Karen Black
Mrs. Alix Martin
Advanced Placement English
4/15/98
The Relation Between Infectious Mononucleosis and Mental Illness

Those people who suffer from mononucleosis are likely to suffer from depression as well as other, less initially alarming, mental problems. These problems are varied, if common, and may appear preceding, during, or following the bout of mono. The examination of the nature of this connection could well be the basis of a completely new view of health, or at least aid the birth of this new view.

Although there have been studies to this effect since the late 1950s or even earlier, the general public has not been exposed to these studies and therefore is not fully aware that a direct relationship exists between physical and mental illness. To the mononucleosis patient, however, this relationship amounts to a constant battle of mind and body. One anonymous patient who took this researcher's survey painstakingly planned out his suicide for weeks. He told his friends that he was dying of an unknown illness and began to make his good-byes, giving away his prized possessions. His depression was discovered when his unwitting parents received a caring phone call from his friend's mother. Soon afterward, he was diagnosed with mono. Another survey participant says, "I was falling further in the hole every day. I knew that something was wrong with me mentally, but I didn't want to seek psychiatric help. I was sure I could handle it myself if I just had one more day--but every day it got worse" (Black).

Upon hearing the stories of these and other patients, one may well begin to wonder why mono patients, once diagnosed, are not checked for psychiatric illness as well. It would appear, if depression is allowed to progress unchecked, that even the doctors who treat mononucleosis are not aware of the magnitude of mental illness accompanying physical illness.

In order to study the controversies and discoveries relating to mononucleosis and its relation to depression, one must first understand the terms and facts which describe mono itself. It is also crucial to understand the basics of depression and the new field of psychoneuroimmunology.

Infectious mononucleosis--or IM--is a viral illness which is caused by the Epstein-Barr virus--or EBV--which is frequently present in people's blood without causing any obvious signs of illness. IM tends to strike young adults, although children or even adults can also have it.

There are two main tests which may be performed on a patient's blood to determine the presence or absence of IM. One test is the complete blood count. This test measures red and white blood cells. If IM is present the white blood count will be up and so will the percentage of blood cells which lymphocytes make up. These lymphocytes are atypical and appear to be abnormal (Shader 38).

The other test is called a monospot. In this test the patient's blood is mixed with the red blood cells of a sheep or horse. If the red blood cells clump together, the test is positive. The thought process behind this procedure is that people with EBV will produce heterophile antibodies (Shader 38).

The first signs of IM are usually flulike symptoms: fatigue, headache, and generally feeling sick (Shader 37). Since IM lowers the defenses of the immune system, the first sign a doctor finds of the illness might be related to another infection--an earache or nausea. Abdominal pain is also commonly associated with IM because it affects the liver and spleen. Shader notes that if the patient is too active, his or her spleen is in danger of rupturing; inflammation of the liver, meanwhile, amounts to a mild form of hepatitis (38). For these reasons alone IM patients should get as much rest as possible; the stress-associated reasons to be explored later also suggest that lack of activity is best.

Two more possible complications of IM include meningitis or encephalitis. The fact that these problems are associated with the nervous system, brain and spinal cord suggests a relationship between IM, thought, and feeling (Shader 39).

One last complication from IM is chronic fatigue syndrome, or CFS. This syndrome can be caused directly by EBV; Shader observes that it was once referred to as chronic mono (40), and Medline adds that it was called chronic EBV syndrome ("Depression" 2) as well. EBV, however, is only responsible for a small portion of CFS cases (Talan 17). The syndrome more commonly caused by myalgic encephalitis, or Coxsackie B (Reichenberg-Ullman 2). CFS can last for years (Shader 40). Its symptoms include fever, depression, aches, decreased sex drive, lack of creativity (Reichenberg-Ullman 2), allergies ("CFS" 1), fatigue and increased susceptibility to other illness. Shader mentions that, since not everyone with continuing symptoms of IM or CFS has large antibody counts, some physicians theorize that many patients with chronic fatigue have a psychosomatic version of the disease (40). Medline, however, simply remarks that "most patients with CFS have an affective"--or emotional--"disorder." EBV and CFS "represent the 1980s equivalent of neurasthenia, a disease of fatigue that influenced the development of psychiatric nosology" ("Depression" 2).

Depression in general is a much more widely publicized and acknowledged, if misunderstood, problem. In depression, as in IM, the patient may feel drained. Thought and mental activity slow down considerably. Ostow tells of Freud's theory that a lack of mental energy caused depression. The symptoms of some neurotic states were determined by the lack of this mental energy; among these states were hypochondria; anxiety neurosis, or constant anxiety without focus; and neurasthenia, or lethargy, fatigue, and weakness without focus (50-51). Medline observes that "patients with depression and anxiety also have chronic fatigue" ("Depression" 2).

Anti-depressants, which have been used for years to help depressive patients, increase the nervous system's contact with amines (Ostow 53). Again, the nervous system comes into play, revealing an underlying theme that all human systems are linked to one another. Moyers notes that the liver and spleen have been key areas in this discovery (213), and Ostow says, ". . .individuals who have had infectious hepatitis are apt to discover that despite good physical recovery, they are left with a profound enervation which leaves them not only inert, but often depressed. Infectious mononucleosis has a similar though perhaps less pronounced tendency to favor depression." (73) Therefore, it is apparent that diseases associated with liver damage are connected to depression.

Thus, the topic of psychoneuroimmunology--the field of combined psychology, neurology, and immunology (Moyers xiii)--is reached. The term for the field is fairly new, although the concept of physical and mental links has been around for 40 years or more. Tests on these links have been performed in many different manners as time has passed, but positive results have been found time and time again. Many researchers hypothesized without backing up their words; yet a significant number of members of the medical community still murmured a vague thought: all kinds of health must have something to do with each other.

In 1959 a researcher named Greenfield claimed that recovery from IM was delayed in those patients who had weaker ego strength. The illness was not, in his opinion, a cause of depression; rather, it was simply prolonged by depression (Cadie 559).

In 1969 Peszke and Mason observed that "those with heterophile antibody titres of 1/96 or more were. . .more likely to seek psychiatric help than those with values below 1/96," and Cornell Medical Inventory scores were lower in those who sought help after IM--therefore, low ego strength did not seem to be a problem. However, there did seem to be mental difficulties in IM patients, since they were more likely to seek professional aid (Cadie 559).

Cadie, Nye, and Storey studied the work of others and then performed their own study. The results showed that men who had had IM tested higher in the following levels: anxiety, phobia, somatic and obsessional. Women who had had IM tested higher in anxiety, phobia, somatic, and depression levels. This study, again, said that IM could lead to mental disorders; however, since it was only performed upon 36 patients, doubt could easily be cast upon the results (Cadie 559). The apparent lack of patients to test has been a problem throughout the time period in which mononucleosis has been extensively studied. This researcher discovered the difficulty in finding IM patients firsthand.

In 1979 Stanislav Kasl studied IM development in cadets at West Point; all cadets were tested regularly for the presence of EBV antibodies and had interviews which were reviewed for information on their family, expectations, and backgrounds. One fifth of ěsusceptible cadets were infected, but only about one-quarter of those infected actually developed symptoms of monoî; those cadets who were really pressured to succeed but weren't doing well academically had higher chances of displaying IM symptoms (Ornstein 152). Higher stress levels seemed to contribute to physical illness; how people view themselves affects their resistance--or lack thereof--to disease (Ornstein 25). Since stress makes people feel that they are incapable of doing what they must do, it decreases their resistance to disease.

Talan gives statistics: 75% of people suspected of having EBV had higher numbers of lifetime episodes of major depression, as opposed to 22% in the comparison group; 42% of EBV victims had current major depression, as opposed to 0% of the comparison group. She also gives her view of the relationship between EBV and depression--that most people who think they have EBV are suffering from depression instead--and another view--that depression is a response to chronic medical illness (17).

Kasl's study closely coincided with studies, explored by Ornstein, which were performed on rats with tumors. Some of the rats were given ordinary wheels on which to exercise; other rats were given mild shocks when they moved their wheels. The rats who received shocks and therefore had higher stress levels also had faster-growing tumors (Ornstein 51). The suggestion has been made that friendships increase one's ability to achieve physical and mental stability and avoid disease (Ornstein 202); this concept is yet another hint that those things which make people feel content and secure are also good for their overall health.

Medline offers studies which showed that depressed patients were resistant to IM because of the presence of EBV in their blood ("Depression" 2-3) and that CFS patients had higher rates of psychiatric illness than other people ("CFS" 2). Unfortunately, these studies, like others performed before them, involved very few patients--12 in one and 28 in the other. Medline also suggests that psychiatric disorders usually came before the chronic fatigue ("CFS" 2), a stance which is exactly the opposite of most.

However the mind and body are connected--and indeed, some modern psychoneuroimmunologists object to even referring to them as separate entities--it is becoming more and more obvious that they are connected. Physical connections have been observed, releasing skeptical scientists from their view that a mystical connection just isn't solid enough to work with.

The majority of immune system organs contain many nerve fibers which communicate with its cells. Since the nerves are the brain's system of relaying messages, it can send information concerning stress to the immune system through the nervous system. The immune system's responses to this information include the correlations between mental and physical illness which led to some of the modern investigations of the matter.

Chemicals and proteins which were once believed to only be present in the brain have, in more recent years, been found all over the body. Although finds to this effect were not acknowledged until the 1980s (Moyers 178), there seems to be reason to believe that they were discovered earlier than that. Among these chemicals and proteins are the peptides. Neuropeptides such as endorphins--generally known as the brain's "happy drugs"--are believed to be the cause of mood changes; peptides and their receptors are regarded as physical versions of emotions. Estrogen, a chemical which, according to Munson, can alter a woman's mood (94), is present in different areas of the body.

Outside of the medical community, few people are fully aware of any of these studies or their implications. Indeed, much of the medical community seems to be unaware. A patient who has been diagnosed with mono is not sent to a psychiatrist as part of the healing process; s/he is given antibiotics to ward off other infections and told that once the IM is past the point where it is contagious s/he may participate in whatever activities s/he feels up to, although it would be best to rest more often. Although the suggestion to rest is a good one, it is still more of a suggestion than an order, and those patients who are under the most stress are probably the ones who are most likely to go back to their normal activities as soon as possible, feeling that they will fall behind unless they stay on their feet.

This issue may seem trivial at first, but it has vast implications. How many people who have IM but are unaware of its presence suffer from depression and perhaps even commit suicide? How much better could people feel if they spent more time indulging themselves?

Yet, in the midst of the public's lack of specific knowledge regarding the links between emotion and health, a kind of dim understanding has begun to appear. Scented lotion and aromatherapy have become popular; there is a Bath and Body Works store at nearly every mall, and candle shops have a much greater variety of scents and colors than they used to. Folk remedies such as St. John's wort, which Bricklin observes to make viruses weaker (18), have gained more and more followers in recent years (Nash 80). Chinese remedies which Moyers says are meant to remove obstructions in circulation which are said to cause stress and physical problems (269) are more widely known, if not more widely used. In a GMC store one can find a plethora of vitamins which are said to increase physical and/or mental health. A single town can support an incredibly large number of tanning beds; those people who use the beds generally say that they use them because it makes them feel good--not look good. All these simple observations indicate that people are beginning to try to heal themselves in a way that few American doctors can.

If this rate of development continues, doctors may eventually become nearly obsolete, or perhaps have to change their practices. Of course, someone will be needed to set broken bones and perform surgery for a very long time in the future. Nonetheless, society, in its own vague way, seems to be stumbling toward a greater understanding of overall health faster than doctors and scientists can come up with the information to prove that the public is right. In 40 years, the only real advancements in the medical field pertaining to the relationship between psychology and physiology have been in the discovery that the nervous system is physically linked to the immune system. That information was already at the scientists' fingertips--photos proving it existed long before anyone actually noticed it. If the masses were to realize that there are foundations to support the theory that physical and mental health are one and the same, the placebo effect might be the only available resort for general practitioners. Even that option might not work for long, since a patient's susceptibility to the placebo effect extends only as far as the patient's faith in his or her doctor and the doctor's faith in the placebo.

In a culture that was completely aware of its physical and mental connections, doctors would still be necessary--but they would have to be doctors who understood both mind and body, not one or the other. The field of psychoneuroimmunology is the first great step toward this goal for the future; although it is still on feeble ground, the outlook for its future is good, if it continues to make progress.

Meanwhile, psychoneuroimmunologists, scientists, doctors, and psychologists should do their best to be informed on general health and to keep their patients informed as well. The more knowledgeable a care giver is, the more likely the care giver's patients will be healthy. Since a healthy patient is a happy patient, greater knowledge would be an all-around good thing. Everyone in America's current society can reap the benefits of better health.

Patients can also make efforts to learn about advancements in the fields of medicine and psychology, if not psychoneuroimmunology. Although the common man tends to grumble about technical terms, most literate people are capable of getting the gist of a concept if they try. Perhaps an occasional discussion with a care giver or informed friend, a magazine subscription, or even a news room on the net might keep the average citizen informed. These ideas aren't likely to be taken seriously at first, but they might help people in the long run.

Although this paper has mostly dealt with relations between mental illness and mononucleosis, the implications in some of the related information are great and extend well beyond IM or CFS. In the pursuit of a cure for IM and the psychological problems which have been linked to it, other discoveries which have a much larger impact upon our culture could be found--the principle cause of cancer, or even the cure for AIDS. Such huge advancements can only be reached by beginning with a seemingly silly question such as, "Why am I going crazy?"


Works Cited

Black, Karen. "Mononucleosis Survey." March 1998.

Bricklin, Mark, and Michele Stanten. "Herbs That Ease the Mind." Prevention January 1996: 15-18.

Cadie, M., F.J. Nye, and Peter Storey. "Anxiety and Depression After Infectious Mononucleosis." British Journal of Psychiatry May-June 1976: 559-561.

"Chronic Fatigue Syndrome." Evaluated Medline. Downloaded from BioMedNet. 13 March 1998.

"Mononucleosis and Depression." Evaluated Medline. Downloaded from BioMedNet. 13 March 1998.

Moyers, Bill. Healing and the Mind. New York: Doubleday, 1993.

Munson, Marty, and Toby Hanlon. "Can Hormones Make You Happy?" Prevention March 1996: 91-97.

Nash, J. Madeleine. "Nature's Prozac?" Time 22 September 1997: 15-18.

Ornstein, Robert, and David Sobel. The Healing Brain. New York: Simon and Schuster, 1987.

Ostow, Mortimer. The Psychology of Melancholy. New York: Harper & Row, 1970.

Talan, Jamie. "Deceptive Depression." Psychology Today July- August 1988: 17.

Reichenberg-Ullman, Judyth, and Robert Ullman. "Healing Chronic Fatigue Syndrome." Downloaded from HealthWorld Online. 27 March 1998.

Shader, Laurel, and Jon Zonderman. Mononucleosis and Other Infectious Diseases. Ed. Dale C. Garell. New York: Chelsea House Publishers, 1989.


Appendix A
Mononucleosis Survey 1. How old are you?___________
2. Have you ever had mono? yes no (if no, proceed to question #6)
3. How many times?_________
4. If you feel that you have recovered from the last time you had mono, approximately how long do you feel that you have been recovered?

5. Think about how you felt when you had mono (if more than once, then what you consider to be the WORST time), physically and psychologically. Please describe.


6. Please rate how you feel, overall, on each of the next 10 days. (scale from -10 to +10)
Physically Psychologically
Overall
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10

7. Do you know anyone from the area who currently has mono and might be willing to take this survey? If so, please give names and where they can be reached:

8. Please write any additional comments on the back. Please put your name somewhere on this page. It will only be used for Karen's study and will not be printed or named without your permission. Thank you for your participation!


Appendix B
Mononucleosis Survey Results
*