Friday, July 22, 2011

Science vs. Psychiatry

Science versus Psychiatry – again

Malcolm Hooper  and  Margaret Williams        22nd July 2011

In her BMJ editorial in which she referred to "myalgic encephalitis"
instead of the correct term "myalgic encephalomyelitis" (Ending the
stalemate over CFS/ME: BMJ 2011:342:d3956), Fiona Godlee described the
disagreement between the biomedical and psychosocial schools of
thought about ME as "an unproductive standoff in which…all progress is
being stifled by increasingly aggressive intimidation of researchers".

The "unproductive standoff" certainly existed and may be said to be
the result of 25 years of inflexible arrogance by "overly powerful
psychiatrists who hold key positions in medicine, research, media
gatekeeping and government policy…suppressing the argument that ME may
be biomedical rather than psychiatric"  (Let psychiatric and
biomedical lobbies be heard equally in CFS/ME research; Caroline
Davis: BMJ 2011:343:d4544).

Following her editorial, Godlee published a letter from Professor
Peter White (Chief Principal Investigator of the notorious PACE Trial)
in which he was joined by Alastair Miller (medical advisor to the
charity Action for ME) and by paediatrician Esther Crawley (renowned
for her belief in the Lightning Process in the management of ME) in
which they decried the need for adequate assessment of patients with
ME as being "a significant burden" on both patients and doctors.

When did careful assessment of sick people stop being part of the
practice of medicine, particularly when the disorder in question is
known to be both complex and chronic? The answer seems to be that it
was when Wessely School psychiatrists and others who work for the
insurance industry became the arbiters of what constitutes disease or

In their published letter, White et al use inverted commas when
referring to "symptoms" of ME such as "ataxia" and "palpitations with
cardiac arrhythmias" and "loss of thermostatic stability", denoting
their dismissal of such symptoms as genuine components of ME; indeed,
White et al go on to refer to the assessment of "too many symptoms of
dubious validity".

Godlee also afforded a platform for psychiatrist Alastair Santhouse
(who, with Esther Crawley, was a member of the Guideline Development
Group that produced the NICE Clinical Guideline on "CFS") to reject
valid criticisms of the PACE Trial ("the sound rebuttal by the Medical
Research Council and the Lancet to allegations that the PACE trial was
in some way improper should be proof enough" – BMJ 2011:343:d4550).

However, a positive step has just been taken towards resolving the "standoff".

Not only were researchers from 13 countries including the UK not
intimidated by their patients with ME, they have now produced
International Consensus Criteria specifically for ME (ME:
International Consensus Criteria; Bruce M Carruthers et al; Journal of
Internal Medicine: Accepted Article:

Between them, the international panel have about 400 years of both
clinical and teaching experience of ME; they have authored hundreds of
peer-reviewed publications and they have diagnosed or treated
approximately 50,000 (fifty thousand) ME patients.

The abstract is clear: "In view of more recent research and clinical
experience that strongly point to widespread inflammation and
multisystemic neuropathology, it is more appropriate and correct to
use the term 'myalgic encephalomyelitis' (ME) because it indicates an
underlying pathophysiology.  It is also consistent with the
neurological classification of ME in the World Health Organisation's
International Classification of Diseases (ICD G93.3)".

The expert authors explain that the purpose of developing the latest
international criteria was to base them on current knowledge of ME
that reflects the complex symptomatology and they have produced
guidelines which "promote optimal recognition of ME by primary care
physicians and other health care providers".

The authors point out that ME "is a complex disease involving profound
dysregulation of the central nervous system and immune system,
dysfunction of cellular energy metabolism and ion transport, and
cardiovascular abnormalities".

They note that the use of overly inclusive criteria in research has
included people who do not have ME and that this leads to "biased
research findings, inappropriate treatments, and waste(d) scarce
research funds".

The International Consensus Criteria are soundly supported by research
and are based on 123 cited references; the authors note that broadly
based studies show a lack of objective findings and state that "the
primary goal of this consensus report is to establish a more selective
set of clinical criteria that would identify patients who have
neuroimmune exhaustion with a pathological low threshold of
fatigability and symptom flare in response to exertion".

The authors are explicit: "Pain and fatigue are crucial bioalarm
signals that instruct patients to modify what they are doing in order
to protect the body and prevent further damage.  Post-exertional
neuroimmune exhaustion is part of the body's global protection
response and is associated with dysfunction in the regulatory balance
within and between the nervous, immune and endocrine systems, and
cellular metabolism and ion transport".

The panel members consider the neurological impairments including
structural and functional abnormalities seen on neuroimaging studies
in ME; they address the immune impairments including decreased natural
killer cell signalling and function; abnormal growth factor profiles;
decreased neutrophil respiratory bursts with a shift towards a Th2
profile; chronic immune activation with increases in inflammatory
cytokines, pro-inflammatory alleles, chemokines and T lymphocytes, and
dysregulation of the antiviral ribonucelase L (RNaseL) pathway.

They consider the evidence of profound energy impairment and poor
cardiac performance and they note the possible involvement of altered
control and reduced cortisol production during and after exercise.

They note the evidence of abnormal blood pressure regulation and the
measurable vascular abnormalities that suggest the brain is not
receiving sufficient circulating blood volume when the patient is
upright and that this is intensified when standing in one place such
as in a grocery checkout line.

The authors discuss the clinical application of their criteria, as
well as paediatric considerations and research applications.

The authors conclude that they "believe the International Consensus
Criteria will help clarify the unique signature of ME" and they state
unambiguously that "individuals meeting the International Consensus
Criteria have myalgic encephalomyelitis and should be removed from the
Reeves empirical criteria and the National Institute for (Health and)
Clinical Excellence (NICE) criteria for chronic fatigue syndrome".

This approach could not be more different from that used by Professor
White in the PACE Trial, in which he used the intentionally broad
Oxford criteria that do not discriminate between ME and chronic
medically unexplained fatigue.

The adoption of these international diagnostic criteria would ensure
that future studies are investigating people with well-defined ME and
would thus satisfy one of the biggest complaints from within the ME
community (ie. that previous studies have not been looking at a
homogeneous group of ME patients). It would certainly be a positive
step towards resolving the standoff between science and psychiatry.

Permission to repost.

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