Treating medically unexplained physical symptoms: Effective interventions are available (1997) Sharpe & Mayou

This isn't of huge interest, but I thought I'd post up for newer members who might be interested in reading a short summary from Sharpe.

I find it kind of amazing to see how confidently they asserted their views on the basis of such flimsy evidence. They talk of providing 'positive explanations' of symptoms, but they cannot possibly have thought that anyone thought that they knew the cause of symptoms - there just seemed to be a presumption that everyone would agree that patients deserved to be manipulated.

It's also interesting how they've really followed through on Sharpe's plan regardless of embarrassing results like those seen from PACE and FINE.

Treating medically unexplained physical symptoms: Effective interventions are available

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2127391/pdf/9302942.pdf

 

The interpretation of that "or" in the first paragraph is important. Should it be construed conjunctively or disjunctively? It would appear to be conjuctively-so they regard CFS as a somatisation disorder. That has rarely been admitted.

 

Here are a few quotes from Wessely, Hotopf and Sharpe's book Chronic Fatigue and its Syndromes (1997):

It has already been suggested that the majority of those seen in the CFS clinic fulfil criteria for psychiatric disorder, whatever that means. Somatisation is thus relevant at two levels. First most of those seen in specialist care believe they have a physical illness...If they also fulfil criteria for known psychiatric disorders they hence fulfil the Goldberg criteria for somatisation. Second a subgroup will fulfil criteria for the specific category of somatisation disorder...…

Whereas psychiatric disorder is common in CFS settings, somatisation disorder is not.....Most studies find that between 10 and 20 per cent of patients fulfil criteria.....

Australian researchers have presented data showing that a minority of those seen in a CFS clinic can be differentiated from the majority by such variables as duration, prognosis, psychological morbidity, and disability, and also an index of immunological dysfunction. They argue that the minority group should be classified under the somatoform disorders, reserving the label CFS for those with shorter duration, fewer, more typical symptoms, and less disability.....

Many patients who fulfil criteria for somatisation and attend CFS clinics hold strong convictions regarding their diagnosis, and it is rarely, if ever, fruitful to challenge them. Providing the diagnosis is recognised bythe clinician, it may be more helpful to manage the patient using the strategies currently advocated for the treatment of somatisation disorder, whilst retaining the label of CFS.

pp229 -231

It is difficult to determine what they mean. Probably because it seems unlikely that they know.

 

Thanks @Esther12,

A useful example of exactly how empty the basis for all these studies is. I might make use of it when giving advice to regulatory bodies.

The nonsense of 'mind-body dualism' comes up again. Are they really so stupid that they cannot see it is them that are the dualists?

 

Is it because they have somatization disorder, or because somatization disorder doesn't exist but is simply a catch-all diagnosis for any significant health problem that can't easily be diagnosed? The last time I looked at diagnostic criteria for somatization disorder, it seemed to be almost entirely a description of the expected and normal behaviour of a person with a significant undiagnosed health problem. The main differentiating factor was whether the patient worried excessively or not, which is highly subjective.

 

And the less seriously the doctor takes their patient’s symptoms (and the more the doctor trivialises those symptoms) the more the patient needs to protest. Thus the patient feels they must explain again and again that their symptoms are seriously affecting their lives.

So the doctors themselves could potentially be inducing this so called Somatisation in their patient. All the doctor needs to do is consider that the patient is over sensitive, and so as a consequence of this, to treat their patient with disregard.

And the patient responds by trying to help the doctor to understand their problems - perhaps with increasing desperation, because they are not being given the care they went to the doctor to receive.

But of course THAT isn’t considered a vicious circle!

It “must” be the patient working themselves into a somatizing frenzy!

 

Given that somatisation disorder is sometimes referred to as Briquet's syndrome and Briquet's syndrome as St Louis Hysteria this comment by Slater is instructive

In the same paper, Slater delivered some trenchant criticisms on the revival of Briquet's syndrome (somatisation disorder). Referring to it as St Louis hysteria because of its description by psychiatrists in that Missouri city, he stated, "Faced by symptoms they do not understand, in women who do not engage their sympathy, the male doc tors find an easy way out in relegating them to a category, to a diagnosis, 'hysteria' which follows these hapless patients from one centre to another and becomes a self fulfilling prophecy. I greatly fear that St Louis hysteria is a product of machismo, of male chauvinism, of which one can find many examples in medicine

(SLATER E. What is hysteria? New Psychiatry 1976; 14-15. Reprinted in Roy A. Hysteria. London: Wiley and Sons, 1982)

in Journal of Psychosomatic Research, Vol. 40, No. 4, pp. 345-350, 1996
0022-3999(95)00501-9
EDITORIAL
FROM CONVERSION HYSTERIA TO SOMATISATION TO ABNORMAL ILLNESS BEHAVIOUR?
ISSY PILOWSKY

 

As Goldberg is referred to in a post above this quote is interesting

In such cases there may or may not be a medical condition underlying the somatic complaints but, if there is such a condition, its symptoms are exaggerated or amplified. Goldberg and Bridges 1988 have argued that somatisation is a phenomenon which occurs within the general, non psychiatric population, with some people choosing to express their distress in physical terms while others choose to psychologise theirs. Factors which might affect the somatisation of distress include cultural norms and family influences, sanctions against the expression of emotional states, and lay models of causation which govern the interpretation of bodily change (Katon et al 1982) Goldberg and Bridges (1988) highlight the blame avoiding function of somatisation:

..it is a great way for not seeing oneself as mentally ill, and not seeing oneself as responsible for the life predicament that one appears to be in...It is this blame avoiding function of somatisation that seems to be its key feature, and perhaps why patients do not report such great levels of depression

C Ray Role of depression in Chronic Fatigue Syndrome in Post-viral Fatigue Syndrome (1991) Jenkins and Mowbray

 

I agree with you seeing as the paragraph begins "Such cases may be referred to as ... or ...". Implying the same thing but just different terminologies.

 

Good question. It has taken some time to find the answer. Some pages earlier on p221 it says Table 10.1 shows that psychiatric disorders are frequently diagnosed in CFS. Different investigators have used different instruments and different criteria, but a pattern can be discerned Depressive disorders are common, followed by somatisation disorder and anxiety disorders. However a substantial minority do not fulfil criteria for any psychological disorder....

Table 10.1 is Psychiatric symptoms in fatigued patients. Updated from David with permission.
This is David AS Post -viral fatigue syndrome and Psychiatry Br Med Bull 1991 47 966-988

It seems significant that the table refers to "subjects with chronic fatigue"

 

Some brilliant guy name, S Wessely, no, that's too obvious, let's call him Simon W. You wouldn't know him. But brilliant guy. Lots of people say that, believe me.

 

I'll always marvel at the reality of medical professionals looking at sick people trying to get medical care and noting how strange and unnatural it would be for sick people to so insistently seek medical care because obviously someone experiencing serious health problems but being faced with indifference and hostility would... do... differently and not seek medical care?

The behavior they are describing as abnormal is 100% consistent with patients seeking medical care while facing disbelief. All of it. From "doctor shopping", to being surprisingly knowledgeable about the medical literature and being massively pissed at people implying severe mental incompetence without having the damn courage to actually put their name to it.

A massive circle jerk of ideologues puzzled as to why sick people behave like sick people and coming up with Rube Goldberg alternative explanations for it. Close this whole thing down, it's just embarrassing at this point. More and more I'm getting convinced that likely 90%+ of all psychosomatic diagnoses are false positives. If they look at us and insist that we're the same thing, it just raises all sorts of questions about the entire field's judgment for being unable to properly identify any of their patients. When a bird expert points at a bat and insists that bats are basically just like birds, you gotta question not just their so-called expertise on bats but about birds as well. Yes, they all fly. No, that doesn't mean anything.

This is really the crux of the problem: all the implication and weight of a severe mental incompetence diagnosis with none of the accountability. This is massively broken and shows how little confidence they have in their own assertions. Clearly none of those people have any idea what they're talking about and are arguing some version of angels dancing on a hairpin.

 

So not having a mental disorder is proof that you have a mental disorder.

 

Can I just point out that this article was published in September 1997, so is over 20 years old and pre-dates PACE by quite a few years. I don't know if this is relevant to any of the comments.

 

I think we all recognised that and that it is important to understand the period immediately before about 2002 when Clarke and Layard took IAPT down one road and Wessely, Sharpe etc took ME down a parallel one.

 

It does not diverge from what Sharpe is still writing about. It's also quite similar to the earlier stuff from the late 80's as well. It shows that the conclusion of what treatment they promote was the starting point, rather than a result of any significant research. This is ideological, evidence and reality do not really factor in.