The Subsetter
The SubsetterFor decades, virtually everybody has believed ME/CFS is larded with subsets, yet very few researchers, due to a lack of money or initiative, have actually looked for them in an organized fashion. Dr. Natelson has, and in a review article published in The Frontiers of Physiology, he’s imploring others to do the same.
He’s also telling the research community that this ‘wastebasket’ disorder you’ve turned your noses up for so long can and is being tamed. Dr. Natelson, is an ‘old-school’ researcher who parses his words carefully, doesn’t move until he’s got his ducks in a row, and the publication of this review article suggests he’s pretty confident. In this article, Natelson wraps his research findings over the past five or ten years with the proposal that this disorder is ripe for splitting.
The New ‘Dropsy’
Because CFS is defined using a clinical case definition, patients with this diagnosis must constitute a heterogeneous group, probably with multiple causative agents
Natelson starts by asserting that the nature of the ME/CFS definition means ME/CFS MUST have subsets and will likely have several causes, and he compared the current state of affairs to the 18th century when the term ‘dropsy’ term applied to people with swelling in their limbs probably due to congestive heart as well as other organ failures.
Chronic fatigue syndrome’s tendency to co-appear with fibromyalgia and other disorders has lead some researchers to suggest it’s nothing more than a somatization disorder. Early on, however, Natelson determined that a diagnosis of somatization disorder simply depended on whether their symptoms were coded as psychiatric or physical.
Nearly every ME/CFS patient met the classification of somatic disorder if their symptoms were classified as psychiatric, but if those same symptoms were classified as physical, the somatization label disappeared, so with Natelson’s research consistently turning up physiological abnormalities, he dropped the somatization idea and moved on.
The Mood Disorder Conundrum
“..Our working hypothesis (is) that the group of CFS patients with no co-existing psychiatric problems has an underlying brain disease “
Early on, Natelson took an interesting cut at this disorder, stratifying his patients into groups depending on whether they’d been diagnosed with a mood disorder, and the results were startling; he found a lot more neurological problems in the ME/CFS patients without mood disorders than in those with them. He found that ME/CFS patients without mood disorders had….
- Significantly worse neurological test results
- Significantly higher number of MRI abnormalities (usually in the frontal lobe)
- Significantly worse physical functioning
- More spinal fluid abnormalities (white blood counts/protein concentrations)
- More areas of reduced cerebral blood flow (than patients with current depression)
- Higher ventricular lactate levels in the brain (p<.07)
–than the patients with mood disorders, it was remarkable to see ME/CFS patients without mood disorders racking up more severe results on brain dysfunction than patients with ME/CFS, but there we were. Not only did they have more central nervous system abnormalities, but they were worse functionally, as well, which should have led to, …a great incidence of mood disorders…but the evidence suggested not. In fact, one wonders if this suggests this was a mood disorder-resistant group.
The Fibromyalgia Connection
Comparing neuropsychological (cognitive) test results between ME/CFS patients with and without fibromyalgia, Natelson didn’t just find more neuropsychological test results in the ‘pure’ ME/CFS patients; they were the only ones to have neuropsychiatric (cognitive) issues and Natelson which suggested people with FM do not have significant cognitive issues.
The fact that people with fibromyalgia appear to have double the number of psychiatric issues as people with chronic fatigue syndrome provided a bit more foundation for Natelson’s theory that ME/CFS patients without co-existing psychiatric diagnoses have an underlying ‘brain disease’ that causes their fatigue and cognitive issues.
Put everything together, and you may have a group of ME/CFS patients with a brain disorder that’s showing up in the form of high rates of lactate in the brain and small nonspecific MRI white matter abnormalities, mainly occurring in the frontal lobes of the brain.’
Dr. Natelson has two theories about what’s going on in this group.
Dr. Pall in the Limelight: Theory #1
” Our current working hypothesis—that a subgroup of patients with CFS has an underlying neurological disease which leads to the symptoms of fatigue and cognitive dysfunction.”
Two theories might explain what’s causing this ‘neurological disorder’. The first suggests that a depleted antioxidant system (aka Pall), in the form of reduced glutathione (aka Rich Konynenburg), results in the formation of more free radicals (isoprostanes – aka the MERUK studies), which slam the membranes of brain cells in the frontal lobe causing them to function poorly.
Could free radicals be causing small lesions in the brains of people with ME/CFS?
Natelson’s work with Dr. Shungu suggests that glutathione levels (the main antioxidant) in the brains of ME/CFS patients have taken a big hit (@36%). The increased brain lactate levels (a byproduct of anaerobic respiration) – found by no less than three studies – fit right into Natelson’s scenario of impaired cellular metabolism.
(When Natelson re-evaluated the data from a 2009 study finding higher lactate in ME/CFS patients than people with anxiety, he found that ME/CFS patients without mood disorders tended to have higher lactate readings. Shungu, however, found similar brain lactate levels in people with ME/CFS and major depression.
Not the Mitochondria
Dr. Natelson does not believe the mitochondria are the problem – but reduced blood flows may be. The free radicals found in ME/CFS (the isoprostanes) are also potent vasoconstrictors, i.e., they tighten up blood vessels, causing reduced blood flows (Baraniuk’s brain proteome study also implicated the blood vessel problems.) Baraniuk’s findings of increased rates of migraine suggest that brain blood flows may play an important role in this disease.
Orthostatic Train Wreck: Theory #2
The second theory suggests orthostatic intolerance problems are causing reduced blood flow to the brain, hypoxia-induced brain lesions, and cognitive problems.
A Look Back
Researchers thought delayed hypotension (sudden drops in blood pressure after standing) might be causing ME/CFS for almost twenty years. The nearly identical symptoms and a promising first study (that first study effect….) primed the field for a good deal of investigation into OI.
Delayed hypotension didn’t pan out in ME/CFS, but it pointed in the direction of postural or orthostatic tachycardia, a condition in which the heart rates race upon standing. POTS is a big deal in ME/CFS but in an interesting way. It appears to be rampant in ME/CFS adolescents but is much less prevalent (10-25%) in adults.
Something New
Or is an unusual form of orthostatic intolerance causing hypoxic conditions that cause small lesions in some people with ME/CFS?
Although POTS was not able to explain many ME/CFS adults’ problems with standing, a new form of orthostatic intolerance called ‘orthostatic hyperventilation’ may be able to.
This problem, characterized by low end-tidal CO2 values, appears to affect about 20-30% of adult ME/CFS patients. That’s about double the incidence of POTS, and it’s hardly ever found in healthy adults (3%). Women were out in front again (:)), with 35% testing positive for OH.
Orthostatic hyperventilation, then, provides a cleaner differentiating factor in ME/CFS than the better-known POTS; it’s more common in ME/CFS and it’s less common in the population at large.
When you think ‘hyperventilation’, anxiety and images of bag-breathing come to mind, but the anxiety angle did not pan out. Instead, the hyperventilation found in ME/CFS appears to be a physiological response to reduced blood flows to the brain.
Dr. Natelson did not address why the switch from heart-racing to ‘breath-racing’ is occurring. It’s not clear if adolescents tend to outgrow POTS or if it and orthostatic hyperventilation are simply consequences of getting this disorder at different times of one’s life.
Natelson suspects this group has high rates of cognitive problems, low rates of mood disorder, low blood flow to the brain, and ‘lesions’ in their frontal lobes.
Conclusion
Natelson’s thrown orthostatic intolerance into research mix and his next round of studies will be able to tell what roles oxidative stress and orthostatic intolerance play in this group of cognitively challenged, functionally inhibited, lactate rich, frontal lobe wounded patients without mood disorders. Natelson may be on the track to defining and even explaining what’s going with a significant subset of patients.
Cort,
Thank you for this information! I’ve never been so happy to have a mood disorder in my life! My functional MD gives me glutathione IVs with methylated B vitamins once a month (after an initial round of one IV per week for 10 weeks), and I’m good to go. The IVs are especially healing now that he is adding a “shot” of phosphatidyl choline (PC) after each IV. I get the impression that he is combining info from Rich Van K and Patricia Kane.
Very interesting Kathy. That brings to mind Dr. Peterson’s statement that most alternative remedies don’t work in his patients but there’s a group they are helpful in and it sounds like you’re in that group. Actually, I’ll bet there will be a bunch of groups over time…
Thanks for a great article, Cort.
One question – when you say that “Delayed hypotension didn’t work out”, do you mean that is was found to not be the whole answer (as opposed to suggesting that neurally mediated hypotension is not present in many ME/CFS patients)?
Yes, it was found to be a smaller piece of the puzzle than originally thought..
How do you think Natelsen’s ideas fit with current research out of the labs of Prof. Sonya Marshall and the Spanish group of J. Castro-Marrero, et al.who’s immunological biomarkers are quite strong indeed. These are also consistent with the mitochondrial dysfunction which is also well established by people such as Brad Chazotte. Indeed chronically raised IFN-gamma causes serious mitochondrial membrane depolarization. If you have such mitochodrial dysfunction you will have glutathione depletion and raised oxidative stress.
I don’t know. Natelson does believe that a pathogen/immunological problem is driving the oxidative stress ( peroxnitrite/isoprostane level) that may be vasocontricting the blood vessels in the brain (causing the cellular hypoxia and white spots on the MRI). He’s not into mitochondrial dysfunction but I think he would probably agree that mitochondrial output would be limited. I didn’t know about the IFN-gamma..thanks.
I believe this is the best theory explaning the symptoms but what drives this problem? It can be the immune system. I was wondering how Natelson split CFS patiënts in 2 groups. One with moodproblems or aniety and the other one without these problems. We know that many CFS patiënts have secondary moodproblems as well. How did he do that? I believe that low bloodflow/vasocontricting in the small vessels of the whole body is the central problem. It can explain every symptom!
I also have little white spots in my brainnot only in my frontal cortex (cerebrum and cerebellum). I have severe POTS.
He split the groups up throughout a series of papers over 10 years or so. I’m not sure how he determined who had mood disorders or not I would bet though that the great majority of patients with mood disorders got their mood disorders after coming down with ME/CFS. It could have been the same triggering agent -and a different ‘host response’ as they say.
I’m with you on the vasoconstriction in the small blood vessels! My body tells me that’s where it is…we’ll see if intuition ends up being right. (Hopefully we will :))
Do you know many who have tried THC, especially low dose THC.
This article is interesting:
http://www.aftau.org/site/News2/66249501?page=NewsArticle&id=18625&news_iv_ctrl=-1
I don’t. I haven’t tried THC but in my experience medical marijuana is really good with sleep, relaxation and pain. I don’t get high from it….I just feel like my system calms down…Thanks for the article I plan to do a blog on medical marijuana.
I believe i have both a neurological and immunological problem as i have acquired a late onset epilepsy and b-cell leukemia (also classified as a non-hodkin’s lymphoma) which is more often prevalent in the much older male population. Perhaps this is a different subgroup again?
I would think so. Dr. Peterson appears to have increased rates of NHL in his group in Nevada.. I imagine there’s an seizure/epileptic group present. Good luck!
I’m 61 and was diagnosed with CEBV at age 34, which was later called CFS. My first outbreak was age 27. Took that long to find someone able to diagnose it. When the CEBV was active and I was very tired, I would have some kind of black outs. I’d be driving and conscious of it and end up finding myself at my destination and having no recognition of getting there as if I’d been asleep. If I get extremely tired, I get so dizzy that I have to go to bed for 3-4 hours. With increased fatigue comes increased pain. I now also have Neuropathy, HBP that started at age 34, osteoarthritis, have had multiple broken bones and intermittant tachycardia and irregular heartbeat. I’m using Neurontin but need occassional Hydrocodone. In my area, all the Drs know is pain killers that cause CA and antidepressants. There has to be a better treatment. The very worse part is that no one believes you and treats you accordingly. A lot of what you are feeling doesn’t even show on your face.
Why has so little progress been made with this ailment all these yrs? We have suffered much.
The federal government has never made a commitment to ME/CFS. That’s where the money is….When that changes we’ll make progress. Our system is not set up to support those in need. Its set up to support what researchers want to study. When those intersect the system works; when they don’t it doesn’t; it certainly hasn’t for us…