Internal medicine at the crossroads of long COVID diagnosis and management, 2025, Ranque and Cogan

[SNT Gatchaman]

Internal medicine at the crossroads of long COVID diagnosis and management
Ranque, Brigitte; Cogan, Elie

The lack of specificity in its definition is a major obstacle to both explanatory and therapeutic research in long COVID. It brings together, on the one hand, patients with severe COVID-19 who suffer the classic complications of prolonged hospitalization and decompensation of comorbidities and, on the other hand, patients with non-severe acute COVID-19 who report multiple symptoms that cannot be fully explained by a biomechanical model. Indeed, despite numerous studies, it remains unclear how persistent viral infection, immunological or coagulation disturbances may contribute mechanistically to long COVID.

Nevertheless, internal medicine should be in good place to manage these patients. Indeed, the diversity of symptoms may evoke a broad spectrum of differential diagnoses that are familiar to internists. Their experience in the exploration of unexplained symptoms is also valuable. It can reduce the need for multiple consultations with specialists and unnecessary laboratory or imaging tests. However, long COVID diagnosis cannot be limited to the exclusion of all other conditions one by one.

An open and non-dualistic approach is required to identify other mechanisms that may explain the symptoms. Based on their clinical experience, most French internists who responded to an opinion survey consider that long COVID corresponds most closely to a functional somatic disorder (FSD) and seek the help of specialists in mental health care to assist in the management of the patients in a multi-disciplinary approach. However, as with other FSDs, patients with long COVID are usually reluctant to be managed by mental health care specialists, given the very physical nature of their presentation. Unfortunately, most physicians are in turn reluctant to take care of them, due to poor knowledge about FSD, leading to management failure. Alternatively, a comprehensive multidisciplinary care orchestrated by an experienced internist is generally well-accepted. It includes providing rational cognitive explanations for the symptoms and support for behavioral changes tailored to the patient.

While waiting for hypothetical randomized controlled trials assessing drugs with positive results, such a holistic approach has been successfully applied in many individuals with severe long COVID. However, its generalization would require a much broader training for FSD of all health care providers.

Link | PDF (Frontiers in Medicine) [Open Access]

 

[SNT Gatchaman]

Following the section "A critical approach to the literature" is the section "Arguments for a functional disorder" —

unlike patients suffering from these biologically explained diseases, patients with long COVID do not present objective clinical signs that would allow their diagnosis. Most symptoms are either subjective or compatible with a dysfunction of the autonomic nervous system (hyperventilation, postural orthostatic tachycardia syndrome…), but without criteria of severe dysautonomia. Furthermore, in patients without history of severe acute COVID-19, there is no abnormal biological or imaging findings or they cannot entirely explain the symptoms

For other symptoms than anosmia and dysgeusia, the only abnormal results that are frequently observed are hypometabolisms of right medial temporal lobes (hippocampus and amygdala), right thalamus brainstem and cerebellum at brain PET scans, whose interpretation is controversial. Indeed, there is no established correlation with the type and intensity of symptoms and the cause of the observed anomalies could be organic or functional.

The clinical picture of long COVID, on the other hand, has strong semiological similarities with other biomedically unexplained conditions that have different presumed causes (like chronic Lyme disease, hypersensitivity to electromagnetic waves or chemicals, etc.) or are defined by a main symptom (fatigue for myalgic encephalomyelitis/chronic fatigue syndrome, pain for fibromyalgia, etc.). It is commonly, though not unanimously accepted, that these entities are part of the broader group of “functional somatic disorders” (FSD). FSD are usually defined as patterns of persistent bodily complaints for which adequate examination does not reveal sufficiently explanatory structural abnormality or other specified pathology, with severe impact on functioning and quality of life.

FSD vary in names based on the predominant symptoms and the medical specialty involved (e.g., irritable bowel syndrome in gastroenterology, hyperventilation syndrome in pneumology, fibromyalgia in rheumatology, chronic fatigue syndrome in internal medicine….). They represent the medical side of the psychiatric nosologic category “somatic symptom disorder” in DSM V. Importantly, FSD is often triggered by a somatic illness (in particular an infectious disease) but also involves brain conditioning along with socio-psychological predisposing factors (perfectionism, alexithymia, childhood traumatic experience…).

Most importantly the long term persistence of symptoms is favored by cognitive (involuntary attentional focusing on symptoms, catastrophism, illness-related anxiety, feeling of rejection…) and behavioral factors, including avoidance of physical effort that leads to physical deconditioning as well as avoidance of uncertainty that leads to never-ending request for medical tests and consultations. These conditions can be associated to varying degrees in the same person, suggesting shared transdiagnostic mechanisms, Thus, the term “bodily distress syndrome” (International Classification of Diseases 11), has been suggested as a more neutral term to cover them all (53). Strikingly, bodily distress syndrome shares all its symptoms with those that are most common in long COVID (see Table 1).

A significant number of symptoms observed in patients with long COVID are also similar to those found in people suffering from post-traumatic stress disorder (PTSD). In particular, experiencing neurocognitive symptoms, such as difficulties with memory and thinking, after mild COVID-19 infection was strongly associated with the presence of persistent PTSD-like symptoms. The occurrence of PTSD is common in the context of infectious epidemics

A final argument in favor of the FSD hypothesis is that to date, only cognitive behavioral therapy and gradual physical activity have proven effective in treating long COVID (34).

[34] is of course Interventions for the management of long covid post-covid condition: living systematic review (2024, BMJ)

 

[Turtle]

In my 34 years of ME/CFS the internal medicine doctors were the most unwilling ones to do any testing at all.
The last one only offered one hematocrit test.
The first one only willing to pay attention to my thyroid. The other symptoms were dismissed.
I stopped seeing that one and it could have killed me. Near toxic levels of hyper.
They've tried everything to boycot finding anything wrong; first in ME/CFS, now in LC.
CBT an GET proven effective according to the writers of this paper shows how little knowledge they have.
They've not read about NICE guidelines obviously.

 

[Trish]

Ugh, so they don't know what's wrong so it must be psychosomatic, but they can't send us to psychs because we don't like it, so they will provide us with the psych rubbish themselves in multidisciplinary teams. Ugh.

It's awful seeing such prejudiced ignorant rubbish being presented as the answer to LC after all the years pwME have suffered crap about perfectionism and childhood trauma and exercise avoidance and deconditioning and all the rest.

 

[Eleanor]

It's like reading a treatise by a couple of medieval theoreticians earnestly explaining the theory of the humours and how digestive disorder is caused by excess phlegm driven out from your brain to your stomach by the autumn winds. Those guys probably had a good old sneer at their patients' "never-ending" need for help too.

 

[Aldebaran's Star]

Well, perhaps this is what our doctor thinks, though he is sympathetic, he is not a believer. The more you talk and explain, the more coo coo you come across. I thought we were almost over this psychological crap hurdle? We were all excited for the attention LC has been getting, this is freaking awful. I learned some new terms today, thank you. Also, came across this interesting criterion while googling some of the terms: covid-blitshteyn-multi-disciplinary-tables-1222.pdf
My poor child has 80% of what is described there, must be Munchausen syndrome by proxy.

 

[rvallee]

symptoms that cannot be fully explained by a biomechanical model

unlike patients suffering from these biologically explained diseases, patients with long COVID do not present objective clinical signs that would allow their diagnosis

An open and non-dualistic approach

Hmm. Yes. Words and their meaning. So complicated. Much coherence. See, this stick of butter is totally fat-free, it's written right on the label!

Based on their clinical experience, most French internists who responded to an opinion survey consider that long COVID corresponds most closely to a functional somatic disorder (FSD) and seek the help of specialists in mental health care to assist in the management of the patients in a multi-disciplinary approach

It's widely known that there are no treatments for LC, and that health care for it is a complete disaster, so pointing out the current disastrous handling of this illness really does it no favor. There are literally thousands of articles, news reports, even studies and papers all supporting this. But since they can get away with lying then nothing matters.

Anyway, it sure is true that internal medicine has nothing to help with, not until the pathophysiology is figured out, and even then it probably won't involve them. But it hasn't been figured out in large part because of this pseudoscientific BS. The horrible beauty of this model is that focusing exclusively on their pseudoscience guarantees that the cause isn't figured out, thus making them appear to be correct. As long as you don't mind the ethical and moral bankruptcy in it, which is clearly not something psychosomatic ideologues ever bother with.

The only saving grace is just how thoroughly psychosomatic ideology will be discredited once any breakthrough occurs, given how they openly they put out this stuff. This isn't just nonsense they used to say a full century ago, it sure is, but they're still saying it the same way, for all the same reasons. Not that I expect it to end, beliefs don't respond to facts or reason, but wow are they showing themselves to be a completely hollow ball of nothing, a bunch of flim-flam con artists.

 

[Sean]

An open and non-dualistic approach​

So open, apparently, that their brains have fallen out.

 

[Snow Leopard]

*facepalm*