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BMJ Rapid Response: Is Chronic Fatigue Syndrome a meme? 18 June 2014

Leopardtail

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I am inclined to agree with Sasha. There are comments from patients that are just be expressions of personal views, so it is clear that this RR forum is not intended to be formal scientific material at all. But this particular response is written as if it was a paper. This is what makes it so pathetic - rather than submit it as a paper it has been sent to the comments page. And it deserves to be moderated out on the grounds of being grossly offensive in the way the cartoons of Mohammed probably did - if not more so. You choose to be a muslim. You do not choose to have ME/CFS. The idea that you can dress up an insulting claim that people are just inventing their illness as a 'scientific theory', and an inane and unoriginal one at that, and 'pretend-publish' it in a comments list is offensive not just to patients but to any one who wants to take pride in being a member of a health care profession. In fact nobody in scientific medicine has taken the BMJ seriously for years - it's a bit like Lyon's Corner Houses were in the late 1960s - a memory of a genteel mediocrity of former times. Dark brown tea and half stale scones. It seems to have taken that role to heart in recent years.
I think I would be more inclined to compare it to "The Daily Sport" or "Viz" (smutty and teenage newspapers for those not in England.
 

Dx Revision Watch

Suzy Chapman Owner of Dx Revision Watch
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Susan Blackmore, who developed the idea of memes, has now replied:
http://www.bmj.com/content/329/7472/928/rr/759419

I find some of her response annoying. I think it was a high-risk strategy referring to her as an expert who "seems uniquely positioned to contribute to this discussion".

For clarity - Ms Blackmore was not referred to in my comment, as an "expert."

What I wrote was:

http://www.bmj.com/content/329/7472/928/rapid-responses

Collings and Newton (1) resurrect a ten year old editorial (2) to present an essay on the potential for viewing CFS as a 'meme-mediated' syndrome.

In the Preface to her 1999 book 'The Meme Machine' (3) Susan Blackmore writes that most of the ideas in her book were conceived whilst bedbound for many months with a chronic, debilitating, post-viral illness.

Forced to give up work, unable to walk, unable to talk for more than a few minutes, unable to use a computer. But she could read and she could think, and as time went on, make notes. It would be two years or so before Ms Blackmore was well enough to consider working again and to develop her ideas into the book.

Ms Blackmore seems uniquely positioned to contribute to this discussion.

1 Collings AD, Newton D. Re: What causes chronic fatigue syndrome? BMJ 2014 (18 June).

2 White PD. What causes chronic fatigue syndrome? BMJ 2004; 329: 928-929 (21 October).

3 Blackmore, Susan (1999), The Meme Machine, Oxford University Press, ISBN 0-19-850365-2.

------------

Ms Blackmore has published on memes.
Ms Blackmore has experienced a chronic, debilitating, post-viral illness.

-------------

Note that the BMJ site is currently loading with a new Beta website platform for which the "like" button counters have been reset to 0.
 

Antares in NYC

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as it has been said before most people who got CFS/ME didn't know enough about the illness to copy the behaviour.
This can be easily verified. :whistle:
Exactly!
If my personal experience mirrors that of many other patients, it took almost 15 years for me to get a diagnosis. Fifteen long years. I had no idea of the specifics of ME/CFS until then, and I knew no other patients or anyone else affected by this disease. Nevertheless, that didn't stop a myriad of doctors to prescribe me every antidepressant under the sun when they didn't understand what was happening to me.

Collings and Newton also make an erroneous assumption. They claimed that "being Asian" is a deterrent to getting this so-called "CFS meme fever". May I point the authors to Japan? It is well recorded that Japan is one of the countries with the highest percentages of ME/CFS patients in the world (with at least 300,000 confirmed cases). Last time I checked, Japan was an Asian country, but what do I know. I do not get to write "scholarly papers" for the BMJ.

Some "researchers"...
 
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Sean

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I had never heard of ME or CFS before I got sick, and didn't until I was diagnosed 4 years later.

I couldn't possibly have heard of CFS because the term was only introduced in March 1988 with the Holmes definition, and I was diagnosed in late 1988.

Furthermore, this was in the pre-internet era, when there was very restricted access to medical info for the general public.

Not too much chance there for a memetic infection to take hold.
 

Valentijn

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I couldn't figure out what I had at first. I just got very sick every time I came home from class after walking very fast for 15-20 minutes + 2 bus rides + 1 train ride.

Eventually I stumbled across "exercise intolerance" - I hadn't even known that existed, but it seemed to fit with what was happening to me. Sometime after that I came across the CDC's definition of CFS, and ruled that out (along with a lot of other things) due to the symptoms not really fitting well, and the associated info making it clear it was intended to be a psychological disorder.

It wasn't until I came across a definition of ME, I think from the Hummingbird group, that I realized it was describing my symptoms spot-on. When I realized that ME was also sometimes called CFS, after I had ruled out CFS, I was pretty shocked :jaw-drop:

The internist independently (and probably much more quickly) came to the same conclusion when the followup appointment came around after the lab results were in.
 

chipmunk1

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Furthermore, this was in the pre-internet era, when there was very restricted access to medical info for the general public.

Not too much chance there for a memetic infection to take hold.
[satire]
Time for the next psych research study:

Internet discussion forums as a cause of ME: Does availability of broadband access aggravate somatic symptoms?

[satire]
 

alex3619

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Similar to @Valentijn , some time after I got sick I heard about ME or something (I no longer recall), but I didn't have the symptoms the journalist was referring to, so I ignored it. Later I head about CFS, but I didn't have chronic fatigue but something else, so I ignored it. Then blow me down and colour me turquoise, I got diagnosed with CFS under Holmes in 1989. Yet it was two years or more before I started looking into CFS. I naively presumed what my doctors were telling me was accurate. In 1993 I started to wake up to the truth, and first did some CFS advocacy.

Today I much prefer to use ME over CFS or ME/CFS or CFS/ME. Let me give a reason why: do doctors refer to a patient having possible heart-disease/cancer/AIDS? Why should we lump things together? The criteria select an only partially overlapping cohort, and technically if you have ME you cannot have CFS, because CFS is a diagnosis of exclusion.
 

Nielk

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Eleven years ago, I was at the height of my career. I was an active member of my community and took care of my family and household.

One day, I decide that I had enough of this rewarding life. I wanted a change. I started searching on the internet for some strange obscure illnesses. I considered various different options but, finally settled on the much desired chronic fatigue syndrome.

It seemed like a perfect fit for me. I loved being ridiculed, and I was particularly seeking to become very isolated from all people that I loved in my life.

I made sure to memorize all the critical symptoms in order to hopefully qualify for a diagnosis. I searched for a cfs specialist in my area and came to him with all my "new symptoms". I felt really excited when I finally received an official diagnosis.

Since then, my life has improved so much that I have kept insisting all this time that this is what I suffer from in order to remain in this much desired state of having this disease. I love my life now as it is. I love the way doctors and people in general look at me.

The best part is the fact that my family have lost a functioning mother/wife. I can't describe how rewarding this feels and this is why I am so satisfied in this state and will keep on insisting that I have this disease no matter what.
 

Cheshire

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Eleven years ago, I was at the height of my career. I was an active member of my community and took care of my family and household.

One day, I decide that I had enough of this rewarding life. I wanted a change. I started searching on the internet for some strange obscure illnesses. I considered various different options but, finally settled on the much desired chronic fatigue syndrome.

It seemed like a perfect fit for me. I loved being ridiculed, and I was particularly seeking to become very isolated from all people that I loved in my life.

I made sure to memorize all the critical symptoms in order to hopefully qualify for a diagnosis. I searched for a cfs specialist in my area and came to him with all my "new symptoms". I felt really excited when I finally received an official diagnosis.

Since then, my life has improved so much that I have kept insisting all this time that this is what I suffer from in order to remain in this much desired state of having this disease. I love my life now as it is. I love the way doctors and people in general look at me.

The best part is the fact that my family have lost a functioning mother/wife. I can't describe how rewarding this feels and this is why I am so satisfied in this state and will keep on insisting that I have this disease no matter what.
Yes, the only "secondary gain" that could explain we resort to such a meme is masochism.
 

Firestormm

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If I understand this notion of 'memes' (and I don't pretend to understand it very well), then it would also apply to doctors. The way I see it - and it's all philosophical so has no relevance at all in the medical domain in my view - then doctors would 'latch on' to CFS and apply the label to patients before properly trying to understand and diagnose what was wrong with them. So, whilst many of the critiques above are I think valid - we can also perhaps lend this same theory to doctors and one might then use it to 'explain' why it is that patients are arbitrarily assigned this umbrella... It could go even further and be used to help try and explain why things that might previously have been put down to other factors become assigned to ill-health and CFS. Things that have no right doing so... How often do we complain that 'chronic fatigue' has become wrongly a part of 'ME'? Or that in media reports only 'fatigue' is shown as the problem? If anything I would say that 'fatigue' has become a meme...

Sorry. Just rambling and delaying taking a shower...
 

A.B.

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What's the secondary gain for doctors and health care providers when labelling CFS as psychosomatic?

If I look back, people who proposed psychological explanations for my problems were really just looking for excuses to avoid the issue.
 

chipmunk1

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if patients don't want to get better why do they keep visiting healthcare providers?

also why are the symptoms relatively stable? Conversion could take any form any time. Why do most patients keep a constant symptom pattern over time?

if the psyche can emulate so many diseases why don't we have cases that switch between ME, Psychogenic Blindness and Psychogenic Epilepsy? On and off.

Bedridden to energetic epileptic becoming blind and deaf later only to become bedridden again.
 
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heapsreal

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Exactly!
If my personal experience mirrors that of many other patients, it took almost 15 years for me to get a diagnosis. Fifteen long years. I had no idea of the specifics of ME/CFS until then, and I knew no other patients or anyone else affected by this disease. Nevertheless, that didn't stop a myriad of doctors to prescribe me every antidepressant under the sun when they didn't understand what was happening to me.

Collings and Newton also make an erroneous assumption. They claimed that "being Asian" is a deterrent to getting this so-called "CFS meme fever". May I point the authors to Japan? It is well recorded that Japan is one of the countries with the highest percentages of ME/CFS patients in the world (with at least 300,000 confirmed cases). Last time I checked, Japan was an Asian country, but what do I know. I do not get to write "scholarly papers" for the BMJ.

Some "researchers"...
Interesting what you say about Japan as i think they were one of the first authorities to find nk function abnormalities and named the illness nk disease??

I also wonder if there is alot of translation issues with other non english speaking countries and also use other names then cfs or even ME. Possibly even other treatments(not necessarily cures?) in these other countries.

It also seems that research outside of say usa, uk and australia is just ignored or not relevant so we have to invent the wheel again.

I have spoken about this before but eastern block countries have been researching ways to treat viral infections for decades and having some success with different interferon inducers. It seems that the western countries aim their viral research into vaccines and preventing viral infections rather than treating viruses once they occur??
 

heapsreal

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if patients don't want to get better why do they keep visiting healthcare providers?

also why are the symptoms relatively stable? Conversion could take any form any time. Why do most patients keep a constant symptom pattern over time?

if the psyche can emulate so many diseases why don't we have cases that switch between ME, Psychogenic Blindness and Psychogenic Epilepsy? On and off.

Bedridden to energetic epileptic becoming blind and deaf later only to become bedridden again.

Also why would one pick cfs/me if they were going to fake something. oh lets pick this illness that no one believes so we can rip off the system. Doesnt make sense to me??

Psychobabbler diagnosis is used when they cant work something out, hopefully antidepressants make you not worry about feeling like shit and stop pestering doctors who dont know how to treat you.
 

Tom Kindlon

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I submitted this in reply to the Collings & Newton BMJ e-letter http://www.bmj.com/node/759165 which said "CFS, then, might be usefully viewed as a meme, a dysfunctional culturally-transmitted idea-infection."

Normally the BMJ publish nearly all of my e-letters but didn't on this occasion for some reason. I've heard from two other people whose e-letters also weren't posted.

This isn't my tightest letter - I just wrote it quickly but it ended up taking some time so thought I'd share it.

-------

The meme that people with ME/CFS can be returned to full health with graded activity/exercise programmes

Collings & Newton argue that myalgic encephalomyelitis (ME) or chronic fatigue syndrome (CFS) might be considered a meme(1). However, they offer no compelling evidence to support their theory, and have ignored the hundreds of papers that been published that found an assortment of physical abnormalities in ME/CFS. Possibly some of the most convincing studies are those which found that a stereotypical collection of symptoms is found in a percentage of patients after an infection; in this regard, the BMJ published an important study, funded by the US Centers for Disease Control and Prevention (CDC), back in 2006(2).

A more interesting meme to discuss is the idea that ME/CFS is primarily maintained by maladaptive beliefs and behaviours, and that patients can be rehabilitated back to full functioning and health with rehabilitation methods such as graded exercise therapy (GET) and a form of cognitive behavioural therapy (CBT) based on graded activity/exercise. There are now dozens of studies that have found exercise abnormalities that can’t be explained by the GET and CBT models of the illness which are based on symptoms being due to deconditioning(3-6). Despite a lack of evidence, this meme has spread quickly. Humans (including doctors) seem to have difficulty accepting conditions which are not fully medically explained and in such scenarios can often see the victims as responsible for their own condition. The CBT and GET models for the illness do this: the impairment and disabling symptoms are claimed to be reversible with the therapies(3,4).

This meme is attractive to insurance companies who can use it to deny disability payments and pensions to patients who are unable to work.

The meme can be attractive to health bodies who are wondering what services to provide for such patients but who want to minimise spending on testing and drug therapies.

The meme seems to be difficult to dislodge as audits of ME/CFS services, that have provided such therapies, have reported poor results(7-10) particularly on objective measures, but the enthusiasm for such therapies does not seem to abate.

Collings and Newton mention such therapies in their Rapid Response(1) and a representative from their service previously claimed(11): “These guidelines recommend rehabilitation therapies to help patients recover their health, along with specialist medical care. We are pleased to say we can help the majority of patients whom we see, using an integrated, holistic approach provided by a team of therapists and a consultant physician working closely together. Some patients make a complete recovery, which is better news for patients than just symptom relief, as outlined by Dr Greensmith in the Gazette.”

Recovery is the key measure by which the GET/CBT model or meme should be tested. The model suggests there is no ceiling of activity, in contrast to other models such as those for pacing, so patients using CBT & GET should be able to work their way to full functioning.

The PACE Trial was supposed to be the “definitive” trial to assess such issues(12). It was a very expensive trial costing £5 million of UK taxpayers' money. What it found was though patients self-reported some improvements on subjective outcomes such as the SF-36 physical functioning (SF-36 PF) subscale and the Chalder fatigue questionnaire (CFQ), there were generally no differences on more objective measures such as for employment, disability payments, total service use and the 6-minute walking test(13-14) (this echoed what was found previously in the Belgian rehabilitation clinics and a mediation analysis of three Dutch CBT studies(7-9,15)). There were slight improvements for the GET group (but not the CBT group) on the 6-minute walking test in the PACE Trial, to an average of 379 metres, or 35 metres more than the (no therapy) specialist medical care-only group; however this is well-short of the 644 or so metres predicted by population norms(6). Such slight improvement could be predicted by the ceiling of activity model (cf. CBT and GET model), where certain patients may be below their ceiling of activity before treatment and so could do a little more (without being able to get back to full functioning as predicted by the CBT and GET model).

Unfortunately, the data for the recovery criteria promised in the PACE Trial’s published protocol have never been published(16). Such data would give a good idea for what percentage of patients the CBT/GET model holds. I estimate that the percentages who would have been counted as recovered following CBT and GET would be in single figures in the PACE Trial (based on mean and standard deviation data that has been published). Such low figures suggest that that CBT and GET model is not a good general model for ME/CFS. The post hoc recovery criteria that have been published for the PACE Trial are so broad that they do not give us proper data on whether recovery has occurred(17-33). To give an idea of how absurd the post hoc recovery criteria are as recovery criteria, patients can score worse on either the SF-36 PF or CFQ than baseline (when they were required to have disabling fatigue) and still be counted as recovered.

An appeal has recently been lodged to try to get the data on the protocol defined recovery criteria from the PACE Trial under the Freedom of Information Act(34). I hope Peter White and Queen Mary, University of London will have a change of heart and release the important data (that was promised in the published protocol) now that we have seen the preposterous speculations clinicians with authority over patients are led to when they are provided with such exaggerated claims for the biopsychosocial interventions they provide. I believe the sobering results would once and for all help kill off the inaccurate meme which so distorts the way that ME/CFS patients are viewed and treated. The field could then move forward with theories that are more plausible and evidence-based given our knowledge of the biology of the condition.

References:

1. Collings AD, Newton D. Re: What causes chronic fatigue syndrome? BMJ 2014 (18 June).

2. Hickie I, Davenport T, Wakefield D, Vollmer-Conna U, Cameron B, Vernon SD, Reeves WC, Lloyd A; Dubbo Infection Outcomes Study Group. Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study. BMJ. 2006 Sep 16;333(7568):575.

3. Bavinton J, Darbishire L, White PD -on behalf of the PACE trial management group. Graded Exercise Therapy for CFS/ME (Therapist manual): http://www.pacetrial.org/docs/get-therapist-manual.pdf (Accessed: June 25, 2014)

4. Burgess M, Chalder T. PACE manual for therapists. Cognitive behaviour therapy for CFS/ME.http://www.pacetrial.org/docs/cbt-therapist-manual.pdf (Accessed: June 25, 2014)

5. Twisk FNM, Maes M. A review on Cognitive Behavorial Therapy (CBT) and Graded Exercise Therapy (GET) in Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS): CBT/GET is not only ineffective and not evidence-based, but also potentially harmful for many patients with ME/CFS. Neuro Endocrinol Lett. 2009;30:284-299.

6. Kindlon T. Reporting of Harms Associated with Graded Exercise Therapy and Cognitive Behavioural Therapy in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Bulletin of the IACFS/ME. 2011;19(2):59-111http://www.iacfsme.org/BULLETINFALL2011/Fall2011KindlonHarmsPaperABSTRACT/tabid/501/Default.aspx

7. Rapport d’évaluation (2002-2004) portant sur l’exécution des conventions de rééducation entre le Comité de l’assurance soins de santé (INAMI) et les Centres de référence pour le Syndrome de fatigue chronique (SFC). 2006. <http://www.inami.fgov.be/care/fr/re...mation/studies/study-sfc-cvs/pdf/rapport.pdf> . (French language edition) (Accessed: June 25, 2014)

8. Evaluatierapport (2002-2004) met betrekking tot de uitvoering van de revalidatieovereenkomsten tussen het Comité van de verzekering voor geneeskundige verzorging (ingesteld bij het Rijksinstituut voor Ziekte- en invaliditeitsverzekering) en de Referentiecentra voor het Chronisch vermoeidheidssyndroom (CVS). 2006. Available online: <http://www.inami.fgov.be/care/nl/re...mation/studies/study-sfc-cvs/pdf/rapport.pdf> Accessed September 16, 2011 (Dutch language version) (Accessed: June 25, 2014)

9. Stordeur S, Thiry N, Eyssen M. Chronisch Vermoeidheidssyndroom: diagnose, behandeling en zorgorganisatie. Health Services Research (HSR). Brussel: Federaal Kenniscentrum voor de Gezondheidszorg (KCE); 2008. KCE reports 88A (D/2008/10.273/58)https://kce.fgov.be/sites/default/files/page_documents/d20081027358.pdf (Accessed: June 25, 2014)

10. Crawley E, Collin SM, White PD, Rimes K, Sterne JA, May MT; CFS/ME National Outcomes Database. Treatment outcome in adults with chronic fatigue syndrome: a prospective study in England based on the CFS/ME National Outcomes Database. QJM. 2013 Jun;106(6):555-65

11. "How we can help ME sufferers in north Essex" http://www.gazette-news.co.uk/search/4453571.How_we_can_help_ME_sufferers_in_north_Essex/

12. Walwyn R, Potts L, McCrone P, Johnson AL, DeCesare JC, Baber H, Goldsmith K, Sharpe M, Chalder T, White PD. A randomised trial of adaptive pacing therapy, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome (PACE): statistical analysis plan. Trials. 2013 Nov 13;14:386.

13. White PD, Goldsmith KA, Johnson AL, et al; PACE trial management group. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet. 2011 Mar 5;377(9768):823-36.

14. McCrone P, Sharpe M, Chalder T, Knapp M, Johnson AL, Goldsmith KA, White PD. Adaptive pacing, cognitive behaviour therapy, graded exercise, and specialist medical care for chronic fatigue syndrome: a cost-effectiveness analysis. PLoS One. 2012;7(8):e40808.

15. Wiborg JF, Knoop H, Stulemeijer M, Prins JB, Bleijenberg G. How does cognitive behaviour therapy reduce fatigue in patients with chronic fatigue syndrome? The role of physical activity. Psychol Med. 2010 Aug;40(8):1281-7.

16. White PD, Sharpe MC, Chalder T, DeCesare JC, Walwyn R; PACE trial group. Protocol for the PACE trial: a randomised controlled trial of adaptive pacing, cognitive behaviour therapy, and graded exercise, as supplements to standardised specialist medical care versus standardised specialist medical care alone for patients with the chronic fatigue syndrome/myalgic encephalomyelitis or encephalopathy. BMC Neurol. 2007 Mar 8;7:6.

17. White PD, Goldsmith K, Johnson AL, Chalder T, Sharpe M. Recovery from chronic fatigue syndrome after treatments given in the PACE trial. Psychol Med. 2013 Oct;43(10):2227-35.

18. Adamowicz JL, Caikauskaite I, Friedberg F. Defining recovery in chronic fatigue syndrome: a critical review. Qual Life Res. 2014 May 3.

19. Shepherd C. Letter to the editor: comments on 'Recovery from chronic fatigue syndrome after treatments given in the PACE trial'. Psychol Med. 2013 Aug;43(8):1790-1.

20. Maryhew C. Letter to the editor: comments on 'Recovery from chronic fatigue syndrome after treatments given in the PACE trial'. Psychol Med. 2013 Aug;43(8):1789-90.

21. Cox D. Letter to the editor: 'Recovery from chronic fatigue syndrome after treatments given in the PACE trial': data on the recovery groups as a whole would be useful. Psychol Med. 2013 Aug;43(8):1789.

22. Courtney R. Letter to the editor: 'Recovery from chronic fatigue syndrome after treatments given in the PACE trial': an appropriate threshold for a recovery? Psychol Med. 2013 Aug;43(8):1788-9.

23. Carter S. Letter to the editor: 'Recovery from chronic fatigue syndrome after treatments given in the PACE trial': recovery or remission? Psychol Med. 2013 Aug;43(8):1787-8.

24. Agardy S. Letter to the editor: comments on 'Recovery from chronic fatigue syndrome after treatments given in the PACE trial'. Psychol Med. 2013 Aug;43(8):1787.

25. Kindlon T. Author's response: Criticisms of the PACE Trial were justified. BMJ. October 16, 2013http://www.bmj.com/content/347/bmj.f5963/rr/667107

26. Kindlon T. PACE trial: Simply giving a reason why an outcome measure was changed is not necessarily sufficient. BMJ November 2013 http://www.bmj.com/content/347/bmj.f5963/rr/670755.

27. Clarke D. It is wrong to prevent patients from making informed decisions about their medical care. BMJ November 26, 2013. http://www.bmj.com/content/347/bmj.f5963/rr/674255

28. McPhee G. A fundamental misuse of statistics. BMJ November 21, 2013http://www.bmj.com/content/347/bmj.f5963/rr/673572

29. Baldwin A. PACE trial steering group fail to spot error in reasons for protocol changes. BMJ November 21, 2013 http://www.bmj.com/content/347/bmj.f5963/rr/673502

30. Matthees A. Did PACE make major unapproved protocol changes after seeing outcomes data? BMJ November 29, 2013 http://www.bmj.com/content/347/bmj.f5963/rr/674770

31. Carter S. Published protocols exist to protect patients. BMJ December 2, 2013http://www.bmj.com/content/347/bmj.f5963/rr/675525

32. Clifford Couch I. SF-36 Scale for Normal Physical Function, Age Matters. BMJ December 2, 2013http://www.bmj.com/content/347/bmj.f5963/rr/675527

33. Kirby SBM. Re: PACE trial authors’ reply to letter by Kindlon. BMJ February 1, 2014http://www.bmj.com/content/347/bmj.f5963/rr/684828

34. "Selected data on PACE Trial participants" request:https://www.whatdotheyknow.com/request/selected_data_on_pace_trial_part
 
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