Chronic Illness

Physicians classify diseases in a variety of ways. Clinical classifications are often made according to either the suddenness of onset or the expected prognosis. Diseases are considered acute if they develop suddenly and have a short clinical course. Chronic diseases, on the other hand, have a slow onset, indolent course, and long duration. They heal slowly if they improve at all.

Diseases may also be categorized by the organ system in which they occur in the human body or by their etiology (i.e., the cause and origin of the disease), concomitant with the pathophysiological process with which they are associated. Some classifications incorporate both of these characteristics resulting in an even more helpful guide for the clinician. For example, the number one cause of morbidity (i.e., sickness) and mortality (i.e., death) in industrialized nations is sometimes referred to atherosclerotic cardiovascular disease — that, of course, includes myocardial infarctions (heart attacks), which refers both to the organ system affected, as well as to the etiologic and pathophysiologic processes of the disease per se.

In this article, we are discussing diseases that due to their specific etiology and pathophysiology present as chronic illness. We will discuss how patients and their families cope with chronic illness, which is part and parcel of the human condition in the perpetual struggle of health and life against illness and death.

Diseases that typically affect the human body as chronic illness include:

* Atherosclerotic, hypertensive, cardiovascular diseases (AHCVD), such as high blood pressure, heart attacks, heart failure; and atherosclerotic cerebrovascular disease (ACVD), such as hemorrhagic stroke (cerebral hemorrhage) or cerebral infarct (the ‘typical’ stroke).

* Neoplastic diseases, such as metastatic cancers, breast, lung, renal, colorectal and prostatic cancers, as well as malignant tumors of the brain, lymphomas, leukemias, etc.

* Infectious diseases, such as Acquired Immune Deficiency Syndrome (AIDS). Most frequently these viral or bacterial illnesses are acute conditions that respond favorably to antibiotics and/or to the body’s immune system. For the most part, they run their course with medical treatment and they are usually curable. AIDS, the hemorrhagic Ebola virus infection, and Dengue fever remain notable exceptions, both in the industrialized and underdeveloped world.

* Immunological diseases (formerly “collagen vascular diseases”), including systemic lupus erythematosis, rheumatoid arthritis, scleroderma, multiple sclerosis, polyarteritis nodosa, sarcoidosis, etc.

* Degenerative diseases, such as osteoarthritis and other “wear and tear” diseases of aging, as well as the more serious central nervous system (CNS) maladies, including Parkinson’s Disease, Alzheimer’s Dementia, Friedreich’s Ataxia and Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease).

* Psychiatric illnesses, such as the neuroses and psychoses, severe depressions and bipolar disorders (formerly manic-depressive illnesses); nevertheless, they are not usually life-threatening or terminal conditions. Patients with psychiatric disorders usually succumb to other diseases or from suicide, and therefore, these psychiatric, functional disorders will not be further discussed here, unless it’s reactive depression secondary to the underlying, major primary illness.

Of particular interest in recent years have been chronic illnesses of unknown causes, such as fibromyalgia and chronic fatigue syndromes. Although these diseases have been subject to much research and discussion in the medical literature, no immunologic or metabolic causes have been identified to definitely explain them. Fibromyalgia presents with overall muscle and joint pain, whereas chronic fatigue illness patients present with generalized lassitude and joint stiffness, although the clinical symptomatology of these conditions overlap. Some authorities such as Dr. Garth L. Nicolson and his associates believe that these conditions are related to chronic mycoplasmal infections, and they have successfully treated many of their patients with multiple cycles of antibiotics plus nutritional support. The full significance of their findings, however, has yet to be explained and corroborated by others.

There are a myriad of health conditions that are, in fact, caused or aggravated by poor health habits, such as obesity (e.g., diabetes); smoking (e.g., AHCVD and ACVD, chronic obstructive pulmonary disease [COPD], cancer, etc.); illicit drug use (e.g., depression, suicide); poor nutritional habits (e.g., cancer, ACVD and HCVD); as well as overt, self-destructive behaviors such as sexual promiscuity (i.e., AIDS), illicit drug use (i.e., AIDS, hepatitis B, etc.) and alcohol abuse (i.e., chronic liver disease, depression, suicide, etc.).

The shift in leading causes of death from acute conditions (i.e., readily treatable diseases) to chronic ailments (i.e., degenerative conditions, atherosclerosis, cancer, etc.) has been paradoxically the result of advances in scientific medicine as well as improvement in the standard of living. In other words, we are suffering conditions such as cerebral atherosclerosis, prostate cancer, Alzheimer’s disease and Parkinson’s disease because we are living longer. These chronic diseases were not seen as much in earlier centuries because people died younger from lack of surgical knowledge as with appendicitis or a perforated ulcer, or from infectious and contagious diseases such as tuberculosis, pneumococcal pneumonia, syphilis, etc., which have been conquered today for the most part.

Chronic illness is a management challenge for the physician of the twenty-first century, just as syphilis and tuberculosis were diagnostic and therapeutic challenges for physicians in the nineteenth and early twentieth centuries.

Patients with chronic illnesses not only have to contend with debilitating diseases such as COPD (i.e., emphysema and asthma), diabetes and cancer, for which cures may not be available, but frequently these patients are also afflicted with associated muscle, joint or neurological disorders that result in chronic pain syndromes.

The Chronic Pain Dilemma

Chronic pain is difficult to treat because of the potential double-edge sword of drug dependence and addiction in patients who are not terminally ill but have persistent, intractable (i.e., unresponsive to treatment) pain. Additionally, there are problems of reactive depression, insomnia, and socioeconomic factors frequently associated with these conditions.

To make matters worse for these patients, physicians are often reluctant to treat them, including many with terminal illnesses, with the appropriate pain killers (e.g., narcotic analgesics) due to fear of being prosecuted for unwittingly violating the many prescribing regulations and statutes enforced by the Drug Enforcement Administration (DEA). Fear of prescribing the proper medications to control chronic pain syndromes has become an unresolved controversy in clinical medicine. Many patients suffer unnecessarily because of the lack of administration of the proper types and dosages of medications necessary to control their pain. Many of these patients end up committing suicide as a way out of their pain and suffering. Moreover, this persistent problem fans the perilous flame of the euthanasia and assisted-suicide movements.

It is not surprising that the patients’ families frequently have difficulty coping with these illnesses, the pain, the depression and anxiety, and, not infrequently, economic worries — such as the cost of medical care and the fact many of these patients cannot work and thus may place an added financial burden on their families. And, if the patient had been the income-earner, it may mean that the family will have to find a new financial source.

Physicians are not immune to the problems of chronic illness. They must preserve their professionalism while extending their compassion, both to the ailing patient and the grieving family. For some physicians, this is very difficult. Their inability to cure the patient is seen, erroneously, as a personal and professional failure, an inadequacy, which is difficult to reconcile with their role as healer. Thus, some physicians show disconcerting aloofness that is misinterpreted by the patient as being unsympathetic and uncaring. Other physicians cannot separate themselves from their work and bring these troubles home, to the detriment of their family life. After all, physicians are human beings too, not gods or machines.

Fortunately, most doctors maintain their equanimity and are able to preserve the trust that is required in the patient-doctor relationship and to maintain a good rapport with the patient’s family.

Family members suffer shock and acute stress reactions after the sudden loss of a loved one. The stages of acute grief, first described in 1944 by the psychiatrist E. Lindeman, include: “An intense subjective sensation of mental pain accompanied by a feeling of exhaustion; preoccupation with the image of the deceased; a sense of guilt concerning the relationship to the deceased; sometimes an inexplicable and unwarranted hostility toward friends and relatives; [and] a loss of the usual pattern of conduct. Bereaved persons are unable either to initiate or to organize their daily affairs and tend to perform routine tasks in an automatic and uninterested fashion.” (Victor and Adams, p. 978)

Thanatology

The study of death and dying and the psychological mechanisms of coping with them is referred to as thanatology, a term derived from the Greek word thanatos, meaning “death.” This is an evolving professional discipline that also attempts to explain the psychological reactions to the process of dying by the terminally ill and those around them.

How do patients react to their own imminent death? In 1969, in one of the most momentous psychological studies of the past century, Dr. Elisabeth Kübler-Ross described the now famous, five psychological stages experienced by a patient in anticipation of death: Denial and isolation; anger; bargaining; depression; and acceptance. She then elucidated and expounded on how, despite tragedy, hope can be brought about at this difficult time for all involved — the patient, the family, and the professionals who are caring for the patient.

In 1975, Raymond A. Moody, M.D., a resident in psychiatry, described a number of patients who survived “near-death” experiences and who recounted for him their unusual recollections. Patients who have had a close brush with death or suffered transient cessation of cardiopulmonary function, approaching “clinical death” (but not brain death), recalled a number of eerily similar, mostly (but not always) pleasant “near-death” experiences that took place during their period of “unconsciousness.”

The two most common experiences were those of suddenly finding oneself floating “out of body” and then rapidly being drawn through a dark tunnel and experiencing an almost inexpressible moment of peace and tranquility upon reaching a very bright but calming white light or comforting spiritual presence. The other recollection was that of a sudden, panoramic review of one’s life, that is being displayed rapidly, chronologically, and almost instantaneously before the patient. Both of these near-death experiences are described for the most part as peaceful, meaningful and fulfilling; for most, a reassurance of a promising spiritual life after death. The physiologic phenomenon responsible for these subjective “near-death” experiences is yet to be fully elucidated. 

Chronic illness and its associated pain and suffering in the final confrontation with death will continue to be a challenge for patients and their physicians in the foreseeable future.

References

1. Faria MA Jr. Vandals at the Gates of Medicine: Historic Perspectives on the Battle Over Health Care Reform. Macon, GA, Hacienda Publishing, Inc., 1995.

2. Faria MA Jr. The police state of medicine — the nature of the beast. Medical Sentinel 1998;3(4):119-123, 138.

3. Faria MA Jr. Pain control or state control. Medical Sentinel 2001;6(3):103-104.

4. Kübler-Ross E. On Death and Dying. New York, NY, Macmillan Publishing Company, Inc. 1969.

5. Lindemann E. Symtomatology and management of acute grief, Am J. Psychiatry 1944;101:141 cited in Victor and Adams, Principles of Neurology, New York, NY, McGraw-Hill Book Company, 1977, pp. 978-980.

6. Lonergan T. A personal experience in the criminal justice system. Medical Sentinel 1998;3(4):139-140.

7. Moody RA. Life After Life and Reflections on Life After Life. Carmel, CA, Guideposts, 1975.

8. Nicolson GL, Nasralla MY, Haier J, Erwin R, et al. Mycoplasmal infections in chronic illnesses: fibromyalgia, and chronic fatigue syndromes, Gulf War illness, HIV-AIDS, and rheumatoid arthritis. Medical Sentinel 1999;4(5):172-175.

9. Orient JM. Sapira’s Art and Science of Bedside Diagnosis. 2nd edition. Philadelphia, PA, Lippincott, Williams and Wilkins, 2000.

10. Rowland LP. Merritt’s Textbook of Neurology. 7th edition. Philadelphia, PA, Lea and Febiger, 1984.

11. Scott O. Pain. Medical Sentinel 1998;3(4):141-143, 148.

12. Summers WK. Tacrine in the treatment of Alzheimer’s Disease. Medical Sentinel 2000;5(1):15-18.

Resources

1. American Foundation for Suicide Prevention, 120 Wall Street, New York, NY 10005.

2. National Chronic Pain Outreach Association, 7979 Old Georgetown Road, Suite 100, Bethesda, MD 20814-2429.

3. National Academy of Hospice Physicians, P.O. Box 14288, Gainesville, FL 32604-2288.

Written by Dr. Miguel A. Faria, Jr.

This article was written in 2002 but was edited and published exclusively for HaciendaPublishing.com on October 26, 2012.

The article can be cited as: Faria MA. Chronic illness. HaciendaPublishing.com, October 26, 2012. Available from: http://www.haciendapub.com/randomnotes/chronic-illness

The Medical Sentinel has published a number of the articles cited in the reference list above. These articles and others on the politics of pain are available at http://www.haciendapub.com.

Copyright ©2002-2016 Miguel A. Faria, Jr., M.D.

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Sonja Eva Singletary M.D. RIP

Sonja Eva Singletary M.D. (1952-2015)

It is with great sadness and deep sense of loss I post the Obituary below of my dear friend and classmate, Dr. Eva Singletary, printed in several newspapers and the funeral home, Geo. H. Lewis & Sons. I was one of Eva’s classmates and close friends at MUSC, Class of 1977, and then we were surgical residents at the University of Florida. She stayed there to complete her residency in general surgery, while I went to Emory University to complete mine in Neurosurgery. Eva was a ray of sunshine, an extraordinary woman. We all knew she was destined for greatness and she did just that becoming one of the top surgical oncologists in the world. She gave her life to M.D. Anderson. I only regret we did not remain in touch. Nevertheless, her loss saddens me despite nearly 40 years since our parting. I extend my sincere condolences to her family. I know she will be sorely missed by her colleagues at M.D. Anderson, her surgical residency team at the University of Florida, and her admiring classmates at the Medical University of South Carolina.--- Miguel A. Faria, M.D., Associate Editor-in-Chief and a World Affairs Editor of Surgical Neurology International, Clinical Professor of Surgery (Neurosurgery, ret.) and Adjunct Professor of Medical History (ret.) Mercer University School of Medicine. Website: www.haciendapub.com and www.drmiguelfaria.com

Obituary

Dr. Sonja Eva Singletary, M.D., age 62, passed away on Wednesday, the 29th of July 2015 in Houston, Texas. She was born on a small family farm near Florence, South Carolina.Dr. Singletary After completing an accelerated undergraduate program at Clemson University and receiving her medical degree at the Medical University of South Carolina, Dr. Singletary finished her surgical residency at the University of Florida, including research in Tumor Immunology. She dedicated her entire surgical career to the M.D. Anderson Cancer Center with the firm belief that the Anderson was a "big happy family with the focus always on the patient." She was asked to join the M.D. Anderson staff upon completion in 1985 of a two-year fellowship; in 1987 she was named Chief of the Melanoma Section and in 1990 she became Chief of Breast Surgery.

Dr. Singletary became one of the premier breast surgeons in Texas and the United States. Her expertise in the clinical care of women affected by breast cancer was recognized in 1992 when she was named to a 17 member Special Commission on Breast Cancer by the President's Cancer Panel to assess the status of breast cancer research, detection, treatment and prevention throughout the United States. She also served on the Intervention Task Force of the Texas Cancer Council.

Dr. Singletary worked closely with basic and clinical researchers to identify genetic factors associated with development of breast cancer, to design more effective combination therapies and to implement prevention strategies. Her grasp of the complete breast cancer picture placed her in frequent demand as a teacher and speaker. Dr. Singletary authored numerous peer-reviewed journal articles, books, and patient educational CDs. Her concern and dedication provided the knowledge that now empowers women to make informed decisions and choices that affect their quality of life.

Dr. Singletary was the daughter of the late Josiah B. Singletary and Agnes Kull Singletary. She is survived by her beloved son, Benjamin Harkrider; her brother, Dr. Frank Singletary and his wife Gayle and their three children, Jennifer, Christopher and Brittany; her sister, Anna Marie Schuster and her two children, Douglas and Deanna; her sister, Dr. Loretta Singletary and her husband William Chounet and their five children, Joseph, Robert, Cassandra, Noel, and Jean Pierre.

The memorial service will be conducted at four o'clock in the afternoon on Sunday, the 2nd of August, in the Jasek Chapel of Geo. H. Lewis & Sons, 1010 Bering Drive in Houston. The family will gather for a private interment at Memorial Oaks Cemetery at a later date.



Diary of Dreams performs at the 2016 M’era Luna festival in Hildesheim, Germany. M’era Luna, “one of the biggest dark music events in Germany,” is held each year on the second weekend in August. Close to 25,000 people attend the festival annually to hear gothic, metal and industrial music performed on two large festival-style stages.