Monday, December 2, 2024

The Importance of Malaise...


About a year ago – a good friend of mine shared his observations about death and dying. 

“I have known 5 people who told me that they ‘felt the worst they had ever felt in their life’ and by that afternoon – they were dead.”  The “people” were all men.

He went on to describe what happened to our long-time mutual acquaintance and what he said on that fateful morning.  He described a man who went to work at a local factory despite his wife’s suggestion that he stay home and see a doctor. In every case the “worst I have ever felt in my life” predicted death in a few hours and did not deter these men from their usual daily routine.  Most of these men died of heart attacks.  They had atypical symptoms rather than chest pain – but my friend is not a physician and was not interested in the details only what they all said on the morning of their deaths.

The only time I felt that badly was when I sustained a ruptured and gangrenous appendix at age 18.  I had a very complicated course that included a Penrose drain being placed in my side to drain the remnants of the necrotic appendix. Even as I was healing, I felt horrible. I felt so badly that I did not care if I lived or died at that point. I was not depressed, nauseated, or in pain – just a very intense sick feeling.

That may be why I have had an interest in malaise as a syndrome.  I equate malaise with flu-like illnesses and that feeling you get from a severe case of the flu or flu-like viruses.  I had malaria once back in the 1970s and was very ill for several days.  That bout of illness was characterized by low energy, fever, and severe chills associated with the fever.  I can remember crawling across the floor of my house draped in a sleeping bag and into a tub of hot water just to warm up.  That was about 6 years after the appendicitis and the disease features were clearly different, but again not nausea, depression, or pain. 

Steadman’s medical dictionary defines malaise as:  A feeling of general discomfort or uneasiness, an out-of-sorts feeling, often the first indication of infection or other disease.  That definition captures the general experience but not the intensity.  I could tell that something was wrong in the early stages of appendicitis.  But in the space of 2 or 3 hours something was really wrong and the sick feeling was amplified a hundred-fold.  Are they both malaise?  Can malaise occur during a chronic condition – can you have acute and chronic malaise?  This semantic confusion may be why not many people seem interested in using the term. 

Interestingly there is a Malaise Inventory and it is in the psychiatric literature (1-3).  It was originally conceived by Michael Rutter as a measure of psychological well-being and the associated physical components.  It was adapted from the 195-item Cornell Medical Index Health Questionnaire.  The inventory itself consists of 24 self-competed questions and can be viewed here.  Many of the items (eg. Do you often feel miserable or depressed?) decrease item specificity.  Many of the items (eg. Do you often get worried about things?) are not specific for physical illnesses.  That may be why some authors found that psychological dimensions accounted for the more variance than physical ones.  It has generated very little research interest and is generally referenced once or twice a year in PubMed except for the year 2021 where there were 10 references.  In more recent studies it is used as a measure of psychological distress rather than malaise associated with a physical illness.

Why might it be important to have a more physically defined malaise? It could lead to earlier recognition of serious physical illnesses.  Based on what we currently know about pathophysiology – I would not be surprised if there were subtypes of malaise.  For example, the severe illnesses I have experienced were all most likely related to inflammatory signaling and the well documented effects of some of those molecules like cytokines. On the other hand, hyperadrenergic states associated with acute cardiovascular diseases could produce a different type of illness feeling.  We are generally limited by knowing the possible presentations (typical and atypical) to not miss a serious problem without reference to any non-specific illness feeling.  It may also allow for treatment of those associated symptoms. One of the striking features of the modern approach to appendicitis is rapid symptomatic treatment or pain and nausea. Are there better ways to treat acute infectious inflammatory conditions than NSAIDs and acetaminophen?  Are there better ways to treat chronic malaise?

My proposed analysis of malaise does not replace the need for common sense and recognizing the dangers of denial.  I am fully aware of the difficulty getting timely emergency care in the US health care system unless you need a trauma surgeon or interventional cardiologist.  But – if you are experiencing the “worst I have ever felt in my life” feeling you owe it to yourself and your family to get it checked out as soon as possible.  EMTs are called for a lot less.  I have talked to too many people who in retrospect would have called the EMTs instead of driving themselves to the hospital while they were having a heart attack.  

 

George Dawson, MD, DFAPA

 

References:

1:  Grant G, Nolan M, Ellis N. A reappraisal of the Malaise Inventory. Social psychiatry and psychiatric epidemiology. 1990 Jul;25:170-8.

2:  Rutter M, Graham R Yule W (1970a) A neuropsychiatric study in childhood. London, Heinemann.

3:  Rutter M, Tizard J, Whitmore K (1970 b) Education, health and behaviour. Longmans, London.

 

Photo Credit:  Eduardo Colon, MD - Thunderstorm over Minneapolis.


Supplementary 1: The Malaise Inventory

How are you feeling generally…

1. Do you often have backache?

2. Do you feel tired most of the time?

3. Do you often feel miserable or depressed?

4. Do you often have bad headaches?

5. Do you often get worried about things?

6. Do you usually have great difficulty in falling or staying asleep?

7. Do you usually wake unnecessarily early in the morning?

8. Do you wear yourself out worrying about your health?

9. Do you often get in a violent rage?

10. Do people often annoy and irritate you?

11. Have you at times had twitching of the face, head or shoulders?

12. Do you often suddenly become scared for no good reason?

13. Are you scared to be alone when there are no friends near you?

14. Are you easily upset or irritated?

15. Are you frightened of going out alone or of meeting people?

16. Are you constantly keyed up and jittery?

17. Do you suffer from indigestion?

18. Do you suffer from an upset stomach?

19. Is your appetite poor?

20. Does every little thing get on your nerves and wear you out?

21. Does your heart often race like mad?

22. Do you often have bad pains in your eyes?

23. Are you troubled with rheumatism or fibrositis?

24. Have you ever had a nervous breakdown?

 

Supplementary 2: 

I put the following questionnaire together based on some of my previous inventories for tracking flu-like illnesses.  

The Minnesota Malaise Index (MNMI)

1:  I have a fever

2:  I am fatigued

3:  I feel physically sick like I have the flu or another serious infection

4:  I have a difficult time concentrating on tasks and thoughts that I need to focus on and this is a new problem.

5:  I have a difficult time making decisions that used to be easy for me.

6:  I have a cough

7:  I have a runny nose

8:  My nose is congested to the point that it blocks or partially blocks air flow.

9:  I have a headache

10:  I have a sore throat

11:  My muscles are sore

12:  My joints are sore

13:  I am sneezing

14:  I am sleeping less than 6 hours per night

15:  I am sleeping more than 9 hours per day

16:  I have no appetite

17:  I have nausea, vomiting, or diarrhea

18:  I am in pain

19:  My activity level has changed and I am hardly doing anything

20:  Severity level:

A.       Some impairment in daily activity due to illness.

B.       Moderate impairment postpones desired activity.  No longer able to exercise.

C.       Severe impairment – need to rest due to illness and feeling physically ill

D.       Very severe impairment-cannot stand or sit due to severe illness and in some cases indifferent to living or dying due to illness severity

 

Supplementary 3:

Minnesota Malaise Index Tracker

 


 

 

 

 

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