The Dysfunctional Belief Model, Karl Popper, and my Book

WARNING: Philosophy Alert!

I intend to write a series of blogs giving the flavour of one line of argument in the book I am writing, though I am using many other lines of investigation as well. This is the view from a position of critical rationalism. Using different but well recognized philosophical stances it can be shown that there are major problems with psychogenic explanations of CFS. Over time I hope to discuss other philosophical stances.

DBM: Dysfunctional Belief Model

The primary psychosomatic claim about the cause of CFS, sometimes called the Wessely School, has become synonymous with the claim that patients with CFS have a dysfunctional belief system that drives the illness. This claim is derived from older Freudian claims including claims about hysteria. They put forward the hypothesis that it can be treated with modified forms of CBT and GET. I have come to call this model of CFS the Dysfunctional Belief Model. This is the core philosophical stance underlying their treatments and it has major failings.

Critical Rationalism and Popper

Critical Rationalism is largely derived from the philosophy of science by Karl Popper. It is based on the idea that hypotheses must be testable. If they are testable, they can be found false with the right data, which makes the theory falsifiable: capable of being found false.

The DBM is descended from views held in the psychoanalytic tradition of Sigmund Freud. While Freud's ideas have largely been discredited, they have lived on in the ideas of psychosomatic illness including conversion disorder, somatization and hysteria. Hysteria is an old name that is now in disfavour, though it is still sometimes invoked.

Psychoanalysis was labelled by Karl Popper as non-science. It fails to be falsifiable, and hence fails to be testable. The claim by Popper and others is psychoanalysis relies on self-referential explanations but this is circular reasoning - nowhere does it ground out in objectively verifiable hypotheses or facts. There are so many additional secondary hypotheses that every item of data can be explained by the model, but none of these are testable hypotheses either. They cannot be testable if they cannot be falsified. They can only be subject to the steady accumulation of data intended to verify them.

Edward de Bono would call this a superstition: internally explicable but immune to external criticism or the evidence. Superstitious thinking tends to look like cults: there is often a central dogmatic figure. Once upon a time that was Freud. Of course that criticism can be levelled at Popper too. :eek: Its sometimes a subtle argument by authority, which is a recognized logical fallacy. Popper at least has the strength that his arguments are rational and well developed, and not dependent on secondary hypotheses, though they have also been extensively criticized. It is hard to cite argument without refering to authorities though - that is called plagiarism.

The name for this claim about CFS has changed over time, but the core is the same. Our beliefs about our illness drive us to maladaptive behaviour and drive our symptoms. Challenging and correcting these beliefs is the essence of treating or curing us.

Its a pity the evidence does not back their claim, and that very large numbers of us have tried these approaches and failed. I am not going to recite the litany of failure here though, there is so much material on this already out there. Its a pity because a cure would be really really nice. It is wrong, as I will discuss in later blogs, to claim we reject their model because of the stigma of mental illness or conflict with our supposed dysfunctional beliefs.

Popper calls everything that cannot be falsified non-science. He has another name for it, a name which is well known and considered derogatory: pseudoscience. I intend to return to this point in a later blog, but there is an entire section planned for my book on pseudoscience. The DBM fits every established description of pseudoscience I have yet seen, and I have investigated (so far) the primary definitions put forward by the leading philosophers of science.

My Reply to the Popperian View

The DBM is only derivative of psychoanalytic hypotheses. Its nowhere near as well evolved, it lacks the huge raft of secondary protective hypotheses, though I note their number is growing. There are numerous valid complaints about this approach yet they tend to reply with standard phrases and ideas.

These are hard to engage with, hard to refute, largely because they are true in one sense (often a trivial or irrelevant sense) but have so many vague secondary meanings that they cannot be pinned down and discredited except one by one. I have looked at several of the stock replies and they can be discredited by the tactic of identifying and isolating specific or concrete implications from the replies and demonstrating that they are either counter-factual or irrational. This is something I hope to do in detail in my book, but for now I do not wish to expand on this, only to point out it can be done. As they generate new versions of such claims, it is necessary to criticize them one by one - in all their alternative meanings.

Engaging in Wider Scientific Criticism

I think that due to our limitations, both in terms of cognition and material resources, we have failed to properly engage in the wider scientific debate on these issues.

We see the Wessely School, but it is based on the the ideas of Sigmund Freud and so inherits many of the criticisms. It is established within the current philosophy of the Biopsychosocial model yet fails to live up the that model. There is a claim the DBM is evidence based, but I am in the process of showing this claim is spurious. At some point I might look at writing a blog on the Cochrane review on CFS treatments.

There is so much debate and information against these views in the wider science. I encourage every advocate, every patient who is fed up with DBM claims, to look beyond ME and CFS and see what others are saying. Psychosomatic medicine is dying. Its being overshadowed by other branches of psychiatry. In a century they have failed to find substantive evidence of biomarkers that support their models, and yet I think its impossible to make their claims and be consistent with evidence and to not acknowledge that such biomarkers must exist if psychosomatic theory is correct. Vague claims relating to mind-body Cartesian dualism do not change this conclusion. This is a field of medicine that appears to be either stagnant or degenerating. Paying lip service to the BPS model has not done much to revive it that I can see.

I am not bothered with calling psychosomatic medicine by its more modern label changes, at least just yet. Its not substantially different - the names just keep changing because the old names are associated with a litany of failure and dubious reputation. People know to avoid the old hypotheses, so they change the name in the hope of catching the unwary. Its spin over substance.

Progress on My Book

A working title for my book is The Dysfunctional Belief Model of CFS, with a subtitle Embracing the Null Hypothesis. It looks like being nine chapters with numerous appendicies, and threatens to blow out to many hundreds of pages (possibly over a thousand) even before I count references. It has become clear that I will not ever be able to do an exhaustive analysis - that would be a life's work by a healthy person, and probably require an institute with many experts in different fields. What I can do however is establish multiple frameworks of analysis and establish common themes of error in the DBM and how it is promoted. My goal is to expose, in detail, how irrational these claims are.

There will also be a long series of critical questions arising from this. If some of these can be sufficiently substantiated by the evidence this may lead to formal complaints to oversight and regulatory bodies involved in medicine and medical research.

My best estimate is that writing the first draft of this book will take 2-5 years. Two years presumes I can regain the health I had briefly in January, five years if not. Five years might not be nearly enough however, I will have to see. Maybe I will release my writing in stages: part one for the problem, part two addressing possible solutions. I will have to see about that.

Currently I am only writing a few pages a day at best, none at worst, and the background reading is probably less than 20 pages a day. At this rate, for a thousand page book, we are talking maybe 500 days just to write the first draft, and thats after I have done sufficient analysis. It also presumes I can sustain writing at least two pages a day, and that is doubtful as the book advances and the complexity increases. On the other hand this project has some momentum. Things might advance faster once I can establish a workable writing process.

The good news is that I am at the stage where every morning I wake up with the idea for several new sections and arguments for my book. In fact I have trouble making notes about them before I forget them. The muse is fleeting. I wake up with whole paragraphs written in my head, but by the time I walk to my desk I often only remember one thing - whatever I was thinking of last. This blog was what I woke up with this morning.

In the meantime I hope the debate intensifies. There are so many things wrong with the model that it is easy to poke holes in it, its just that doing so requires casting a very broad net and a whole lot of sustained effort. This is not easy for very sick people with underdeveloped advocacy organization and a fractured community. Its not easy when the wider medical community and political institutions fail to care.

With any luck you will all debunk DBM before I finish, and I can stop spending years writing this stuff. ;) Alternatively I hope the evidence from the Phase 3 clinical trials of Rituximab is so strong that it will severely discredit the DBM.

However, sad as it is to say, I think even if most of us are cured by Rituximab the DBM will just change its secondary hypotheses and go on, this time targeting a modified subset of the idiopathic fatigue population. That is why I think the problems with the model need to be engaged with - by the wider medical profession, research scientists, philosophers, statisticians and by the people with the biggest vested interest: patients.

My blog on verificationism is being reworked at the moment. I hope to get it out there soon.


As a non-scientist alex, what really riles is that the medical profession (in whom we place so much trust) actually do not believe their patients even with obvious (eg falling over) problems. I met the extreme (all in your mind) and to watch the disbelief in the eyes of so many Docs as to any real illness is a sight to behold. It's a rod for their own backs - patient disbelief in their professional medical capabilities. Theirs one might say is the DBM problem.
Hi Enid, This attitude is one reason the DBM has to be countered. Its irrational in the extreme (see my signature) yet its a very pervasive view. Dogma is alive and well in the medical profession, and most doctors do very well at bringing the profession into disrepute by using this kind of reasoning. Most ME patients I know have a low opinion of doctors generally, but a high opinion of those who actually try to learn and keep up to date - and no, I do not mean as up to date as the next doctor who is also woefully out of date.

I am looking at BPS and EBM as well, as these are part of the problem too. EBM claims that only RCTs are reliable, although there is some recognition that other studies might, if the result is good enough, suffice. The problem is that a huge proportion of RCTs give false results - they are later disproven. In addition if the problem is one of design and methodology, like in DBM, a thousand studies with very significant results are just so much non-science. So you can do meta-analysis on these poor studies, but you still don't get reliable results. I will be discussing this with respect to the Cochrane reviews at some point. Generally I think they do a good job, but they are fundamentally flawed as well at the conceptual level.

The medical profession needs to wake up. They need to take responsibility for their own failures. I do understand there are many reasons for this, it isn't a simple thing, but something needs to be done and EBM and BPS are not it, at least not in their current implementation.

Bye, Alex
Just following you Alex - my philosophy a module at Uni only, and glad to to see you are taking on the subject here and exposing circuitous reasoning of the psyche brigade. Presumably they see patients as subjective only whilst they are being purely objective. Isn't there a basic flaw here somewhere. Both in fact are both. They have built an industry on their subjective unprovable (luckily for them) DBM.
I have just read Richard Sykes paper "Medically Unexplained Symptoms and the Siren Psychogenic Inference, 2010. He makes very similar points to me in a clear and logical manner, enough so that I can use some of his framework to establish further criticism of the DBM. While I am aware he is not popular with some patients due to past associations, most of what he says is rationally defensible. There are a few points I disagree with, but for the most part his arguments go hand in hand with mine. Its a sustained attack on two things: the over-psychologization of patients with Medically Unexplained Symptoms, and the use of confusing and ambigous terms like "functional" where the meaning of the term changes mid argument. He does not go as far as I would like though - he focuses on confusion and invalid reasoning, but does not discuss the terms that are used this way in the context of non-scientific pursuasion. He is also clearly stating that he regards the psychologization of CFS as a huge mistake with very bad consequences.
What ever Alex it is also common sense (like the lay judges brought into the Anders B trial in Norway despite legal eagles for precisely that). Who has lost touch more in medicine than the psychos - and we must fight it on every level. And to anyone looking in don't doubt it - we will. I'm imagining - the truth is they are.

This is the hub Alex - a disbelief (Freud on) - any archaic mind body problems who in this day and age has. One simply knows when one is ill - the pathetics and ignorance of psychiatry still trying to sort out whilst Rome burns. I had a psychiatrist (whom I had to fight off in Accident and Emergency despite collapsing drawing on my Uni psychology) telling me I was the worst.
Hi, Alex, Your book sounds very interesting; a lot of effort when we're so brain-struggling but really worthwhile. It benefits you and the wider world in one go. One suggestion for capturing fleeting ideaskeep some scrap paper and pencil by you near your bed so you can lean over and make brief notes of your pre-waking ideas before you lose them. You can even write in the middle of the night without turning on the light if you keep your finger on the line so you don't overwrite. (Although we don't want to wake in the middle of the night, of course!)


Hi Lynne, thanks for the suggestion. I had thought of keeping pen and notepad close by, I used to be a lucid dreamer and thats standard dream practice, but the problem is that its the focusing of my thoughts that drives other thoughts out - its a fog thing. If I only wake up with one thought then I can easily do what you suggest, if I wake up with multiple I risk losing most of them regardless. So what I try to do is keep hold of key words, and write those down. From those words I can regenerate the thought. For example, yesterday it was ... darn my notes are so scrawled I can't read them today. Doh. Something about dog(matic) veri(ficationism), reply to popper, and something totally indeciphable. What happens though is I can read those notes for a while after writing them, I do know what they say they are just signposts, and then I type a few things in the appropriate chapter of my book - even if its just one sentence. I do not like using cryptic words though because I run into the problem that they only make sense if I am thinking along certain lines.

Some people might be wondering why I am spending my time discussing this. Its because there are practical problems associated with a project like this, and as and when I find solutions I hope to post them. Indeed, part two of appendix A will deal with methodological issues for a patient with ME writing a book like this, including limitations.

Bye, Alex
Hi Alex,

Sounds like it is going to be a great book. If you write it, I will buy one.

Any idea what years Freud started implementing the Dysfunctional Belief Model for his patients, and what types of patients he used it for? Sounds interesting.

Just wondering how that timeframe may correspond to the times when people first started getting vaccinated etc....

I'm just wondering if they implemented this DSM model way back then to hide health problems... Cause I thought somebody mentioned the first causes of autism were like in the 30's from vaccinations.

Hi Jarod, Freud was big on similar ideas. The DBM inherited from his ideas, but is not something Freud ever talked about I don't think - just very very similar. Its what Freud might be saying if he were alive today.

I am thinking, currently, of releasing the book as a free to dowload online pdf file. Thats just my current idea. It keeps changing. I am doing this for advocacy not financial gain - such books rarely lead to making much money in any case. I might make some afterward by giving lectures, who knows? This book will cost me money, my guess is about $1000 and maybe five thousand hours (give or take a few thousand hours). Once I am well underway I might see about applying for a book grant or something, presuming any still exist with all the cuts going on. In fact I just ordered another $120 worth of books, and this time I remembered to do it though PR so it gets a cut, though I did start ordering elsewhere on Amazon and so had to cancel and restart on PR. This money isn't all wasted though, I do get to keep the books (like I need more books).

Freud is really about psychoanalysis, and includes the idea that physical problems manifest because of emotional and mental issues. The DBM is a modern variant of this, really only arising in the late 1980s - so its origins is in hysteria, but its not quite the same as hysteria. I am still researching Freud, I may have more to say in some months. The DBM variant arose, I think, when Freudian ideas were translated into a CBT framework - that is cognitive and behavioural rather than emotional. The idea and underlying philosophy appear to be almost identical though, so problems that were recognized with Freudian ideas should also apply to the DBM. This is what I am currently researching, there is a lot of material to go through.

It started as hysteria in the late 1800s, then became conversion disorder, which later on became either somatoform disorder or disassociative disorder (follow the blue links in my blog, they mostly go to the Wikipedia entries, though Popper's non-science is somewhere else, a paper he wrote that is online).

Hypochondria is another in this family of supposed disorders.

These disorders are all irrational so far as I can see at this point, but my research is continuing. The underlying philosophy I may discuss, generally, in a new blog I am writing: The Witch, The Python, The Siren and The Bunny.
Its a very irreverent look at psychobabble. The Python has a first name: Monty.

Freud significantly predates modern ideas of vaccination, though according to the Wikipedia smallpox vaccines were used as far back as 1000 BC in India. Some forms more resembling modern smallpox vaccines were in use in the early 1700s. Mass vaccination for multiple pathogens only really began in the mid twentieth century though. If there is a link as a cover-up for vaccination issues, which I do not concede as it is very hard to find hard evidence, then it most likely began in the mid to late 80s.

My book will not only be using philosophical arguments - there are other analytical methods I intend to use.

Bye, Alex
I am starting to think this is the most important work that can be done for our community - clarifying that the psychological pseudo-research is invalid - along with the work real scientists and clinicians are actually doing to find a cure, treatment, or the cause.

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