The Background To My Work On Chronic Fatigue Syndrome: A Treatable And Potentially Curable Disorder Using Conventional Medical Approaches
I qualified in Medicine in 1969 in Edinburgh and during which time I studied for a B.Sc, Hons in Neurophysiology.
I am a mainline organically based clinician who has been looking at the field of Chronic Fatigue Syndrome for 30 years. I spent 12 years as Medical Adviser to the M.E.Association, then based in Stanford-le-Hope, and wrote and published, after peer review, some ten papers based on the concept that this illness was caused, sustained and maintained by a virus of one kind or another.
In 1990, it became quite clear that this illness was simply triggered by a virus and in many cases I was convinced that viruses were not involved. The presence of viral antibodies, if found in the blood, became irrelevant. In 1992, it became clear that the fatigue syndrome was purely centrally based and that problem was that of disturbed brain function. With further work it became clear that probably every neurone and all brain function within the central nervous system is affected and neural networks suggest that a diminished brain function would be associated with diminished neurotransmitter regulation. Thus a treatment became apparent and that it would be a neurotransmitter regulator; in other words, the use of antidepressants became axiomatic.
Fortunately seventy percent of neural transmission is made up of the ‘classic’ six neurotransmitters namely 5Hydroxytryptamine (5HT) (Serotonin), Nor-adrenaline, Adrenaline, Gamma Aminobutyric Acid, Dopamine, Acetyl Choline Glutamate etc. There are, of course, many other neurotransmitters, (in excess of one hundred and twenty as yet known to date), present in very much reduced amounts. By using a tailor made mixture of Tricyclic Antidepressants (TCIs) , such as Amitriptyline, Trimipramine, Doxepin etc, and/or SSNRI like Mirtazapine at night and stimulating 5HT re-uptake inhibitors (SSRIs) in the morning the treatment approach began in 1994.
Since then, having had a poor treatment outcome previously the effect upon this illness has been dramatic. Of course, all of this, at the moment, is anecdotal and can only be proven by peer review published papers. My paper, written with others (Dr Maxine Patel, Professor Simon Wessely, and Prof Trudie Chalder), relating to the treatment of children using these medications in conjunction with a modified activity programme was published in the BMJ publication Archives of Diseases of Childhood in October 2003 and demonstrated that this illness is now effectively curable in children.
CHRONIC FATIGUE SYMDROME (CFS)
In 1969 The World Health Organisation acknowledged CFS/ME as a neurological disorder.
The 5th October 1996, found the Royal College of Physicians officially recognising the presence of Chronic Fatigue Syndrome and in January of 2002 the Chief Medical Officer of Great Britain stated that the medical profession also recognised this illness. Disliking the terminology M.E. they stated that the illness was not physical, not perpetuated by a virus, not psychological (although recognising that complicating psychological problems were relevant and, usually, frequent), not stating what they believed it might be but more what it was not.
This however, is how I had been perceiving the illness for the last several years, and I will tell you that the illness lies as a biochemical dysfunction of the central nervous system affecting all neuronal tissue and sustained by an immunological dysfunction of heightened immune activity, loss of central regulatory mechanisms and intellectual cognitive processing. Despite popular understanding to the contrary this illness is not only treatable but potentially curable.
Within this website you will find the description of how these various named disorders came about, definitions of C.F.S. and some of its major subsets. Understanding the generation of the symptoms experienced by sufferers and the philosophy of what is going wrong in this illness is complex. More importantly however, you will find details of how to develop the three major stages to recovery. Firstly, the development of a modified activity programme (M.A.P) for both physical and mental activity, secondly the use of sedative tricyclic antidepressants to restore, normalise and regulate sleep pattern and thirdly the introduction of antidepressants in the day to try and help the reduction of fatigue and anxiety to help sufferers move forward.
Since 1994 I have been using a combination of Fluoxetine Hydrochloride (Prozac) in the day for its anti-fatigue property and for its improvement in cognitive function and also the use other SSRIs for similar reasons but also for their anxiolytic effect and to lift mood. These are medications that are used during the day and at night various combinations of tricyclic antidepressants to help normalise and restore sleep pattern. Since that time the success rate in treating C.F.S. and more specifically the subset that appears to have been precipitated by an acute virus onset has risen dramatically. These medications do not work if you have not developed a M.A.P. prior to their introduction.
CFS AND ITS SUBGROUPS
There is no doubt that opinions from countries around the world that have been studying Chronic Fatigue Symdrome (C.F.S.) are drawing to a consensus on a working definition, (currently the Fuduku Working Definition) of what we should all be looking at when we talk about C.F.S.
There have been many others. It is however interesting that the countries that appear to be complaining more of this disorder are those of westernised or ‘advanced’ countries, Australia, New Zealand, South Africa, North America, Canada, Great Britain, Europe. I will draw your attention to the fact that these countries probably suffer more mental stressor factors than maybe elsewhere.
It is a syndrome, which means it probably includes different illness processes with similar symptoms but in all of them the principal complaint is one of persistent chronic fatigue and fatigueability without any other reasonable explanation for its cause. One can see that there must be a number of possibilities for the cause of this type of complaint, but if you have come to this stage I would have assumed that all other medical explanations would have been excluded but you might have been told its psychological. It is not.
There are two major sub-types:-
1) The slow onset variety
2) The acute onset variety. Within the latter, and to some lesser extent the former, the major complaint is that of chronic fatigue and fatigueability (and invariably many other symptons) which then would draw the attention to a diagnosis of C.F.S., but often widespread muscle pain appears to be the principal complaint in which case the diagnosis would include that of Fibromyalgia Syndrome (FMS). In all of these conditions I will argue that the predominant pre-morbid factor is that of significant negative mental and other stressor factors as the cause of these conditions. One of the major sub-groups of C.F.S. is that of acute onset where the fatigue disorder has been apparently precipitated acutely by some kind of infective agent. There are many sorts of infective agents but it appears that the majority are brought on by some kind of ‘virus’ type infection. The symptoms of this ‘virus’, would typically be malaise, high temperature, aches and pains sore throat, and headache. Something of the kind that we have all had at some stage in our lives. I have looked at several thousand cases of C.F.S. over the last thirty years and have seen many patients who appear to have some predictable factors that make them worse and others that make them better. By analysing these various markers I have developed strategies for patients to help them feel better. To optimise their chances of recovery by preventing them from making themselves worse you can encourage their ability to make themselves better. The majority of patients realise that by doing too much either mentally or physically they make themselves worse, but what they don’t realise is that by making themselves worse they actually perpetuate the illness process itself – chasing rainbows
There are many worldwide centres studying C.F.S. and most have independently adopted various types of management programmes and strategies that have similar treatment styles and they amount to those of management programmes Cognitive Behavioural Therapy (C.B.T.) and Graduated Exercise Treatment (G.E.T.) The only two clinically proven approaches that are known to work – evidence based medicine.
I, too, have found that this type of approach is the most effective treatment presently available but with significant modifications. It is crucial to restore refreshing sleep and stabilise the illness pattern before gradually increasing one’s activity tolerance. This can only be done by doing less than can be achieved on a mental and physical basis, while restricting to a minimum visual input such as reading and screen based activities.
This is done by breaking up the whole day into tolerable activity slots with regular rest periods and personalised to the individual patient. However, I will suggest that this is not the whole answer and that antidepressants help the recovery as well. They are not necessarily used because you are depressed. This is not universally accepted.
These antidepressant medications are used here as neurotransmitter regulators to try and help correct the biochemical disturbances within the central nervous system and act as post-synaptic membrane support systems; these medications are not only safe but non-addictive and non habituating.
They have problems in their use and side effects, but the prescription is designed and tailor made to treat the patients themselves, and nothing should be taken that makes the symptoms worse or the patient feel unwell. They need to be taken for quite considerable lengths of time, often years, typically two to four years. They are, however, highly efficient not only in relieving the symptoms but I believe in actually treating the illness process itself. Success of this type of regime is high and a ‘Dr Smith’s Get Well Club’ exists to offer group support for patients with C.F.S., all of whom, I am happy to say, have a positive and optimistic approach to their illness process and, as they have one source of information, the approach is the same. C.F.S. is not only treatable but potentially curable.
I trust that you will find this approach thoughtful and well worked out. I am a middle of the road Clinician and offer evidence based medicine. There is nothing here that would be not recognised by all practising Physicians as being reasonable and acceptable. I hope you find the contents of this website educational, enlightening and an answer to your problem.
CFS AND ITS SUBGROUPS
For a more detailed background on Dr Smith and his medical theories behind his treatment plan, the PDF Understanding and Diagnosing ME/CFS (123 pages 737KB) can be downloaded here.
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This document outlines how the successful treatment plan was developed and how and why it works. Primarily for those in the medical profession it will be of interest to patients and their supporters.
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