Medically unexplained syndromes: irritable bowel syndrome, fibromyalgia and chronic fatigue (2018) Luty

MeSci

MeSci

Senior Member (Voting Rights)
Source: BJPsych Advances

Preprint

Date: June 6, 2018

URL:
https://www.cambridge.org/core/jour...onic-fatigue/056188C35015F793F283E6F385386289

Medically unexplained syndromes: irritable bowel syndrome, fibromyalgia and chronic fatigue
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Jason Luty

- Liaison Psychiatry, Farm Lodge, C/O Bradgate Unit, Glenfield Hospital, Groby Road, Leicester LE3 9EJ, UK. Email: jason.luty@yahoo.co.uk

Abstract

This is a review of three of the more common medically unexplained syndromes that present for treatment to liaison psychiatry services in general medical hospitals: chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome. The three are interrelated, extremely
disabling and comorbid mood disorders are frequent. In general, treatment, whether psychological or medical, has very modest impact. The disputed classification of medically unexplained syndromes is also reviewed. There is a clear gulf between the views and experiences of patients with these syndromes and the medical establishment. In this article I summarise give the evidence for pharmacological, psychosocial and 'alternative' or 'complementary' interventions for a range of disorders, about which there is some dispute. I leave it to the reader to decide which interventions hold the most promise.

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(c) 2018 The Royal College of Psychiatrists
(c) 2018 Cambridge University Press
 
It ends with
The suggestion that these syndromes may be ‘psychogenic’ is highly disputed by many patients and is likely to be a distraction from focused research into the potential neurological or physical cause.
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It also acknowledges the poor long term followup results in PACE, and reports the recovery outcomes from the PACE reanalysis. Unfortunately it doesn't make clear that this was the analysis as originally planned or that there were no statistically significant differences between groups.

Anyway, the PACE criticism is slowly getting into the literature.
 
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This looks like a muddled review by a junior doctor who has not himself quite worked out what he wants to say. It mentions some of the issues patients have with treatments but makes no constructive analysis. The account of PACE is still woefully inaccurate.

This reminds me that maybe ME advocacy should be deliberately targeting very young professionals and students in medicine and allied professions (therapists). These are the people who may still have an open mind about what they should be doing. Judging by this they may see some of both sides and be uncertain. They need to hear loud and clear that the studies of treatments are simply not informative because they are too badly designed.
 
I think the conclusion is interesting:
Edit: I mean in the sense that he does at least question the psychological approach.
Conclusions Patients with somatoform disorders are preoccupied with symptoms, the presence of an undiagnosed illness or other ‘abnormal illness behaviour’ (at least, in the opinion of many doctors). Indeed, one of the features of these disorders appears to be a conflict between the expectations of doctors and patients. The aetiology of medically unexplained syndromes has traditionally been presumed to be psychological – that is, a result of ‘unconscious’ processes, rather than physical disease. Nevertheless, medically unexplained syndromes such as CFS, fibromyalgia and IBS are notoriously disabling, persistent and difficult to treat.

Both CBT and graded exercise exposure require patients to increase activity, which often aggravates their symptoms, especially pain. Graded exercise therapy is often conducted by physiotherapists and commonly produces an increase in symptoms as the activity levels increase. This seems to make these options notably unpopular with patients, particularly compared with adaptive pacing therapy, which is self-directed.

There is some clear evidence from patient groups that many were unhappy with CBT and graded exercise therapy for chronic fatigue, reporting that they found it unhelpful – of course, this may be a consequence of patients being stigmatised as ‘mentally ill’ (‘psychosomatic’) when they are actually suffering from a physical disorder (National Institute for Health and Care Excellence 2007). Doctors, CBT therapists and physiotherapists may maintain that they would not regard medically unexplained syndromes as being ‘psychogenic.’ However, this does not seem to be the experience of patients. By contrast, complementary therapists (including those offering dietary advice and acupuncture) tend to validate the patient’s sick role and complementary therapies are popular and widely used by patients (National Institute for Health and Care Excellence 2007).

It is likely that patients with fibromyalgia and IBS remain in contact with medical specialists (rheumatologists and gastro-enterologists), whereas patients with CFS are discharged by medical specialists after they have been referred to psychiatrists. Patients with chronic fatigue lack any further contact with ‘conventional’ organic medical specialists to validate the view that they have a physical disorder.

Selective diets and vitamin supplements are particularly popular with people who have chronic fatigue, especially in respect to symptoms of IBS, and alternative therapies (acupuncture and hypnotherapy) are often used for fibromyalgia symptoms, although these are not recommended by authorities such as NICE in the UK (National Institute for Health and Care Excellence 2007).

There is a significant gulf between the beliefs and expectations of patients and medical professionals in the cause and treatment of medically unexplained syndromes, with patient groups rejecting the psychological aetiology of these disorders. This dispute is likely to have been aggravated by the longer-term follow-up of the PACE trial of psychological treatment for CFS, which validated patient groups and reported significantly poorer results than the initial analysis (Sharpe 2015).

When faced with patients who are disabled by overt physical symptoms, doctors are naturally challenged by their inability to find the cause of these symptoms despite ever more sophisticated investigations. These patients are often referred to liaison psychiatry, although the treatments available within mental healthcare (such as antidepressants and psychotherapy) remain of marginal benefit.

Regardless of their supposed causes, IBS, fibromyalgia and CFS remain common, extremely disabling and lack effective treatment. The suggestion that these syndromes may be ‘psychogenic’ is highly disputed by many patients and is likely to be a distraction from focused research into the potential neurological or physical cause.
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ladycatlover said:
Interesting review of Jason Luty! :eek: It seems he's left the Bradgate Unit now.
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Interesting clearly he didn’t give this person a feeling of being empathised with. Maybe if you have doubts about what you’re having to say to people that makes it harder to show empathy because you have to make yourself more of a robot to do it. My IAPT CBT person was quite robotic and I put it down to the process rather than her personally. I did get the feeling she was not comfortable being a sausage machine operator.
 
Trish said:
I think the conclusion is interesting:
Edit: I mean in the sense that he does at least question the psychological approach.
Click to expand...

What seems odd is that he has picked up from the PACE follow up that there was no long term benefit yet that is not how the paper he quotes presents it at all. And he seems oblivious to the much more obvious problems with the original PACE results - not just the re-analysis but the uselessness of the trial design.

Perhaps this was all he felt he could say without losing his job. Maybe he overdid it as it is!
 
I think he has done a very superficial overview - he keeps referring to 'chronic fatigue' instead of CFS, quotes whole chunks of the NICE guidelines, doesn't refer at all to the methodological flaws in PACE, and only seems aware of Oxford and Fukuda criteria ...
 
Re the PACE, and other trials using the Oxford criteria: 6 months of medically unexplained fatigue; do we know much about these study subjects? Other than that 13 percent in the PACE trial were actually quite healthy.

Of course we can assume there were several people with depression. How about
IBS, and whatever else the GET/CBT band calls unexplained? It would be interesting to know what "diagnoses"the subjects have.

It seems circular and confusing; for example, depression can cause fatigue, depression is a medical diagnosis, and yet it's also medically unexplained chronic fatigue. So on the one hand a person can be diagnosed with depression, but also labeled as having a mystery condition causing fatigue. Egad!

And, what about misdiagnosis? The arrogance of medicine to categorize people with medically unexplained chronic fatigue, while dismissing important signs and symptoms. For example someone diagnosed with CFS, who actually had a life threatening ilness they died from.
 
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