The "chronic brucellosis" papers.

Maybe they got behind the Eight-Ball?

 

I got tested for Brucellosis when I first got ill because I was a vet working with large animals. It was negative thankfully.

 

It was one of the potential pathogens for which I was originally tested also. That probably accounts, in part, for my interest in the subject. It was negative, of course.

 

I suspect that the Imbodenet al results would be much more persuasive if we had any information about the brucellosis tests which must have been carried out on the Whitecoats in the eight-ball. There is a paper by Canter from 1972 on hypersensitivity to the tularaemia vaccine which provides some description of the testing process. One can only suppose that those tested thought their chances of survival better in Fort Detrick than in Viet Nam. I think that research was carried out in about 1965 or 66.

One suspects that this may have been a point at which the paths of Willy Burgdorfer and Imboden, Canter and Cluff must have crossed. Tularaemia was one of WB's areas of expertise and I think I read that he worked on the vaccine.

 

It should have been before 1969, but I would not bet the ranch on that.

 

Not to digress, but I seem to recall reading somewhere that the number one cause of disability in vets is Bartonella. Can't be sure since I don't recall where I saw it, though.

 

I've not been tested for that but I have been bitten/scratched by an awful lot of cats...

ETA: My symptoms didn't fit with Bartonella infection.

 

Cats, dogs, all kinds of carriers.

Bartonella is one of the weird ones. It manifests it many different ways. It is easy to mistake for another disease. I was fortunate on a couple of fronts: I had a common manifestation - bad pain in the soles of my feet. Plus, I carried one of the few strains they actually test for, so I tested positive and received aggressive treatment.

But take away the pain in my feet, and the occasional tell-tale "scratches", I'd have been diagnosed with ME/CFS yet again, because very few clinicians include Bartonella in the differential diagnosis.

 

For the sake of completeness I will lpost the link to this paper which was found by @Snow Leopard and posted on another thread

https://sci-hub.st/10.1093/clinids/13.Supplement_1.S138

Medical Aspects of Delayed Convalescence
Leighton E. Cluff
From the Robert Wood Johnson Foundation, Princeton, New Jersey

Disease and illness are not synonymous. In most instances, disease is demonstrable by anatomic, physiologic, biochemical, microbiologic, or immunologic abnormalities. Disease is a pathologic process. Not all persons with a disease are sick or ill. Symptoms of illness associated with a disease may be manifest or persist after the disease has disappeared. The absence of demonstrable disease, however, does not necessarily mean that symptoms of illness are unreal. Recovery from disease and recovery from illness are not always equated. Many factors, including personal characteristics and social circumstances, can be responsible for recovery from disease and illness. Chronic fatigue syndrome or symptoms of illness can persist in some patients but not in others after many different diseases.

Reviews of Infectious Diseases 1991;13(Suppl l):St38-46 © 1991 by The University of Chicago.

It is interesting that Cluff's former John Hopkins colleague Eisenberg brought these ides to the UK in 1987 and Cluff is still preaching them in 1991.

It is also interesting to note Cluffs interest in the Department of Veterans Affairs, given how closely connected to the military SW was to become.

 

There is a potentially interesting paper by Cluu listed in the cittations in that last paper

Cluff LE. Delayed convalescence from influenza: its prediction and implications. Clin Ther 1979;2:98-10

I have been unable to find it.

One can see the major area of concern to Cluff from this paragraph

The economic impact or cost of medical care is being carefully and critically scrutinized. Economic controls are being imposed to curtail the cost of medical care. Increased demands for care and improved methods of care, however, certainly will further increase costs. New diagnostic or therapeutic developments may improve care of those who are sick, but in the past have, and certainly in the future will further increase the cost of care. It is irreconcilable to institute economic controls to curtail cost while simultaneously pursuing a course that leads to increased demands for medical care
https://sci-hub.se/10.1093/infdis/129.1.86
Cluff, L. E. (1974). Infectious Diseases: A Perspective. Journal of Infectious Diseases, 129(1), 86–91. doi:10.1093/infdis/129.1.86

 

I was tested too because I had a fair bit of contact with cows as a child and we drank unpasteurized milk, used butter made from it etc.

The result was negative.

 

In 1985, about a year after the start of the Lake Tahoe outbreak on the the other side of the country, there was an outbreak of unknown fatiguing illness in Lyndonville, New York - a rural, farming community.

If I recall correctly, the town doctor, David S. Bell, initially suspected brucellosis because some local farmers were known to consume milk which had not been pasteurized. The outbreak was notable for the large number of children affected (about 1/3 of the 200+ cases were kids) and many of them had also consumed raw milk. My memory is that a connection to brucellosis could not be proven, however.

The CDC knew of both the Lake Tahoe and Lyndonville events, but they never told the reporting physicians (Dr. Dan Peterson and Dr. Bell, respectively) about each others' similar outbreaks.

https://en.wikipedia.org/wiki/David_Sheffield_Bell

 

There has certainly been strange behaviour displayed at an official level, but the interest with brucellosis is perhaps that it has so often been thought necessary to exclude it as a diagnosis.

On reflection I think that the problem with the influenza papers is the apparent determination to prove the hypothesis formed with the brucellosis papers correct, rather than attempt to refute it. The chronic brucellosis cases investigated had persisted for a number of years. Ask about a severe case of flu and the answer may be that some symptoms persisted for a month or two, or perhaps more, but then disappeared. A very small number might lead to chronicity. It seems positively perverse to expend money on this research and only enquire about symptoms within the period during which persistence of symptoms may not be unexpected.

A six week delay in recovery is no evidence for chronicity.

There were tens or hundreds of thousands of people within the US contracting flu at this time. Perhaps what was needed was a further study of people who were still symptomatic at six weeks but who went on to make a full recovery.

These papers were quoted widely by the BPS proponents. Did no-one see any flaws, or have I just seen problems where none exist?

When people with long covid are diagnosed with anxiety or depression it will be these papers behind it.

 

Is it that back in those days peasants like us were unlikely to read and assess the evidence for ourselves and then have the temerity to question it?

It it that those who did have an interest, also had a vested interest in specific interpretations and therefore chose that interpretation?

Would those downstream whose decisions about patients and further research were affected by the conclusions have simply relied on the authority of the original authors?

I think the boil on humanity that is the existing BPS implementation has probably been slowly developing for a long time and we're seeing early signs of it here. Let's hope it will be lanced soon before it can wreak even more damage.

 

I've been meaning to start a thread about the history of psychogenic attribution but looks like @chrisb beat me to it.

Here are a few links I found: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1030503/?page=4 about Fibrositus (arguably the predecessor of Fibromyalgia).

Psychiatry and Biological Factors - P248 Wessely wasn't the first to say viral/physical attribution led to worse outcomes. Chronic Brucellosis was around before Chronic Lyme.

Not much chance of The Lancet doing that.

 

Here is the passage in the paper "Are psychiatric (EDIT) disorders "real"" by Leon Eisenberg in the book Illness Behaviour: a multidisciplinary approach by McHugh and Vellis 1987 in which the Imboden Canter Cluff model was brought into the formal illness behaviour narrative. This book represented the procedings of the international conference on illness behaviour held in Toronto in 1985.

The later views expressed by Eisenberg at the Oxford lecture in 1987 may have been taken to be a passing reference to the subject with only a passing interest. It is now clear that this was far from the case, and that he had been working on this idea, sometimes in conjunction with Kleinman, for some years. The trouble with Eisenbergs, as with icebergs, is that the dangerous part may be submerged.

Illness Behavior: A Multidisciplinary Model: Amazon.co.uk: McHugh, Sean, Vallis, T. Michael: 9780306424861: Books

 

I am not so blind as not to recognise that this is becoming tedious, but detail is and the ogre in all its manifestations is not yet slain.

It is instructive to compare and contrast the two versions of Eisenberg's views, the one given at Toronto to the Illness Behaviour conference in 1985 and the other to Oxford psychiatrists in 1987. The social construction of mental illness (cambridge.org)

[Yet, thirty years later, it is reasonably clear that chronic brucellosis is a spurious disease construct which legitimizes and thereby perpetuates chronic illness behaviour.

Comparisons of fully recovered patients with those complaining of persistent symptoms after bacteriologically confirmed acute brucellosis reveals no difference on physical examination or laboratory tests (Cluff et al. 1959). However, on mental status examination, the symptomatic patients display signs of depression. Are the symptoms somatized depression or are patients depressed for having a chronic bacterial disease?

To discriminate between the two possibilities, Imboden and his colleages (Imboden et al. 1961) assessed 480 male civil service workers by the Minnesota Multiphasic Personality Index shortly before an expected epidemic of influenza. During the 'flu season, the rate of infection (as determined by serological surveillance of all subjects) was no greater in persons identified as 'psychologically vulnerable' by their test scores, but they made clinic visits five times more often. Almost all the patients who exhibited prolonged convalescence from 'flu were in the vulnerable group. The chronic aftermath of acute infection represents a pattern of persistent illness behaviour precipitated by a disease episode in psychologically vulnerable individuals. Once sanctioned by a physician, the symptoms are more likely to persist; the persistence of the symptoms is mistaken for confirmation of the diagnosis.

Chronic brucellosis no longer has much cachet as a diagnosis, but candidates for the succession are very much in evidence. Currently, considerable attention is being devoted to 'chronic mononucleosis', also known as 'chronic active Epstein-Barr virus (EBV) infection'. The syndrome is characterized by chronic fatigue, fever, myalgia, pharyngitis, headache, depression and cognitive change (Buchwald et al. 1987; Holmes et al. 1987). Antibody titres against EB virus are somewhat higher in patients with these symptoms than they are in the general population, but exposure to EBV is so ubiquitous that there are no cut-off levels which reliably distinguish patients from controls. Whatever the cause of this symptom pattern, EBV infection is an unlikely bet. If some cases indeed prove to be due to an as yet to be discovered virus, many more, in my estimation, represent the somatization of personal distress, legitimized by a newly fashionable diagnosis.]


By 1987 he had added chronic mononucleosis or chronic active EBV and the description "spurious disease construct". He had also added the important caveat regarding the possible distinction betwen cases due to "somatisation" and some other cases potentially due to virus, thoughhe seems unpersuaded on the point.

This appears to pose problems in the absence of any attempt offer indications as to how diferentiation might be effected and the possible consequences of non differentiation. Those familiar only with te views offered in 1985 might not be familiar with the later more nuanced approach. It is hard to see how one gets from this to simply lumping all cses together as CFS, though it is easy to see how that might be the conclusion from the 1985 view.

 

It now appear that, between 1960 and 1963, Imboden co-authored three papers on "Conversion Reactions" with Ziegler and Meyer. In two of these he made reference to the Imboden, Canter Cluff papers in such a way as to indicate that this model applied to perpetuation of symptome in the brucellosis cases.

This is stated in the first paper:

In a study by one of the authors(21) of patients with a history of acute brucellosis, the development of a chronic syndrome, so called “chronic brucellosis,” was positively correlated with the concomitant presence of potentially depressing life situations. Most of the chronically symptomatic patients denied emotional problems and con- sidered whatever depression they expe-rienced as secondary to symptoms such as fatigue and somatic pain, which were attributed to an allegedly persistent infection with brucella. There was strongly suggestive evidence that this preoccupation with somatic symptoms had a self-esteem supporting function.

Conversion reactions, then, may be used as defenses against more overt depression, which may thereby be obscured. Even when depression predominates, however, con- version reactions may still be defensively employed.

And this in the second:

This investigation suggested that conversion reactions may serve to reduce or avoid a variety of painful affects. To apply the term "anxiety" to a variety of painful affects presents real semantic difficulty, es¬ pecially since even Freud made only a quantiative distinction between "signal anxiety" and clinically overt anxiety. The "defense mechanism" theory of conversion symptoms might actually be challenged on logical grounds since, except for abundant inferential clinical data, no experimental evidence or "proof" has heretofore been produced. We wish to cite 2 additional studies that also seem to provide some of this (to us) desirable evidence. In the first, of delayed convalescence following acute brucellosis,30 individuals who had recovered quickly from the disease were compared with patients who had developed "chronic brucellosis." Both groups were given the TDMA "Self-Concept Scale" (which pro¬ vides some indication of the degree to which the subject perceives himself "positively"). As expected, the control ("acute, recov¬ ered") group scored significantly higher on this scale than did the chronic group. How¬ ever, those patients who had had "chronic brucellosis," but had symptomatically re¬ covered by the time of the investigation, scored lower on the Self-Concept Scale than did those patients who still had symptoms at the time of this study. This finding, which was confirmed by data derived from the psychiatric interviews, strongly supported the view that the somatic symptoms had a significant function in the maintenance of self-esteem. In another study, of delayed convalescence after the Asian influenza epi¬ demic,29 it was demonstrated that those pa¬ tients who showed objective test evidence of depression before the epidemic retained symptoms significantly longer (tending to¬ ward chronicity) than did undepressed con¬ trols.

On the one hand, these studies all support the concept that the conversion symptom or syndrome is a personality defense. On the other hand, they strongly suggest that there are any number of dysphoric affects which may be defended against with conversion symptoms..


Sci-Hub | CONTEMPORARY CONVERSION REACTIONS: A CLINICAL STUDY. American Journal of Psychiatry, 116(10), 901–910 | 10.1176/ajp.116.10.901 (sci-hub.se)

Sci-Hub | Contemporary Conversion Reactions. Archives of General Psychiatry, 6(4), 279 | 10.1001/archpsyc.1962.01710220021003 (sci-hub.se)

Sci-Hub | Contemporary Conversion Reactions. JAMA, 186(4), 307 | 10.1001/jama.1963.03710040033006 (sci-hub.se)

The fact that Imboden drew certain conclusions from his results does not preclude the possibility of others drawing different conclusions. However, if they areto do so it would seem aprudent ti indicate an awareness of the original authors views and to distance oneself from them. Failure to do so suggests acceptance and endorsement.

 

IT is interesting to see that the idea expressed by Ziegler, Imboden and Meyer and described by them as a "conversion reaction", alleged to occur in patients with chronic brucellosis, and thus, probably, by extension ME, provided protection for self esteem and alleviation of guilt turned up in very similar form in a Wessely paper:

Significant symptomatic differences between the depressed CFS group and depressed controls were observed for features such as self-esteem and guilt as well as attribution of illness. All the CFS groups tended to attribute their symptoms to external causes whereas the depressed controls experienced inward attribution. This may have resulted from differences in the severity of mood disorder between the samples, but it is also suggested that an outward style of attribution protects the depressed CFS patients from cognitive changes associated with low mood but at the expense of greater vulnerability towards somatic symptoms such as fatigue.

Powell, R., Dolan, R., & Wessely, S. (1990). Attributions and self-esteem in depression and chronic fatigue syndromes. Journal of Psychosomatic Research, 34(6), 665–673. doi:10.1016/0022-3999(90)90111-g
url to share this paper:
sci-hub.se/10.1016/0022-3999(90)90111-G