Wednesday, November 4, 2009

2 letters about CFS

[Some people might like to reply to take part in this correspondence and,
for example, reply to some of Dr Mayer's statements such as: "Chronic
fatigue syndrome has become a diagnosis that seems to do more harm than
benefit. One study concludes: Poor outcome was predicted by membership of a
self-help group and being in receipt of sickness benefit at the start of
treatment. [6]".  I don't have the time. TK]

http://www.bmj.com/cgi/eletters/339/oct27_2/b4393#223884

Rapid Responses published:



Suggestions for diagnosis of patients presenting with fatigue
Nancy Blake   (29 October 2009)

Re: A comment from a psychiatrist on Nancy Blake`s letter on patients
presenting with fatigue in primary care.
Karl C. Mayer   (1 November 2009)

----------------------------------------------------------------------------
----

Suggestions for diagnosis of patients presenting with fatigue 29 October
2009

Nancy Blake,
UKCP Accredited Neurolinguistic Psychotherapist
64 Ella Street, Kingston upon Hull, HU5 3AY




As a very experienced psychotherapist who also is nearly recovered from
Myalgic Encephalomyelitis after 24 years, I would offer the following
suggestions:

Consult www.ahummingbirdsguide.com  the article Smoke and Mirrors for a
detailed account of the nature of ME, and the political/economic interests
which have lead to the label Chronic Fatigue Syndrome, an umbrella term for
any patient who has suffered fatigue for six months, with a wide range of
possible causes.

Very recent developments, reported on the front page of The Independent a
week or so ago, suggest that there may soon be a diagnostic test for ME,
based on the finding of a specific retrovirus in a large percentage of
people with ME, and antibodies for this virus in an even larger percentage.

In the meantime, it is easy to make a differential diagnosis between
depression and ME. As Professor Douglas Hooper confirms, exercise
intolerance is a definitive symptom of ME. A person who is depressed has a
low mood, and will have to be persuaded to exercise, after which the mood
will lift, due to the production of endorphins as a result of exercise.

People who have ME are typically highly motivated, very active people up to
the point where they become ill. A person who has ME will be eager to
perform some activity, and almost immediately find themselves unable to
continue, at which point they are likely to become quite upset.
Straightforward diagnosis: If your patient feels better after exercise, he may be depressed. If your patient feels worse after exercise, he may have ME.

Fatigue is also a feature of many other physical illnesses, and I think a
doctor would be wise to perform at least a range of routine tests to
eliminate other possibilities - anaemia, MS, chronic low-grade infection,
and so on, before deciding on a psychiatric diagnosis. People don't normally die from a misdiagnosed psychiatric condition, or at least not as often as from a misdiagnosed physical condition.

The post-exertional malaise associated with ME is a result of defective
functioning of muscle metabolism - the aerobic system doesn't work, so even
slight exertion calls the anaerobic metabolism into play. ME is apparently
the result of damage or disfunction in the lower brain stem, hence
disruption of normal body control mechanisms - appetite, sleep patterns,
body temperature, as well as short-term memory problems, and confusion
especially after exertion; also emotional responses may seem exaggerated.
Symptoms vary from hour to hour and day to day, and make the patient sound
like a raving hypochondriac, but the configuration of symptoms is very
recognisable, and a person would have to be very creative to make them up.

Because the level of disability present in ME (especially if a patient is
forced, either by circumstances or by medical misjudgement, to exercise) is
very expensive to pay for, insurers, and our government, have been willing
to pay well psychiatric consultants prepared to testify that this is a
psychiatric, rather than a medical condition. The 'effectiveness' of
therapies such as CBT and GET is researched with funding which should be
used for medical investigation, and based on studies which eliminate
individuals who suffer 'post exertional malaise', but the results are then
used to justify forcing these therapies onto people who have ME and can be
severely damaged both by the assumptions implicit in treatment for 'faulty
thinking' and by physical exercise. Hopefully further research on viral
factors will discredit these approaches sooner rather than later.

Nancy Blake, UKCP Accredited Neurolinguistic Psychotherapist
alternatives@alternatives.karoo.co.uk

Competing interests: None declared

Re: A comment from a psychiatrist on Nancy Blake`s letter on patients
presenting with fatigue in primary care. 1 November 2009

Karl C. Mayer,
psychiatrist and neurologist
Bergheimer Straße 56a, 69115 Heidelberg, Germany, www.neuro24.de


The study you cite shows, that there was a lack in psychiatric diagnotics
by the participating general practices across the Netherlands. Not only that
the medical records listet just one out of 34 patient complaints of sleep
problems, it also listet only 1 in 14 patient complaints of distress or
worry. So in my opinion the study of I. Nijrolder et al [1]shows a clear
need for a better intergration of psychiatric diagnoses in the differential
diagnostics of fatigue complaints. The letter of Nancy Blake [8]is definitly
wrong in her statement : "People don't normally die from a misdiagnosed
psychiatric condition, or at least not as often as from a misdiagnosed
physical condition" . Suicide is still one of the leading causes of death in
psychiatric disorders.  The World Health Report  WHO 2001[3] lists 4
psychiatric disorders among the 10 leading causes of years of life lived
with disability, unipolar depression beeing the number one. On the other
hand psychiatric disorders can be treated with greater success than most
"physical conditions". Psychiatric treatment is not only saving lives, it
makes lives for many people worth living again. Studies have shown that
elevated premorbid stress is a significant risk factor for chronic
fatigue–like illness and that emotional instability assessed 25 years
earlier is associated with chronic fatigue.  [4]

Up to now, there is no prove of a "chronic low-grade infection" as a cause
of chronic fatigue. Nancy Blake states a simple test to differentiate
between the organic chronic fatigue syndrome and depression.  She claims
that exercise intolerance is a definitive symptom of chronic fatigue
syndrome, where as depressed people just have to be persuaded to start
going, and their body will produce the healing  endorphins. Depressed people
have mostly great difficulties in getting startet with excercise, often only
possible when symptoms are getting better. The profit of excercise in both
depression and chronic fatigue usually comes late and probably needs weeks
of regular graded excercise. For both conditions there is some proof of the
effect of excercise. Selfhelp groups for people with CFS often persuade
their members to abstain from excercise, which worsens their condition. A
study says: The severity and chronicity of chronic fatigue syndrome symptoms
do not predict response to psychological treatment aimed at encouraging
graded exercise[6] . An other study shows, that benefits of an educational
intervention designed to encourage graded activity for CFS patients were
maintained at 2 years. [7]

A birth cohort study comes to the conclusion: "Individuals who exercise
frequently are more likely to report a diagnosis of CFS in later life. This
may be due to the direct effects of this behaviour or associated personality
factors. Continuing to be active despite increasing fatigue may be a crucial
step in the development of CFS." [5]   Chronic fatigue syndrome has become a
diagnosis that seems to do more harm than benefit. One study concludes: Poor
outcome was predicted by membership of a self-help group and being in
receipt of sickness benefit at the start of treatment. [6]



1.        Iris Nijrolder et al., Diagnoses during follow-up of patients
presenting with fatigue in primary care CMAJ 2009.DOI:10.1503/cmaj.090647
2.        David Spurgeon  Fewer than half of patients with fatigue get
explanation for their symptoms within a year, study shows BMJ 2009;339:b4393

3.        The World Health Report 2001, World Health Organisation, 2001.
available under https://apps.who.int/whr/2001/main/en/figures/figure2.3.htm
last visited 1 november 2009
4.        Kenji Kato, Patrick F. Sullivan, Birgitta Evengård, et al.,
Premorbid Predictors of Chronic Fatigue Arch Gen Psychiatry.
2006;63:1267-1272.
5.        Samuel B. Harvey, et al., Etiology of Chronic Fatigue Syndrome:
Testing Popular Hypotheses Using a National Birth Cohort Study Psychosomatic
Medicine 70:488-495 (2008)
6.        Richard P. Bentall et al., Predictors of response to treatment for
chronic fatigue syndrome  The British Journal of Psychiatry (2002) 181:
248-252
7.        Pauline Powell, et al., Patient education to encourage graded
exercise in chronic fatigue syndrome 2-year follow-up of randomised
controlled trial The British Journal of Psychiatry (2004) 184: 142-146
8.       Nancy Blake Suggestions for diagnosis of patients presenting with
fatigue, Rapid Responses bmj.com, 29 Oct 2009 [Full text]

Competing interests: None declared

1 comment:

Aylwin said...

As per usual, Dr. Mayer, you are confusing the artificial, American nonspecific construct of "CFS" for the WHO-defined neurological disease ME, which the article was about. As for me, my ME started suddenly one day 23 years ago with a daily fever of 104 deg. for 3 years. Doesn't that sound like an infection to you? I have classic progressed ME symptoms & have been properly diagnosed by both an immunologist & neurologist. PWME are dying 25 years earlier than their non-ME cohorts from damage to the heart, neurological system, & other organs. MS, Parkinson's, Polio & others were considered "hysterical" before the causes were found.

We are getting very "tired" of the psychiatric tendency to dismiss all you don't understand (or properly research, go back before the "CFS" invention & you will find 60 years of solid research into ME. Go do your due diligence & really look at ME before offering up your potted "expertise". Aylwin Catchpole, Whitehorse Canada.