New Oxford Textbook of Psychiatry, 2012 and 2020 editions - Sharpe et al on CFS

Discussion in 'Historical Documents' started by Trish, Nov 5, 2023.

  1. Trish

    Trish Moderator Staff Member

    New Oxford Textbook of Psychiatry

    Second edition
    published 2012

    Chapter 5.2.7 Chronic Fatigue Syndrome

    by Michael Sharpe and Simon Wessely

    Abstract (paragraph breaks added)

    Chronic fatigue syndrome is a controversial condition, conflicts about which have frequently burst out of the medical literature into the popular media. Whilst these controversies may initially seem to be of limited interest to those who do not routinely treat such patients, they also exemplify important current issues in medicine. These issues include the nature of symptom-defined illness; patient power versus medical authority; and the uncomfortable but important issues of psychological iatrogenesis. The subject is therefore of relevance to all doctors.

    Fatigue is a subjective feeling of weariness, lack of energy, and exhaustion. Approximately 20 per cent of the general population report significant and persistent fatigue, although relatively few of these people regard themselves as ill and only a small minority seek a medical opinion. Even so, fatigue is a common clinical presentation in primary care. When fatigue becomes chronic and associated with disability it is regarded as an illness.

    Such a syndrome has been recognized at least since the latter half of the last century. Whilst during the Victorian era patients who went to see doctors with this illness often received a diagnosis of neurasthenia, a condition ascribed to the effect of the stresses of modern life on the human nervous system the popularity of this diagnosis waned and by the mid-twentieth century it was rarely diagnosed (although the diagnosis subsequently became popular in the Far East—see Chapter 5.2.1).

    Although it is possible that the prevalence of chronic fatigue had waned in the population, it is more likely that patients who presented in this way were being given alternative diagnoses. These were mainly the new psychiatric syndromes of depression and anxiety, but also other labels indicating more direct physical explanations, such as chronic brucellosis, spontaneous hypoglycaemia, and latterly chronic Epstein–Barr virus infection. As well as these sporadic cases of fatiguing illness, epidemics of similar illnesses have been occasionally reported.

    One which occurred among staff at the Royal Free Hospital, London in 1955 gave rise to the term myalgic encephalomyelitis (ME), although it should be emphasized that the nature and symptoms of that outbreak are dissimilar to the majority of those now presenting to general practitioners under the same label.

    A group of virologists and immunologists proposed the term chronic fatigue syndrome in the late 1980s. This new and aetiologically neutral term was chosen because it was increasingly recognized that many cases of fatigue were often not readily explained either by medical conditions such as Epstein–Barr virus infection or by obvious depression and anxiety disorders. Chronic fatigue syndrome has remained the most commonly used term by researchers.

    The issue of the name is still not completely resolved however: Neurasthenia remains in the ICD-10 psychiatric classification as a fatigue syndrome unexplained by depressive or anxiety disorder, whilst the equivalent in DSM-IV is undifferentiated somatoform disorder. Myalgic encephalomyelitis or (encephalopathy) is in the neurological section of ICD-10 and is used by some to imply that the illness is neurological as opposed to a psychiatric one.

    Unfortunately the case descriptions under these different labels make it clear that they all reflect similar symptomatic presentations, adding to confusion. Official UK documents have increasingly adopted the uneasy and probably ultimately unsatisfactory compromise term CFS/ME. In this chapter, we will use the simple term chronic fatigue syndrome (CFS).
  2. duncan

    duncan Senior Member (Voting Rights)

    I don't think they love us any more.
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  3. Trish

    Trish Moderator Staff Member

    The 2012 Edition chapter on CFS is in a large section headed Psychiatry in Medicine, with chapters including somatoform, MUS, somatisation, conversion disorder, hypochondriasis, factitious disorder and malingering, neuresthenia etc.
    MEMarge, Ash, Hutan and 4 others like this.
  4. Trish

    Trish Moderator Staff Member

    The 2020 edition seems to have shrunk that section

    It's now headed
    Somatic symptoms and related disorders
    with chapter headings:

    129 Deconstructing dualism: The interface between physical and mental illness
    by Michael Sharpe and Jane Walker

    Illness is conventionally categorized into two main types: ‘medical’ or ‘psychiatric’. This dichotomization is such an accepted feature of current medical practice that we take it for granted. But is it really the best way to think about and manage illness? In order to answer these questions, the chapter reviews what is meant by ‘medical’ and ‘psychiatric’ illness and considers the assumptions underpinning this division. The chapter then outlines alternative and more unified conceptualizations of illness, as well as the development of integrated models of clinical care.


    130 Neural mechanisms in chronic pain relevant for psychiatric interventions

    131 Treatment of fibromyalgia (chronic widespread pain) and chronic fatigue syndrome
    by Jonathan Price
    [Note: Jonathan Price is one of the authors of the 2019 Exercise therapy for CFS Cochrane review, and all previous versions of that review. He is a colleague of Michael Sharpe at Oxford University].

    Fibromyalgia (FM), one of the chronic widespread pain syndromes, and chronic fatigue syndrome (CFS) are important and common conditions. They are considered together here because they are commonly comorbid and because of their similarities—they are long-term conditions with a relatively poor prognosis; central nervous system mechanisms and deconditioning play an important role in aetiology; graded exercise and psychological treatments have an important role in management; and comorbid mental disorders are common and have an adverse impact on important outcomes, including disability and chronicity. The prevalence of FM is rising, while that of CFS is declining. There is increased acceptance of the pivotal role of central nervous system factors in FM, while in CFS, the positions of different aetiological ‘movements’ appear bitterly entrenched. The main focus of this chapter is on FM and, in particular, key aspects of aetiology and treatment, especially those relating to the central nervous system.

    132 Factitious disorder and malingering
    Factitious disorder and malingering are two forms of abnormal illness behaviour in which mental or somatic symptoms are deliberately fabricated or grossly exaggerated or otherwise grossly misrepresented. They are forms of other-deceit, with the person in question assumed to be fully aware of this deceit. The central distinguishing feature of both is that factitious disorder is commonly thought to be motivated by internal incentives (primary gain: medical treatment, assuming the sick role), while malingering is directed towards an external goal (secondary gain, for example monetary compensation, sick leave). The utility of distinguishing between the two forms of feigning has long been questioned. Similarly, it must be questioned why factitious disorder is apprehended as a mental disorder in its own right. Neither the Diagnostic and Statistical Manual of Mental Disorders (DSM) nor the International Classification of Diseases (ICD) contains useful diagnostic guidelines for reliably diagnosing feigned illness presentations; in particular, several decades of malingering research and conceptual developments have found no repercussion there.


    133 Functional neurological symptom disorder (conversion disorder)
    by Jon Stone and Michael Sharpe
    Conversion disorder (now also called functional neurological symptom disorder) describes symptoms (of motor and sensory dysfunction such as limb weakness, tremor, visual loss, with or without ‘blackouts’), which can be positively identified as being inconsistent with neurological disease. The disorder is common in neurological services and frequently seen by psychiatrists working in such settings. It is often associated with chronic severe disability. The diagnosis previously hinged on the neurologist’s demonstration of the lack of disease and the psychiatrist’s hypothesis of a ‘conversion’ of stress into a physical symptom. It is now based on positive findings on neurological assessment supplemented by a psychiatric assessment to confirm the diagnosis. Comorbid anxiety and depression disorders are common. Treatment is multi-disciplinary. Explanation of the condition to the patient is a crucial initial step supplemented, where necessary, by psychological treatment (especially for dissociative or non-epileptic attacks) and physiotherapy for functional motor symptoms. The prognosis without treatment is poor once the disability is established.
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  5. Peter Trewhitt

    Peter Trewhitt Senior Member (Voting Rights)

    I am not sure that CFS was ever ‘aetiologically neutral’, despite being presented as such in the 1980s and 1990s. It was used to distance from the label ME which was seen as a biomedical condition and I suspect always contained the unspoken inference that CFS was definitely not biomedical, so therefor psychogenic.

    My GP, when I was first diagnosed in the early 1990s, did support using the label CFS as neutral on causation, and I think he did believe this never once recommending GET/CBT but rather symptom management, and clearly stating that all we could use for prognosis was each individual’s previous/ongoing experience. Even then it was over a decade in before I was aware, as defined ideas, of PEM, orthostatic intolerance and food intolerances, which have for me been the most valuable symptom management tools.

    I think the term CFS has, intentionally or not, directed clinicians and patients away from ideas such as PEM, making symptom management much harder, and reinforced the idea that CFS is not qualitatively any different to normal fatigue, so any patient failing to get to grips with it is psychologically and even morally lacking.

    My believe is that CFS was for many never neutral about causation, rather a euphemism for psychogenic, and even if for some it was genuinely seen as neutral it had the effect, whether intended or not by its proponents, of misdirecting clinicians and patients away from effective symptom management.

    To now deliberately use CFS rather than ME/CFS in the UK and, though perhaps seeking an international audience Oxford is in the UK, is a deliberate political act signalling opposition to the new NICE ME/CFS guidelines. Though this was written before the publication of those guidelines, it would have been written with knowledge of their likely conclusion. [added - the 2020 draft that is.]
    Last edited: Nov 5, 2023
  6. duncan

    duncan Senior Member (Voting Rights)

    Textbooks are more dangerous than studies or articles. Textbooks carry an implied imprimatur of codified authority.

    Perhaps more damaging, textbooks imprint.

    Then they endure as authenticated reference materials, from classrooms and lecture halls to home studies and bookshelves.

    Hard to undo the damage.
    ItsMERJD, Sean, alktipping and 12 others like this.
  7. DokaGirl

    DokaGirl Senior Member (Voting Rights)

    @Peter Trewhitt

    You note the term "morally lacking". Very good point. That view of pwME may be one of the important issues at the heart of why we are maligned and mistreated. We are viewed as not only misguided in our illness beliefs, but are seen as immoral. Perhaps even criminal, in our attempts to acquire disability insurance payments, medical assistance etc.

    All of course, terribly incorrect assumptions.

    ETA: Added the word "payments".
    Last edited: Nov 5, 2023
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  8. SNT Gatchaman

    SNT Gatchaman Senior Member (Voting Rights)

    Aotearoa New Zealand
    This abstract does seem to be being a bit more open about what they think FND actually is (conversion disorder by another name), rather than the usual hokum about software, introception, top-down, bottom-up etc.

    I also note they're here missing the usually included "positively identified as being inconsistent with [known] neurological disease".
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  9. duncan

    duncan Senior Member (Voting Rights)

    If their target audience was medical students, what better way to start teaching those future clinicians and researchers that it's "such patients" who present as an unstable challenge to "medical authority", than in a textbook, presumably used in medschool. The authors literally pit future doctors against CFS patients before they've even left the starting gate.

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  10. Sean

    Sean Moderator Staff Member

    How to disappear an inconvenient disease.

    (I actually doubt that decline is true.)
    ItsMERJD, Lou B Lou, EzzieD and 7 others like this.

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