G
Gerwyn
Guest
Identification of ambiguities in the 1994 chronic fatigue syndrome research case definition and recommendations for resolution
William C Reeves, 1 Anndrew Lloyd,2 Suzane D Vernon,1 Nancy Klimas,3 Leonard A Jason,4 Gijs Bleijenberg,5 Birgitta Evengard,6 Peter D White,7 Rosane Nisenbaum,1 Elizabeth R Unger,1 and the International Chronic Fatigue Syndrome Study
This paper is co authored by dr Susan Vernon Dr Klimas along with members of the wesselly school of psychiatrists amoung others.
I have attempted to translate the medicospeak into English.if the paper is too fatiguing my comments are in black
Although, the 1994 case definition comprises the current international standard for classification of research subjects as CFS, there are substantial differences between the earlier definitions and it is important to understand this when interpreting results of research studies. CFS is identified by symptoms and disability and by excluding
So Dr Vernon must know that patients selected using different diagnostic criteria make interpretation of results difficult if not meaningless.Yet she is not raising this issue but tacitly accepting the Oxford croterea as perfectly valid
The 1994 case definition stated that any past or current diagnosis of major depressive disorder with psychotic or melancholic features, anorexia nervosa, or bulimia permanently excluded a subject from the classification of CFS. Because these illnesses may resolve with little or no likelihood of recurrence and only active disease or disease requiring prophylactic medication would contribute to confusion with evaluation of CFS symptoms, we now recommend that if these conditions have been resolved for more than 5 years before the onset of the current chronically fatiguing illness, they should not be considered exclusionary.
The five year relapse rate of a patient with melancholy depression is horrendous
the Composite International Diagnostic Instrument (CIDI) [8]. The CIDI is a computerized structured psychiatric interview that can be administered by general medical personnel.
So now a general nurse can diagnose psychiatric conditions using a questionnaireno real need for psychiatrists now is there.Why bother to train them at all.This is bound to be Sooo accurate and wont cause any inconsistency at all will it?
Alternatively, the Structured Clinical Interview for DSM-IV Axis 1 (SCID) [9] may be utilized. However, trained interviewers (i.e., psychiatrists, clinical psychologists, psychiatric social workers, psychiatric nurse practitioners or research nurses with experience in psychiatric assessments) must administer the SCID
If you use this method there is a real danger of getting the diagnosis right.And anyway why waste money?
We recommend that research studies of CFS consider using the more extensive Checklist Individual Strength, but shorter instruments such as the Chalder and Krupp scales are also appropriate.
Lets make things as subjective and simplistic as possible
The Group was not aware of an internationally standardized and validated instrument that measures the cumulated symptom complex of CFS. We recommend that investigators use the Somatic and Psychological Health Report (SPHERE)
I think the above speaks for itself
Systematic evaluation with objective sleep studies is not practical (or necessary) in most CFS studies, and we recommend two instruments for use in CFS research studies. The Pittsburgh Sleep Questionnaire was developed to measures sleep quality in psychiatric research [29]. The Sleep Assessment Questionnaire (SA
They are making it up anyway but we will do the sleep bit if it suits us
Newly emerging technology (e.g., functional neuroimaging) may complement and eventually replace traditional neurocognitive function tests. However, the Group did not recommend specific imaging measurements at this time
we cant have anything objective can we
The Cambridge Neuropsychological Test Automated Battery (CANTAB) is currently the most practical single tool to assess cognition in CFS research studies [35,36].
And of course the most biased
c
patients with exclusionary conditions may be diagnosed and managed as having CFS on the basis of the physician's medical opinion as to whether the exclusionary condition is likely to be a major contributor to the patient's fatigue.
Lets make it even more subjective and exclude psychiatric disorders based on a whim
The 1994 case definition excluded psychiatric conditions that prevent a subject from accurately reporting symptoms and those with fatigue as a reasonably anticipated symptom. Consistent application of these exclusionary criteria has proven difficult The following guidelines include recommendations for exclusionary psychiatric conditions and for stratification of study subjects54647. We recommend that somatization disorder be identified and serve as a stratification diagnosis. Only subjects who recount having always felt fatigued should be excluded as having "lifelong" fatigue.
Lets get as many patients with somatoform disorders in as we can
The stipulation that the fatigue be unrelated to ongoing exertion was intended to distinguish the unexplained fatigue in persons with CFS from that due to ongoing physical demands.
Therefore, this requirement should be interpreted as referring to exhaustion unrelated to an excessively demanding schedule that would induce fatigue in an otherwise healthy adult.
There let them put that in their pipe and smoke it
The requirement that rest should not substantially alleviate the fatigue is also unclear. ITherapeutic use of rest or a partial response to rest should not exclude a subject's illness from classification as CFS.
There we are that should get us more depressed patients
Finally, reliance on an affirmation that the fatigue substantially limits performance of daily activities is insufficient because "substantial" limitation is undefined, and independent confirmation of the reported level of disability is rarely sought. Fatigue is highly subjective, multidimensional, and variable
That is of course how we can define fatigue to suit ourselves
48
The 1994 case definition defines CFS by the presence of debilitating fatigue accompanied by at least four of eight designated symptoms. These symptoms are non-specific and variable in both nature and severity over time.
They were selected on the basis of consensus clinical opinion and were not identified empirically.
This is how we can make the oxford critere appear to match the CDC
Most CFS patients report unrefreshing sleep. However, narcolepsy and clinically significant obstructive sleep apnea are considered exclusionary diagnoses.
It is unclear whether as yet-undefined sleep pathologies should be considered as 29Thus, assessment of sleep must detect treatable primary sleep disorders and evaluate sleep-related symptoms that may be part of CFS.
So we can decide whether you have sleep problems or not
CFS patients typically complain of difficulties with concentration, memory, and thinking, yet neuropsychological testing does not generally confirm the reported cognitive dysfunction [49,50]. 51
They are making it uo
Investigators should use the report of cognitive impairment by the individual or a reliable informant as an initial screening tool. Measurement of cognitive function is complex, time consuming, and cannot be currently recommended for use in classifying CFS in research studies. Other
We wont bother with any objective measurements but we will record cognitive dysfunction if it suits us to.
Conclusion
If done, research studies on patients with CFS are more likely to be comparable.
So they are not comparable at the moment then Why is Dr Vernon a co author not shouting this from the rooftops
Competing Interests
WCR, AL, SDV, LAJ, GB, BE, RN and ERU declare no competing interests. NK has protocol agreements with pharmaceutical industry to assess the affects of various drugs on CFS, does paid and unpaid consultancy work and receives paid and unpaid speaking invitations. PDW does both paid and unpaid consultancy work for Universities, the United Kingdom government, the United States Centers for Disease Control and Prevention, legal claimants and defendants, and insurance companies.
Other Sections▼
o Abstract
o Background
o Methods
o Results
o Discussion
o Conclusion
o Competing Interests
o Author's Contributions
o Pre- publication history
o References
disclaimer
The above comments in black are my attempt at interpreting the meaning of the extracted tests coloured red
as with any interpretation my expectations past history and cognitive constructs are heavily involved so the reader must judge as to the accuracy of said construct
William C Reeves, 1 Anndrew Lloyd,2 Suzane D Vernon,1 Nancy Klimas,3 Leonard A Jason,4 Gijs Bleijenberg,5 Birgitta Evengard,6 Peter D White,7 Rosane Nisenbaum,1 Elizabeth R Unger,1 and the International Chronic Fatigue Syndrome Study
This paper is co authored by dr Susan Vernon Dr Klimas along with members of the wesselly school of psychiatrists amoung others.
I have attempted to translate the medicospeak into English.if the paper is too fatiguing my comments are in black
Although, the 1994 case definition comprises the current international standard for classification of research subjects as CFS, there are substantial differences between the earlier definitions and it is important to understand this when interpreting results of research studies. CFS is identified by symptoms and disability and by excluding
So Dr Vernon must know that patients selected using different diagnostic criteria make interpretation of results difficult if not meaningless.Yet she is not raising this issue but tacitly accepting the Oxford croterea as perfectly valid
The 1994 case definition stated that any past or current diagnosis of major depressive disorder with psychotic or melancholic features, anorexia nervosa, or bulimia permanently excluded a subject from the classification of CFS. Because these illnesses may resolve with little or no likelihood of recurrence and only active disease or disease requiring prophylactic medication would contribute to confusion with evaluation of CFS symptoms, we now recommend that if these conditions have been resolved for more than 5 years before the onset of the current chronically fatiguing illness, they should not be considered exclusionary.
The five year relapse rate of a patient with melancholy depression is horrendous
the Composite International Diagnostic Instrument (CIDI) [8]. The CIDI is a computerized structured psychiatric interview that can be administered by general medical personnel.
So now a general nurse can diagnose psychiatric conditions using a questionnaireno real need for psychiatrists now is there.Why bother to train them at all.This is bound to be Sooo accurate and wont cause any inconsistency at all will it?
Alternatively, the Structured Clinical Interview for DSM-IV Axis 1 (SCID) [9] may be utilized. However, trained interviewers (i.e., psychiatrists, clinical psychologists, psychiatric social workers, psychiatric nurse practitioners or research nurses with experience in psychiatric assessments) must administer the SCID
If you use this method there is a real danger of getting the diagnosis right.And anyway why waste money?
We recommend that research studies of CFS consider using the more extensive Checklist Individual Strength, but shorter instruments such as the Chalder and Krupp scales are also appropriate.
Lets make things as subjective and simplistic as possible
The Group was not aware of an internationally standardized and validated instrument that measures the cumulated symptom complex of CFS. We recommend that investigators use the Somatic and Psychological Health Report (SPHERE)
I think the above speaks for itself
Systematic evaluation with objective sleep studies is not practical (or necessary) in most CFS studies, and we recommend two instruments for use in CFS research studies. The Pittsburgh Sleep Questionnaire was developed to measures sleep quality in psychiatric research [29]. The Sleep Assessment Questionnaire (SA
They are making it up anyway but we will do the sleep bit if it suits us
Newly emerging technology (e.g., functional neuroimaging) may complement and eventually replace traditional neurocognitive function tests. However, the Group did not recommend specific imaging measurements at this time
we cant have anything objective can we
The Cambridge Neuropsychological Test Automated Battery (CANTAB) is currently the most practical single tool to assess cognition in CFS research studies [35,36].
And of course the most biased
c
patients with exclusionary conditions may be diagnosed and managed as having CFS on the basis of the physician's medical opinion as to whether the exclusionary condition is likely to be a major contributor to the patient's fatigue.
Lets make it even more subjective and exclude psychiatric disorders based on a whim
The 1994 case definition excluded psychiatric conditions that prevent a subject from accurately reporting symptoms and those with fatigue as a reasonably anticipated symptom. Consistent application of these exclusionary criteria has proven difficult The following guidelines include recommendations for exclusionary psychiatric conditions and for stratification of study subjects54647. We recommend that somatization disorder be identified and serve as a stratification diagnosis. Only subjects who recount having always felt fatigued should be excluded as having "lifelong" fatigue.
Lets get as many patients with somatoform disorders in as we can
The stipulation that the fatigue be unrelated to ongoing exertion was intended to distinguish the unexplained fatigue in persons with CFS from that due to ongoing physical demands.
Therefore, this requirement should be interpreted as referring to exhaustion unrelated to an excessively demanding schedule that would induce fatigue in an otherwise healthy adult.
There let them put that in their pipe and smoke it
The requirement that rest should not substantially alleviate the fatigue is also unclear. ITherapeutic use of rest or a partial response to rest should not exclude a subject's illness from classification as CFS.
There we are that should get us more depressed patients
Finally, reliance on an affirmation that the fatigue substantially limits performance of daily activities is insufficient because "substantial" limitation is undefined, and independent confirmation of the reported level of disability is rarely sought. Fatigue is highly subjective, multidimensional, and variable
That is of course how we can define fatigue to suit ourselves
48
The 1994 case definition defines CFS by the presence of debilitating fatigue accompanied by at least four of eight designated symptoms. These symptoms are non-specific and variable in both nature and severity over time.
They were selected on the basis of consensus clinical opinion and were not identified empirically.
This is how we can make the oxford critere appear to match the CDC
Most CFS patients report unrefreshing sleep. However, narcolepsy and clinically significant obstructive sleep apnea are considered exclusionary diagnoses.
It is unclear whether as yet-undefined sleep pathologies should be considered as 29Thus, assessment of sleep must detect treatable primary sleep disorders and evaluate sleep-related symptoms that may be part of CFS.
So we can decide whether you have sleep problems or not
CFS patients typically complain of difficulties with concentration, memory, and thinking, yet neuropsychological testing does not generally confirm the reported cognitive dysfunction [49,50]. 51
They are making it uo
Investigators should use the report of cognitive impairment by the individual or a reliable informant as an initial screening tool. Measurement of cognitive function is complex, time consuming, and cannot be currently recommended for use in classifying CFS in research studies. Other
We wont bother with any objective measurements but we will record cognitive dysfunction if it suits us to.
Conclusion
If done, research studies on patients with CFS are more likely to be comparable.
So they are not comparable at the moment then Why is Dr Vernon a co author not shouting this from the rooftops
Competing Interests
WCR, AL, SDV, LAJ, GB, BE, RN and ERU declare no competing interests. NK has protocol agreements with pharmaceutical industry to assess the affects of various drugs on CFS, does paid and unpaid consultancy work and receives paid and unpaid speaking invitations. PDW does both paid and unpaid consultancy work for Universities, the United Kingdom government, the United States Centers for Disease Control and Prevention, legal claimants and defendants, and insurance companies.
Other Sections▼
o Abstract
o Background
o Methods
o Results
o Discussion
o Conclusion
o Competing Interests
o Author's Contributions
o Pre- publication history
o References
disclaimer
The above comments in black are my attempt at interpreting the meaning of the extracted tests coloured red
as with any interpretation my expectations past history and cognitive constructs are heavily involved so the reader must judge as to the accuracy of said construct
Just don't kill off the rest of them.
