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.
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:
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
