Sunday, January 16, 2011

Making Sense of ME/CFS

From Frank Twisk:
 
On December 13th, 2010
we submitted a Letter to the Editor of Occupational Medicine

Making sense of ME/CFS: the need for a biological-oriented approach.

in which we comment on an article of Wessely et al.

Making sense of fatigue: the need for a balanced approach.
Occup Med (Lond) 2010;60:665-666.
doi: 10.1093/occmed/kqq166.
Harvey SB, Mykletun A, Wessely S.

which itself was a comment on

Making sense of fatigue.
Occup Med (Lond) 2010; 60:326-329.
doi:10.1093/occmed/kqq014.
Newton JL, Jones DEJ.


Our letter was not accepted for publication.

While Wessely and co are allowed by the Editor to reiterate their
mental examination is the most effective way of diagnosing "CFS" and
CBT/GET is an evidence-based effective treatment for "CFS"-claim
in his journal,

the Editor uses a previous article of ours in another journal

Chronic fatigue syndrome:
Harvey and Wessely's (bio)psychosocial model
versus a bio(psychosocial) model
based on inflammatory and oxidative and nitrosative stress pathways.
BMC Med. 2010 Jun 15;8(1):35. doi:10.1186/1741-7015-8-35.
Maes M, Twisk FNM.
http://www.biomedcentral.com/content/pdf/1741-7015-8-35.pdf

as an argument not to publish our counter arguments in his journal.


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Making sense of ME/CFS: the need for a biological-oriented approach.


Summary:


Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS),
a multi-system disease, 
is declared to be a controversial disease by various others.

In this letter we substantiate
why the (bio)psychosocial model of Harvey and Wessely is largely inadequate
to explain the pathophysiology of ME/CFS.

Looking at the evidence, biological aberrations
(e.g. inflammation, immune dysfunction, infections,
oxidative and nitrosatieve stress, and mitochondrial dysfunction)
should be key players in a bio(psychosocial) model for ME/CFS.

Since exertion intensifies the underlying pathophysiology,
exercise therapy/cognitive and behavioural focused therapies (GET/CBT),
as promoted by advocates of a bio(psychosocial) model,
are potentially harmful for many patients.

Future research should therefore be aimed at
interventions to reverse the biological abnormalities,
thereby promoting recovery or improvement.


 
Letter:


Dear Sir,

With interest we have taken notice of
the observations raised by Newton and Jones (1);
the arguments raised by Harvey, Mykletun and Wessely (2); and
the reply by Newton and Jones (3).

We endorse the arguments made by Newton and Jones
that the imbalance in the biological and psychosocial aspects of ME/CFS should be addressed;
that "fatigue" s accepted by the clinical community to be biological in its origin;
that "fatigue" has profound psychological consequences; and
that psychological problems are secondary rather than primary phenomena (3,4).

Harvey, Mykletun and Wessely (2) state that
"approaches that dichotomize the mind and body …
ignore the current evidence base and are likely to be suboptimal".

However, the explanatory variables in the (bio)psychosocial model
of Harvey and Wessely (5) are mainly psychosocial ones.

The studies cited by Harvey and Wessely (2) used to endorse the argument
"that attempts to identity a consistent pattern of biological abnormalities, have failed"
are highly selective.

As explained (6),
Harvey and Wessely's (bio)psychosocial model
does not encapsulate the biological pathophysiology of ME/CFS,
despite abundant evidence of various organic abnormalities.

Although ME/CFS is a heterogeneous disorder (7,8),
many, if not all, ME/CFS patients suffer from
inflammation, immune dysfunction, infections,
oxidative and nitrosative stress, intestinal hyperpermeability, etc.

These aberrations, demonstrated in many studies (9,10),
are encapsulated in the inflammatory and
oxidative and nitrosative stress model of ME/CFS (6).

Advocates of bio-psychosocial models
should include these biological pathways in their models.

Harvey and colleagues state that
"randomized control studies have established
the effectiveness of cognitive and behavioural focused therapies in .. CFS ..".

They fail to discuss recent reviews (11),
which demonstrate that
the evidence base for these cognitive and behavioural focused therapies in ME/CFS is non-existent and
that these therapies are even potentially harmful for many patients,
because graded exercise treatment intensifies the pathophysiological mechanisms in ME/CFS,
such as inflammation, oxidative stress, etc. (11).

In an evaluation by the Belgian government,
the effects of CBT/GET have been analyzed in hundreds of patients with ME/CFS (12).

It was found that ME/CFS did not result in any clinical improvement.

On the contrary,
CBT/GET aggravated  the symptoms of many patients (often up to 30-80% of the patients),
including fatigue, daily physical and psychological functioning (12).

Harvey, Wessely and Mykletun state that
"a simple mental state examination remains
one of the most productive investigations in prolonged fatigue" (5).

However, even for chronic fatigue this assertion is invalid (6).

According to recent study by Jones and colleagues (13)
"chronic fatigue" in general is secondary to medical conditions in 71% of the patients and
accompanied by psychological/psychiatric illnesses in only 15% of the cases.

As explained (6), we strongly reject the recommendation of Harvey and colleagues that
"a simple mental state examination remains one of the most productive investigations" in ME/CFS.

Therefore, we recommend that
future research should scrutinize the above-mentioned pathways and
delineate novel drugs targeting these pathways
to treat this complex multisystem disease,
instead of iterating on the psychosocial aspects (6).



Frank N.M. Twisk and Michael Maes.




References

1.   Newton JL, Jones DEJ.
      Making sense of fatigue.
      Occup Med (Lond) 2010; 60:326-329. doi:10.1093/occmed/kqq014.
2.   Harvey SB, Mykletun A, Wessely S. Making sense of fatigue: the need for a balanced approach.
      Occup Med (Lond) 2010;60:665-666. doi: 0.1093/occmed/kqq166.
3.   Newton JL, Jones DEJ.
      Making sense of fatigue. Reply.
      Occup Med (Lond) 2010;60:666-667. doi:10.1093/occmed/kqq169.
4.   Matsuda Y, Matsui T, Kataoka K, Fukada R, Fukuda S, Kuratsune H, et al.
      A two-year follow-up study of chronic fatigue syndrome co-morbid with psychiatric disorders.
      Psychiatry Clin Neurosci 2009;63:365-373. doi: 10.1111/j.1440-1819.2009.01954.x.
5.   Harvey SB, Wessely S.
      Chronic fatigue syndrome: identifying zebras amongst the horses.
      BMC Med 2009;7:58. doi:10.1186/1741-7015-7-58.
6.   Maes M, Twisk FNM.
      Chronic fatigue syndrome: Harvey and Wessely's (bio)psychosocial model
      versus a bio(psychosocial) model based on inflammatory and oxidative and nitrosative stress pathways.
      BMC Med 2010;8:35. doi:10.1186/1741-7015-8-35.
7.   Wessely S. Chronic fatigue syndrome.
      Summary of a report of a joint committee of the Royal Colleges of Physicians, Psychiatrists and General Practitioners.
      J R Coll Physicians Lond 1996;30:497-504.
8.   Zhang L, Goudh J, Christmas D, Mattey D, Richards S, Main J, et al.
      Microbial infections in eight genomic subtypes of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME).
      J Clin Pathol 2010;63:156–164. doi:10.1136/jcp.2009.072561.
9.   Gow JW, Hagan S, Herzyk P, Cannon C, Behan PO, Chaudhuri A.
      A gene signature for post-infectious chronic fatigue syndrome. BMC Medical Genomics 2009;2:38. doi:10.1186/1755-8794-2-38.
10. Kaushik N, Fear D, Richards SC, McDermott CR, Nuwaysir EF, Kellam P, et al.
      Gene expression in peripheral blood mononuclear cells from patients with chronic fatigue syndrome.
      J Clin Pathol 2005;58:826-832. doi:10.1136/jcp.2005.025718.
11. Twisk FNM, Maes M.
      A review on cognitive behavorial therapy (CBT) and graded exercise therapy (GET)
      in myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS):
      CBT/GET is not only ineffective and not evidence-based,
      but also potentially harmful for many patients.
      Neuro Endocr Lett 2009;30:284-299. NEL300309R02.
12. Maes M, Twisk FNM.
      Chronic fatigue syndrome: la bête noire of the Belgian health care system.
      Neuro Endocrinol Lett 2009;30:300-311. NEL300309R04.
13. Newton JL, Mabillard H, Scott A, Hoad A, Spickett G.
      The Newcastle NHS Chronic Fatigue Syndrome Service: not all fatigue is the same.
      J R Coll Physicians Edinb 2010;40:304-307. doi:10.4997/JRCPE.2010.404.

1 comment:

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