The ‘medically unexplained symptoms’ syndrome concept and the cognitive-behavioural treatment model, 2021, Scott, Crawford, Geraghty and Marks

Yes, CBT as a treatment for ME/CFS is simply bogus. Even if (big if) there are any comorbidities that CBT might be applied to, similar to might be the case with comorbidities encountered by cancer sufferers for example, the comorbidities are distinct and separate from ME/CFS, and have no part in any treatment for ME/CFS. Same as CBT plays no part in treating cancer, even though it might be used to help with comorbidities.

CBT as a treatment for anything, is based on the assumption that the issue being treated is a cognitive behavioural one. If it is not then CBT is the wrong treatment!

 

Actually the current NICE guidelines make it clear that there is no evidence to support the use of CBT or GET for those with severe ME, and that they are only appropriate for mild or moderate cases. Then it goes on several lines later to make suggestions as to what sort of GET would be suitable for someone with severe ME!

 

From my perspective as a psychologist, within and outside of the NHS, SSD is little used because clinicians avoid it and see it as unhelpful in day to day clinical practice. It is not useful clinically, therapeutically nor has it a sound basis from validity or reliability perspective. Therefore, it is not or rarely used. Occasionally, SSD appears in medico-legal cases as I mentioned above.

Regarding "DSM-5 abandoned the use of the term ‘medically unexplained symptoms’ for non-neurological disorders" MUS on its own was not included within DSM-5. SSD did make the cut. Within the somatic symptoms chapter DSM-5 retained Conversion disorder with changed criteria and this is listed in DSM-5 as Conversion disorder (functional neurologic symptom disorder) making this distinct from SSD. So in essence DSM-5 retained MUS in this way for the types of presentations seen within neurology clinics, for example, where patients have symptoms of altered voluntary motor, cognitive, or sensory function that are not compatible with any recognized neurological condition. My impression is that the FND diagnosis and this label is being used more often of late. I have not seen the use of conversion disorder at all.

 

I am afraid that I agree.

Using Maes and Twisk as a comparator is unwise. Maes produces as much nonsense as BPS people.

The suggestion that what is needed is more training of psychologists is wrong. If we do not know what is wrong with people and we have no evidence that psychological intervention helps then there is no reason to involve psychologists at all. The only justified approach is to provide patients with what information is possible about the likely cause and prognosis of their problems and the people trained to do that are doctors. I do not see how a psychologist can provide information about pain or fatigue.

 

I fully agree.

In general, why is it a problem to admit, that something hasn`t been understood? As a patient I had had the expectation that I am not lied at. I can bear my bad luck. What do people think can they achieve with wishy-washy-somehow-it-might-be-do-anything? In fact a lie is an intended falsehood, and a typical danger of falsehoods are failures in deeds. (I am getting angry here, btw.)

 

which are not considered by many clinicians who work in the area of "functional neurological disorders" to be neurological conditions. Therefore they are considered "non-neurological disorders".

But you have said:

and:

I'm afraid I'm still struggling with the logic here.

 

David Marks, one of the co-authors of this editorial, is the editor of the Journal of Health Psychology and Keith Geraghty is a member of the editorial board.

 

Unfortunately, every bloody pain clinic I’ve ever been referred to has claimed the exact opposite….

Edited for clarity of phrasing. Blame brain fog.

 

The suggestion regarding the training of psychologists is to educate them that MUS is not a viable, useful, or helpful approach. We do not need or want more psychologists working in MUS, we would like them to be aware of the bogus claims of MUS and the bogus and flawed CBT MUS model.

The paper is aimed at psychologists, the vast majority of whom have little or no idea about MUS; the MUS CBT model; the push to incorporate MUS within IAPT, and so forth. The purpose of the paper is largely to raise awareness that in some small quarters MUS is being pushed as a way of incorporating poorly understood medical conditions, for example, within IAPT. Most jobbing psychologists, who are the audience for this paper, are unaware of MUS or the CBT MUS model and what it entails. In my experience, those that encounter MUS and read into it consider it poor and unhelpful. Their responses to our paper confirms this.

Using Maes & Twisk may be unwise; however, we are not commenting on the quality of the biomedical evidence, that is not our role. We highlight that biomed variables are better predictors of outcome than psychological ones.

Our article highlights just how bad MUS and the CBT MUS model are and educates psychologists by highlighting the poor reliability, validity and harms caused by it. This is our intention and the feedback from the intended audience has that this is what is being understood as the take home message.

In an ideal world when doctors are working with patients with poorly understood conditions, they would be honest with them about this. This has not been my experience, nor the experience of many pwME. Sadly, a few BPSers have filled this void in medical knowledge by claiming a warped CBT model can solve multiple problems without evidence. Much of the medical professional has gone along with this and have accepted it uncritically. MUS is but one of multiple BPS approaches. We can only cover one such BPS approach in this one editorial.

When reading the paper please keep in mind that there is a limited word count, and we are constrained in what can realistically be covered in one editorial. MUS is duplicitous, harmful garbage that needs challenging. As I and my colleagues are aware of the multiple issues with MUS, if we were to stay silent, we are to some degree complicit. To remain silent could send the message that we are fine with it – when we are clearly not. By publishing we are not in any way legitimising MUS as a concept – not at all - we aim to educate and demolish. MUS deserves to be in the garbage can. If we speak out, we may be misunderstood on this forum, however, please keep in mind that this forum is not the intended audience.

To be clear – we are not advocating for more psychologists for MUS. Nor do we think that MUS is a good thing.

Thanks for taking the time to engage on this topic. It is good to discuss, debate and so on.

@Jonathan Edwards @Hutan @Dx Revision Watch @Trish @Sly Saint @Barry @Andy @Arvo @Creekside

 

This explanation of the dynamic behind the strained patient-doctor relationship was really on point:

"Attempting to induce patients into cognitive behaviour therapy (CBT) to change the way they are alleged to habitually think has not proved a successful strategy, as the revised NICE (2020) guidance has concluded.

Rather than question the legitimacy of CBT and the treatment model, clinicians can attribute the failure of CBT to patients’ unwillingness to change their beliefs and behaviours. Thus a recursive vicious circle is established: doctor’s analysis→MUS patient’s unhelpful beliefs and behaviours→CBT→failure→doctor’s analysis→patients’ unhelpful beliefs.

This recursive victim-blaming cycle is likely to make patients with MUS feel worse, frustrated and angry"

And the visual representation as well:

 

https://mecentraal.wordpress.com/20...nd-the-cognitive-behavioural-treatment-model/