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Simon Wessely wins prize for "Standing Up For Science."

Merry

Senior Member
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1,378
Location
Columbus, Ohio, USA
Our FOI system covers data that is held by universities, but with many exclusions.
It can be a protracted process.

Thanks, Bob, for the explanation. Yeah, going that FOI route would be hard work. On reflection, I emailed Ellen Goudsmit not because I need evidence but because I bristled at her letter that to me seemed to be trying to shut down noisy activism. She posted this letter in the quasi-public space of co-cure (anyone can subscribe) but warned that what she wrote wasn't to be reposted. I believe her letter was a warning to the leadership of whatever ME charity (can't remember which) had called for evidence of abuse that Simon Wessely claims he has suffered in the pursuit of scientific truth.
 

Firestormm

Senior Member
Messages
5,055
Location
Cornwall England
I don't recommend pursuing any demand for proof or evidence of the harassment, death-threats or otherwise. It would prove counter-productive and damaging. Said it before. Have said it again.

Wessely has not been silent about his award and has been engaging with his critics. Here his replies (have bolded those relating to publishing names etc. of those harassing him):

Simon Wessely Says:
November 9, 2012 at 13:24

David G writes “Even if we were to accept that Simon Wessely were right about ME, the way in which he has interacted with or described the patient-population is deeply troubling, for instance: “The average doctor will see they are neurotic and he will often be disgusted with them.” Wessely S. In: Psychological Disorders in General Medical Settings. Ed: N Sartorius et al. Hogrefe & Huber, 1990.”

Yes this is indeed deeply troubling, because the full quotation is as follows:

“The absence of abnormnal tests leads to the erroneous conclusion that nothing is wrong, or alternatively to the understandable but misguided tendency to over interpret minor abnormalities or variants. The description given by a leading gastroenterologist at the Mayo Clinic remains accurate: “the average doctors will see they are neurotic, and he will often be disgusted with them. Often he sends them away with as little ceremony as possible” (Alvarez, 1935). Thus, attitudes towards psychiatric illness affect both patient and doctor with equally adverse effects on prognosis”

I was quoting myself from a physician at the Mayo Clinic in 1935. He disproved of the way in many patients presenting with what would now be called CFS were dealt with, and continued “and yet these poor people suffer the tortures of the damned”.

I was suggesting that nothing much had changed over the years to 1990, and the harm that this does to patients, that having no abnormal tests does not mean that nothing is wrong, and that doctors must always treat sufferers with respect.

This misquotation of what i wrote, done deliberately so as to reverse the meaning, is I am afraid all too common. The people who originally did this many years ago, continue to repeat this, despite knowing that this is a distortion.

The purpose of this and numerous other examples is to persuade people that I have said things that I have not said, written things that I did not write, and believe things that I do not believe. For that reason all my research on CFS is available for free on my website – http://www.simonwessely.com.

By all means take issue with what I have written, but first of all make sure it is indeed what I have written, and not what others say I have. They are sadly rarely one and the same thing.

Simon Wessely

Simon Wessely Says:
November 9, 2012 at 14:48

I am not going to respond to questions like why haven’t I named those who have threatened me and such, because it doesn’t really matter what I say, you either believe what journalists have written on this issue and who have seen the evidence or you don’t.

Nor am I going to get into a prolonged exchange. I do however wish to respond specifically to this point, which is often made, and which is a variation on the theme of the claim that the patients that I have seen, now numbering over a thousand in the last couple of decades, do not have this illness, or do not have abnormalities on various research led investigations that we have done over years and so on and so forth.

I respond to that, because basically it is an insult to them to claim that they do not have CFS/ME, and must in some way be “psychiatric” whatever that word means.

So here is the response that Tony Cleare and I wrote to thisalgto,wihi when it surfaced when we published the first non replication of the XMRV study, and which in turn triggered a considerable number of deeply unpleasant e mails, threats and allegations made against not me, but against the virologists who carried out the lab work for the paper.

PO o here is our response from the PLOS ONE website. If you don’t want to read the whole reply, here is the key closing sentence:

“”On behalf of the patients that attend our CFS clinic, we resent the implication that they are in some way different, less ill, less disabled, let alone less deserving, than CFS patients in any other service or setting. It is otherwise, and we have provided a wealth of published data to back this assertion”"

and here is the full response:

“As the clinicians and scientists who provided the samples that were tested at Imperial, we wish to respond to some of the comments here and elsewhere regarding the patients who provided these samples.

In the paper we provided extensive details of the sample selection, criteria, assessments and investigations that are routine in our service, together with references/citations to all the material

To re iterate.

1. The criteria that we use are the Fukuda et al 1994 criteria that are far and away the most widely used across the world and in the research literature. We do not use the so-called “Canadian criteria”, which are designed for clinical use, not operationalised and do not translate easily for use in research. Even so, had we attempted to do so, a substantial proportion would have also met these clinical criteria.

2. The patients resembled those seen in secondary care and tertiary care services elsewhere – most particularly they are similar to those seen in clinics in Australia, USA, Scotland, England and Northern Ireland (Wilson et al, 2001; Hickie et al, 2009).

3. We follow the same psychiatric exclusion criteria as mandated by the Fukuda criteria. We do this on the basis of semi structured interviews and assessment that we have also published. In addition, we also exclude patients with chronic somatisation disorder as defined by DSM-IV, which is not required by the Fukuda criteria, but most experts and clinicians agree are a different population. This is only a small percentage of our referrals.

4. In answer to one question, yes, our patients all report both mental and physical fatigue, exacerbated by mental or physical effort. Nearly all also describe post exertional fatigue and malaise.

5. We have a standard laboratory protocol for investigations, which are performed on all those referred to the clinic, unless they have been done recently by the referring doctor. These are solely for the purpose of excluding other diseases that can sometimes mimic CFS, and are part of the differential diagnosis.

This is standard practice in every CFS service of which we are aware and forms part of every definition of which we are aware, including the “Canadian criteria”. In addition to the standard work up, we also now routinely test for coeliac disease, because we found a 2% prevalence of undetected coeliac disease (Skowera et al, 2001). In answer to another question, we perform a 9.00 am cortisol as a screener for Addison’s disease.

6. In addition we also perform tests as part of research protocols. We always tell patients that these additional tests and investigations are not necessary clinically, and are performed with informed consent.

Thus patients in our service have also co operated in studies of PET and fMRI neuroimaging, autonomic dysfunction, neurochemistry, respiratory function, vitamin status, anti nuclear antibodies, immune function, neuroendocrine function and genetics (see references).

Hence it is untrue to state that patients at King’s for example do not show alterations in immune function – in fact they do – see Skowera et al, High levels of type 2 cytokine-producing cells in chronic fatigue syndrome.” Clinical and Experimental Immunology 2004: 135: 294-302.

Similarly, many of our patients also show altered neuroendocrine, neurochemical and other biological parameters, and we have published many examples of these (see references below). It is therefore simply untrue that we either seek to find no biological changes in CFS, or fail to report those that we do find.

7. On the other hand, it is true that those who receive a diagnosis of cancer would be and are excluded from a diagnosis of CFS and if this is detected they would be immediately referred to the relevant clinical services.

It is possible that this may be a difference from the cohort originally reported in Science, if the Wall St Journal is correct (http://online.wsj.com/art…).

8. We do not perform these additional tests to confirm or refute a diagnosis of CFS, but to further understanding of the illness.

If and when a properly validated diagnostic test is developed for use within the National Health Service, all our patients will be offered it free of charge, just as they are already offered diagnostic assessment, investigation and treatment free of charge.

9. We did not perform any selection in any shape or form of the samples that we hold to send to Imperial College, as again has been suggested.

Overall, we wish to emphasis, and to do so emphatically, that our patients are typical of CFS patients seen in specialist care elsewhere.

We specifically refute the suggestion that our patients are in some way more “psychiatric”, whatever that means, than those with “real CFS”, an assertion that has been repeatedly made in other venues.

The rates of co morbid psychiatric disorder, for which we routinely screen, are again similar to those seen elsewhere.

We draw attention to another study that compared two services run in the same London teaching hospital, one by an immunologist, the other a psychiatrist, but showed no fundamental differences between the two (White et al, 2004).

On behalf of the patients that attend our CFS clinic, we resent the implication that they are in some way different, less ill, less disabled, let alone less deserving, than CFS patients in any other service or setting. It is otherwise, and we have provided a wealth of published data to back this assertion”

Professor Simon Wessely, Professor of Psychological Medicine
Professor David Collier, Professor of Psychiatric Genetics
Dr Anthony Cleare, Reader in Neuroendocrinology

[Note: Firestormm hasn't included the references to save some space]

simon wessely Says:
November 9, 2012 at 16:41

two points Ke.

First , you respond to my post in which i actually give you the chapter and verse showing that the patients that we see in the clinic have abnormalities in both their neuroendocrine and immune systems, by saying “if you exclude people with the neuroimmune illness then you wont find anyone with neuroimmune abnormalities.

Your criteria select for people with idiopathic chronic fatigue. Why should such people present with such abnormalities?”. I have just pointed you to the evidence that they do.

Second, you tell me what reasonable people who have received threats would do. Well, in my opinion reasonable people who have received credible and serious threats would contact the appropriate authorities and also take the advice that the experts offer. That advice does not include publishing the names or details of those making the threats on the internet. I am a reasonable person.

OK, said my piece. Done my best. Back to work, no further posts I am afraid.

All comments appear on the following blog: http://noodlemaz.wordpress.com/2012/11/07/john-maddox-prize-2012/

Firestormm has included additional spacing to help him read this all again in the morning when he hopes to be more compus mentus :)
 

alex3619

Senior Member
Messages
13,810
Location
Logan, Queensland, Australia
Thanks Firestormm, I loved some of Wessely's comments there, I have saved that for later analysis. Some of the claims made in the post are perfect examples of the things I am demonstrating in my analysis. Oh my, fallacy after fallacy. Its pursuasive political rhetoric, much as politicians use, its not logic. Bye, Alex
 

Firestormm

Senior Member
Messages
5,055
Location
Cornwall England
Thanks Firestormm, I loved some of Wessely's comments there, I have saved that for later analysis. Some of the claims made in the post are perfect examples of the things I am demonstrating in my analysis. Oh my, fallacy after fallacy. Its pursuasive political rhetoric, much as politicians use, its not logic. Bye, Alex

I have been editing Alex. So please be sure to read in full old chap. Not sure of the fallacies to which you refer.
 

Bob

Senior Member
Messages
16,455
Location
England (south coast)
On reflection, I emailed Ellen Goudsmit not because I need evidence but because I bristled at her letter that to me seemed to be trying to shut down noisy activism. She posted this letter in the quasi-public space of co-cure (anyone can subscribe) but warned that what she wrote wasn't to be reposted. I believe her letter was a warning to the leadership of whatever ME charity (can't remember which) had called for evidence of abuse that Simon Wessely claims he has suffered in the pursuit of scientific truth.

I don't know anything about Ellen Goudsmit, myself, Merry.
It is reasonable to quote small sections of people's text, but maybe polite not to if that's what they request.
 

Bob

Senior Member
Messages
16,455
Location
England (south coast)
Simon Wessely Says:
November 9, 2012 at 13:24
David G writes “Even if we were to accept that Simon Wessely were right about ME, the way in which he has interacted with or described the patient-population is deeply troubling, for instance: “The average doctor will see they are neurotic and he will often be disgusted with them.” Wessely S. In: Psychological Disorders in General Medical Settings. Ed: N Sartorius et al. Hogrefe & Huber, 1990.”
Yes this is indeed deeply troubling, because the full quotation is as follows:
“The absence of abnormnal tests leads to the erroneous conclusion that nothing is wrong, or alternatively to the understandable but misguided tendency to over interpret minor abnormalities or variants. The description given by a leading gastroenterologist at the Mayo Clinic remains accurate: “the average doctors will see they are neurotic, and he will often be disgusted with them. Often he sends them away with as little ceremony as possible” (Alvarez, 1935). Thus, attitudes towards psychiatric illness affect both patient and doctor with equally adverse effects on prognosis”
I was quoting myself from a physician at the Mayo Clinic in 1935. He disproved of the way in many patients presenting with what would now be called CFS were dealt with, and continued “and yet these poor people suffer the tortures of the damned”. I was suggesting that nothing much had changed over the years to 1990, and the harm that this does to patients, that having no abnormal tests does not mean that nothing is wrong, and that doctors must always treat sufferers with respect. This misquotation of what i wrote, done deliberately so as to reverse the meaning, is I am afraid all too common. The people who originally did this many years ago, continue to repeat this, despite knowing that this is a distortion. The purpose of this and numerous other examples is to persuade people that I have said things that I have not said, written things that I did not write, and believe things that I do not believe. For that reason all my research on CFS is available for free on my website – http://www.simonwessely.com. By all means take issue with what I have written, but first of all make sure it is indeed what I have written, and not what others say I have. They are sadly rarely one and the same thing.
Simon Wessely
http://noodlemaz.wordpress.com/2012/11/07/john-maddox-prize-2012/#comment-3029

How bizarre that he's posted on a blog, and engaged directly with the patient community! That's surely a first, isn't it?

I will never defend Simon Wessely, but I do think it's absolutely essential for everyone in our community to always quote him correctly (by finding the original source of the quote) when we criticise him, otherwise it makes the criticisms meaningless, and it backfires on us when he shows people in authority how we 'twist his words' in order to attack him. It supports his case.

I had always suspected that that quote might be taken out of context.
 
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13,774
David G writes “Even if we were to accept that Simon Wessely were right about ME, the way in which he has interacted with or described the patient-population is deeply troubling, for instance: “The average doctor will see they are neurotic and he will often be disgusted with them.” Wessely S. In: Psychological Disorders in General Medical Settings. Ed: N Sartorius et al. Hogrefe & Huber, 1990.”

Ugh.

I'm sure that I sometimes make mistakes, or get my notes mixed up or confused about something so don't want to just condemn one person... but these sorts of misleading manipulations of quotes are really harmful. If you are going to condemn someone for saying something, try and make sure that you've tracked down the context for the quote first.

It makes it so easy for Wessely to make it seem as if all patient ire about his work is the result of ignorance when people go on posting those sorts of quotes as if they reflect his views. I've not noticed anyone posting that sort of thing around here over the last couple of years, so I thought that word had spread that some of those quotes are dodgy and not to be used, but maybe we're just a bit sheltered here. The fact that we have access to a lot of CFS papers probably leaves us better able to check them out too.

I don't think these problems would have ever occurred if people had access to the papers in the first place. Lack of open access meant that for a long time patients could not read what was being said about them, but knew that it was leading to them being treated poorly by many doctors. Often BPS CFS papers, while bad, are not as bad as the treatment that they led to patients receiving once BPS ideas had filtered down to the front-line.
 

Bob

Senior Member
Messages
16,455
Location
England (south coast)
Interesting:
Simon Wessely said:
Thus patients in our service have also co operated in studies of PET and fMRI neuroimaging, autonomic dysfunction, neurochemistry, respiratory function, vitamin status, anti nuclear antibodies, immune function, neuroendocrine function and genetics (see references). Hence it is untrue to state that patients at King’s for example do not show alterations in immune function – in fact they do – see Skowera et al, High levels of type 2 cytokine-producing cells in chronic fatigue syndrome.” Clinical and Experimental Immunology 2004: 135: 294-302. Similarly, many of our patients also show altered neuroendocrine, neurochemical and other biological parameters, and we have published many examples of these (see references below). It is therefore simply untrue that we either seek to find no biological changes in CFS, or fail to report those that we do find.
7. On the other hand, it is true that those who receive a diagnosis of cancer would be and are excluded from a diagnosis of CFS and if this is detected they would be immediately referred to the relevant clinical services. It is possible that this may be a difference from the cohort originally reported in Science, if the Wall St Journal is correct (http://online.wsj.com/art…).
8. We do not perform these additional tests to confirm or refute a diagnosis of CFS, but to further understanding of the illness. If and when a properly validated diagnostic test is developed for use within the National Health Service, all our patients will be offered it free of charge, just as they are already offered diagnostic assessment, investigation and treatment free of charge.

http://noodlemaz.wordpress.com/2012/11/07/john-maddox-prize-2012/#comment-3036

Be we can't work out what it all actually means, unless we study the research papers that he has referenced.
It all sounds good, but does it stand up to scrutiny?
 

alex3619

Senior Member
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Location
Logan, Queensland, Australia
I have been editing Alex. So please be sure to read in full old chap. Not sure of the fallacies to which you refer.

Hi Firestormm, yes, I went to the source, I will also be making use of SWs repository of his own papers. Unlike many I do not start with a presumption this is all a conspiracy or deliberate spin. I am uninterested in motivations because they are nearly always impossible to prove. My methodology is about other things than motivations. Bye, Alex
 
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And there's more misplaced certainty over CFS vs neuroimmune illness vs ME and whatever any of that really means. Did Wessely just respond to the weakest comments? Were most that poor.
 

alex3619

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I don't know anything about Ellen Goudsmit, myself, Merry.
It is reasonable to quote small sections of people's text, but maybe polite not to if that's what they request.

Ellen Goudsmit is a highly respected psychologist, I think, who is on our side. She has semi-retired I think, which is why many in the current ME advocacy movement do not know who she is. I used to follow her writing many years ago, though I didnt always agree with her.
 

alex3619

Senior Member
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Location
Logan, Queensland, Australia
Something else about misquoting SW: there is sometimes a presumption its deliberate or malicious. In some cases this may be true, but I also think in some cases this is due to our limited memory span ... we simply don't recall most of what we read, and can't hold enough of the context in our minds to properly engage with the material. In writing a simple post very few take the level of care needed to write, for example, an academic paper. If such errors occur then I do not blame the people who make them. However, I equally have to acknowledge that it is damaging to advocacy. Consequence and blame are two different things. In part that is how I will be analyzing SW and others in this field. I want to determine processes and consequences, not assign blame. Blame is something else entirely, and more legal/moral than scientific.
 
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13,774
Something else about misquoting SW: there is sometimes a presumption its deliberate or malicious. In some cases this may be true, but I also think in some cases this is due to our limited memory span ... we simply don't recall most of what we read, and can't hold enough of the context in our minds to properly engage with the material. In writing a simple post very few take the level of care needed to write, for example, an academic paper. If such errors occur then I do not blame the people who make them. However, I equally have to acknowledge that it is damaging to advocacy.

Some of the misquoting is clearly malicious imo. The example Wessely replied to was very unlikely to have originated in an honest mistake, even if the person posting it failed to realise this. We all make mistakes, and with a topic like CFS where different people can use words to mean different things, and people often start with very different assumptions, honest mistakes and confusion will occur, but I don't think that means that we should ignore good evidence of people being deliberately misleading. I think that the evidence is pretty clear that there was dishonest intent in the way that the PACE results were spun, and the same is true for the way some quotes from Wessely etc have been taken out of context.
 

Bob

Senior Member
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Location
England (south coast)
Simon Wessely said:
Incidentally, far from retreating into the lager and hiding away from dissent and alternative views, I have spent a long time doing the opposite, provided that it is expressed courteously, as it usually is. I have a feeling that might have been why I was awarded the prize earlier this week – but I don;t know, because in answer to an earlier post, no, I wasn’t on the committee!

http://noodlemaz.wordpress.com/2012/11/07/john-maddox-prize-2012/#comment-3046

My emphasis.
 

Bob

Senior Member
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16,455
Location
England (south coast)
Some of the misquoting is clearly malicious imo. The example Wessely replied to was very unlikely to have originated in an honest mistake, even if the person posting it failed to realise this. We all make mistakes, and with a topic like CFS where different people can use words to mean different things, and people often start with very different assumptions, honest mistakes and confusion will occur, but I don't think that means that we should ignore good evidence of people being deliberately misleading. I think that the evidence is pretty clear that there was dishonest intent in the way that the PACE results were spun, and the same is true for the way some quotes from Wessely etc have been taken out of context.

Alex was suggesting that many people see a quote, and fail to do their research to make sure it is accurate. As Alex says, we can't really blame people for that.
The original act of taking a quote out of context may or may not have been malicious (we don't know - it could have just been a misunderstanding due to a foggy brain), but then every time the quote was used, after it had been taken out of context, it could have been used honestly, if ignorantly.

Not that I'm happy about it. I find it really frustrating when people propagate misleading information.
 
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13,774
Alex was suggesting that many people see a quote, and fail to do their research to make sure it is accurate. As Alex says, we can't really blame people for that.
The original act of taking a quote out of context may or may not have been malicious (we don't know - it could have just been a misunderstanding due to a foggy brain), but then every time the quote was used after it was taken out of context, it could have been used honestly, if ignorantly.

I've got to admit... I did misread Alex's post somewhat. Fortunately, as it's a post about people misreading things/typing carelessly on a forum, he also provided me with the perfect excuse!
 

ukxmrv

Senior Member
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4,413
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I'd personally be careful about emailing Ellen G. My feeling is that she may be partly be referring to the abuse she received and the court case on that.

My comment is not intended as a slight against Ellen. Just that people need to be aware that she has been through some abuse and took police action against someone who was involved with ME politics.

Ellen has ME herself
 

Bob

Senior Member
Messages
16,455
Location
England (south coast)
My memory is so bad, that I can't actually remember any of Wessely's actual quotes or research, so I had a look at a paper he co-authored with Michael Sharpe in 2005.
I managed to get access to just a very short section of the book that it was published in:
http://www.amazon.co.uk/Somatoform-Disorders-Experience-Psychiatry-ebook/dp/B000QCS6FS

Somatoform Disorders.
(WPA Series in Evidence & Experience in Psychiatry)
Volume 9
2005
Editors: Mario Maj, Hagop S. Akiskal, Juan E. Mezzich and Ahmed Okasha
ISBN: 978-0-470-01612-1
http://eu.wiley.com/WileyCDA/WileyTitle/productCd-0470016124.html


The authors take a rather ambiguous position in much of the text that I read, as follows:
Chapter 5: Chronic Fatigue and Neurasthenia

Chronic Fatigue and Neurasthenia: A Review
Michael C. Sharpe and Simon Wessely
[Page 253]

Introduction
...
CFS, along with many other similar syndromes defined by somatic symptoms, such as fibromyalgia, is a condition whose home both in medicine (as a functional syndrome) and in psychiatry (as a somatoform disorder) remains somewhat precarious. These functional disorders [1] are, however, of central concern to psychosomatic medicine in its broadest meaning.

General issues.

A Discrete Disorder?

Although CFS is often regarded as a discrete condition, much as neurasthenia used to be, the severity of the symptoms of fatigue is continuously distributed in the general population [2] and the case definition can also be regarded as simply defining cut-off points on these continua.

Organic or Psychogenic?
...
The extreme psychological view ignores the demonstrable physiological disturbances asssociated with the condition and, if perceived as dismissive and rejecting, can paradoxically encourage the patients in a defensive entrenchment of the belief that they really do have a disease [5]. An aetiologically neutral and integrated perspective that recognizes CFS as real and that acknowledges the likely contribution of biological, psychological, and social factors is almost certainly the best basis for effective clinical practise [6].


But then suddenly, their approach becomes even more extreme than I had previously given them credit for:
Medical or Psychiatric Diagnosis?

Parallel with the debate about aetiology is the argument about whether CFS is most appropriately regarded as "medical" or as "psychiatric". For the same symptoms, the medical diagnosis may be CFS and the psychiatric diagnosis may be an affective, anxiety or somatoform disorder. It can be argued that neither of these diagnoses alone is adequate. The proper use of the DSM-IV axes allows the patient to be given both a medical (Axis III) and a psychiatric (Axis I) diagnosis: the final diagnosis may, for example, be CFS/generalized anxiety disorder. However, we ideally need a classification that avoids two diagnoses being given for the same symptoms. This is a task for the authors of the forthcoming DSM-V [7].

Here they seem to be explicitly and clearly equating (exactly) CFS, with an anxiety/somatoform disorder.
They say that the two different labels (anxiety/CFS) can be given for exactly the same symptoms.
I think that makes their position clear.


I'd like to read the whole paper.
 

biophile

Places I'd rather be.
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8,977
Without analyzing all the details of his comments, I have to say that Wessely is right to say that it is important to establish the full context of quotes. Accuracy is important, however in general, sometimes it is difficult to establish such context if the author is being ambiguous.

Just for the record, he stated that "all" his research is available for free on his website so we can access it and see what has really been said; but in reality, about half the links do not work, and when I leeched the PDF files off the website, there was less than 100 out of 207 listed references.

Edit: He later clarifies:
It is after enduring twenty years of this that I decided to set up the website and put as much as possible of everything that I have published, not just in journals but in the media, on the website. Indeed, if any of you have access to anything at all that I have written and isn’t there (I am afraid I am not the best archivist) please send it to me, and I will add it as well. The only things missing are things that I can;t find anymore. Go on, take the trouble to read what I have actually written, and see then if I am the person that you think I am, or have the views that others have told you that I have. And also just think for a moment who is it that is misleading you, cos I am afraid it ain’t me.