(Care)

(Care)

I’m probably going to reach the point soon where I can’t communicate either by speech or typing, and I’ve neglected to put in place any detailed care instructions or living will or anything like that. So I’m going to start here explaining and I’ll just have to hope I can get it done before I lose the ability to type. [I can’t.]

In my previous post last year I tried to explain how I’ve got worse over time because it’s easy to deteriorate and impossible, in my own experience, to improve without drugs. It’s difficult to explain exactly how vulnerable this leaves me and what the future might hold because everyone with ME seems to be affected differently and it’s hard to extrapolate.

For starters, the health of even the illest patients seems to have a springy quality mine lacks that allows them some fluctuation or bounceback. Secondly, the thing which keeps me in bed – extreme lack of muscular stamina – seems very different from the more colourful illness that keeps other people in bed. Malaise, flu-like symptoms, dizziness, weakness, paralysis, other autonomic dysfunction, generalised mysterious pain, unrefreshing sleep, “brain fog”, indigestion, – you name it, I barely have it. I’d say I’m at about 1 or 2 out of 100 on the Bell Fatigue Scale in terms of how little I can do, which is very bad, but the scale also assumes it’s typical to have constant “severe symptoms at rest” at this end of the scale, and I don’t seem to have any symptoms at rest. I feel pretty much ok until I try to do or experience anything. I don’t usually even feel tired. I used to have a few more of the typical symptoms around 2000-2002, but they never amounted to much more than a nuisance.

I don’t know how common it is to have so much absence-of-ability at the same time as so little presence-of-illness, but I would imagine that any of these problems would (re)appear if I get very ill, especially sleep, pain, nausea and general malaise. But in the mean time, extreme lack of stamina is enough of a problem and I will go through its consequences, which are nightmarish. The lack of stamina is not only physical but cognitive, psychological, emotional, sensory, everything.

The cognitive mental fatiguability is the least serious, but still currently prevents me from reading more than a few middlebrow short articles a day at best, and only non-fiction. My brain starts to physically hurt, much like a muscular exercise burn, in fact; then even being talked to becomes torturous like having raw skin poked, and then I might start to get flashes of jamais vu and aphasia and eventually I lose the ability to reason entirely. In the past I’ve woken up blank and not knowing what urination is or how I go about doing it.

I don’t think this is brain fog; it is brain fatiguability. I have brain fog too sometimes and it is, as its name suggests, a woozy, spacey occlusion or obstruction that prevents you doing anything in the first place rather than a lack of resources limiting the exertion once you have embarked upon it. As such it is more like lethargy, the-presence-of-fatigue, which I don’t usually experience, rather than exertion intolerance, the absence of energy, which I do. The end result of both of them is that you cease to be able to make sense of anything but I don’t know if brain fog is actually painful.

Physical fatiguability is my most disabling and constant problem but there is a lot more to it than meets the eye. I explained in my previous post how my condition deteriorates when I exceed my limits and doesn’t recover, and that this leads, in practice, to progressive decline. It also leads to an accelerating decline as my available energy becomes less and less and it gets easier and easier to exceed it.

Additionally, past a certain point, physical deconditioning as a result of inactivity becomes unavoidable and keeps making all activity more demanding. I don’t think this is the major causative or perpetuating behavioural factor that some psychologists imagine it to be, but a tertiary effect that only started being a problem for me about 18 months ago. In the previous 15 years, while I could walk to the bathroom and back, i.e. 20-30 paces each day, I could keep my muscular strength constant and good enough that if my ME symptoms remitted a bit as a result of drug treatments I could increase my activity with no problem.

Thus in 2004 I went very rapidly from eighteen months’ worth of walking to the bathroom once every 24 hours and getting overstretched if I typed too many things into Google, to going downstairs two or three times a day or putting together a five foot flatpacked bookshelf by myself. I didn’t have any problems “reconditioning” at all. A similar improvement happened in 2008. But once ME setbacks stopped me being able to walk that far that often, in 2015, things began to slide, and now I am constantly deconditioning and I can’t reverse it because the threshold of activity required to reverse or even stave off further deconditioning is way beyond the ceiling of activity currently imposed on me by ME. (I can draw you a graph if you like.) And as I said in my previous post, if I try to ignore the ME limits for fear of deconditioning I will simply get more ill more quickly.

The result of all of this is that my health is deteriorating quite rapidly, and smaller and smaller things are taking bigger and bigger chips off me. I expect I’m imminently – possibly before the end of this piece – going to reach a critical point of negative energy equity where I have to do things – inevitable things like using the bedpan or eating – more often than I can recover from them.

I will, therefore, find myself in a permanent and probably constantly worsening state of PEM. This would involve a lot of muscle pain/burning/stiffness in my limbs, which painkillers may or may not help, plus restlessness, disrupted sleep, nightmares, and possibly pain when resting on my ribs and/or back and/or arse (“sitting bones”) that prevents me from being able to lie still for very long or go to sleep, all of which is disastrous in a condition which already demands more rest than I find humanly possible.

Unfortunately, the other side of physical fatiguability is that as well as getting PEM when I move myself, I also get PEM when weight/pressure/vibration is put upon me, or even when my body is moved without effort from me. There’s being bedbound because you can’t move yourself, and then there’s being bedbound because you can’t endure being moved, and I also find it tiring to be lifted/pushed/manoeuvred/touched by someone else. So getting help from a carer will not stop this decline.

Piling PEM on top of PEM leads to a very rapid downward spiral, nausea, the sort of shaking/shivering that everyone gets when they have exercised a muscle beyond capacity, and after that I don’t know what happens, and to be honest I would be curious to find out, except that:

a) although my pain with extreme PEM has usually up till now been bad but not *that* bad, maybe a 3 or 4, it is very, very obvious that bad things are happening to my muscles on a microscopic level, it feels ghastly and terrifying, and when I lose function I don’t recover it, and

b) the sensory hypersensitivity that I suffer from already will become magnified to horrific proportions, you can end up in vicious circles of sensitisation and physical decline, and

c) there is no adequate help for this or any other aspect of the disease.

For example, I have and will again end up in a condition in which I can’t bear ambient noise without industrial ear defenders but I also can’t bear the pressure of the ear defenders clamping on the sides of my head. There is no solution to this: I can alternate the source of the irritation but it doesn’t relieve the overall suffering. Or if I can’t bear light, I can’t bear wearing an eye mask and I can’t bear the upheaval of having the windows blacked out, then I will have to bear at least one of them. Or if I feel distressed without heavy and bulky bedding on top of me but increasingly I’m too weak to move around under it without incurring PEM, but I have to because pain builds up if I don’t shift position regularly, then I will have to bear at least one of them.

These sensitivities include extreme intolerances to the slightest: physical pressure (or sometimes lack of it), vibration, noise, sound, light, visual stimulation such as patterns or movement, commotion, fuss, confusion, intrusion, interruption, interaction, someone coming into the room, someone looking at me, someone displaying enthusiasm or any emotion etc. etc. etc. I start to feel very frail and thready and flinch at any sound, not from fear but from pain, as though I consist mainly of nerves flayed bare that will scream if they’re so much as breathed on. It probably resembles what you’d get if you subjected someone with an extremely thin-skinned hangover to sensory overload torture.

It also means I have a thimbleful of tolerance for more conventional psychological stress. Given that a) stress is defined as the discrepancy between the demands placed upon a system and that system’s perceived ability to meet those demands, and b) almost everything is already too much for me and pretty much everything else is borderline, almost everything in life, certainly all pressure, suspense, change, conflict, in-person interaction or interference, is if not stressful at least taxing for me.

The more frequently I’m subjected to these assaults, the worse my mental and physical health gets. It doesn’t matter whether the people inflicting this torture are doing it unintentionally, you are poking a raw nervous system and the result is agony, and I can’t afford agony. I can’t afford to scream (though I do), because screaming (i) takes a fuckload of physical energy and (ii) produces an adrenaline rush that washes me out; I can’t even silently scream because I still get exhausted by (ii); nor can I afford to cry or feel frustration or rage because it all ravages me in the same way and there is no catharsis in this situation, you just end up further down the same hole.

I am aware this puniness is as absurd as the dying Beth in Little Women setting aside her sewing needle because it was “so heavy”. It is also, to use an unnuanced term, “real”. These sensitivities are not caused by psychological or behavioural issues which can be rehabilitated, though they do result in extreme distress. They seem to be sensory processing issues, they diminish spontaneously during my overall remissions and, as with physical exertion intolerance, they do not respond to cognitive behavioural therapy, gradual exposure to the aggravating factor, hyperacusis therapy or any effort to coax or wean or distract or inure or acclimatise or soothe or persuade myself to tolerate them. I have tried. They get worse and they keep getting worse.

The best informed advice is to avoid such stressors exactly as you do with extreme physical stressors, but of course in practice this is not possible and people go further and further downhill. There are many people who end up completely unable tolerate any stimulation; they spend their lives with earplugs in blacked out rooms, they can’t bear anyone touching them, they can’t bear anyone coming in, which is bad enough, but when they also can’t do anything at all for themselves, they need spoon feeding or tube feeding and nappy changing, then they have to bear it, they have to have people violating these limits and they also can’t speak or communicate in any way so they can’t let you know when what you are doing is particularly horrific.

People talk of spending hours stuck between desperately needing basic help like water or excretion yet desperately unable to tolerate the help, waiting to build up the strength to endure the daily necessities of life and then trying to recover before the next time they need them. This is not a tolerable quality of life. It must be like locked in syndrome except you’re locked inside out and it keeps getting worse because the stress of suffering makes it worse and any attempt to explain or even endure anyone alleviating the cause of the suffering also makes it worse. People live for decades in this state. I don’t know whether you ever touch bottom or just find yourself tumbling ever deeper into horror, but I’ll probably find out, because this is my future.

And I don’t know what to do. You may have noticed that I’ve written 2000 words of a blog about care without providing any care instructions and that’s because I don’t know what to do about it and. always devised and implemented as much as I could for myself, not just because I prefer it and I don’t want to atrophy but also because it is so much less stressful than enduring care or trying to explain the layers of practicalities to anyone else. Trying to execute my needs with people who typically fail to understand the general precept, refuse or demand justification for my decisions or argue with me at every turn that they might know better is very stressful, it amounts to light coercion when I’m too weak to resist or explain and it behaviourally reinforces excessive self-reliance. Add that to entropy and the result is a pile of improvisation that only I have any clue about but I’m too weak now to explain to anyone else.

What will happen when taking care of my basic needs myself is too much for me and makes me worse, but getting someone else to do it for me is also too much for me and makes me worse? Who will brush my teeth, Optrex my eyes, put in my earplugs, change my tampons, position my urinal, explain things to doctors, telepathically arrange all the stuff I need in easy reach and retrieve it from inaccessible places when I drop it and all the other things, too numerous or horrible to mention, that are only feasible and/or tolerable when I do them myself? Who will prevent the whole clutter of entropy when things need doing but I can’t explain, endure or even list what they are? My current, pretty typical Severe ME needs are patchily met and understood no matter how hard I try to get the message across and I’m made to feel like I’m being unreasonable when I complain. What will happen when my condition gets even worse?

I don’t know. The medical advisor to the main ME charity doesn’t know, and he’s written books on living with ME, he’s a kind and dedicated man, and he told me, “Sorry, but I don’t have an adequate answer to your dilemma”. When I expressed a hope that I might find some help via the main local ME charity, its Chair of Trustees told me, “Well, don’t hold your breath.” It’s not that they don’t know, in fact: they do know, we all know, that no answer exists because no adequate help exists.

Medical and public health institutions have spent decades assiduously ignoring or denying the fact that people as ill as me exist so they don’t have to acknowledge the inadequacy of their current treatment of ME.  I’ve already been substantially harmed by the NHS approach both physically and psychologically, but when patients report these harms and ask for less ideology and abuse and more of the known medical realities in our treatment, please, we are loudly condemned as dangerous “anti-science extremists” by many of our supposed specialists, they compare us to anti-vaxxers and climate change deniers, and everyone believes them. So people like me are not only physically helpless but misunderstood, disbelieved and disdained.

This is a bad position to be in. The best I can reasonably hope for is neglect; at worst patients are blamed for medicine’s shortcomings, sectioned into psychiatric wards, subjected to barbaric treatment and then dumped back home with severe permanent physical damage and PTSD. But then I wouldn’t expect a much better outcome from ordinary care, either, because this kind of fragility is simply incompatible with life. And if I ever have to go to hospital for even the most insignificant issue, the nature of ME and the nature of hospitals means that the staff won’t be able to prevent it becoming a nightmare for me even if they wanted to or knew how.

In view of all this I’m quite sure that in terms of my quality of life, if I should ever come down with something that is certain to kill me relatively painlessly at home if left untreated, I want it to be left untreated. In reality I know that most things that can kill you are more likely just to make your quality of life worse without killing you, plus I haven’t come down with so much as the flu in 15 years. Refusal of food and water would be a quality of life issue like a DNR but triggers psychiatric assessment, and there is a history of pwME, both children and adults, being detained or sectioned, and/or having their carers suspected of Munchausen syndrome by proxy, simply for believing they have an organic disease or failing to get better, let alone if they can’t speak or show suicidal intent, so I am afraid of doing anything that might lead an ignorant psychiatrist to classify me as insane. And I don’t know what to do about that either, and I know that nobody else does either.

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Something I’ve been meaning to say…

Something I’ve been meaning to say…

spoons

I’m writing this now, a few sentences a day, because I don’t think it’ll be very long before I’m not able to type at all.  This is because I’ve gradually deteriorated to the point where doing pretty much anything other than lying quietly in bed makes me worse.  I can’t walk to the bathroom any more or stand for more than a few seconds, I can’t talk for more than a minute or two or comfortably lift a litre bottle of water.  I’m starting to mix up homophobes when I rite, witch eye never yous too due, and I can’t read or think properly any more.  And just as poverty breeds poverty, the more depleted you are the more vulnerable you are to further depletion, and once you reach a certain point a downward spiral becomes very likely.

This is not a self-fulfilling prophecy: it’s a well-informed probability, considering that I don’t know of any available treatment which I haven’t already tried and found ineffective several times over, and that the less you can do or say or read or think or feel, the greater the number of treatments that become unavailable to you.  It’s also not ‘defeatist’ to look reality in the face when the national health service won’t do it for me, especially since my morale, good or bad, has never had any effect upon that reality.  I probably shouldn’t feel I have to explain the severity of my condition as though I’m at fault for not recovering, but I do, and that’s an issue beyond the scope of this post. I would just like to explain my experience of the mechanics of illness that bring this sort of situation about. I’ll be using the term ME rather than CFS (though I don’t like either), because I’m taking CFS to be a more vaguely defined condition than ME, and things which may be true of one are not necessarily true of the other. Before I start, though, it’s only fair to tell you that I’ve found an excellent blog that says most of what I’m going to say here in much less verbose posts of a few hundred words plus graphs, so you might prefer to head to the Just ME blog instead. If you’re staying here then let’s begin.

First of all, the problem with fatigue in ME is not up front, in how much you can do in the first place. The problem is how much you can recover from. The defining characteristic of the illness is exertion intolerance, which may sound like a euphemism for laziness but essentially means you don’t recover properly from even trivial effort, you don’t respond in the normal biological way and pushing your limits makes them worse instead of better. This is different from other kinds of fatigue in which you have a lack of stamina that will however improve with training or you feel exhausted whether you’ve done anything or not or you feel a sluggish lack of motivation to do anything in the first place. It’s not the presence of fatigue that disables me, it’s the absence of energy.  I want to do stuff but, as Byron put it, the sword outwears the sheath.

So for instance, if you put me at the bottom of a flight of stairs, it’s not that I’d feel already drained, or faint, or feeble, or in a deep fug of lethargy that prevents me from summoning up the will to move. Nor would I be paralysed, or shaking, or dizzy, or in some other way unable to initiate normal movement. Some people with ME (henceforth pwME) do get these symptoms, but they’re not necessary for a diagnosis. The problem is that after I’ve got to the top of the stairs I will be spent, there will be an onslaught of disabling symptoms – ‘fatigue’ is a little effete for my taste – and my stamina during this acute period will become even smaller, exponentially so, so that tiny things which would normally be within my powers will now take further huge chunks out of me. And unlike the tiredness healthy people feel after exercise, it isn’t the short-term effect of a process that is overall making you stronger.

This catastrophic response to exertion is usually known as post-exertional ‘malaise’ (PEM), as though patients are feeling kind of languidly unwell like Baudelaire on a fainting couch, but that doesn’t really capture it. Different people experience it in different ways, and for some people there’s a lag or cushion of one or two days before it fully sets in. For me it’s much quicker.  I am a bit unusual in that PEM doesn’t make me feel sleepy or washed out or jetlagged or “brain foggy” or any of the ordinary types of tiredness that sap the average person’s will to do things, nor do I often feel the immobilising exhaustion that your body manufactures in response to a virus in order to get you to conserve energy, though other pwME do get all these things in spades. In fact I don’t think malaise is the word for me at all, because I don’t really feel ill in an immune-activated way most of the time. If I had to link my PEM to any normal kind of fatigue it’s probably like an extremely toxic exercise burn but branching out into various horrible new ways of feeling bad, mostly in my muscles but also in the meat of my brain and nervous system. It feels as though I’m being burnt up by a medium strength acid or poisoned, pulled, peeled, strangled, scrunched, stung, perished, fuzzed or suffocated, on a cellular level, but it doesn’t usually stop me wanting to fidget instead of resting. It can last days, weeks, or, for some people, months.

There is plenty of evidence by now about what might be causing exertion intolerance and unfortunately it’s not merely subjective, i.e. something which feels unpleasant but isn’t harming you. I’m trying to describe how ME works in practice, not write a polemic about its causes, but it helps now that scientists are corroborating my experience in their labs that I can talk about what’s happening to me without worrying that I’m merely anatomising a massive delusion. There are numerous documented biological dysfunctions, though their ultimate cause is still unclear, and you tend to find different dysfunctions in different patients, which suggests that we’re dealing with a category of disease rather than a single illness. But for whatever reason, the end result seems to be that ME sufferers don’t produce enough energy via aerobic respiration (1).  It builds up very slowly, like trickle charging a battery, so there may be enough at rest but with activity it runs out far sooner than it’s supposed to, which probably leads to excessive reliance on anaerobic respiration. Even in healthy people anaerobic respiration is inefficient, messy and painful, and the longer it goes on the more problems it creates for aerobic respiration to mop up afterwards, which healthy people can deal with but pwME cannot.

In addition, researchers have corroborated many pwME’s reports that trying to improve this problem the way you would with someone who was simply unfit or deconditioned, i.e. by challenging yourself with activity, does not work and makes it worse (3).  This is a problem because many UK doctors believe inactivity to be a cause of ME rather than an effect and use a definition of the illness so vague that it doesn’t mandate exertion intolerance or PEM. So we end up with treatments which make sense for people who for any number of different reasons don’t exercise, but which are useless or even harmful to people who can’t exercise. If you’re merely unfit and start exercising of course you’ll find it difficult at first but exertion will increase your capacity and it’ll get easier as you keep going – this is the ‘No Pain, No Gain’ paradigm. But in ME exertion that makes you feel worse really is making you worse. Your exercise capacity diminishes when you challenge it and future exertion becomes even more difficult and so on.  Far from being a sloth’s charter or the refuge of an ‘exercise phobia’(4), it’s actually very frustrating that effort in ME is counterproductive to improvement, and most people kick against their limits and do more than is good for them. And like most pwME, and this is the second major point I wanted to make, I find that if I challenge my limits too severely this harm isn’t just confined to PEM which can be convalesced off and left behind. My baseline (the amount I can do without incurring PEM) diminishes, so my limits become even tighter and it’s even easier to fall foul of them and so on (5).

This is the principal cause of deterioration. I don’t know exactly why it happens, but in practice it works a lot like a bank account. You’re receiving a small daily energy income in a current account, which has a low ceiling so that you can never save up very much in it even if you don’t spend anything, and this is funded by the interest from a capital sum in a savings account. If you spend your current account balance you go into the red and incur punitive overdraft charges, even trivial further expenditures become disproportionately costly, and to pay off the debt you have take a chunk out of your savings capital. And of course when you erode your capital in this way it generates less interest for you to live upon so you can’t rebuild your savings and you’re more likely to get overdrawn again and so on and so on.

This downward spiral is not the result of rest and deconditioning. (6).  It’s a separate process, as attested to by people in good condition who suddenly deteriorate and find that they lose capacity much faster than ordinary deconditioning will account for (7). Of course I’m vulnerable to deconditioning just as anybody else is, and of course if I have to rest more I get physically weaker and it makes future exertion more costly.  But PEM is by far the more severe limiting factor, and if I try to ignore it for fear of deconditioning I simply get more ill more quickly. I’m sure I occasionally overestimate how much rest I need (although I think I underestimate it a lot more often); I could do with a device that could scan a muscle and measure the exact amount of metabolic debt and the perfect amount of rest that would pay it off.  But it would only minimise the Catch-22 between ME damage and deconditioning damage, not solve it. Like hangovers, there is no known cure for PEM and its consequences so the only thing you can do is try to avoid it.

Some people do gradually recover from severe setbacks with time and prudent energy management. Other people, including me, do not, and this is point #3 . Maybe I’m just not prudent enough, but my ceiling ratchets down and doesn’t go back up on its own and I can’t make it. I’ve had two significant remissions of my illness in fifteen years, but only as a result of drugs, and nobody knows for sure why they worked and what problem they were addressing.  And I know a lot of people, including many doctors, find the idea of exertion from which you don’t recover very difficult to believe. Whenever I’ve cited X or Y event from which I haven’t recovered as evidence of this phenomenon, my dad has said “But that was a year ago!”, or two years, or three years, and so on through the turtlebacks of infinity, as though that does anything other than illustrate my point. He seems to be saying, “Well, but that was a long time ago, it shouldn’t have a lasting effect.” Well, but it does. I expect sooner or later researchers will confirm its physical reality, as they are confirming all the other weird stuff pwME have consistently reported all these years, and eventually they’ll be able to explain it. Until then I can only guess.

In the mean time, it isn’t helpful, if I’m about to undertake an unavoidable activity such as going to the dentist and I warn you that it will be too much for me, it isn’t helpful to advise me, “Well you’ll just have to try.” I hope I’ve done enough to explain that trying is beside the point. I’m not saying I won’t do it or that it’s impossible, or even that I’m reluctant or afraid. It’s nice to get out of the house, actually – even for dentistry, even when it’s seriously fucked me up, I’ve still enjoyed it as an adventure as much as possible. I’m merely advising you that it will make me a lot worse, and telling me to try feels like telling a diabetic who’s just eaten a box of fudge to “try” not to become hyperglycaemic. Similarly, when I choose to forego a pleasure such as seeing a friend or coming downstairs at Christmas, it’s not because the consequences will be merely subjectively unpleasant for a bit; it’s because I judge they will do me lasting damage.  I can choose to exceed my limits, but I can’t choose to recover from that. I know this because I mess up and get worse quite a lot.

And this brings me to the last point I want to make. Because of the sting-in-the-tail nature of ME, it’s not only possible to make the mistake of doing more than you can recover from, it’s easy. Avoiding it is much harder, especially if you’re generally fidgety and compulsive and when you’re tired you just get more wired and want to keep going well into the red, which is the case with most pwME that I know of. There are unmistakable signs that I’m doing too much, my muscles feel like several kinds of crap and it’s frightening, but I can choose to ignore that and press on against my better judgement and screw the consequences.

This is a problem because it means I’m always having to try and stop myself consciously rather than rely on anything as convenient as collapse. Some people talk about ‘going floppy’ with paralysis or seizures when things get really bad; maybe things have just never got that bad for me, or maybe, more likely, I have a different subtype of the disease, but for whatever reason it’s never happened(8) and it doesn’t have to, because the damage happens without it and I can do without more symptoms that could be considered psychogenic.  I always openly tell doctors that I can enact activity which I choose not to because the consequences would be too severe.  That’s the reality and a faint, fit or paralysis won’t make it any realer.  I presume there is a point of unendurable exhaustion at which I would collapse and not be able to get up again, just as there is with everyone, but the point at which I’ve started to do myself severe lasting damage will have been and gone well before that.

And I get that all this probably seems weird to you. It’s weird to see people keep avoiding things that they seem to you to be able do. It seems weird to the Department of Work and Pensions, which decides that claimants are well enough to cook for themselves every day because it sees them go downstairs once, ignoring the fact that they take more than 24 hours to recover from it. It seems weird to a lot of doctors because yes, the idea of exercise making someone less fit is straight out of Bizarro world and I can understand why at first glance – at first glance – they might think the patient’s response to activity is irrational.  Walking on a broken leg is a lot more blatantly inadvisable than walking on a broken energy metabolism. When you add to that the extremely lax definitions of ‘CFS’, usually devised by psychiatrists, and the mishmash of people who are therefore considered representative of it, I can’t blame non-experts I otherwise respect when they start talking about deconditioning, confirmation bias and ‘the sick role’.

It seems weird to me too. For a long time I wanted to believe that the illness was a neurological illusion, my brain sending me false alarms about my body, so that I could keep going even when I felt like crap. The post I wrote for this blog just two years ago takes this kind of Scrappy-Doo mentality even further by wondering if I couldn’t just force a reset on my faulty neurology (and any knock-on biological dysfunction caused by it) by calling its bluff by getting incredibly much iller than ill and just keeping going till I literally dropped and sort of reductians it ad absurdum. In the end I didn’t try it: the CFS consultant at the RLHIM rightly nixed the proposed hospital admission which formed the substance of this scheme because it would have been too much for me. But of course it doesn’t work. People with ME who do get very very overtaxed, they don’t somehow turn full circle through to recovery, they just get severely and often irreversibly damaged, enter realms of torment that unfortunately I probably can imagine, and in extreme circumstances die. Whether they die directly or indirectly from ME probably nobody knows for sure, but in such circumstances I can’t see it as anything other than a mercy.

Nor have I ever quite let go of the hope that I can improve my physical condition by changing what I do or think. People are very much getting the wrong end of the stick when they think ME patients reject psychological or behavioural interventions because we’re desperately craving the validation of a ‘physical’ illness. By far the quickest and easiest way out of this would be if I or my hypothalamus or my amygdalas were stuck in a loop that I could unstick with rational thought, a reformed attitude and/or careful adjustment of my boundaries.  These approaches have never worked for me, and most of the assumptions behind them are speculative or disproven. But they were sort of consistent with a theory that I liked, which is that ME is the bodily result of brain dysregulation or damage and that at least in some cases people can retune or refashion their nervous system back into normal function.

This could possibly be achieved by all manner of methods, cognitive or behavioural ones included. I’ve tried psychiatry, psychotherapy, ‘sleep hygiene’, occupational therapy, cognitive behavioural therapy, graded activity or exercise therapy, ‘amygdala retraining’, ‘dynamic neural retraining’, every possible relaxation method and a partridge in a pear tree, willingly, on my own initiative and with my own money, over and over again, despite none of them ever having made even the ghost of a difference to my illness, because I’d rather be surprised by success than confirmed by failure. I kept trying on my own once I was too ill to talk to health professionals and it still kept not working, and if a patient is trying their best at a treatment and it doesn’t work it’s bad practice to blame the patient. It also has all sorts of undesirable consequences to keep telling someone that they should be able to get themselves better when there’s no good reason to suppose they can. So I don’t criticise the psychologisation or behaviouralisation of ME because I feel stigmatised by mental illness, I criticise it because it’s flawed, unsubstantiated and the treatments based upon it don’t work on me.

But then there’s no reason they should, actually, because these treatments aren’t designed for people as ill as me. No treatments are designed for people as ill as me. The UK medical establishment is simply not bothering with severe ME, and by this I mean the illest 25% of people, which runs to tens of thousands of patients. The studies that inform the NHS treatment guidelines don’t include anyone who isn’t already well enough to get to a clinic, and nor do most specialist services.  And that seems really weird, because if you want to understand a poorly-understood illness rather than just, say, bung at it the cheapest possible stopgap treatment you can pass off as effective, you probably shouldn’t be ignoring the people in whom its symptoms are most unambiguously present. It’s creating a vicious circle of inaccurate definitions leading to misleading research leading to inaccurate definitions. Progress in understanding ME is slowly being made, but it’s being made by doctors who started by believing their patients.  I don’t think that’s a coincidence; I think it’s vital.

And this is the final thing I want to say. I had wanted to explain how the workings of this disease have affected me specifically and in precisely what a precarious place it has left me, but this piece is already longer than I can read through in one go and it probably sounds disjointed and choppy, so thank you if you’ve stuck with it to the end.  The last thing I want to say is this. For me as an extremely badly affected ME patient, my quality of life is terrible and medical understanding is as yet inadequate, and these are misfortunes. But the lack of even the will to understand it among people whose job it is to do so is probably more traumatic and it is culpable. The gap in their knowledge has been filled with conclusions instead of questions, with ideology instead of evidence, and government seems OK with this because in the short term it’s cheaper. I much prefer the doctors – and there are plenty of them – who admit they don’t know what to do because nobody really does yet, but who want to understand and don’t start by presuming I’m an unreliable witness and don’t think that branding me delusional is preferable to admitting they don’t know. Nothing I’ve said here is new. It’s not distinctive, it’s not particularly insightful and it shouldn’t be controversial, it’s just bog-standard first-hand knowledge of an illness which I don’t fully understand and nobody else does either. I would like to be listened to, please, by people whose job it is to listen to me, and to be believed unless there’s good reason not to.

 

Notes
I’m including various references to substantiate my statements but please don’t feel you have to read on past here. I can’t read very much of anything any more so I’ve only got the gist of some of these articles myself, but most of the basic facts of ME that I’m talking about are pretty well established now. Again, I am trying not to make this post into a polemic but I do want to show that inactivity and fear of exercise are not the cause of ME because this misapprehension continues to do huge damage to patients and to the prospects of research and understanding.

1) http://www.ncbi.nlm.nih.gov/pubmed/23813081

The researchers who demonstrated this problem found a big decrease in aerobic function as measured by a cardiopulmonary exercise test (CPET), which is an objective measure, i.e. it doesn’t rely on a person saying they feel tired.  The clever bit is that they used a repeat test to allow for PEM’s delayed onset because it can take 24-48 hours to hit a person fully.  So they got people to do exercise on the first day, on which their results were normal or a bit unfit, and then tested them again on the second day once PEM had hit them and saw their results plummet. Apparently this is so unusual it sends exercise scientists scurrying off to check their equipment to ensure it’s working properly.  And apparently even people with seriously limiting fitness problems such as heart failure or COPD are roughly able to reproduce their previous day’s levels rather than nosediving the way ME patients do, and this is crucial because it demonstrates the difference between people with ME who can’t recover from effort and people who for whatever reason can’t put in the effort to begin with.  (Severely ill ME patients don’t have as much of a cushion and would probably get worse much quicker, but then severely ill patients are generally too ill to get anywhere to be studied. (But see note 7))

2)  I had to remove the reference to the famous twenty-times-lactic-acid in vitro result after further in vivo experiments didn’t replicate it.

www.meassociation.org.uk/2013/04/biological-breakthrough-offers-fresh-hope-for-me-sufferers-the-times-23-april-2013/

I’m not sure this is the study referred to in the ME Association’s article but you’re welcome to go through Dr. Newton’s publications and find the correct one for me if it isn’t. I know that conventional exercise burn is in fact thought to come from hydrogen ions in general, not lactic acid, but twenty times more lactic acid than normal suggests a problem with some process somewhere.   Many doctors think that CFS is a category rather than a single illness, and Dr. Newton has found different subtypes of abnormalities in the CFS patients she studied, including some which she thinks may actually respond to exercise. Here she is chatting about it with Dutch subtitles.  But I think she used one of the definitions of CFS in which exertion intolerance and PEM are optional, which illustrates the need for much more research into precisely what is going on in the biology of these conditions and the pressing need to disentangle the diagnostic clusterfuck of CFS and ME and ME/CFS and CFS/ME.

3) This later study confirms the findings in the (1) study and explains their implications in greater detail.

4) Dr. VanNess who is an author of the study in note 1 underlining the point that fear of exercise in ME is a rational protective response, not a phobia.

5) At 24:30 in this video Dr. VanNess from note 1 talks about a woman who believed she could fix her aerobic capacity with training and made it worse according to the cardiopulmonary exercise test. There isn’t a formal study of this sort of thing, presumably because it would be wrong to deliberately harm people to prove a point, but we do now have a lot of evidence verifying pwME’s perceptions that when we feel as though there is a problem with energy production it is because there is a problem with energy production. You might think this is depressing but mainly it’s a huge relief to have our experience heard, investigated and verified after decades of doctors setting out with the assumption that we’re all imagining, misunderstanding or overreacting to what is in fact a pretty unmistakable experience.

6) m.openheart.bmj.com/content/3/1/e000381

Another study by Dr. Newton, which finds physical pathology correlated with severity of fatigue but not length of disease, i.e. the findings are unlikely to be caused by inactivity.

7) A Dutch doctor with long-term severe ME who was formerly a highly trained amateur athlete wrote this rather charming if sprawling n=1 study on himself, analysing his muscle metabolism after exertion.  Unfortunately we don’t have data for before his illness, only his first-hand accounts:

“Overnight, from one day to the other, I lost 70 to 80 % of power in my legs and suddenly, walking 15-30 yards was very far, and after that my legs felt very heavy and needed 15 minutes to recover before I could walk 15-30 yards again.”

Not everyone gets this sudden onset – I didn’t –  but given how often ME does start suddenly in active people and produces symptoms which can be verified by blood tests it’s unhelpful that the current UK definition calls it chronic fatigue syndrome and requires the illness to have been present for six months before you can diagnose it.

8) Obviously I have had the seven things-which-are-probably-seizures, but they don’t happen when I’m particularly tired or stressed, they’re random.  My possibly-myoclonus tends to only happen when I’m feeling relaxed, bubbly and alone, so if it is psychogenic attention-seeking I don’t know why it doesn’t happen when anyone’s paying attention, unless that’s just too easy for the likes of me.  But I did get it on video once in the hope that somebody could tell me whether it is myoclonus or what, so if you want to see me making extravagant involuntary movements in my bra, you’re in luck.

Answers From CFS Specialist

This isn’t finished but I’m posting it anyway because life is currently unbearable and, I don’t know, maybe communication or the deluson of communication formed by posting this into the ether is better than nothing. So these are the things I was discussing with the CFS doctor in February (before the hospital admission was cancelled) and haven’t been arsed to write up properly till now.

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1)  Is there an omega point of CFS? (Or do only fatal diseases have an omega point?) I.e., can I die of exhaustion? What is the worst that can happen?

Some people do seem to achieve this, and kudos to them, but in general no, you can’t. Which I knew, but I was sniffing around the question of how much harm is the tiredness really doing me, then; is it damaging me, and why can’t I just ignore it – all of it?  You might as well ask why can’t anyone ignore their tiredness, healthy people too, given that science is becoming increasingly aware that fatigue is in the brain, it is a prophylactic mechanism. Your body chooses to shut down before (quite a long time before) poverty of resources compels it to shut down.  But I think the answer is that it is, still, shutting down, neurologically/phenomenonononologically if not metabolically.  And it’s bloody convincing: if you get tired in the Matrix you get tired in real life.  I think there are ways to overcome this sensation, provided there is no neurological damage, but they are not surface interventions: you have to take drugs or be like a yogi or something.  Anyway, to get back to the main question, I think the doctor said that the worst fate in CFS was you’d get to a point of collapse where you wouldn’t die but nor would you be very likely to get up/move/recover.  This seems the likely result of the hospital trip.

2) The CFS sufferers who are completely immobile and spend their lives fed through a tube and drained through a catheter: how did they get to that point?  Was it, for instance, by making wildly overambitious trips to the National Hospital for Neuroscience and Neurosurgery?

This caused confusion because by ‘fed through a tube’ I meant too weak to lift cutlery or chew (this is not unheard of), but he meant, I think, people who are unable to eat due to phobias or maybe psychogenic food intolerances: he put it as “severe emotional problems”.  But I think, essentially, yes, if I wanted to get myself to this point, this would be one of the ways to do it.

3)  Is what Vicki Cook [CFS recoveree and coach] said true about people without carers don’t get bedbound?

This is complicated, but the gist of his reply was, you keep what you aren’t prepared to let go of – your non-negotiables – but other stuff falls by the wayside.  So if you are absolutely unable or refusing to become bedbound, for instance, then that’s what will go last, but meanwhile other areas of your life will lapse, like tidiness or socialising or bursting into song every morning with the dawn chorus.  Probably the advance of the illness is enabled or limited by just what and how much you’re prepared to let slide.

I’m tempted to ask what happens if you’re not prepared to let anything slide, but I think it may be a nonsense question, because nobody does everything all the time, and nobody leads a totally facsimilic existence in which they maintain not only everything they do but also everything they think and experience day in and out.  (And if they did, they wouldn’t have developed CFS, because the increase or incursion of fatigue into that existence is itself a decline, i.e. a decline of the tendency not to feel tired.)  And more to the point, CFS/ME makes inroads into those aspects of yourself over which you have no direct control: urges, implulses, spontaneity and so on. So to cut long story short: you do some things less than others, and those things atrophy.  As I write this it seems like an absurdly esoteric discussion or the kind of stoned revelation that is simply sloughing the skin off things you already knew, but the experience of CFS/ME does lend itself to these existential hair-splittings, because it is so much about perception and the material effects of perception.

(Short answer: No.  Or perhaps Maybe.)

4)  Is ME vs CFS a genuine distinction? (I was looking at the Hummingbird Society’s ME vs CFS chart, which I suspect is probably bollocks, at http://www.hfme.org/comparisonchart.htm)

For the purposes of this blog, or at least until I contradict myself, I am making the following distinction:

CFS Persistent fatigue and fatigability, not relieved by rest and with no readily identifiable cause, could be a load of obscure and complicated reasons.

ME Persistent fatigue and fatigability, not relieved by rest and of neurological cause, i.e., to cut a long story short, extreme tiredness for no other reason than that your brain is telling you that you’re extremely tired.  This may result in subsequent biological inflammations and dysfunctions and vicious circles all over the place and thus make it very difficult to distinguish symptoms from causes.  I think this difficulty is a key aspect of M.E..  But then I am prone to thinking in this way anyway, or as my occupational therapist put it, “You really love your semantics don’t you?”

Further questions I might write up properly later IAIAICBA:
Does mitochondrial dysfunction always entail delayed fatigue?/
Can the NHNN investigate the cause of my exercise intolerance?/
Would I recover if I just stopped spending all day looking at computer screens?

(No/No/No)

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Failure Of Imagination

I’m not much interested in a general Oh-the-humanity-of-CFS blog, which is why I haven’t been arsed updating this site since the hospital was indefinitely postponed. That was on 4th March, and I’ve been enjoying a Netflix and junkfood holiday from the duties of being a chronic patient and a person for some of the time since then, and subsequently I’ve been unusually productive. Except blogwise.

This is what happened. A few weeks ago I had my phone appointment with the CFS expert about the general survivability of the hospital enterprise. I told him I thought that the hospital would be far too much for me, however many or few tests we did, and that it was quite possible I’d be unable to speak or respond well before the first day was out. I was hoping he would tell me my predictions were alarmist, but he didn’t. I told him the slender history of my blackouts (two and a half of them, eight months ago, plus minor attendant neurological strangenesses), my current energy limits and my consequences-of-exceeding-limits history, and he said something like, “So why are you doing this?” We seemed to agree that this trip could be bad for me, but I gave him my reasons for going as outlined in the first paragraph of the Going To The Hospital post. They are fairly nihilistic reasons, but then there is a lot of nothingness in my life.

So I seemed to be faced with a choice. Or rather, since I’d already made up my mind, at least with the obligation to justify sacrificing my remaining health on this goose chase. When I started laying out my long shots (see the fourth paragraph of GTTH), he was quick to see that I was approaching hospital, as he put it, as a “behavioural experiment”, but he pointed out that “there are less extreme ways to challenge yourself”. Less schmess, I thought. Meet the measure to the mentalist.

I wasn’t scared, but this is only because I couldn’t properly imagine the consequences. My episodic memory and imagination is poor, and I remember facts much better than experience. (I don’t know if that’s M.E., or if it’s just me, but it’s been that way since I was a small child.) I know when such-and-such happened or that it was two days after this-and-that, and I know that I enjoyed it or regretted it or was tormented by it, but I can’t remember what it actually felt like, unless maybe there’s a particular trigger or a similarity with what I’m feeling now. After the phone appointment I was very tired, afraid I’d overdone it, and occupied by physical pain and dread, panic, blame, regret. It was a tiny glimpse of what the hospital and its aftermath would be like, and for the next few hours I was crawling with anxieties as the truth of this doomed enterprise came home to me. And then I forgot it again. I took some drugs and calmed down and slept, and by Sunday I was back to normal. Composure. Insouciance. Phlegm.

But I do remember the fact that the change in mood was as bad as the physical stuff, and not much easier to shake off. When Milton’s Satan says,

The mind is its own place, and in itself
Can make a Heaven of Hell, a Hell of Heaven

he seems to believe that he can believe whatever he wants to. I don’t think free will stretches that far, or at least not that fast. As Peter O’Toole says in Lawrence Of Arabia, you can do what you want, but you can’t want what you want: we’re all as encased in our minds, their dispositions and preferences, as we are in our bodies – however much that may be. I could expect to return from the hospital not only physically devastated but also irritable, depressed and unable to concentrate, and perhaps also under the thumb of a despair that might discourage me from tackling all the rest. It feels strange, losing the illusion of free will, but not new; I’ve always found in hard to distinguish between what’s me and what’s illness.

These concerns didn’t affect my morale because, well, let’s see, soon they were all lost like tears in rain, innit (see above). But the CFS expert spoke to the neurologist about how severely fucking decking the hospital would be, and the neurologist emailed me apologising because he’d changed his mind and decided that “an admission would not be in your best interests at the moment.” I’m partly disappointed, or at least deflated, partly relieved, and partly embarrassed that I’ve written a whole smegging blog for something that didn’t happen. Oy.

The next step, now that I’ve finished scoffing my hospital sweets, watching the whole of Breaking Bad and losing the weight I put on as a consequence of scoffing all my hospital sweets, is occupational therapy. The CFS Expert has recommended me a neurological occupational therapist and I hope between us we will have expertise enough to get me moving in the right direction. Thank you to everyone who offered visits or services or just goodwill, it meant a lot to me. I will also at some point post CFS Expert’s answers to my list of questions, because Genevieve wanted them. And as I’ve already mentioned, comments can now be left on this blog anonymously or with a nonsense name or email. But you can all keep commenting on Facebook if you prefer and I’ll just keep manually assuring the blog readership that these comments exist. It will allow me to exaggerate their volume and fervence, for one thing.

FAQ

Oh look! It’s almost as though I wrote a blog called Frequently Asked Questions and then realised six weeks later that I ought to include a Frequently Asked Questions section.

Can I come and visit you before you go to hospital?

I’m afraid I probably won’t have any opportunity for that, no, unless I’ve specifically invited you, in which case you are probably the dentist come to deal with that lost filling. But thank you to everyone who’s asked :)

Can I come and visit you after you leave hospital?

That depends on how much of me they’re able to scrape off the floor once it’s all finished, but I don’t expect to be visitable for weeks if not months if not a limited lifetime afterwards.

Can I come and visit you in hospital?

Well… no. I would like it, but it’s very unlikely I’ll be able to. Obviously if you are Cate Blanchett or look like her and you’re in town that day, like from Manchester or something, I’ll be delighted to have you visit Even If It Kills Me.

When, where and for how long are you going?

The NHNN – National Hospital for Neurology and Neurosurgery, Queen Square. Provisional plan is an overnight admission during the last week of March (2014).

Is there anything I can do to help?

In general:
image If I think of anything else I’ll put it in a separate Wanted post so I can highlight it properly on the Facebook share :)

What tests will you be having?

EEG, ECG, nerve conduction studies, and “possibly” an MRI. I don’t know what that possibly depends on; it’s the one I’d most like to see.

Will you keep your fascinated public updated from the hospital?

Probably I will because I’m fidgety and compulsive, but PLEASE don’t write back anything that invites a response from me.

What do you think is wrong with you?

Well, I hope it’s not mitochondrial, because that seems intractable and not especially reversible.

The best (by which I mean the most elegant and convincing) of the brain-type theories I’ve seen is Ashok Gupta’s, which you can find at

https://www.youtube.com/watch?v=SEtyMHbf08U&feature=youtube_gdata_player (video)
and

http://www.guptaprogramme.com/causes-of-me/ (academicish paper)

This kind of cognitive and behavioural approach is, I think, about uncoupling your experience of your symptoms from your reaction to your symptoms – not only your emotional reactions of fear, despair, frustration and so on, but also the urge to interpret, decipher, or reform. It’s not construing your symptoms in any way, while at the same time not suppressing or denying them. It’s the Buddhist attitude of non-attachment and acceptance, really. I can write more about this IAIAICBA (see Glossary).

Will you take a bear?

I’m planning on taking Grey Eeyore, because I enjoy reassuring him, or trying to. I have a thing for downbeat animals. His tail is securely attached and won’t be misappropriated as a bell pull or nurse-calling alarm or something. (Do hospitals have stuff like that?)
IMG_20140213_183412

Will you take a beer?

No.

Glossary of Abbreviations except actually they are acronyms

BD/AD – Before Dentist/After Dentist (don’t get me started on this)

CFS – Chronic Fatigue Syndrome. This term is often used interchangeably with ME. A lot of people have a problem with it because it trivialises what is in fact a disabling symptom –“the equivalent of trivialising dementia by calling it a chronic forgetfulness syndrome” – and, just as perniciously, it generalises it, so that anyone who’s ever been tired, i.e. everyone, can think that they know what the illness feels like and that it can’t possibly be that disabling and that you should be able to get over it just by, well, mainly by ignoring it. Sigh. There are about half a dozen sets of definitions of CFS (seriously), some of them so hopelessly vague as to require not much more than, just, feeling kind of, you know, out of sorts for a while.

IAIAIAWE – If Anyone’s Interested And I Am Well Enough

IAIAICBA – If Anyone’s Interested And I Can Be Arsed

ME – Myalgic Encephalomyelitis. I am grudgingly using this term to mean a serious neurological or neuro-immune illness that results in exertion intolerance, pretty-much-everything intolerance and a constellation of other symptoms. If I don’t have any particularly definitive description of it it’s because not enough research has been done to define it.

There is much strife and worry about what this illness should be called, and recently the American Institute Of Medicine has started calling it Systemic Exertion Intolerance Disease (SEID) . I thought this was a step in the right direction because it puts exertion intolerance front and centre, but other people I respect say the diagnostic criteria are still a bit askew. But don’t worry, they are planning to review it in five years…

Some people get very angry if you conflate ME with CFS, and after a decade or so of not bothering to find out why I looked it up: (this link) sets out the most popular arguments. There are also people who believe that ME always involves observable neurological damage (myalgia = muscle pain, encephalomyelitis = inflammation of the brain and spinal cord), and that CFS is entirely a bogus category entirely composed of atypical versions of other disorders and concocted by obliging doctors in order to aid medical insurance companies to avoid paying for chronic disease. But many of these people would also believe that my illness is not ME because its onset was gradual, so to me they sound like fanatics who can’t cope with subtlety.

My opinion is that there are probably some ME-type illnesses caused by brain damage and some caused by dysfunction, and some of this can be retuned or rewired and some of it can’t. We may have a situation where this isn’t a single illness so much as a category of illness a bit like mitochondrial disorders or muscular dystrophies. We won’t know until we study its biology more. But as you’re probably working out for yourself, this much strife about what to call the Judaean People’s Front an illness means the problem is not only how to define it but who gets to define it. The division is not in fact {patients} vs {doctors} but {doctors and patients who think that biology is relevant and should be studied} vs {doctors who avoid biomedical investigation because it only encourages people to think they’re ill}. Seriously.

NHNN – National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N. Where I will be going. Provisional plan is an overnight admission during the last week of March.

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RLHH – Royal London Homeopathic Hospital, between the famous Great Ormond Street children’s hospital and the National Hospital for Neurology and Neurosurgery (see map). The RLHH is my dad’s old hospital, now renamed…

…RLHIM – Royal London Hospital for Integrated Medicine. It isn’t really relevant to this blog except that I’ve spent a lot of time there and I love the area, which is one of the things that makes going to the NHNN less daunting. I suspect flavoured vodka might be another.

Finished packing and now considering possible outcomes of adventure

On Thursday I finished off my last bit of advance packing, although I do keep eating the snacks I plan to include, and except for a wheelchair and an eyelash comb I have everything I need to take.  My willingness to go depends on maintaining an attitude of unreality towards the event, and so far I’m cheerful – “I am looking forward to the whole enterprise, actually,” I told the neurologist, “sort of like how Meursault looked forward to the guillotine.” Before it becomes more real, and before my talk with the CFS which may alter my understanding, I will list for you my own view of the possible outcomes from worst to best. (Numbers in brackets are the estimated order of likelihood at the time of writing… which is February 2nd, Groundhog Day.)

1. No change (no deterioration and no useful information gleaned)  (2)

2. Severe deterioration and no useful information gleaned – this would at least prove my father wrong.  (I  think he thinks my that tiredness consists of lethargy/enervation/limpness and that I can do things if I really put my mind to them.  Not going to go into that now.)  (1)

3. Useful information gleaned but no effective treatment possible.  (4)

4. It would be only slightly less onerous if suggestive information were gleaned and led to unproven treatment ideas, because hope is a consumable, if renewable, resource, and I’ve been chasing these pissing shadows for over a decade now. (3)

5. Death (5 or 6)

6. Useful information gleaned leading to effective treatment and significant improvement (5 or 6)

7. Finding a benign but wonderfully culpable tumour, whipping it out, and rainbows shine and bunnies hop and the forest* all rejoices. (7)

We’ll see what my appointment with Dr.B does to these predictions. Or rather I’ll see, and if I have the energy I’ll type it out for you. (I’m following the Charlie Brooker school of audience engagement here.)

* In Cloud Cuckoo Land