All Change: A New Diagnosis

I have been sick for at least 13 years, with some symptoms going back into my childhood. At first I was told I had Post Viral Fatigue Syndrome, then later Myalgic Encephalomyelitis. (ME.) ME is also referred to as Chronic Fatigue Syndrome, (CFS) although this is controversial as chronic fatigue is often a symptom of other illness. ME/CFS is a diagnosis of exclusion. That is, there is no  known cause or definitive test for it and when every other possibility is excluded the symptoms get labelled as ME. I have often wished that I had any other disease – something with a known cause, where it is not so easy for people to label you a fake or a lazy scrounger. This wish got even more intense when I went to see a psychiatrist after becoming suicidal with pain. His response was to ignore my depression and suicidal ideation and instead “diagnose” me with Chronic Fatigue Syndrome, which from his point of view is a mental illness, and prescribe exercise as the cure to all my problems.

Then four years ago I became diabetic too. It wasn’t unexpected given my family history and I adapted to it pretty easily, although I resented having to change what I eat. Since I was diagnosed my diabetes has progressed rapidly and a few weeks ago I went to see a specialist because despite insulin treatment I was responding unpredictably and finding it hard to control my blood glucose. He suspected that I had a form of diabetes called MODY and had some blood samples taken for a genetic test.

On Friday I got the results of that test back and everything changed.
I don’t have MODY, I have Maternally Inherited Diabetes and Deafness. (MIDD.) It’s caused by a mutation in mitochondrial DNA (3243 tRNA), specifically 3243A>G.

I spoke to the diabetes consultant this morning and he confirmed that what I have is the mitochondrial 3243 A>G mutation. Unfortunately he is a bit clueless about the impact of that mutation outside of diabetes and he dismissed my questions about muscle pain and weakness and about issues with taking metformin. When I first saw him I had asked if my diabetes could be the cause of the muscle pain and burning pain that I have had for years, but he was adamant that it could not be, especially since I have been diagnosed with ME for much longer than I have had diabetes. He said that he had a couple of other patients with MIDD and they had no pain so that was that.

Apart from diabetes and deafness (The deafness part is only about 75% of cases) MIDD is associated with some other symptoms. From the information sheet at the Diabetes Genes website:

Myopathy (Muscle weakness): muscle problems of either weakness or cramps may be present in around 40% of cases of MIDD.  This generally involves proximal muscles (shoulders, buttocks and thighs) which are used when climbing stairs and presents as exercise induced muscle cramps or weakness.

 And

Metformin, a commonly used treatment in diabetes is probably best avoided as Metformin is known to interfere with mitochondrial function and the risk of lactic acidosis may be increased although this has not been reported to date.

From looking at what other people with this condition have said the pain and weakness is rather understated in the above quote. The following is typical of what is actually reported.

I’ve been feeling so, so tired recently with aching legs, and I can barely get out of bed and get dressed some days, most of the time I just want to lie on the sofa and sleep. I knew MIDD could make you tired after exercise, but I didn’t realise it could make you so fatigued after not doing anything at all!

Turning to The NHS Rare Mitochondrial Disease Service for more information I found this under General Information > Exercise

Because in mitochondrial disease the cells cannot make ATP in sufficient quantity, anything that requires a lot of ATP such as exercising a muscle will mean that the body will not be able to keep up with demand. This has two main effects; firstly the muscle will become tired sooner than normal and secondly the muscle makes other compounds such as lactic acid in an attempt to keep up with energy demand. This can lead to pain and cramp in the muscles and patients often feel “like they have run a marathon” even after only moderate exercise. The temptation is to avoid all exercise so that you never get to this stage, but this is not recommended for two reasons. Firstly, it is important for general fitness to exercise and as well as exercising the muscles it is important to keep the heart and circulation healthy. Secondly, there is good evidence that if you become very unfit this will adversely affect your muscles. In many patients’ muscles there is a mixture of good and bad mitochondria and the hope is that exercise can increase the good mitochondria, boosting the level of ATP back to normal and so avoiding symptoms. At this stage this remains just a theory and there are large trials looking in to this idea. At the present time our advice is to exercise regularly at a level that feels comfortable, but without pushing yourself to the point that your muscles become painful.

But that’s not all. The Rare Mitochondrial Disease Service has another perspective on the 3243A>G mutation. It is responsible for a condition called Mitochondrial Encephalomyopathy, Lactic Acidosis and Stroke-like episodes (MELAS). And it’s scaring the shit out of me.

The clinical features associated with this mutation can, as stated above, be very variable. We have a number of individuals who clearly carry the mutation who are completely asymptomatic. Other patients have very, very mild symptoms perhaps with a tendency to have diabetes or very mild deafness requiring no treatment. These patients might not be aware that they had the mutation apart from the fact that they were family members of somebody who had more serious disease. Some people with the 3243A>G mutation, also develop diabetes and deafness ultimately requiring the use of a hearing aid or requiring insulin to control their diabetes. Other patients have more severe involvement with muscle weakness sometimes affecting the peripheral muscles and sometimes affecting the muscles around the eyes. Finally there is a group of patients who do develop the MELAS syndrome, which is associated with episodes of encephalopathy . Encephalopathy is really the medical term for an episode that disturbs brain function. These disturbances can take the form of stroke- like episodes and/or seizures. This is a much more troublesome and difficult group of symptoms to control and clearly have a significant effect on people’s lifestyle.

My next step is to see my GP to talk about what all of this means for me and I will ask for a referral to the mitochondrial disease service. Unfortunately my GP is away this week so I will have to wait before I can sort anything out.
I thought finding proof of what is wrong with me would be a relief, but it’s not. Acceptance of my old diagnosis has given way to panic about my new one. All I have is questions swirling round and round in my head. The thought that keeps hitting me is that I wasn’t making this up. I wasn’t imagining it. People have been throwing out accusations and belittling my illness for so long that I had almost convinced myself I was a lazy fake, questioning if symptoms were real or just my brain tricking me. And now I know I’m not imagining it. There’s proof, right there on paper, but I almost don’t believe it. I want to feel relief but all I feel is grief.

Mental ME

I have depression. I get stuck in a spiral of negative thoughts until I reach the point of wanting to die. It happens often, and has been going on for about a year. A few months ago I asked my GP to refer me to a mental health team for more in-depth help as anti-depressants alone were not working.  My GP wrote to the mental health team asking for help with my suicidal thoughts, and she listed some of my circumstances too – imminent homelessness, massive housing benefit screw-up, and suffering from ME and lots of other diseases.

The three times that I have seen a psychiatrist have been rubbish. I talked about that in a previous blog post. Basically, the psychiatrist focussed on my fatigue and would talk about nothing else. I even said to him “I’ve had M.E. for eleven years and know how to manage it, but I really need to know how to stop the loops of negative thought and the suicidal thoughts.” I was ignored. He decided to treat my fatigue by giving me amitriptyline, which is the first drug used in cases of M.E. even though I have tried many similar drugs over the years to no effect. Amitriptyline caused me to lose two entire weeks because it made me sleep all day every day, so I cut it down and then stopped it.

I went back to my GP to find an alternative to this useless psychiatrist. She gave me a copy of the letter that he had sent to her. Here is what it says:

Diagnosis: Chronic Fatigue Syndrome

Current Mental State/Progress:
Unchanged, symptoms of fatigue.

Risk profile (+Crisis Plan if applicable):
Nil.

There is no mention of the periods of despair, the suicidal thoughts, the risk to myself that my GP had told them about. Just a diagnosis of Chronic Fatigue Syndrome. I have pointed out on this blog many times before that my illness is ME/CFS which is a physical condition. As such, my psychiatrist has no business writing CFS as my diagnosis for my mental health problems because it’s not a mental health problem.

I had a bit of a freak out this morning because I suddenly realised that this psychiatrist will be asked about my condition for my application for Disability Living Allowance. That could be disastrous if he tells them his version of what is wrong with me rather than my official diagnosis of M.E. by the neurologist that I saw years ago. However, after panicking for a few hours I have managed to call the mental health hospital and explain my problem. The manager there was extremely helpful and nice about it. My next appointment there will be with the Consultant Psychiatrist who is in charge rather than the idiot that I have previously seen, and because my DLA claim is imminent I will be called in earlier if there are any cancellations. She has also made a note that they must see me before replying to any letters about my DLA claim.

Hopefully that’s one less thing to worry about. The last thing I need is clueless doctors making my life even more stressful.

Managing ME

People often assume that medicine can cure M.E, or at least keep it under control. Unfortunately, they are wrong. While I can and do take many medicines to treat pain, insomnia and other symptoms, none of them will cure me or help me keep the fatigue at bay. The main symptom of M.E. for most people is Chronic Fatigue. The World Health Organisation says of this:

“Chronic fatigue syndrome (CFS) is a clinical diagnosis characterized by an unexplained persistent or relapsing chronic fatigue that is of at least six months’ duration, is not the result of ongoing exertion, is not substantially alleviated by rest, and results in substantial reduction of previous levels of occupational, educational, social, or personal activities.”

The important parts to note here are “not alleviated by rest” and “not the result of ongoing exertion”. The result of this is that when someone suffering with M.E. tries to do something important – such as going for a compulsory interview at the job centre – there will be a payback for that activity which will cause them a disproportionate amount of fatigue as well as many other symptoms that they might suffer from. The payback may not hit straight away, or there might be several stages to it, and it can last for days or weeks. Stress often has the same effect as physical activity, and can result in the same payback.

I have found only one successful way to alleviate these problems and keep the fatigue at bay, and that is pacing. When I was a patient at the M.E. clinic at Oldchurch Hospital back in 2005, pacing was the most important thing that they taught me, and in fact getting pacing right was the bulk of my treatment there. Pacing played a large part in getting me back into work at the end of 2006.  Now that I have had a serious relapse and have been well and truly in the “severe M.E.” category for a few months, I need to re-introduce pacing so that I can have some chance of getting my illness under control again. In fact, I should never have stopped pacing at all. For most sufferers, M.E. never really goes away, and without careful management it will strike back with a vengeance.

What is Pacing?

“Pacing is a technique used by many people with M.E. Pacing is about learning what activities your body will tolerate or cope with, without causing a relapse or a set back. It’s about taking a positive attitude to your recovery but discovering and recognising your limitations.” (Definition from action 4 me)

“Pacing is sometimes called adaptive pacing therapy (APT). Pacing is a strategy in which people with CFS/ME are encouraged to achieve a balance between rest and activity. This usually involves living within the limitations caused by the illness, but having some limited types of activity alternating with periods of rest.” (Definition from patient.co.uk)

The most important part of pacing is getting the right amount of rest. The M.E. clinic helped me divide my day into short periods of rest and activity. Every one to three hours of activity would be followed by half an hour of rest. Rest, in people with M.E. meaning lying still, not looking at anything or listening to anything that requires thought, and preferably not thinking about anything. Reading, television, radio and thinking can all be tiring to someone with M.E. Hell, I list sitting on the sofa quietly as an activity, not a rest! Not only that, but I was told not to sleep during rests. Sleeping in the day makes it harder to sleep properly at night. In my case I take a long time to wake up and recover from sleeping no matter when it is, so I definitely want to avoid sleeping in the day. To help me with my resting (and getting to sleep) I was taught breathing exercises and relaxation techniques that calm the mind down.

Some suggestions for achieving relaxation, taken from my hospital notes:

  • Soft, ambient music
  • Guided relaxation techniques such as:
    • Visualisation or guided imagery
    • Progressive or physical relaxation
    • Autogenic techniques
  • Diaphragmatic breathing
  • Warm bath/aromatherapy
  • Meditation

I was told to position myself very carefully so as to support all my limbs and joints for maximum rest. Here are some examples from the notes that they gave me. Note that everything is supported with pillows or cushions. That makes things hard for someone like me who can get very restless and want to change position a lot.

Rest position: crook lying
Crook lying
Rest position: side lying
Side lying
Rest position: long sitting
Long sitting

These are the techniques that I must start using again.

  • Limit each activity to an amount I can deal with without pushing through
  • Rest after each activity
  • Adopt relaxing positions while resting
  • Use breathing and relaxation techniques to clear my mind
  • Not sleep in the day
  • Try not to get so obsessed with anything that I spend too long on it at once
Because I have very little self control, I have made a new timetable which includes appropriate length activity and rest periods. I’m rubbish at stopping for rests, so I have put four rests into my day but it might have to be more. It is important for me that I stick to the timetable as closely as possible since I have a tendency to get absorbed in things and suddenly notice that I have been going for 16 hours and am now dead. (Probably.) The idea is that I smooth out the level of activity to make every day contain the same amount, but the timetable will have to be flexible to some extent because some days I might not be able to achieve even that level of activity. I might have to move getting dressed to later in the day, for example, or take an extra rest.
An example weekly plan for an ME patient
An example weekly plan for an ME patient
Once I have found a baseline of activity that I can keep up I can then experiment with slowly adding more activity and introducing exercise in to my routine. I need to build up the pace slowly and carefully, never pushing too far and causing relapse, but not letting myself slack either. Keeping going and not going too fast are both very important. I was taught all of this in 2005, and with the help of all of these techniques I was able to slowly regain enough control over my body to go back to work at the end of 2006. I was lucky though; many people are not able to regain that much of their health even when they are perfect at pacing. And ultimately, I got lazy and let the pacing slip. If I had still been keeping up a (less strict) regime of rests while working I might not have got quite so ill this time round.

Let’s talk about ME

Today is ME awareness day. Or this week is ME awareness week. Or possibly both, I’m slightly confused. Confusion (cognitive difficulties) being one of the problems that affect people with ME.

ME is an invisible disease. Often inaccurately called Chronic Fatigue Syndrome, (CFS) especially in the USA, it is a lot more than just chronic fatigue. ME stands for myalgic encephalomyelitis. Myalgia means muscle pain and encephalomyelitis means inflammation of the brain and spinal cord. The symptoms are many and harsh. Crippling fatigue, headaches, dizziness, loss of balance, nausea, irritable bowel syndrome, muscle pain, joint pain, cognitive problems, and all sorts of other unpleasant things. Any activity results in a massively disproportionate payback. Walking to the shops can cause leg muscles to lock up, go solid and produce agonising pain. Standing in a line is difficult because of pain and dizziness. I’ve written more about this in my blog post What is ME? and I also described how I struggle with waking up in A morning with ME.

ME varies a lot too. I have been so ill as to be housebound or bedbound through much of the last eleven years, but I have also been well enough to work for a reasonable portion of that time. Of course “well enough” is relative, as while I might have looked fine at work (and sometimes I didn’t, to the consternation of my colleagues) I often collapsed in bed as soon as I made it home and was able to do nothing until going out to work the next day. Today I am going to go out for a meeting which is the other end of an hour long motorbike ride. Two months ago I didn’t have a hope of even getting on the bike, but at the moment I can as long as I pace myself, and even then it will hurt tomorrow.

People with ME look well because unless you visit them at home, you only ever see them on a good day, when they have mustered the strength to venture out. That is why the illness is invisible. Spend any length of time with an ME sufferer and you will notice signs of exhaustion creeping in. Visible wilting, muddling of words as brain fog takes over.

Earlier today I was sent this video made by @daisydinosaur_, I think it is a good summary of the problems that we face.  Continue reading “Let’s talk about ME”

What’s wrong with me?

I’m ill. I suffer from several serious diseases. As such it shapes my life, and affects everything that I do and say. When I am talking to someone, sooner or later my illness comes up when I have to explain why my life is a certain way or why I cannot do something. Many of those people ask what is wrong with me, and since it is very hard to explain it every time especially on twitter, I have explained it here for future reference.

So here’s the official list of diagnosis.

I’ve had the migraines all my life. I get between one and four a week. The main trigger is fatigue, other triggers are red wine and some blue cheese. I get migraines with pain over the right eye, pressure throughout the head, tension in the neck, and aura including nausea, vomiting and bright flashing lights in my vision. I treat the migraines with Sumatriptan (Imigran) nasal spray which is fast and effective at stopping them.

I was diagnosed with Diabetes the day before my 30th birthday. Given my family history I had fully expected to become a diabetic one day but I had expected it to be at least another ten years away. I control my diabetes with tablets, but it is progressing absurdly quickly and so I may well be given insulin injections soon. Note to detractors and “it’s your own fault” idiots: I am not obese.

Restless legs is fairly common, affecting 1 in 12 people. I have extreme restless legs. It makes me move, twitch, stretch and convulse any time I am required to keep still, especially when trying to sleep or in a car. Combined with ME and an inability to move sometimes, it’s torture. It is a major cause of insomnia for me so that I am now afraid to even try to sleep. I treat it with Pramipexole which is a dopamine agonist aimed at parkinsons disease. It makes me feel horrible and sick, but if I don’t take it, my legs try to rip themselves off of my body.

Insomnia is an obvious one really. I don’t sleep when I should. It is quite debilitating in its own right since going to sleep at 6am makes it nearly impossible for me to get up and do anything at 8 or 9am. It is fueled by a natural obsessiveness in me that won’t give up on whatever I am doing just for sleep, but also by my Restless Legs and by an inability to switch my mind off and stop thinking, which is a common problem in those with ME.

I have had ME/CFS for 10 years now. Many people get ME after a viral infection such as flu. They simply never recover from it. I first got sick after being in bed for a week with flu. After the flu seemed to be clearing up, the exhaustion, the headaches and the muscle pain stayed on. Those are the primary symptoms of ME.

When I talk about chronic fatigue the words really don’t cover the reality of it. People use words like tired, exhausted, and fatigue all the time but they have no clue what it really means. When I say I am too tired to get out of bed it’s not hyperbole. I mean it. When I am that tired I can’t get the five metres from the bed to the toilet. When I am at my worst I cannot lift my head from the pillow or turn myself over in bed. If you have ever experienced sleep paralysis then imagine it continuing for hours. For the really unlucky ones it continues forever. One of the most frustrating things that people can say to me apart from “Have you tried…” is “oh, yes, I’m quite tired after work too.” I want to scream at them. You just have no clue!

The fatigue is not logical either. It starts about as low as energy levels can get so that every action is an extra effort. That effort must be gauged incredible carefully. Each action results in a bit more fatigue and in a bit more pain. Where most people could perform a physically demanding task for a day and then be refreshed by one nights sleep or perhaps a day off, when you have ME the refreshment doesn’t happen. A few minutes of extra effort can result in days of exhaustion and pain. Sleep can make things feel worse. The best analogy I can think of is that every bit of energy used must be borrowed from a loan shark. He isn’t forgiving. That energy will be demanded back the next day with menaces, and whatever you pay won’t be enough. The loan shark will be back again for more.

Other symptoms are many and varied. I have already mentioned fatigue, headaches and muscle aches. i also have burning pain in various muscles, brain fog, irritable bowel syndrome, problems with vision which appear when most tired, and more that I can’t remember.

Brain fog is worth explaining. Once again words are inadequate but it is often described as a head full of cotton wool or as thinking through treacle. Brain fog prevents me from remembering words that I need, from completing thoughts in my head, from finishing sentences that I am speaking. It’s frightening and horrible because it strikes at my own sense of self.  It is brain fog that can prevent me from speaking at all on some day

For me, my illness varies a lot. I tend to have cycles of relatively good (~80%) health and then relapse for a few weeks of months where things get bad. I had flu, the real deal, not once but twice in the last few weeks. Since then my health has gone steadily downhill and I am now in a complete state of relapse. I have barely been able to leave my bed for the last few days and have been in a lot of pain with burning sensations in my muscles. I would say that i have rarely been as ill as this in the past.

I wrote about how ME affects me every time I wake up in my article A morning with ME.

For a full understanding of how chronic illness affects me I recommend reading Spoon Theory by Christine Miserandino or watch the video below to see Christine reading Spoon Theory to a conference. This is the origin of the #spoonie tag that you may have seen me use on Twitter.

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