Wednesday, March 10, 2010

DSM-V criteria -- vague "fatigue" definition

The comment period for the proposed DSM-V criteria for the APA ends April
20, 2010. Persons interested in commenting on the highly problematic and
vaguely defined  Complex Somatic Symptom Disorder might also wish to note
that CFS patients are not the only patients whose "fatigue" is unrelated to
the definition promoted by Somatic Distress Disorders Work Group member UK
psychiatrist Michael
of "a feeling of lack of energy, weariness, and aversion to effort" (Mead 2007) or
depression.  Fatigue is common symptom of several dozen medical diseases
unrelated to a psychosomatic disorder. In CFS specifically, according to
Carruthers et al (2003) also known as the Canadian Consensus Criteria for
Chronic Fatigue Syndrome/myalgic encephalomyelitis, "fatigue" is an
inappropriate label because the fatigue experienced in ME/CFS is not
normal fatigue whereby energy is promptly restored with rest.

Additionally, in the first half of the decade disability insurance
conglomerate UnumProvident was the subject of multiple law suits brought by
the states of New York, Georgia and California, as well as corrective
regulatory measures brought on behalf of the states of Maine, Massachusetts
and Tennessee. At issue were claims practices that incorrectly listed
multiple diseases under mental disorders including Parkinson's Disease,
Multiple Sclerosis, Chronic Fatigue Syndrome among others primarily because
medical symptoms were incorrectly deemed psychosomatic. This allowed the
insurer to either deny benefits due or restrict payouts to the two years of
payments allowed for stress or mental disorders rather than paying a life
time of benefits as is required for organic diseases.

UnumProvident is but one of the many insurance companies listed under
conflicts of interest by Dr. Sharpe.

As Carol S. North MD, MPE former member of the Committee on Gulf War and
Health: Physiologic, Psychologic, and Psychosocial Effects of
Deployment-Related Stress noted in one study, "...Identification of
disorder requires the ability to rule out medically based explanations of
symptoms. Only when medically based etiologies can be confidently dismissed
can symptoms be considered somatoform, and assessment cannot
proceed without it." (North 2002)

The totality of the biomedical research is steadily growing and enough
studies provide a medical explanation that such etiologies cannot be
"confidently dismissed."

Dr. North also notes (North 2002) the methodological failures of many of the
checklists and scales used by psychiatrists results in "...the failure to
exclude medical explanations for the symptoms contaminates the desired
somatization data with somatic symptoms of medically based conditions,
thereby overestimating somatization." Dr. Leonard Jason and IACFS president
Dr. Fred Friedberg also note that many of the fatigue scales used have a
ceiling effect whereby they are appropriate for the non-patient population
but do not have the capacity to measure the severity of pathogenic fatigue.

Below is but one study of patients with Parkinson's Disease which
illustrates some of the points noted above. Others can be found relating to
fibromyalgia and Gulf War Illness.

*Fatigue in levodopa-naive subjects with Parkinson disease.***

Schifitto G, Friedman JH, Oakes D, Shulman L, Comella CL, Marek K, Fahn S;
Parkinson Study Group ELLDOPA Investigators.

Collaborators (139)

BACKGROUND: Fatigue is a common complaint in Parkinson disease (PD). We
investigated fatigue in a cohort of previously untreated patients with early
PD enrolled in the Earlier vs Later Levodopa (ELLDOPA) clinical trial.

METHODS: A total of 361 patients were enrolled in the randomized,
double-blind, placebo-controlled ELLDOPA trial and assigned to receive
placebo or carbidopa-levodopa 37.5/150 mg, 75/300 mg, or 150/600 mg daily
for 40 weeks, followed by a 2-week medication washout period. Subjects who
scored >4 on the Fatigue Severity Scale were classified as fatigued. PD
severity was assessed using the Unified Parkinson's Disease Rating Scale
(UPDRS), Hoehn-Yahr scale, and Schwab-England Activities of Daily Living
Scale. A subgroup of subjects underwent [(123)I]-beta-CIT SPECT to measure
striatal dopamine transporter density.

RESULTS: Of the 349 ELLDOPA subjects who completed fatigue measures, 128
were classified as fatigued at baseline. The fatigued group was
significantly more impaired neurologically (UPDRS, all subscales and Hoehn
and Yahr staging) and functionally (Schwab-England Scale) but no significant
differences were observed in beta-CIT measurements between the two groups.
Analysis of covariance showed a greater increase in fatigue score from
baseline to the end of the 2-week washout in the placebo group (0.75 points)
than in the three groups receiving levodopa (increases of 0.30 [150 mg/day],
0.36 [300 mg/day], and 0.33 [600 mg/day]; p = 0.03 for heterogeneity).

*CONCLUSIONS:* Fatigue is a frequent symptom in early, untreated,
non-depressed patients with Parkinson disease (PD), affecting over 1/3 of
the patients in this cohort at baseline and 50% by week 42. Fatigue was
associated with the severity of PD, and progressed less in patients treated
with levodopa.
Neurology. <javascript:AL_get(this,%20'jour',%20'Neurology.');> 2008 Aug

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