Coping with chronic fatigue.

Dr. William Weir, Consultant at Coppett’s Wood Hospital, part of the Royal Free, specialising in infectious and tropical diseases.

Dr. Weir began saying that some people have the impression that CFS/ME is a new condition that started in the 1980’s when the Sun and the Mirror were writing about ‘yuppie flu’ and a ‘malingerer’s charter’. Not so. He gave a detailed account of how in the 17th century a condition very like CFS/ME was described and how Charles Darwin and Florence Nightingale may well have had the symptoms.

However, in the psychiatric community it is still felt that CFS/ME is subconsciously produced and is in some way the patient’s fault.

Dr. Weir does not believe that it is valid to group illnesses into psychological and organic conditions. All disease has an organic basis. Patients suffering with depression have neuro-chemical abnormalities in their brains that can be treated with chemicals, ie antidepressant drugs. Patients with schizophrenia have been found at post mortem to have a disorder in the temporal lobes of the brain. These illnesses are just as organic as pneumonia.

Most disease is the product of environmental factors and individual susceptibility. Old people are more vulnerable to infections than younger people. Children get more viruses than adults but deal with them more effectively. Genetic make-up can also affect our susceptibility to disease. For example, Europeans in Africa are as likely to develop malaria as the local population but get it more severely.

The presence of pathogens is an important environmental factor. Dr Weir gave examples of several medical misunderstandings in this area. Until recently it wasn’t realised that a bacterium called helicobacter causes peptic ulcers. A further striking example comes from the past: general paralysis of the insane, a condition where patients develop dementia, have grandiose delusions and believe they are Napoleon or Hitler. This was once thought to be the result of too much hard work and intellectual effort, but is, in fact, the end stage of the venereal infection Syphilis. Dr. Weir raised laughter in the audience when he said it was not their brains that these patients had over-exercised.

Stress: deer who were stressed by being chased by a motorbike developed TB but the other deer who were not chased didn’t, though they had been equally exposed to the pathogen. Research on humans has shown that patients who are stressed prior to developing the common cold excrete the virus for longer than patients who are not stressed. There is clearly cross talk between various centres of the brain controlling psychological functions and the immune system.

People with ME show abnormalities in the immune system, in the vascular system and in the mitochondria, the powerhouse in cells. Abnormalities in the vascular system are both micro-vascular (eg. reduction of capillary blood flow to the brain stem) and macro-vascular (eg. problems with blood pressure control which can lead to dizziness when standing, which is known as postural hypertension). Annoyingly, these irregularities are not consistent in all patients and are variable in individual patients, so that a patient can sometimes feel dizzy and other times not. This variability provides scope for sceptics.

Dr. Weir’s clinical approach is to exclude other causes. He has had patients present with AIDS and brain tumours. He uses the Fukuda criteria which require patients to have throat, sore neck glands, joint pain, post exertion fatigue lasting more than 24 hours and cognitive difficulties. Many patients are very sensitive to alcohol and anti-depressants.

In relation to treatment he says that there is no magic bullet; his approach is to maximise the body’s own ability to recover through pacing activity. His clinical impression is that red meat and refined sugar are bad for people with ME. It may be worth trying cutting out grain and dairy products for 4 to 6 weeks. It is important to eat a good diet with fruit, vegetables, chicken and fish. Supplements of Omega 3 and 6 fatty acids are beginning to achieve respectability. Small doses of amitryptiline can help with disturbed sleep and have less addictive potential than the benzodiazepines. The non-steroidal anti-inflammatory drug Celebrex which is a prostaglandin inhibitor can help, possibly by affecting micro-vascular disturbances in the brain stem by opening up the small capillaries. However, long-term use may increase the likelihood of cardio-vascular disease and therefore it should only be taken for 3 or 4 weeks during bad periods.

Recovery is frequent within the first year of the illness and there is a better prognosis if there are periods of remission. He has seen patients recover after 10 years but this is rarer. He does not believe there is a specific pathogen. CFS has followed from EB virus infection, salmonella, tetanus injections or whiplash injuries, probably triggering a common pathway in a susceptible individual. CBT can be helpful to some patients early in the illness if they are very negative and depressed about the illness, but he believes medication techniques are more effective. The mind and body are closely allied. Probably what is most helpful about psychotherapy is not specific techniques, but therapeutic engagement with the therapist.

Dr. Weir concluded by saying that CFS/ME is a real illness and a serious problem. People with ME can’t carry on with activity because of a physical disorder in the brain cells. Anyone who denies this is inhumane; the medical establishment is coming to recognise the illness. Finally he told the audience that there was light at the end of the tunnel. A cause is going to be found fairly soon and those who deny the organic basis of the condition will “have egg on their faces!”

Catriona Courtier