Help with Advocating - responding to claims that ME is a psychological illness

Tara Green

Tara Green

Senior Member (Voting Rights)
Can someone help remind me please. If a comment like this was made to me: "According to the DSM-5 it [ME] is a psychological illness, that’s why it is categorised as such".

How is this addressed?

Found some ME discrimination in a newly written teaching Law module.
 
Tara Green said:
Can someone help remind me please. If a comment like this was made to me: "According to the DSM-5 it [ME] is a psychological illness, that’s why it is categorised as such".

How is this addressed?

Found some ME discrimination in a newly written teaching Law module.
Click to expand...
It isn't in DSM 5 ! At least not in the recently published DSM -5 TR - list of codes here: DSM-5 Diagnostic Codes

Edit for clarity
 
CRG said:
It isn't in DSM 5 ! At least not in the recently published DSM -5 TR - list of codes here: DSM-5 Diagnostic Codes

Edit for clarity
Click to expand...

I've been searching everywhere, that explains it! Thanks! These are Law students thinking this so will do my best to explain this to them. For added info my husband has outlined the issue he has come across:

"I'm currently studying for a Law Degree with the Open University.

UNIT 8 of Module W112 deals with the legal concept of 'pure psychological harm'. This is distinct from 'consequential psychological harm' where psychological harm results from an accident involving actual physical injury. In cases of 'pure psychological harm' there is involvement in an accident but there is no physical injury as a result. However, psychological harm can still occur as a result of the mental/emotional trauma involved.

In one of the fictional examples provided, "Aoife is in a car accident. The accident triggered a recurrence of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), despite not being physically injured in any way. The commentary then states: Aoife has suffered from pure psychiatric harm because she has not been physically injured. It is worth mentioning that the facts of Scenario 2 are like those in Page v Smith [1996] AC 155, which is a central case in pure psychiatric harm."
Page v Smith is an actual case reference from 1996 where a victim of an accident suffered from ME/CFS as a result. My understanding is that, at the time, ME/CFS was considered a psychological condition, and the issue being looked at in this case is whether the claimant was legally entitled to compensation for the 'pure psychological harm' of ME/CFS resulting from the accident in the absence of any physical injury.

I believe that ME/CFS is now accepted as a physical condition, but the Open University, in using this example, are implying that ME/CFS is still a psychological condition. This may not be entirely their fault - the courts rely on two sources to decide whether something is a recognised psychiatric illness:

  • the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013)
  • the International Statistical Classification of Mental and Behavioural Disorders (WHO, 2019).
If either, or both, of these sources have not yet been updated to reflect the physical nature of ME/CFS this is potentially going to affect a lot of people".
 
@Tara Green

It is concerning that Law students think that ME is classified in the DSM.

ME has never been classified in the DSM.

ME has never been classified in the Mental and Behavioral section of the WHO International Classification of Diseases (WHO ICD).


The International Statistical Classification of Mental and Behavioural Disorders (WHO, 2019) is the "Clinical Descriptions and Diagnostic Guidelines" - the expanded text version of ICD-10's Chapter V, intended for use by psychiatrists and clinicians. Also known as the "Blue Book".



Benign Myalgic Encephalomyelitis was first placed into the WHO International Classification of Diseases (WHO ICD), in the Physical Diseases section, in 1969 (WHO ICD 8), and then again in the Physical Diseases section in the 9th Edition (ICD9)


In the 10th Edition of the ICD Myalgic Encephalomyelitis and Chronic Fatigue Syndrome were both in the Physical Diseases section, Neurological Chapter (G), ICD10 G93.3.

The most recent version of the ICD is the 11th. Myalgic Encephalomyelitis and Chronic Fatigue Syndrome are currently in the WHO International Classification of Diseases, 11th edition (WHO ICD 11) under Diseases of the Nervous System, specifically under 08, Other Diseases of the Nervous System.

WHO ICD11
8E49 Post Viral Fatigue Syndrome
Inclusions: Myalgic Encephalomyelitis
Chronic fatigue Syndrome.


This diseases under 8E49 are not dual classified in the ICD11, so, PVFS, ME and CFS cannot be claimed to be a mental and behavioral disease under ICD11.


The WHO ICD are on record stating there is no intention of placing ME in the mental and behavioral section of the ICD.


.........................................................................................................



See
https://dxrevisionwatch.files.wordp...ion-of-pvfs-me-cfs-for-icd-11-august-2020.pdf

for more detailed information.
 
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I'm guessing young lawyers would like a clear line of argument as to why disease x may or may not be considered, or to previously have been considered, to be psychiatric, even if that view is contested or has been changed.

While it is true that neither ME nor CFS was ever listed in the ICD as psychiatric, the ICD is, unlike the DSM, not a diagnostic listing, this allows diagnostic freedom in the UK (English & Scottish Law) for medical authority to match ME and/or CFS to any ICD code that is deemed appropriate, which has led (and continues to do so) some psychiatrists to use the ICD code F48.8 = Neurasthenia, as classification of ME/CFS cases. It is important to recognise the use of the ICD numbering is a bureaucratic not a diagnostic designation.

Neurasthenia was at some point included in the DSM but seemingly absent after DSM 2. The conflation of Neurasthenia with ME/CFS has allowed the presentation of ME/CFS as psychiatric in legal contexts based on individual medical authority, but absent of any unchallenged publication.
 
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I think some types of physical injury such as miscarriage may fall within tort rules on psychiatric injury/nervous shock (for example, see Bourhill v Young [1943]). Page v Smith was considered on the basis of nervous shock leading to (psychiatric) illness/injury (not as direct physical harm caused by the collision), and the emphasis in general terms throughout the judgement was on psychiatric illness, but, for example, Lord Jauncey of Tullichettle defined nervous shock as follows:

The primary issue in this appeal is whether in a case of injury resulting solely from nervous shock a plaintiff must show that injury of such a type was foreseeable or whether it is sufficient to show that any personal injury was foreseeable. By nervous shock, I mean such an impact upon the mind or nervous system as is recognised by modern medical science as capable of causing physical or psychiatric illness. The ordinary emotions of anxiety, fear, grief or transient shock are not conditions for which the law gives compensation.
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Whereas Lord Keith of Kinkel defined it thus:

It is necessary at the outset to particularise what is meant by "nervous shock," such as may result in liability for damages. The decided cases indicate that it means a reaction to an immediate and horrifying impact, resulting in some recognisable psychiatric illness. There must be some serious mental disturbance outside the range of normal human experience, not merely the ordinary emotions of anxiety, grief or fear.
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https://www.bailii.org/cgi-bin/form.../1995/7.html&query=(Page)+AND+(v)+AND+(Smith)
 
Tara Green said:
I've been searching everywhere, that explains it! Thanks! These are Law students thinking this so will do my best to explain this to them. For added info my husband has outlined the issue he has come across:

"I'm currently studying for a Law Degree with the Open University.

UNIT 8 of Module W112 deals with the legal concept of 'pure psychological harm'. This is distinct from 'consequential psychological harm' where psychological harm results from an accident involving actual physical injury. In cases of 'pure psychological harm' there is involvement in an accident but there is no physical injury as a result. However, psychological harm can still occur as a result of the mental/emotional trauma involved.

In one of the fictional examples provided, "Aoife is in a car accident. The accident triggered a recurrence of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), despite not being physically injured in any way. The commentary then states: Aoife has suffered from pure psychiatric harm because she has not been physically injured. It is worth mentioning that the facts of Scenario 2 are like those in Page v Smith [1996] AC 155, which is a central case in pure psychiatric harm."
Page v Smith is an actual case reference from 1996 where a victim of an accident suffered from ME/CFS as a result. My understanding is that, at the time, ME/CFS was considered a psychological condition, and the issue being looked at in this case is whether the claimant was legally entitled to compensation for the 'pure psychological harm' of ME/CFS resulting from the accident in the absence of any physical injury.

I believe that ME/CFS is now accepted as a physical condition, but the Open University, in using this example, are implying that ME/CFS is still a psychological condition. This may not be entirely their fault - the courts rely on two sources to decide whether something is a recognised psychiatric illness:

  • the Diagnostic and Statistical Manual of Mental Disorders (APA, 2013)
  • the International Statistical Classification of Mental and Behavioural Disorders (WHO, 2019).
If either, or both, of these sources have not yet been updated to reflect the physical nature of ME/CFS this is potentially going to affect a lot of people".
Click to expand...


I have no background in law at all. But have just looked up the case summary here: https://www.lawteacher.net/cases/page-v-smith.php

It is interesting that it isn't until the latter paragraphs that psych words came in (so it feels like these were terms more to describe the 'mechanism' via which harm triggered the relapse).

When I read this through to the appeal House of Lords decision I wonder whether it is a 'law is an ass' or 'letter vs spirit' issue being rectified however, because they judged for the claimant in the end on the basis that 'if physical harm was foreseeable then harm in the form of a relapse of CFS was foreseeable'(I've summarised here). Which seems to sidestep the complicated way it had been 'put to' which I guess was down to 'routes under which' claims need to be made?

Given this was 1996 and more facts are known of CFS triggers then you may well be correct (if your lecturer is open to it/it's that kind of module) in noting these facts - and how these days a different 'route' might have been more appropriate anyway? I guess the way the judgement was worded (about the illness rather than 'psych aspect') you'd hope the precedence might however still be 'secure to such changes' ie if someone else had a similar car accident?

How old is the textbook (often these just update editions from original prints) - because what 'chapter' ie 'lesson' it is under would also be insightful e.g. are they using this as an example to test the 'psychological bit' hence the DSM stuff (which might have been used in the original case) or a 'chronic illness/CFS/ME specific' aspect?

What is the textbook and what is the date of the edition it is using (and original print as quite often revised versions just update bits quickly)?

Was it just fellow students being 'functionally fixed' in assuming the condition would be in the DSM because the harm caused is described as psych, or was the textbook citing this specifically?
 
Tara Green said:
Can someone help remind me please. If a comment like this was made to me: "According to the DSM-5 it [ME] is a psychological illness, that’s why it is categorised as such".

How is this addressed?

Found some ME discrimination in a newly written teaching Law module.
Click to expand...


Who made it? If a person you are able to respond with in this way, given it is a law class, then I'd demand that they show you it. At least that way they can prove what they are referring to and you can answer on that exact 'proof' directly.
 


https://dxrevisionwatch.com/icd-11-me-cfs/


'In a letter dated 16 October 2001, Dr B Saraceno, WHO HQ, Geneva, provided the following:

“I wish to clarify the situation regarding the classification of neurasthenia, fatigue syndrome, post viral fatigue syndrome and benign myalgic encephalomyelitis. Let me state clearly that the World Health Organisation (WHO) has not changed its position on these disorders since the publication of the International Classification of Diseases, 10th Edition in 1992 and versions of it during later years.

“Post viral fatigue syndrome remains under the diseases of the nervous system as G93.3. Benign myalgic encephalomyelitis is included within this category. Neurasthenia remains under mental and behavioural disorders as F48.0 and fatigue syndrome is included within this category. However, post viral fatigue syndrome is explicitly excluded from F48.0.


“The WHO ICD-10 Diagnostic and Management Guidelines for Mental Disorders in Primary Care, 1996, includes fatigue syndrome under neurasthenia (F48.0) but does not state or imply that conditions belonging to G93.3 should be included here.

“I would also like to state that the WHO’s position concerning this is reflected in its publications and electronic material, including websites. It is possible that one of the several WHO Collaborating Centres in the United Kingdom presented a view that is at variance with WHO’s position. Collaborating Centres are not obliged to seek approval from WHO for the material they publish. I understand that the Collaborating Centre concerned has now made changes to the information on their website after speaking with WHO.” Source: ME/CFS: TERMINOLOGY: M Williams, 27 April 2009

2] In a response dated 23 January 2004, Andre l’Hours, WHO HQ, Geneva, provided the following:

“This is to confirm that according to the taxonomic principles governing the Tenth Revision of the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD-10), it is not permitted for the same condition to be classified to more than one rubric as this would mean that the individual categories and subcategories were no longer mutually exclusive.”

(This confirmation related to a contemporaneous issue concerning the WHO Collaborating Centre, Institute of Psychiatry.)


3] In responses from early 2009, Dr Robert Jakob, WHO Classifications, Terminology and Standards reaffirmed that statements made in the past by Dr Saraceno and Mr l’Hours regarding coding and classification are still valid, adding that:

“there is no evidence that any change should be made to this in ICD-11”

“the same principles will apply to ICD-11”
 
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bobbler said:
Who made it? If a person you are able to respond with in this way, given it is a law class, then I'd demand that they show you it. At least that way they can prove what they are referring to and you can answer on that exact 'proof' directly.
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It was her tutor in a year 2 module, last year who told her this when she queried it. Chinese whispers stamped out with fact now.

Thank you, thank you everyone for your replies and insightful help and links. It reminds me just how much in depth, intelligent advocacy has been done over decades.

I will return after rest.
 
Initially, in 1969, the name the WHO ICD selected for ME was 'Benign Myalgic Encephalomyelitis'. At that time ME was not thought to ever be fatal. However, now the severity of ME is established and ME (or CFS) has been stated as cause of death by Coroners.

In 2019 the word 'Benign' was removed from the Myalgic Encephalomyelitis name in the ICD.



https://dxrevisionwatch.com/2020/02...c-encephalomyelitis-for-final-icd-10-release/

In January, the WHO released ICD-10 Version: 2019. With ICD-11 on the horizon, this release will be the final update for the WHO’s international version of ICD-10, apart from corrections and exceptional additions.

In March 2016, a representative from the Canadian Institute for Health Information submitted a request and supporting rationale to the ICD-10 Update and Revision Committee (URC) for removal of the prefix “Benign” from “Benign myalgic encephalomyelitis”.

This request for a change was approved by the URC in September 2016 for implementation in the next release.

For ICD-10 Version: 2019, the G93.3 Tabular List inclusion term is now Myalgic encephalomyelitis.

(The term, “Benign myalgic encephalomyelitis” has been retained as an Index term.)
 
It's frankly hard to understand how that's even an argument. The DSM is wildly known as inaccurate, psychiatric diagnoses are essentially the least reliable thing that exists in all of medicine, they are based on superficial behavior and hefty doses of imagination. It used to contain all sorts of ridiculous nonsense, and still does.

It's hard to believe it has any credibility in a court setting, as if the mere presence of a vague description in this book makes something a fact. In fact, it has so little credibility, that people genuinely don't care what's in it, simply imagining that a condition must be there is, somehow, an argument when it comes to the DSM.

All it serves is to discredit someone's testimony, which is a perversion of justice. An attorney can win a case this way if they leave their ethics behind, but to teach this? Absurd.
 
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Sarah said:
I think some types of physical injury such as miscarriage may fall within tort rules on psychiatric injury/nervous shock (for example, see Bourhill v Young [1943]). Page v Smith was considered on the basis of nervous shock leading to (psychiatric) illness/injury (not as direct physical harm caused by the collision), and the emphasis in general terms throughout the judgement was on psychiatric illness, but, for example, Lord Jauncey of Tullichettle defined nervous shock as follows:



Whereas Lord Keith of Kinkel defined it thus:



https://www.bailii.org/cgi-bin/form.../1995/7.html&query=(Page)+AND+(v)+AND+(Smith)
Click to expand...

Thanks Sarah. This is what has happened I think. In my simple understanding, an injury is put into two categories Physical injury which can only occur at the time of the accident and psychiatric harm which is brought about by stress/shock and can lead to physical injury but it is still classed under psychiatric harm such as heart attack, miscarriage, ME relapse.

Although it's not as bad as first thought, it might be better to have a footnote or use a different example as it does seem to be leading students astray and it was a tutor last year who told the student that ME was classified under DSM-5 so maybe tutors are confused too. Husband will bring it up with the student law team to look at. All links have been helpful.
 
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