2002 paper: Physical or mental? A perspective on chronic fatigue syndrome [physical]

[Wildcat]

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Richard Sykes isn't a Doc, he's a Philospher of Language.
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So, no, there's no medicine or bio-science in his papers. Not surprising that Richard Sykes' papers were of such interest to Profs Michael Sharpe and Francis Creed.
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[Enid]

Where are these people stuck one has to ask (not that I have the slightest interest) - we have outgrown them, and much more knowledgeable now.

Profs they may be - two in my own family Neurology and Radiology happily into real medicine.

 

[Esther12]

Regardless of his associations, I still agree with some of the points he makes, and think that having them in peer reviewed papers could be useful for references in support of similar points.

Thanks for the additional information about his though, it's always good to know where people are coming from.

 

[Wildcat]

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The whole point of Richard Sykes papers is to skillfully present several disparate points of view but to never reach any conclusion. That way people like us can say "Yes, thats a good point", whilst people like Michael Sharpe profitably exploit the other points, doing us no good whatsoever.

I read Richard Sykes early 2000's papers early on, and concluded that he says everything and nothing.

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Sykes' linguistic ramblings about 'Chronic' 'Fatigue' and 'Syndrome' have been picked up by other Linguistic Academics who are less subtle about their beliefs about 'CFS'. One in particular, who has taken his cue and his linguistic interest in 'Chronic Fatigue Syndrome' from Sykes, has made it clear that they are talking about a psychosomatic disorder (I have the evidence somewhere in the dungeons of my files, but it takes about two hours to find 'em).
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[Enid]

I find these people very difficult to support Esther - 6 years ago I just managed to escape A & E UK following one of many collapses in the street and being confronted with 3 junior Docs and a psychiatrist. Are you trying to tell me they are getting their act together - that is their problem - mine at the time - can I get home.

 

[Wildcat]

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I agree, Enid. These people exploit 'CFS' to advance their own career (or in the case of Richard Sykes, his hobby) then they retire, leaving ME sufferers struggling in dire straits, whilst the new generation of Psychology or Linguistics academics exploit us, and our illness, as just another component of their career trajectory.
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[Enid]

But this is a 2002 paper - why are we bothered now.

 

[biophile]

Those interested in Sykes' paper may also be interested in Per Dalen's comments about the abuse of somatisation notions for "medically unexplained physical symptoms" ...

Main article: "Somatic medicine abuses psychiatry and neglects causal research" (http://art-bin.com/art/dalen_en.html) ... Extract: "Since I am a psychiatrist, I have for a long time been intrigued by the extraordinary use of psychiatric causal explanations for illnesses that not only go with predominantly somatic symptoms, but also lack any basic similarity to known mental disorders."

Foreword to Martin J. Walker's "SKEWED" (http://www.prohealth.com/me-cfs/blog/boardDetail.cfm?id=323925 - scroll down to [angeldust 1/4/04 4:57 AM]) ... Extract: "Emotional states can give rise to bodily symptoms; this is a matter of everyday experience. It is, however, deceptively easy to exaggerate the importance of this mind-body connection. The necessary question therefore becomes what, and how much can be reliably attributed to which emotional causes and for how long."

 

[Esther12]

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I agree Esther. These people exploit 'CFS' to advance their own career (or in the case of Richard Sykes, his hobby) then they retire, leaving ME sufferers struggling in dire straits, whilst the new generation of Psychology or Linguistics academics exploit us, and our illness, as just another component of their career trajectory.
.

I didn't mean to criticise Sykes like that.

I really don't know much about Sykes as an individual, or how his work has been used, but from what little I've read, I think that he does understand and write about some legitimate and important patients concerns, when few others have done so.

Anyone who has done work on CFS in the UK is likely to be associated with quacks, that's just a reflection of the sad state of things. Others may have used his work to undermine patients, but I think (from what little I've read) that we could also use his work to buttress our own points when we need academic references.

 

[Wildcat]

.
Richard Sykes and his CISSD Project was taken up by Action for ME at the time of the suspect 'merger' of Sykes's Westcare charity with Action for ME (AFME). Sykes's Conceptual Issues In Somatoform and Similar Disorders (CISSD) Project was then also taken up by Michael Sharpe.
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It really is a good idea to thoroughly investigate any professional's work before confidently suggesting that it could be used in our interests.

A cursory look at Richard Sykes work may well lead to a conclusion that he genuinely explores Conceptual Issues in 'CFS'. But please remember that Sykes is involved in Language - and Close Reading is required to get at what he is Really saying.
.

Those who HAVE explored Richard Sykes' work conclude that it is most definitely NOT in our interests.
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For example, the first two of the three tranches of funding (below) claim they are provided to "help lobby the World Health Organisation for the recognition of M.E. and its re categorisation as a physical illness.

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Err??? Lobbying for ME's 're caterorisation as a physical illness????

When ME has Always been categorised as a physical illness by the WHO!! ME has never been categorised as anything else by the WHO. That is part of what I mean by the need to do close reading of the work of professionals before diving in and claiming that their work could be in our interests.

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http://meagenda.wordpress.com/2009/06/03/cissd-project-report-from-dr-richard-sykes/

'The report by Dr Richard Sykes, below, contains information about the aims, objectives and administration of the CISSD Project that Action for M.E. (Principal Administrators for the Project) sought not to disclose to its membership and to the wider ME community. The CISSD Project ran from 2003 to 2007 it has taken years for much of this information to reach the public domain.

The sum total that Action for M.E. has published to date on the aims and objectives of the CISSD Project amounts to the following:

WHO Somatisation Project Incoming Resources 2006: 24,000 Outgoing Resources 2006: 24,000

This grant is provided to help lobby the World Health Organisation for the recognition of M.E. and its re categorisation as a physical illness.
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WHO Somatisation Project Incoming Resources 2007: 18,750 Outgoing Resources 2007: 18,750

This grant is provided to help lobby the World Health Organisation for the recognition of M.E. and its recategorisation as a physical illness. This grant ceased in March 2007.
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CISSD Project Restricted Funds 2008: 20,000 Total Funds 2008: 20,000

This grant, from the Hugh and Ruby Sykes Charitable Trust is provided to disseminate the findings of the WHO Somatisation Project whose research came to an end in 2006. The aim is to produce a number of recommendations which, if accepted by the World Health Organisation, would be of direct benefit to people with M.E.....'....
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[Enid]

Do we need the likes of him to "buttress" - when real science/medicine - pathology findings/interventions/treatments have now outstripped them.

Though suddenly listening and believing patients may be a step in the right direction.

 

[Wildcat]

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In post 26 I mistakenly wrote that I agreed with Esther, when I meant to write that I agreed with Enid. I apologise to you both for confusing the issue with a mis-type, which I have now corrected.

 

[Esther12]

Personally, I don't think that we need to agree with someone in order to find a use for their work.

It could well be that I've just not yet read enough of Syke's work to spot the problems with his use of language, but I didn't want others to think that I had already reached condemning conclusions of him and his ideas.

 

[Wildcat]

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I refer you back to Suzy Chapman's posts #15 and #16 on this thread, and her series 'Elephant in the Room' Series One and Two, for investigation of the problems with Richard Syke's work.
.

When I first started reading 'Richard Sykes's Long Report', at first it seemed that he made some valid points, but as I read on I reached the "hang on a minute" moment that started to question his infinitely circular arguments; I applied critical reading, and could see how his points could be appealing on the surface, but found them ultimately redundant and endlessly circular (and I was totally in the dark about ME politics at the time as still too ill to use a computer, and so had no pre-conceptions about any kind of double speak in ME politics, nor any knowledge of ME politics per se).

 

[Enid]

Yep agree Wildcat - and use of work lies with Virologists/Immunologists/Neurologists and that handful of Docs beginning to to unravel and aid sufferers. (biomedical only).

I think until one has gone through (as many here told to accept depression) and my own experience of "it's all in your mind" it's difficult to really appreciate the poverty and ignorance of psychiatric involvement in ME and as often said in the past dangerous.

 

[WillowJ]

thanks for info

 

[Esther12]

Just pulling out some quotes from the recent Sykes paper, more for myself than others. I didn't think that paper was that great, but it's still good to have it published, and maybe encourage people who may not have thought about these matters to consider some basic points. My comments refer to the quotation above the comment (Whoops. sorry - I know it makes it a bit harder to browse).

The historical problem is that the history of
medical science is littered with examples where it
was assumed that there was no physical cause for
a condition and where a physical cause for that
that condition has later been established. These
examples include spasmodic torticollis, blepharospasm,
writers cramp, and more recently peptic
ulcer (Jenkins 1991, 30).

I don't know about some of the examples above, but I may look in to them.

Four main problems in diagnosis, all of which
can lead to faulty treatment, can occur when the
psychogenic inference is made. In the first place,
physiological factors can be neglected and not
taken into account. This can occur where the
symptom is the forerunner of later clear disease
and this is not recognized, or where there is a
diagnosable physiological abnormality but not
all the appropriate tests have been done, or where
the severity of an underlying medical condition
is underestimated. In all these cases, a failure to
treat the symptoms at an early stage may result in
a more severe and more prolonged disease.

Second, nonexistent psychological problems
can be diagnosed and psychological treatment can
be given for them.

Third, where there is a psychological problem,
its role may be misunderstoodit may be taken,
for example, to be a cause when it is actually an
effect of the symptoms or is simply coincidental
with them. This would be like assuming that when
a person has influenza and a low mood, it was the
low mood that was the cause of the influenza. This
would lead to treating the low mood rather than
the influenzaputting the cart before the horse.

Fourth, where there actually is a psychological
problem that may have some causal influence, the
extent of the problem and its causal influence can
be greatly exaggerated.

Maybe good to have these basic points made in a paper that can be cited?

When patients have protested against the
diagnoses they have sometimes had additional
imaginary problems foisted on them to account for
their disagreement. If they get angry, they can be
told that they lack insight or, perhaps, that they are
suffering from borderline personality disorder, and
so on. It can be a no-win situation for patients.
The patient is always in the wrong. The judgment
of the doctor is not to be questioned.

Overpsychologizing can easily lead to the alienation
of patients. This seems to have happened
with large numbers of patients with CFS. When
the Royal Colleges of Physicians, Psychiatrists
and General Physicians produced a report on CFS
in 1996 (Royal Colleges 1996), the report was
greeted by a patients petition with over 10,000
signatures asking for its repeal. The main ground
for the opposition was that the report overpsychologized
CFS, a sentiment that was echoed in a
contemporary Lancet editorial (Lancet Editorial
1996). More recently, some of the main CFS patient
organizations in the United Kingdom have
objected to the newly produced National Institute
for Health and Clinical Excellence (2007) guidelines
for the same reason.

Although patient alienation has been uncomfortable
for doctors, it has been nothing short of
tragic for patients. Not only have they failed to
receive appropriate treatment, but they have felt
misunderstood, disparaged, and insulted. When
they become alienated and resentful, they may
refuse to consider any psychological treatment
that may be proposed and even any possible contribution
of psychological factors to their illness.
In doing this, patients can deprive themselves of
potentially useful help.

The first paragraph above is a worry. I'm naturally quite pro-debate, but being diagnosed with CFS means that I have to be rather careful with what I say to medical staff, and that is a pain. They have the power to give me some diagnosis which will serve to discredit my claims forever more, and that's quite a power imbalance.

When a symptom
is said to be functional or nonorganic or a
symptom of somatization, this can mean either
(a) that there is no known physiological basis for
the symptom or (b) that the symptom is of psychological
origin.

This assumption is, of course, none other than
the psychogenic inference. Walton expresses it
openly in his standard textbook Essentials of
Neurology (Walton 1989) and makes clear that
it is commonly made: Thus when a physician
says that a symptom is functional, he usually
means that it has no known physical cause and
by implication that he believes its origin to be
psychological (p. 2; see also Bass 1990, 2). The
psychogenic inference could not be more clearly
expressed. It is entrenched in the dual meaning of
the word functional.

One study (Stone et al. 2002) purported to
show that the term functional was generally
acceptable to patients on the basis of a questionnaire
given to them. The effort to consult patients
and to ascertain their views is most commendable.
There was, however, no mention of any explanation
being given to them that the term functional
is frequently used by neurologists and others to
mean having a psychological cause as well as
being related to functioning. Had this information
been given to the patients, it is extremely
unlikely that they would have given the same judgment.
Frequently, patients with MUS are keen to
avoid the suggestion that these symptoms have a
psychological, but no physical, cause. Withholding
information from patients about the dual use
of the word functional is rather like asking a
group of foreign construction workers, who do
not understand English, whether they would like
to be called cowboys after explaining to them
that cowboys meant tough and independent
men in American folklore, without mentioning
that it had an additional meaning of unqualified
or slapdash persons providing inferior services or
shoddy workmanship for a quick profit (Chambers
1993).
Functional is a term that is currently popular
among psychiatrists and other doctors for symptoms
and disorders that are medically unexplained.
It is, however, strongly tainted with the psychogenic
inference and, for overpsychologizing to be
avoided, it needs to be replaced.

In DSM-IV-TR somatoform disorders are introduced
with the statement The common feature of
Somatoform Disorders is the presence of physical
symptoms that . . . are not fully explained by a
general medical condition, by the direct effects of
a substance, or by another mental disorder (p.
485). What is noteworthy about this account is
that it omits any reference to psychological factors.
In this it is strikingly different from the account of
somatoform disorders given in the earlier edition
of DSM, the DSM-III (APA 1990). In the DSMIII,
it was stated that somatoform disorders are
disorders where there is positive evidence or a
strong presumption that the symptoms are linked
to psychological factors or conflicts and where
the specific pathological processes involved are
conceptualised most clearly using psychological
constructs (p. 241). This presence of psychological
factors or processes is explicitly given in DSMIII
as the reason for classifying such disorders as
mental disorders.
So why did the authors of the DSM-IV-TR
think that the reference to psychological factors
could be dropped from the characterization of
somatoform disorders? Why did they think that
the presence of physical symptoms that were not
fully explained by a general medical condition
was in itself sufficient to classify a condition as
a mental disorder? It seems that there was some
implicit reliance on the psychogenic inference,
on some tacit inference that if the symptoms of a
condition were not physiologically explained, then
the causes of that condition must be psychological
and hence that the condition should be considered
to be a mental disorder.
The effect of the current criteria for somatoform
disorder in the DSM-IV-TR is that any condition
that is medically unexplained can be classified as
a mental disorder. Thus, if it is accepted that CFS
is medically unexplained, CFS can be classified as
a somatoform disorder, specifically as an undifferentiated
somatoform disorder. The suggestion,
however, that CFS is a mental disorder is strongly
resisted by patients and is commonly regarded by
them as a clear instance of overpsychologizing.

Some stuff on DSM changes.

I'm planning to read the other papers soon. Overall, I didn't think that this Sykes one said that much... but it does raise some issues which are often neglected in discussions of CFS.

 

[Don Quichotte]

In the paragraphs you cite, their is an (quite ingenious and hard to notice) ambiguity, that leaves an open place for the exact opposite approach-

The historical problem is that the history of
medical science is littered with examples where it
was assumed that there was no physical cause for
a condition and where a physical cause for that
that condition has later been established

Why is this a problem?

When
they become alienated and resentful, they may
refuse to consider any psychological treatment
that may be proposed and even any possible contribution
of psychological factors to their illness.
In doing this, patients can deprive themselves of
potentially useful help.

This can easily be interpreted as-there is a significant psychological component to this illness, but patients refuse to accept it as they have become alienated and resentful.

The suggestion,
however, that CFS is a mental disorder is strongly
resisted by patients and is commonly regarded by
them as a clear instance of overpsychologizing.

This can easily be interpreted as-because of the way it is worded, the patients refuse to accept that their illness is a mental disorder.

The rest of what he is saying is quite obvious and as opposed to what it initially appears, has nothing to do with the question of CFS being a physical or mental illness.

The fact that certain diseases thought to be of psychological causes were found to be physiological, does not logically lead to the conclusion that all diseases thought to be psychological are in fact physiological.

The fact that failing to recognize a serious illness and attributing it to psychological causes can lead to fatal errors is well known. Again, this does not logically lead to the conclusion that in every case in which a psychological cause is thought to cause an illness, this is the case.

The dishonesty of the term "functional" is also well understood by the vast majority of those who use it. They use it for that exact reason. It enables them to say one thing to their colleagues and quite another to their patient.
Some of them may also be fooling themselves. And when this term will eventually be understood by patients, they will no doubt find a new one to replace it.

What you cite mostly says that patients with CFS are knowledgeable and sophisticated and can't be fooled like that. They know that many diseases were found to have a physiological origin, so think their disease will as well. They know that neglecting a serious illness and attributing it to emotional problems can be dangerous, so they are concerned this will happen to them. They realize that the only reason they are told they have mental problems is because no physiological cause has been found. It says nothing about the true origin of this specific illness.

It mostly discusses the emotional problems, which are the result of the way in which CFS patients are managed.
This emphatic approach and understanding of the emotional needs of the patients, superficially gives the impression that he agrees with what they think. When in fact no where is that mentioned.

There is a big difference between saying-I respect your need to see your illness as a real physiological condition, even though no such cause has been found yet. to saying- I have no doubt that your illness is a real physiological condition and every effort should be done to find its cause.

It's like the significant (and subtle) difference between saying- I respect your need to be seen as the prime minister and realize that I should say to you-yes prime minister when I talk to you (which can be said to a schizophrenic patient by an emphatic physician taking care of him), to- I know you are the prime minister and realize that I need to say to you- yes, prime minister when I talk to you (which is said to the prime minister).

 

[Enid]

Where are you coming from DQ - we are not talking mental but physical pathologies. We have argued over years - and who cares - I know I had/have a real illness - - as one Doc eventually crept to the bottom of my bed and admitted "you know when you are ill" - like most of us we do indeed know.

Are you a Doctor - there are 4 in my family looking for answers to diseases Neurolgy and Radiology diagnostics who actually believe their patients and not concerned with the (Cartesian) mind body endless debate which allows so much free conjecture.

 

[alex3619]

Hi, I read the Siren paper by Sykes last night. It is indeed possible to isolate individual points and disagree with them, but the case analysis and the logical pattern of the entire paper makes a lot of sense. Where there is disagreement, I think, arises out of some of the cases (options) he discussed. He runs through a range of options and discusses them - we just happen to object to the idea of some of those options.

He is unapologetically pro-psychosomatic, and while in a trivial sense I agree with this, I am still to be convinced that any conversion or somatization disorder is real. This is perhaps the biggest flaw with the paper - he is so very careful not to alienate some branches of psychiatry that his message is watered down (although this might relect my message and I am just being overly lenient toward him). My interpretation is this is deliberate, perhaps for political reasons to do with acceptability of his analysis. As a patient I would say pretty much the same as him but I would be less inclined to be diplomatic about psychobabble.

I liked his discussion on word ambiguity, it parallels my own. However, as I pointed out on my blog, he only looks at confusion and irrationality. He does not address the issue of people deliberately using these words to spin and deceive. Indeed, there was a recent paper by Wessely and others, if I recall correctly, in praise of the word "functional".

The discussion of these words is not an academic exercise. This is what doctors read, what doctors are taught. Its what the media sees. Ambiguity allows statments to be used out of context to justify things they do not actually support.

One of the things I think Don Quichotte is pointing out in post 38 is that there is still ambiguity, even in a paper trying to point out the problems of ambiguity. The entire field is filled with amiguous claims - what Sykes is pointing out is that such ambiguity needs to be addressed. It doesn't mean he is immune from it himself, only that he recognizes the problem.

One of the problems that occurs is that many people think words mean what is in the dictionaries. While we can use words that way, we are not limited to it. How else could poetry exist? When a med student hears the word "functional" a thousand times in a year, and 900 times it relates to mental disease, the subtleties of the meaning their brain is absorbing is a distinct bias toward mental disease. This is language as a living thing. Its not what is written up in dictionaries, its whats in the minds of people who use it. Allowing for ambiguity in science is allowing for error, confusion and invalid reasoning. As much as possible it needs to be stamped out.

The real problem though, I think, is it allows statements to be used to pursuade that are only trivially or incidentally correct. It allows spin to be thought of as fact or reason, especially to busy people who do not have time to look into things. And that means practicing medical professionals. Medicine has to give up ambiguity or it cannot be considered fully scientific. If a medical professional reads ambiguous spin a thousand times that implies something that is not true, and they don't recognize this, they will adopt the same attitude. Dogma and spin are contagious.

Ambiguity is the realm of poets and spin doctors. Poetry has wide value (most songs are poetry), spin doctoring serves agendas. Science by spin is a hallmark of pseudoscience.

Bye, Alex

PS If you look at the proposals in relation to definitions including DSM there are inherent problems with the definitions. There is a trend in DSM to weaken the definition of psychosomatic. The DSM-IV claims that it can be justified without reason to believe its psychological, on the basis that there is no physical disorder that explains all of it. The ICD on the other hand allows that there only have to be physical explanations of symptoms to reject a diagnosis - the entire disorder does not have to be explained. So we have the situation, with current biomedical findings in CFS and ME, that they can be considered somatization by DSM-IV (and V I think) and not by ICD.

PPS There is a claim that the current view in cognitive neuroscience is that all mental diseases are physical. There are only physical diseases, though some affect mental capacity. I have yet to read much on this though. Those really into BPS will argue against this I am sure.