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The Underlying Cause of Fatigue.

Benjamin Natelson is a neurologist who directs the New Jersey Chronic Fatigue Center. He's just written "Facing and Fighting Fatigue: A Practical Approach." (Yale University Press) He specializes in treating chronic fatigue syndrome. He says that while many people think CFS is all in their heads, there is actually a physiological component to the condtion.


Other segments from the episode on June 22, 1998

Fresh Air with Terry Gross, June 22, 1998: Interview with Sonia Ascoli-Israel; Interview with Benjamin Natelson; Review of King Sunny Ade's album "Odu."


Date: JUNE 22, 1998
Time: 12:00
Tran: 062201np.217
Head: How'd You Sleep Last Night
Sect: News; Domestic
Time: 12:06

TERRY GROSS, HOST: This is FRESH AIR. I'm Terry Gross.

How'd you sleep last night? If your partner's snoring kept you awake, stay tuned. My guest Sonia Ancoli-Israel is an expert in sleep disorders. She's going to tell us about some of the problems she treats, including loud snoring.

Ancoli-Israel directs the Sleep Disorders Clinic at the San Diego Veterans Affairs Medical Center, and is a professor of psychiatry at the University of California-San Diego. She's also the author of "All I Want Is A Good Night's Sleep." This is her second visit to FRESH AIR.

I told her I sometimes wonder if people are having more difficulty than ever sleeping, and if contemporary life provides more stress and distractions that keep people from sleeping.

SONIA ANCOLI-ISRAEL, DIRECTOR, SLEEP DISORDERS CLINIC, SAN DIEGO VETERANS AFFAIRS MEDICAL CENTER, PROFESSOR OF PSYCHIATRY, UNIVERSITY OF CALIFORNIA-SAN DIEGO, AUTHOR, "ALL I WANT IS A GOOD NIGHT'S SLEEP": There are definitely two parts to that. We're not only having more trouble sleeping because we're busier, we're turned into a 24-hour society where you can go food shopping in the middle of the night and you can certainly be on the Internet all night long. Radio stations, many of them go all night long. Television is available all night long.

And so there's lots of options of things to do other than sleeping and people take those options because they think they can get by with less sleep. So that's one part of it.

The second part is that both the public and physicians have become better educated about sleep, about sleep problems, and about the need for sleep. And so that people are now more aware that perhaps being tired during the day is not normal and that in fact might indicate something's wrong with their sleep.

GROSS: Are there different short-term and long-term consequences when you cheat on sleep, as so many of us constantly do?

ANCOLI-ISRAEL: There are. The very short-term consequences, like if you just skimp on sleep one or two nights, is that you might be a little tired, but on the third night, when you get your full night's sleep, you'll feel better and everything will be OK.

The long-term consequences include things like problems with memory, problems in concentration, problems with relationships, and that could be family relationships, social relationships, relationships at work -- basically anything that requires attention will be changed because it becomes very difficult when you're tired to attend to things. Reaction time is slower, so your driving could be affected.

GROSS: A lot of people find at night that when they're watching TV or when they're reading, they just kind of nod off; they just kind of doze off. Is that normal or is that a sign that you're not getting enough sleep?

ANCOLI-ISRAEL: That's a sign that you're not getting enough sleep. Dozing off at any time of the day or night means your body needs to sleep. So, if you're in a dark lecture hall at eight in the morning or in church of synagogue and you're dozing off, it's not because the situation is boring; it's not because the room is dark. It's because you're sleepy and you need more sleep.

The situation may unmask the sleepiness, but the sleepiness is always there.

GROSS: Well, there's two levels of sleep problems that I can think of off-hand. One is that, you know, you don't have enough time so you're not sleeping enough. The other is that there's things that are physiologically interfering with your ability to sleep.

I think we'll have to leave our listeners to their own devices in terms of finding the hours to sleep, but I'd love to hear some of your advice dealing with actual problems that interfere physiologically with sleeping.

You run the Sleep Disorder Clinic at the Veterans Administration Hospital in San Diego. Is there -- is there a change in the kind of disorders that you're seeing?

ANCOLI-ISRAEL: The most common sleep disorder that most clinics see, and this has been true for about 10 years now, is a disorder called "sleep-disordered breathing" or sleep apnea. This is a disorder where people stop breathing in their sleep. They fall asleep. They stop breathing. In order to start breathing, they have to wake up, so they wake up. They start breathing. They go back to sleep. They stop breathing. And this can go on throughout the night.

Every time they stop breathing, it could last anywhere from 10 seconds to a minute or more. And these events could happen hundreds of times during the night. So many of these people cannot breathe and sleep at the same time. The arousals -- the awakenings that they experience in order to start breathing again might be so brief that they don't realize they're waking up. But it's enough to disrupt their sleep.

GROSS: Now I've been hearing a lot and reading a lot about sleep apnea lately, and it seems like it's just very recently that it's been penetrating the mass media in the way that it has. And you say you're seeing more of it in the past 10 years. Why do you think it's more common than it was? Or more noticed than it was?

ANCOLI-ISRAEL: I don't think it's more common. I think it is more noticed. And again, I think it's education. The National Sleep Foundation, which is a nonprofit organization in Washington, has done an excellent job in educating the public about these serious sleep disorders. And so I think people are just becoming more aware of them. The symptoms and the signs have always been there.

The most common symptoms would be very loud snoring. In fact, we ask our patients: "how loud to you snore? Can you be heard only in your bedroom? Can you be heard one room away? Can you be heard two rooms, three rooms away from your bedroom?" And many of them will say yes, they're heard throughout the house. So this is a very, very loud snore.

The other common symptom is what we call excessive daytime sleepiness, and that means that these patients have a very difficult time staying awake, pretty much anytime they're sitting down quietly. That would be in the extreme case. So, at their desk at work; at the computer; while in conversation with friends sitting around the living room; during a board meeting -- any time they're pretty much sitting and not being active, they will start dozing off.

GROSS: I suspect that some of the sounds of sleep apnea can, you know, be easily heard by the partner sleeping next to the person with the apnea. There's the loud snoring that you mention. But what else can the partner observe that would help diagnose sleep apnea?

ANCOLI-ISRAEL: The partner can observe the patient during the night to see if he or she actually stops breathing. Sometimes it's hard to see, but usually you can tell. And the snoring has a characteristic pattern to it, where there'll be this very loud snorting snoring, and suddenly there'll total quiet. And that's the point where the patient has stopped breathing.

And then they'll hear the snoring and the snorting begin again. If the partner is aware of that, then it's time to get their spouse or their bed partner into see the doctor. The problem is that often the partner is sleeping while all this is going on. They may have gotten into the habit of going to sleep before the snorer, so that the snoring doesn't bother them or keep them awake, and then they're not as aware of what's going on.

But if a patient is snoring that loudly and is sleepy during the day, then it's time to talk to your physician about it.

GROSS: You mention snoring and snorting. Is snorting the...


... a different system than the snoring?

ANCOLI-ISRAEL: It sometimes comes hand in hand. You can have just the snorting -- and you did that very well, Terry.

GROSS: Thank you. Thank you.


ANCOLI-ISRAEL: You could have just the snorting. That's not as concerning. It's when it's with the snoring or the very loud snoring in combination.

GROSS: Mm-hmm. So, is this a dangerous disorder? You said go to the doctor.

ANCOLI-ISRAEL: It can be. You're not getting oxygen to your brain for periods throughout the night. This disorder is often associated with hypertension, with heart disease, and with increased risk of mortality. That is, we think that many of these patients with severe apnea who are not treated often die in their sleep and die sooner than they might have if they were treated.

So it is -- it can be a serious disorder and it should be treated.

GROSS: Is it only recently that doctors have realized that this kind of snoring is actually a serious problem; that it's not just, you know, a disturbance to other people sleeping in the house?

ANCOLI-ISRAEL: Right -- or a joke.

GROSS: Or a joke; exactly.

ANCOLI-ISRAEL: Yeah, I think it is recent and some doctors may still not realize how important snoring on its own can be. There have been some epidemiological studies, survey studies, in Scandinavia that have indicated that loud snoring on its own, even when there's no apnea present, leads people to increased risk of stroke and certain types of heart disease.

So snoring on its own can increase blood pressure during the night, which is what happens with apnea as well. So snoring is an important sign and it's something that needs to be paid attention to. But I don't want to frighten the listeners either. We're talking here not about a quiet snore. We're talking about a very loud, consistent snore where it's every night, all night long. And it's really heard outside of the bedroom.

GROSS: How much is known about what causes the sleep apnea -- this disruption in somebody's breathing while they sleep?

ANCOLI-ISRAEL: There is some known about it. There are actually a few different types of sleep apnea. One of the most common is called "obstructive sleep apnea." And the reason it's called that is because there's actually an obstruction in the airway. The person is still attempting to breathe. If you watch their chest and their abdomen you see that it's still moving. But the airway has literally collapsed in, the muscles in the airway collapse in.

And so even though the person's trying to breathe, the air can't get in or out. It's as if you take a hose -- a water hose -- and you clamp it at one point, the water can't flow anymore. That's exactly what's happening in the airway. And that obstruction could be caused -- it's partially caused by the muscles relaxing and collapsing, but it also is contributed to by a narrow airway, which many of these patients have; or excess fatty tissue; or large tonsils; or a long, large uvula (ph) -- you know, that flap that hangs down in the back of your throat.

GROSS: Mm-hmm.

ANCOLI-ISRAEL: That's called a uvula. That often is very long or very large. It would be a large tongue. It could be a very long, soft palate. So, the whole anatomy of the mouth and of the airway also contributes to this.

GROSS: So what are some is some of the solutions a doctor might offer someone with apnea if it's -- you know, if it's diagnose?

ANCOLI-ISRAEL: Right. The treatment of choice these days is a device called "CPAP." It stands for Continuous Positive Airway Pressure. It's a nosepiece connected via a hose to a machine which pushes pressure into the airway. And this airway acts as a splint to keep the airway open during the night.

The patient has to wear it every night, but it is very effective for patients that can tolerate it and that are compliant; that is, that actually do use it.

GROSS: This isn't going to very popular with people who are dating.



GROSS: And having early -- early relationships with somebody. I mean, look, I've seen pictures of it and it looks like -- I don't know how comfortable it is, but it's probably...

ANCOLI-ISRAEL: It's not a pretty sight.

GROSS: Yeah, right.

ANCOLI-ISRAEL: Let's be honest about it. It is not a pretty sight.

There are other options and with out younger patients or patients who don't have one steady bed partner and are concerned about this, we do try to offer other options for treatment. Other options would include first of all, weight loss.

Many of these patients are overweight and sometimes losing a significant amount of weight is enough to make the apnea go away. And sometimes it doesn't have to be hundreds of pounds. Sometimes losing 20, 30 or 40 pounds is enough to make it better. I don't say that lightly. I know it's not easy to lose 20 pounds. But if the patient can do it, sometimes that's all they need.

Another option is surgery. There are some surgeries that can be effective. And it would be up to the physician to decide if the particular patient is a good candidate for the surgery. Sometimes sleep apnea is related to body position, and people only have it when they're on their back. This is true of snoring, too. Some people have only positional snoring; that is, the snore only when they're on their back.

If that's the case, it's much easier to treat and we do that by teaching the patient not to sleep on their back. And the way you do that is you have them sew a pocket into the back of a T-shirt or the back of their pajamas, and you put a tennis ball or a whiffle ball into that pocket. And of course, everytime they roll on their back, it's so uncomfortable, they roll right back off again.

And so that -- in the positional problems -- can also be effective.

GROSS: My guest is Sonia Ancoli-Israel, author of the book All I Want Is A Good Night's Sleep. We'll talk more after a break.

This is FRESH AIR.

If you're just joining us, my guest is Dr. Sonia Ancoli-Israel. She's the author of All I Want Is A Good Night's Sleep and she's also director of the Sleep Disorder Clinic at the Veterans Hospital in San Diego.

What other sleeping disorders are you seeing a lot of now at your disorders clinic?

ANCOLI-ISRAEL: Another sleep disorder that's fairly common is a disorder called "periodic limb movements in sleep." It's also been called "nocturnal miaclonis." This is a disorder where people kick or jerk their legs every 20 to 40 seconds for periods throughout the night. It's as if every time you fell asleep, someone shook you just enough to wake you up again. So, it's a very annoying disorder.

These patients might complain of insomnia because the kicking is constantly waking them up. They might also complain of daytime sleepiness because they're sleep is so disrupted at night. They may or may not be aware that they're kicking. Sometimes their bed partner is aware of it because they're being kicked all night long.

And this disorder is related to another disorder called restless leg syndrome, where people have creepy crawly sensations in their legs and feel they have to constantly move their legs about. But it happens in the awake, relaxed state. And everyone with restless legs has the leg-kick stirring sleep, but not everyone that kicks during sleep has the restless legs when they're awake.

GROSS: What causes this kicking during sleep?

ANCOLI-ISRAEL: We have no idea. There are several theories that it might be related to the dopamine system in the brain; it might be related to circulation; it might be neurologically related. We really have no idea.

GROSS: How do you treat it?

ANCOLI-ISRAEL: It's treated with medications. There are three different classes of medications that have been shown to be somewhat effective, and again it depends on the patient. It's usually a trial and error. The physician will prescribe one of the medications. The patient will try it and if it works, that's great. And if not, he'll switch to another one and they'll keep trying until hopefully they find one that works.

GROSS: And what do the medications do?

ANCOLI-ISRAEL: They do different things. Some of them decrease the number of kicks during the night, but don't totally get rid of them. Some of them decrease the awakenings. Even though the person is still kicking, they don't wake up as much from it. And some of them actually change the amount of dopamine in the system, in the body, which seems to have somewhat of an effect of decreasing both the kicks and the awakenings.

GROSS: Do a lot of people hit a double jackpot and have sleep apnea and the leg kicking at the same time?

ANCOLI-ISRAEL: Yes. Yes, a lot of them do. It's not at all uncommon to see those two come hand-in-hand. And then it becomes even more difficult to treat because you have to treat both of the disorders. And one of the medications that is sometimes used to treat the leg kicks would make the breathing worse. So then you lose that as an option, even, for treating the leg kicks.

GROSS: Hmm. So is there any explanation for why these happen in tandem?

ANCOLI-ISRAEL: There isn't, and there are other sleep disorders that you often see in tandem with these as well. Narcolepsy, for example, which is another disorder where the symptom is a lot of excessive daytime sleepiness, you often see patients who have narcolepsy who also kick their legs or who might also have sleep apnea.

So something in the whole sleep mechanism has gone awry, and the result is these different sleep disorders.

GROSS: Now, something I think we should mention. You point out that a lot of people who are losing sleep because of sleep apnea figure well, I should take some sleeping pills to help me sleep, but that could be very dangerous, actually. Why?

ANCOLI-ISRAEL: That's right. Sleeping pills are respiratory depressants, which means they make it harder to breathe. And the person who has sleep apnea is already having a difficult time breathing. So, we don't want to make it worse.

GROSS: Right.

ANCOLI-ISRAEL: Most patients with apnea, however, have no trouble falling asleep. So it would be more unusual for them to try to take sleeping pills. They usually have the problem of being too sleepy.

GROSS: We've been talking about disorders like sleep apnea and the legs that kick and twitch. What about plain old insomnia? Do we know any more about that than we used to? You know, people who just have a very difficult time getting much sleep or falling asleep at night.

ANCOLI-ISRAEL: Right. And that's a very, very common complaint. About a third of all adults complain of some form of insomnia or difficulty sleeping. But again, the first question that needs to be answered is: what is causing that difficulty sleeping? Is it one of the sleep disorders that we talked about? Is it medication? Is it illness? Is it circadian rhythm changes?

First, you want to rule all those out. Then if you're sure it's not one of those things, then you need to work with the patient to see: is it tension? Is it stress? Is it depression? Is it alcohol? If they're using alcohol, that could be causing insomnia. And by using alcohol, I mean drinking in the evening hours before they go to bed.

And if it is one of those things, then we usually suggest some behavioral treatments, behavioral therapies, and good sleep hygiene, to improve the problem.

For example, if the person is having difficulty falling asleep because their mind is going, and of course the problem for most of us in today's busy society is the first moment we have to sit quietly and think about our day or think about what's going on is when we get into bed at night. And of course, that's the wrong time to start thinking about everything; to start worrying.

So if that's the person's problem, we might suggest that they set aside a worry time earlier in the day.


I know that sounds silly.

GROSS: Nice idea.

ANCOLI-ISRAEL: It sounds very funny, but it works. And what we mean is, set aside half an hour earlier in the evening or earlier in the day where you put out the "do not disturb" sign and you turn off the phone and no one's allowed to bother you. And you get to sit and worry. You get to make lists about all the things you didn't get done or all the things you need to do. Or whatever it is you're worrying about, that's your chance to do it, so that when you get into bed at night or when you wake up at the middle of the night, you don't have to start thinking about all these things.

There are all sorts of techniques like that that can teach people how to relax; how to relax their body; how to relax their mind -- to help them fall asleep faster.

GROSS: Sonia Ancoli-Israel is the author of All I Want Is A Good Night's Sleep, and she's a professor of psychiatry at the University of California-San Diego School of Medicine. She'll be back in the second half of the show.

I'm Terry Gross and this is FRESH AIR.

This is FRESH AIR. I'm Terry Gross.

Back with Sonia Ancoli-Israel, author of All I Want Is A Good Night's Sleep. She directs a sleep disorders clinic in San Diego.

Now, in your book you talk a little bit about what you measure at the Sleep Disorder Clinic. And that includes you measure brain waves and eye movements and chin muscle tension. And I'm thinking: why are you -- you know, what is chin muscle tension and why are you measuring it?

ANCOLI-ISRAEL: The reason we measure the muscle tension of the chin is it helps us distinguish REM sleep from non-REM sleep. Non-REM sleep stands for non-rapid eye movement sleep. And it is broken down into four stages: stage one, two, three, and four -- which are four of our basic stages of sleep.

Stage one is the very lightest level of sleep, when we're just dozing off. It's that transitional sleep. And then stages two, three, and four get progressively deeper, with stage four being our deepest level of sleep. Our fifth stage of sleep is called REM sleep, which stands for rapid eye movement. That's where we usually have our dreams, so REM is our dream sleep.

So during REM, we see the eyes moving and we see the muscle tension drop out because during REM, we are paralyzed except for our eyes and our breathing. And this is believed to be a protective mechanism which keeps you from acting out your dreams. And so we measure the tension under the chin because we watch for when it drops, 'cause it helps us identify the REM sleep.

GROSS: If you're the kind of person who wakes up fairly frequently during the night, does that mean you're never getting a chance to get to that deepest stage of sleep further down the line?

ANCOLI-ISRAEL: It depends how often you're waking up. If you're waking up very often, like for example because of the leg kicks, then yes, you never get a chance to get into the deeper levels of sleep and that's one of the things we see in the patients who have the leg kicks during sleep.

GROSS: And that's one of the reasons why they're so tired, I guess, 'cause they never get into the deepest sleep.

ANCOLI-ISRAEL: That's one of -- that's right. And they never get much sleep anyway because they're constantly waking up and their sleep is very fragmented and disrupted.

GROSS: Mm-hmm.

ANCOLI-ISRAEL: But if you're waking up just periodically, and we all do that a few times during the night, then that won't -- won't keep you from getting into your deeper levels and having a good night's sleep.

GROSS: When you're studying somebody in the sleep disorder clinic and you're asking them to sleep while they're monitored, is there an element of, well stage fright or self-consciousness.

ANCOLI-ISRAEL: Yeah, right.

GROSS: I mean, it's hard to sleep when you know you're being monitored and they're watching you. You're being studied.

ANCOLI-ISRAEL: Absolutely. Of course, it is difficult for a lot of people to sleep all wired up. But the key is: many of the patients, most of the patients that come in that are being recorded are too sleepy. They'll sleep no matter what you do to them. And so the wires aren't going to make any difference. They'll fall asleep sometimes while we're still putting the wires on them. We actually have to wake them up so they can get into bed so we can record them falling asleep.


ANCOLI-ISRAEL: For someone like that, the wires aren't going to make any difference. If however, someone comes in complaining of insomnia -- difficulty sleeping -- and we decide we need to record them, the wires might make a difference. They might take a little longer to fall asleep. They might wake up a few extra times during the night. But basically if they have a physiological problem, we'll see it, even if they only sleep two or three hours, so we'll still be able to make a diagnosis.

And then again, that type of person might be the perfect candidate to be recorded at home instead of in the sleep lab.

GROSS: So many people now are on anti-depressives. And depression can lead to insomnia and some of the anti-depression drugs can affect sleep as well. And I'm wondering how your work at the sleep disorder clinic is being affected by the anti-depressives that people are taking now? If you're seeing any direct impact from that?

ANCOLI-ISRAEL: Right. Many of our patients are depressed and are taking anti-depressants. And we always take that into account. And one of the things you need to try to do is separate out: is it the depression that's causing the sleep problem? Or is it the sleep problem that's causing the depression? Now which -- you know, it's the old chicken and the egg problem.

Because if you're having great difficulty sleeping, that is in itself enough to make you depressed. So, what we will often do is have the patient's physician take the patient off the anti-depressant for a short while and then study their sleep to see what it's like without the medication. Because medications -- many medications, not just antidepressants -- can make sleep worse.

And then sometimes we'll also have the physician adjust the dose of the medication or adjust the time of day or switch to a different type of anti-depressant. And that, in itself, can improve the sleep problem sometimes.

GROSS: Everybody's got little things that bother them about sleeping. Very few people are as talented at sleeping as they'd like to be. But how do you know if you really need help? If you have a real problem?

ANCOLI-ISRAEL: Right. The time to seek help is when you find you cannot function during the day because you're sleepy. If you're falling asleep at the job. If you're falling asleep driving. If you don't feel as alert and as in control as you could be, then you're not getting enough sleep and it's time to seek help.

GROSS: Do people ever come to you thinking they just have a sleeping disorder and what they actually have is chronic fatigue syndrome or one of these mysterious fatigue-related illnesses?

ANCOLI-ISRAEL: Sometimes. Not as often. The patients that we see aren't complaining about being fatigued. They're complaining more of either being unable to stay awake or unable to fall asleep, which is a little different than feeling just so fatigued like you can't move and you want to sleep. But there's a slight distinction there between being very sleepy and being very fatigued.

GROSS: What's some of the most interesting research that you think is going on now in the area of sleep?

ANCOLI-ISRAEL: Oh, there's so much of it. I think that some of the work looking at the biological clock and the circadian rhythms and how sleep fits into all of that and how hormonal changes during the day and night affect our sleep. I think that work is very promising and very exciting.

GROSS: Mm-hmm.

ANCOLI-ISRAEL: I think the genetics of sleep disorders is a brand new area where we're going to learn a lot about sleep disorders and what we can then do about it and how it runs in families. And the function of sleep -- there's still a lot of research going on trying to figure that out 'cause we still don't know what the true function of sleep is.

GROSS: Well, good. I want to thank you very much for talking with us.

ANCOLI-ISRAEL: Oh, thank you so much for having me on the air.

GROSS: Sonia Ancoli-Israel directs the Sleep Disorders Clinic at the San Diego Veterans Affairs Medical Center. She's the author of All I Want Is A Good Night's Sleep.

Coming up, chronic fatigue.

This is FRESH AIR.

This is a rush transcript. This copy may not
be in its final form and may be updated.

Dateline: Terry Gross, Philadelphia
Guest: Sonia Ancoli-Israel
High: Sonia Ancoli-Israel specializes in sleep disorders, including sleep apnea, insomnia and sleep disturbances in the elderly. She is the author of "All I Want is a Good Night's Sleep." She directs the Sleep Disorders Clinic at the Veterans Affairs Division of the San Diego Health Care System.
Spec: Books; Authors; Sonia Ancoli-Israel; Health and Medicine; Sleep

Please note, this is not the final feed of record
Copy: Content and programming copyright 1998 WHYY, Inc. All rights reserved. Transcribed by FDCH, Inc. under license from WHYY, Inc. Formatting copyright 1998 FDCH, Inc. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to WHYY, Inc. This transcript may not be reproduced in whole or in part without prior written permission.
End-Story: How'd You Sleep Last Night
Date: JUNE 22, 1998
Time: 12:00
Tran: 062201np.217
Head: Facing and Fighting Fatigue
Sect: News; Domestic
Time: 12:30

TERRY GROSS, HOST: Exhaustion seems to be a growing problem in contemporary life. For some people, fatigue is so extreme they can no longer function. Medical researchers are trying to understand the underlying causes of the most extreme and long-lasting forms of fatigue.

One of those researchers is my guest Dr. Benjamim Natelson. He directs one of two federally funded chronic fatigue research centers. It's based in New Jersey. He's written a new book called "Facing and Fighting Fatigue." I asked him if doctors are seeing more patients complaining of fatigue.

BENJAMIN NATELSON, NEUROLOGIST, DIRECTOR, NEW JERSEY CHRONIC FATIGUE CENTER, AUTHOR, "FACING AND FIGHTING FATIGUE": I think that the problem of fatigue has always been there, but doctors really didn't pay attention to it. What's happened in medicine over the past decades is that when I trained in the '60s, we really were oriented more to calamity-type problems -- someone who had horrible heart problems; someone who was bleeding; difficulty breathing et cetera.

And what's happened in the years since I was a medical student is we've really caught up with the calamities, and now medicine can pay attention to the chronic problems -- the problems that are sort of smoldering and bothering people.

GROSS: How common a complaint is debilitating fatigue?

NATELSON: It's actually remarkably common. It's probably one of the most common complaints that a person reports to his or her doctor. Somewhere in the neighborhood of some 20 percent of people have complaints about severe fatigue. Now, debilitating fatigue, obviously, the worse the complaint, the lower the number of folks that have it. And the longer it lasts, the lower the number.

GROSS: Is there any quantifiable test -- blood test -- you could do to evaluate if somebody has CFS?

NATELSON: Well, I would have to say that the answer is no. There still -- there are some tests which are in the research mode which look very suggestive. But right now, the doctor makes that diagnosis based on the patient's report of severe, often debilitating, fatigue lasting more than six months and accompanied by a host of symptoms that we usually associate with the flu or with infectious mononucleosis -- the feeling of weakness; swollen glands; fever; sore throat; headache; muscle ache; joint ache; and difficulty thinking, et cetera.

So it is very much a clinical disease entity, and yet we can, because a number of physicians at the international level sat down and came up with a case definition of the ailment, we can decide whether a patient has it or not. And if the individual has it, then we can do what we do in medicine, which is we try to prognosticate about the patient's status and we try to come up with a treatment profile.

GROSS: What kind of help can you give somebody at this point who has chronic fatigue syndrome?

NATELSON: Well, one of the things we are doing in our center, first of all, are experimental drug trials. So that is one -- always a very important thing for patients. The neat thing about an experimental drug trial is that if a drug works, it helps you understand an ailment where you're not sure of its cause.

So for instance, there are drug -- there is a drug trial just coming down the line now of an immunological product called "ampligen." If ampligen is proven to work, that will then support the idea that chronic fatigue syndrome is an immunologically based disease. But in the here and now, when a patient comes into my private doctor's office and I don't have any experimental drugs, what do I do? Well, what we do then is we use our medical pharmacopoeia to help patients cope with the major problems that they have.

And those -- and the major problems that a patient with CFS has is severe fatigue, severe muscle and joint ache, and difficulty with thinking and concentration. Those are the big three. And there are medicines that the doctor can use to help reduce those symptoms.

GROSS: Well, what do you prescribe? Do you prescribe coffee?


NATELSON: Well, sometimes, if it doesn't make people jittery, stimulants are reasonable. Sometimes, obviously if there's -- by the way, if there's any underlying depression, depression is an illness-magnifier and so we always want to get that out of the picture. No matter what illness someone has, if he or she is also depressed, that's a major problem.

But we -- there are medicines that relieve muscle aches. There are indeed stimulants. There are medicines that improve ability to focus. So again, there's this whole pharmacopoeia, but that's the least effective limb. One of the problems with chronic fatigue syndrome that makes a problem for the patient is the inactivity produced by the ailment.

So one of the things we try to do therapeutically for patients is help them turn around this inactivity and make them more active.

GROSS: Like what? Like walking?

NATELSON: Well, sometimes walking; sometimes just doing things that you haven't done. For instance, if you have a dog and you're just too exhausted to walk the dog, I say: walk the dog. Or if you have something to mail and the post-box is at the end of the corner, go there. So, sometimes it's not even structured. It's just get up and don't lie -- sit up, do more, even about the house. And yes, go out of the house more often.

GROSS: What's the typical advice you give people who are suffering from chronic fatigue about napping?

NATELSON: Well, again, if they feel better, I tend to -- I tend to let the patient -- I try to work out sort of a modus vivendi with the patient. Some CFS patients tell me they cannot get through the day without an afternoon nap or two. And that really is the thing that makes them so disabled -- their inability to have a normal life and the severe fatigue and pain-related.

So, I don't have much of a problem with that. But if it's an individual who I think has fatigue based on a sleep disorder; that is, based on insomnia, poor sleep hygiene -- then that's a total no-no.

GROSS: Do you find that people actually get over chronic fatigue syndrome? Or, do you consider it more as a kind of life-long condition you're stuck with?

NATELSON: Well, the tendency is to improvement. The tendency is to improvement. We've studied only the most severely ill patients, and about half improve and about half stay the same over a four-year period. Now, that of course is the most severe. The best prognostic indicator is if the individual can keep working.

When I see patients who've got it, and they tell me: "Dr. Natelson, the only thing I do in my life is work and then I come home and crash" -- the fact that their illness is not so severe that it prevents them from working is a good prosnostic indicator that they will be beat the illness.

GROSS: If you're just joining us, my guest is Dr. Benjamin Natelson. He's the author of the new book Facing and Fighting Fatigue. He's a neurologist who directs the New Jersey Chronic Fatigue Syndrome Center. He's also medical director of the Gulf War Research Center at the Veterans Administration Medical Center in New Jersey.

Are we in a phase now where doctors are seeing fatigue more as a perhaps biological problem than a psychological problem?

NATELSON: Well, again we don't know what the cause of chronic fatigue syndrome is, and certainly fatigue can have many medical causes and can be biological. You know from your own experience that after a day of vigorous sports, you're exhausted. That's certainly on a biological basis.

I think you'd have to say it has biological causes, psychological causes, and in some people the two interact. It's not that the brain and the mind are separate. Some -- in some people, the two interact and again magnify it.

GROSS: Now what about Lyme disease? And that's a disease that's spread by a certain kind of tick. And in -- certainly in the Northeast, there's a lot of deer that carry these ticks.


GROSS: What's the connection of Lyme disease with the kind of fatigue that you've been studying?

NATELSON: Well, Lyme disease is an example, as is infectious mononucleosis, of infectious diseases that clearly have an infectious cause in which some of the patients simply do not get better -- something like five or 10 percent. And when those patients are evaluated six to eight months later, it appears that many of them -- many of those few patients, that is, who don't get better, have chronic fatigue syndrome.

So the -- those examples -- mono and Lyme are examples of post-infectious fatigue and is -- are one of the things that make doctors think that there may be some underlying infectious cause to at last some of the patients with CFS.

But patients with Lyme who have CFS don't have the Lyme bacteria evident. So, something has happened. Has it been that their immune system is different? Are they psychologically different from people who have recovered? These are all research questions that are really under investigation now.

GROSS: So are you saying, too, that CFS can have many different causes? It's not like there's one virus that causes CFS. It could be an immunological problem. It could be something associated with depression. It could be caused by a virus.

NATELSON: That's the whole concept of "syndrome." A syndrome is collection of signs and symptoms that people complain of, and we know that with other examples -- for instance, a sore throat -- that's just a syndrome. And there are many different things which can produce a sore throat -- bacteria, viruses et cetera.

And so what we do therefore is we need to try to find the causes of these various syndromes. And that's the approach we've taken with CFS and it seems to be paying off.

GROSS: Dr. Benjamin Natelson -- he directs the New Jersey Chronic Fatigue Syndrome Center. His new book is called Facing and Fighting Fatigue.

We're going to take a moment to hear a great torch song, as we remember the lyricist Edward Elliscue (ph). He died Thursday at the age of 96. His songs include "Flying Down To Rio," "The Carioca," and "Orchids in the Moonlight." The song we're going to hear, "More Than You Know," was co-written with Billy Rose and Vincent Youmans. They wrote the song in 1929. Later that year, Ruth Etting (ph) made this recording of it.


RUTH ETTING, SINGER, SINGING: Whether you are here or yonder
Whether you are false or true
Whether you remain or wander
I'm growing fonder of you

Even though your friends forsake you
Even though you don't succeed
Wouldn't I be glad to take you
Give you the break you need

More than you know
More than you know
Man of my heart I love you so
Lately I find
You're on my mind
More than you know

Whether you're right
Whether you're wrong
Many of my heart
I'll string along
You need me so
More than you'll ever know

Loving you the way that I do
There's nothing I can do about it
Loving may be all you can give
But honey I can't live without you

Oh how I'd cry
Oh how I'd cry
If you got tired and said good-bye
More than I'd show
More than you'd ever know

Loving you the way that I do...

GROSS: Coming up, new music from Nigeria's King Sunny Ade.

This is FRESH AIR.

This is a rush transcript. This copy may not
be in its final form and may be updated.

Dateline: Terry Gross, Philadelphia
Guest: Benjamin Natelson
High: Benjamin Natelson is a neurologist who directs the New Jersey Chronic Fatigue Center. He's just written "Facing and Fighting Fatigue: A Practical Approach." He specializes in treating chronic fatigue syndrome. He says that while many people think CFS is all in their heads, there is actually a physiological component to the condition.
Spec: Health and Medicine; Sleep Disorders; CFS
Please note, this is not the final feed of record
Copy: Content and programming copyright 1998 WHYY, Inc. All rights reserved. Transcribed by FDCH, Inc. under license from WHYY, Inc. Formatting copyright 1998 FDCH, Inc. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to WHYY, Inc. This transcript may not be reproduced in whole or in part without prior written permission.
End-Story: Facing and Fighting Fatigue
Date: JUNE 22, 1998
Time: 12:00
Tran: 062201np.217
Head: Odu
Sect: News; International
Time: 12:55

TERRY GROSS, HOST: Along with Bob Marley and Fela (ph), King Sunny Ade is a founding figure in current world music. Although Ade's juju (ph) music has never quite caught on, critic Milo Miles listened to King Sunny Ade's latest release and says the King shouldn't be counted out.



MILO MILES, FRESH AIR COMMENTATOR: The King is back. Well, at least he's released his most vigorous record in about 10 years. It's called "Odu" and it's solid proof that there is life for world music stars even after their American bandwagon crashes into the ditch. There's nothing tragic about King Sunny's failure to conquer America in the 1980s, but it's a good cautionary tale.



MILES: About 15 years ago, King Sunny Ade looked like a guaranteed world music sensation, maybe with enough charisma to fill the gap left by the death of Bob Marley. Ade led a crack 20-member band that played a dramatic nonstop dance music that was the rage of Nigeria, the most populous country in Africa.

Floating on waves of polyrhythms, juju was also in motion. Seeming in full flight, Ade's band would stop on a dime so talking drums or hot electric guitars of high-stepping dancers could solo. His American shows revealed the power of modern African music to whoever saw them. But not enough people saw them and King Sunny couldn't get a radio hit. Though his songs had hooks, it's hard to get a tune in the Top 40 if the listeners can't follow all the beats or understand the language.

King Sunny did not do no Macarena. He was already a superstar in Nigeria and nobody ever came up with a way to repeat the process in this country. Then, King Sunny's band mutinied during a tour of Japan and he went home a sadder but wiser performer. In the modern media world, you can become famous without doing much of anything. But as always, you can do everything and still not become famous.



MILES: But hey, so other people might determine if you're a star, you decide if you're a professional. And King Sunny has been keeping up the good work habits ever since his dark days more than 10 years ago. Not with much success, mind you. His new band has had a hard time matching the sparkle of the old outfit. He's put out a couple of routine live albums and his last studio release seemed to be a misguided effort to squeeze his expansive jams into three-minute singles.

Odu is not a style breakthrough for King Sunny, but innovation in juju is a matter of inches, so I'll settle for satisfying reworkings of some old tunes, the slinky new organ solos by Jonah Samuel (ph), and above all the balanced mix and warm sound of the recording, done at Dockside Studio in Louisiana.

Sunny Ade has never sounded as clear, natural, and relaxed. You also get a lyric sheet with many bits of wisdom from the Aruban people, which are keys to King Sunny's sense of style. As one line puts it: "the grass that the elephant steps on has been stepped on definitely."

Take heed.

GROSS: Milo Miles is features editor for

This is a rush transcript. This copy may not
be in its final form and may be updated.

Dateline: Milo Miles; Terry Gross, Philadelphia
High: Nigeria's King Sunny Ade has a new album. World music critic Milo Miles reviews "Odu."
Spec: Music Industry; Sunny Ade; Africa; Nigeria

Please note, this is not the final feed of record
Copy: Content and programming copyright 1998 WHYY, Inc. All rights reserved. Transcribed by FDCH, Inc. under license from WHYY, Inc. Formatting copyright 1998 FDCH, Inc. All rights reserved. No quotes from the materials contained herein may be used in any media without attribution to WHYY, Inc. This transcript may not be reproduced in whole or in part without prior written permission.
End-Story: Odu
Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.

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