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SOMATISATION, DEPRESSION AND ME

Discussion in 'Action Alerts and Advocacy' started by Marco, Feb 10, 2012.

  1. Marco

    Marco Old blackguard

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    Dolphin kindly suggested that I repost this as a separate topic for discussion.

    I'd initially posted this on the thread discussing comments made by members of the biopsychosocial school (Peter White specifically) which may provide a clearer insight into their attitudes to ME/CFS.

    These are excerpts from a presentation given by Peter white in 2009 :


    This is essentially the core of the biopsychosocial model of ME/CFS. No physical abnormalities are found (the doctor cannot explain the symptoms), there is (by some accounts) high co-morbidity of depression, ergo self reported symptoms have no physical basis and arise as a consequence of mental distress.

    A 'classic' case of a psychosomatic illness.

    Except 'psychosomatic' as used today is a corruption of the initial intent of those psychiatrists that first described the phenomenon.

    This paper is from the journal Biopsychosocial Medicine :

    Symptoms of somatization as a rapid screening tool for mitochondrial dysfunction in depression

    Far from a multitude of vague and varying symptoms being highly suggestive of a psychosomatic disorder as is often stated as an accepted fact in some quarters, somatic symptoms occurring in conjunction with depression is actually highly suggestive of a mitochondrial disorder.

    The authors suggest that a small subset of questions from the Karolinska Scales of Personality questionnaire can be used to effectively distinguish those patients whose depression, as well as somatic symptoms, are likely to have arisen from a mitochondrial disorder.

    Here are the six KSP questions used as the screening tool :

    If you have co-morbid depression and score two or more of these items as Applies Completely the authors suggest that you are likely to have a mitochondrial disorder.

    http://www.bpsmedicine.com/content/2/1/7

    Perhaps Peter White doesn't subscribe to 'Biopsychosocial Medicine'?
     
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  2. Marco

    Marco Old blackguard

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    It appears then that the modern concept of a somatoform disorder is radically different from that originally proposed by Briquet and Freud.

    The original notion was of an unknown pathology that manifests itself through various symptoms and that the specific collection of symptoms experienced may be mediated by psychological factors.

    At some point in time this concept, that didn't deny a possible biological etiology, has been corrupted to posit multiple non-specific symptoms arising solely from psychological factors. How, when I and why this changed I don't have time to research at present.

    If the biopsychosocial school believe that 'CFS' is essentially a psychosomatic disorder, why do they not diagnose it as such and/or how frequently is CFS diagnosed (or misdiagnosed) as a psychosomatic or somatisation disorder? How frequently does somatisation disorder occur in a 'CFS' cohort?


    Appearing in the journal Psychosomatic Medicine (a peer reviewed journal dedicated to the integration of the biological, psychological and social factors in medicine) Johnson et al (including Ben Natelson), 1996, tackled this question head-on in :


    Assessing Somatization Disorder in the Chronic Fatigue Syndrome

    http://www.psychosomaticmedicine.org/content/58/1/50.full.pdf html

    This is from the introduction :


    'Problematic' is an understatement! The concept of somatisation and its diagnosis appears to rest solely on a series of assumptions and arbitrary judgements including :

    multiple symptoms occurring over a number of organ systems cannot be due to an organic illness. Clearly this must relate back to an earlier stage of medical knowledge before systemic diseases such as mitochondrial disorders were recognised. The cut-off point of 13 or more symptoms appears completely arbitrary;

    the finding of 'no significant pathology' assumes that medical knowledge has been perfected; makes a further assumption about what findings are 'significant' and finally extends absence of evidence to evidence of absence;

    that the disorder 'must begin before the age of 30' again appears entirely arbitrary but is presumably intended to reflect a lifelong tendency to 'catastrophise' somatic symptoms arising from psychological distress. Why this disorder can't occur at a later age, as with other psychological disorders, is not clear and it also presents problems for conditions that may have early prodromal symptoms;

    Finally, and most critically, it is left to the judgement of the interviewer to determine which symptoms are of organic origin or of psychological origin.


    From the starting point that there are two perspectives that propose that the symptoms or 'CFS' have either a biological or psychological basis, the paper examines the frequency of a diagnosis of somatisation disorder (SD) in patients with CFS (Holmes, 1988), MS (mild), depression plus healthy controls.

    The paper estimates the rates of SD in each group under various conditions which include various levels of 'strictness' of SD criteria, whether patient reported symptoms are classified as organic or psychiatric and where CDC CFS listed symptoms are excluded from classification as psychiatric.


    Without going into too much detail (the paper is well worth a read to see how the various conditions affect the prevalence of a diagnosis of SD in all three conditions) they found :

    Interestingly, CFS patients endorsed a much wider range of symptoms than those detailed in the CDC case definition which, depending on your conception of the illness, could be interpreted as indicative of symptoms of somatising or suggests that the case definition is rather lacking.

    As for co-morbid depression the authors note :

    Contrary to the existing literature and the parallel symptomatology with the depressed group, however, is the present finding that the CFS subjects with depression and anxiety disorders did not report significantly more SD symptoms than CFS subjects with no DIS diagnoses. Furthermore, screening out chronic psychiatric disorders in our population did not result in a decrease in somatic symptom reporting compared with previous CFS studies. These results strongly suggest that psychiatric factors alone are not a sufficient explanation for the broad array of somatic symptoms reported in CFS.

    The killer of course is that CFS patients reported these symptoms only following onset of illness and not as an ongoing lifelong pattern of somatic symptoms which is incompatible with the strict definition of SD.


    As for the discussion, on a first read, I found the following final statement in the paper disturbing. Initially I interpreted this as their endorsement of the statement. On reflection it could also be a rather arch critique of the status quo :

    Perhaps Peter White doesn't subscribe to Psychosomatic Medicine either?
     
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  3. alex3619

    alex3619 Senior Member

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    The Rise and Fall of the Biopsychosocial Model

    Subtitle: Reconciling Art & Science in Psychiatry
    S. Nassir Ghaemi, M.D., M.P.H.
    The Johns Hopkins University Press, 2010

    I have just finished reading part one of this book, called "The Rise of the Biopsychosocial Model". Part two which I am about to start is called "The Fall of the Biopsychosocial Model".

    According to Ghaemi, BPS has its origin in the theories of Freud. Earlier accounts of psychosomatic medicine, indeed up to at least the 1950s, merely refered to illness that had mental issues as a component. Lets face it, even if you just stubbed your toe you have a mental component to it. So the early accounts presumed it was physical, but then explored the mental/psychological issues that went with it.

    Freud pushed the idea of psychosomatic as primarily mental. Adolf Myer introduced the term psychobiology. This was a man who endorsed surgical removal of the colon and frontal lobotomies as treatment for psychiatric disorders.

    The 1950s saw the rise of psychiatric eclecticism. I would sum this attitude up with the phrase "If it works use it". However the trend in eclecticism seems to have been the embracing of dogmatism, the undue influence of authority, even though it rose as a way to avoid dogmatism.

    Roy Grinkler was interested in using General Systems Theory as a framework to advance psychiatry. He created the term biopsychosocial, although in his earlier 1952 work it was called psycho-somatic-social. It was an attempt to create a holistic psychiatric approach, and avoid excessive psychoanalytic dogmatism, by putting emphasis on all three areas that can give rise to mental problems. By 1966 somatic had become bio-.

    In 1977 George Engel appropriated the term for his paper on a systems theoretic view toward all of medicine, not just psychiatry, although I think it was about 1951 he started talking about such issues. He was interested in the mental aspects of physical disease, but was attracted to psychoanalytic theory. The origins of the formal BPS model we know today are with Engel, first really expounded in his Science paper "The need for a new medical model: a challenge for biomedicine."

    http://www.healtorture.org/files/files/englearticle.pdf

    Engel is quoted as saying: "All three levels, biological, psychological, and social, must be taken into account in every health care task."

    In the several decades that followed, the pharmacological advances put the psychoanalytic models in perspective as outdated theories. However, the rise of the cognitive behaviourial model has replaced it as the dominant -psycho- aspect of BPS.

    Ghaemi is critical of DSM-IV though he doesn't say much about it in this book. He is also not impressed with DSM-V.

    Ghaemi claims the BPS model rose in significance because the dying psychoanalytic approach, which was increasingly being rejected, could find a haven in the -psycho- aspect of the BPS model. Gaemi also claims, as do I, that BPS has undue emphasis on the P part, while paying lip service to the B and S.

    My analysis is a little different. The BPS model is based on GST. Its a system theoretic model. What has happened, in my view, is that the BPS proponents are treating the model as reality on the one hand, and not taking it seriously on the other. One of the oldest maxims in systems theory is "The map is not the territory". The model is not reality, its an abstraction of reality. While it is fair to say that a systems theoretic view is a good antidote to excessive reductionism, it is also fair to say, as I see it, that its still reductionism, just not as extreme.

    Where I think this is heading, for me (although I have lots of work to do still) is that CBT/GET (for ME) proponents of BPS have used it to give themselves an air of acceptability. They pay lip service to the model, they fit it like ticking a checklist, but violate the spirit and wider meaning of the model. This checklist criticism I think also applies to evidence based medicine, but it will be months before I talk about that.

    More to follow.

    Bye, Alex

    PS I have said this before but I think it is worth repeating: if we have a psychosomatic illness because a physical illness cannot be objectively shown, how is a psychosomatic illness any more valid since it cannot be objectively shown?

    PPS I have also made this a blog, where I can add the additional comments on the book.

    PPPS The checklist critique is now being applied to DSM V.
     
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  4. Marco

    Marco Old blackguard

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    Good luck with this Alex.

    I doubt I could be bothered spending much time researching the development of something that seems so arbitrary and lacking in susbstance.
     
  5. alex3619

    alex3619 Senior Member

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    Hi Marco, the only reason I am researching it is so I can debunk CBT/GET. Bye, Alex
     
  6. Marco

    Marco Old blackguard

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    I appreciate that Alex. Its not your research I'm criticising but the vaccuous labels that are churned out with no supporting evidence.
     
  7. Enid

    Enid Senior Member

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    Good luck and thanks for all your hard work alex....."the model is not reality" indeed. If I recall another member referred to them as "gods of the gaps".
     
  8. SilverbladeTE

    SilverbladeTE Senior Member

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    "They see what they want to see"
    "By the fruit of their tree, ye shall know them"
     
  9. Snow Leopard

    Snow Leopard Senior Member

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    Thanks Alex. The fact is that the BPS model automatically excludes concepts like 'medically unexplained' and regards them as non-sense. A BPS explanation has to include the link between all three domains which means that 'somatisation' and the like are not real BPS concepts until the process by which the somatisation occurs is adequately explained biologically. In which case it is no longer 'medically unexplained' right?

    This is why the BPS paradigm cannot be used to justify the use of CBT for example, because that places an overemphasis on the P without connecting it with the B and P.
     
  10. alex3619

    alex3619 Senior Member

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    Hi Snow Leopard, the BPS model does not have to exclude medically unexplained conditions, but in practice it is frequently used by those who used to be considered psychosomatic psychiatrists. Again, psychosomatic meant mind and body, it did not exclude the physical. Freudian psychosomatic theory, including the idea of hysteria, changed all that. They pay lip service to the somatic elements, mumble something about mind-body dualism without articulating a sound argument, then proceed to treat it as psycho-. That is indeed one place they go wrong. BPS has been used as a device to maintain Freudian psychiatry in a world increasingly hostile to it.

    You are right they dismiss the B part. The B part in the CBT/GET view of ME and CFS is GET. We must be deconditioned (tick, B part covered). They haven't bothered to draw on the numerous studies on exercise physiology, or the more numerous ones on neurology, metabolism or immunology. They just ignore them. A few studies do exist on basic immunology or endocrinology for these proponents of BPS, tick, they did that it doesn't need to be examined again.

    BPS was developed to be anti-reductionist, an anodyne for the reliance of medicine on reductionistic biomedicine. However in current practice for medically "unexplained" symptoms, they ignore the vast bulk of the data to rely instead on theory. It is anti-scientific, a retreat to dogma. Their view of "unexplained" is one of full explanation - something must fit their definition of a disease, have a definitive diagnostic test, and an understanding of both causality and mechanism. It conveniently slips their mind that this is not yet true for many diseases, including Multiple Sclerosis.

    Bye, Alex
     
  11. Dolphin

    Dolphin Senior Member

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    Yes, in reality "medically unexplained-ness" should really be measured on a spectrum or continuum rather than categorically (yes/no) - the latter seems like a good example of "dualism" (cf. "mind-body dualism").
     
  12. Dolphin

    Dolphin Senior Member

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    Example of how a somatisation disorder diagnosis in CFS patients is pretty arbitrary

    Thanks for this post, Marco -- very interesting -- as was the initial post (I've just read the paper now - doubt I would have come across it if it were not for you).

    A good example of how a diagnosis of somatisation disorder in CFS patients is pretty arbitrary I think can be seen in the audit of the Belgian rehabilitation clinics (see images below).

    These patients had their diagnosis confirmed as CFS (Fukuda et al., 1994).

    The last row is for the paediatric clinic which was generally analysed separately from the others.

    The second last row is the average of the adult clinics.

    The figures are percentages, not raw numbers.

    I'm including both the French and Dutch language as some people may prefer one over the other. But you don't really need to understand either to see the figures.

    Note that the first clinic, with the very high rate, isn't a small clinic - it has 496 or 45.7% of all the adult CFS patients.

    [​IMG]

    [​IMG]
     
  13. alex3619

    alex3619 Senior Member

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    Hi Dolphin, its certainly non-science and defies reason. Its an assertion on their part. I am not sure a simple spectrum or continuum would suffice though, given the range of medically unexplained illnesses. A high dimension graph might do it, looking at multimensional clustering of symptoms and pathology might be an interesting thing to do. Personally I think nearly all symptoms of ME and CFS can be explained now, as symptoms, based on current understanding of pathophysiology. What we need now is a reliable diagnostic test and one or more causal mechanisms (depending on how many there are). Oh, and a cure of course. :D

    There is a reason why the number of medical professionals going into psychiatry is dwindling: they are acutely aware of just how little evidence there is for so much of psychiatry. A sceptical psychiatrist called Niall McLaren puts it this way: if you look at a paper on heart surgery, and look at the references, you can trace a history of science. Go to a papers references, check what they reference. Repeat. At some point they ground out in basic biology, like the function of nerves in heart muscle for example. Do this with psychiatry and at some point you usually wind up ground out with something like "The Great Master said...." Its grounded in dogma, in appeal to authority, and not to scientific evidence. He claims (I think, I have only started reading him) this is true even of psychiatric biomedicine, though it is clear he is very anti-Freud.

    Bye, Alex
     
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  14. Snow Leopard

    Snow Leopard Senior Member

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    Niall McLaren definitely has some valid criticisms. The problem is that as a consequence of his point of view, he falls back to justification of a pseudoscientific approach...
     
  15. Dolphin

    Dolphin Senior Member

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    Yes, I suppose more than one dimension makes sense. Although I'm think a lot of people have difficulty understanding more than 3 dimensions. One can collapse more than one dimension onto a single dimension with a function (aka a weighting); however this would requirement agreement on what it should be so you are right than a multidimensional approach captures "medically unexplained-ness" better
     
  16. alex3619

    alex3619 Senior Member

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    Hi Snow Leopard, indeed, I am finding numerous logical fallacies and holes in McLaren's work. I do not think its worth me writing a review though, as it does not suffiently relate to ME or CFS. Ironically I find his problem is excessive and needless reductionism, even though he claims he is trying to move beyond reductionism. He loves to present false dichotomies .... the "do you still beat your wife?" kind. I have done this many times too, its an easy trap to fall into.

    In reply to Dolphin's post 15, the complexity of the data has to be accounted for in any good model. It probably is beyong the capacity of anyone to mentally appreciate directly, but so is Quantum Physics. We have math for that instead. However, using such multi-dimensional representations we can both test and generate hypotheses.

    Bye, Alex
     
  17. Marco

    Marco Old blackguard

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    Thanks Dolphin

    Its nice to see that there is empirical data that fully supports the research findings.

    The rates of diagnosis of somatoform disorder in those clinics pretty much ranges from 0-100%.

    Are you aware of any related discussion of this data?
     
  18. Marco

    Marco Old blackguard

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    Hi Alex

    I'm not sure the issue is any more complicated than a simple matter of the credibility of the symptoms reported by patients.

    While (as per Osler) it can be argued that physicians should take the lead from patients and dignify them with the respect to at least not doubt what they are telling them, I'm sure there are occasions when symptoms are exaggerated, misinterpreted, misreported or (rarely) pure invention. So patients can't be relied on to be reliable witnesses. This is a problem not unique to ME/CFS.

    However, more importantly, I think is whether or not physicians are able to reconcile the range of symptoms described by ME/CFS patients with clinical findings on standard tests which are generally unremarkable.

    The logical response should be to simply admit that you accept that the patient is genuinely (physically) ill but can't at present explain why and can offer no treatment.

    Unfortunately most medics are reluctant to offer such an admission and instead find it easier to question the credibility of the disease itself leaving the door wide open for 'alternative explanations'.
     
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  19. Enid

    Enid Senior Member

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    Very much agree with your last paragraphs in particular Marco - something to do with the whole culture of some medics - supposed to know answers and if it doesn't fit into any of their learning it has to be questionable as a real illness. Imagined is what I received all the way through until one Neurologist who admitted (only privately) he didn't understand. But by then abnormalties were showing up on the MRI brain scan.
     
  20. alex3619

    alex3619 Senior Member

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    Hi Marco, I have had many doctors say they can't treat CFS, don't know about CFS, don't believe about CFS or whatever. I have had three say they believe in CFS and are willing to try to help. I have only ever had one doctor who admitted he neither knew nor understood anything about it, and all he could do was help me with symptoms. I got along well with that doctor. I am far happier with a doctor who admits lack of knowledge, than a doctor who pretends to knowledge they do not have. Medicine would be far better off if "I do not know" was a part of their vocabulary. I think doctors are trained to avoid saying that, it seems a deep part of medical culture. Its something I keep thinking about and I might one day write a blog on it if I can come to a better understanding than I now have. If someone else would like to write a blog on it, I would be happy to read it. It keeps bugging me.

    The point of a multidimensional mapping is for cluster analysis and related methods. Its a research tool, not really valid in a clinical setting.

    Bye, Alex
     

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