Oxford criteria

[chrisb]

I still have not seen any indication as to why Gelder might have provided financial assistance, of any sort to the Oxford conference. I'm sure that I have seen comments from Sharpe that Gelder was supportive but had no particular interest in CFS. It is puzzling.

 

[JohnTheJack]

Merged thread
I seem to recall there was something right from soon after the Oxford criteria were created that showed or had Sharpe admitting that something like 43% of patients as diagnosed using Oxford have mental health problems.

I may be confusing different papers.

Is anyone able to help?

Anything showing things along these lines would help.

Thanks.

 

[Andy]

This?

Objectives
The aim of this study was to examine the accuracy of doctors at diagnosing co-morbid psychiatric disorders in patients with chronic fatigue syndrome (CFS).

Design
Case series comparing clinical diagnoses with a standardized structured psychiatric interview.

Setting
Secondary care specialist chronic fatigue syndrome clinic.

Participants
One hundred and thirty-five participants of a randomized controlled trial of non-pharmacological treatments at one centre in the PACE trial.

Main outcome measures
Current psychiatric diagnoses made by CFS specialist doctors, compared with current psychiatric diagnoses made independently using a structured psychiatric interview.

Results
Clinicians identified 59 (44%, 95% CI 39–56%) of patients as suffering from a co-morbid psychiatric disorder compared to 76 (56%, CI 53–69%) by structured interview. Depressive and anxiety disorders were most common. Clinicians were twice as likely to miss diagnoses (30 patients, 22%) than misdiagnose them (13, 10%). Psychiatrists were less likely to miss diagnoses than other clinicians, but were as likely to misdiagnose them.

Conclusions
Doctors assessing patients in a chronic fatigue syndrome clinic miss psychiatric diagnoses more often than misdiagnosing them. Missed diagnoses are common. CFS clinic doctors should be trained to diagnose psychiatric disorders.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2984352/

 

[JohnTheJack]

This?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2984352/

Yes, thanks, Andy. I think it was that. That's great.

 

[Peter T]

So on the basis of this study just over half those diagnosed with CFS under the Oxford criteria are likely to have a psychiatric disorder.

For the BPS crew this presumably is not seen as a problem, but for the rest of the world this means it is impossible to conclude anything about ME/CFS from a study using the Oxford criteria, even before any data has been collected. How would people react to a study of MS where in the region of half the MS participants also had cancer?

Do the BPSers ever try to explain this situation? Would they characterise these psychiatric conditions as distinct conditions co-occurring with the ME/CFS or are they somehow connected with the ME/CFS? Do they even see CFS as a discrete condition, or do they just see it as 'chronic fatigue' that is a symptom of various psychiatric conditions?

What seems to be a persistent feature of the BPSers is a profound lack of intellectual rigour, and a willing acceptance of methodological and theoretical ambiguity/confusion.

 

[Barry]

What seems to be a persistent feature of the BPSers is a profound lack of intellectual rigour

Mainly, it would seem, because of a profound lack of understanding of intellectual rigour

 

[DokaGirl]

Very good points @Peter Trewhitt and @Barry.

It seems they aim for methodological and theoretical ambiguity/confusion. That appears to be what they want. I don't think I'm wrong in saying,it seems the boundaries between "cfs" and mental health disorders have always been deliberately blurred by this group. That way "cfs" may always
remain in their bailiwick. Bigger empire and all that.

ETA: The Oxford criteria itself appears to prove this obfuscation.

ETA#2: I don't know if they lack intellectual rigour, or misunderstand it. My thought would be they don't lack it, and do understand it.

 

[rvallee]

Do the BPSers ever try to explain this situation?

Historical footage of this explanation:

 

[Sarah]

Anything showing things along these lines would help

Looks like Andy's post covers it, but I thought I'd post the following anyway. Short 1995 paper, first-named author is Russell Lane (co-author of Oxford). Ppts met Oxford Criteria. 43 of 96 participants were screened, 18 of which (42%) met criteria for psychiatric caseness.

Exercise responses and psychiatric disorder in chronic fatigue syndrome.
R. J. Lane, A. P. Burgess, J. Flint, M. Riccio, and L. C. Archard
BMJ. 1995 Aug 26; 311(7004): 544–545

We studied 96 consecutive patients meeting the Oxford criteria for diagnosis of the chronic fatigue syndrome3 by using the subanaerobic threshold exercise test.4 Subjects pedalled an electronically braked bicycle ergometer for 15 minutes at 90% of the predicted work rate at their anaerobic threshold, based on age, weight, and sex; venous blood lactate concentrations were measured before, immediately after, and 30 minutes after exercise. Continuous electrocardiographic monitoring allowed measurement of mean heart rate during exercise. An abnormal result was defined as lactate concentrations exceeding the upper 99% reference limit for normal control subjects4 at two or more time points. We screened a convenience sample of 43 of the 96 patients using 11 established neuropsychological and psychiatric instruments, including the present state examination, for assessment of psychiatric caseness and prediction of psychiatric diagnoses.5

The 43 patients studied by psychological and psychiatric tests did not differ significantly from the 53 other patients in terms of age (mean 34-6 v 34 4 years); mean duration of symptoms (43-6 v 37-1 months); sex distribution (19 men v 24 men); whether they were working (27 unemployed v 27 unemployed (not recorded in two cases)); or proportion with abnormal lactate responses (15/43 v 16/53). Eighteen of the 43 (42%) patients fulfilled criteria for psychiatric caseness. Diagnoses were neurotic depression (12 patients), manic depression (3), phobic anxiety (2), and anxiety state (1). Patients with normal lactate responses were more likely to fulfil criteria for psychiatric caseness than those with abnormal lactate responses (15/28 v 3/15; odds ratio 4-6 (1 06 to 20- 1)).

Obviously Oxford is to some extent explicit as to which mental health diagnoses are cause for exclusion and which may not necessarily be.

{f) Certain patients should be excluded from the definition. They include:
....
(ii) Patients with a current diagnosis of schizophrenia, manic depressive illness, substance abuse, eating disorder or proven organic brain disease. Other psychiatric disorders (including depressive illness, anxiety disorders, and hyperventilation syndrome) are not necessarily reasons for exclusion.

 

[JohnTheJack]

Looks like Andy's post covers it, but I thought I'd post the following anyway. Short 1995 paper, first-named author is Russell Lane (co-author of Oxford). Ppts met Oxford Criteria. 43 of 96 participants were screened, 18 of which (42%) met criteria for psychiatric caseness.

Exercise responses and psychiatric disorder in chronic fatigue syndrome.
R. J. Lane, A. P. Burgess, J. Flint, M. Riccio, and L. C. Archard
BMJ. 1995 Aug 26; 311(7004): 544–545





Obviously Oxford is to some extent explicit as to which mental health diagnoses are cause for exclusion and which may not necessarily be.

Thanks, Sarah. That's useful. Appreciate it.

 

[ME/CFS Skeptic]

I don't know if the figures of patients with a mental health diagnosis such as depression or anxiety are higher, using the Oxford criteria than with other criteria. At the time the Holmes criteria were used I think 50-75% of CFS patients had such a comorbid diagnosis.

 

[Barry]

It seems they aim for methodological and theoretical ambiguity/confusion. That appears to be what they want.

My feeling is that that it is all they've got, quite literally. I think psychiatry is all about grey areas, intangibles. It's as if psychiatry has evolved its own research practices, independently of mainstream science, but they call it science anyway ... but in many ways more akin to religion, a closed belief system.

 

[Sly Saint]

Didn't know about this angle in the creation of the Oxford criteria:

THE UK DEFINITIONS AND THE LURE OF AMERICAN GOLD

Starting well prior to 1988 a deepening crisis loomed in both US and North American
Research funding, in fact, there was no place in the world where there was sufficient
funds to support the scientific community who did not work for commercial interests.

With the publication of the 1988 CFS definition, N1H made it public that there was
going to be millions of dollars distributed to worthy scientists and clinicians who
wished to investigate CFS, not just in North America but also in the world.
Generally speaking it was not true of course and as mentioned earlier, most of the first 38 million
dollars went to existing projects on alcoholism, herpes virus research and other
projects that had nothing to do with M.E. or CFS.

Nightingale was able to document this in 1992 but later it became a generally openly published scandal. Of course the financially starved UK physicians and researchers did not know the history of the NIH funding. .......

Never the less, the British trout jumped at the bait and organized what was published as
the Oxford Guidelines in February 1991.

p26
https://www.imet.ie/imet_documents/BYRON_HYDE_little_red_book.pdf

 

[chrisb]

That is interesting. I have seen it before, but did not then have the knowledge which I now have.

My view is that the British psychiatrists may merely have been useful idiots. It seems to have been Eisenberg who introduced the idea of "spurious disease concepts" and somatisation to Oxford in 1987, which ties in suspiciously with the goings on at the CDC. We had to put up with "hysteria" but that was clearly outmoded.

Eisenberg co authored with Leighton Cluff and with Arthur Kleinmann on the travails of the US medical system. I still do not understand how we came to have a Harvard "cultural anthropologist" (Kleinmann) chairing the CIBA conference which set the tone for the future of ME (or CFS as they would have preferred to call it).

 

[Sly Saint]

posted elsewhere but definitely relevent here and worth a read.

July 2016 Addendum
Go to:
Introduction
The AHRQ evidence report on the Diagnosis and Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome was published in December, 2014 and provided a literature review for the National Institutes of Health Pathways to Prevention Workshop on Advancing the Research on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.1, 2 The review found eight case definitions for either chronic fatigue syndrome (CFS), myalgic encephalomyelitis (ME), or ME/CFS, and since its publication, an additional case definition was published by the Institute of Medicine along with the recommendation of a new name, Systemic Exertional Intolerance Disease.3 The Oxford (Sharpe, 1991) case definition is the least specific of the definitions and less generalizable to the broader population of patients with ME/CFS. It could identify individuals who have had 6 months of unexplained fatigue with physical and mental impairment, but no other specific features of ME/CFS such as post-exertional malaise which is considered by many to be a hallmark symptom of the disease.3 As a result, using the Oxford case definition results in a high risk of including patients who may have an alternate fatiguing illness or whose illness resolves spontaneously with time. In light of this, we recommended in our report that future intervention studies use a single agreed upon case definition, other than the Oxford (Sharpe, 1991) case definition. If a single definition could not be agreed upon, future research should retire the use of the Oxford (Sharpe, 1991) case definition. The National Institute of Health (NIH) panel assembled to review evidence presented at the NIH Pathways to Prevention Workshop agreed with our recommendation, stating that the continued use of the Oxford (Sharpe, 1991) case definition “may impair progress and cause harm.”2 In light of this, we have received public comment requesting a separation of results based on case definition to appraise the impact of Oxford based trials on conclusions of the report. Additionally, the public has requested that we separate cognitive behavioral therapy (CBT) from other counseling and behavioral interventions given that CBT is a specific therapeutic approach.

The purpose of this addendum to our original report is to assess the impact of studies using the Oxford (Sharpe, 1991) case definition on conclusions and to assess the impact of separating studies of cognitive behavioral therapy from other counseling and behavioral interventions.

Results
What are the (a) benefits and (b) harms of therapeutic interventions for patients with ME/CFS, and how do they vary by patient subgroups?
All intervention trials used a case definition for CFS as eligibility for trial inclusion. The results may not be applicable to individuals fulfilling criteria for ME or ME/CFS. Harms are generally poorly reported and conclusions surrounding harms are not impacted by this further analysis.

Cognitive Behavioral Therapy
...
Based on these results, the overall analyses of function outcomes, including the studies using Oxford (Sharpe, 1991) case definition inclusion criteria, provided low strength of evidence that CBT improves function. In removing the two Oxford case definition based studies, we are left with four fair-quality studies, two finding benefit (n=174), one finding no benefit (n=153), and one finding stable function in the CBT group but worsening function in the usual care group (n=65).
Unlike the positive results of the Oxford based trials, the results of the trials fulfilling the CDC criteria are mixed and would provide insufficient evidence to determine the effectiveness of CBT on the outcome of function due to study limitations, inconsistency and imprecision of results.

Fatigue
Fatigue outcomes were evaluated in six trials (n=930), one of which used the Oxford (Sharpe, 1991) case definition for inclusion.30 Decreased fatigue was found in four (n=807), including the Oxford based trial30and three fair quality CDC based trials.22, 23, 28, 34 The overall analyses of fatigue outcomes, including the single study using Oxford case definition inclusion criteria, provided low strength of evidence that CBT improves fatigue. In removing the Oxford case definition based study, we are left with four fair-quality studies, three finding benefit (n=327) and one finding no benefit (n=65), and one poor-quality study finding no benefit (n=58). The results are generally consistent with the overall conclusion and would provide low strength of evidence that CBT improves fatigue.

Global Improvement
Two trials (n=540), one with Oxford inclusion criteria, evaluated global improvement and found benefit with CBT providing low strength of evidence that CBT benefits global improvement22, 23, 30 By excluding the study that used the Oxford case definition, there would be insufficient evidence to determine the effectiveness of CBT on the outcome of global improvement although the results of the single CDC based trial are consistent with the Oxford based trial.

Function
Of the six trials evaluating measures of function (n=725), two used the Oxford (Sharpe, 1991) case definition for inclusion and both did not find improvement in function, n=301.31, 38-40 Of the four trials fulfilling the CDC (Fukuda, 1994) case definition, two found benefit (n=283),24-26,33,35 and two found no benefit (n=141).32,36 Four of the trials considered the SF-36 physical function subscale as the outcome measure (Figure 2). Of these, none found statistically significant benefit. Two of the other trials (n=183), one comparing self-instruction with wait list control and one comparing cognitive therapy with anaerobic activity therapy or relaxation, found improvement in measures of function.24-26, 33, 35 Overall, the analyses including the trials based on the Oxford (Sharpe, 1991) case definition provides low strength of evidence that counseling and other behavioral therapies do not improve function compared with controls. By excluding the Oxford case definition based trials, we are left with two trials finding benefit (n=283) and two trials, including one poor-quality trial, finding no benefit (n=141), which would provide insufficient evidence to determine the effectiveness of counseling and other behavioral therapies on the outcome of function. The CDC based results are mixed and thus inconsistent with the Oxford based studies, which found no improvement.

Exercise Therapies
Six trials compared different forms of exercise therapy with control groups. Three trials used the Oxford (Sharpe, 1991) case definition for inclusion, all of which evaluated the effectiveness of graded exercise therapy (GET).12, 30, 41 Of the three trials using the CDC (Fukuda,1994) case definition, one trial evaluated the effectiveness of GET.42 The other two trials evaluated other exercise interventions and do not impact this addendum.43-45

Graded Exercise Therapy
Four trials evaluated the effectiveness of GET compared with a control group (n=656) (Table 6, Figures 3 and 4). Of these, three used the Oxford (Sharpe, 1991) case definition (n=607)12, 30, 41 while one small trial used the CDC (Fukuda, 1994) case definition (n=49).42 The results are consistent across trials with improvement in function, fatigue, and global improvement and provided moderate strength of evidence for improved function (4 trials, n=607) and global improvement (3 trials, n=539), low strength of evidence for reduced fatigue (4 trials, n=607) and decreased work impairment (1 trial, n=480), and insufficient evidence for improved quality of life (no trials) (Table 7). By excluding the three trials using the Oxford (Sharpe, 1991) case definition for inclusion, there would be insufficient evidence of the effectiveness of GET on any outcome (1 trial, n=49).

Conclusions
Although future studies should refrain from using the Oxford (Sharpe, 1991) case definition as eligibility requirements, this early work provided a foundation on which future work can expand. This addendum has delineated differences in treatment effectiveness and harms according to case definitions, highlighting studies that used the Oxford (Sharpe, 1991) case definition and how these studies impacted our conclusions. Additionally, results of studies evaluating CBT have been considered independently from other counseling and behavioral therapies. Our sensitivity analysis would result in a downgrading of our strength of evidence on several outcomes which can be attributed to the decrease in power, dominance of one large trial, or lack of trials using criteria other than the Oxford (Sharpe, 1991) case definition for inclusion. Blatantly missing from this body of literature are trials evaluating effectiveness of interventions in the treatment of individuals meeting case definitions for ME or ME/CFS.

https://www.ncbi.nlm.nih.gov/books/NBK379582/

 

[Sly Saint]

This reminds me of the advice given to Steven Holgate (CMRC? or MEGA) by Simon Wessely about the 'sprinkling' a few biomedical researchers to add credence.

someone has asked me for the source of this; so thought I should post it here

It was posted on PR back in the day........

"Wessely supervised the appointees to the committee


https://www.dropbox.com/s/92m09l9tq55pihh/Behind the Scenes - Research Collaborative.pdf

Professor Holgate then emailed Professor Simon Wessely with importance marked as ‘High’ and copied only to Dr Esther Crawley of Bristol University and Joe McNamara of the MRC.

It read

•“Dear Simon, If you feel there is anything you can do to help in identifying researchers or in other ways, I would be very grateful. Thank you so much. Kind regards, Stephen.” (quote 2)

•Simon Wessely replied “First of all, it looks very good...... can’t see many ommissions (sic). I would probably sprinkle one or two scientists/researchers not particularly connected with CFS into the mix myself. Experimental psychologist perhaps, joe, do you know one?....” Simon Wessely’s suggested researchers were redacted. (quote 3)

•Stephen Holgate replied “Wow! This is terrific, Simon – thanks so much. I will add your suggested names. Kindest regards, Stephen” (quote 4)
"

post is John Mac
https://forums.phoenixrising.me/thr...ual-science-conference-2016.47067/post-768731

 

[DigitalDrifter]

The Oxford criteria is tantamount to research fraud. How would cancer or AIDS patients feel if research for their illness included anyone who felt a bit tired?

ME should be defined as patients who experience an adverse reaction to exercise or exertion.

 

[Mithriel]

ME was defined as an adverse reaction to exercise and exertion, it was CFS that made it a disease of fatigue. Fatigue in ME was always like fatigue in MS, a difficult symptom but not the defining one.

The BPS people included everyone who experienced fatigue and lumped them together. They concentrated on things which made diseases the same instead of distinguishing differences which made it much harder to find any consistent biological findings. It is almost as if they wanted to make it difficult to disprove it is a psychological condition.

A bit late to the discussion, but I read that Wessely was at the conference in the US which defined CFS and Sharpe was involved too. Other psychologists may have come in to get some of the research money but they were part of the initial fraud. It is beyond understanding that the CDC could be brought in to understand an outbreak of disease then define it as "needing 6 months of fatigue"