The chronic fatigue syndrome; psychiatric aspects, 1991, K.E. Hawton et al.

While researching the origins of the ideas regarding ME, I came across this paper. I'm going to post it in full, translated, because I think it's also a document of key importance for UK researchers interested in the history of the Wessely School's ideas about ME.


It appeared in Nederlands Tijdschrift voor Geneeskunde (Dutch Journal of Medicine) in October 1991 (accepted July 26th 1991); Nederlands Tijdschrift voor Geneeskunde 1991; 135, nr 43, page 2014-2017, which included several other articles about CFS, including the first official publications of the Dutch Nijmegen group.

Translated with Google translate and then refined by me:

The chronic fatigue syndrome; psychiatric aspects, 1991, K.E. Hawton and M.W. Hengeveld.

28-10-1991


See also the articles on p. 2005, 2010, 2017 and 2019 .

A number of contributions in this journal issue are devoted to chronic fatigue syndrome. This article provides an overview of the characteristics and possible psychiatric and psychosocial causes of this syndrome. In addition, a cognitive-behavioral therapeutic approach as developed in the United Kingdom is described.

CHARACTERISTICS
Chronic fatigue syndrome is likely synonymous with or related to several other syndromes, which have been given a rich variety of names, such as epidemic (or post-infectious) neuromyasthenia, neurocirculatory asthenia, myalgic encephalomyelitis (ME), post-viral fatigue syndrome, and chronic Epstein-Barr syndrome. . However, the frequently used term chronic fatigue syndrome is preferable because it implies no suspicion of its cause.

Recently, at a consensus meeting of UK experts, diagnostic criteria have been developed for future research into chronic fatigue. 1Two syndromes were described: the chronic tiredness syndrome (CMS; [het chronische-moeheidssyndroom] ‘chronic fatigue syndrome’) and the post-infectious tirednes ssyndrome (PIMS; [het postinfectieuze moeheidssyndroom] ‘post-infectious fatigue syndrome’), a subtype of the CMS. The criteria for the CMS are: a syndrome characterized by severe and debilitating tiredness as the main complaint, impairing both physical and psychological functioning, with a clear onset (ie not for life) and present for at least six months for more than 50% of the time. Side complaints may also be present, such as persistent sore throat, headache, muscle aches, sensations of fever, and swollen joints and lymph nodes. Common psychological complaints are: sadness, crying spells, irritability, concentration problems, insomnia or excessive need for sleep,feelings of hopelessness and even suicidal thoughts. Exclusion criteria are: physical illnesses known to cause severe tiredness (eg severe anemia) and schizophrenia, manic-depressive disorders, psychotropic substance abuse, eating disorders or organic-psychiatric disorders. Other psychiatric disorders (including non-bipolar major depressive disorders, anxiety disorders and hyperventilation syndrome) are not necessarily grounds for exclusion, especially because they could also occur secondary to the CMS.

CHARACTERISTICS OF THE TIREDNESS
There is a pronounced muscle fatigue at the CMS. Patients usually complain that exercising is extremely demanding and leads to severe fatigue that can last for hours, days, or even weeks. The fatigue seems to be of a central nature: muscle function is generally normal and the muscles are neither weakened nor noticeably fatigued. 2 3 Nor have there been any indications of impaired neuropsychological functioning in objective tests, while psychological fatigue is also an important complaint at the CMS. 4

PSYCHIATRIC DISORDERS
A high prevalence of psychiatric disorders has been found in patients with the CMS. 5-10 For example, of 100 patients with CMS presented to an internal medicine outpatient clinic in the US, 66 were found to have one or more psychiatric disorders: 47 had depressive disorders, 15 somatization disorders and 9 anxiety disorders. 7 Depressive disorders are the most common psychiatric diagnosis in all studies, ranging from nearly half to more than two-thirds of cases. It is important, however, that depressive disorders have never been diagnosed in àll cases.


CAUSES

Psychiatric causes.
While it is well established that psychiatric disorders, especially depression, play an important role in patients with CMS, the nature of this role is unclear. One study found a greater number of depressive episodes in the history of patients with CMS than would be expected, 5 while another study found no difference with the general population in this regard. 10There may be an association between susceptibility to major depressive disorder and susceptibility to the CMS. It is likely that the depression is part of the syndrome rather than a response to it, as major depressive disorder was more frequently diagnosed in patients with CMS than in patients with at least equally disabling neuromuscular diseases. 9 Another possibility is that the CMS is a variant of major depressive disorder. An essential difference is that depressed patients with CMS, compared to a control group of depressed psychiatric patients, were much more likely to attribute their illness to a physical cause. 9 In addition, a large minority of patients with CMS do not meet the criteria for a major depressive or other psychiatric disorder.

Psychosocial causes.
Several authors have pointed to the striking susceptibility to CMS of people who had consistently worked very actively on their physical fitness. Excessive exercise could lead to an increased risk of CMS, but such people may also be overprotective of physical symptoms and therefore respond more strongly to post-infectious fatigue.

Like neurasthenia towards the end of the last century, 11 CMS is a fashion diagnosis. The general, positive interest in the syndrome probably shapes the complaints of people who have various disorders, both psychiatric and somatic, by which an epidemic of the syndrome suddenly seems to appear. Other suggested causes of the CMS are the speed and pressure of modern existence, like it was said about the neurasthenia a century ago. 12 Although such general ideas probably contribute little to our understanding of the syndrome, the specific role of stress in the CMS needs further investigation.

The firm belief of many patients with CMS that their disease is caused by a viral infection may also be of significance for the maintenance of complaints, as evidenced by a follow-up study that found a link between this belief and an unfavorable course . 13 Another factor that contributes to the maintenance of the CMS may be the belief, reinforced by patient associations and by some authors, 14 that physical and mental exertion lead to damage and possible relapse, so patients should rest as much as possible. Some patients with the CMS spend months or even years in relative inactivity.

With the current state of our knowledge, it seems sensible to take an open stance about the causes, avoiding an artificial mind-body dualism. 15 The most suitable is an interactive causal model, in which somatic, psychiatric and psychosocial factors can be integrated. It is also very important to distinguish between predisposing factors, luxerende* factors and factors that maintain the CMS.

DIAGNOSTICS
In patients who present with chronic fatigue, the physician should of course take a complete history, including somatic, psychiatric and psychosocial, perform a thorough physical examination and have laboratory tests performed, necessary to rule out a physical illness. Some authors recommend a very large number of laboratory tests as routine, 16 but most now consider this wasteful given the small number of positive outcomes. 17 Extensive research can even be harmful, as it could reinforce the patient's belief that there is a physical illness. Requesting an examination is often interpreted as an expression of uncertainty on the part of the doctor.


TREATMENT

Psychiatric treatment.
Many patients with CMS are reluctant to be referred to a psychiatrist or psychologist, partly because of their conviction that they have a physical illness, and partly because they believe this suggests that they are not being taken seriously. Any referral must therefore be made carefully and with great explanation; good cooperation between the referring physician and the psychiatrist or psychologist is decisive for the patient's acceptance of the referral.

Antidepressants.
Although no control group studies have been conducted on the effects of antidepressants in the CMS, their use is supported by the high prevalence of depressive and anxiety disorders in the CMS and the demonstrated efficacy of a low dose of a tricyclic antidepressant in fibromyalgia. 18 One objection to its use is the low tolerance of patients with CMS to the side effects of antidepressants. In patients with a clear depressive disorder, a trial treatment is certainly recommended, in combination with sufficient guidance and support.

Cognitive behavioral therapy.
Whatever the predisposing and luxerende* causes, the CMS is in many cases maintained by specific ideas about the disease (such as: 'I have a chronic physical illness', 'Exertion is harmful to me' and 'I must rest' ) and the resulting behavior (such as: avoiding effort and social contacts). As a result of a loss of condition, every effort leads to physical complaints, which in turn confirms the ideas described. 19 Thus the patient gets into a vicious circle (figure), resulting in feelings of frustration, depression and hopelessness, which in turn contribute to the feeling of illness. This theoretical model has three advantages: it is free from assumptions about the original causes of the syndrome, it is acceptable to many (but not all) patients, and it can form the basis of cognitive-behavioral therapeutical treatment.

Cognitive-behavioral therapy is a form of psychotherapy that was originally developed for depressed patients, but has since been shown to be useful for many other psychiatric disorders. 20 The aim of this therapy is to change disturbing behaviors and thoughts, which may underlie the continued existence of psychological disorders and problems. In patients with CMS, the aim is first of all to explain the described model, then to revise the ideas mentioned about the disease and finally to gradually implement a somatic and psychological rehabilitation program that restores the original way of life as much as possible. .

While other psychological approaches to the CMS are conceivable, the cognitive-behavioral therapy certainly seems promising. An English open study of this treatment in 55 severely disabled patients with CMS resulted in statistically significant and lasting improvements in functioning in 69% of the 32 patients who were willing to have the treatment. 21 For a number of these patients it was a matter of a full recovery of the previous level of functioning. Control group studies into this form of therapy are now being conducted.

CONCLUSION
The chronic tiredness syndrome leads to severe morbidity and has a poor prognosis. Although a considerable amount of research has been done, a convincing somatic explanation for the syndrome is lacking to date. A lot of patients with CMS have a psychiatric disorder, especially a depressive syndrome.

Despite the feelings of powerlessness that patients with CMS evoke in their doctors, their complaints deserve serious attention and every effort should be made to help them. In our view, extensive somatic aid inverstigation is not useful and may be harmful. Antidepressants should be considered when marked major depressive disorder exists. Careful examination of the factors that may maintain the syndrome should precede advice for gradual rehabilitation, requiring comprehensive support and understanding of patients. This approach can certainly be applied by the general practitioner.Referral to a specialist is necessary if the GP does not have sufficient skills or patience or if the patient shows severe psychiatric symptoms or has very persistent ideas about the disease.

Research into the somatic and psychiatric aspects of the CMS should be continued. It is most likely to have meaningful results when it is performed in collaboration between somatic and psychiatric or psychological researchers.

This article was written during the period when Dr. Hawton was working as a Boerhaave Professor of Consultative Psychiatry at the Faculty of Medicine of the University of Leiden.



Accepted on July 26th 1991



*Note of translator: The original tekst speaks of “luxerende factoren”, which can be said to correspond with ‘precipitating factors’. However, in dutch “luxerend” explicitly specifies events that provoke a psychiatric disorder, and I didn’t want to translate it in a way that lost the original meaning and context.

 

Literature

1. Sharpe MC, Archard LC, Banatvala JE, et al. Guidelines for the conduct of research into the chronic fatigue syndrome. JR Soc Med 1991;84:118-21.

2. Lloyd AR, Hales JR, Gardevia SC. Muscle strength, endurance and recovery in the post-infectious fatigue syndrome. J Neurol Neurosurgical Psychiatry 1988; 51:1316-22.

3. Stokes MJ, Cooper RG, Edwards RHT. Normal muscle strength and fatigability in patients with effort syndrome. Br Med J 1988; 297:1014-7.

4. Altay HT, Toner BB, Brooker H, Abbey SE, Salit IE, Garfinkel PE. The neuropsychological dimensions of postinfectiousneuromyasthenia (chronic fatigue syndrome): a preliminary report. Int JPsychiatry Med 1990; 20: 141-9.

5. Taerk GS, Toner BB, Salit IE, Garfinkel PE, Ozersky S. Depression in patients with neuromyasthenia (benign myalgicencephalomyelitis). Int J Psychiatry Med 1987; 17:49-56.

6. Kroenke K, Wood DR, Mangelsdorff AD, Meier NJ, Powell JB. Chronic fatigue in primary care: prevalence, patient characteristics, andoutcome. JAMA 1988; 260: 929-34.

7. Manu P, Matthews DA, Lane TJ. The mental health ofpatients with a chief complaint of chronic fatigue: a prospective evaluationand follow-up. Arch Intern Med 1989; 148:2213-7.

8. Kruesi MJP, Dale J, Straus SE. Psychiatric diagnoses in patients who have chronic fatigue syndrome. J Clin Psychiatry 1989; 50:53-6.

9. Wesseley S, Powell R. Fatigue syndromes: a comparison ofchronic 'postviral' fatigue with neuromuscular and affectivedisorders. J Neurol Neurosurgeon Psychiatry 1989; 52:940-8.

10. Hickie I, Lloyd A, Wakefield D, Parker G. The psychiatric status of patients with the chronic fatigue syndrome. Br J Psychiatry 1990;156: 534-40.

11. Wesseley S. Old wine in new bottles: neurasthenia and 'ME'. Psycho Med 1990; 20:35-53.

12. Beard G. American nervousness. New York: Putnam's,1881.

13. Sharpe MC, Pasvol J, Hawton K. Chronic fatigue: initial assessment and follow-up of 200 cases. (in press.)

14. Dawes B, Downing D. Why ME? A guide to combating viralillness. London: Grafton, 1989.

15. Jennekens FGI, Gijn J van. The 'post-viral fatigue syndrome' or the 'myalgic encephalomyelitis'. Ned Tijdschr Geneeskd 1988; 132:999-1001.

16. Gantz NM, Holmes GP. Treatment of patients with chronic fatigue syndrome. drugs 1989; 38:855-62.

17. Lane TJ, Matthews DA, Manu P. The low yield of physical examinations and laboratory investigations of patients with chronic fatigue.Am J Med Sci 1990; 299: 313-8.

18. Carette S, McCain GA, Bell DA, Fam AG. Evaluation of amitriptyline in primary fibrosis. Arthritis Rheum 1986; 29:655-9.

19. Wesseley S, David A, Butler S, Chalder T. Management of chronic (post-viral) fatigue syndrome. JR Coll Gen Pract 1989; 39:26-9.

20. Hawton K, Salkovskis PM, Kirk J, Clark DM. Cognitive behavior therapy for psychiatric problems: a practical guide. Oxford: Oxford University Press, 1989.

21. Butler S, Chalder T, Ron M, Wesseley S. Cognitivebehavior therapy in chronic fatigue syndromes. J Neurol Neurosurgical Psychiatry1991; 54:153-8.

 

Translation of the figure of the model:

• 'Oorspronkelijke oorzaak' = 'original cause'
• Klachten (b.v. moeheid, spierpijn, depressiviteit) = Complaints (e.g. tiredness, muscle ache, being depressed)
• Overtuigingen (b.v. 'ik ben ziek', 'ik moet rust houden') = Convictions (e.g. 'I am ill', 'I have to keep rest')
• Gevoelens van frustratie, hopeloosheid = Feelings of frustration, hopelessness
• Vermijden van inspanning = Avoiding exertion/effort
• Conditieverlies (verminderde inspanningsintolerantie) = Loss of condition (reduced exertion tolerance)
• Pogingen tot inspanning: Attempts at exertion

 

That is unexpected. Hawton, a professor at Leiden.

It is perhaps worth noting part of the Preface to Chronic Fatigue and its syndromes by Wessely, Hotopf and Sharpe:

His (Sharpe's) researches have been guided and supported by Keith Hawton, Michael Gelder and Tim Peto.

 

Insomnia is not a psychological problem.

How do they know this? Somatization is a harmful quack diagnosis with no test, it's used by doctors as a euphemism for hypochondria and hysteria.

 

There's a LOT that can be said about this paper (and a lot to unpack), so I'm not going into all that now, but I want to make the following additional remarks to it:

1. Hawton was active in The Netherlands at this time. He was was working as a Boerhaave Professor of Consultative Psychiatry at the Faculty of Medicine of the University of Leiden. In 1986 he was a speaker at a symposium in Utrecht, in January 1990 he was speaker at a symposium on sexual deviant patients in Utrecht. In both cases he was introduced as being from Oxford University. The sexual deviance sympostium was organised by Hengeveld, his co-author of the chronic fatigue syndromepaper, who was then secretary of the Sexuology section of the Dutch Psychiatry Association (which mailing address was the Obstetrics and Gynaecology ward of a Utrecht hospital) . When writing the cfs article, Hengeveld was working as a psychiatrist, I think in Leiden.

2.Hawton was one of the authors of the Oxford criteria. He also authored papers with Sharpe: in '91 and '94 about chronic fatigue syndrome, and in 1990 about psychological sequelae of physical disorders/unexplainedsomatic symptoms

3. This paper shows that the Wessely School ideas and smokescreen talking points were already formed in full by this time. It is an interesting sister document to the Oxford criteria report, that was published only 6 months before this paper was accepted by the NTvG.

4. It mentions the Oxford criteria, but adds some typical physical symptoms that point to infection from the Holmes criteria to them like they are from Oxford, while they are notably absent from Oxford. (continuous throat ache, sensation of fever, swollen joints and lymph nodes). It mentions PIFS, the second syndrome described by the Oxford criteria: that report places the whole of the acknowledgement that "CFS" could be caused by an ongoing or past infection (it isn't much) under that category, presumably to neutralize any upcoming biomedical research finds. But the Hawton paper then drops the second syndrome for the rest of the piece, and puts physical infection symptoms under the header "CFS", like there are no "two syndromes" like Oxford claims.

5. The Oxford criteria, in contrast to what the Hawton paper says, says nothing about depression, anxiety or hyperventilation occuring secondary to CFS.

6. It describes PEM.

7. Having a "firm belief that the illness is caused by a viral infection" is actually ok under the Oxford second syndrome PIFS description. (Which is probably why they left it out, otherwise the cbt model doesn't work.)

8. The claim that being convinced that your illness is caused by a viral infection (again: no problem under Oxford-PIFS!) might keep "complaints" persistent and the "research" proving a connection between that conviction and a poor course of the illness, is linked to a reference to Hawton's own upcoming paper written with Sharpe. (Reference 13)

9. They ditch Holmes' recommendation (from both the CDC criteria and a paper Holmes wrote) to do a thorough physical examination.

10. Hawton himself is one of the 3 references to the effectiveness of CBT. The other two are by Wessely/David/Butler/Chalder, and Butler/Chalder/Ron/Wessely. This is (as far as I know so far) the first time CBT is advised as a treatment for "CFS" in The Netherlands.

 

Yet this is simply contradicted in the next paragraph:

If it isn't physical, then what is it?

It's so disappointing that the people who frequently mention how mind-body dualism is the problem and the reason why illnesses are not understood, are often dualists themselves.

 

@Snow Leopard You're trying to makes sense where there isn't any. The point isn't consistency or to express knowledge based on a solid foundation. The point at this stage is getting their profession/themselves acknowledged as valid participants in "CFS" research and treatment, which evolved into selling their "product" CBT.

Pointing out the many (ooo, so many) inconsistencies is a valid part of calling out their nonsense, but trying to "understand" them substantively will only make your head hurt.


The image of what they think ME actually is shifts slightly depending on who their audience is or what the message is they're trying to send, and it can even shift within one article.
Although if you put those two quotes together (and reading some of Wessely's work), I'd say the argument is basically that yes, the symptoms are physical, but they are caused by psychology. (Although he is rather unclear on how merely thinking you are ill can cause joint and lymph node swelling. And apart from the PIFS-issue I mention in post #6, he's also unclear on how "relative inactivity" can cause "severe and debilitating tiredness" in ME patients but not in the average couch potato. But then we're back at the usual avalaunch of inconsistencies.)

So, if you want an answer it is probably: It isn't physical, but it also isn't psychological, because then people would point out that the symptoms are physical (plus you could lose the gig if pathology gets commonly known or more of it found and all your eggs are in the psychology basket, even though you're a psychiatrist), SO, the only way to keep up the rickety model is to invert the recent scientific finds that pathology has an influence on psychology by making a lot of noise about being all modern and now-ey when you declare mind and body are the one and same entity while presenting the old psychosomatic bullshittery that has been the core part of your profession since the beginning, but that was (o, so unfairly) proven to be unhelpful nonsense by actual science and got sidelined for a lot of illnesses (asthma, parkinsons, tuberculosis, MS, etc. and of course all the other illnesses that now actually were diagnosed instead of shoved under "hysteria", "neurasthenia" etc.).

Just like it for example was with tuberculosis (that had a lot of the same treatment as ME patients), the whole psychosomatic concept serves psychiatrists so they can have a claim on patient treatment and "expertise", it never serves the patient or the actual science.

Interestingly, in The Netherlands, in early 1987, Bleijenberg (who was at that point already heavily into psychologising bowel complaints as functional, away from other experts, despite their rebuttal of Bleijenberg's pet theories) claimed he couldn't make a distinction between organic and functional stomach complaints (in a later article about IBS he expressed his desire that "functional" was replaced by non-organic explained) via anamnesis or psychological examination, after which he went on about "One might wonder how it is possible that the now contradicted views on the distinction between organic and functional could continue to exist.", and saying that stomach issues of organic origin would have the same psychosocial criteria. In several pieces you can see he's already laying the groundwork for MUS, which he later first applied on a large scale in his CFS "expertise", including the advise that no additional physical examination/tests should be done as that would be bad for the poor patient.

I'm sorry, my post is again turning into a mini-lecture.

Long story short: the focus on the supposed unjustness of cartesian dualism is nothing but an ordinary turf claim.

 

@Arvo @Snow Leopard My impression is that folks who go for psychological interventions are told to stay away from physical explanations - I assume this is because it would undermine the "benefits" of the psychological intervention.
From the perspective of what gets funded by Government I recall Jaime Seltzer's [MEAction] advice - we know these [CBT/GET] interventions don't work so why fund them?

So Governments shouldn't fund psychological studies, exercise studies, etc. which are unblinded and use subjective outcome indicators - seems to cover all of those studies!

 

@FMMM1 It is explicitly stated by the dutch branch of the psychosomatic enterprise that the goal of CBT is to stop CFS patients labelling themselves as such. A physical explanation would get in the way of that. (And it would get in the way of the smoke-and-mirror legitimacy of The Product CBT)

Governments shouldn't fund shoddy studies into stuff that obviously has been shown to not work for patients, but governments do stupid, immoral, money-wasting, illogical stuff like that more often.
Also: it might not work for the patients, but it can work wondrously for them, when research is not about finding a workable truth but supporting a narrative for personal interests.

In The Netherlands in the 00s, the dutch minister for health, now sometimes mentioned as a possible PM, has been personally and very actively involved in a widespread, vocal and cruel campaign to blacken ME patients with every nasty BPS crap there was, in collaboration with the dutch Nijmegen group, so she could roll out MUS and throw people off benefits en masse without generating protest. She made them an "other" so she could get away with her inhumane policy. BPS "science" was very useful for that. (Our UWV, the dutch equivalent of the British DWP, was even dubbed "The Lourdes of the Lowlands" because people went there ill and came out miraculously "cured".)

 

Fun with reference juggling!

The reference in Hawtons piece to substantiate what he says about "avoiding an artificial mind-body dualism" (reference 15, Jennekens & Van Gijn), what is nothing more than a the turf claim, mentions that dividing the organic and psychological factor is artificial,

referenced to (and substantiated by) David/Wessely/Pelosi "Postviral fatigue syndrome: time for a new approach" (1988),

who in turn substantiate and reference that claim with Kendell's paper of 1967 (more on Kendell and his influence on the hijacking by Wessely & friends on this forum here , also bits on other places. He wrote a Lancet comment in 1991 that was used for the Wessely School CFS = psychosomatic promotion, and in 2001 he wrote an article with statements like: "In reality, neither mind nor bodies develop illness." and "Pain, the most characteristic feature of so-called bodily illness, is a purely psychological phenomenon." I understand he was quite esteemed, but from these quotes, he sounds absolutely bonkers to me.)

and

Another piece by David!

That I can't access, like the '67 Kendell piece, but somehow I have the feeling that I would find more clique wishful thinking, possibly from themselves again or a mate.





Not a surprise Hawton took a reference detour, or he would have had yet another Wessely piece in his reference list, he already had 4.
Makes me wonder how many more are actually redirected Wessely bits.

 

Well why not blacken her name via social media --- particularly if she's competing to be PM --- EU has set up a scoping study into poorly understood diseases with a high disease burden --- ME/CFS, Lyme, Long covid --- how does that sit with her policy as health minister?

Get the ME/CFS, Lyme, Long covid --- folks to support a campaign to challenge her

@Michiel Tack

 

CORRECTION ( @FMMM1 ):
She was health minister and vice prime minister for 8 years until 2002 after which she took positions as president of the dutch health council comittee (in which capacity in '05 she undertook the media campaign with grotesque and stigmatising disinformation to accomodate throwing patients with a CFS diagnosis out of sickness benefits and forcing them to comply to CBT or be declared unwilling to participate in effective treatment) and -not very surprising- leading on reform of the dutch health insurance system into a free market process (enacted in '06) which greatly grew the influence of private health insurers, turning them into the most influential players in dutch health care.

She has died since then, and I confused her with another problematic female former health minister, who was mentioned as possible PM candidate when our current one got into trouble.