Michael Sharpe: Mind, Medicine and Morals: A Tale of Two Illnesses (2019) BMJ blog - and published responses

BMJ Medical Humanities
https://mh.bmj.com/content/early/20...v0hzcMAtp1py0pa19_6XmUWojVfQLeZCDjp-p0X3wNzqw

Current controversy

The concept of ‘illness without disease’ impedes understanding of chronic fatigue syndrome: a response to Sharpe and Greco
  1. Steven Lubet1,
  2. David Tuller2
Abstract
In a recent article in Medical Humanities, Sharpe and Greco characterise myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) as an ‘illness without disease’, citing the absence of identified diagnostic markers. They attribute patients’ rejection of psychological and behavioural interventions, such as cognitive–behavioural therapy (CBT) and graded exercise therapy (GET), to a ‘paradox’ resulting from a supposed failure to acknowledge that ‘there is no good objective evidence of bodily disease’.

In response, we explain that understandings about the causes of and treatments for medical complaints have shifted across centuries, and that conditions once thought to be ‘psychosomatic’ have later been determined to have physiological causes. We also note that Sharpe and Greco do not disclose that leading scientists and physicians believe that ME/CFS is a biomedical disease, and that numerous experts, not just patients, have rejected the research underlying the CBT/GET treatment approach.

In conclusion, we remind investigators that medical classifications are always subject to revision based on subsequent research, and we therefore call for more humility before declaring categorically that patients are experiencing ‘illness without disease’.
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paragraphs added for easier reading.
 
The Faculty Lounge
Is ME/CFS an "Illness without Disease"?
No. No it is not. No matter what certain psychiatrists have opined. David Tuller and I have an essay on Medical Humanities -- titled "The concept of ‘illness without disease’ impedes understanding of chronic fatigue syndrome" -- explaining how psychiatry has frequently mischaracterized biomedical diseases, including ME/CFS. Here is the gist:
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https://www.thefacultylounge.org/2020/06/is-mecfs-an-illness-without-disease.html
 
ACLP Appoints Hochang Lee, MD, FACLP, as Psychosomatics Editor-in-Chief from January 2021
Dr. Lee is the John Romano Professor and Chair of the Department of Psychiatry at the University of Rochester School of Medicine and Dentistry. Prior to his chairmanship at University of Rochester, he was the founding director and Chief of Yale's Psychological Medicine Section, at Yale New Haven Hospital's York Street and St. Raphael campuses. He also directed Yale's Psychological Medicine Research Center. Previously, he was Associate Professor of Psychiatry at Johns Hopkins University School of Medicine, and Director of Research Development at the Johns Hopkins Bayview Medical Center.

Dr. Lee is board certified in psychiatry with sub-specialty certification in psychosomatic medicine.
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ACLP President Michael Sharpe, MA, MD, FACLP, said, "The appointment of a new Editor-in-Chief for our journal is great news for the Academy, and a notable success in what is turning out to be an extraordinary year for us all. Despite the challenges of COVID-19, the task force led by Dr. Don Rosenstein that was charged with searching for and recommending a new editor, continued their work with great thoroughness. In the event, they had to select from many highly qualified applicants. Their search and selection processes are now complete and on August 6 the ACLP Board unanimously confirmed the appointment of Ben Lee. Ben will take over the reins of the journal from Dr. Ted Stern, our Editor-in-Chief for the last 13 years, in January 2021. I congratulate Ben on his appointment and thank Ted for his long and diligent stewardship of our journal. Our Academy is very fortunate to be served in this way by such great physicians and scholars."
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https://myemail.constantcontact.com...-2021.html?soid=1102670834514&aid=r4SJf-xEeCk
 
‘Important Moment in Disseminating the Proactive C-L Model across the Atlantic’
Paper describes a new version of Proactive C-L Psychiatry for medical inpatients with multimorbidity

ACLP president Michael Sharpe, MD, FACLP, has taken the Proactive C-L Psychiatry model into Europe. A recent paper, authored by Dr. Sharpe and two other ACLP members, Jane Walker, MBChB, PhD, and Mark Toynbee, describes Proactive Integrated Consultation-Liaison Psychiatry (PICLP).

Proactive-model.jpg

Michael Sharpe, MD, FACLP (right), Jane Walker, MBChB, PhD, and Mark Toynbee
PICLP is a fusion of the proactive C-L Psychiatry model and the integrated care model. It was specifically designed for medical inpatients with multimorbidity. The paper describes the new PICLP service model and includes a service manual and checklists, used to ensure consistent delivery of PICLP from the time patients arrive on hospital wards until their discharge.

PICLP is currently being evaluated in The HOME Study, the first randomized trial of Proactive C-L Psychiatry and the largest trial of C-L Psychiatry ever done. Dr. Sharpe and colleagues have recruited 2,744 patients to the trial.
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https://www.clpsychiatry.org/aclp-news/y2020/m09/proactive-model/

thread on HOME study here
https://www.s4me.info/threads/the-home-study-michael-sharpe-s-cbt-for-the-elderly.2499/
 
Amw66 said:
The study with no control group ?
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Yup. The same one with extremely perverse incentive of discharging patients quicker without any consideration for whether it's a good idea or not. It's all about money, cheapening the delivery of care to a standardized fast-food medicine. But, hey, it's "personalized" since you get a fortune cookie with a unique generic words-of-cheap-wisdom.
 
The illness-disease dichotomy and the biological-clinical splitting of medicine
Luigi Tesio ,1,2 Marco Buzzoni3

Abstract
In a recent paper, Sharpe and Greco (2019) argue that some clinical conditions, such as chronic fatigue syndrome (sometimes called myalgic encephalomyelitis), should be treated by altering the patient’s experience and response to symptoms without necessarily searching for an underlying cause.
As a result, we should allow for the existence of ’illnesses without (underlying) diseases’. Wilshire and Ward (2019) reply that this possibility requires unwarranted causal assumptions about the psychosocial origins of conditions not predicted by a disease model.
In so doing, it is argued that Sharpe and Greco introduce epistemological and methodological problems with serious medical consequences, for example, patients feel guilt for seeking treatment for illnesses that only exist ’all in the mind’, and medical researchers are discouraged from looking for more effective treatments of such conditions.
We propose a view that integrates the insights of both papers. We abandon both the strict distinction between disease and illness and the naïve unidirectional account of causality that accompanies it.
This, we claim, is a step towards overcoming the current harmful tendencies to conceptually separate (1) Symptom management and disease-modifying treatments. (2) Rehabilitative-palliative care and ’causal’ curing. (3) Most importantly, biomedicine and clinical medicine, where the latter is currently at risk of losing its status as scientific.
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pdf
https://mh.bmj.com/content/medhum/early/2020/09/28/medhum-2020-011873.full.pdf
 
This is infuriating.

And I know exactly why they write this. It is precisely because they believe that the Sharpe / Greco paper doesn't make the case as best it could to KEEP the rehabilitative / disease modifying therapies in the mix. This is the purpose of the supposed synthesis of the two positions (Sharpe/Greco)(Wiltshire/Ward).

For example:

In medicine, the success of the illness-disease dichotomy, which Sharpe and Greco strive to bridge, shares the same ‘reductionist’ origin with the simplistic distinction between ‘symptomatic’ and ‘disease-modifying’ approaches. Of course, ‘symptomatic’ treatments are those focused on problems downhill* from the ‘true cause’ of the clinical condition. This distinction inspires everyday medical research language. For example, consider the case of multiple sclerosis, a chronic and disabling neural disease wherein ‘symptomatic’ approaches may include psychotherapy and motor rehabilitation,22while ‘disease-modifying’ approaches may include immune ‘modulating’ drugs to marrow transplants.
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*they mean downstream here

As far as I am aware of the total pool of people with MS probably all of them are looking for a treatment for their symptoms and are waiting hopefully for a treatment that is curative. Of that total some sub-set (minority) may want to receive psychotherapy.

It is this constant arrogance of the people who do these kinds of treatment to elevate their approach as of equal importance / weight with patients. Just to repeat myself, they are extremely arrogant.

But there's more arrogance to come:

However, as argued above by Sharpe and Greco (and confirmed from the perspective of a pragmatic and contextual theory of causation), symptoms should be considered equally real as possible underlying ‘causes’. The usefulness of reaching deeper causal layers is justified only insofar as it opens up a greater scope of possible interventions. Unfortunately, the implicit symptom-disease hierarchy may strongly bias research investment: why waste resources on ‘symptoms’ if we can search for a ‘cause’? Further, it could delay useful hypotheses based on behavioural observations, consistent with a spiraliform rather than unidirectional process of knowledge advancement.
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So patient advocacy perspectives that ask for research into cause are unfortunate. Implicitly, I presume by affecting the BPS pocketbook for future funding and not being allowed to run totally free with no oversight. Those poor people. (bps) Don't we all just feel their pain.

Should I mention as an FYI that this is my mild-mannered version? The gall of bps thinking (if one can really call it that), metaphorically it pretty much blots out the sun.
 
This philosophizing is just an attempt to give credibility to an approach that we already know has failed. Sharpe tried to make his BPS illness model work and failed.

It's a tactic to shift the debate away from objective reality and actual research findings into a purely theoretical territory where rhetoric alone can win.
 
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I am confused

However, while we accept that both the experience of illness and what is usually called disease are ‘abstractions’, this is not enough. It is still necessary to raise the question of the relationship both between such abstractions and between them and the rest of reality, clarifying how abstractions thus conceived are connected, at least in principle, in an intersubjectively reproducible and testable way.

I do not understand what they mean by "reality". I thought that such reifications were better avoided.
 
chrisb said:
However, while we accept that both the experience of illness and what is usually called disease are ‘abstractions’, this is not enough
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I can almost guarantee that if they became seriously ill with ME they would no longer view their experience of illness as a mere abstraction. It is the privilege of the healthy to talk this kind of nonsense and impose it on others.
 
strategist said:
This philosophizing is just an attempt to give credibility to an approach that we already know has failed. Sharpe tried to make his BPS illness model work and failed.

It's a tactic to shift the debate away from objective reality and actual research findings into a purely theoretical territory where rhetoric alone can win.
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Maybe I'm weird, but I prefer scientists who have mastered object permanence.

This is just mental masturbation. I don't think anyone should pay attention to it, just self-important people who think their thoughts are just as good as real evidence, talking about things they neither understand now have experienced.
 
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