift to the couch and the more frequent meetings had aroused fears that the therapist, like Mr. B’s mother and his high school girlfriend, would now be better able to “suss him out” and use the information to belittle him. He would be exposed as the incompetent man he felt himself to be. In other words, the therapist had shifted from being a source of comfort and support to being a potential source of humiliation. Mr. B then spoke about his concern that he would prove to be a disappointment to the therapist, who he was sure would no longer have an interest in treating him. Therefore the only available course of action to protect his fragile self from humiliation was to quit therapy. This examination of the transference appeared to have a profound effect on Mr. B. A new vitality seemed to infuse his attitude with regard to his career and to the analytic work. His activity level increased and his reports of fatigue diminished as well. He once again expressed positive feelings towards the therapist who apparently was restored as an idealized figure in the transference. This scenario occurred repeatedly in Mr. B’s life and throughout treatment. When fears associated with the shame and humiliation of his earliest object relations were aroused, he withdrew in order to protect his fragile sense of self. This further alienated him from required sources of comfort and soothing. He seemed unable to hold onto the object as a source of comfort, strength, security, and affirmation. His state of withdrawal appeared to lead to a reemergence of his CFS symptoms. However, as this scenario was repeatedly observed, interpreted, and understood, clinical im-
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provement occurred. His reports of fatigue diminished, his work performance improved, and his object relationships appeared to stabilize. Case
2
Ms. M was a 29-year-old single woman who lived alone and worked as a social worker at a major pediatric hospital. At her request she was referred by the Family Medicine Service of a university teaching hospital, after extensive medical evaluations failed to reveal organic factors contributing to her incapacitating fatigue and multiple somatic symptoms. Her family physician suggested that she might benefit from an antidepressant, which she grudgingly accepted but discontinued within 1 week due to intolerable side effects. She was so angered by the implicit suggestion that she was depressed that she relied exclusively thereafter on the prescriptions of unconventional, alternative “practitioners,” which involved stringent diets and high-dose vitamins. She became desperate when she only partially improved, and with embarrassment, arranged for psychiatric evaluation after reading an article relating cancer patients’ recovery to psychological factors. Ms. M frequently stressed that she had doubts about psychiatry and wondered whether the therapist was “just another doctor who thinks the problem is all in my head.” In early sessions she repeatedly apologized for complaining about her life. She suspected that the therapist was skeptical about the legitimacy of her need for therapy. Over several sessions it emerged that this suspicion reflected the general lack of supportive, validating relationships in her life and the resulting failure to develop a genuine sense of entitlement to empathic responsiveness from those around her. Her mother had been depressed throughout Ms. M’s childhood because of her father’s frequent business trips and had relied on Ms. M for comfort and support. Her relationship with her current boyfriend also left her feeling exploited and unfulfilled. Ms. M’s identity was consolidated by her function as a caretaker for her mother, a role that enabled her to maintain vital ties to the family and gave her a sense of self-worth. She therefore had difficulty trusting that the therapist would be genuinely interested in her. Much of the early therapeutic work focused on allowing Ms. M to freely express her worries. These were initially related to her physical condition but gradually shifted to her
Psychodynamics
life, particularly her feelings related to two catastrophic events in the life of the family 10 years ago, namely, the car accident that rendered her sister paraplegic, and the death of her older brother from cancer 18 months ago. In both instances Ms. M recalled having to comfort her mother and having no one with whom to share her grief. She remembers feeling tremendous resentment when forced to catheterize her newly disabled sister, because her mother’s hand shook with anxiety. Her brother was a particularly significant figure in her life.. He was the only person who listened to her and accepted her. She intensely idealized his accomplishments. She remarked that she knew who she was when she was with her brot.her, and in his presence, felt good about herself. Following his death she fell ill with CFS. She revealed that she had rarely spoken about her brother since his death and had not had the opportunity to grieve for him. Over the initial 9 months of treatment there was a gradual improvement in her fatigue symptoms. She reported an increase in energy and a reduction in muscle pain. However, there was a noticeable deterioration at the time of the therapist’s first vacation. Although Ms. M claimed to be unperturbed by the announced 2-week break, she began experiencing increasing fatigue as the vacation approached. When the therapist returned, Ms. M related how she had been unable to work for several of the days the therapist was absent. This pattern repeated itself several times but was gradually recognized and understood as a reawakening of the loss of the self-regulatory function of the brother. Ms. M became aware that the therapist wa,s able to accept her dependency needs and consequently she became more tolerant of herself. The process of validating the patient’s experience and encouraging the tolerance of affects led to major changes over the first 18 months of treatment. Ms. M’s, relationship with her male partner deepened as she was able to clarify her own desire for intimacy and to confront him over his avoidance. Moreover, she felt better able to rely on him for comforting and understanding of her affective experience. She also developed a trusting relationship with the therapist and displayed much freer access to dreams and fantasy. As her somatic preoccupation diminished, she was able to resume a more active work schedule and abandoned her severe dietary restrictions.
emotional
of Chronic
Fatigue
Syndrome
Discussion Disturbances in object relations appeared to initiate the onset of illness in both cases presented. Ms. M fell ill following the death of her brother and Mr. B fell ill following disappointments in key relationships such as those within his family, his work, and his love life. The relationship of object loss to illness onset has been widely reported but poorly understood [23,24]. Taylor 1171 suggests that what is lost is not so much the object itself but the vital regulatory functions the object provides for the nascent self. Relationships with idealized objects had helped both patients to compensate for self defects that had arisen from early child-caregiver misattunements. It is hypothesized that when these compensatory relationships were disrupted there was a concurrent loss of the regulatory functions provided by these selfobjects.* In other words, there was a disregulation of the psychological and physiological systems which heralded the onset of the CFS. The transference relationship helped stabilize these patients and provided a new opportunity for the internalization of self-regulatory structures which had failed to develop in early life. Conversely, disruptions in the transference preceded the exacerbation of CFS symptoms. These disruptions were often difficult to detect and were often only discovered during a retrospective analysis of the events leading up to the deterioration in the patients’ condition. The establishment and maintenance of a stable self-selfobject tie between patient and therapist provides a facilitating medium through which the self-regulating capacities of the patient can be reinstated. The capacity for self-regulation is enhanced through an internalization of the tensionregulating functions of the selfobject. Bacall and Newman [25] believe that this occurs through the “sustained empathic attentiveness” of the therapist to the patients’ subjective psychological states. This allows the analyst to be optimally responsive to the patient’s selfobject needs. Bacall and Newman go on to say that there is no analyst whose
* A selfobject is an important figure who is perceived as part of the self and who performs vital functions in a relationship that evokes, maintains, or positively affects the sense of self. These functions include attunement to affective states; validation of subjective experience, affect containment, tension regulation, and soothing sustaining and organizing, and recognition of uniqueness and creative potential [25].
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G. Taerk and W. Gnam responses are so optimal as to preclude the patient’s experiencing frustrating and hurtful discrepancies between what is sought and what is obtained. The establishment and reestablishment of the self-selfobject relationship following disruptions associated with inevitable frustrations (as occurred in Case 1, where the patient felt humiliated or shamed by the therapist, or in Case 2 when the patient’s CFS would worsen following the therapist’s announcement of his vacation) strengthens the self. Gradually over time, this repeated working through leads to less dependency on the selfobject and greater capacity to sustain empathic failures in the transference and in outside object relations. Interpretations or explanations offered by the therapist could be considered to create meaning and coherence for the “child’ in the patient, a function similar to that provided by the mother when she names experience and thereby meets the child’s innate need and striving for organization. The naming of affective experience was especially important for the CFS patients who had difficulty identifying and labeling inner states. Doing psychotherapy with CFS patients presents formidable challenges. Severe misattunements in the early child-caregiver relationship, which give rise to psychic deficits, can have a negative impact on the course of therapy. These deficits include a decreased capacity to identify, label, and regulate affects; a decreased capacity for symbolization; and a tendency to express distress in physical rather than psychological terms. Also, patients are often mistrustful of physicians who in the past have failed to relieve their suffering and who seem to dismiss the severity of their symptoms. Therefore, care must be taken to establish a trusting relationship. Becoming embroiled in arguments with the patient over whether symptoms originate in the mind or body will further alienate the patient. The model of disease susceptibility shown in Figure 1 avoids the mind-vs-body argument that develops in the course of treating CFS patients. The therapist considers symptoms as a sign of a failure of self-regulating capacities which can potentially lead to psychological and physiological disregulation. Thus the therapist is free to listen to the patient’s symptoms empathically without trying to convince the patient that his disease is strictly psychological. A number of factors including cost makes psychoanalytic treatment impractical for most CFS patients. However, using the model of disease susceptibility described above, treatment interventions can be instituted at
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various points in the system depending on the psychological makeup of the patient, the presenting complaint, the goals of treatment, and the patient’s understanding of the illness. These interventions might include cognitive-behavioral therapy, antidepressants, anxiolytics, antiviral agents, and so forth. Psychoanalytic treatment, while providing an important source of data about the nature of CFS, would likely be appropriate for a subgroup of CFS patients who are verbal, introspective, and whose goals include self-knowledge and personality change, in addition to symptom relief. This treatment approach and the model of disease susceptibility it is based upon are attempts to understand the interplay between psychological and biological factors in the pathogenesis of CFS. The psychoanalytic approach provides a unique viewpoint from which to observe the psychological vulnerability purported to exist in these patients, and enhances the patient’s capacity to better deal with previous disruptive, emotional experiences. This in turn may increase the self-regulating capacity of the patient and appears to prevent prolonged states of fatigue. However, definitive conclusions cannot be drawn from single case studies such as those presented in this paper. Future research could attempt to correlate clinical improvement with physiological or immunological evidence of change. In addition, comparison studies between groups receiving different treatment modalities such as antiviral agents, antidepressants, psychotherapy, rest, and so forth need to be conducted in order to get a truer sense of the clinical value of the psychoanalytic treatment approach.
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