by Alan Gurwitt, M.D.
The Massachusetts CFIDS/ME & FM Association Winter 2002 UPDATE
Every so often there is an upsurge of debate about the place of psychological problems in regards to Chronic Fatigue Syndrome (CFS), Fibromyalgia (FM), and Myalgic Encephalopathy (ME). As a psychiatrist who has been seeing patients with these illnesses since 1986, as well as following the literature closely, I have often been embarrassed by and angry at many of my colleagues who fall in line with self-declared "experts" who see somatization everywhere. Ever since the mid-1980's there have been "researchers", with an uncanny knack at cornering research funds because of their already-formed biases that are in synch with the biases of the funding government organizations, who declare CFS, FM, ME to have a psychological basis or, more recently and insidiously, avoiding specificity about etiology, indicate that Cognitive Behavioral Therapy (CBT) and graded exercise will do the therapeutic job, thus in part implying a major psychological causative factor.
I have noticed the following deficits in their work, their thinking, their word choices—or should I say—choice of terms, and their research methods:
1. They often fail to clearly distinguish between "chronic fatigue" and "chronic fatigue syndrome." The former is a common symptom in medical clinics that does have a high linkage to already-present psychological problems. The latter, as we know, is a fairly specific medical condition with an unfortunate name. Their sloppiness has led to all kinds of trouble and misunderstanding.
2. They fail to distinguish between pre-illness psychological functioning and post-onset occurrence of psychiatric symptoms, which are both organic and understandably reactive in origin. This error would disappear if they did thorough psychiatric evaluations which included a careful review of past history and current functioning, i.e., where they really got to know their patients. Even medical students are taught how to do this. Their failure to do proper in-depth psychiatric evaluations in at least some of their studies is a serious error with drastic implications.
3. Their studies make use of flawed, inappropriate, and superficial tests of psychological state which then lead to flawed, inappropriate, and superficial conclusions. Leonard Jason has discussed this problem in detail. Their use of large numbers of study subjects and sophisticated statistics give the impression that they are really scientific; in my view it is pseudo-science.
4. They often fail to include, or to be unaware of, the mounting medical-neurological-immunological evidence demonstrating the medical nature of CFS/FM/ME.
5. They demonstrate instead a morbid preoccupation with psychiatric morbidity. There are moderate and sometimes severe psychiatric conditions following onset which as physicians and psychiatrists we need to be aware of, but there is no definitive and convincing evidence that I am aware of indicating psychological causation.
Dr. Gurwitt is a member of the Board of Directors of the Massachusetts CFIDS/ME & FM Association.
Thirteen years have passed since I wrote this. While much has happened in the interim, some of it good (scientific progress) and some of it bad (a brick wall of ignorance), the situation with the medical schools, residency programs, medical journals, and the average practicing physician has not changed much at all. The myth of psychological causation of ME/CFS is still very much present and the eyes and ears and minds of so many healthcare professionals remain closed despite the availability for over two years of a Primer (and other publications around the world) about the nature, diagnosis and managementof this terrible disease. Children and adolescents are still locked up in psychiatric units for some trumped up somatization disorder. Adults go misdiagnosed, mistreated, and dismissed. In the United States, most disappointing of all has been the near total failure of NIH to wake up and see to it that adequate funding, like at least 100 million dollars a year, goes towards basic and advanced research.
Recent stirrings at NIH such as the Pathways to Prevention (P2P) project, which confirmed the biological nature and gross underfunding of research for ME/CFS, will go nowhere unless top officials, Congress, medical leaders, and the media become significantly involved. The expected report on ME/CFS from the Institute of Medicine (IOM), to be released on February 10th 2015 may also be helpful. However I believe that two steps are necessary.
- Patients, advocates, various ME/CFS organizations and the scientific communities must finally unite to form a national organization to focus on advocacy, to be a reliable source of information, and to assist local and regional groups.
- There needs to be a carefully planned and comprehensive effort by this national organization to lobby Congress to see to it that all federal health agencies actually do what has been missing for thirty years.
We have a lot of eyes, ears, and minds to open instead of morbidly focusing on psychological causation. We must find ways to get it done.
Alan Gurwitt, M.D., Feb. 15, 2015