Mitochondria, not hypochondria
Public Service Review: Central Government - Issue 21
Thursday, January 06, 2011
University of Hull Professor of Psychology Rhona Johnston argues
against the widespread belief that ME/chronic fatigue is a
ME/chronic fatigue syndrome (ME/CFS) is a chronic state of profound
exhaustion, often accompanied by pain, sleep problems and cognitive
dysfunction, and it is made worse by exercise. In my local health
authority area, individuals with a long-term fatigue problem used to
be sent to the immunology department at the regional hospital for
diagnosis and treatment, but now they are referred to a psychiatrist.
This is a growing trend throughout the UK. These days, getting a
diagnosis of chronic fatigue is tantamount to getting a psychiatric
diagnosis. This is good for creating work for psychiatrists, but is it
good for the individuals concerned? If their condition is a physical
illness, they will not receive suitable treatment and so will not make
a full recovery.
The psychiatric view of what they term 'chronic fatigue syndrome' (the
term 'fatigue' clearly trivialises the severity of this illness) has
gained considerable ground in the UK in recent years, aided by the
supposed lack of evidence of physical causes of the condition. What
evidence can psychiatrists adduce to support their assertion that
ME/CFS is a purely psychological illness, that is, a form of
Psychiatrists argue that individuals with medically unexplained
symptoms have 'functional somatic syndromes' – that is, although their
symptoms appear to be physical, they are psychological in origin. It
has been argued, on the basis of an analysis of the literature, that
having the belief that ME/CFS is a physical illness leads to a poorer
prognosis, and that these faulty attributions perpetuate the illness.
Thus the fact that these individuals believe that they have a physical
illness is seen as a further manifestation of their psychological
problems. However, if those who assert that they have a physical illness do indeed have one, the prognosis for recovery without suitable treatment is clearly going to be poor.
One of the main treatments on offer for the condition is cognitive
behavioural therapy (CBT), which has been shown to lead to a
significant reduction in fatigue symptoms. This finding might be taken
as support for the idea that ME/CFS has a psychological cause.
However, there is a higher incidence of depression in those with
chronic physical illnesses than in the general population, although in
the case of ME/CFS this has been found to be no higher than in, for
example, rheumatoid arthritis. Thus CBT may, for a subset of
individuals, ameliorate some of the tiredness resulting from a
concomitant depression, while not addressing the underlying fatiguing
disorder. It is unclear, however, if this is indeed the case, as the
authors of these studies use ME/CFS classification criteria that take
fatigue as the main symptom. The exclusion of physical symptoms allows
the inclusion of individuals who do primarily have a psychiatric
disorder. Thus the statistical reduction in fatigue found with CBT may
be largely due to the fact that individuals suffering purely from
depression are included in these studies. It should also be noted that
there is a lack of evidence of long-term benefits of CBT for
individuals with an ME/CFS diagnosis.
The higher proportion of women suffering from ME/CFS is also thought
to be evidence that the illness is psychosomatic. It is unclear why
this should indicate a psychological illness; after all, women are
more prone to gallstones as well. It is noteworthy that when a doctor
made a study of viral illnesses in his patients over a 40 year period,
of those who subsequently experienced central nervous system
pathology, 67.8% were women (of whom a third also experienced ME/CFS)
and 32.2% were men (of whom a third also had ME/CFS). Thus there was a
clear physical basis for the disproportionate number of females
suffering from ME/CFS in this study.
It has also been asserted that ME/CFS is a psychiatric illness because
patients have often experienced abuse in childhood. However, stressors
like abuse are known to cause physical ailments. For example, it has
been found that child abuse is associated with an increased incidence
of ischemic heart disease. It has also been shown that individuals
having severe chronic stressors in the 12 months prior to being
deliberately exposed to a virus were significantly more likely to
become ill than those with acute stressors or a low number of
stressful life events.
A mitochondrial problem?
It is clear that there is little evidence in favour of a psychological
explanation of ME/CFS. We therefore need to consider the biomedical
evidence for a physical disorder, of which there is a considerable
amount. To aid simplicity, the approach taken here is to consider the
possibility that individuals with ME/CFS may in the majority of cases
have a similar physical problem, but that it may have diverse causes.
A recent study has found that 70 out of 71 individuals suffering from
chronic fatigue had abnormally low mitochondrial function.
Mitochondria are organelles within cells and are the main producers of
cellular energy. Mitochondria have to have an intact inner membrane to
produce energy via a process called the electron transport chain.
There is evidence that a wide range of chemicals impair mitochondrial
function, including pesticides, herbicides, PCBs, solvents, toxic
metals (such as dental amalgam), plastics, and fluoride. Impairments
can also be caused by drugs such as antibiotics, non-steroidal
anti-inflammatories and anti-parasite drugs.
There are also infections that cause mitochondrial problems, such as
mycoplasma. This is a micro-organism that lacks a cell nucleus and a
cell wall; it damages the inner membrane of mitochondria, depleting
the nutrients in the cells, disrupting the electron transport chain,
and causing chromosomal aberrations in the host cell. Studies by Dr
Garth Nicolson have shown that individuals with ME/CFS have many
bacterial and viral infections; however, a high percentage of them
have mycoplasma infections. Thus, over a number of studies, Nicolson
and his group have found that between 51% and 68.9% of individuals
with a chronic fatigue diagnosis have a mycoplasma infection. Most of
these studies were carried out in the United States, but the higher
figure comes from a Belgian study, in which only 5.6% of controls
showed signs of the infection. Nicolson's group has also shown that
using a supplement that restores the mitochondrial membrane leads to
both a reduction in fatigue and an increase in mitochondrial function
in individuals with chronic fatigue. Clearly, the infection scenario
is a complicated one; susceptibility to mycoplasma and other
infections may arise from having an immune system weakened by viruses,
and viruses themselves might damage mitochondria. However, getting rid
of a mycoplasma infection in those affected will be very beneficial
for energy levels, and so reduce stress on the body.
Chronic exposure to stress can in itself damage mitochondria and also
impair the functioning of the adrenal glands. Adrenal insufficiency
could be a primary cause of ME/CFS in some individuals, as the
symptoms are similar to those of Addison's disease. Less extreme
debilitating adrenal problems also occur. It has been shown that
overworking the stress system leads to problems in keeping a balance
between the functioning of the hypothalamic-pituitary-adrenal (HPA)
axis and the immune system. If there is an immune challenge, this
produces inflammation, and the actions of the HPA axis reduce it by
damping down the inflammation. However, if the body has to do this
often it becomes overstressed and cannot maintain the balance – this
is likely to happen if the body is dealing with a long-term infection
What can the NHS do to help individuals with ME/CFS? At the moment,
many individuals are offered expensive but harmless CBT. This
technique is now widely used for so many illnesses, including cancer,
that it can even be purchased online. They are also offered
potentially damaging graded exercise regimes. Exercise can be very
beneficial, but not if misinformed practitioners believe their
patients to be depressed and persuade them to exercise beyond their
reserves of cellular energy. Pacing is excellent and can cost nothing – here, individuals make sure that they keep their activity level
within their energy envelope, and so avoid bouts of disabling exhaustion.
In order to help at least some people recover, it would seem a good
use of resources for the NHS to screen ME/CFS patients for low
mitochondrial function, adrenal problems (not just testing cortisol
levels at midday) and mycoplasma infections. The latter can be treated
by antibiotics, which if administered early on could mean that these
individuals would avoid having to suffer this debilitating disease for
decades, with the consequent weakening of their adrenal glands.
Removing this infection is unlikely to lead to an immediate cure for
long-term sufferers because of collateral damage to other bodily
systems, but there must be a chance that a proportion of individuals
will regain their health and lead happier and more productive lives.