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Human Biology 75.3 (2003) 411-412

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Letter to the Editor

Response to Brimacombe et al., Birth Order and Its Association with the Onset of Chronic Fatigue Syndrome

In the August 2002 issue of Human Biology, Brimacombe et al. (74:615-620) reported an interesting study on the possible significance of birth order in differentiating subgroups in chronic fatigue syndrome (CFS). However, we would like to formulate some criticism of the authors' basic assumptions, and make some suggestions for further research.

First, the authors believe to be able to clearly differentiate CFS patients into two subgroups, those with a gradual and those with a sudden illness onset. In our multidisciplinary chronic fatigue clinic, however, we often see a combination of both types of onset. Indeed, by carefully listening to their story, one can determine that many CFS patients have felt fatigued and overburdened for a period of many months (sometimes years). They obstinately try to keep their head above water, until an acute infection (or another additional physical or emotional stressor) eventually obliges them to give up.

Second, although birth order can be conceived as an objective measure, it is loaded with highly personal and subjective meaning, which can only be understood within the context of gender and family dynamics. For example, a 'parentified' eldest daughter in a large family, who has to replace her chronically sick mother, is not necessarily the eldest child in the family.

In conclusion, this study shows that vulnerability for CFS should not solely be investigated using nomothetic, but also ideographic strategies (Van Houdenhove 2002). In other words, to resolve the biopsychosocial puzzle of CFS—including the problem of illness heterogeneity—an evidence-based medicine approach should be complemented and inspired by a narrative-based medicine approach (Greenhalgh and Hurwitz 1999).

   Department of Liaison-Psychiatry
   University Hospital Gasthuisberg
   K.U. Leuven
   Herestraat 49
   B-3000 Leuven, Belgium

Literature Cited

Greenhalgh, T., and B. Hurwitz. 1999. Narrative-based medicine. Why study narrative? Brit. Med. J. 318:48-50.

Van Houdenhove, B. 2002. Listening to CFS. Why we should pay more attention to the story of the patient. J. Psychosom. Res. 52:495-499. [End Page 411]

Reply to Dr. Van Houdenhove

While we also occasionally find patients whose history of fatigue precedes their getting a flu-like illness from which they are unable to recover, our own careful approach certainly does find appreciable numbers of patients who were perfectly well until succumbing to a sudden flu-like illness. In fact, we have reported that the chronobiological pattern of these illness onsets is not random in that their rate peaks in January (Zhang et al. 2000).

We totally agree with the writer's second point that psychosocial variables can be heavily involved in any birth order study. In fact, that was why we hypothesized we would find a birth order effect in CFS patients whose illness began gradually and not in patients whose illness followed an abrupt flu-like onset.

Finally, while we as clinicians depend heavily on narration to inform us about the patient and the patient's illness story, we believe that the evidence-based approach is the only way the medical field can solve the problem of illness cause. Self-reported data are open to substantial recall bias. For example, a number of studies have linked abuse in childhood as reported to have occurred by adults with fibromyalgia (e.g., Walker et al. 1997). However, Raphael et al. (2000) have recently shown that rates of widespread pain do not differ in people with documented abuse in childhood compared to nonabused samples.

   Professor of Neurosciences
   UMD-New Jersey Medical School
   Newark, NJ 07013

   Director, War-Related Illness and Injury Study Center
   New Jersey VA Health Care System
   East Orange, NJ 07018

Literature Cited

Zhang, Q., B.H. Natelson, J.E. Ottenweller et al. 2000. Chronic fatigue syndrome beginning suddenly occurs seasonally over the year. Chronobiology International 17(1):95-100.

Walker, E.A., D. Keegan, G. Gardner et al. 1997. Psychosocial factors in fibromyalgia compared with rheumatoid arthritis. 2. Sexual, physical, and emotional abuse and...


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