Annals of Internal Medicine/IoM/Comments

[Tom Kindlon]

You can use whatever word you want but if the ME Association recently ie 29th of May 2015 published a very large survey about CBT GET etc which led to the following conclusions / recommendations:
"CBT" has "no role to play in the management of ME/CFS and increase the risk of symptoms becoming worse" and "GET should be withdrawn with immediate effect as a primary intervention for everyone with ME/CFS."

And when the honorary medical advisor of this Association together with Tom respond to a comment by White et al. about CBT and GET and then forget to mention their own survey and recommendations then there's something very wrong, especially as they said GET should be withdrawn immediately.

We didn't forget. One is only allowed five references and that includes the paper being replied to so effectively one only has four references to play with to try to make a cogent and referenced argument that has a chance of being published in the print journal (the Peter White and co. letter would look like it has a good chance of being published and it would be unfortunate if readers only got that viewpoint so we aimed for a letter that had a reasonable chance of being published).

Nothing should be read into the survey not being quoted except that on this occasion, it couldn't fit into the confines of the letter.

 

[Bob]

@Dr Speedy, you may be disappointed that stronger language wasn't used, but it seems a bit harsh to criticise people for making an effort when they needn't bother at all. It's exceptionally difficult writing letters for academic publication. There are strict rules that you have to adhere to; You have very limited space in which to make an argument, and you simply can't fit in all the points that you'd like to. So you've got to make one narrow point, and try to make it well. If you want a good chance of being published, you have to avoid writing in a polemic style and you have to stick to making rather sober academic arguments. You're in a particularly weak position when writing a letter in response to another publication for a number of reasons. For example: 1) the letter can easily be ignored - e.g. if the editor doesn't like it for whatever reason. 2) It has to directly address the issues raised in the original publication - if you write about your own interests or indirectly address the issues in the original publication then your letter will likely be ignored. 3) the space restriction and restriction to the number of references allowed means that it's impossible to create the full argument that you'd like to. Unfortunately the letter has to be written within the tight confines of the expectations of the editor, or it will be overlooked and ignored, and the writer has to second-guess the preferences of the editor. It's a very difficult balancing act and all the power rests with the editor. There will many chances for Dr Shepherd to highlight the ME Association's excellent survey, but he can't necessarily mention it in every letter he writes. It's an important piece of research and I hope the ME Association will be able to attract a lot of attention to it when they've finalised writing it up.

 

[Bob]

I'd like to add my appreciation for all the letters written, including what I think is an excellent letter by Tom Kindlon and Dr Charles Shepherd. Combined, I think the letters are a powerful rebuttal of the letter by White et al., and a powerful statement about the nature of GET. If people didn't make the huge efforts to write such letters then we'd be in a much worse place. Just my opinion, of course.

 

[Esther12]

When the honorary medical advisor of the ME Association together with Tom write a comment about GET and they have 400 words and 4 references they can use, and a month before that a big survey by the ME Association was published asking for the immediate withdrawal of GET than that together with the harms paper by Tom should be the centre of the comment.

And if asking for the immediate withdrawal of GET is not even mentioned then you are asking for criticism and rightly so.

That's not really an argument for anything though. If you were to just say "if I was them, I would have focussed on the MEA survey, dropping out [whatever you think should have been dropped out]", then it's fine for you to express that preference. But you can't just act like your preference means that Kindlon and Shepherd were 'asking for criticism and rightly so' - you need some substantive argument before you can claim that.

In this sort of short letter it is difficult to build an argument, and I think that the Kindlon/Shepherd letter makes a good attempt of this, and is much better than if they'd just cited the MEA's recent call for the withdrawal of GET as a first-line treatment [sorry - can't remember exactly what the MEA called for] without being able to explain why that call had been made.

Also, while I've got no idea if this did affect things and some may think it should not, there are a lot of prejudices within the medical community about ME/CFS and about patient's concerns over GET, so I think that letters to journals benefit from being phrased differently to account for that. Just jumping in with assertions risks making things worse.

 

[Valentijn]

And if asking for the immediate withdrawal of GET is not even mentioned then you are asking for criticism and rightly so.

Since you know best, write your own damned response and stop tearing down advocacy efforts that you perceive as being imperfect. And until you manage to get your supposedly perfect response published, at least refrain from attacking those who have managed it.

 

[worldbackwards]

And if asking for the immediate withdrawal of GET is not even mentioned then you are asking for criticism and rightly so.

From who else precisely?

 

[leela]

May I please suggest that while we all have differing points of view and opinions, and are entitled to them, in the case of advocacy we need
urgently to locate and cultivate a common ground. It is also productive and galvanizing to find our appreciation for the unique beneficial contributions we each make, and focus on encouragement rather than fault-finding, empowerment rather than blame, and each one of us in ourselves committing to refraining from fracturing a community that now more than ever needs unity. We are poised at the beginning of a real tidal wave of change at this very moment on many fronts. It's exciting.

If there is something you think urgently needs to be said, empower yourself to say it in the appropriate venue rather than pointing an accusatory finger at those you have decided should be The Sayers. Trust also that those people will indeed say it when they feel so moved. Everyone gets to make decisions for themselves as to the time, place, and circumstance that is perfect, and most beneficial, to express the things they wish to express.

Tom Kindlon and Dr Shepherd have been tireless, wonderful allies for many years, and Dr Speedy has been boldly and persistently blogging about things many people are afraid to say--and both these unique approaches have such value. There's nothing gained in Shoulding all over each other. In fact it becomes counter-productive.

It seems totally clear that the authors will find the perfect time place and circumstance to further disseminate their excellent findings about GET. It also seems clear that repeatedly criticizing our allies does not create a harmonious advocacy environment. Rather than contributing to infighting amongst ourselves, perhaps it is more productive and empowering to trust and recognise that each has the right to their own decisions on what to share and when, based on our unique experience and circumstance.

Solution-orientation, in my experience, is always more satisfying and useful than problem-orientation.
Each situation is unique, and thus so is each solution. Sometimes it is in several small quiet steps, sometimes a big loud leap. Both are ways forward, so let's take pleasure in that.

 

[Undisclosed]

Just to note, a few posts on this thread have either been edited or deleted to remove rule breaches -- personal attacks. A few were removed because they were no longer applicable i.e., commenting on posts that have now been removed.

Please stick to commenting on the content rather than focusing on making negative comments about a member who has made some comment you don't like.

Any further rule breaches on this thread, for the sake of peace, will result in those breaching the rules being banned from the thread.

Thank you.

 

[Tom Kindlon]

Well done to Dr Speedy for his comment that was posted today:

Graded Exercise Therapy for ME/CFS: ineffective at best, harmful in reality
Posted on July 21, 2015
Miak Speedy, MD
Family Physician

Conflict of Interest:None Declared

Smith et al. concluded that “trials of ... counseling therapies, and graded exercise therapy suggest benefit for some ... whereas evidence for …. harms is insufficient.”(1)

As a doctor, bedridden with ME for over a decade and totally dependent on others, all thanks to a major relapse caused by Graded Exercise Therapy (GET), I'm in a unique position to answer how harmful GET and CBT really are. The basis of GET and CBT is false illness beliefs, meaning it is all in the mind, ignoring all the evidence, for example intracellular immune dysfunctions, which not only restrict exercise capacity, but are also made worse by exercise [2], that this is a physical disease.

ME's main characteristic is an abnormally delayed muscle recovery after doing trivial things, not chronic fatigue, and GET and CBT force you to ignore your symptoms to exercise your way back to full fitness. If you do that, you go over your limit, causing a relapse, and the more you go over your limit, the bigger the relapse and the less likely you are to recover from it.
Many ME patients have been made homebound/bedridden, the result of a major relapse caused by GET and we will only get our health/independence back if we get proper medication.

The Norwegian Rituximab studies suggest that ME is an autoimmune disease and 2/3 of responders are still in remission at the 36-month follow-up. [3] The ME Association recently published a big study, concluding there's no role for CBT, which increases the risk of making things worse, and GET is harmful and should be withdrawn immediately. [4]

Falk Hvidberg et al. recently found that ME/CFS patients have the lowest health-related quality of life of 21 conditions looked at, which included chronic renal failure, strokes, lung cancer etc. [5]

In reality, only two sorts of ME patients can do graded exercise therapy. A small minority where the disease is in remission, and "ME" patients were the diagnosis is wrong.
In all other ME patients, GET causes severe relapses and BREACHES the do no harm principle of medicine.

The alarming findings by Falk Hvidberg et al. [5] show that CBT and GET, tried by most ME patients, are not effective, and that there is an urgent need for effective medication for this debilitating disease, so that we get our health and independence back, can come off benefits and go back to work.

References:
1. Smith MEB, Haney E, McDonagh M, Pappas M, Daeges M, Wasson N, et al. Treatment of myalgic encephalomyelitis/chronic fatigue syndrome: A systematic review for a national Institutes of Health pathways to prevention workshop. Ann Intern Med 2015; 162: 841-50.

2. Nijs J, Nees A, Paul L, DeKooning M, Ickmans K, Meeus M, et al.
Altered immune response to exercise in patients with chronic fatigue syndrome/myalgic encephalomyelitis: a systematic literature review. Exerc Immunol Rev. 2014;20:94-116.

3. Fluge Ø, Risa K, Lunde S, Alme K, Rekeland IG, Sapkota D, et al. (2015) B-Lymphocyte Depletion in Myalgic Encephalopathy/ Chronic Fatigue Syndrome. An Open-Label Phase II Study with Rituximab Maintenance Treatment. PLoS ONE 10(7): e0129898. doi:10.1371/journal.pone.0129898

4. ME Association, Our CBT, GET and Pacing Report calls for major changes to therapies offered for ME/CFS, 29 May 2015, http://www.meassociation.org.uk/2015/05/23959/
(accessed 18 July 2015)

5. Falk Hvidberg M, Brinth LS, Olesen AV, Petersen KD, Ehlers L (2015) The Health-Related Quality of Life for Patients with Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS). PLoS ONE 10(7): e0132421. doi:10.1371/journal.pone.0132421

 

[Bob]

Great letter, @Dr Speedy. Thanks so much for the time and effort you have taken to do that. You've got some great references in there.

 

[Mark]

Well done to Dr Speedy for his comment that was posted today:

Great stuff! Thanks @Dr Speedy.

 

[Dolphin]

Would be good if one or more people replied to this http://annals.org/article.aspx?articleid=2322800 (click on "comments")

Comment
Posted on July 6, 2015

James Webster, MD, MS, MACP

Feinberg School of Medicine of Northwestern University

Conflict of Interest: None Declared

As recommended by Haney et. al. (1) the diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is best made using nine sets of "inadequately tested" clinical criteria. These are quite non-specific symptoms and there are no associated positive laboratory findings. Thus it is not surprising that most physicians have problems with the diagnosis much less with the difficult diffuse treatment approaches (2) for this entity.

In a large, but admittedly convenience, sample of patients with the symptoms outlined (1) for ME/CFS the experience was that the overlap with the diagnosis of major depression and persistent (formerly dysphoric) depressive disorder (DSM V, 300.4) was huge. For these illnesses there are diagnostic criteria and proven effective therapies which were used to benefit a number of these latter patients. The differential diagnosis of ME/CFS and depressive disorders is difficult, but not impossible (3). The patients with the symptoms of depression and ME/CFS do indeed have real illnesses (4), but to ignore clear psychiatric possibilities and aspects, including the potential for a therapeutic trial, does them a great disservice.


1. Haney E, Smith MEB, McDonagh M, et al. Diagnostic methods for myalgic encephalomyelitis/chronic fatigue syndrome: A systematic review for a national institutes of health pathways to prevention workshop. Ann Intern Med. 2015:162:834-840.


2. Smith MEB, Haney E, McDonagh M, et al. Treatment of myalgic encephalomyelitis/chronic fatigue syndrome. A systematic review for a national institutes of health pathways to prevention workshop. Ann Intern Med. 2015;162:841-850.

3. Hawk C, Jason LA, Torres-Harding S. Int J Behav Med. 2006;13:244-51

4. Komaroff AL. Myalgic encephalomyelitis/chronic fatigue syndrome: A real illness. Ann Intern Med. 2015;162:871-872.

 

[Dolphin]

Another good (IMHO) comment by Dr Chu. Unfortunately I imagine only a maximum of one of her letters can make the print edition:

From: http://annals.org/article.aspx?articleid=2322804 (click on "comments")

Estimated annual economic burden of ME/CFS in the US is between $9-$54 billion, not $2-$7 billion
Posted on July 17, 2015

Lily Chu, MD, MSHS
Independent Consultant, Burlingame, CA
Conflict of Interest: LC is involved in ME/CFS research.

Green et. al estimate the annual economic burden of myalgic encephalomyelitis/ chronic fatigue syndrome between $2 - $7 billion in the United States (1) but no citation is given. This is a far lower figure than the $18-$24 billion in direct and indirect costs estimated by Dr. Leonard Jason (2) or the $54 billion estimated by the Centers for Disease Control and Prevention (3). Even when only labor force productivity is accounted for, the annual amount lost was estimated at $9 billion (4). Accurate economic costs are important as they influence the amount of effort, resources, and dollars invested in the research and clinical care of a medical condition.

This is especially important for ME/CFS given that it has remained among the bottom 10 of over 240 conditions funded by the National Institute of Health for many years (5). Annual extramural funding of $5-$6 million a year divided among a conservatively estimated 1 million patients means that only $5-$6 a year is invested in research per patient annually. In contrast, for example, multiple sclerosis and systemic lupus erythematosus are both funded at more than ten times the level of ME/CFS, $112‐$152 million and $92‐$127 million annually respectively, although ME/CFS may be more common (5, 6). Thus, it should come as no surprise why we still do not understand the pathophysiology behind ME/CFS nor have any diagnostic tests or effective disease-modifying treatments. I support many of the recommendations put forth by Green et al. but funding for research must be increased if we are to make any progress.

References:

(1) Green CR, Cowan P, Elk R, O'Neil KM, Rasmussen AL. National Institutes of Health Pathways to Prevention Workshop: Advancing the Research on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Ann Intern Med. 2015;162:860-865. doi:10.7326/M15-0338
(2) Jason LA, Benton MC, Valentine L, Johnson A, Torres-Harding S. The Economic impact of ME/CFS: Individual and societal costs. Dynamic medicine : DM. 2008;7:6. doi:10.1186/1476-5918-7-6.
(3) Lin JM1, Resch SC, Brimmer DJ, Johnson A, Kennedy S, Burstein N, et al. The economic impact of chronic fatigue syndrome in Georgia: direct and indirect costs. Cost Eff Resour Alloc. 2011 Jan 21;9(1):1. doi: 10.1186/1478-7547-9-1.
(4) Reynolds KJ, Vernon SD, Bouchery E, Reeves WC. The economic impact of chronic fatigue syndrome. Cost effectiveness and resource allocation : C/E. 2004;2:4. doi:10.1186/1478-7547-2-4.
(5) Estimates of funding for various research, condition, and disease categories (RCDC) [Internet]. Washington, DC: National Institutes of Health; 2015 February [cited July 15, 2015]. Available from: http://report.nih.gov/categorical_spending.aspx
(6) The cost burden of autoimmune disease: the latest front in the war on healthcare spending [Internet]. Eastpointe, MI: American Autoimmune Related Diseases Association; 2011 [cited 2016 July 16]. Available from: http://www.diabetesed.net/page/_files/autoimmune-diseases.pdf

 

[Dolphin]

The authors of the AHRQ treatment review have now posted a comment:

Treatment of Myalgic Encephalomyelitis/Chronic Fatigue syndrome: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop
Posted on July 30, 2015

M.E. Beth Smith†, DO; Elizabeth Haney†, MD; Heidi D. Nelson†¶, MD, MPH

†Pacific Northwest Evidence-based practice Center, Oregon Health & Science University and ¶Providence Cancer Center, Providence Health and Services Oregon, Portland, Oregon

Conflict of Interest: None Declared

We thank the authors for their comments and Dr. Speedy for sharing his personal experience. Regarding Dr. White’s comments about the harms of exercise, we acknowledge that exercise testing is distinct from graded exercise programs. However, both forms of exercise may be considered harmful by patients. To clarify the results of the Moss-Morris trial, while 44% of participants in the intervention group declined repeat exercise testing, 20% declined because of their perception of harm.1 Also, although the Cochrane review did not identify harms of exercise, the authors drew similar conclusions to ours stating that, “limited information makes it difficult to draw firm conclusions about the safety of exercise therapy.” 2

To address Dr. Chu’s comment about safety data in the Nunez trial, we agree that a decline in physical function and pain were reported in the intervention group. However, the trial reported within-group differences, not between-group differences,3 which are necessary to support results of comparisons of interventions in the trial.
Dr. Chu’s comment regarding the importance of analyzing data based on case definitions used for inclusion to trials is consistent with our approach. For example, in the trials of cognitive behavioral therapy (CBT) using the SF-36 physical function item as an outcome measure, the two studies using Oxford criteria indicated improvement, while the two using CDC criteria reported no improvement.4 We also agree with Dr. White’s comment that combining counseling and CBT trials in a meta-analysis may dilute the effectiveness of each individually, which is why our meta-analysis included only trials of CBT.

The studies referenced by Drs. Chu and Kirby, regarding the effectiveness of CBT and graded exercise therapy (GET) and predictors of outcomes, were excluded from our analysis because they included participants with chronic fatigue rather than ME/CFS.5,6 Of the fatigued participants, 31% met criteria for CFS (CDC Fukuda). Although CFS participants had more fatigue and functional impairment compared to other participants, no case definitions were compared and outcomes for the CFS participants based on intervention were not evaluated.

(1) Moss-Morris R, Sharon C, Tobin R, Baldi JC. A randomized controlled graded exercise trial for chronic fatigue syndrome: outcomes and mechanisms of change. J Health Psychol 2005; 10: 245–59.
(2) Larun L, Brurberg KG, Odgaard-Jensen J, Price JR. Exercise therapy for chronic fatigue syndrome. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD003200.
(3) Nunez M, Ferna´ndez-Sola J, Nunez E, Ferna´ndez-Huerta JM, Godas-Sieso T, Gomez-Gil E. Health-related quality of life in patients with chronic fatigue syndrome: group cognitive behavioural therapy and graded exercise versus usual treatment. A randomised controlled trial with 1 year of follow-up. Clin Rheumatol. 2011;30:381-9.
(4) Smith MEB, Haney E, McDonagh M, Pappas M, Daeges M, Wasson N, et al. Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015;162:841-850. doi:10.7326/M15-0114
(5) L. Ridsdale, M. Hurley, M. King, P. McCrone1 and N. Donaldson
The effect of counselling, graded exercise and usual care for people with chronic fatigue in primary care: a randomized trial
Psychological Medicine (2012), 42, 2217–2224.
(6) Darbishire L, Seed P, Risdale L. Predictors of outcome following treatment for chronic fatigue. Br J Psychiatry. 2005; 186 (4) 350-351

 

[Dolphin]

Serious adverse reactions were rare in both groups (RR 0.99, 95% CI 0.14 to 6.97; one study, 319 participants; moderate-quality evidence), but sparse data made it impossible for review authors to draw conclusions.

Peter White, DJ Clauw, MD, JWM van der Meer MD R Moss-Morris PhD, RR Taylor PhD spun the Cochrane results a different way in a comment to the journal, Annals of Internal Medicine

Secondly, there is little evidence of harm caused by graded exercise therapy (GET); a Cochrane systematic review of eight trials of exercise therapy for chronic fatigue syndrome (CFS), published this year, concluded that “..no evidence suggests that exercise therapy may worsen outcomes.”

There was not good reporting of harms in the eight trials PD White et al. refer to (at best one could say there was good reporting in one, the PACE trial) so it's misleading to talk about eight trials. Average scores don't tell one whether some people disimproved or not.

 

[Tom Kindlon]

7 letters, all entitled "Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome", have just been published in Annals of Internal Medicine, a leading US general medical journal. These were in reply to a AHRQ ME/CFS treatment review.

- Maik Speedy, MD
- Peter D. White, MD; Daniel J. Clauw, MD; Jos W.M. van der Meer, MD; Rona Moss-Morris, PhD; and Renee R. Taylor, PhD
- Sean B.M. Kirby
- Alem Matthees
- Lily Chu, MD, MSHS; Lucinda Bateman, MD; Todd Davenport, PT, DPT, OCS; Eleanor Stein, MD; and Staci Stevens, MA
- Tom Kindlon; and Charles Shepherd, MB BS
- M.E. Beth Smith, DO; Elizabeth Haney, MD; and Heidi D. Nelson, MD, MPH

http://annals.org/issue.aspx?journalid=90&issueid=934718

---

The letters are not open access, but one can read for free the e-letters that were submitted here (under comments): http://annals.org/article.aspx?articleid=2322801

 

[Kati]

7 letters, all entitled "Treatment of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome", have just been published in Annals of Internal Medicine, a leading US general medical journal. These were in reply to a AHRQ ME/CFS treatment review.

- Maik Speedy, MD
- Peter D. White, MD; Daniel J. Clauw, MD; Jos W.M. van der Meer, MD; Rona Moss-Morris, PhD; and Renee R. Taylor, PhD
- Sean B.M. Kirby
- Alem Matthees
- Lily Chu, MD, MSHS; Lucinda Bateman, MD; Todd Davenport, PT, DPT, OCS; Eleanor Stein, MD; and Staci Stevens, MA
- Tom Kindlon; and Charles Shepherd, MB BS
- M.E. Beth Smith, DO; Elizabeth Haney, MD; and Heidi D. Nelson, MD, MPH

http://annals.org/issue.aspx?journalid=90&issueid=934718

---

The letters are not open access, but one can read for free the e-letters that were submitted here: http://annals.org/article.aspx?articleid=2322801

i can't help myself but notice Dr Claw's association with Dr White in one of the responses. Dr Claw is associated with many research projects in fibromyalgia and was also seen associated with interstitial cystitis (MAPP publications).
Also Dr Claw is associated with Marie-Ann Fitzcharles which does a lot of fibromyalgia research, she is based in Montreal and whose position is that FM patients should have access to less care not more, and no specialist care, and less drugs, less access to disability insurance. She also talks at long lengths about personalities associated with FM including catastropizing. Rings a bell?

There is a web of psychologizers standing behind the British psych lobby out there. The names behind this group is getting clearer and clearer.

 

[Tom Kindlon]

i can't help myself but notice Dr Claw's association with Dr White in one of the responses. Dr Claw is associated with many research projects in fibromyalgia and was also seen associated with interstitial cystitis (MAPP publications).
Also Dr Claw is associated with Marie-Ann Fitzcharles which does a lot of fibromyalgia research, she is based in Montreal and whose position is that FM patients should have access to less care not more, and no specialist care, and less drugs, less access to disability insurance.

There is a web of psychologizers standing behind the British psych lobby out there. The names behind this group is getting clearer and clearer.

Yes, it can be interesting to see who co-sign letters with Peter White.

Here's a group who wrote together on XMRV in 2010:
Andrew Lloyd,1 Peter White,2 Simon Wessely,3 Michael Sharpe,4 Dedra Buchwald5
https://www.sciencemag.org/content/328/5980/825.2.full.pdf (let's keep discussions of XMRV to elsewhere).

I remember Peter White thanking Kurt Kroenke for comments on an earlier draft of an (annoying (IMHO)) paper which suggests Peter White sees him as somebody along the same wavelength as him (perhaps not a major surprise).

 

[Kati]

Yes, it can be interesting to see who co-sign letters with Peter White.

Here's a group who wrote together on XMRV in 2010:
Andrew Lloyd,1 Peter White,2 Simon Wessely,3 Michael Sharpe,4 Dedra Buchwald5
https://www.sciencemag.org/content/328/5980/825.2.full.pdf (let's keep discussions of XMRV to elsewhere).

I remember Peter White thanking Kurt Kroenke for comments on an earlier draft of an (annoying (IMHO)) paper which suggests Peter White sees him as somebody along the same wavelength as him (perhaps not a major surprise).

Dedra Buchwald is also involved in MAPP research, brings on her psych twist.

 

[SOC]

Is anyone keeping a list of people who co-sign letters and write papers with White and SW? It's probably worth keeping an eye on the quality of their research as well. We need to make sure all the associated research is eventually reviewed for scientific flaws. We're focussed on PACE at the moment, but all psychogenic theory-based research must come under the same careful scientific spotlight so that any of it that is not scientifically sound can be exposed. Those desperately supporting White at this point probably have a lot invested in keeping the theory out of the bright light of public scrutiny and therefore are a good place to start looking for more questionable practices. Solid scientific research will stand up to scrutiny. That which doesn't meet sound scientific practice won't. That's the way science is supposed to work.

In case there's not already a list, here's a start:
Andrew Lloyd
Michael Sharpe
Dedra Buchwald
Kurt Kroenke