CFS - Catastrophe theory: why we get into and how we get out of CFS
This page is a reproduction of Chapter 24 of Diagnosis and Treatment of Chronic Fatigue Syndrome and Myalgic Encephalitis
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Catastrophe theory and CFS/ME
By Craig Robinson
The above article 'Catastrophe theory and CFS/ME' cannot be re-published or copied for commercial purposes without specific permission of the author and the publisher.
Before we begin, apologies are due to any students, or indeed scholars, of Catastrophe theory, as the discussion here may well cause you to break out in a cold sweat and scream at the author for his cavalier approach to such a beautiful theory! My only defence is that age-old one of pragmatism before idealism.
The idea that Catastrophe theory might be linked to, or perhaps a convenient and accessible way of modelling, the recovery process from CFS/ME arose during one long weekend when Dr Myhill was encouraging me to inject as much magnesium as possible in as short a time as possible. This was not pure sadism on her part but rather the result of clinical observations she had made over the years that some CFS/ME sufferers demonstrated recovery patterns and behaviour that were ‘sudden’ or at least certainly ‘not linear’. There appeared to be a ‘tipping point’ beyond which the recovery was kick started into action.
The purpose of this final chapter is to give you, the reader, an overview of how this ‘sudden’ or ‘not linear’ recovery behaviour can be modelled. It is hoped that this overview will allow a greater understanding of this kind of recovery behaviour and that in so doing, it is further hoped that those who are on the recovery path will better understand what is likely to speed up this process, and likewise what actions will most likely set them back. Moreover, it is anticipated that those who are struggling to begin their recovery process may both be encouraged and also possibly gain insights into the blockages they are experiencing to beginning on such a path to recovery.
This brief summary is not an attempt to make direct linkages between the biological processes and Catastrophe theory as explained below. However, one could easily imagine such a scenario, for example, with regard to the workings of a single mitochondrion. If, having tested a CFS/ME sufferer – using, for example, the mitochondrial function profile test – the efficiency with which ATP is made from ADP is determined to be abnormal, then this could be indicative of a deficiency of magnesium. It may be that such a patient’s system, having been stressed into a CFSME state, now requires a certain minimum level of magnesium to be present in order properly to ‘start’ the conversion process from ADP to ATP. This minimum level would be the ‘tipping point’ as mentioned above.
This is, of course, a much simplified example, designed only to demonstrate the basic point rather than give the complete picture, which is, as readers will know, much more complicated and indeed unique to each CFS/ME sufferer.
Catastrophe theory is a new branch of mathematics which was developed initially by the French mathematician René Thom in the 1960s, and became very popular due to the efforts of Christopher Zeeman in the 1970s.
Mathematics, as applied to real world situations, had, not exclusively but largely, concerned itself up to this point with applications that were taken to be ‘continuous’. An example of such ‘continuous’ behaviour is the acceleration of a car. When the accelerator pedal is applied, depending on the coefficient of friction between the tyre and the ground and any other forces applied to the car, such as ‘drag’, one can calculate the manner in which the velocity of the car will increase. However, we all know ‘how’ cars accelerate in subjective terms. We don’t need some mathematician to calculate a rather complicated equation to show the exact velocity at any given time. What we know, from our own experience, is that cars accelerate, say, from 40 mph to 60 mph in a ‘continuous’ fashion. It is never the case that the car is travelling at 40 mph and then the very next instant, it is travelling at 60 mph (although it sometimes feels like this when my wife is driving!). No, the car gradually accelerates from 40 mph to 60 mph in a fairly ‘uniform’ or ‘continuous’ manner.
This is all well and fine, but this kind of ‘continuous’ modelling fails to address very many real-life situations that mathematicians wanted to understand. For example, the apple that perhaps fell on Sir Isaac Newton’s head and enlightened him as to the nature of gravity, did so suddenly. Said apple did not gradually detach itself from the tree but rather all of a sudden it just fell. This type of behaviour is described as ‘catastrophic’ in that something (here an apple) changes from one state of being (hanging attached to the tree) to another state of being (falling not attached to the tree) in an instant. There is no gradual change of state, as there was with the car and its velocity, but rather things happen suddenly after a ‘tipping point’ has been reached.
There are many examples of this type of behaviour, not only in the physical world (icebergs suddenly breaking off ice sheets is another obvious one) but also in the behavioural, psychological and relationship social sciences. Perhaps the most famous is the ‘cornered’ animal. Put simply, say a dog is cornered, and a perceived threat is gradually approaching the dog. Initially the dog will display passive behaviour, or the ‘fear response’. It will stay exactly where it is and hope that the perceived threat will not materialise. However, if the perceived threat continues to advance on the dog, there will come a distance (the ‘tipping point’) where the behaviour of the dog ‘flips’ suddenly from passive (‘fear response’) to aggressive (‘fight response’), and the dog will suddenly charge its perceived threat. Here the ‘tipping point’ is measured simply by way of the distance between the dog and the perceived threat. In more complicated examples, it is considerably harder to determine how to measure the ‘tipping point’.
So, what has all of this got to do with CFS/ME?
A catastrophe theory model: CFS/ME and the treatment protocol
As a vast simplification, imagine that a person is in either one of two states – they either have CFS/ME or they do not have CFS/ME. We all know that this condition is a very wide spectrum and this fact will also be reflected in the theory below, once fully explained. Imagine also that we can describe the required ideal treatment protocol for an individual sufferer. Then we can imagine a situation as described in the graph (Figure 17)
So, to describe the behaviour, we must first understand the graph. The axis going up the page (the ‘y’ axis if you can remember that far back!) represents increasing levels of fatigue; I have used ‘fatigue’ as shorthand for intensity of symptoms. The axis going along the page (the ‘x’ axis) represents the level of compliance with the ideal treatment protocol for this individual
It will be realised that the ideal treatment protocol for an individual patient will not actually be known! It may never be known. However, the results of various medical tests, clinical signs and symptoms, a detailed history and, perhaps most importantly, a careful recording of the patient’s reactions to various treatments, will all provide clues as to what constitutes such an ideal protocol. As such, the patient and physician will gradually move together towards the required ideal protocol by means of such methods, and also via a certain amount of trial and error,
serendipity and dogged perseverance!
So we return to the graph: for example, at point X (top left of the graph) this patient has high levels of fatigue (indeed, is in a severe CFS/ME state) and has not put in place any elements of the ideal treatment protocol. Meanwhile, at point Y (bottom right of the graph), this patient is in a non-CFS/ME state, having relatively low levels of fatigue and has put in place much of the ideal treatment protocol. However, the interesting point of this graph is how the patient ‘gets’ from X to Y and also how s/he might slip back again from Y to X.
Getting from X to Y – Recovery
Hint – imagine you are starting from point X on the upper part of the curve and then, in your mind’s eye, move gradually to the right along this upper curve. Then follow the guide as explained in the paragraph below. Kinaesthetic learners may prefer to trace the curve with their index finger along the page, starting at point X and gradually moving to the right.
The ‘good’ patient, starting at point X on the upper curve, moves along the upper curve to the right, gradually increasing his (for the sake of linguistic simplicity) level of compliance with the ideal treatment protocol and in so doing does see some reduction in levels of fatigue as the upper curve comes down the page a little. This patient may feel a little despondent as he thinks to himself, ‘For the effort I am putting in here (no chips, injections in the stomach every other morning), I really am not seeing that much of an improvement!’. But his physician is a good one and continues to encourage and cajole him until finally the patient arrives at point A on the upper curve. At this point the patient suddenly ‘falls’ into a non-CFS state and arrives at point A' on the lower curve. Immediately he rings up his physician in triumph!
The patient now has renewed vigour and belief in the treatment package and continues to comply more and more with the ideal protocol, moving himself further to the right of the lower curve, and eventually reaches point Y, where he wants to be.
Getting from Y to X – Relapse
Hint – likewise, imagine you are starting from point Y on the lower part of curve and then move gradually to the left along this lower curve. Once again, kinaesthetic learners can trace this movement with their index finger.
The patient is now at point Y on the lower curve and after a while feels that he has recovered and so begins to lapse on the ideal treatment protocol. This slides him to the left of Y and towards, initially A’ on the lower curve. This is no problem because he is still in a non-CFS/ME state. So, the patient thinks to himself, ‘I must be cured because I am now doing less of this treatment protocol and yet I still feel well – bring on the chips!’ The patient is now somewhere between A’ and B on the lower portion of the curve and so is still in a non-CFS/ME state. He continues to do less and less of the protocol until he reaches point B on the lower portion of the curve. At this point, he suddenly falls ‘up’ to point B’ on the
upper curve and reverts to a CFS/ME state. He is despondent now and regrets his decisions to lapse on the protocol. Note also that for this patient to revert to a non-CFS/ME state, he has to work hard to get back to point A; he can’t just do a ‘bit’ of the protocol to revert to a non-CFS/ME state, but rather has to move from his newstate B’ back to A.
Implications for management and treatment
The implications are clear and can be stated as below:
- It is important to recognise that we have symptoms for very good reasons – it is so that the body can protect itself from itself. Without the symptoms of pain and fatigue we would ‘use’ our bodies to destruction. In essence, the body can put up with only so much stress, which could be physical, mental, emotional, infectious, nutritional or whatever, but then, and suddenly, the cumulative effects of those stressors become critical and the system has to shut down into protection/hibernation mode. This results in the clinical picture of CFS/ME (if fatigue is the main factor) or fibromyalgia (if pain is the main factor) and often both. Remember that stress is the symptom we experience when we do not have the energy reserves to cope with demands. This ‘deficit’ of energy reserves can be masked in the short term by the release of stress hormones, but this kind of masking is not sustainable in the long term.
- Complying with the individualised treatment protocol will yield results in the form of decreasing levels of fatigue and this will be sustained but perhaps not very marked initially.
- At a certain point of compliance with the treatment protocol, the patient arrives at a ‘tipping point’ and will suddenly move from a CFS/ME state to a non-CFS/ME state – this is the drop from A to A’ on the graph.
- After arriving at a non-CFS/ME state, the patient can see further improvements in his/her health by continuing to comply with the protocol and will eventually arrive at a very comfortable state – point Y on the graph.
- If the patient lapses on the protocol then s/he can ‘get away’ with this for quite some time. In fact, s/he can stay in a non-CFS/ME state with less compliance to the treatment protocol than it originally took to ‘flip’ him/her out of the CFS/ME state – that is, point B is to the left (and therefore less protocol compliant) than point A.
- However, eventually, continuing reductions in compliance with the protocol will bring the patient to point B and s/he will ‘flip’ back into a CFS/ME state. This is the ‘flip’ from B to B’. Having reached point B’, the patient will then require renewed vigour in protocol compliance in order to get to the point (that is, point A) where s/he will ‘flip’ back into a non-CFS/ME state.
- We should all be putting in place the measures to improve health, and to stay well clear of the tipping point B so as not to risk the devastating ‘flip’ into CFS/ME.
This kind of ‘flipping’ (both ways – from CFS/ME to non-CFS/ME and non-CFS/ME to CFS/ME) is something which Dr Myhill has observed on many occasions and the lessons are really quite simple:
- Persevere – If you are complying with the protocol you are moving towards the right on the upper part of the curve, even if it doesn’t feel like it at first. Any movement along the upper curve to the right gets you closer to the sought-after ‘tipping point’ (point A).
- Do not backtrack on the protocol if you start to feel better. This will either move you further to the left of point A on the upper part of the curve, thus getting you further away from ‘flipping’ into a non CFS/ME state, or may even ‘flip’ you back into a CFS/ME state from a non-CFS/ME state if you are on the lower part of the curve.
- Kick-starting the system – But what of the rationale for trying megadoses of magnesium, or other micronutrients? Going for large doses, or ‘flooding’ the system, with particular micronutrients can sometimes give results totally out of proportion to what you might expect – if this (or these) micronutrient(s) is (are) key to ‘flipping’ you from the CFS/ME state part of the curve to the non-CFS/ME state part of the curve, then that may be all you need to push you to point A and thus ‘flip’ you into a non-CFS/ME state. This was the rationale behind my taking large doses of magnesium over that long weekend. Further to this point, it seems that the large doses of whatever micronutrient(s) are causing the blockage, which push the patient over point A on the curve to point A’ then also ‘self-correct’ the system so that the system becomes self-perpetuating. In this way you don’t need to continue with such large doses of said micronutrient(s) for evermore. This is because the biological systems at work here have interlocking feedback systems. So that if I were ‘short’ on magnesium, then by flooding my system with surplus amounts of it, this blockage is overcome and the system then starts to work as it is supposed to, with micronutrients being recycled and all the other elements of the various cycles in the process ‘kick-started’. In this way, one can sometimes ‘short-circuit’ the long-drawn-out process of protocol implementation and compliance and get to the non-CFS/ME state much more quickly, simply by finding the micronutrient which is causing the blockage and then flooding the patient’s system with this micronutrient. Once again, this kind of ‘short-circuiting’ and getting to a non-CFS/ME state more quickly by ‘kick-starting’ the system using a particular micronutrient is something that Dr Myhill has seen in her CFS/ME patients.
Finally, and this is difficult to represent fully here, but Dr Myhill’s experience is that if a patient has had CFS/ME for a longer period of time, then his/her recovery path differs from those who have suffered for less time. The curve as described will still be valid, but it will be shifted so that it is harder to reach point A and thus flip into a non-CFS/ME state, and likewise it will be easier to slip back to point B and ‘flip’ back into a CFS/ME state. So, CFS/ME sufferers of longer standing have to work harder to get into a non-CFS/ME state and also have to work harder to stay in that newly acquired non-CFS/ME state. Their curve may look more like the one shown in Figure 18. Point A (tipping from CFS/ME to non-CFS/ME) is further to the right and so requires more work to get there, and point B (tipping from non-CFS/ME to CFS/ME) is also further to the right, making it easier to flip back to the CFS/ME state with only minimal lapsing on the protocol. The interval between B and A’, in any case, can be referred to as the ‘danger zone’
‘Ex-CFS/ME sufferers’ who find themselves in this danger zone, and are thus in a non-CFS/ME state, must not be complacent and must do all they can to move to the right of the lower part of the curve so as to get away from the dreaded tipping point B which flips them back into a CFS/ME state. One could go further with the graphical representation of this model and have a time axis perpendicular to the page and then, by plotting the various curves for CFS/ME sufferers at certain ‘illness time lengths’, one could obtain a 3-D representation of the illness curve over time as well as with respect to protocol compliance. It is not necessary to understand this finer point, but for those who may (still!) be interested the 3-D curve, it might look something like Figure 19.
It will be recognised that this is only a model and its real intention is to give sufferers a guide as to what they might expect, a warning as to what may happen if they lapse on the protocol and an insight into why large doses of certain micronutrients may help them out of their CFS/ME state.
Addendum - refinements
Having described the basic ideas of how catastrophe theory can be utilised as a tool to help patients understand their illness, there are three ‘refinements’ to this basic model which can now be made.
Refinement one - delayed 'flips'
It will be seen that at point A on the upper part of the curve in
Figures 17 and 18, a patient will have the same degree of protocol
compliance as a patient at point A’ on the lower part of the curve.
In effect the same degree of protocol compliance can result in two
different patients being in two completely different states – A is a
CFS/ME state and A’ is a non-CFS/ME state. The question has to be asked
as to why some patients remain ‘hovering’ at point A whereas
other patients ‘flip’ to point A’ and reach a non-CFS/ME state. To understand this, we should first consider a different example, that
of the ‘phantom limb’. The brain has an internal map of the body
and also of what is going on in the body, and this internal map
may not always reflect reality. So, a limbless person may still feel
as though s/he has a (painful) limb because of this ‘incorrect’
internal body map that his/her brain is still relying on. In effect,
the brain has not ‘updated’ its internal map of the body in the
light of new information In a similar way, it is possible that the immune system has
such an internal map of what is going on within itself and this
map will reflect the situation as it has subsisted for some time,
rather than the situation as it actually is now. So, just as the brain
’registers’ a limb, or limb pain, because that is the situation which
has subsisted for some time, even though this is no longer the
reality, so does the immune system ‘register’ CFS/ME because that is
the situation that has subsisted for some time, even though the
reality is now that the patient is in a non-CFS/ME state.
This is not to say that the patient is unable to make the ’flip’ from a
CFS/ME state to a non-CFS/ME state as a result of some psychological block.
This is far from the truth. It is rather that patients may have to be on
the ‘cusp’ of ’flipping’ from a CFS/ME state to a non-CFS/ME state for some
time before the immune system recognises this fact and registers that
this is the ‘new’ reality. It is possible that the physician can aid this
process of recognition by re-assurance and test results and so on.
Once again, this ‘delayed flip’ from a CFS/ME state to a non-CFS/ME
state is something that Dr Myhill has witnessed in her clinical
practice. Indeed, this may be the mechanism by which certain
psychological techniques are effective. Moreover, if this is the
case it is doubly important to address the underlying physical
problems first – Dr Myhill suggests this because there are cases
where such psychological techniques have made the patient
much worse. This would occur if the psychological techniques
were applied at a time when the body did not have the physical
reserves to respond to such.
Refinement two - negative events
Just as positive interventions (such as magnesium therapy) can
‘flip’ a patient from a CFS/ME state into a non-CFS/ME state, the opposite is also the case. So, it is possible that a ‘bad event’ can suddenly ‘flip’ a patient back into a CFS/ME state without that patient
‘doing anything’ or changing the protocol that s/he is currently following. For example, a (possibly ex-) CFS/ME sufferer who has
good protocol compliance and has reached a fairly comfortable
non-CFS/ME state but then is suddenly exposed to organophosphate
pesticides, say, may be pushed back to a CFS/ME state. This gives a
painful symmetry to the theory in that patients can be flipped
back into CFS/ME states not only by reducing their protocol compliance but also by such random unavoidable negative events.
In addition, and crucially, this point reinforces the message that
CFS/ME patients must be careful not only to stick to their individual
protocols as closely as possible but also to avoid potentially ‘bad
tipping factors’, such as viruses, exposures to toxins and so on.
For ease of reference, these ‘bad tipping events’ can be referred
to as ‘negative events’. Sadly, Dr Myhill has treated patients
such as this, where good recovery has been made and then some
negative event, not related to patient protocol compliance, has
pushed the patient back into a CFS/ME state. It is important at this
stage not to lose hope but rather to see this as a ‘set back’. The
physician and patient will now have to work together to develop
a new ‘ideal protocol’ which takes into account and addresses
the new stresses that have been placed on the patient’s system by
this negative event. Once again, the patient will progress along
the curve as s/he did before, with the newly devised protocol
having been fully put in place.
Refinement three - stepped recovery
The discourse above has so far only admitted the possibility of
one ‘flip’, simply from a CFS/ME state to a non-CFS/ME state. This is
something that Dr Myhill does experience in practice. However,
as was noted at the beginning of chapter 8, to divide patients into
two distinct sets, those who are in a CFS/ME state and those who are
in a non-CFS/ME state, is simplistic. More often, Dr Myhill discusses
with patients the probability of experiencing ‘quantum leap’
improvements in their condition and that these ‘quantum leaps’ will most likely be many and will also be varied in their impact
on symptom intensity. So, one could envisage a refinement to the
generalised graph, as shown below, whereby, there are gradual
‘stepped’ reductions in fatigue levels as the patient progresses
eventually to a non-CFS/ME state. Each of these ‘steps’ should be
regarded as very positive by both physician and patient because
such a ‘step’ represents an indication that the protocol has resulted in one of these ‘mini-flips’. In effect this is evidence that the
patient is addressing some of the stresses on the system which
are causing his/her symptom load. Nevertheless, the trick is not
to sit back, once such a ‘mini-flip’ has been secured, but rather
to look for the next intervention, whilst keeping all the current
protocols and interventions in place, which will result in the next
‘mini-flip’, and to continue to do so until the patient finally arrives at a non-CFS/ME state.
- Overview of CFS/ME Treatment protool<
- Diagnosis and Treatment of Chronic Fatigue Syndrome and Myalgic Encephalitis
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